CHF path reduces LOS by improving follow-up care

Strategies include providing home health care

An Ohio hospital has developed a comprehensive clinical path for congestive heart failure (CHF) that has increased discharge education by as much as 75%, reduced length of stay (LOS) by more than a day, and decreased Medicare loss per case by more than $500. The path, developed at St. Rita’s Medical Center in Lima, OH, was not among the first to be developed there by the multidisciplinary clinical pathway team, says Cindy Mefferd, RN, critical pathway coordinator.

"Everybody was kind of afraid of congestive heart failure," she says. "They said the patients have so many comorbid conditions, many of them aren’t compliant with their medications and diet, so we kept steering away from it. But it was a high-volume DRG for our hospital, it was a very costly DRG, and our costs were continuing to grow. So we decided to tackle the problem."

The first concern detected during a data search was that about one in five, or 21%, of CHF patients were being readmitted within a year of discharge because patients had poor follow-up or experienced compliance problems with their medications or diet. In addition, 6% of patients who were indicated to receive angiotensin converting enzyme (ACE) inhibitor therapy weren’t being discharged on those drugs. Documentation on patient teaching about CHF was poor, with only 20% of patients receiving instructions on the signs and symptoms of CHF and 40% of patients receiving information about weight gain. (See story on counseling about CHF, p. 13.)

"There wasn’t documentation in the charts to support that we were doing a very good job of patient education," says Mefferd.

To help improve discharge education, she says the cardiovascular clinical nurse educator began following the CHF patients to complete the education and to document patient and family understanding of educational materials. In addition to preprinted materials, a congestive heart failure patient and family pathway was designed. The pathway is printed in large type to accommodate the aging population that commonly has CHF and includes information on the disease process, diet, weight gain, and medication.

Team is multidisciplinary

The hospital’s clinical path team then evaluated those problems. The team consisted of nursing educators, nutritionists, administrators, hospice and home health care nurses, the outpatient intravenous intervention team, and discharge planners. Later, cardiologists and internists provided input. Mefferd says the team looked at resources that were available to patients, such as obtaining medication, receiving home health care, and access to outpatient clinics.

"A big part of the problem was that these patients weren’t getting the follow-up that they needed," says Mefferd.

First, the team developed a clinical path that addressed those problems. (See sample path, pp. 7-8.) Because of the problems the team had detected, in late 1995 the hospital opened a CHF clinic for patients to receive follow-up care. An outpatient nurse manager runs the clinic and keeps tabs on patients’ weights, medications, diet, and other routine aspects of care. In the first six months after it opened, 29 admissions were avoided by clinic interventions, says Mefferd.

"There are times that the nurse manager can tell by the way patients are talking over the telephone that they need to come in and get some IV Lasix or other medication, and that intervention keeps patients out of the [emergency department]," she notes.

Home health care use also increased for CHF patients. When the path was developed and the clinical path team members presented it to medical staff, the physicians were supportive. The only addition they made was to try to make dobutamine available to patients at home through home health care. Dobutamine is a drug given intravenously that improves cardiac output in CHF patients.

"The studies have shown that dobutamine has increased the functional outcome for patients and that it increases their quality of life," says Mefferd. "So what we wanted to do was to offer this to some of these patients who don’t have much ejection fraction left with their heart, but they didn’t want to be in the hospital."

LOS down to 5.3 days

Since the CHF pathway was implemented, the average LOS for CHF patients has dropped from 6.59 days to 5.3 days, and the average Medicare loss per case has fallen from $1,262 to $712, says Mefferd. In addition, 100% of patients who require ACE inhibitors are receiving them on discharge, and 95% to 100% of patients are receiving documented instruction about CHF. The annual readmission rate has dropped from 21% to 11%.

What recommendations does Mefferd have for other clinicians who would like to improve CHF care at their facilities?

"First, check your data," she recommends. "If you have a readmission problem, start with those readmissions. Find out why the patient is coming back in. Do some drilling down and find out what’s going on. Then develop a plan of implementation."