Transcript

11/29/2011

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IHI Expedition:

Effective Implementation of Heart Failure Core

Processes

Peg Bradke, RN, MA, Faculty

Christine McMullan, MPA, Director

December 1, 2011

These presenters have nothing to disclose

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11/29/2011

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Today’s Agenda • Homework Discussion

─ Peg Bradke

• Improved Care for Patients

With Heart Failure at

Stonybrook University

Medical Center ─ Lisa Sokoloff

• Questions and Answers

• Increasing Reliability ─ Chris McMullan

• Homework for next session

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Christine McMullan

Chris McMullan, MPA, is the Director of

Continuous Quality Improvement at Stony Brook

University Medical Center. She served as an

adjunct faculty member at the Harriman Business

School and School of Professional Development

at Stony Brook University. She was Lead Faculty

on the IHI Early Warning Systems: The Next Level

of Rapid Response Expedition and a Faculty

member on the IHI Sepsis Detection and Initial

Management Expedition. She was a co-faculty

member of the Hospital Association of New York

State's 2007 learning collaborative to prevent

ventilator associated pneumonia. Ms. McMullan

has held a variety of managerial positions in

quality improvement and human resources.

Peg Bradke, RN, MA

Peg M. Bradke, RN, MA, Director of Heart Care

Services, St. Luke's Hospital, coordinates services for

two intensive care units, two step-down telemetry

units, the Cardiac Catheter Lab, Electrophysiology

Lab, Diagnostic Cardiology, Interventional/Vascular

Lab, and Cardiopulmonary Rehabilitation. In her 25-

year career, she has had various administrative roles

in critical care areas. Ms. Bradke works with the

Institute for Healthcare Improvement on the

Transforming Care at the Bedside initiative and

Transitions Home work. She is President-Elect of the

Iowa Organization of Nurse Leaders.

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Follow up discussion from Nov. 17 Call

• Concurrent vs Retrospective Chart Audits

• What has been the most efficient and effective process for your facility?

• How are you making the process work for you?

• If you could change how you are presently doing your audit”

What would it be?

What would it take to do?

Improved Care for Patients With Heart

Failure

“…to infinity and beyond”, Buzz Lightyear

But it feels like forever already!

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HEART FAILURE NATIONAL HOSPITAL

INPATIENT QUALITY MEASURES

• HF-1 Discharge Instructions

• HF-2 Evaluation of LVS Function

• HF-3 ACEI or ARB for LVSD

• HF-4 Adult Smoking Cessation Advice/Counseling

HEART FAILURE- Other Considerations

•Readmission

•Length of Stay

•Mortality

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HIDE and SEEK! Question: Where are the Heart Failure Patients?

Answer: Everywhere!

Currently…

• we have dedicated Heart

Failure RNs who screen

new admits to assist us in

identification (we still have

surprises)

Plan to…

• Utilize electronic record

more effectively (problem

lists; PowerPlans etc.)

• Link diagnosis and

PowerPlan to specific lists

(to notify HF team for

example) and required

activities

Discharge Instructions DESCRIPTION:

• HF patients discharged home with written

instructions or educational material given

to patient or caregiver at d/c or during the

hospital stay. The information must

address all of the following: activity level,

diet, discharge medications, follow-up

appointment, weight monitoring, and what

to do if symptoms worsen.

• Non-compliance with diet and medications

is an important reason for changes in

clinical status. Health care professionals

should ensure that patients and their

families understand their dietary

restrictions, activity recommendations,

prescribed medication regimen, and the

signs and symptoms of worsening heart

failure.

85.7%

92.4%

87.5%

93.4%

50%

60%

70%

80%

90%

100%

Q3 2010 Q4 2010 Q1 2011 Q2 2011

Compliance Target

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Currently… • All adults patients are given a generic

discharge instruction sheet on admit

(covers all required elements)

• Concurrent Review- Heart Failure

Service Nurse screens new admits to

identify heart failure patients and follow

up on completion of the

education/additional, documentation

• Zone Guide given at discharge to assist

with self management and early

recognition of impending exacerbation

They are missed when the diagnosis seems

secondary ; the standard work

strategies are not employed; hand

written D/C plan – error prone process

Plan to… • Electronic Depart Process to facilitate

medication reconciliation and discharge

instructions (roll- out imminent)

• Consider trialing Discharge Contract for

Cardiac patients

• Expand Clinical Integration role

– Enhance communication and early

f/u with community LIP or HF Clinic

– Smooth transitions for the patient

related to various needs including

medication management

– Early alternative intervention for

symptom management and

exacerbations

Discharge Instructions-

Discharge Planning

Starts on Admit:

This generic tool is given to

all adult patients on

Medicine units upon

admission, to start the

process of discharge

planning and satisfy the core

measure

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Heart Failure

Specific Discharge

Education

DISTRIBUTION: White-Medical Record; Yellow-Patient

What is Congestive Heart Failure (CHF)? CHF means that your heart muscle is weak and can no longer pump blood with enough force to all parts of your body. When this happens, fluid backs up in the lungs and other parts of the body. CHF can make it more difficult for you to do normal daily activities that may have been easy for you in the past. Good control of your disease can improve the quality of your life Please follow the following guidelines: MEDICATIONS

♥ Take your medicine as prescribed by your physician(s). It may take many months to feel the effect of these medications.

♥ Do not take more than the prescribed dose. ♥ If you miss a dose, take it as soon as you remember, but do not take two doses at the same

time. ♥ Take your medications at the same time every day. ♥ If you have several physicians, make sure they all know what medications you are taking.

DIET ♥ Eat a well balanced diet of three meals per day; restricted to 2 grams of sodium per day. ♥ Eat at regular times every day. ♥ Follow fat, salt and other possible restrictions if your physician has told you to do so.

WEIGHT ♥ Check you weight every day on the same scale with minimal clothing and write it

down on a calendar. This is because one the symptoms of worsening CHF is fluid

accumulation, which would cause a gain in weight.

ACTIVITY

♥ Some regular activity is very helpful for your heart. ♥ Do not undertake an exercise program without first speaking to your physician. ♥ Walking is an excellent routine form of exercise, but recognize your limitations. ♥ Take frequent rest periods and pace yourself to conserve energy. ♥ Plan your activities, so you avoid temperature extremes. ♥ If you are too short of breath talk, you need to slow your pace or stop. If you remain short of

breath after slowing down, you need to call your physician.

PREVENTION

♥ Get a Pneumonia vaccine shot at least once in your life. ♥ Get a FLU vaccine shot every year in the Fall unless directed otherwise by your physician. ♥ Smoking Cessation advice and counseling have been provided if you smoked cigarettes

within the last twelve months. Discontinue smoking to maintain or improve heart function.

CALL YOUR PHYSICIAN IF: ♥ You experience: weight gain of more than 3 pounds in a day (or 5 pounds in a week),

increase in cough, swelling in your body, shortness of breath, or chest pain.

♥ You need to increase the number of pillows to sleep at night. ♥ You are running low on medication.

Sign below to acknowledge that I have received and reviewed these instructions with a nurse.

Patient Signature: _________________________ Date:___________________

Nurse Signature:___________________________ ID#___________ Date:_______ Time:_______

CONGESTIVE HEART FAILURE (CHF) DISCHARGE SHEET

ME2C033 (4/05)

Heart Failure Zone Guide

– An educational tool created to

help patients & families

recognize symptoms of HF

and seek treatment before

emergency care is needed

– Goal is to improve symptom

management and recognition

to decrease CHF

exacerbations and

readmissions

– Spanish version to be printed

on reverse side

– Efforts to roll out to SNFs also

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Evaluation of Left Ventricular

Systolic (LVS) Function DESCRIPTION:

• HF patients with

documentation in the hospital

record that LVS function was

evaluated before arrival, during

hospitalization, or is planned

for after d/c.

• Rationale: Appropriate

selection of medications to

reduce morbidity and mortality

in HF requires the identification

of patients with impaired LVS

function.

100% 100% 98.3% 100%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Q3 2010 Q4 2010 Q1 2011 Q2 2011

Compliance Target

ACEI or ARB for Left Ventricular

Systolic Dysfunction (LVSD) DESRIPTION:

• HF patients with LVSD prescribed an

ACEI or ARB at hospital d/c.

• For purposes of this measure, LVSD is

defined as chart documentation of a left

ventricular ejection fraction (LVEF) less

than 40% or a narrative description of

left ventricular systolic (LVS) function

consistent with moderate or severe

systolic dysfunction.

• Rationale: ACEI therapy reduces

mortality and morbidity in patients with

HF and LVSD and are effective in a wide

range of patients.

94.7%

90.5% 90.0% 90.0%

50%

60%

70%

80%

90%

100%

Q3 2010 Q4 2010 Q1 2011 Q2 2011

Compliance Target

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LVF Assessment and ACE I/ARB

Use/Documentation Currently…

• Powerplans (Heart Failure

Admit; Heart Failure as a

Secondary Diagnosis; order

sentences built into Medicine

Admit Powerplan)

• Concurrent review by Heart

Failure Service (1 MD in-patient

and out-patient; 1 RN, M-F)

• Paper rounding tools (DGS)

Plan to…

• Enhanced opportunities for

documentation during

hospitalization

• In-patient Heart Failure Service

Team (2 MDs and 2 RNs) sees

all patients with a primary or

secondary diagnosis of HF (as

per their screen)

• Electronic Depart Process

They are missed because of

documentation issues primarily; lack of discreet fields; lack of hard stops at D/C

Currently

bedside

rounding tools

cue the team to

consider core

measures and

offer another

opportunity for

documentation

MEDICINE GOALS /PLAN OF CARE

Hospital Admission:_____________ Unit Admission:_____________ Planned date of discharge:_____________

Current Diagnosis: _____________________________________________________________________________ Isolation? No Yes: Code: ______ Organism(s):____________ Surveillance cultures sent Advance Directives Discussed ? Yes No Patient has Advanced Directive with copy in chart Code Status: Full code DNR DNI Code status renewed on: _____________________

Medication Reconciliation complete: Yes No SYSTEM STATUS/PROBLEMS

Date/Time: ____________________

PLAN & DAILY GOALS/OUTCOMES:

Date/Time: ____________________

Prophylaxis:

DVT: SCDs Heparin Lovenox NA

GI: Yes No Contraindicated NA

Cont. Current Management

Diagnostics planned: __________________________

Monitor parameter: __________________________

Change therapy: __________________________

IMPORTANT: Evaluate Patient’s ability to switch to PO medications as soon as possible.

Fluids/medications: IV abx IV Fluids:__________________ Antibiotic day ____ of ____

Switched to PO medications IV fluids: Continue Discontinue

Change to : ______

Neurological: A&O X 3 Confused H/O seizure

Maintain patient’s orientation/safety Seizure precautions

Respiratory: Lungs clear Trach Adventitious: Describe:_________________ Requires O2: Sats: ________ Home O2 On Nebulizer

Maintain O2 sat of _________ Wean off oxygen Head of bed elevated Suction as needed Continue Nebulizer

Cardiovascular/Hemodynamic: Chest pain: Yes No

Requires telemetry

Elevated/low: BP: ____, HR: ____, RR:____,

Temp:____, TMax:_____

>0.15 Troponin % EF: ___________

Re-new telemetry Cardiology consult EKG Transfuse HF d/c Instruction sheet signed and in chart For LVSD, prescribe ACE/ARD or document

contraindication for both Anticoagulant at d/c for HF patient with atrial

fibrillation. GI/GU/Nutrition: Feeding: self assist tube feeding NPO Swallowing difficulty

Pain/difficulty on urination Urinary catheter Constipation Diarrhea Abdominal pain Date of last BM: _____________

Speech and swallow consult

Discontinue catheter

Stool for CDiff

Order stool softener

Resume diet Nutrition Consult

Skin: Skin intact Pressure ulcer: Stage: _______ Location: _______

ET consult Continue dressings as ordered New dressing regimen: see chart for orders

SIDE 1 OF 2 cm (8/10/07)

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Electronic

Solutions?

Adult Smoking Cessation Advice/Counseling

DESCRIPTION:

• HF patients with a history of smoking

cigarettes, who are given smoking

cessation advice or counseling during

hospital stay. For purposes of this

measure, a smoker is defined as

someone who has smoked cigarettes

anytime during the year prior to hospital

arrival.

• Rationale: Smoking cessation reduces

mortality and morbidity in all

populations. Patients who receive even

brief smoking-cessation advice from

their care providers are more likely to

quit.

100% 100% 100% 100%

0%

25%

50%

75%

100%

Q3 2010 Q4 2010 Q1 2011 Q2 2011

Compliance Target

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Staff Education is Ongoing

Summary / Next Steps:

• Actively driving the use of the electronic PowerPlan for primary and

secondary Heart Failure (electronic alert in place)

• Concurrent screening of all new admits for a primary or secondary

diagnosis of HF or an admitting diagnosis or profile suggestive of such

(review of B-type natriuretic peptide results, ejection fraction %

reports, chief complaint on admit etc.)

• Real time reminders/education to the staff to consider/document a

specific element of care; utilize hard stops

• Implement electronic depart process

– drive medication reconciliation process

– provide opportunities to staff at discharge for documentation and

patient education related to core measures

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Summary/Next Steps:

• Annual nursing and physician education regarding heart failure and

core measures

• Distribute pocket guides describing heart failure care and core

measures.

• Unit and physician specific data regarding HF core measure

compliance reported to leadership monthly and compliance data is

posted on the units Quality boards.

• Globalization of discharge instructions

• Implement Clinical Integration to smooth transitions (early f/u;

medication reconciliation and poly pharmacy; enhanced

communication; improved support services post d/c)

Summary/Next Steps:

• Develop/Implement ED /Observation Unit HF Protocol

• Work with area SNFs to identify s/s earlier and work

collaboratively

• VAD program

• Concurrent Coding / Clinical Documentation

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Composite Score

DESCRIPTION:

• The total number of

patients eligible to

receive all of the core

measure indicators

divided by the actual

number of patients

that received them all.

87.0%

91.0%

87.0%

92.8%

50%

60%

70%

80%

90%

100%

Q3 2010 Q4 2010 Q1 2011 Q2 2011

Compliance Target

Heart Failure 30-Day Mortality and 30-Day

Readmit Rates Q3 2007 - Q2 2010

8.80%

11.30%

0%

4%

8%

12%

Our Hospital's RiskStandardized Mortality

Rate

US National Rate

24.60% 24.80%

0%

10%

20%

30%

Our Hospital's RiskStandardized Readmission

Rate

US National Rate

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Follow-up discussion after Stony Brook

Stony Brook shared their bedside

rounding tool.

• What trigger tools have you used to

assure compliance to core measures?

• How are you educating staff on the

core measures patients?

IHI Expedition

Effective Implementation of Heart Failure Core

Processes

Increasing Reliability

Christine McMullan, MPA, Director

11/29/2011

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Survey Responses

Director of Quality, Nurse Practitioner, Registered Nurse, Chart

Abstractor and Clinical Nurse Specialist

Survey Question: How are you

identifying patients?

• Admitting diagnosis

• Concurrent review

• H&P medical diagnosis history

• Elevated BNP levels

• EMR triggers

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Survey Question: What are your

barriers to reliability?

• Physician and nurse lack of

understanding of core measures

• MD and RN collaboration on discharge

instructions/medication reconciliation

• Electronic health record – both pro and

con

• Inability to identify HF patients on

admission

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Increasing Reliability

• Provide prompts on admission for standard order sets for patients with congestive heart failure (CHF).

• Implement standard, diagnosis-based order sets, with an “opt out” (with documented explanation of why the standard is not being followed).

• Create a standard process to obtain prior LVS assessments before ordering a new LVS assessment.

• Use alerts and reminders, electronic or paper, that the patient has CHF and requires automatic implementation of standard orders.

• Introduce a concurrent review process to identify patients who have not received all the evidence-based care.

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Homework for Next call

Have a discussion with coding.

• What has been you experience with

your identification of HF patients as it

relates to the final diagnosis code

assigned?

• What action have you taken to assure

findings are similar?

Expedition Communications

• If you would like additional people to

receive session notifications please send

their email addresses to

[email protected].

• We have set up a listserv for the

Expedition to enable you to share your

progress. To use the listserv, address an

email to [email protected].

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Next Session

December 15, 2011, 12 – 1 PM ET

Reliably Offering Smoking Cessation

Counseling to Heart Failure Patients

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