Hudson Valley Hospital Center Heart Failure Project

1
Hudson Valley Hospital Center Heart Failure
Project

• A collaborative approach to improving heart
  failure care

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Hospital to Home (H2H)

• A national quality improvement initiative
• Sponsored by the American College of Cardiology
  (ACC) and the Institute of Healthcare Improvement
  (IHI)
• Purpose to reduce cardiovascular-related
  hospital readmissions improve transitional care
  from hospital to home
• Strategic partnerships are encouraged as a
  vehicle for improving care and outcomes

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HVHC Heart Failure Task Force

• Purpose To improve the care delivered to heart
  failure patients across the continuum

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Members of the HVHC HF Task Force

• Myrna Cuevas RN, Esq
• William Higgins MD
• Maggie Adler RN-C
• Jennifer Fell RD
• Ann Marie Beall DPh
• Visiting Nurse Association of Hudson Valley

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ACE Star Model
6
ACE Star Model EBP Process

• PICO Question
• What interventions for heart failure patients
  help decrease their rehospitalization and
  mortality rates?

7
Knowledge Discovery Evidence Summary
Literature Search Research Studies, Guidelines,
Stats
AHA, ACC, IHI, AHRQ, CMS
8
Facts on Heart Failure

• 50 readmission rate within 6 months
• 25 to 35 incidence rate of death at 12 months

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Facts on Heart failure

• The mortality rate for women with breast cancer
  is 1 in every 29 deaths, the mortality rate for
  women with cardiovascular disease is 1 in every
  2.4 deaths

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Trends in Hospitalization for Heart Failure by
Age Group 1979-2004(CDC, 2006)
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CMS Quality Measures Heart Failure (HF)

• 100 compliance with the following
  evidenced-based guidelines
• Discharge instructions
• diet
• MD f/u
• weight monitoring
• worsening s/s
• Medications with reconciliation
• Left ventricle systolic function evaluation
• ACEI/ARB for LVSD
• Smoking cessation counseling

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Heart Failure at HVHC

• Heart failure is the second highest DRG
• Average costs per patient per day 2,000
• Average LOS is 6 days
• 30 day readmission rate is 24.2, national rate
  is 24.5 (HHS, 2008)
• Mortality rate is 9.7, nationally it is 11.1
  (HHS, 2008)

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Translation into practice
Clinical Expertise to translate your findings
into practice
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How can we improve practice?

• Standardize treatment plans for heart failure
• Standardize patient education for heart failure
• Case Management referral for heart failure
  patients to Telehealth program at VNA
• Collaborate with the Visiting Nurse Association
  of Hudson Valley (VNA)
• Collaborate with community based physicians

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Integration
Integrating your findings into practice
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Standardize Treatment

• Physician Order Set
• LVSF assessment
• ACEI or ARBs
• Beta Blockers
• Anticoagulants for atrial fibrillation
• Diuretics
• Lab assessment
• Influenza Pneumoccocal vaccination
• Diet and fluid restriction
• Daily weights
• Exercise/activity tolerance
• Smoking cessation counseling
• Patient education
• Case management Nutrition referral
• (ACCF/AHA, 2009 AHRQ, 2009)

• Evidenced-based
• Recommendations
• promote
• a reduction in
• rehospitalization and
• mortality for patients
• with heart failure
• (IHI, AHRQ, ACC)

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Considerations in Treatment of Special
Populations

• Elderly patient's have an altered ability to
  metabolize or tolerate medication therapy
• Isosorbide dinitrate and hydralazine is
  recommended for African-Americans in addition to
  standard heart failure treatment
• 50 of Asian patients develop a ACEI induced
  cough
• Majority of patients with heart failure are
  women

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Standardize Patient Education

• Provide education literature from the AHA
• Document education completed in EHR
• Revise Discharge Instruction sheet to include HF
  care instructions
• HF education reinforced by VNA nurses
• Future
• In CPOE create notification link from
  physician order for HF education to nurses task
  list

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Heart Failure (HF) Screening Flow Chart
Present to ED
No Health Care Services Provided
N
HF symptoms w/i 1 year and/or present HF
symptoms and/or R/A 31 days with previous HF
diagnosis
Case Manager assesses patient for homecare or
skilled nursing need.
Admit as Inpatient
N
Y
Case management evaluates patient/
Family/caregivers goals Collaborates
discharge plan with patient and health care team
Y
Homecare or skilled nursing referral made
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Telehealth Program

• Screening for eligibility will be performed by
  the VNA while the patient is hospitalized
• Remote home monitoring will include vital signs,
  oxygen level assessment, and weight
• Patient education provided by VNA nurses will
  reinforce education provided by HVHC nurses
• Telehealth visits are in addition to regular home
  nursing visits

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Accomplishments Outcomes of the Heart Failure
Project

• Interdisciplinary approach
• Physician Order Set
• Patient Education
• Comprehensive discharge instructions
• Telehealth program
• Collaboration across the continuum of care

• Increase in patient self-management skills
• Increase in patient satisfaction
• Decrease variation in care delivered
• Decrease LOS from 6 to 4 days
• Decrease 30 day readmissions to 16
• Decrease mortality by 10

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Evaluation
HF Readmission Mortality rates
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Heart Failure Readmissions

• Heart Failure Task Force Update
• Total 27 HVHC patients referred to Visiting Nurse
  Association Hudson Valley in 10 months (9/09
  06/10)
• Readmission rate 11
• HVHC Goal 16

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Future Opportunities for Collaboration
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Improving Care at HVHC

• At HVHC we are dedicated to caring for our
  patients across the continuum.

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References

• Academic Center for Evidenced-based Practice.
  (2004). ACE Learn about EBP ACE Star Model of
  EPB Knowledge Transformation. The University of
  Texas Health Science Center at San Antonio.
  Retrieved July 8, 2009, from http//www.acestar.ut
  hscsa.edu
• Centers for Disease Control and Prevention.
  (2006). Heart Failure Fact Sheet. Retrieved
  August 16, 2009, from the CDC on the World Wide
  Web http//www.cdc.gov/DHDSP/library/pdfs/fs_hear
  t_failure.pdf
• Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman,
  A. M., Francis, G. S., Ganiats, T. G. et al.
  (2005). ACC/AHA 2005 guideline update for the
  diagnosis and management of chronic heart failure
  in the adult A report of the American College of
  Cardiology/American heart Association Task Force
  on Practice Guidelines. Retrieved August 10,
  2009, from Circulation on the Wide World Web
  http//circ.ahajournals.org/cgi/reprint/112/12/182
  5?maxtoshowHITS10hits10RESULTFORMATfulltex
  tACC2FAHA2005GuidelineUpdatesearchid1FIRST
  INDEX0resourcetypeHWCIT
• Institute for Healthcare Improvement (2008). 5
  Million Lives. Getting started kit Improved care
  for the patients with congestive heart failure.
  Retrieved July 19, 2009, from IHI on the World
  Wide Web http//www.ihi.org

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References

• Jessup, M., Abraham, W. T., Casey, D. E.,
  Feldman, A. M., Francis, G. S., Ganiats, T. G. et
  al. (2009). 2009 Focused Update ACCF/AHA
  guidelines for the diagnosis and management of
  heart failure in adults a report of the American
  College of Cardiology foundation/American Heart
  Association Task Force on Practice Guidelines.
  Retrieved August 10, 2009, from Circulation on
  the Wide World Web http//circ.ahajournals.org/cg
  i/reprint/119/14/1977?maxtoshowHITS10hits10R
  ESULTFORMATfulltext2009FocusedUpdatesearchid
  1FIRSTINDEX0resourcetypeHWCIT
• National Guideline Clearinghouse. (2007). Heart
  Failure in Adults. Retrieved July 20, 2009, from
  NGC on the World Wide Web http//www.guideline.go
  v/summary/summary.aspx?doc_id11531nbr005972str
  ingheartANDFailure
• Schroetter, S. A., Peck, S. D. (2008, April).
  Womens risk of heart disease Promoting
  awareness and prevention-a primary care approach.
  MEDSURG Nursing, 17(2), 107-113.
• U. S. Department of Health and Human Services.
  (2009). Hospital Compare-A quality tool provided
  by Medicare. Retrieved July 19, 2009, from HHS on
  the World Wide Web http//www.hospitalcompare.hhs
  .gov/Hospital/Search/Welcome.asp?versiondefaultb
  rowserIE7C87CWinXPlanguageEnglishdefaultstat
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