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INR Self-Testing, an Effective Alternative for Heart Failure
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Abstracts / Heart & Lung 42 (2013) 301e308
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Connecting the Care Team: Supporting the Heart Failure Patient From Hospital to Community E. BILL 1, K. MCADAMS 2, M. COILEY 1 1 Cardiovascular Services, CJW Medical Center, Richmond, VA, United States 2 Cardiovascular Services, Henrico Doctors’ Hospital, Richmond, VA, United States
INR Self-Testing, an Effective Alternative for Heart Failure T.J. FAULKNER 1 1 Advanced Heart Failure Treatment Center, University of Cincinnati Medical Center, Cincinnati, OH, United States
Background: Approximately 50% of preventable heart failure (HF) readmissions result from inadequate discharge teaching, nonadherence, or failure to follow-up with a provider post-hospital discharge. CJW Medical Center and Henrico Doctors’ Hospital implemented a HF program with HF APN inpatient education and 7 day follow up appointments with an APN-run Heart Failure Clinic. Yet, the program lacked a consistent method to provide patients and caregivers ongoing support for at least 30 days post-discharge. Implementing Care Team Connect (CTC) provides the structure needed to follow patients weekly for 30 days post-discharge, providing support for discharge instructions, medications and follow-up appointments. Methods: The Care Team Connect Pilot Program strives to reduce heart failure (HF) readmission rates by connecting the hospital HF team with the patient or patient’s caregivers postdischarge through a web-based program. Caregivers include those at home and home health agency (HHA) and skilled nursing facility (SNF) personnel. CJW Medical Center (758 beds) and Henrico Doctors’ Hospital (767 beds) are community hospitals located in the HCA Virginia market with APN run heart failure clinics. In September 2012 HF APNs implemented CTC, a web-based platform that supports care coordination through protocols and date-driven tasks for managing patients postdischarge. Protocols are generated based on patient data and discharge disposition. Protocols include queries related to medications, weight, signs and symptoms, diet and MD followup. A prompt occurs within 24-72 hours of discharge and then weekly for a 30-day period. For those discharged home, APNs call patients and document per protocol template while HHA and SNF personnel document per their template. If HHA/SNF identifies an issue, a note can be sent to the attention of the APN to assist with problem solving. Results: In August 2012 HHAs and SNFs were invited to participate in this web-based program. Those consenting were trained in program use. In September 2012, the Care Team Connect program was initiated with community partners. Readmission rates (all cause all payers) are found in Table 1. Conclusion: Prior to CTC implementation, HF follow-up was disjointed and inconsistent across patient dispositions. We now have a consistent method to follow every HF discharge. The benefits are measurable by decreased readmission rates and also immeasurable by anecdotes from patients, HF APNs and subacute providers. Many near misses have been caught via phone calls such as medication misunderstandings, unmade MD appointments and missed home health visits. Challenging populations have been identified prompting development of new CTC protocols for HF dialysis patients. We still struggle with program limitations including time required for data input, unanswered phones and sub-acute providers not participating in the Care Team Connect software, but the gains made over the last several months with patient outreach and improved care is extraordinary. Table 1 HF Readmission Rate (all cause all payers)
CJW HDH
3Q2012 22.46% 15.7%
Oct 2012 20.0% 10.64%
Nov 2012 13.1% 13.16%
Background: An aging population and the continuing expansion of clinical indicators for Warfarin therapy have increased pressure on hospital anticoagulation clinics. One evidence based solution is patient self-testing (PST) of the International Normalized Ratio (INR), using capillary blood samples on point-of-care coagulation monitors at home. INR self-testing has been suggested as an effective alternative to standardized warfarin clinic based testing for heart failure patients on long term oral anticoagulation therapy. The purpose of this quality improvement initiative was to evaluate the feasibility and effectiveness of an INR self-testing program in the Heart Failure Clinic (HFC) at a large Level I urban medical center in the Midwest. Specifically, we examined whether INR self-testing would increase testing compliance, improve therapeutic range, and increase patient satisfaction compared to standard clinic based testing. Methods: A needs assessment was completed in the HFC related to the 70 heart failure patients actively utilizing warfarin therapy. A quality improvement business plan was created and approved to initiate an INR PST. Twenty one warfarin patients met eligibility using established inclusion criteria. The mean age was 68.9 in this convenience sample that was primarily married (50%), Caucasian (81%), and male (57%). Patients that met criteria and elected to participate in INR PST completed education using an established program. PST would be perform by patients either weekly, biweekly, or monthly based on the practitioner’s assessment and recommendations. Patients would report results to the vendor’s results team, who would then verify and send information to the practitioner. Retrospective retrieval of data from this single group reflected 12 months of pre- PST implementation testing compliance and therapeutic range data and 12 months of post PST implementation results. Data were reviewed and maintained using electronic medical record software and transferred to a spreadsheet. A three question, investigator created patient satisfaction telephone survey was completed with each patient after 12 months of PST. Results: Subjects in this convenience sample showed a 21% higher level of testing compliance, 10% improvement in therapeutic range, and an 80% increase in satisfaction during the post intervention period when they were using PST than they did when they were undergoing standard clinic based testing. If we remove two patients’ results that showed fallout related to comorbidity issues, testing compliance increased 33% and therapeutic range increased 18%. Conclusion: The safety benefits that resulted from improved testing compliance, staying in therapeutic range, as well as increase in patient satisfaction, supported the decision to continue the PST program. An eighteen month evaluation has shown sustainability. PST permits nursing to offer an alternative testing method to empower patients to become active in their healthcare. Unfortunately, PST is often limited due to insurance coverage. Medicaid currently does not cover this option. Future research is needed related to impact on stroke reduction in this PST population. 5 Utilizing a Electronic Medication Reconciliation Form to Improve Clinical Outcomes of Chronic Heart Failure Patients J. GANDIA 1, R. NJOROGE 1, K. JOHNSON 1, A. BRYAN 1, A. BERRY 1, A. HEATH 1 1 WellStar Kennestone Hospital, Marietta, GA, United States Background: Approximately 550,000 patients are diagnosed with Chronic Heart Failure (CHF) yearly. CHF is a complex clinical
Abstracts / Heart & Lung 42 (2013) 301e308
3
4
Connecting the Care Team: Supporting the Heart Failure Patient From Hospital to Community E. BILL 1, K. MCADAMS 2, M. COILEY 1 1 Cardiovascular Services, CJW Medical Center, Richmond, VA, United States 2 Cardiovascular Services, Henrico Doctors’ Hospital, Richmond, VA, United States
INR Self-Testing, an Effective Alternative for Heart Failure T.J. FAULKNER 1 1 Advanced Heart Failure Treatment Center, University of Cincinnati Medical Center, Cincinnati, OH, United States
Background: Approximately 50% of preventable heart failure (HF) readmissions result from inadequate discharge teaching, nonadherence, or failure to follow-up with a provider post-hospital discharge. CJW Medical Center and Henrico Doctors’ Hospital implemented a HF program with HF APN inpatient education and 7 day follow up appointments with an APN-run Heart Failure Clinic. Yet, the program lacked a consistent method to provide patients and caregivers ongoing support for at least 30 days post-discharge. Implementing Care Team Connect (CTC) provides the structure needed to follow patients weekly for 30 days post-discharge, providing support for discharge instructions, medications and follow-up appointments. Methods: The Care Team Connect Pilot Program strives to reduce heart failure (HF) readmission rates by connecting the hospital HF team with the patient or patient’s caregivers postdischarge through a web-based program. Caregivers include those at home and home health agency (HHA) and skilled nursing facility (SNF) personnel. CJW Medical Center (758 beds) and Henrico Doctors’ Hospital (767 beds) are community hospitals located in the HCA Virginia market with APN run heart failure clinics. In September 2012 HF APNs implemented CTC, a web-based platform that supports care coordination through protocols and date-driven tasks for managing patients postdischarge. Protocols are generated based on patient data and discharge disposition. Protocols include queries related to medications, weight, signs and symptoms, diet and MD followup. A prompt occurs within 24-72 hours of discharge and then weekly for a 30-day period. For those discharged home, APNs call patients and document per protocol template while HHA and SNF personnel document per their template. If HHA/SNF identifies an issue, a note can be sent to the attention of the APN to assist with problem solving. Results: In August 2012 HHAs and SNFs were invited to participate in this web-based program. Those consenting were trained in program use. In September 2012, the Care Team Connect program was initiated with community partners. Readmission rates (all cause all payers) are found in Table 1. Conclusion: Prior to CTC implementation, HF follow-up was disjointed and inconsistent across patient dispositions. We now have a consistent method to follow every HF discharge. The benefits are measurable by decreased readmission rates and also immeasurable by anecdotes from patients, HF APNs and subacute providers. Many near misses have been caught via phone calls such as medication misunderstandings, unmade MD appointments and missed home health visits. Challenging populations have been identified prompting development of new CTC protocols for HF dialysis patients. We still struggle with program limitations including time required for data input, unanswered phones and sub-acute providers not participating in the Care Team Connect software, but the gains made over the last several months with patient outreach and improved care is extraordinary. Table 1 HF Readmission Rate (all cause all payers)
CJW HDH
3Q2012 22.46% 15.7%
Oct 2012 20.0% 10.64%
Nov 2012 13.1% 13.16%
Background: An aging population and the continuing expansion of clinical indicators for Warfarin therapy have increased pressure on hospital anticoagulation clinics. One evidence based solution is patient self-testing (PST) of the International Normalized Ratio (INR), using capillary blood samples on point-of-care coagulation monitors at home. INR self-testing has been suggested as an effective alternative to standardized warfarin clinic based testing for heart failure patients on long term oral anticoagulation therapy. The purpose of this quality improvement initiative was to evaluate the feasibility and effectiveness of an INR self-testing program in the Heart Failure Clinic (HFC) at a large Level I urban medical center in the Midwest. Specifically, we examined whether INR self-testing would increase testing compliance, improve therapeutic range, and increase patient satisfaction compared to standard clinic based testing. Methods: A needs assessment was completed in the HFC related to the 70 heart failure patients actively utilizing warfarin therapy. A quality improvement business plan was created and approved to initiate an INR PST. Twenty one warfarin patients met eligibility using established inclusion criteria. The mean age was 68.9 in this convenience sample that was primarily married (50%), Caucasian (81%), and male (57%). Patients that met criteria and elected to participate in INR PST completed education using an established program. PST would be perform by patients either weekly, biweekly, or monthly based on the practitioner’s assessment and recommendations. Patients would report results to the vendor’s results team, who would then verify and send information to the practitioner. Retrospective retrieval of data from this single group reflected 12 months of pre- PST implementation testing compliance and therapeutic range data and 12 months of post PST implementation results. Data were reviewed and maintained using electronic medical record software and transferred to a spreadsheet. A three question, investigator created patient satisfaction telephone survey was completed with each patient after 12 months of PST. Results: Subjects in this convenience sample showed a 21% higher level of testing compliance, 10% improvement in therapeutic range, and an 80% increase in satisfaction during the post intervention period when they were using PST than they did when they were undergoing standard clinic based testing. If we remove two patients’ results that showed fallout related to comorbidity issues, testing compliance increased 33% and therapeutic range increased 18%. Conclusion: The safety benefits that resulted from improved testing compliance, staying in therapeutic range, as well as increase in patient satisfaction, supported the decision to continue the PST program. An eighteen month evaluation has shown sustainability. PST permits nursing to offer an alternative testing method to empower patients to become active in their healthcare. Unfortunately, PST is often limited due to insurance coverage. Medicaid currently does not cover this option. Future research is needed related to impact on stroke reduction in this PST population. 5 Utilizing a Electronic Medication Reconciliation Form to Improve Clinical Outcomes of Chronic Heart Failure Patients J. GANDIA 1, R. NJOROGE 1, K. JOHNSON 1, A. BRYAN 1, A. BERRY 1, A. HEATH 1 1 WellStar Kennestone Hospital, Marietta, GA, United States Background: Approximately 550,000 patients are diagnosed with Chronic Heart Failure (CHF) yearly. CHF is a complex clinical