Editors: Peacock, W. Frank
Title: Short Stay Management of Heart Failure, 1st Edition
Copyright 2006 Lippincott Williams & Wilkins
> Table of Contents > 8 - Performance Measurement, Staffing, and Facilities Requirements for Observation Unit Heart Failure Management
Performance Measurement, Staffing, and Facilities Requirements for Observation Unit Heart Failure Management
Nancy M. Albert
When planning to open a heart failure (HF) management program in a chest pain center (also known as a short stay or observation unit), there are behind-the-scenes aspects to consider that promote optimal patient outcomes. Even though emergency care quality indicators are not specific to HF management, a substantive HF program should meet performance standards deemed important to inpatient and ambulatory HF care. Thus, the purpose of this chapter is to discuss performance measurement specific to HF care. Staffing and facilities requirements are discussed because they provide the structure and process aspects of a quality HF program that advances performance scores to improve patient quality of life, decrease morbidity, and reduce the quantity and length of hospitalization episodes.
No specific HF performance measures exist for a HF management program in a short stay unit setting. Performance measures were developed for hospitalized and ambulatory patients with HF by national organizations (Table 8-1) to improve the quality and consistency of care that hospitalized patients receive and to provide expectations of quality ambulatory care for programs that wish to be certified as a HF disease management program.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed the HF Core Measure Set in 2002 as one of four initial priority focus areas for hospital core measure development. Measuring the processes and outcomes of hospital care for patients with HF increases health care provider awareness that HF is a highly prevalent condition, uses more Medicare dollars for diagnosis and treatment than any other diagnosis, and is a common Medicare diagnosis-related group, reflecting
TABLE 8-1 Performance Measures in Heart Failure
In addition to the four JCAHO core measures, researchers from the Organized Program to Initiate Lifesaving Treatment in Hospitalized patients with Heart Failure (OPTIMIZE-HF), a registry and performance improvement program for patients hospitalized with HF, found that discharge use
The American College of Cardiology (ACC) and American Heart Association (AHA) developed performance measures for chronic HF. In addition to the four JCAHO core predischarge hospital measurements, a fifth measure was applied: use of an anticoagulant in patients with atrial fibrillation. In these performance measures, use of an ACEI was expanded to include angiotensin receptor blockade as an equivalent drug class.3
Although the JCAHO and ACC/AHA HF core measures and OPTIMIZE-HF beta-blocker measure were developed for patients hospitalized with HF, they should be applied in a short stay HF management program. These six core measures are easy to assess and implement when facility planning includes the resources necessary for patient education, left ventricular function assessment, and ordering of core HF medications. Of note, in a study of JCAHO core measures applied at a two-campus university hospital health care system, availability of standardized order forms, computer discharge instructions, and education materials did not lead to improvement in core measures scores; however, a dedicated nurse practitioner implementing resources led to rapid and sustained improvements.4 Clearly, having a champion to develop, implement, and continually monitor the quality of care patients receive is an asset to HF management program success. In a short stay unit setting that does not use a dedicated advance practice nurse, nursing and physician personnel who make up the team must understand the importance of consistent application of core performance measures to achieve outcomes consistent with long-term goals of HF management: to cause reversal or prevent progression of left ventricular remodeling.
Performance measures have been developed for ambulatory HF management programs by ACC/AHA3 and JCAHO.5 Table 8.1 includes 15 performance measures, many of which are essential to both inpatient and outpatient HF care. There is not 100% agreement in stated performance measures by ACC/AHA and JCAHO; however, each measure is an essential element in improving specific clinical HF care. Because a short stay unit visit is uniquely different from an in-patient hospital stay or a chronic ambulatory visit, the 15 ACC/AHA and JCAHO performance measure profiles should be applied in a short stay HF management program but require some revision to fully apply. In Table 8-2, four measures from Table 8-1 were modified for use in a short stay HF management program. Rationale for the suggested changes is provided in Table 8-2.
Thus far, performance measures have been described with rationale for use. Placing words on paper is much easier than developing and implementing systems that promote reaching predetermined benchmarks for each performance standard. The next sections discuss staffing and facilities requirements that will help programs meet performance measures.
TABLE 8-2 Modified Performance Measurements for a Short Stay HF Management Program
To determine staffing needs in a short stay unit HF management program, a review of the literature included studies of patients treated in an emergency care short stay unit, in a hospital, and in an outpatient setting. Very few groups prospectively studied the safety, cost, and outcomes of HF management in an emergency department short stay unit, and there were no randomized trials that compared outcomes of an emergency care based short stay unit HF management program with a hospital admission.6,7 Of the published emergency care, hospital, and outpatient management studies, no information on staffing was reported in study designs except to describe caregiver type in programs as combination physician/nurse, advance practice nurse, multidisciplinary (i.e., home care nursing or pharmacist involvement), or physician led.
Because staffing was not a theme found in the literature, studies were reviewed of HF management by caregiver. There were many reports of differences in outcomes by physician caregiver type. Cardiologist participation improved guideline adherence,8 reduced the risk of composite death and cardiovascular hospitalization in outpatients8 and in newly hospitalized patients,9 increased use of diagnostic testing, and improved clinical outcomes in hospitalized patients.10 In a self-report study design between primary care physicians and cardiologists, cardiologists were more likely to conform to published guidelines for chronic HF than were internists and family practitioners,11 and when cardiologists were compared with HF specialty cardiologists, HF specialists were more likely to conform to chronic HF guidelines than cardiologists.12 In a survey of family physicians and cardiologists, family physicians had less understanding of
The literature provides evidence that there is a gap between science and practice by physician caregiver type. There was no literature that compared HF care by emergency care physicians, general practitioners, cardiologists, or HF specialty cardiologists; however, emergency care physicians may be similar to general practitioners in that they must have a broad range of knowledge to care for a broad patient population. Their focus in training is more likely to be on emergent and acute situations rather than conditions that fall into the category of chronic care. Thus, emergency care physicians who oversee HF management programs in a short stay unit may require additional knowledge and training to provide HF care that is consistent with adherence to national HF guidelines.
No research literature was found on nurse staffing requirements for a short-stay HF management program. There were articles in the literature of specialized HF or cardiovascular nurses providing care that led to improved outcomes over usual care. However, in most cases, the setting was a HF disease management program led by HF specialty cardiologists. Advanced practice nurses (nurse practitioners or clinical nurse specialists) provided some aspects of care but did not provide independent care.16,17 In other reports, nurses worked collaboratively with physiotherapists, social workers, and case managers.18,19 Thus, encouragement and support must be provided to all caregivers involved in clinical management. Nurse caregivers, who are likely to be responsible for patient education, must be properly educated before they can teach others. In a study of nursing knowledge of HF patient education principles, nurses who regularly cared for patients with HF had a mean score of 75% correct on a survey of statements applicable to patient education principles. Scores were highest for HF specialty nurses and lowest for cardiology floor nurses.20 Therefore, emergency care nurses responsible for patient education may also require additional education.
Short stay unit nurses are responsible for patient assessment, drug delivery and monitoring, review of laboratory results, and discharge planning. To facilitate optimal collaboration with physician colleagues, nurses must understand HF pathophysiology, treatment strategies, and performance measures so they can augment and optimize care. Although there were no reports that compared nurse caregiver type, discussed using an advance
To facilitate the application of guidelines and performance measures, clinical leadership should be sought. This can be in the form of a cardiologist, HF specialty cardiologist, or advance practice nurse with HF specialty training. Changing and aligning the behavior of clinicians and managers will not be an easy task for the clinical leader. The ACC uses the Guidelines Applied in Practice (GAP) project and the AHA uses the Get with the Guidelines (GWTG) project to apply HF guidelines in practice. In both of these projects, effective clinical leadership is the key to achieving behavioral changes. Clinical leaders are center stage in motivating peers to achieve benchmarks for each performance measure and in influencing administration to provide resources that will facilitate goals.21 When a clinical leader has a professional association with a national organization that ensures the scientific integrity of the recommendations for care, provides incentives for delivering optimal care, and aids in developing a leadership role, pressure for quality improvement intensifies and the need to manage change that supports the application of guidelines will be paramount.21
Part of the role of the clinical leader will be to structure the environment so that health care providers automatically deliver care that matches guideline recommendations. This requires tools that simplify and provide focus of HF care expectations by embedding evidence-based care into the care itself. In a HF management program for a short stay unit, some examples are as follows: preprinted HF admission order set; preprinted HF discharge planning checklist; HF discharge sheet; HF medication therapies list that includes the right drugs in each class, dosage steps from initial to target dosing, side and adverse effects, contraindications, and associated electrolyte monitoring; patient education handouts/booklet or video; and performance improvement prospective data collection flowsheets for assessment and medication administration. As noted earlier, availability of tools is not enough; they must be used by all health care providers and supported by institutional management.4,21 Examples of tools are available in the ACC/AHA Clinical Performance Measures document3 and through the GAP and GWTG projects.
A multidisciplinary team can provide patient support at a cost. Other professional caregivers that may benefit a short-stay HF management program are a pharmacist, social worker, gerontologist, echocardiographer,
To achieve benchmark scores for the performance measures outlined in Table 8-1, facility requirements or enhancements may be needed, based on current operations and resources. Rationale for facility requirements is provided in Table 8-1.
Equipment for appropriate assessment is necessary for optimal investigation of diagnosis or HF cause, especially for echocardiography, B-type natriuretic peptide (BNP) laboratory testing, electrocardiography, and radiology. It is not necessary that the HF management program have exclusive use of equipment. Equipment can be shared by multiple departments or care providers can be sent to the short-stay area to perform services, as needed. Specialized equipment availability may not be needed around the clock because the patient is treated for a 23-hour period; however, delays in testing could lead to misdiagnosis, mismanagement, misappropriation of patient disposition, and increased cost of care. Table 8-3 lists ancillary facility resources that can benefit health care providers in care planning and implementation.
Materials that augment patient education and forms/algorithms that promote health care provider delivery of medical treatments should be developed, readily available for use, and consistently used by team members when patients meet criteria. Patient education materials (paper, video, and telehealth materials) can be costly when purchased from a vendor, and they may not be up-to-date with guideline recommendations. Developing patient education materials in-house requires attention to reading level; use of pictures, color, and formatting to make specific messages stand out; study of content for simplicity, accuracy, and thoroughness (including information on prognosis); and messages about who to contact for a variety of needs. In-house development can also be expensive, especially if the number of orders placed per shipment is low and/or health care providers or service availability is frequently altered.
Prespecified forms can augment documentation of routinely performed activities and remind providers of care expectations related to performance measures. When knowledgeable personnel use prespecified forms and algorithms to advance care and ensure care consistency, patients benefit by receiving optimal care and the system benefits by meeting or exceeding care expectations known to improve quality of care, morbidity, and
TABLE 8-3 Ancillary Facility Resources That May Be Considered
Facilities requirements must include systems that promote routine influenza and pneumococcal vaccination, documentation of assessment and treatments (signs and symptoms; laboratory testing; weight; functional status; medication classes, dosage, and side effects), documentation of patient education delivered, and documentation of delivered care compared with performance measure quality benchmarks. A quality monitor coordinator can devote time to chart review, data collection and entry of data into an electronic database, communication of outcomes, and replanning of services to enhance outcomes, as needed. There is no evidence that using a dedicated nurse or other professional person to promote evidence-based practice in a short-stay setting leads to enhanced performance or promotes patient health beyond what can be accomplished by training all nurses and
There are many gaps in best practice in regard to implementing a short-stay HF management program. Performance expectations need to be adapted from in-patient and ambulatory measures and modified to match the setting. It will be important to conduct research on performance measures in a short-stay environment so that standards of care are tailored to this setting. Staffing requirements include a clinical HF leader who can champion the program not just during development but over time. Other staffing requirements consistent with best practice suggest that knowledgeable nurses can augment physician care and that both physicians and nurses require education in HF, at least initially. Facilities resources can not only improve throughput for patients but also optimize care services that improve health care provider assessment, diagnosis, and management capabilities. Availability of well-developed patient education materials can enhance patient knowledge and improve self-care after discharge. A well-developed HF management program will have given considerable attention to performance measures, staffing, and facilities resources before program implementation.
1. Joint Commission on Accreditation of Healthcare Organizations. Overview of the heart failure core measure set (3/22/2002). Available at http://jcaho.org/pms/core+measures/ hf_overview.htm (accessed September 23, 2005).
2. Fonorow G, Abraham W, Albert N, et al. Should beta blocker use at the time of hospital discharge be included as a heart failure performance measure? A report from OPTIMIZE- HF. J Cardiac Fail 2005;11[Suppl]:S182.
3. American College of Cardiology/American Heart Association Task Force on Performance Measures. ACC/AHA clinical performance measures for adults with chronic heart failure. J Am Coll Cardiol 2005;46:1144 1178.
4. Ennis S, Moore S, Zichitella G, et al. Impact of a dedicated in-patient heart failure program on JCAHO core measures of heart failure care. J Cardiac Fail 2005;11[Suppl]:S183.
5. Joint Commission on Accreditation of Healthcare Organizations. Disease specific care. Request for public comment on disease-specific care standardized heart failure measure set. Available at http://jcaho.org/dscc/dsc/performance+measures/heart+failure+measure+ set.htm (accessed September 23, 2005).
6. Peacock WF 4th, Remer EE, Aponte J, et al. Effective observation unit treatment of decompensated heart failure. Congest Heart Fail 2002;8:68 73.
7. Storrow AB, Collins SP, Lyons MS, et al. Emergency department observation of heart failure: preliminary analysis of safety and cost. Congest Heart Fail 2002;11:68 2.
8. Ansari M, Alexander M, Tutar A, et al. Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting. J Am Coll Cardiol 2003;41:62 68.
9. Jong P, Gong Y, Liu PP, et al. Care and outcomes of patients newly hospitalized for heart failure in the community treated by cardiologists compared with other specialists. Circulation 2003;108:184 191.
10. Reis SE, Holubkov R, Edmundowicz D, et al. Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes. J Am Coll Cardiol 1997;30:733 738.
11. Edep ME, Shah NB, Tateo IM, Massie BM. Differences between primary care physicians and cardiologists in management of congestive heart failure: relation to practice guidelines. J Am Coll Cardiol 1997;30:518 526.
12. Bello D, Shah NB, Edep ME, et al. Self-reported differences between cardiologists and heart failure specialists in the management of chronic heart failure. Am Heart J 1999;138:100 107.
13. Baker DW, Hayes RP, Massie BM, Craig CA. Variations in family physicians' and cardiologists' care for patients with heart failure. Am Heart J 1999;138:826 834.
14. Indridason OS, Coffman CJ, Oddone EZ. Is care associated with improved survival of patients with congestive heart failure? Am Heart J 2003;145:300 309.
15. Khunti K, Hearnshaw H, Baker R, Grimshaw G. Heart failure in primary care: qualitative study of current management and perceived obstacles to evidence-based diagnosis and management by general practitioners. Eur J Heart Fail 2002;4:771 777.
16. Whellan DJ, Gaulden L, Gattis WA, et al. The benefit of implementing a heart failure disease management program. Arch Intern Med 2001;161:2223 2228.
17. Smith LE, Fabbri SA, Pai R, et al. Symptomatic improvement and reduced hospitalization for patients attending a cardiomyopathy clinic. Clin Cardiol 1997;20:949 954.
18. Capomolla S, Febo O, Ceresa M, et al. Cost/utility ratio in chronic heart failure: comparison between heart failure management program delivered by day-hospital and usual care. J Am Coll Cardiol 2002;40:1259 1266.
19. Eliaszadeh P, Yarmohammadi H, Nawaz H, et al. Congestive heart failure case management: a fiscal analysis. Dis Manage 2001;4:25 32.
20. Albert NM, Collier S, Sumodi V, et al. Nurses' knowledge of heart failure education principles. Heart Lung 2002;31:102 112.
21. Eagle KA, Garson AJ, Beller GA, Sennett C. Closing the gap between science and practice: the need for professional leadership. Health Affairs 2003;22:196 201.
22. Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practical Guidelines. Available at http://www.acc.org/clinical/guidelines/failure/index.pdf (accessed August 17, 2005).
23. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation 2005;111:179 185.
24. American Heart Association. Heart disease and stroke statistics 2005 update. Dallas, TX: American Heart Association, 2004.
25. Shivkumar K, Jafri SM, Gheorghiade M. Antithrombotic therapy in atrial fibrillation: a review of randomized trials with special reference to the Stroke Prevention in Atrial Fibrillation II (SPAF II) Trial. Prog Cardiovasc Dis 1996;38:337 342.
26. Rame JE, Sheffield MA, Dires DL, et al. Outcomes after emergency department discharge with a primary diagnosis of heart failure. Am Heart J 2001;142:714 719.
27. Gattis WA, O'Connor CM, Gallup DS, et al. Predischarge initiation of carvedilol in patients hospitalized for decompensated heart failure: results of the Initiation Management Predischarge: Process for Assessment of Carvedilol Therapy in Heart Failure (IMPACT-HF) trial. J Am Coll Cardiol 2004;43:1534 1541.
28. Mueller C, Scholer A, Laule-Kilian K. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004;350:647 654.