Effectiveness of a standardized heart failure disease management program in an academic versus community hospital setting

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Heart Failure Quality of Care at an University Hospital in Brazil and Limited Patient’s Disease Awareness: Pattern in an under Development Country Eneida R. Rabelo,1,2,3 Graziella Aliti,1,3 Daniela S. Marona,1,3 Fernanda B. Domingues,1,3 Livia Goldraich,2 Luis E. Rohde,1 Nadine Clausell1,2—1Servico de Cardiologia, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil; 2Universidade Federal do Rio Grande do Sul, Brazil; 3Servico de Enfermagem em Terapia Intensiva, Brazil

One Hospital System’s Success To Meet JCAHO Mandates for Heart Failure Education Kismet D. Rasmusson,1 Dale G. Renlund,1 Jill A. Hall,1 Janette A. Orton,1 Thomas K. French,1 Holly L. Rimmasch,1 Linda C. Hofmann,1 Dale E. Cable,1 Donald L. Lappe,1 Colleen C. Roberts1—1Cardiology, LDS Hospital, Salt Lake City, UT

Background: Several congestive heart failure (CHF) studies show that patient’s limited knowledge about the disease and compliance associated with lack of adherence to quality care parameters at the hospital level, imply in high rates of hospital re-admissions in developed countries. Objectives: To assess awareness about the disease and self-care in patients with CHF and in-hospital quality of care in a Brazilian University Hospital. Methods: Patients with CHF were consecutively interviewed at the ward level. Structured questionnaires were applied by trained nurses during the first 72 hours of hospital admission. Results: 155 patients were interviewed; 65 ⫾ 14 years (53% male). From those, 59 (38%) had been admitted at least once in the last year with CHF and 40 (25%) twice. Regarding fluids and salt restriction intake, 88 (56%) and 30 (19%) of the patients respectively, had never been informed about these issues by the care team. Most of the patients 103 (66%) were also unaware about the importance of regular weight control. Regarding awareness of previous use of medication, 66 (42%) of the patients could not inform the drugs they should be using, 32 patients (20%) discontinued at least one prescribed drug in the week previous to the admission. In the medical orders at the hospital, all had salt restriction, although in 112 (71%) there was no fluid control. Regarding weight control, in 93 patients (59%) daily weight was ordered, however in a approximately 54% of the cases only, regular daily basis fluid balance was in fact carried out. Conclusion: In an under development country, at a tertiary university hospital, awareness about the disease and self-care, and quality of care are still limited, featuring a similar profile to previously reported studies from wealthier countries. Thus, strategies to improve quality of care aiming at reduction in CHF morbidity should be equally pursued worldwide.

Background: In 2002, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) outlined a measure mandating that patients hospitalized with heart failure (HF) receive instruction on self-management (SM) before discharge. Intermountain Health Care (IHC), a twenty-hospital, non-for-profit, integrated health care system, under the direction of their Cardiovascular Clinical Program (CVCP), adopted SM instruction as a system-wide goal. This goal would be met if SM instruction was provided to ⬎50% of patients within the first year of implementation. IHC’s CVCP HF team presumed that successful implementation of this core measure would require designing a HF education tool, educating providers and staff, establishing reasonable goals during implementation, and developing a data tracking system on the HF tool’s use. Methods: IHC’s CVCP HF team developed an inexpensive education booklet for patients based on the acronym MAWDS쑓 (Table 1). This tool included a self-care diary with simple instructions that focused on monitoring daily weight and blood pressure, and instructed when to access care for significant changes. The first phase of implementation was initiated at the larger hospitals within IHC during 2001-2002. System-wide education for nurses and providers on the HF education tool occurred. Next, bedside nurses delivered the tool to inpatients with a HF diagnosis. Over 6,000 HF education booklets had been distributed within its first year of production. IHC’s CVCP HF team developed a database tracking system to monitor achievement of the SM instruction goal. The data has been continually updated, then made available on IHC’s intranet web page for all employees and management to assess and review efficacy of teaching throughout the system. Table 1 Medications Activity Weights Diet Symptoms

Take as directed, keep a current list, understand their names and importance Stay as active as you can, every day, understanding your limitations Weigh yourself daily, learn what to do when you lose/gain weight Limit sodium to 2gm per day, limit fluids to 2 quarts/liters per day Recognize when your symptoms are getting worse; call your provider early

Results: In 2002, 2212 patients in 10 IHC hospitals were measured for documentation of HF teaching in 6 categories (MAWDS plus when to call a provider). Data on SM instruction was abstracted from 3 sources: IHC discharge instruction form, electronic nursing education charting, and provider discharge summaries. The average of these categories exceeded 58%, meeting IHC’s first phase goal. Conclusion: IHC has displayed how a health care system can become JCAHO compliant with inpatient HF teaching. Success factors include: designing a simple and effective HF self-management tool, educating providers and staff, setting reasonable goals during implementation, and developing a tracking system to monitor documented HF education. IHC believes this system will make it possible to achieve 100% compliance with HF SM teaching within 3 years.

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Telemedicine Improves Titration of Medications and Patient Symptoms in Eldery Male Veterans with Chronic Heart Failure Richard S. Schofield,2,1 Sheri E. Kline,1 Carsten M. Schmalfuss,2,1 Hollie Carver,1 Daniel F. Pauly,2,1 James A. Hill,2,1 Juan M. Aranda Jr.2,1—1Cardiology Section, North Florida/ South Georgia Veterans Health System, Gainesville, FL; 2Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL

Effectiveness of a Standardized Heart Failure Disease Management Program in an Academic Versus Community Hospital Setting Melanie Shatzer,1 Lauren Saul,1 Peg Richards,1 Bonnie Anton,1 Andrea Schmid,1 Mark Schmidhofer,2 Helen Chang,2 Srinivas Murali3—1Nursing, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Institute for Performance Improvement, University of Pittsburgh Medical Center, Pittsburgh, PA; 3Cardiac Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA

Background: Veterans with chronic heart failure (HF) are generally elderly, have a high prevalence of coronary artery disease, and have frequent co-morbidities that increase risk for cardiovascular events and worsened HF. We have implemented a home-based program of HF management using an advanced practice nurse and in-home telemedicine technology to better coordinate the care of high-risk elderly veterans with HF. Methods: Patients with systolic HF and difficult-to-manage symptoms were screened for enrollment in the project. Accepted patients underwent intensive education about dietary and fluid management from a heart failure nurse specialist, and patients were assigned to in-home monitoring devices (Health Buddy, Health Hero Network Inc, or LifeLink, LifeLink Monitoring) for monitoring of patient symptoms and/or vital signs. Data was transmitted electronically to the nurse specialist and was used to expedite titration of oral HF medication and to imrove access to medical care. Results: 92 patients were enrolled and followed for up to 6 months. Mean patient age was 67, mean ejection fraction 23%, and mean NYHA classification was 2.7. Nearly all patients (98%) were males and most had recent hospitalizations for worsening HF. Mean serum creatinine was 1.6, 40% were diabetics, and 57% had HTN. At enrollment, mean BP was 129/73 mmHg, mean weight was 196 lbs, and mean shortness of breath rating (0-10 scale) was 4.0. At 6 months of followup, these parameters had improved to 120/69 mmHg (P ⬍ 0.02), 192 lbs (P ⬍ 0.01), and 2.7 (P ⬍ 0.01). The total daily dose of fosinopril increased from 23 to 34 mg/day (P ⬍ 0.01), and total daily dose of metoprolol also improved from 82 to 94 mg/day (P ⫽ 0.02). Total number of inpatient hospital days improved from 625 for the previous year to 157 for the 6 month duration of the telemedicine program. Nearly all patients (96%) were able to successfully use the in-home technology devices, and patient satisfaction with the program was high. Conclusions: A nurse directed HF management program using in-home telemedicine technology improved patient symptoms, vitals signs and titration of life-sustaining oral medications in a high-risk group of elderly male veterans. Despite a high incidence of co-morbid disease, these patients had an improvement in hospitalization rates while on the telemedicine program.

Background: Heart failure (HF) disease management programs in single institutions have been shown to achieve desirable outcomes in hospitalized patients. It is unclear however, if such intervention targeted efforts are equally effective in academic institutions with HF specialists and community hospitals where HF patients are cared for by general cardiologists and internists. Methods: The University of Pittsburgh Medical Center, representing 12 Western Pennsylvania hospitals (2 academic; 10 community) implemented a standardized HF disease management program across the various facilities. The program was designed by an “expert panel” chaired by a HF specialist and a general cardiologist and implemented across the 12 institutions. A multidisciplinary team was formed in each representative hospital comprising of a cardiologist, internist, clinical nurse specialist, dietitian, cardiac rehabilitation specialist, pharmacist and social worker. Standard orders were developed to provide national guideline based recommendations for quality HF patient care delivery, regardless of the institutional setting. Orders addressed medication prescription, laboratory and cardiac function testing, disease management education, and discharge planning. In addition, standardized patient educational materials, an instructional delivery model, and patient knowledge questionnaire were selected to serve as the foundation of HF patient teaching throughout the system. The “expert panel” provided heart failure seminars, clinical learning opportunities, and mentoring for local multidisciplinary teams prior to program implementation. Outcomes measured at baseline and after 6 months included length of hospital stay (LOS, days); 31 day all cause and HF readmission rates; and all cause mortality rate. Results: Across the entire program (n ⫽ 3285), LOS decreased from 5.19 to 4.99 days; all cause 31 day readmission rate decreased from 22.8% to 21.1%; HF 31 day readmission rate declined from 8.8% to 8.2%; and all cause mortality rate decreased from 3.6% to 2.5% at 6 months compared to baseline. Changes in outcomes from baseline in the academic ( n ⫽ 916) and community hospitals ( n ⫽ 2369) are tabulated and compared (Table) Conclusions: Our data suggest that though HF disease management programs improve outcomes in patients, this improvement is particularly evident in community hospitals where patients are managed by internists and cardiologists rather than HF specialists. This highlights the need for implementing a HF disease management program to optimize delivery of cost-effective care in the community hospital setting where the majority of HF patients receive care. Improvement in Outcomes

Data LOS (Days) Mortality % 31 Day Readmission % 31 Day HF Readmission %

Academic Hospital n ⫽ 916

Community Hospital n ⫽ 2369

⫺0.26 ⫺0.4 ⫹1.7 ⫹0.2

⫺0.15 ⫺1.3 ⫺3.0 ⫺1.0

HF ⫽ Heart Failure; LOS ⫽ length of hospital stay