Consortium benchmarks CHF, develops care path

Focus is on patient education and physician CE

When a New York state study showed that congestive heart failure (CHF) is one of the most common reasons for hospital readmissions among the elderly in the state, 16 Buffalo-area hospitals decided to try to do something about it.

This unusual collaboration of otherwise competitive hospitals was brought about by a common need to address a major health problem in their community and the economies such a collaboration would ensure.

The benchmarking project was motivated by a February 1996 study by Island Peer Review Organization (IPRO), in Lake Success, NY, titled Congestive Heart Failure Patient Education in New York Hospitals. The IPRO study analyzed 686 inpatient charts to see whether hospitals had documented providing patient education during each admission for CHF. The focus was on the five categories of CHF patient education recommended by the Agency for Health Care Policy and Research (AHCPR): general counseling, activity recommendations, dietary recommendations, medical prescription and adequate discharge planning.

The study revealed that among all hospitals, general counseling was provided only 6% to 26% of the time, indicating that the counseling area offered the greatest opportunity for improvement. General counseling includes a discussion of CHF, its symptoms and causes, and the use of daily weight monitoring.

Other findings indicated that while nonspecific activity recommendations were given 87% of the time, specific instructions were given only 20% of the time. Medication education also has room for improvement. Discussion of the purpose of the medication occurred only 18% of the time, a review of possible side effects happened 10% of the time, and talk of the consequences of missing a dose occurred just 3% of the time.

To address the problems revealed by the study, IPRO and the Western New York Healthcare Association queried local hospitals to find those interested in developing a quality improvement plan related to the AHCPR patient education guidelines. Sixteen hospitals in the Buffalo region agreed to work together in a Multi-Organizational Collaborative Inpatient Program to develop a uniform plan for treating and educating inpatients with CHF.

"It is very unusual," says Terri Straub, RN, MBA, senior director of quality improvement programs at IPRO, of the collaboration. But the group is held together by the benefits such a project is expected to generate: working with managed care companies to keep patients out of the hospital; reducing lengths of stay for CHF patients; and enjoying these benefits without duplicating the work and resources at each of the 16 hospitals, she explains.

The group’s initial step was to break into three task teams. The first team was charged with creating a patient education booklet, the second with developing a CHF critical care pathway (see sample page, p. 6), and the third with putting together a continuing medical education (CME) program. Team members, which include physicians, nurses, and quality assurance and utilization management personnel, worked together through a series of face-to-face meetings and telephone conference calls.

The patient education booklet team began their task by sharing any CHF patient education materials already in use among the individual facilities. Together they determined that the booklet should cover the following areas:

• basic terms that define heart failure, its causes, signs, and symptoms;

• diet, including specific sodium and fluid restrictions;

• medications, with information on their function, side effects, and handling a missed dose;

• exercise, with specific activity recommendations based on degree of heart failure;

• family responsibility in taking care of patient; general guidelines in managing the illness; and follow-up medical appointments and medications the patient’s doctor has ordered.

Patient status will determine when education begins, but generally, the booklet will be provided two days after the critical event, says Cynthia Elbow, nursing supervisor at Wyoming County Community Hospital in Warsaw, NY, and education booklet team leader. Once patients receive the booklet, they will get a daily dose of education during their hospital stay, Elbow adds.

To successfully tackle its task, the critical care pathway team broke into two subgroups — one to develop the pathway, and one to identify and address challenges of implementation.

The development team planned on creating a common clinical pathway that each facility could use, says team leader Karen B. Meyer, RN, surgical unit charge nurse at Lake Shore Health Care Center, in Irving, NY. The variety of facility sizes within the group posed some challenges, however. For example, the pathway indicates that an echocardiogram should be done within 24 hours of admission. This posed no problem for larger hospitals with echocardiogram machines in the facility, but many smaller hospitals only have access to this test once or twice a week.

The answer lay in building in some leeway so that each hospital could tailor the path to fit its needs. Team members questioned their cardiologists — is an echocardiogram really necessary if one had been done in the past year? — and the doctors agreed to adopt a one-year margin for echocardiograms unless one is clinically indicated at the time of admission.

The resulting clinical pathway indicates a five-day admission and is broken down into nine sections: Diagnostic/Consults, Patient Assessment, Medications, Activity, Nutrition, Psycho/Social/Spiritual, Health Teaching, Discharge Planning, and Daily Outcomes.

To ensure smooth adoption of the pathway, the implementation team identified several key areas hospitals should address. The most critical areas are insuring buy-in commitment within the organization and communicating the pathway to the entire medical staff, says team leader Christine Juliano, system director of quality improvement at Mercy Health System of Western New York.

The third task team developed a CME program aimed at primary care and emergency room physicians. "The program will stress the importance of patient and family education and keeping patients out of the hospital, from a quality-of-care and cost-efficiency standpoint," says team leader Brad Truax, MD, associate director for medical management and medical director/MCO at Millard Fillmore Heath System in Buffalo.

Implementation of the patient education booklet, clinical pathway, and CME program is slated to begin in February. At a later date, IPRO will evaluate the impact of the intervention by comparing this group to other New York hospitals that were not involved in the project. Compliance with AHCPR guidelines and readmission rates will be measured.

The team of 16 hospitals plans to continue meeting periodically to look at the successes and challenges of the program, and to continually update the clinical pathway and patient education materials. "By adopting best practices in patient education and following a standard of care, we expect to decrease readmissions and increase the quality of life for these patients after discharge," Meyer asserts.