heart failure by kismet rasmusson, fnp-bc, faha

LCAC Presentation(FINAL BMS-SANOFI 10-17-01)

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Heart Failure Heart Failure Transitions in CareTransitions in Care

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Kismet Rasmusson, FNPKismet Rasmusson, FNP--BC, FAHABC, FAHAFebruary 17, 2009February 17, 2009

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Feb 14-20, 2010

ObjectivesObjectives

••To understand the To understand the impact heart failure has impact heart failure has on healthcare deliveryon healthcare delivery

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••To learn strategies to To learn strategies to provide best practices for provide best practices for heart failure careheart failure care


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Case StudyMr. C is a 68 year old man with cough and shortness of breath whose MD squeezes him in to his busy schedule.He was hospitalized 3 weeks ago with CHF, discharged on captopril and a “no added salt diet,” with encouragement to see his MD in three weeks. His MD does not have information about the

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hospitalization.On exam, Mr. C is told by his MD he still has “some heart failure,” is encouraged to continue cutting salt out of his diet, and told to call back if he is not better. Two weeks later, Mr. C calls 911 because of severe breathlessness and lower extremity swelling, and is admitted to the hospital. A more complete history in the hospital reveals that he has been taking the captopril only as needed because it seems “strong,” and he has never added salt to his diet, so his diet has not been changed.

Heart FailureScope of Problem

• Most common cause of hospital admission in patients over age 65years

• Accounts for > 1 million hospitalizations/year• Accounts for more than 6 million hospital days/year

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• Accounts for $37 billion in costs annually in the U.S.• Re-hospitalization or death approximately 50% within 6 months• Median length of stay 5 - 6 days• In-hospital mortality 5 to 8%

Thom et al. Circulation 2006 February 14;113(6):e85-151. Felker et al. Am Heart J 2003;145(2):S18-S25. Felker et al. J Card Fail 2004;10:460-466. Lee et al. JAMA 2003;290(19):2581-2587. Hunt SA et al. ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2001. Graves EJ, Gillum BS. 1994 Summary: National Hospital Discharge Survey. National Center for Health Statistics; 1996.

Heart Failure

… is a serious public health concern… is a serious public health concern… is a substantial cause of morbidity and mortality and … is a substantial cause of morbidity and mortality and health expenditureshealth expenditures… evidence… evidence--based therapies have been demonstrated based therapies have been demonstrated

1350g.6www.myamericanheart.org

to improve outcomesto improve outcomes… requires tremendous efforts of care across the … requires tremendous efforts of care across the continuum continuum


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Heart Failure Hospitalizations

70% due to worsening chronic HF70% due to worsening chronic HFWith either preserved or reduced LVEF (46With either preserved or reduced LVEF (46--54%)54%)

25% due to de novo HF25% due to de novo HF5% due to advanced HF5% due to advanced HF

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Refractory to therapyRefractory to therapySevere LV systolic dysfunctionSevere LV systolic dysfunctionLowLow--output stateoutput state

Mean age 73 yearsMean age 73 yearsAge > 75 years in 50% of admissionsAge > 75 years in 50% of admissions52% female52% female

Georghiade. Circulation 2005;112:3958-3968Adams. Am Heart J 2005;149:209-216

Age-Adjusted Heart Failure Hospitalization Rate

800

1000

1200

000 Men 1st

National Hospital Discharge Survey, 1979-2004

HF Diagnosis Listed

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0

200

400

600

1979 1984 1989 1994 1999 2004

Per

100,

0

Women 1stMen 2nd+Women 2nd+

Fang et al. J Am Coll Cardiol 2008;52:428-434

Comorbidities in Patients With HF

ents

(%)

45

31

40

35

30

2518 20

3228

42

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Patie 20

15

10

5

0

11

3 36

14 15

Fonarow et al. Arch Intern Med. 2007;167:1493−1502. Abraham et al. J Am Coll Cardiol 2008;52:347-356. The OPTIMIZE-HF Registry [database]. Final Data Report, Duke Clinical Research Institute, July 2005.


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Heart Failure Hospitalization Rate

2500

3000

3500

4000

000 Men < 65 Yrs

National Hospital Discharge Survey, 1979-2004

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0

500

1000

1500

2000

2500

1979 2004

Per

100,

0

Men > 74 YrsWomen < 65 YrsWomen > 74 Yrs

Fang et al. J Am Coll Cardiol 2008;52:428-434

4,183

3,506

3,814

2,924 2,947 2,812 2,806

3,193

3,000

4,000

5,000

s (n

)

LVEF in Hospitalized HF Patients

Documented LVEF Measured Prior to or During Hospitalization

15,215/36,115 (42%) with LVEF > 40%

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44

1,137

2,345 2,331

1,833

1,270

553274

100 32 10 10

1,000

2,000

Patie

nts

0-5

6-10

11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

71-75

76-80

81-85

86-90

91-95

96-100

Fonarow GC, et al. J Am Coll Cardiol. 2007;50:768−777.

Left Ventricular Ejection Fraction (%)

Outcomes

5

6

7P=NS

P=NS P<.0001

6.05.7

4.0 4.0 3.9

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0

1

2

3

4

LVSD

PSF

Length of Stay,Mean (days)

Length of Stay,Median (days)

In-Hospital Mortality(%)

2.9


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STAGES OF HEART FAILURE

Stage A Stage B Stage C Stage D

• Known heart failure• Known symptoms:

Shortness of breathFatigue, reduced activity tolerance

• Marked symptomsdespite optimal therapies

• High blood pressure• Atherosclerosis• Diabetes• Obesity• High cholesterol• Sedentary lifestyle

• Prior heart attack• Evidence of enlarged

or thickened heart• Valve disease

*ACCF/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult. 2009

IDENTIFYING EACH STAGE….

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• Treat high BP• Smoking cessation• Treat lipid disorders• Exercise• Treat diabetes• Avoid illicit drugs• Limit excess alcohol

• Continue stage A • Start medications:

ACE-I or ARBBeta-blockers

• Internal cardiovertor defibrillator

• Continue stagesA, B

• ACE-I or ARB• Beta-blockers• Diuretics• Spironolactone• Digitalis• Hydralazine/ISDN• Biventricular pacing

+/- defibrillator

• Continue stages A, B, and C

• IV inotropes • Nesiritide• Heart transplantation• Mechanical devices:

LVAD• Hospice care

• Sedentary lifestyle• Family history of

cardiomyopathy• Use of cardiotoxins

TREATING EACH STAGE….

The Course of Heart FailureComplete Care = Heart Failure Care + Supportive Care

1350g.14Goodlin et al, J of Card Fail, Vol 10. 2004

Successful Heart Failure Management

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Algorithm for ADHF

↓PCWP and Diureserales, edema, JVD, S3

Unload and ↑SV/CImixed presentation

↑CO/BP/renal perfusionlow BP, cool, clammu

CI/SV d ↑PCWP ↓CO

Goals of TherapyCONGESTED HYPOPERFUSED

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CI/SV adequate ↑PCWP, ↓CO ↓CO, ↑↓PCWP

DiureticsLoop bolus

Combo AgentsCont. infusion

Diuretics & vasodilatorNesiritide

NTGNitroprusside

Ultrafiltration / HD

Combined therapyDiuretic +/- vasodilator

Consider InodilatorMilrinone, dobutamine

InotropesVasopressors

IABPVAD

Transplant?

Compilation of ACC/AHA, HFSA and ESC Guidelines

Mainstay of Heart Failure Management

Medical & device therapies proven to reduce Medical & device therapies proven to reduce symptoms, improve mortality and symptoms, improve mortality and readmissions…readmissions…•• ACE inhibitors (ARBs)ACE inhibitors (ARBs)

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( )( )•• Beta blockersBeta blockers•• Aldosterone antagonists (spironolactone)Aldosterone antagonists (spironolactone)•• DigoxinDigoxin•• DiureticsDiuretics•• ICDs ICDs

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Getting the “Congestion” out of Heart Failure

Pharmacologic therapy:Pharmacologic therapy:DiureticsDiureticsVasodilatorsVasodilatorsNatriuretic peptidesNatriuretic peptides

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p pp pInotropesInotropesAvoidance of NSAIDs/COX II and some oral Avoidance of NSAIDs/COX II and some oral hypoglycemic agentshypoglycemic agents

Nonpharmacologic therapy:Nonpharmacologic therapy:Sodium and fluid restrictionSodium and fluid restrictionUltrafiltrationUltrafiltrationHemodialysisHemodialysis

JCAHO & CMSJCAHO & CMSHeart Failure Core Performance MeasuresHeart Failure Core Performance Measures

Assess left ventricular function; Assess left ventricular function; •• prior to admission, during hospitalization, or plan after prior to admission, during hospitalization, or plan after

dischargedischargePrescribe ACEI or ARB for LVEF < 40%; Prescribe ACEI or ARB for LVEF < 40%;

document contraindications todocument contraindications to bothboth when not prescribedwhen not prescribed

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•• document contraindications to document contraindications to bothboth, when not prescribed, when not prescribedProvide discharge instructions: Provide discharge instructions: Provide smoking cessation counselingProvide smoking cessation counseling

Document Document Document Document Document…Document…

Recommendations for the Hospitalized Patient Recommendations for the Hospitalized Patient –– New New RecommendationsRecommendations

2009 Focused Update Recommendations2009 Focused Update Recommendations17. Comprehensive written discharge instructions for all patients with a

hospitalization for HF and their caregivers is strongly recommended, with special emphasis on the following 6 aspects of care:

- diet discharge medications, with a special focus on adherence, persistence, and

tit ti t d d d f ACE i hibit /ARB d BB

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- uptitration to recommended doses of ACE inhibitor/ARB and BB medication,

- activity level, - follow-up appointments, - daily weight monitoring, and - what to do if HF symptoms worsen. (Level of Evidence: C)


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Indications for the Cardiac Resynchronization Indications for the Cardiac Resynchronization TherapyTherapy

Moderate to severe heart Moderate to severe heart failure (NYHA Class failure (NYHA Class III/IV)III/IV)QRS QRS ≥≥ 120 ms 120 ms LV j ti f tiLV j ti f ti

Right Atrial

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LV ejection fraction LV ejection fraction ≤≤35%35%Symptomatic despite Symptomatic despite stable, optimal medical stable, optimal medical therapytherapy

gLead

Right VentricularLead

Left VentricularLead

22

Sudden Cardiac Death

Heart enlargesSusceptible to cardiac dysrhythmiasWhen sustained VT/ VF, sudden death occursInternal Cardioverter Defibrillators:

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Analyze, pace terminateAnalyze, pace terminateshock lethal arrhythmiasshock lethal arrhythmiasreduce mortalityreduce mortality

ICDs save lives

© 2008 Fitzgerald Health Education Associates, Inc. 23

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Stage D Heart Failure TherapiesLVEF < 25%?

Poor toleration of ACEI, ARB and/or Beta blocker?Estimated life expectancy < 2 yrs?

Repeated hospitalizations?Progressive symptoms?

Poor oxygen consumption?Elevated filling pressures?

Requiring escalating diuretics?

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q g g

Consider referral forcardiac transplantationif physiologically <65 yo

Consider referral for destination LVAD

if physiologically > 65 yo or non-transplant candidate

25

1350g.26Renlund & Kfoury. NEJM 2006;355:1922

UTAH Cardiac Transplant Program 1985-2010 @ Intermountain Medical Center

Number of Transplants: 10581 & 3 year survival: 100%Alive/dead = 50/50 @ 12 yearsNumber of publications: >300

$

•LDSH/IMED

•PCMC

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Research dollars: >$7,800,000Trainees: 57UNOS certificationCMS certified since 1988JCAHO accredited

•VAMC

•UUHSC

March 2009:SRTR www.ustransplant.org


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The Utah Artificial Heart Programwww.uahp.com 1-877-784-2226

Leading center in the USLeading center in the US>20 years of experience in artificial heart >20 years of experience in artificial heart technologiestechnologiesMultidisciplinary approachMultidisciplinary approach

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Multidisciplinary approachMultidisciplinary approachAcute, temporary supportAcute, temporary supportBridge to transplantationBridge to transplantationDestination therapyDestination therapy

End-of-Life Considerations

Discuss prognosis and chance of survivalDiscuss advanced directives, and how this may change with changing clinical statusDiscuss option of deactivating an ICDProvide continuity of care between inpatient and outpatientUse strategies for palliation of symptoms

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g p y pDiureticsInotropesNitroglycerinOxygenAnxiolyticsMorphine

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Patient Support Network

Referring Physician

Administrative Representative

UtahArtificial

HeartProgram

Patient

Cardiac Surgeon Community

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Clinical Research

HeartTransplant

Patient

Interventional Cardiologist

Heart Failure Team

CriticalCareTeam


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Heart Failure at

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Intermountain Health Care

Intermountain Health CareHeart Failure Prevention and Treatment Program

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HFPTP—UTAH Cardiac Transplant—UAHPat Intermountain Medical Center

BC Cardiothoracic Surgeons BC Cardiothoracic Surgeons ––44BC HF/Transplant Cardiologists BC HF/Transplant Cardiologists –– 33BC Intensivists BC Intensivists –– 44NursesNurses

HF/TransplantHF/Transplant–– NPs/PAsNPs/PAs –– 77

Pharmacists Pharmacists –– 66Pathologists Pathologists –– 33LCSWs LCSWs –– 11CV AnesthesiologistsCV Anesthesiologists-- 66Interventional/EP cardiologistsInterventional/EP cardiologists-- 1111Full diagnositic support (cath/EP/echo) Full diagnositic support (cath/EP/echo)

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–– NPs/PAs NPs/PAs –– 77–– Nurse Coordinators Nurse Coordinators –– 55–– MA MA –– 33–– CV Research CoordinatorsCV Research Coordinators--22–– HF care managerHF care manager

UAHPUAHP–– Nurse Coordinators Nurse Coordinators –– 55–– Outreach Nurse Coordinator Outreach Nurse Coordinator –– 11–– Research Nurse Research Nurse –– 11–– BioBio--Engineers Engineers –– 44–– Nurse administratorNurse administrator

g pp ( )g pp ( )PT/OT/STPT/OT/STHistocompatability & ImmunogeneticsHistocompatability & ImmunogeneticsLifeflightLifeflightIntermountain Donor ServicesIntermountain Donor ServicesFinancial SpecialistFinancial SpecialistAdmin. SupportAdmin. Support

–– Operations officerOperations officer–– Nurse administratorNurse administrator–– Director of cardiovascular servicesDirector of cardiovascular services


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Intermountain Healthcare’s Cardiovascular Clinical Program

Extends HF care throughout the systemExtends HF care throughout the systemHF disease managementHF disease managementTargeted goals and JCAHO/CMS core measures Targeted goals and JCAHO/CMS core measures Provider/nursing HF educationProvider/nursing HF education

Cli i l l il d thlCli i l l il d thl

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–– Clinical pearls emailed monthlyClinical pearls emailed monthlyStandardized tools Standardized tools –– Admission orders, computerized DCM program, Admission orders, computerized DCM program,

standing orders, patient tools, remindersstanding orders, patient tools, remindersOutcomes monitoringOutcomes monitoring–– By provider, unit, hospital, region, systemBy provider, unit, hospital, region, system

HF Liaisons at each hospitalHF Liaisons at each hospital

Institutional Heart Failure Discharge Medication Program Reduces Readmissions and Mortality

100

tes

(%)

Pre-Intervention (n = 11,038)Post-Intervention (n = 8,045)

65

95

HR 0.80P < 0.0001

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0

50

ACEI Rx Readmissions

Trea

tmen

t Rat

1-year Mortality

1823

3846

Intermountain Health Care: 10 Hospitals Pre 1/96-12/98 (n = 11,038) to 1/99-3/00 (n = 8,045)Pearson TA. Circulation. 2001;104:II–838.

HR 0.77P < 0.0001

Intermountain’s Heart Failure Tools

Admission ordersAdmission ordersDischarge orders (computerized)Discharge orders (computerized)Cardiovascular pharmacistsCardiovascular pharmacistsHeart failure care managerHeart failure care manager

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Heart failure care managerHeart failure care managerHeart failure “liaisons” at each hospitalHeart failure “liaisons” at each hospitalEmail updates; readmissions, IV diuretics, EFEmail updates; readmissions, IV diuretics, EFReminder tools; sticker, postersReminder tools; sticker, postersEducationEducation-- CME, Nursing, Clinical PearlsCME, Nursing, Clinical PearlsHeart Failure Prevention and Treatment Program; 801Heart Failure Prevention and Treatment Program; 801--507507--40004000


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Pharmacist’s Role

Identify heart failure patientsIdentify heart failure patientsEducate physicians, nursing, care managersEducate physicians, nursing, care managersMonitor for appropriate medication therapyMonitor for appropriate medication therapyM it t fM it t f

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Monitor reports for accuracyMonitor reports for accuracyBe creative to meet facilities specific needsBe creative to meet facilities specific needs

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Identify Pts & Track HF MeasuresIdentify Pts & Track HF Measures

List of all admissionsList of all admissionsReview Dx: Review Dx:

Sure bets: HF, CHF, SOB, pleural effusionsSure bets: HF, CHF, SOB, pleural effusionsCould be: CP, syncope, AMI, arrythmias, PECould be: CP, syncope, AMI, arrythmias, PEP ibl HF f ti i hP ibl HF f ti i h

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Possibly HF: fatigue, pneumonia, coughPossibly HF: fatigue, pneumonia, coughReview records; chart &/or computerizedReview records; chart &/or computerizedReview w/ providers if questionsReview w/ providers if questionsTrack 4 HF measuresTrack 4 HF measuresHave HF diaries, pt ed manuals, DVD/videos readyHave HF diaries, pt ed manuals, DVD/videos readyUse CV discharge formUse CV discharge formCare managers and pharmacistsCare managers and pharmacistsOther toolsOther tools


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Primary Dx

charge sheet, and t’s been done

HF

NO YES

~ Similar Dx that could be coded HF (i.e. Hypoxia, SOB, Edema, increasing fatigue or lethargy)

~ Teach MAWDS with packet & video~ Check for ACE/ARB~ Check Echo~Teach smoking cessation~ Call dietician & pharmacy for teaching~ Document in Tandem, Discharge sheet, and on karedex

NO YES

~ Give MAWDS Steps ~ Ask Doctor if HF

Heart Failure

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t s been done. Give MAWDS Steps flyer & teach~ Document in Tandem, Discharge sheet, and on karedex

~ Ask Doctor if HF

YES NO

~ Teach MAWDS with video/packet~ Get Echo unless one has been done~ ACE or ARB or contraindication~ Teach smoking cessation~ Call pharmacy & dietician~ Document teaching in Tandem, Discharge sheet, and on karedex

~ Give MAWDS Steps ~ Document in Tandem, Discharge sheet, and on karedex

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Self-management tools:

Diary

Patient education manual

Video/DVD

Website

2008 Classes

HF Education 2002

6 week6 week--outpatient HF selfoutpatient HF self--management curriculum offered to any patientmanagement curriculum offered to any patientPrePre--test and posttest and post--test given to assess knowledgetest given to assess knowledgePrePre-- and postand post--class determination of use of health resources (ED or office class determination of use of health resources (ED or office visits, hospitalizationsvisits, hospitalizations34 of 37 completed the lecture series34 of 37 completed the lecture seriesAverage preAverage pre test score 75% posttest score 75% post test 97%test 97%

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Average preAverage pre--test score 75%, posttest score 75%, post--test 97%test 97%All felt the series improved their understanding of HFAll felt the series improved their understanding of HF90% reported feeling like they could improve self90% reported feeling like they could improve self--management and QOL after management and QOL after the lecture seriesthe lecture seriesThe majority felt the class would help them follow their provider’s treatment The majority felt the class would help them follow their provider’s treatment planplanPatients had fewer ED visits and hospitalizations, and had a slight increase in Patients had fewer ED visits and hospitalizations, and had a slight increase in office visits. office visits.

Rasmusson et al. J of Card Fail. Aug 2002:8(4),S5.


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MAWDS…makes a difference!

1000

750

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n=523 n=983

• 1,506 cases met the JCAHO/CMS eligibility requirements for receiving Discharge Instructions 2002 – 2004. Subjects receiving Discharge Instructions are more likely to be alive 1 year following dischargethan those who don’t [Hazard Ratio: 0.79, p-value: 0.027, adjusted for age, gender, severity, los ]

p=0.027500

250

0

Supplement to the Journal of Heart and Lung Transplantation

Volume 24, number 2S, S68, 79, February 2005.

An Intermountain Healthcare Analysis showed an:Incremental 1-year Survival Benefit with Better Adherence to JCAHO Heart Failure Core Performance Measures*

Heart Failure Core Measures:

1. Assess left ventricular function:

2. Prescribe ACEI or ARB for LVEF < 40%:

3. Provide discharge instructions:

4. Adult smoking cessation

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•G0: adherence to 0 HF measure

•G1: adherence to 1 HF measure

•G2: adherence to 2 HF measures

•G3: adherence to 3 HF measures

•G4: adherence to 4 HF measuresKfoury et al. J of Card Fail. 2008; 14(2)95-102.

Public Reporting on Heart Failure Carehttp://www.hospitalcompare.hhs.gov

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Heart Failure

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Heart Failure Disease Management

Care Gap for Patients with CHF

Percent of CHF patients given:Percent of CHF patients given: Average for all Average for all hospitals hospitals

reporting in the reporting in the USUS

Top 10% of Top 10% of hospitals hospitals

nationwidenationwide

ACE i hibi ARB f l fACE i hibi ARB f l f 81%81% 100%100%

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ACE inhibitor or ARB for left ACE inhibitor or ARB for left ventricular systolic dysfunction ventricular systolic dysfunction (LVSD)(LVSD)

81%81% 100%100%

Assessment for left ventricular Assessment for left ventricular function (LVF)function (LVF)

81%81% 95%95%

Discharge instructionsDischarge instructions 54%54% 89%89%

Smoking cessation advice/counselingSmoking cessation advice/counseling 76%76% 100%100%

CMS and HQA data from 1/05 through 12/05


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HFSA 2006 Practice Guideline (8.7)

Heart Failure Disease Management

Patients recently hospitalized for HF and other patients at high risk

h ld b id d f f l

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should be considered for referral to a comprehensive HF disease management program that delivers individualized care.

Strength of Evidence = A

Adapted from: Adams KF, Lindenfeld J, et al. HFSA 2006 Comprehensive Heart Failure Guideline. J Card Fail 2006;12:e1-e122.

ACC/AHA HF Guidelines

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HF Disease Management and the Risk of Readmission

Ekman

0.9

1

1.1

RiskRatio

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ClineJaarsma

Rich

Naylor

Stewart

Rauh

Lasater

Venner

Fonarow0.5

0.6

0.7

0.8

Summary RR = 0.76 (95% CI .68-.87)Summary RR for randomized only = 0.75 (CI = .60-.95)


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HF DM Lessons Learned

Success will depend on your structural supportSuccess will depend on your structural supportAdministrative/operationalAdministrative/operationalFinancialFinancialInformation technologyInformation technology

RN d d ti li i i MDRN d d ti li i i MD

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RNs, advanced practice clinicians, MDsRNs, advanced practice clinicians, MDsSupport staffSupport staff

Access to urgent care and to HF specialistsAccess to urgent care and to HF specialistsSupporting this processSupporting this process

TeleTele--management and remote monitoringmanagement and remote monitoringCare manager phone calls, twice in first month postCare manager phone calls, twice in first month post--dischargedischarge

Summary:Guiding Appropriate Heart Failure Care

Identify all patients with heart failureIdentify all patients with heart failure

Assess ventricular functionAssess ventricular function

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Prescribe appropriate medical therapies Prescribe appropriate medical therapies

Include nonInclude non--pharmacologic therapiespharmacologic therapies

Ensure appropriate follow up plans been madeEnsure appropriate follow up plans been made

Heart Failure Quality Improvement

Collect baseline data or use existing data sourceCollect baseline data or use existing data sourcei.e. collect data with HF nurse, case manager, PharmD, or medical i.e. collect data with HF nurse, case manager, PharmD, or medical student, etc.student, etc.

Select a champion, appoint a teamSelect a champion, appoint a teamDevelop (adapt) treatment algorithms, preprinted orders, Develop (adapt) treatment algorithms, preprinted orders, discharge formsdischarge forms

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discharge formsdischarge formsCommunicate with key departments to get buyCommunicate with key departments to get buy--ininPresent at grand rounds, lectures, and staff inPresent at grand rounds, lectures, and staff in--servicesservices

present rationale for program and toolspresent rationale for program and toolsreview prior successes and failuresreview prior successes and failureslead discussion regarding recommendations on protocol improvement lead discussion regarding recommendations on protocol improvement

Implement program to close gaps in careImplement program to close gaps in careRepeat cycle frequently (every quarter) = CQIRepeat cycle frequently (every quarter) = CQI


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Key Elements to Quality Improvement

Why Do Some Hospitals Succeed?Why Do Some Hospitals Succeed?Access to current and accurate data on Access to current and accurate data on treatment and outcomestreatment and outcomesHave stated goalsHave stated goals

1350g.55Bradley EH et al. JAMA. 2001;285:2604–2611.

Administrative supportAdministrative supportPhysician champion, support among cliniciansPhysician champion, support among cliniciansUse of preUse of pre--printed orders, care mapsprinted orders, care mapsUse of data to provide feedbackUse of data to provide feedbackWillingness to modernize, change with the timesWillingness to modernize, change with the times

Resources

AmericanAmerican HeartHeart AssociationAssociationwww.americanheart.orgwww.americanheart.org

Heart Failure Society of America Heart Failure Society of America

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www.hfsa.orgwww.hfsa.orgAmerican Association of Heart Failure NursesAmerican Association of Heart Failure Nurses

www.aahfn.orgwww.aahfn.orgIntermountainIntermountain HealthcareHealthcare

www.intermountainhealthcare.com/heartfailurewww.intermountainhealthcare.com/heartfailure

Thank You…Thank You…

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[email protected]@imail.org

heart failure by kismet rasmusson, fnp-bc, faha

Health & Medicine