1. HEART FAILURE CORE MEASURE SET A Guide for Nursing Staff Developed by Kathy Wonderly RN, BSPA, CPHQ Performance Improvement Coordinator Developed:September 2009 Most recent revision: October 2013

2.  To recognize the 2 measures included in the Heart Failure Core measure set.  To identify the need for documentation of measure compliance or reasons for non- compliance.  To identify the measures that are nursing staff driven.

3. MEASURE SET CHANGE  For the first time, there differences in the requirements for Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) heart failure measure set requirements.  CMS only has one indicator in their measure set while TJC requires two measures.

4. INTRODUCTION There are two measures included in the CHF measure set.  1. Documentation of the evaluation of left ventricular systolic (LVS) function.  2. ACEI or ARB ordered for left ventricular systolic dysfunction (LVSD) Changes in the measure set starting January 1, 2014 will be in italics.

5. LET’S EXPLORE EACH OF THESE FURTHER

6. EVALUATION OF LVS FUNCTION (REQUIRED BY BOTH CMS AND TJC)  National guidelines advocate the evaluation of left ventricular systolic function as the single most important diagnostic test in the management of all patients with heart failure. Jessup. 2009 and HFSA, 2006

7. EVALUATION OF LVS FUNCTION  This measure is a practitioner driven indicator. There must be documentation in the medical record that the LVSF has been evaluated. This evaluation can be done prior to admission, during the hospital stay or planned for after discharge.  This evaluation can be documented in the H&P, progress note, consult note, discharge summary or if the actual diagnostic test results are on the chart.  If the evaluation is not done, the practitioner must clearly state why not. Examples include: life expectancy < 1 month, patient refuses test or technically poor test due to patient inability to cooperate.

8. HOW CAN NURSES HELP? 1. After reviewing the chart, remind the physician that the documentation is missing. 2. Place a copy of the most recent diagnostic test on the chart if it is not already there.

9. ACEI OR ARB MEDICATION FOR LVSD  This indicator is required by TJC only. Hospitals can choose to submit their data voluntarily to CMS if they wish.  Please follow your hospital plan of care for heart failure patients.

10. ACEI OR ARB MEDICATION FOR LVSD  This is also a practitioner driven measure. If the ejection fraction is documented as less than 40% or the physician describes moderate to severe systolic dysfunction (LVSD), the patient should be ordered an ACEI or ARB medication.

11. YOUR ROLE  To help meet this measure you should review the medical record. If you noticed the patient has LVSD check to see if he/she is on any of the medications included on the approved lists that follow.  If not, remind the practitioner to either order a medication or document why the patient cannot take one.  Pharmacy can help with this measure by reviewing the diagnostic test results and the medication list.

12. APPROVED ACEI MEDICATION LIST Accupril Accuretic Fosinopril Aceon Fosinopril Sodium/hydrochlorothiazode Altace Lisinopril Benazepril Lisinopril/hydrochlorothiazide Benazepril Hydrochloride Lotensin Benazepril/amlodipine Lotensin HCT Benazepril/hydrochlorothiazide Lotrel Capoten Mavik Capozide Moexipril Captopril Moexipril Hydrochloride Captopril HCT Moexipril Hydrochloride/hydrochlorothiazide Captopril/hydrochlorothiazide Moexipril/hydrochlorothiazide Enalapril Monopril Enalapril Maleate/hydrochlorothiazide Perindopril Enalapril/hydrochlorothiazide Perindopril Erbumine Enalaprilat

13. APPROVED ACEI MEDICATION LIST Prinivil Prinzide Quinapril Quinapril HCL Quinapril HCL/HCT Quinapril Hydrochloride/hydrochlorothiazide Quinapril/hydrochlorothiazide Quinaretic Ramipril Tarka Trandolapril Trandolapril/verapamil Trandolapril/verapamil hydrochloride Uniretic Univasc Vaseretic Vasotec Zestoretic Zestril Specifications Manual for National Hospital Inpatient Quality Measures Discharges 01-01-13(1Q13) through 12-31-13(4Q13) Appendix C

14. SMOKING CESSATION ADVICE/COUNSELING  The Smoking Cessation indicator has been retired from the CHF measure set starting January 1, 2012. CMS feels this should occur for all patients and are considering this as a global measure for future use.  That said, each hospital will need to determine how they will address this change.  If your facility chooses to continue to offer smoking cessation the requirements are on the next slides.

15. SMOKING CESSATION ADVICE/COUNSELING  This is a nursing driven measure.  CMS defines a smoker as anyone who has smoked cigarettes anytime during the year prior to admission.  With this definition in mind it is important to get the most accurate smoking history possible. Ask very specific questions such as: Have you smoked cigarettes within the past year? Do you still smoke? If not when did you quit (month/year if possible)? Would you like information or help to quit smoking?

16.  Our role as healthcare providers is to offer help to all smokers. The patient has the right to refuse, just be sure that the refusal is clearly documented.

17. IN CLOSING  Heart failure is one of the leading causes for admission and readmission to hospitals in the USA. By providing care as established through evidence based medicine research and great patient teaching the experts feel these patients will be able to handle their health issues better and improve their quality of life therefore reducing the number of hospital stays.

18. TEST YOUR KNOWLEDGE 1. It isn’t important to evaluate the Left Ventricular Systolic function of patients with heart failure. A. True B. False

19. TEST YOUR KNOWLEDGE 2. Left systolic ventricular dysfunction is defined as having an ejection fraction of less than 40%. A. True B. False