1. HEART FAILURE Team Membership Clinical Departments: Cardiology, Cardiovascular Surgery, Nursing, QRM, CCE, Medical Records Project Coordinators: Carmen Barc, RN, BSN Carol Keeler, RN, MS

2. Opportunity for Improvement Heart failure accounts for more hospital admissions than any other Medicare diagnosis. Research shows that the following care processes decrease morbidity and mortality rates for heart failure patients: 1.Left ventricular assessment 2.ACEI of ARB prescribed for EF <40% (moderate/severe dysfunction) 3.Smoking cessation counseling 4.Written discharge instructions regarding activity, diet, medications, symptoms worsening, and weight management Retrospective chart review indicated an opportunity to improve adherence to this standard of care for our heart failure population

3. Initial Interventions (2003) Development of a multidisciplinary team Staff education - nursing inservices, physician grand rounds Standardized CHF admission orders Development of a Heart Failure Discharge Progress Note (DPN) Addendum UR nurses notify the Heart Failure case manager of heart failure patient admissions via the MIDAS+ SmarTrack Worklist pathway

4. Follow-up Interventions (2004) Heart Failure packets distributed to the Emergency Department and EP Lab Development of a Heart Failure education packet for agency/registry staff Revised the Heart Failure DPN Addendum to include ARBs Identified smoking cessation liaisons on each nursing unit Ongoing staff education

5. Definition: HF patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge / All HF Patients. Datasource: Original data extracted from LUMC charts by RNs. Percent Heart Failure - Patients Receiving Left Ventricular Function Assessment Month p chart Mar-03 (pilot) (n=13) Apr-03 (pilot) (n=16) Sep-03 (n=30) Oct-03 (n=48) Nov-03 (n=42)Dec-03 (n=51) Jan-04 (n=55) Feb-04 (n=56) Mar-04 (n=37) Apr-04 (n=58) May-04 (n=60) Jun-04 (n=46) Jul-04 (n=59) Aug-04 (n=56)Sep-04 (n=36) Oct-04 (n=57) Nov-04 (n=49) Dec-04 (n=52) 85 90 95 100 105 110 UCL = 104.41 Mean = 97.56 LCL = 90.72 Progress Note Addendum Initiated Nursing In-service Increase Use of HF Order Set Percent Heart Failure - Patients Receiving Left Ventricular Function Assessment Month p chart Mar-03 (pilot) (n=13) Apr-03 (pilot) (n=16) Sep-03 (n=30) Oct-03 (n=48) Nov-03 (n=42)Dec-03 (n=51) Jan-04 (n=55) Feb-04 (n=56) Mar-04 (n=37) Apr-04 (n=58) May-04 (n=60) Jun-04 (n=46) Jul-04 (n=59) Aug-04 (n=56)Sep-04 (n=36) Oct-04 (n=57) Nov-04 (n=49) Dec-04 (n=52) 85 90 95 100 105 110 UCL = 104.41 Mean = 97.56 LCL = 90.72 Progress Note Addendum Initiated Nursing In-service Increase Use of HF Order Set Left ventricular function assessment remains at an excellent performance level

6. Definition: Heart Failure patients who are prescribed an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at hospital discharge / HF patients with LVSD and without ACEI contraindications. LVSD is defined as chart documentation of a left ventricular ejection fraction less than 40% or a narrative description of left ventricular function consistent with moderate or severe systolic dysfunction. Datasource: Original data extracted from LUMC charts by RNs. Percent Heart Failure - ACE Inhibitor for Left Ventricular Systolic Dysfunction Month p chart Mar-03 (pilot) (n=7) Apr-03 (pilot) (n=10) Sep-03 (n=13) Oct-03 (n=28) Nov-03 (n=18)Dec-03 (n=29) Jan-04 (n=25) Feb-04 (n=24)Mar-04 (n=15) Apr-04 (n=25) May-04 (n=25) Jun-04 (n=20) Jul-04 (n=26) Aug-04 (n=22)Sep-04 (n=16) Oct-04 (n=26) Nov-04 (n=24)Dec-04 (n=23) 50 60 70 80 90 100 110 120 UCL = 108.28 Mean = 84.57 LCL = 60.87 Progress Note Addendum Initiated Nursing In-service Increase Use of HF Order Set Percent Heart Failure - ACE Inhibitor for Left Ventricular Systolic Dysfunction Month p chart Mar-03 (pilot) (n=7) Apr-03 (pilot) (n=10) Sep-03 (n=13) Oct-03 (n=28) Nov-03 (n=18)Dec-03 (n=29) Jan-04 (n=25) Feb-04 (n=24)Mar-04 (n=15) Apr-04 (n=25) May-04 (n=25) Jun-04 (n=20) Jul-04 (n=26) Aug-04 (n=22)Sep-04 (n=16) Oct-04 (n=26) Nov-04 (n=24)Dec-04 (n=23) 50 60 70 80 90 100 110 120 UCL = 108.28 Mean = 84.57 LCL = 60.87 Progress Note Addendum Initiated Nursing In-service Increase Use of HF Order Set ACEI for LVSD performance improved with physician documentation of contraindications

7. Definition: HF patients with documentation that they or a caregiver received discharge instructions (weight monitoring, what to do if symptoms worsen, diet, medications, activity level, follow-up appointment) prior to hospital discharge / HF patients discharged to home. Data Source: Original data extracted from LUMC charts by RNs. Written documentation of discharge instructions improved with distribution of Heart Failure packets.

8. Definition: Smokers receiving smoking cessation counseling / HF Patients who have smoked cigarettes at any time in the 12 months prior to hospital arrival. Data Source: Original data extracted from LUMC charts by RNs. Implementation of unit-based smoking cessation liaisons improved smoking cessation counseling

9. Next Steps Evaluate process/outcome improvement resulting from interventions Ongoing physician and nursing education Concurrent staff feedback Chart audits for smoking history documentation and counseling for active smokers Continue public reporting of performance measures