- Email: [email protected]
Nurse-Led Heart Failure Quality Collaborative for Rural Hospitals
Clinical Innovation Abstracts
and support was provided. Several departments were found to be vital to the success of Aquapehresis and required coordination from the CNS. Process refining continued over several months. Appropriate patient and line selection criteria were developed. The anticoagulation protocol was the most difficult to operationalize. The therapy was successfully moved from critical care to progressive care allowing for better allocation of resources and was recognized as an opportunity for progressive care staff growth and identity formation. Results: The first 67 Aquapheresis therapies were evaluated prospectively to allow for timely refinement of process. An average of 5.7 liters of ultrafiltrate was removed per patient with no adverse events. Length of stay was found to be as low as 2.2 days when therapy was started within 24 hours of admission. There were no volume related 30 day readmissions post therapy and the majority of patients remained out of the hospital for more than 7 months after Aquapheresis. Refinement of the anticoagulation protocol resulted in the elimination of multiple filter use. Opportunities for improvement after the first 67 therapies included earlier identification of patients and expansion of providers beyond nephrology. Results and process details were published in the fall of 2008 in Progress in Cardiovascular Nursing. Conclusion: Aquapheresis as an alternative means of fluid removal was effective, well tolerated and held sustained clinical benefits in those suffering from volume overload. Aquahperesis therapy can be safely delivered outside of critical care.
INTEGRATING DEVICE DIAGNOSTIC DATA INTO A DISEASE MANAGEMENT CARE MODEL R. Germany, University of Oklahoma, Oklahoma City, OK; K.B. Neisen, F.J. Kueffer, Medtronic, Mounds View, MN; A.J. Naftilan, Vanderbilt University, Nashville, TN Background: Integrating the use of device data for the management of heart failure (HF) can be difficult for the busy HF clinic. The Disease Management (DM) care model may provide a means to effectively integrate device data leading to more timely and appropriate care for the HF clinic provider. Methods: 36 NYHA class III HF patients with ICD/ CRT-D devices were enrolled into INTEGRATE, a non-randomized, single arm study for 6 months
270
www.heartandlung.org
Health Care Utilization Visit Rates Per 6 Months (n = 36) Visit Type
Hospitalization/ ED (HF Related) Outpatient (HF related) TOTAL (HF Related)
Prior 6 Months
0-6 Months
0.7 (0.4) 0.9 (0.5) 5.9 (3.5) 3.71 (1.4)2 6.6 (3.8) 4.63(1.9)4
1 p<0.001 2p<0.001 3p=0.002 4p<0.001 all compare to prior 6 months
of follow up. Patients remotely transmitted their device data, which included intrathoracic fluid status, heart rate variability, day and night time heart rate, patient activity and monitoring for atrial and ventricular arrhythmias, to a web-based network. DM clinicians reviewed these data at a minimum of bi-weekly, provided summaries of patient updates and notified HF clinics when patients started declining, per study investigators pre-set guidelines. Results: Total HF health care utilization (HCU) visit rates reduced by 50% from 3.8 to 1.9 visits/6 months (p < 0.001). Outpatient visit rates reduced from 3.5 to 1.4 visits/6 months (p < 0.001). Hospitalization rates did not change; 0.4 to 0.5 visits/6 months. Conclusion: The INTEGRATE study suggests that DM clinicians may be adequately trained to manage HF patients with ICD/CRT-D devices in a supporting role to HF physicians and have an impact on health care utilization. Further randomized study is deserved to assess the impact on mortality and hospitalizations.
NURSE-LED HEART FAILURE QUALITY COLLABORATIVE FOR RURAL HOSPITALS C.R. Dennison, Health Systems and Outcomes, Johns Hopkins University School of Nursing, Baltimore, MD; R. Newhouse, School of Nursing, University of Maryland, Baltimore, MD Background: Rural hospital nursing often lacks experts to lead the translation of research into
May/June 2009
HEART & LUNG
Clinical Innovation Abstracts
practice. Heart failure (HF) is a growing public health concern, affecting over 5 million Americans at an estimated cost of $33.2 billion annually, with 22% of all patients being discharged from rural hospitals. This high cost is in large part due to the underutilization of effective therapies despite well-publicized management guidelines. Methods: A rural hospital collaborative model, including 24 rural hospitals in the Mid-Atlantic area, was developed to facilitate nurse-led improvements in the quality of care for HF inpatients by improving evidence-based nursing practices through dissemination and translation of research. An evidence-based HF toolkit has been implemented through the HF quality collaborative. The quality collaborative began with a 2-day on-site training session for nurse site coordinators, and includes ongoing facilitation through monthly conference calls and completion of a team check up tool. Key components of the HF toolkit include: 1) a HF fact sheet and relevant scientific articles, 2) nurse education modules, 3) HF admission orderset, 4) HF discharge checklist, 5) standardized patient education booklet [moderate and low-literacy levels available], 6) recommended HF patient education videos, and 7) recommended smoking cessation counseling based on Health and Human Services guidelines. Results: Interim evaluation at six months after initiating the collaborative has identified the following: 1) Major forces which have impacted collaborative efforts include major organizational (18%) and staffing (46%) changes; 2) Most (91%) were successful at implementing a multidisciplinary team to guide HF improvement, and 45% accelerated HF specific nurse education; and 3) One third (36%) stated that they had encountered physician barriers to implementing improvements. Conclusion: In our experience thus far, rural hospital settings have embraced and utilized collaborative resources to implement HF improvements in their hospitals. Major organizational and staffing changes have presented a challenge to collaborative participants. Site coordinators have been effective in implementing multidisciplinary teams. This collaborative approach including explicit nursing interventions in the HF toolkit has significant potential to improve HF patient care and outcomes. However, successful HF quality improvement efforts require strategies to foster resources, prepare organizations for change and promote sound implementation approaches. Quality Collaboratives provide a network to share best practices in rural hospitals.
HEART & LUNG VOL. 38, NO. 3
ADVANCING THE TREATMENT OF VOLUME OVERLOAD: SECONDARY ASSESSMENT AND REFINEMENT OF A SUCESSFUL AQUAPHERESIS PROGRAM M. Peterangelo, Good Samaritan Hospital, Fairborn, OH Background: National guidelines suggest the use of ultrafiltration in the treatment of volume overload when there is diuretic resistance. A simplified ultrafiltration modality (Aquapheresis) has been successfully incorporated into treatment options for volume overload at Good Samaritan Hospital. Patient and line selection criteria were developed and an anticoagulation protocol was refined. Initial success was demonstrated with decreased recidivism, lower lengths of stay with early treatments as well as sustained clinical benefits while adopting the process improvements. Next steps included secondary analysis and further advancement of the therapy. Methods: Aquapheresis treatments received over a twelve month period were analyzed in an effort to further improve efficiency of therapy delivery. Elements of data abstraction included discharge diagnosis, length of stay, time of admission to treatment initiation, and time from discontinuing treatment until discharge. Volumes removed and readmissions were also analyzed. During this same timeframe Aquapheresis services expanded beyond the traditional heart failure admission. Specifically targeted patient populations included cardiac surgery and percutaneous intervention populations. These patients often had underlying heart failure, had received contrast medium, and exhibited volume overload as well as diuretic resistance. Results: Discharge diagnoses were divided into three groups including heart failure (47%), renal failure (25%), and other (28%). Diagnoses other than heart failure or renal failure were variable and could not be categorized with further value. There was often a secondary diagnosis of heart failure and/or renal failure for those falling in the ‘‘other’’ category. Length of stay was analyzed collectively and then again by discharge diagnosis. Renal patients had a mean length of stay 2.5 days longer than each of the counterparts. Most therapies were started within the first day of admission with heart failure patients having the shortest median start time of ten hours into admission. Surprisingly, more time elapsed from discontinuing treatment to discharge (heart failure 26 hours, collective median 38 hours). Median volumes removed were 5.9 liters for heart failure, 7.6 liters for renal failure and 5.7 liters for
www.heartandlung.org
271
and support was provided. Several departments were found to be vital to the success of Aquapehresis and required coordination from the CNS. Process refining continued over several months. Appropriate patient and line selection criteria were developed. The anticoagulation protocol was the most difficult to operationalize. The therapy was successfully moved from critical care to progressive care allowing for better allocation of resources and was recognized as an opportunity for progressive care staff growth and identity formation. Results: The first 67 Aquapheresis therapies were evaluated prospectively to allow for timely refinement of process. An average of 5.7 liters of ultrafiltrate was removed per patient with no adverse events. Length of stay was found to be as low as 2.2 days when therapy was started within 24 hours of admission. There were no volume related 30 day readmissions post therapy and the majority of patients remained out of the hospital for more than 7 months after Aquapheresis. Refinement of the anticoagulation protocol resulted in the elimination of multiple filter use. Opportunities for improvement after the first 67 therapies included earlier identification of patients and expansion of providers beyond nephrology. Results and process details were published in the fall of 2008 in Progress in Cardiovascular Nursing. Conclusion: Aquapheresis as an alternative means of fluid removal was effective, well tolerated and held sustained clinical benefits in those suffering from volume overload. Aquahperesis therapy can be safely delivered outside of critical care.
INTEGRATING DEVICE DIAGNOSTIC DATA INTO A DISEASE MANAGEMENT CARE MODEL R. Germany, University of Oklahoma, Oklahoma City, OK; K.B. Neisen, F.J. Kueffer, Medtronic, Mounds View, MN; A.J. Naftilan, Vanderbilt University, Nashville, TN Background: Integrating the use of device data for the management of heart failure (HF) can be difficult for the busy HF clinic. The Disease Management (DM) care model may provide a means to effectively integrate device data leading to more timely and appropriate care for the HF clinic provider. Methods: 36 NYHA class III HF patients with ICD/ CRT-D devices were enrolled into INTEGRATE, a non-randomized, single arm study for 6 months
270
www.heartandlung.org
Health Care Utilization Visit Rates Per 6 Months (n = 36) Visit Type
Hospitalization/ ED (HF Related) Outpatient (HF related) TOTAL (HF Related)
Prior 6 Months
0-6 Months
0.7 (0.4) 0.9 (0.5) 5.9 (3.5) 3.71 (1.4)2 6.6 (3.8) 4.63(1.9)4
1 p<0.001 2p<0.001 3p=0.002 4p<0.001 all compare to prior 6 months
of follow up. Patients remotely transmitted their device data, which included intrathoracic fluid status, heart rate variability, day and night time heart rate, patient activity and monitoring for atrial and ventricular arrhythmias, to a web-based network. DM clinicians reviewed these data at a minimum of bi-weekly, provided summaries of patient updates and notified HF clinics when patients started declining, per study investigators pre-set guidelines. Results: Total HF health care utilization (HCU) visit rates reduced by 50% from 3.8 to 1.9 visits/6 months (p < 0.001). Outpatient visit rates reduced from 3.5 to 1.4 visits/6 months (p < 0.001). Hospitalization rates did not change; 0.4 to 0.5 visits/6 months. Conclusion: The INTEGRATE study suggests that DM clinicians may be adequately trained to manage HF patients with ICD/CRT-D devices in a supporting role to HF physicians and have an impact on health care utilization. Further randomized study is deserved to assess the impact on mortality and hospitalizations.
NURSE-LED HEART FAILURE QUALITY COLLABORATIVE FOR RURAL HOSPITALS C.R. Dennison, Health Systems and Outcomes, Johns Hopkins University School of Nursing, Baltimore, MD; R. Newhouse, School of Nursing, University of Maryland, Baltimore, MD Background: Rural hospital nursing often lacks experts to lead the translation of research into
May/June 2009
HEART & LUNG
Clinical Innovation Abstracts
practice. Heart failure (HF) is a growing public health concern, affecting over 5 million Americans at an estimated cost of $33.2 billion annually, with 22% of all patients being discharged from rural hospitals. This high cost is in large part due to the underutilization of effective therapies despite well-publicized management guidelines. Methods: A rural hospital collaborative model, including 24 rural hospitals in the Mid-Atlantic area, was developed to facilitate nurse-led improvements in the quality of care for HF inpatients by improving evidence-based nursing practices through dissemination and translation of research. An evidence-based HF toolkit has been implemented through the HF quality collaborative. The quality collaborative began with a 2-day on-site training session for nurse site coordinators, and includes ongoing facilitation through monthly conference calls and completion of a team check up tool. Key components of the HF toolkit include: 1) a HF fact sheet and relevant scientific articles, 2) nurse education modules, 3) HF admission orderset, 4) HF discharge checklist, 5) standardized patient education booklet [moderate and low-literacy levels available], 6) recommended HF patient education videos, and 7) recommended smoking cessation counseling based on Health and Human Services guidelines. Results: Interim evaluation at six months after initiating the collaborative has identified the following: 1) Major forces which have impacted collaborative efforts include major organizational (18%) and staffing (46%) changes; 2) Most (91%) were successful at implementing a multidisciplinary team to guide HF improvement, and 45% accelerated HF specific nurse education; and 3) One third (36%) stated that they had encountered physician barriers to implementing improvements. Conclusion: In our experience thus far, rural hospital settings have embraced and utilized collaborative resources to implement HF improvements in their hospitals. Major organizational and staffing changes have presented a challenge to collaborative participants. Site coordinators have been effective in implementing multidisciplinary teams. This collaborative approach including explicit nursing interventions in the HF toolkit has significant potential to improve HF patient care and outcomes. However, successful HF quality improvement efforts require strategies to foster resources, prepare organizations for change and promote sound implementation approaches. Quality Collaboratives provide a network to share best practices in rural hospitals.
HEART & LUNG VOL. 38, NO. 3
ADVANCING THE TREATMENT OF VOLUME OVERLOAD: SECONDARY ASSESSMENT AND REFINEMENT OF A SUCESSFUL AQUAPHERESIS PROGRAM M. Peterangelo, Good Samaritan Hospital, Fairborn, OH Background: National guidelines suggest the use of ultrafiltration in the treatment of volume overload when there is diuretic resistance. A simplified ultrafiltration modality (Aquapheresis) has been successfully incorporated into treatment options for volume overload at Good Samaritan Hospital. Patient and line selection criteria were developed and an anticoagulation protocol was refined. Initial success was demonstrated with decreased recidivism, lower lengths of stay with early treatments as well as sustained clinical benefits while adopting the process improvements. Next steps included secondary analysis and further advancement of the therapy. Methods: Aquapheresis treatments received over a twelve month period were analyzed in an effort to further improve efficiency of therapy delivery. Elements of data abstraction included discharge diagnosis, length of stay, time of admission to treatment initiation, and time from discontinuing treatment until discharge. Volumes removed and readmissions were also analyzed. During this same timeframe Aquapheresis services expanded beyond the traditional heart failure admission. Specifically targeted patient populations included cardiac surgery and percutaneous intervention populations. These patients often had underlying heart failure, had received contrast medium, and exhibited volume overload as well as diuretic resistance. Results: Discharge diagnoses were divided into three groups including heart failure (47%), renal failure (25%), and other (28%). Diagnoses other than heart failure or renal failure were variable and could not be categorized with further value. There was often a secondary diagnosis of heart failure and/or renal failure for those falling in the ‘‘other’’ category. Length of stay was analyzed collectively and then again by discharge diagnosis. Renal patients had a mean length of stay 2.5 days longer than each of the counterparts. Most therapies were started within the first day of admission with heart failure patients having the shortest median start time of ten hours into admission. Surprisingly, more time elapsed from discontinuing treatment to discharge (heart failure 26 hours, collective median 38 hours). Median volumes removed were 5.9 liters for heart failure, 7.6 liters for renal failure and 5.7 liters for
www.heartandlung.org
271