Team effort helps hospital exceed standards for CHF

Careful examination of indicators is the key

A team effort to improve care for congestive heart failure and heart attack patients has paid off for Saint Luke’s Hospital and Mid American Heart Institute of Kansas City, MO.

The health care organization has been recognized by VHA Inc., a cooperative of not-for-profit health care organizations, for surpassing national standards for clinical excellence in treating the two cardiac conditions.

The hospital takes a different tactic with patients hospitalized with congestive heart failure and those with heart attack, but the strategy for managing both means keeping a close eye on the performance indicators recommended by the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), says Geri Seavey, quality resource analyst at Saint Luke’s Hospital and Mid America Heart Institute.

The hospital’s quality department examines all of the records of patients whose care doesn’t meet expected performance measures to find out what has happened.

A heart failure team that includes physicians, heart failure case managers, research nurses, and Seavey meets once a month to examine heart failure data and ways to improve patient care.

Before the meeting, Seavey reviews the previous month’s data, including the indicators and the charts of each patient whose care did not meet the indicator recommendations. She reports her findings to the team.

"We look at our level of performance in terms of meeting indicators, and if we see a negative trend, we discuss why it might be happening and if any additional analysis needs to be done," she says.

Correct the shortcomings

The team determines what steps need to be taken to correct the shortcomings.

For instance, a significant number of the heart failure patients who were not discharged with ACE inhibitors were renal patients. The committee educated the renal and internal medicine physicians to make them aware of the performance measures.

In other instances, the physicians were not always documenting why the patients should not have the ACE inhibitors, particularly those who received an angiotensin receptor blocker (ARB).

"A lot of the problems with our past ACE inhibitor indicators performance were with lack of documentation. We could read the chart and understand that because of what is going on clinically with the patient, an ACE inhibitor shouldn’t be prescribed, but the doctor should state that ACE inhibitors were not prescribed and include the reason," Seavey says.

If a patient did not receive a recommended treatment as defined by the indicators, the team sends a letter to the patient’s physician, pointing out the missed treatment.

"We’ve gotten positive feedback from the doctors when they receive the letters reminding them of the quality initiatives. We have found that they didn’t really understand that a variation from the recommended therapy required documentation. We want to raise physician awareness of the indicators for both heart failure and AMI [acute myocardial infarction]," Seavey says.

The heart failure physicians on the committee send e-mails to their colleagues periodically to make them aware of the indicators.

The committee compiles physician performance reports that are shared with the physicians when they go through the re-credentialing process.

When the team created a one-page discharge instruction sheet, covering all six required components of discharge teaching, performance under the discharge instructions indicators increased by more than 30%.

"We’re not only talking to the patients, we’re reinforcing that education in writing. We’re giving it to them to put on the refrigerator as a reminder of what they need to do to improve their health," Seavey says.

Patients who have been hospitalized for congestive heart failure or a heart attack can be overwhelmed by the stress of hospitalization, and they often may forget verbal discharge instructions, Seavey says.

"The discharge instructions are a lot to be taking in when your health is a concern. The written instructions are a quick reference that reinforces what we tell them after they get home," she adds.

The written instructions contain information on the components required by the indicators: Physical activity, diet, weight monitoring, what to do if symptoms worsen, follow-up visits to the physician, and discharge medication.

The discharge instructions are formatted so they can be tailored to each patient. For instance, the instructions regarding weight monitoring and what to do if symptoms worsen are used for all heart failure patients.

The other components are changed for each specific patient, depending on the physician’s orders.

The hospital is in the process of beefing up the discharge instructions to include more detail. The new instruction will be two pages, Seavey says.

The quality committee generates unit-specific reports so each nursing unit knows how well they are meeting the discharge instructions indicators. "We have found that if you cover it in one place, it doesn’t mean you shouldn’t cover it elsewhere," Seavey adds.

At Mid American Heart Institute, the care of heart failure patients is coordinated by case managers dedicated to that patient population.

They regularly examine the charts and progress notes to make sure the indicators are being followed, reminding the physicians when they are not. For instance, if a heart failure patient is not on an ACE inhibitor, the case manager puts a sticker on the chart and on the progress note to remind the physicians they need to document the reason.

The rehabilitation staff follow up on the indicators for the AMI patients.

"Their focus is to address risk modification and smoking cessation and to document it," Seavey says.

Any patient who has smoked at any time within the year prior to admission receives smoking cessation counseling. The hospital reinforces a smoking cessation discussion with videos.

"At one point, we tried having a nurse dedicated to smoking cessation. It worked very well. When she chose to take another position, we decided to incorporate the smoking cessation education with the risk modification instructions being provided by the rehabilitation staff, and this has been successful as well," Seavey says.

The hospital is updating all the order sets and pathways to include the core measures.

"With patients who have comorbidities, we can’t always use the pathway and the order sets," she says.

The hospital currently uses paper records. The nurse prints out the order sets and pathways for the physician. The committees are in the process of revising the pathways and the order sets to include the indicators. The heart failure pathway and order sets have been complete. The AMI orders are still being revised.

"We review the patient charts retrospectively, abstract data from the charts, and enter it into the software. We tried concurrent review, but that’s tough when people are scrambling for the charts. We didn’t want to interrupt patient care," adds Seavey.