Utilizing a Titratable Diuretic Order Set to Prevent 30-Day Readmission from the Skilled Nursing Facility

Heart & Lung 42 (2013) e4ee7

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Heart & Lung Addendums AAHFN 9TH ANNUAL MEETING: 30-DAY HEART FAILURE READMISSION AWARD ABSTRACTS 1 Reducing Heart Failure Patient Readmissions T. McCLURE, C. MEISTER, S. GARRISON, T. MAHER, J. CALLAHAN, C. BROCKWAY, A.M. SHEA, S. GROVES, K. ZOPF-HERLING, D. TAYLOR, K. SOWTI, N. COLEMAN The Chester County Hospital and Health System, West Chester, PA In June 2011 The Chester County Hospital was selected as one of 11 hospitals to participate with Boston University/Medical Center and AHRQ to determine if the components of Dr. Brian Jack’s re-engineered discharge process (RED) could be applied in the “real world” of a community hospital to decrease re-hospitalizations. For the 1 year pilot we chose to focus on patients with heart failure (HF) discharged to home from our Telemetry Unit. We educated staff and implemented the 11 elements of the RED Checklisti (adopted by the National Quality Forum as safe practice -15). We already had 0.8 RN FTE dedicated to the education of patients with HF. This RN continued to provide HF specific education to patients throughout the hospital. The crux of the RED discharge process was the development of an individualized After Hospital Care Plan for each patient. Nurses were educated on how to begin the discharge plan at the time of admission and how to utilize the teach back method for patient education. Nursing support staff was charged with making post discharge appointments and faxing a copy of the discharge plan to the Primary Care Provider. A Nurse Navigator contacted discharged patients by phone within 48 hours of discharge to review the care plan. We tracked readmission rates for HF patients discharged using the RED process and compared them to the readmission rates from the year prior to RED implementation. Additional information was collected during post discharge phone calls to determine patient understanding and compliance with medication follow up appointments, and overall satisfaction with the discharge process. We elicited feedback from physician practices about the timely receipt of and the usefulness of discharge information. In collaboration with our Boston colleagues we assimilated our yearlong experience and the shared experiences of the other 11 hospitals participating in the RED pilot to make a realistic assessment of our resources and the elements of RED that we deemed essential to desired outcomes. Borrowing from BOOSTii we developed an electronic process for identifying patients at high risk for readmission and in August of 2012 rolled out selected elements of the RED discharge process across all patient populations and to all inpatient units. Organizationally, 30 day readmissions for HF, age over 64 went from 24.44% in 2010 to 18.54% in 2011, to 16.74% through quarter 3 2012. Anecdotal evidence supports both increased patient and physician satisfaction. We identified key elements of the discharge process as early and ongoing patient education using the teach back method, the 0147-9563/$ e see front matter Ó 2013 Published by Elsevier Inc.

development of an individualized plan of care which includes a detailed medication list inclusive of the medication name, dose, frequency and the reason for taking the medication, and making post discharge appointments and post discharge phone calls for patients identified as high risk for readmission. We continue to support our HF nurse educator. To date we have been able to maintain a significant reduction in readmissions for patients with HF and believe there are opportunities to decrease readmissions for patients with other chronic conditions.

2 Utilizing a Titratable Diuretic Order Set to Prevent 30-Day Readmission from the Skilled Nursing Facility K. FILL Northwest Community, Arlington Heights, IL Heart failure (HF) is a chronic illness characterized by episodes of decompensation often requiring hospitalization. With direct correlation to reimbursement, quality outcomes are top priority. For this reason, we developed a HF order set to reduce readmissions. Northwest Community Hospital is located in Arlington Heights, a North West suburb of Chicago, Illinois. With a capacity of 496 beds, we care for 1600 HF patients annually. The majority of our HF population is Medicare. The cardiology teams are in private practice. We have a designated 18 bed HF unit, a HF physician champion, and nurse practitioner working in collaboration. Staff nurses rotate in and out of this unit. The nurse patient ratio is 1:4 or 5 for day shift. Quality data revealed the highest number of 30-day readmissions came from the skilled nursing facilities (SNF). In partnering closely with the SNF, a consortium of care was developed. We held quarterly meetings with Medical Directors, Directors of Nursing, and key clinical staff from the local SNF. The group decided to develop an SNF order set to enable staff nurses to treat patients at the earliest sign of decompensation. This order set, completed upon discharge, starts when the patient enters the facility. It prompts the staff nurse to assess patient’s volume status daily and gives diuretic adjustments according to weight through the use of an algorithm. The rationale for using titratable diuretic regimens is to avoid over aggressive diuresis as well as volume overload. Patients most commonly present for readmission with complaints of dyspnea, fatigue, and activity intolerance resulting from volume overload. The HFSA 2010 guideline executive summary suggests that patients may be educated to adjust daily dose of diuretic according to weight gain from fluid overload. The 2005 ACC/AHA guidelines states that although patients are prescribed a fixed dose of diuretic, the dose may need frequent adjustment based on patient’s weight. Furthermore, the European Society of Cardiology feels that selfadjustment of diuretic doses based on weight and physical assessment should be encouraged in outpatient HF care. Quality data is reviewed monthly and pulled from both Clinical Query and Horizon Performance Management electronically. The

Abstracts / Heart & Lung 42 (2013) e4ee7

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data is merged within an Excel spreadsheet containing formulas based on Medicare inclusion and exclusion criteria. The 30-day HF readmission rate from the SNF was 30 % prior to the implementation of the order set. One year after implementation, the readmission rate improved to 13%. Feedback from nursing staff at the SNF has been favorable. Our goal is to use the order set for all patients discharged to the SNF. This order set is included on our HF pre discharge audit checklist. Implementation included staff nurse education on the HF unit as well as at the SNF. This innovative order set empowers staff nurses to treat HF patients with additional diuretics in a timelier manner. This strategy increases efficiency and timing of care provided to prevent acute decompensation resulting in a hospital readmission. This concept could be replicated to impact HF patients receiving home care.

were not scheduled in the HSTC due to travel distance to the clinic. In an effort to address remote market locations, a virtual HSTC is in development for implementation in first quarter 2013.This will allow the patient access to the HSTC team from home, partnering with a home health RN visit within 3-5 days of discharge and accessing the team via laptop technology. Next step is to take the lessons learned from the three pilots to implement best practices across all 25 owned or managed CHS facilities.

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The purpose of this abstract is to summarize our journey of adopting a multi-disciplinary collaborative team led by a nurse practitioner and its effect on West Virginia University Hospital’s heart failure readmission rates. West Virginia University Hospital is a rural 531-bed tertiary care referral center and serves as the primary teaching destination for West Virginia University’s health professions schools. According to the National Vital Statistics Report, 2009, more than 1 out of 4 deaths in West Virginia were due to heart disease (25.7 percent of total deaths). Our strategies included extensive one-on-one education with the nurse practitioner while in the hospital, teach back evaluation of information throughout hospitalization, bedside medication reconciliation with a pharmacist, personalized phone calls, and a specific discharge plan for them which includes communication with the nurse practitioner as needed. They were made aware of them having a follow-up appointment with the nurse practitioner scheduled before being discharged. The collaborative team (nurse practitioner, rehab services, dietician, case manager, bedside/ charge nurse, and nurse clinician) met daily to discuss the patients and to set realistic goals for follow up. The study by Delgado-Passler and McCaffrey 2006, determined that post discharge management by nurse practitioners can improve the quality of care given to heart failure patients while reducing costs to the patient, the institution, and the healthcare system. In addition to the initiation of the collaborative team we utilized the guidelines set forth by QualityBLUE by High Mark Blue Cross/Blue Shield and Get With The Guidelines (GTWG) by the American Heart Association. Our performance improvement initiative was based on meeting QualityBLUE and GWTG outcomes as well as decreasing our all cause readmissions for heart failure patients. During the first 6 months of 2012, a collaborative team was being devised and a nurse practitioner was hired. During the last 6 months, we instituted our improvement plan. The data collected was based on 2012’s comparative readmission rates for primary heart failure diagnosis; an equal six months with and without the nurse practitioner and collaborative team. The readmission rate was 34.41% for the first 6 months, which dramatically decreased to 18.50% with the addition of the heart failure nurse practitioner, and collaborative team for the last six months of 2012. The outcome data for heart failure readmission rates demonstrated a positive reduction in readmissions and therefore is theorized that the one-on-one education bond created during their hospitalization had a causal relationship for the patient adhering to our recommendations and having less exacerbations that require hospitalizations. Findings may provide substantiation for using a nurse practitioner led collaborative team to improve care coordination management for other chronic diseases in the acute care setting through the transition phase and into the discharge arena.

Decreasing Heart Failure Readmissions by Maintaining the Continuum of Care D. FENNER, K. MONZA, D. HARRIS, M. McGRAW, A. STEPP, C. BRACKBILL, MEGHAN EMIG, L. SHELTON, K. KEGARISE, H. VASQUEZ Carolinas Medical Center, Fort Mill, SC At Carolinas Medical Center (CMC), a multidisciplinary team manages patients admitted with Heart Failure (HF). Upon readmission, the HF inpatient teaching team (HIT) identifies each patient admitted with a primary diagnosis of HF and interviews the patient to assess compliance issues. A risk stratification tool is completed to identify specific patient needs, including barriers to selfmanagement and compliance with core measures. The data is documented to outline learning needs for the patient. The inpatient units have met all performance metrics for disease specific certification. Scales are provided for any patient with HF at discharge. The Heart Success Transition Clinic (HSTC) initiative was developed to address the possible gap in the continuum of care in a phased plan approach. Phase I includes all patients discharged from inpatient stay with primary diagnosis of HF. The Nurse Navigator schedules these patients within 3-5 days of discharge in the HSTC. A HF database was developed to allow the nurse navigator to collect data assessing patient status on admission and discharge to modify HF management to improve long-term management of HF. The HSTC team includes an ACP, pharmacist, dietitian, nurse and social worker. The patient is seen in the HSTC for 1-4 weeks and then returns to PCP or general cardiology. The ACP communicates with the PCP using messaging in the longitudinal record. At the patient’s last visit, the PCP may request co-management with the HF physicians. Phase II will include patients discharged from inpatient stay and emergency department referrals with primary or secondary diagnosis of HF. Phase III will allow the PCP to refer directly to the HSTC. The HF Team works with the Post Acute Care Services team (PACS), which includes Home Health and TeleHealth services. The first Home Health visit takes place within 24-48 hours of discharge. Visits are front loaded to monitor the patient closely by nurses specifically trained in HF. All staff has been educated and utilizes TeachWell, a systemwide health literacy program. Providers and staff at each HSTC pilot site train together and rotate between sites to maintain the standard of care and reduce unintentional variation in care. The HF team worked with PACS team to develop competency based curriculum for staff. Patients being followed in the longitudinal HF Clinic were excluded from the HSTC pilot. Chart audits were completed for all HF Clinic patient readmissions. This determined that many of these admissions were unavoidable due to LVAD/Transplant program and complications of advanced therapy. In addition, many patients

4 Outcomes on Heart Failure Readmissions Utilizing a Nurse Practitioner and Multidisciplinary Collaborative Team L. HENRY, R. HULL, A. LITWINOVICH, L. DOXAKIS West Virginia University Hospital, Morgantown, WV