CHF Team Approach

Peter Carson, MD

Jacqueline Gannuscio, MSN, ACNP RN

Washington DC

Performance Measures Improvement: A Team Approach to Acute Hospital Management of CHFABSTRACT: Congestive Heart Failure is a prevalent problem in this country with nearly 5 million patients diagnosed. It is the most common DRG in hospitalized patients, with hospital discharges for heart failure (HF) rising 179% from 1979 to 2003. Readmission rates are as high as 50% within 6 months.

There have been positive outcomes for hospital readmission, adherence to guideline based therapy, costs, and quality of life, in outpatient HF programs. However little is known about the impact Heart Failure Teams on outcomes in the hospital.

The Washington DC Veteran’s Administration (VA) Medical Center tracks quality in the outpatient and inpatient settings by the use of Performance Measures. For heart failure, use of Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARB) discharge instruction for diet, weight and medications are followed. In the last quarter of 2005 compliance with the last two measures met or exceeded the VA goal of 90%. Use of ACEI or ARB however was 75%.

In the fall of 2005 a team approach was initiated for management of patients hospitalized with HF, which included a Cardiologist and an Acute Care Nurse Practitioner. Each of the five medical teams were contacted daily and asked about new patients admitted with HF. Consult orders were also placed to Cardiology Heart Failure Team. These were completed by the NP within 24 hours, and diagnostic and treatment recommendations were made to the medical team. Ongoing education of medical residents and interns is an integral part of the process. There was an improvement in ACEI/ARB use during the period from 10/05 to 6/06 with 100% compliance noted at the latest review.

Use of NP’s as members of HF teams improves outcomes as measured by improvement in HF Performance Measures.

RESEARCH

Washington DC VA

Medical Center Heart

Failure Program

OUTPATIENT CLINIC

INPATIENT MANAGEMENT

JCAHO Heart Failure Measure Trends 04.01.2004-03.31.2005

33

Discharge Medications

The percentages for Aldosterone Receptor Antagonist and Subcutaneous Erythropoietin may be under-reported in the cumulative columns since these medications were added to the case report form in Q1 2004, and therefore were not available options to the total benchmark population.

LAST QUARTERn=1474

01.01.2006-03.31.2006

LAST 12 MONTHSn=13210

04.01.2005-03.31.2006

CUMULATIVEn=140841

01.01.2001-03.31.2006

ACEi or ARB (%) ACE Inhibitor (%)Angiotensin II Receptor Blocker (%)Aldosterone Receptor Antagonist (%)

67511922

67531620

6754159

Aspirin (%)Beta-blocker (%)Digoxin (%)Diuretic (%)

56762584

54742682

49643285

Lipid-Lowering (%)Nitrate (%)Subcutaneous Erythropoietin (%)Warfarin (%)

49254

30

47263

28

39291

28

52

Performance Measures for HF 10/04-8/05 VISN 5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ACE/ARB Priorto Admit

WT InstructPrior to Admit

DC Instruc

ExpectedVISNMWVVAMHCAWASH

HF-Inpt on ACEI/ARB FY05

0

10

20

30

40

50

60

70

80

90

100

visn

22

visn

3

visn

4

visn

19

visn

23

visn

6

visn

8

visn

10

visn

21

visn

7

visn

16

visn

17

visn

18

512

Balti

mor

e

visn

15

visn

12

visn

20

visn

1

visn

11

visn

9

613

Mar

tinsb

urg

visn

5

visn

2

688

Was

hing

ton

Nat

iona

l

VAMCDC Inpatient HF ProgramComponents of Program:• Medical Teams – Primary Providers• CHF MD and NP – Medical Consultants• Nursing – Bedside Care and Education• Case Management – Discharge Planning• Dietary – Dietary Education• PT – Mobility and Functional ImprovementTools • EMR• CHF Order Set• CHF Consult• Discharge Instructions• Advanced Clinic Access

CHF Orders

Select Components of Discharge Instructions

VAMCDC ACEI/ARB 12/05-6/06

0%10%20%30%40%50%60%70%80%90%

100%

DecJanFebMarAprMayJun