Transcript Strength of Evidence = A - Institute for Healthcare Improvement

IHI Expedition:
Effective Implementation of Heart Failure Core
Processes
Peg Bradke, RN, MA, Faculty
Christine McMullan, MPA, Director
November 17, 2011
These presenters have nothing to disclose
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What is an Expedition?
ex•pe•di•tion (noun)
1. an excursion, journey, or voyage made for
some specific purpose
2. the group of persons engaged in such an
activity
3. promptness or speed in accomplishing
something
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 25year 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.
Where are you joining from?
Ground Rules
• We learn from one another – “All teach,
all learn”
• Why reinvent the wheel? - Steal
shamelessly
• This is a transparent learning
environment
• All ideas/feedback are welcome and
encouraged!
Schedule of Calls
• November 17 12:00 – 1:30 PM ET
Introduction, Objectives, Expedition Overview
• December 1, 2011, 12 – 1 PM ET
Importance of LVS assessment in the reliable recognition of HF
• December 15, 2011, 12 – 1 PM ET
Offering adult smoking cessation advice and counseling
• January 5, 2012, 12 – 1 PM ET
Benefits of providing ACE/ARBs at discharge for HF patients
• January 19, 2012, 12 – 1 PM ET
Anticoagulant at discharge for chronic atrial fibrillation
• February 2, 2012, 12 – 1 PM ET
Discharge instructions and dietary considerations
Today’s Agenda
• Expedition objectives and
your survey responses
• Medical management for
heart failure
• IHI’s Model for Improvement
• Overview for increasing
reliability with heart failure
core processes
• Homework for next session
12
Expedition Objectives
• To provide hospitals with highly effective ideas
and practices in improving reliability in the
treatment of heart failure.
The expedition will focus on key elements of care to
ensure patients with heart failure have less severe
symptoms, better quality of life, and fewer
readmissions to the hospital.
• Conduct left ventricular systolic (LVS) assessment
• Provide adult smoking cessation advice and counseling
• Provide ACE inhibitor or angiotensin receptor blockers (ARB) at
discharge
• Provide anticoagulant at discharge for chronic atrial fibrillation
• Establish discharge instructions
Survey Responses
Director of Quality, Nurse Practitioner, Registered Nurse, Chart
Abstractor and Clinical Nurse Specialist
Survey Responses
15
Goal for participation
• Learn from others
• Collaborate with others in improving
quality
• To better understand core measure
processes
• Improve heart failure care
• Prevent readmission
How are you identifying patients?
•
•
•
•
•
Admitting diagnosis
Concurrent review
H&P medical diagnosis history
Elevated BNP levels
EMR triggers
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
18
Last Quarter Composite Score
William E. Lawson, M.D., FACCP, FACC, FSCAI
Dr. William Lawson graduated from Rutgers Medical
School in 1977. Dr. Lawson has been at SUNY, Stony
Brook since 1980, where he is currently Professor of
Medicine in the Division of Cardiology. At Stony Brook he
has acted as Chief of Cardiology, Director of
Echocardiography, Non-Invasive, Invasive, and Preventive
Cardiology. He is currently Director of Cardiac Outcomes
Research and Preventive Cardiology. Dr. Lawson is a
practicing interventional cardiologist and Director of the
Interventional Cardiology fellowship program at Stony
Brook. Dr. Lawson is ABIM certified in Internal Medicine,
Cardiovascular Disease, Interventional Cardiology,
Advanced Heart Failure & Transplant Cardiology and is a
Fellow of the ACC, ACCP, SCAI, ACA. He has broad
expertise and interest in the field of cardiovascular
disease and is actively involved in the teaching and
mentoring of physicians and allied health care
professionals at SUNY, Stony Brook.
CONGESTIVE HEART FAILURE
William E. Lawson, M.D., FACCP, FACC, FSCAI
Stony Brook Hospital
Heart Failure:
A Growing Burden
• Prevalence is increasing:
– Aging populations, HBP, DM, MI survivors.
– Overall rate is 3-20/1,000.
– Rate over age 65 is 30-130/1,000.
• One –year mortality rates are 35-45% in
newly diagnosed cases.
• Heart failure is the most frequent cause of
hospitalization over age 65.
Symptoms
• Fatigue, easy tiring
• Dyspnea, Dyspnea on exertion, Paroxysmal
nocturnal dyspnea
• Edema
• Persistent cough/ wheezing
• Palpitations, presyncope
Congestive Heart
Failure
Cardiac cachexia
Hepatomegaly
JVD/ HJR
Ascites
New Classification of Heart Failure
A
B
C
D
Stage
Patient Description
High risk of developing
heart failure (HF)
•
•
•
•
Asymptomatic LVD
• Previous MI
• LV systolic dysfunction
• Asymptomatic valvular disease
Symptomatic LVD
• Known structural heart disease
• Shortness of breath and fatigue
• Reduced exercise tolerance
Refractory
end-stage HF
• Marked symptoms at rest despite maximal
medical therapy (eg, those who are
recurrently hospitalized or cannot be
safely discharged from the hospital
without specialized interventions)
Hunt SA et al. J Am Coll Cardiol. 2001;38:2101-2113.
Hypertension
CAD
Diabetes mellitus
Family history of cardiomyopathy
HF Risk Factor Treatment Goals
Risk Factor
Goal
Hypertension
Generally < 130/80
Diabetes
See ADA guidelines1
Hyperlipidemia
See NCEP guidelines2
Inactivity
20-30 min. aerobic 3-5 x wk.
Obesity
Weight reduction < 30 BMI
Alcohol
Men ≤ 2 drinks/day, women ≤ 1
Smoking
Cessation
Dietary Sodium
Maximum 2-3 g/day
1Diabetes
2JAMA
Adapted from:
Care 2006; 29: S4-S42
2001; 285:2486-97
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treating Hypertension to Prevent HF
Aggressive blood
pressure control:
Decreases
risk of
new HF
by ~ 50%
56% in DM2
Lancet 1991;338:1281-5 (STOP-Hypertension
JAMA 1997;278:212-6 (SHEP)
UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
Aggressive BP control
in patients with prior MI:
Decreases
risk of
new HF
by ~ 80%
After a 2 year visit to the US, Michelangelo’s David is
returning to Italy
Sponsored
by
Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in
patients at high risk for this syndrome, including those
with:
 Coronary artery disease
 Peripheral vascular disease
 Stroke
 Diabetes and another major risk factor
Strength of Evidence = A
ACE inhibitors and beta blockers are recommended for all
patients with prior MI.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Management of Patients with Known
Atherosclerotic Disease But No HF
Treatment with ACE
inhibitors decreases
the risk of CV death,
MI, stroke, or cardiac
arrest.
16
14
12
% MI, 10
Stroke, 8
CV Death 6
4
2
0
Ramipril
22% rel. risk red. p < .001
0
1
2
3
4
Years
15
EUROPA
12
NEJM 2000;342:145-53 (HOPE)
Lancet 2003;362:782-8 (EUROPA)
Placebo
HOPE
Placebo
% MI,
CV Death, 9
Cardiac 6
Arrest
Perindopril
3
20% rel. risk red. p = .0003
0
0
1
2
3
Years
4
5
CAD; Leading
Cause of Heart
Failure
• Post MI survivors
– Magnitude of initial infarct, cumulative
damage, adverse remodeling all play roles
• Chronic ischemia and LV dysfunction
– Prolonged ischemia causes hibernation,
stunning
– Shorter periods of ischemia result in reversible
myocardial dysfunction
Angioplasty
Pre PCI
Post PCI
The Evolving Model
of Heart Failure
Treatment
Cardiorenal
Hemodynamic
Neurohumoral
Digitalis and
diurtics improve
cardiac and
renal function
Inotropes and
vasodilators
improve LV
performance
Modification of
activation of
adrenergic,
RAAS systems
Treatment of Post-MI Patients with
Asymptomatic LV Dysfunction (LVEF ≤ 40%)
SAVE Study
0.3
Mortality
Rate
 All-cause mortality ↓19%
Placebo
0.2
Captopril
 CV mortality ↓21%
0.1
 HF development ↓37%
 Recurrent MI ↓25%
19% rel. risk reduction
p = 0.019
0
0
0.5
1
1.5
2
2.5
3
3.5
4
Years
Pfeffer et al. NEJM 1992;327:669-77
Added Value of BB Post-MI
Beta blocker (carvedilol) benefit post-MI with LVEF
≤ 40%, receiving usual therapy [revascularization,
anticoagulants, ASA, and ACEI]. Capricorn trial
 All-cause mortality reduced (HR = 0.077; p = 0.03)
 Cardiovascular mortality reduced
(HR = 0.75; p = .024)
 Recurrent non-fatal MIs reduced (HR =.59; p = .014)
Dargie HJ. Lancet 2001;357:1385-90
Causes of Dyspnea
Therapy: ACE Inhibitors
ACE inhibitors are recommended for symptomatic and
asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
ACE inhibitors should be titrated to doses used in clinical
trials (as tolerated during uptitration of other medications,
such as beta blockers).
Strength of Evidence = C
ACE inhibitors are recommended as routine therapy for
asymptomatic patients with an LVEF ≤ 40%.
 Post MI
Strength of Evidence = B
 Non Post-MI
Strength of Evidence = C
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ACE Inhibitors in Heart Failure:
From Asymptomatic LVD to Severe HF
SOLVD Prevention
(Asymptomatic LVD)
CONSENSUS
(Severe Heart Failure)
20%
death or HF hosp.
40%
mortality at 6 mos.
29%
death or new HF
31%
mortality at 1 year
27%
mortality at end of
study
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality

No difference in incidence
of sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91
SOLVD Investigators. N Engl J Med 1991;325:293-302
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
Therapy: Beta Blockers
Beta blockers shown to be effective in clinical trials
are recommended for symptomatic and
asymptomatic patients with an LVEF ≤ 40%.
Strength of Evidence = A
Beta blockers are recommended as routine therapy
for asymptomatic patients with an LVEF ≤ 40%.
 Post MI
Strength of Evidence = B
 Non Post-MI
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
IMPACT-HF Primary End Point:
Patients Receiving Beta Blocker at 60 Days
Improvement
100%
91%
73%
75%
Patients
18%
P <.0001
50%
25%
0%
Carvedilol
Predischarge Initiation
(n=185)
Physician Discretion
Postdischarge Initiation*
(n=178)
Gattis WA et al. JACC 2004;43:1534-41
Therapy: Angiotensin Receptor
Blockers
ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an
LVEF ≤ 40% who are intolerant to
ACE inhibitors for reasons other than
hyperkalemia or renal insufficiency.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ARBS in Patients Not Taking ACE Inhibitors:
Val-HeFT & CHARM-Alternative
Val-HeFT
CV Death or HF Hosp %
Survival %
CHARM-Alternative
50
100
Valsartan
90
80
Placebo
70
Placebo
40
30
Candesartan
20
10
60
p = 0.017
HR 0.77, p = 0.0004
0
50
0
3
6
9
12
15
18
21
24
27
0
9
Months
18
27
Months
Maggioni AP et al. JACC 2002;40:1422-4
Granger CB et al. Lancet 2003;362:772-6
36
Therapy: Aldosterone Antagonists
An aldosterone antagonist is recommended for
patients on standard therapy, including diuretics,
who have:

NYHA class III or IV HF from reduced LVEF (≤ 35%)
One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF < 40%
who are on standard therapy, including an ACE
inhibitor (or ARB) and a beta blocker.
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Aldosterone Antagonists in HF
EPHESUS (Post-MI)
Probability of Survival
RALES (Advanced HF)
1.00
1.00
0.90
0.90
0.80
Spironolactone
0.70
Eplerenone
0.80
Placebo
0.70
0.60
0.60
Placebo
0.50
0.50
RR = 0.70
P < 0.001
0.40
RR = 0.85
P < 0.008
0.40
0
3
6
9
12 15 18 21 24 27 30 33 36
0
3
6
9
12 15 18 21 24 27 30 33 36
Months
Pitt B. N Engl J Med 1999;341:709-17
Pitt B. N Engl J Med 2003;348:1309-21
Therapy: Hydralazine and Oral
Nitrates
A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with HF and reduced
LVEF:
 NYHA III or IV HF
Strength of Evidence = A
 NYHA II HF
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
A-HeFT All-Cause Mortality
43% Decrease in Mortality
100
Survival %
Fixed Dose ISDN/HDZN
95
90
Placebo
P = 0.01
85
0
100
200
Days Since Baseline Visit
300
400
500
600
Taylor AL et al. N Engl J Med 2004;351:2049-57
Therapy: Diuretics
Diuretic therapy is recommended to restore and
maintain normal volume status in patients with
clinical evidence of fluid overload, generally
manifested by:
 Congestive symptoms
 Signs of elevated filling pressures
Strength of Evidence = A
Loop diuretics rather than thiazide-type diuretics
are typically necessary to restore normal volume
status in patients with HF.
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treatment by Heart
Failure Stage
Stage A
Stage B
Treat HBP
Stop smoking
Treat lipids
Exercise
No ETOH
No Drugs
ACEI in DM,
HBP, Vascular
Disease
All Stage A
measures
ACEI in post
MI, reduced
LVEF
BB in post MI,
reduced LVEF
Stage C
Stage D
All Stage A
All Stage A,
measures
B,C measures
ACEI
LVAD
Diuretics
Ht Transplant
BB
Continuous
Digitalis
IV inotropes
Spironolactone
in Class III,IV
Device Therapy:
Prophylactic ICD Placement
Prophylactic ICD placement should be considered in patients
with an LVEF ≤35% and mild to moderate HF symptoms:

Ischemic etiology
Strength of Evidence = A

Non-ischemic etiology
Strength of Evidence = B
In patients who are undergoing implantation of a biventricular
pacing device, use of a device that provides defibrillation
should be considered.
Strength of Evidence = B
Decisions should be made in light of functional status and
prognosis based on severity of underlying HF and comorbid
conditions, ideally after 3-6 mos. of optimal medical therapy.
Strength of Evidence = C
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
MADIT II: Prophylactic ICD in
Ischemic LVD (LVEF 30%)
Probability of Survival
1.0
.9
.8
Defibrillator
.7
Conventional
Therapy
.6
0
0
Number at Risk
Defibrillator
Conventional
1
2
3
4
110 (.78)
65 (.69)
9
3
Year
742
490
503 (.91)
329 (.90)
274 (.84)
170 (.78)
Moss AJ et al. N Engl J Med 2002;346:877-83
Resynchronization
Two leads allow
pacing of the right
atrium and ventricle.
The third lead is
advanced through the
coronary sinus into a
venous branch along
the lateral wall of the
left ventricle,
allowing early
activation of the left
ventricle.
Device Therapy:
Biventricular Pacing
Biventricular pacing therapy is recommended for
patients with all of the following:
 Sinus rhythm
 A widened QRS interval (≥120 ms)
 Severe LV systolic dysfunction (LVEF < 35%)
 Persistent, moderate-to-severe HF (NYHA III)
despite optimal medical therapy.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
CRT Improves Quality of Life and
NYHA Functional Class
Average Change in Score
(MLWHF)
NYHA: Proportion Improving
by 1 or More Class
0
80
-5
*
*
*
60
-10
(%)
-15
*
*
*
40
*
Control
EI
CD
20
0
MI
RA
CL
D
AK
C
CO
NT
SR
ST
IC
MU
MI
RA
CL
E
-20
CRT
MIRACLE
*P<.05
CONTAK
CD
Control
MIRACLE
ICD
CRT
Abraham WT et al. Circulation 2003;108:2596-603
CRT in Patients with Advanced HF and a
Prolonged QRS Interval: COMPANION
Primary End Point: All-Cause Mortality
Death or Hospitalization Due to HF
Risk of all-cause mortality reduced by 19%
in group with CRT and ICD (p =.014)
Risk of death or hospitalization from HF
reduced by 34% in ICD group and by 40% in
ICD-CRT group (p < .001)
Bristow MR et al. N Engl J Med 2004;350:2140-50
Effect of CRT Without an ICD on
All-Cause Mortality: CARE-HF
% Event-Free Survival
100
75
CRT
50
Medical
Therapy
25
HR = 0.64 (95% CI = .48-.85)
p = .0019
0
Number at risk
CRT
Medical Therapy
0
409
404
500
376
365
351
321
Days
213
192
1,000
89
71
1,500
8
5
Cleland JG et al. N Engl J Med 2005;352:1539-49
Treatment Options: Acute Decompensated HF
 Fluid and sodium restriction
 Diuretics, especially loop diuretics
 Ultrafiltration/renal replacement therapy
(in selected patients only)
 Parenteral vasodilators
(nitroglycerin, nitroprusside, nesiritide)
 Inotropes (milrinone or dobutamine)
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Clinical Presentation of
Acute Decompensated
Heart Failure
Clincal Evaluation of
Acute Decompensated
Heart Failure
Impact of Education on Compliance
Nonadherence rate when patients . . .
Recall MD advice
Don’t recall advice
Medications
8.7%
66.7%
Diet
23.6%
55.8%
Activity
76.4%
84.5%
Smoking
60.0%
90.4%
Alcohol
60.0%
81.8%
Kravitz et al. Arch Int Med 1993;153:1869-78
Evidence-Based Treatment Across the
Continuum of Systolic LVD and HF
Control Volume
Diuretics
Improve Clinical Outcomes
Aldosterone
ACEI
-Blocker Antagonist
or ARB
or ARB
±CRT
& ICD
Hydralazine/Isosorbide dinitrate
Treat Residual Symptoms
Digoxin
? The Future: Angiogenesis/ Myogenesis
via Cell Transplants
Questions?
Raise your hand
Use the Chat
62
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Study
Aim of
Improvement
Measurement
of
Improvement
Developing a
Change
Plan
Do
Testing a
Change
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,
Norman, C. L., & Provost, L. P. The Improvement Guide:
A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass, 1996.
Act
• Decide changes to make
•Arrange next cycle
Study
• Complete data analysis
•Compare to predictions
•Summarize learning
Plan
• Compose aim
•Pose questions/predictions
•Create action plan to carry
out cycle (who, what, when,
where)
•Plan for data collection
Do
• Carry out the test and
collect data
•Document what occurred
•Begin analysis of data
Principles & Guidelines for Testing
• A test of change should answer a specific
question
• A test of change requires a theory and prediction
• Test on a small scale
• Collect data over time
• Build knowledge sequentially with multiple PDSA
cycles for each change idea
• Include a wide range of conditions in the
sequence of tests
Repeated Use of the PDSA Cycle
Sequential building of
knowledge under a
wide range of
conditions
Changes That
Result in
Improvement
A P
S D
Spread
Implementation of
Change
Hunches
Theories
Ideas
Wide-Scale Tests
of Change
A P
S D
Very Small
Scale Test
Follow-up
Tests
Aim: Implement Rapid Response Team on nonICU unit
Improved
Communication
A P
S D
A P
S D
Cycle 6: Expand rounds to
one unit for one shift seven
days a week
Cycle 5: Have Nurse Practitioner
respond to calls in addition to RT and
RN
Cycle 4: Expand coverage of RRT on unit
to one unit for one shift for five days
Cycle 3: Have Respiratory Therapist attend
rapid response calls with ICU Nurse
Cycle 2: Repeat cycle 1 for three days
Cycle 1: ICU nurse responds to rapid response team calls on one unit,
one shift for one day
Questions?
Raise your hand
Use the Chat
68
IHI Heart Failure Expedition
IHI Expedition 2011
Peg M. Bradke, RN, MA
St. Luke’s Hospital, Cedar Rapids, Iowa
Heart Failure Core Measures
•
•
•
•
HF1 – Discharge Instructions
HF 2 – Evaluation of LVS Function
HF 3 – AEI or ARB for LVSD
HF 4 – Adult Smoking Cessation
Advice/Counseling
70
What are the drivers?
• Doing the Right thing with Evidenced
Based Care for our Patients
• Meeting requirements for Valued Based
Purchasing
• Marketing –Consumer Access to Hospital
Compare.gov
• Reducing Our Potential Avoidable
Readmissions
Doing the Right thing
• The right care for every patient, every time
• Is any defect acceptable
─ To us as a health care system?
─ To you as a health care professional?
─ To anyone expecting the care we would want our
loved ones to receive?
─ Which would you be okay with your loved not
getting?
Legislative Requirements for
VBP
Multiple Requirements
• Legislation requires that the FY 2013 Hospital VBP
program apply to payments for discharge occurring on or
after Oct. 2012
• Hospital VBP measures must be included on Hospital
Compare website
• Under proposal, measures could be added to Hospital
VBP if measures have been displayed on Hospital
Compare for one year
HQA Recent Report for HF
10%of all Hospital
National Performance
Submitting equal
to or better than
100%
HF 1-discharge
HF 2- LV function
HF 3- ACE/ARB
HF 4- Smoking Cessation
100%
100%
100%
100%
90%
98%
95%
97%
“The Billion Dollar U-Turn”
• 17.6% of all Medicare admissions are readmissions within 30 days
─ Accounting for $15 B in spending
• Not all re-hospitalizations are avoidable, but many are
─
─
─
─
─
13.3% of all Medicare admissions; 76% potentially avoidable
Accounts for $12B in Medicare spending
Heart Failure, Pneumonia, COPD, Acute MI lead the medical conditions
CABG, PTCA, other vascular procedures lead the surgical conditions
Disparities exist along racial and “burden of illness” lines
• There is wide intra-state and inter-state variation
─ Medicare 30-day readmission rate varies 13-24% by state
Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008
MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007
Commonwealth Fund State Scorecard on Health System Performance. June 2007
STAAR Initiative: Two Concurrent Strategies
• Provide technical assistance to front-line teams of providers working to
improve the transition out of the hospital and into the next care setting
•
•
•
Actively engage hospitals and their community partners in co-designing processes to
improve transitions
Provide coaching by content experts and facilitate collaborative learning with the goals
of creating exemplary cross continuum models in each state and identifying highleverage changes in each care setting
Develop quality improvement expertise and content experts to mentor others
• Create and support state-based, multi-stakeholder initiatives to
concurrently examine and address the systemic barriers to improving
care transitions, care coordination over time.
•
•
•
State leadership, steering committees, key allies, aligning initiatives
Technical assistance to “staff” challenges in framing the issue, designing strategy,
scanning for developments in best practice/policy
Specific focus areas: understanding the financial impact of success, aligning payment
to support high leverage interventions, developing state rehospitalization data reports
IHI’s Roadmap for Improving
Transitions and Reducing Avoidable
Rehospitalizations
Post-Acute Care
Activated
Transition from
Hospital to Home • MD Follow-up Visit
Alternative or
Supplemental Care
for High-Risk
Patients *
• Hospice/Palliative Care
• Home Health Care • Transitional Care
• Enhanced
(as needed)
Models
Assessment
• Social Services (as • Intensive Care
• Teaching and
needed)
Management (e.g.
Learning
Patient-Centered
or
• Real-time Handover
Medical Homes, HF
Communications
Clinics, Evercare)
• Skilled Nursing
• Follow-up Care
Facility Services
* Additional Costs
Arranged
for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
Improved
Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations
Creating an Ideal Transition Home
I.
B.
C.
D.
Perform Enhanced Admission Assessment of Post-Hospital
Needs
Involve the patient, family caregivers and community providers as full partners in
completing a needs assessment of the patient home going needs
Reconcile medications
C. Identify the patient’s initial risk of readmission
Create a customized discharge plan based on the assessment.
II.
A.
B.
C.
D.
Provide Effective Teaching and Facilitate Enhanced Learning
Involve all learner in patient education
Redesign patient education process
Redesign patient teaching print materials
Use Teachback regularly throughout the hospital stay
A.
III. Ensure Post-Hospital Care Follow-Up
A. Reassess the patient’s medical and social risk for readmission.
B. Prior to discharge:
•
Schedule timely follow-up care and
•
Initiate clinical and social services summarized from the assessment of post-hospital
needs.
IV.
A.
B.
C.
Provide Real-Time Handover Communication
Give patient and family members a patient-friendly post-hospital care plan which includes a
clear medication list.
Provide customized, real-time critical information to next clinical care provider(s).
For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care
provider(s) to discuss the patient’s status and plan of care.
Analysis of Results-to-Date
• Reducing readmissions is dependent on highly functional
cross continuum teams and a focus on the patient’s journey
over time
• Improving transitions in care requires co-design of
transitional care processes among “senders and receivers”
• Providing intensive care management services for targeted
high risk patients is critical
• Reliable implementation of changes in pilot units or pilot
populations require 18 to 24 months
Other Resources
• BOOST
─Toolkit –Medication Reconciliation, Treatment
plan, discharge summary communication
• Hospital to Home H2H (ACC/IHI)
─Virtual Learning Community and H2H website
• Project RED
─Reconciling the discharge plan with national
guidelines and critical pathways when
relevant – CMS discharge list
Building Reliability
• Need Reliability of the Evidenced Based
Core measures to build on the continuum
of care after discharge
• Core Measures work in tandem with
Readmission Effort
• First step identifying the Core Measure
Patients
Who identifies the HF
Core Measure Patients
• Frontline Staff vs. dedicated individual
Frontline staff needs to understand the measures
and the context of the work
• All departments must take ownership to
manage the process
• Role of Nursing Unit Leadership and
Senior Leadership
How do you identify the HF
Core Measure Patient?
BNP: ß-type Natriuretic Peptide
─ Hormone released into the blood in response to
increased heart pressure or overload
─ Circulating BNP has an inverse relationship to degree
of cardiac dysfunction (the higher the BNP, the lower
the ejection-fraction and the higher New York Heart
Association Level)
IV Lasix/Diuretic Report
Follow Up in EMR
Verify the patient has HF through chart
review and daily rounds
•
•
•
Patient has symptoms of HF
Physician notes that patient exhibits
symptoms of HF
Note if patient has previous history of HF
Is Your Approach “Real Time”
• Reviewing Concurrently with concurrent
chart abstraction
─ Literature reports the results of core measures
improved significantly. These methods prove to be
efficient and cost effective as les time was required
when compared to retrospective chart review and
more current data were available to anaylze and act
upon.
─ Advantages include just in time one to one education
of staff, optimizing evidenced based patient care
opportunities and documentation, and responding to
staff questions.
Documentation
• Documentation is a key driver
─Accurate and complete to meet measure
definitions
─Impact on coding
─Patient Safety
─Maximize Reimbursements
Results Retrospective of Chart
Review
Six patients did not have proper discharge
instructions:
• Two patients had cancer – documentation of
chemo-induced heart failure
• One patient with admitting diagnosis of allergic
reaction
• One patient ICD implant
• Remaining two were heart failure diagnoses that
were missed
Core Measure Discharge
Tools or Checklists
• Are you using a Discharge Checklist to assess
compliance during the hospitalization and then
at the time of discharge with national guidelines
for care of HF patient
Please share you tools/checklist or processes over
the time of this expeditions.
HF – 1 Discharge Instruction
Numerator: Heart Failure patients with documentation that
they or their caregivers were given written discharge
instructions or other educational material addressing all of
the following:
1. Activity level
2. Diet
3. Discharge Medications
4. Follow up appointment
5. Weight Monitoring
6. What to do if symptoms worsen
Denominator: Heart failure patients discharged home
91
HF Discharge Instructions
• Use pre-printed heart failure discharge
instructions on the following patients:
newly diagnosed or history of heart
failure patients that we are currently
treating for HF; history of ischemic
cardiomyopathy or LVEF <40; patients
currently hospitalized to have Bi-V or
ICD implant who have a history of CHF
or LVEF <40%.
PATIENT EDUCATION
• YOU ARE THE PATIENT’S LIFELINE FOR INFORMATION!
• Give in small doses
• Use their terms
• Be empathetic but emphatic!
• Ask specific questions to determine their knowledge level (how
much sodium/how much weight to report/when to weigh, etc.)
Medication Reconciliation
♥ Home Medication List
♥ Hospital Medication List
♥ Discharge Instructions
♥ Physician’s Discharge Summary
ALL MUST MATCH EXACTLY!!
Many errors around lack of medication
reconciliation at discharge
Medication Reconciliation cont.
Includes ♥ All prescribed medications
♥ All over the counter medications
♥ All PRN medications
♥ Medication name, dosage and route
Same rules apply for Long term or skilled care facilities
Medication Reconciliation cont.
• What is your check process for your providers
and staff?
Do you do a discharge time out?
Do you do a double check by two independent reviewers?
Is a Pharmacist involved?
• How do you assure all medications are
addressed?
• How do you assure required discharged
medications are addressed?
HF 2- Evaluation of LVS Function
• Numerator: Heart failure patients with
documentation in the hospital record that
LVS function was evaluated before arrival,
during hospitalization, or is planned for
after discharge.
• Denominator: Heart failure patients
97
EF
• Amount of blood pumped out of the heart
with each contraction
• Normal = 50 – 70%
• Abnormal in CMS world = <40%
HF 3 – ACEI or ARB for LVSD
• Numerator: Heart Failure patients who are
prescribed an ACEI or ARB at hospital
discharge
• Denominator: Heart failure patients with
LVSD
99
Contraindications
CMS updates the measures twice a year –
the contraindications frequently are
areas that are changed. Don’t worry
about specific contraindications. Just
encourage the Providers to document any
contraindications (i.e. CHF & Acute Beta
Blockers or Coumadin and Acute ASA)
HF 4 – Adult Smoking
Cessation Advice/Counseling
• Numerator: Heart failure patients
(cigarette smokers) who receive smoking
cessation advice or counseling during the
hospital stay
• Denominator: Heart failure patients with a
history of smoking cigarettes any time
during the year prior to hospital arrival
101
SMOKING
ALL PATIENTS regardless of diagnosis, need documentation of
smoking education (cessation education, stay quit or second hand
smoke exposure).
♥ If unable to give this to the patient, it can be given to the family.
♥ If unable to give education at the time the initial nursing
history/assessment is completed and documented, smoking
education cessation should be documented when the patient is able
to receive the information
HF BEST PRACTICE
• LVEF Assessment – preferably within the
past two years
• Smoking cessation education for current
smokers and those who have smoked in the
past 12 months
• ACE Inhibitor or ARB prescribed at
discharge for patients with LVEF of less
than 40% (if ACE or ARB is not used the
physician needs to document the reason for
both)
• Preprinted CHF Discharge Instructions
Utilized – to cover key CHF information
including weight monitoring, medications,
diet, what to do if symptoms worsen, activity
and follow-up
Make your process sustainable
over time
• Continually manage the process using the
PDSA cycle
• Keep your eye focused on enhancing the
process rather than blaming someone or
some group for failure
• Key to work: culture change,
communication and teamwork
Let’s use this expedition to share our best practices and
learn from each other.
Homework for Next Call
• What has been your experience in
concurrent data abstraction for core
measures as opposed to retrospective?
─Do you have results that demonstrate
improved efficiency and/or results for a given
method?
─Be prepared to discuss your findings for
advantages/or disadvantages for the method
you are utilizing.
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].
Next Session
December 1, 2011, 12 – 1 PM ET
Importance of LVS assessment in the
reliable recognition of HF
107