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A national quality improvement initiative
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Sponsored by the American College of Cardiology (ACC) and the Institute of Healthcare Improvement (IHI)
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Purpose: to reduce cardiovascular-related hospital readmissions & improve transitional care from hospital to home
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Strategic partnerships are encouraged as a vehicle for improving care and outcomes
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Purpose: To improve the care delivered to heart failure patients across the continuum
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Myrna Cuevas RN, Esq
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William Higgins MD
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Maggie Adler RN-C
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Jennifer Fell RD
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Ann Marie Beall DPh
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Visiting Nurse Association of Hudson
Valley
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PICO Question:
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What interventions for heart failure patients help decrease their rehospitalization and mortality rates?
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Knowledge Discovery & Evidence Summary
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50% readmission rate within 6 months
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25% to 35% incidence rate of death at 12 months
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The mortality rate for women with breast cancer is 1 in every
29 deaths, the mortality rate for women with cardiovascular disease is 1 in every 2.4 deaths
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(CDC, 2006)
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100% compliance with the following evidenced-based guidelines:
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Discharge instructions
 diet
 MD f/u
 weight monitoring
 worsening s/s
 Medications with reconciliation
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Left ventricle systolic function evaluation
ACEI/ARB for LVSD
Smoking cessation counseling
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Heart failure is the second highest DRG
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Average costs per patient per day $2,000
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Average LOS is 6 days
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30 day readmission rate is 24.2%, national rate is 24.5% (HHS, 2008)
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Mortality rate is 9.7%, nationally it is
11.1% (HHS, 2008)
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Clinical Expertise to translate your findings into practice

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Standardize treatment plans for heart failure
Standardize patient education for heart failure
Case Management referral for heart failure patients to Telehealth program at VNA
Collaborate with the Visiting Nurse Association of
Hudson Valley (VNA)
Collaborate with community based physicians
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Integrating your findings into practice
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Evidenced-based
Recommendations promote a reduction in rehospitalization and mortality for patients with heart failure
(IHI, AHRQ, ACC)
Physician Order Set
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LVSF assessment
ACEI or ARBs
Beta Blockers
Anticoagulants for atrial fibrillation
Diuretics
Lab assessment
Influenza & Pneumoccocal vaccination
Diet and fluid restriction
Daily weights
Exercise/activity tolerance
Smoking cessation counseling
Patient education
Case management & Nutrition referral
(ACCF/AHA, 2009; AHRQ, 2009)
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Elderly patient's have an altered ability to metabolize or tolerate medication therapy
Isosorbide dinitrate and hydralazine is recommended for African-Americans in addition to standard heart failure treatment
50% of Asian patients develop a ACEI induced cough
Majority of patient’s with heart failure are women
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Provide education literature from the AHA
Document education completed in EHR
Revise Discharge Instruction sheet to include HF care instructions
HF education reinforced by VNA nurses
Future:
In CPOE create notification link from physician order for HF education to nurses task list
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Heart Failure (HF) Screening Flow Chart
Present to ED No Health Care
Services Provided
N
HF symptoms w/i 1 year and/or present HF symptoms and/or
R/A 31 days with previous
HF diagnosis
Admit as Inpatient
N
Case
Manager assesses patient for homecare or skilled nursing need.
Y
Case management evaluates patient/
Family/caregiver’s goals
Collaborates discharge plan with patient and health care team
Y
Homecare or skilled nursing referral made
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Screening for eligibility will be performed by the
VNA while the patient is hospitalized
Remote home monitoring will include vital signs, oxygen level assessment, and weight
Patient education provided by VNA nurses will reinforce education provided by HVHC nurses
Telehealth visits are in addition to regular home nursing visits
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Interdisciplinary approach
Physician Order Set
Patient Education
Comprehensive discharge instructions
Telehealth program
Collaboration across the continuum of care
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Increase in patient selfmanagement skills
Increase in patient satisfaction
Decrease variation in care delivered
Decrease LOS from 6 to
4 days
Decrease 30 day readmissions to 16%
Decrease mortality by
10%
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HF Readmission & Mortality rates
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Heart Failure Task Force Update:
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Total 27 HVHC patients referred to
Visiting Nurse Association Hudson
Valley in 10 months (9/09 – 06/10)
–Readmission rate: 11%
–HVHC Goal: 16%
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15.89%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
8.08%
0.00%
Routine-
Home/Self Care
13.25%
10.62%
9.67%
To SNF To Home Care
Service
Total for Three
Areas
Readmission Rate
Total for All
Readmissions
Pinnacle Group :
- HVHC
- SSMC
- MVH
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At HVHC we are dedicated to caring for our patients across the continuum…….
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Academic Center for Evidenced-based Practice. (2004). ACE: Learn about EBP: ACE
Star Model of EPB: Knowledge Transformation. The University of Texas Health
Science Center at San Antonio. Retrieved July 8, 2009, from http://www.acestar.uthscsa.edu
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Centers for Disease Control and Prevention. (2006). Heart Failure Fact Sheet.
Retrieved August 16, 2009, from the CDC on the World Wide Web: http://www.cdc.gov/DHDSP/library/pdfs/fs_heart_failure.pdf
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Hunt, S.A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T.
G. et al. (2005). 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 Practice
Guidelines. Retrieved August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/112/12/1825?maxtoshow=&HITS=10&hits=10
&RESULTFORMAT=&fulltext=ACC%2FAHA+2005+Guideline+Update&searchid=1&FI
RSTINDEX=0&resourcetype=HWCIT
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Institute for Healthcare Improvement (2008). 5 Million Lives. Getting started kit:
Improved care for the patients with congestive heart failure. Retrieved July
19, 2009, from IHI on the World Wide Web: http://www.ihi.org
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Jessup, M., Abraham, W. T., Casey, D. E., Feldman, A. M., Francis, G. S., Ganiats, T. G. et al.
(2009). 2009 Focused Update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology
foundation/American Heart Association Task Force on Practice Guidelines. Retrieved
August 10, 2009, from Circulation on the Wide World Web: http://circ.ahajournals.org/cgi/reprint/119/14/1977?maxtoshow=&HITS=10&hits=10&RESULTFO
RMAT=&fulltext=2009+Focused+Update&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT
National Guideline Clearinghouse. (2007). Heart Failure in Adults. Retrieved July 20, 2009, from NGC on the World Wide Web: http://www.guideline.gov/summary/summary.aspx?doc_id=11531&nbr=005972&string=heart+A
ND+Failure
Schroetter, S. A., & Peck, S. D. (2008, April). Women’s risk of heart disease: Promoting
awareness and prevention-a primary care approach. MEDSURG Nursing , 17(2 ), 107-113.
U. S. Department of Health and Human Services. (2009). Hospital Compare-A quality tool provided by Medicare . Retrieved July 19, 2009, from HHS on the World Wide Web: http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE
%7C8%7CWinXP&language=English&defaultstatus=0&pagelist=Home
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