Download Heart Failure Indicator Review

 Report on the VLAD Heart Failure
Indicator Review
Final Summary of Activities
April 2012
TABLE OF CONTENTS Executive Summary ................................................................................................ 3
Heart Failure In‐hospital Mortality Indicator ..................................................................... 3
Heart Failure Readmission Indicator .................................................................................. 3
Heart Failure Longstay Indicator ........................................................................................ 3
New Indicator Definitions................................................................................................... 4
Background............................................................................................................. 4
Indicator Review Process ........................................................................................ 5
Detailed Review...................................................................................................... 6
Heart Failure In‐hospital Mortality Indicator ..................................................................... 6
Heart Failure Readmission and Longstay Indicators – Generic Issues ............................... 7
Heart Failure Readmission Indicator ................................................................................ 10
Heart Failure Longstay Indicator ...................................................................................... 12
Appendices ........................................................................................................... 14
Appendix A ‐ Indicator Review Working Group Terms of Reference ............................... 14
Appendix B ‐ Risk Adjustment Co‐morbidities.................................................................. 15
Appendix C ‐ Full List of Readmission Principal Diagnoses............................................... 16
VLAD Heart Failure Working Group Summary of Activities Page 2 of 16 EXECUTIVE SUMMARY For each of the three heart failure indicators reviewed, the following presents a high‐
level overview of the changes to the indicator definitions. More detail on what was considered in the review is found within the report. The differences between the specifications of the old and new indicator definitions are found on pages 10 & 12. Heart Failure In‐hospital Mortality Indicator •
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The Heart Failure In‐hospital Mortality indicator lacks clinical relevance and critical existing definition limitations can not be overcome. The recommendation of the indicator working group to cease this indicator was endorsed by the QH Patient Safety and Quality Executive Committee at the July 2011 meeting. Heart Failure Readmission Indicator •
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The Working Group recommended that the Heart Failure Readmission indicator continue as it has the potential to identify patient safety and quality issues. Current and potential inclusion and exclusion criteria were considered for clinical relevance. It is recommended to continue the production of the Heart Failure Readmission indicator with modifications outlined below: o Readmission admissions must be emergency admissions o Revise the diagnosis codes for readmissions o Expand age of patients included o Modify risk adjustment criteria Heart Failure Longstay Indicator •
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The Working Group recommended that the Heart Failure Longstay Indicator continue as it has the potential to identify patient safety and quality issues and efficiency issues Current and potential inclusion and exclusion criteria were considered for clinical relevance. It is recommended to continue the production of the Heart Failure Longstay indicator with modifications outlined below: o Increase the longstay point from 14 to 15 days o Expand age of patients included o Modify risk adjustment criteria VLAD Heart Failure Working Group Summary of Activities Page 3 of 16 New Indicator Definitions The revised Heart Failure Readmission and Longstay Indicators are defined as follows. New Heart Failure Readmission Indicator Patients readmitted to any Queensland hospital within 30 days of discharge to home / usual residence with an emergency admission and for a condition that could be considered a consequence of the initial treatment received (see Appendix C for a full list). Inclusion and Exclusion Criteria Principal Diagnoses Code I50
Separation date 1 July 2009 to most recent
State of usual residence Queensland
Episode type Acute
Overnight stay patients Must have spent at least one night in hospital
Age 18+ years
Length of stay 1 – 30 patient days
Admission source Excludes transfers in
Separation mode Excludes transfers out and deaths
Risk Adjustment Criteria Selected co‐morbidities Renal Failure
New Heart Failure Longstay Indicator Patients with length of stay longer than 15 days with a principal diagnosis of heart failure (I50). I50
1 July 2009 to most recent
Queensland
Acute
Must have spent at least one night in hospital
18+ years
1 – 30 patient days
Excludes transfers in
Excludes transfers out
Age, Septicaemia, Anaemia, Diabetes, Hyponatremia, Valvular Disorders, Pulmonary Hypertension, Dysrhythmias, Cerebrovascular Disease, Hypotension and Shock, Acute LRTI and Influenza, Other Chronic Obstructive Pulmonary Disease, Intestinal disorders, Liver Disease, Cellulitis, Ulcer of lower limb or decubitus ulcer, Renal Failure, Urinary Tract Infection (site not specified), Other urinary symptoms, Oedema
BACKGROUND The Variable Life Adjusted Display (VLAD) monitoring methodology was introduced in Queensland Health in 2007. The initial suite of clinical indicators included Heart Failure In‐
hospital Mortality, Heart Failure Readmission and Heart Failure Longstay. In March 2010, the Heart Failure VLAD Indicator Working Group was formed to review the current Heart Failure Indicators for clinical relevance. Following an Expression of Interest process, the working group first met in April 2010. The membership included Heart Failure Clinicians, General Medical Clinicians, Clinical Nurses, Safety and Quality staff, Health Information Managers, Coding Experts and Data Analysts. The working group’s terms of reference, including membership, is included in Appendix A. VLAD Heart Failure Working Group Summary of Activities Page 4 of 16 The Interim Summary of Activity which recommended the cessation of Heart Failure In‐
Hospital Mortality indicator was endorsed by the Patient Safety and Quality Executive Committee at its July 2011 meeting. This Final Summary of Activity includes the results of the review of the Heart Failure Readmission, Mortality and Longstay Indicators. INDICATOR REVIEW PROCESS The review involved an iterative process of statistical and clinical debate and discussion. Using the indicator selection criteria, the indicator was rigorously evaluated. Indicator Selection Criteria The criteria used to evaluate the clinical indicators throughout the review process were: • Clinical significance: The significance in terms of burden to the health system and individual patients • Volume: Sufficiency of patient numbers to provide a statistically reliable measure • Indicator clarity: The indicator definition must be clearly defined and reliable • Responsive potential: The disease, condition or procedure type has to be able to be systematically improved • Systematic Data Collection: The data used to derive the indicators must be collected systematically across hospitals e.g. Queensland Hospital Admitted Patient Data Collection The pyramid of investigation used by facilities in flag reviews include the following causal factors: ƒ Data ƒ Casemix ƒ Structure or Resource ƒ Process of Care ƒ Professional Issues A pattern of identified causal factors related only to Casemix and Data potentially suggests a poorly defined indicator as little clinical improvement is possible. VLAD Heart Failure Working Group Summary of Activities Page 5 of 16 DETAILED REVIEW Heart Failure In‐hospital Mortality Indicator The Heart Failure indicator working group unanimously agreed that heart failure in‐hospital mortality is not a valid indicator for monitoring given the indicator lacked clinical relevance and critical existing definition limitations could not be overcome. The indicator definition (Table 1) and details of the discussion and outcome are provided below. Table 1: Old Heart Failure In‐hospital Mortality Indicator definition In‐hospital Mortality Indicator Definition Old Definition Definition The number of records where separation mode =05 (death) and length of stay was less than or equal to 30 days. Inclusion and Exclusion Criteria Principal Diagnosis Code I50 Separation date 1 July 2003 onwards Episode type Acute patients Overnight stay patients Patients must have spent at least one night in hospital Age 30 – 89 years Length of stay 1 – 30 patient days Admission source Excludes transfers in Separation mode Excludes transfers out Risk Adjustment Criteria Selected co‐morbidities Age, septicaemia malignancy, dementia (including Alzheimer’s disease), hypertension, ischaemic heart disease, dysrhythmias, acute LRTI and influenza, ulcer of the lower limb or decubitus ulcer, renal failure, hypotension and shock, cerebrovascular disease. Indigenous status has not been used to adjust risk in this model. Issue: Clinical Relevance Discussion • The working group believed that the Heart Failure in‐hospital Mortality indicator was of little value. • Heart Failure In‐hospital Mortality is different to a post operation complication/mortality indicator as Heart Failure is a chronic disease. Death may be due to issues other than Heart Failure e.g. pneumonia • In terms of indicator definition criteria, this indicator lacks o Responsive potential due to Heart Failure having a disease course that includes an inevitable decline o Indicator clarity due to the limitations with the definition that can not be resolved as outlined below. • The working group agreed that out of hospital mortality would not be of interest either. • State‐wide HF network previously reported quarterly mortality rates but have since ceased due to members perceiving no value. Previous flag investigations have identified predominately Data (documentation/coding) and Casemix (inadequate risk adjustment) causal factors rather than a significant amount of practice improvement opportunities related to Structure or Resource, Process of Care or Professional. See Table 2 Heart Failure In‐hospital Mortality Causal Factors. VLAD Heart Failure Working Group Summary of Activities Page 6 of 16 Table 2: Heart Failure In‐hospital Mortality Causal Factors: Lower Level Flags 30/09/2009 ‐ 14/12/2010 Indicator Structure or Process Data Casemix Resource of Care Professional Total In‐Hospital Freq 16 22 2 3 0 42 Mortality % 38 52 5 7 0 100 Definitional Issue: – Heart Failure severity and heart failure type Discussion: •
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Severity of Heart Failure and Heart Failure Type influences In‐hospital mortality rates but can’t be adjusted for. It was determined that improvements to the Heart Failure In‐hospital Mortality indicator definition were either not possible or not effective. (for further discussion see the section Heart Failure Readmission and Longstay Indicators – Generic Issues below) Recommendation • As the VLAD Heart Failure In‐hospital Mortality indicator lacks clinical relevance and critical existing definition limitations can not be overcome, it is recommended that the indicator cease to be monitored. Recommendation endorsed by Patient Safety and Quality Executive Committee at July 2011 meeting. Heart Failure Readmission and Longstay Indicators – Generic Issues The following generic definitional issues were discussed amongst the indicator working group. For each issue, a summary of the discussion and decision pertaining to the indicator definitions is included below. Definitional Issue: Type of Heart Failure Discussion: • The current definition includes all types of Heart Failure – Left Heart Failure, Right Heart Failure and biventricular Heart Failure. • Patients with Right Heart Failure (I50.0 Congestive Heart Failure) tend to have elevated pressures in the lung leading to pulmonary Hypertension: a different sub group of patients that have a different treatment modality. • Patients with Right Heart Failure are often readmitted with Chronic Obstructive Pulmonary Disease (COPD) and are coded for Heart Failure but are treated differently. • Right Heart Failure and Pulmonary Hypertension can not be used as exclusion criteria because of identified inconsistent documentation and coding. In addition, possible proxy measures such as COPD or use of diagnostics such as transoesophageal ultrasound are not targeted given that they are distributed across Heart Failure diagnosis groups Decision: • It was decided not to exclude the Pulmonary Hypertension patients as while there is VLAD Heart Failure Working Group Summary of Activities Page 7 of 16 •
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a raised rate of longstay the difference in rates is not big enough to justify exclusion. Pulmonary Hypertension to be considered for inclusion as a risk adjustment criteria. Include Right Heart Failure (I50.0) in addition to I50.1 (Left ventricular failure) and I50.9 (Heart failure, unspecified) It was acknowledged that this is a limitation of the proposed indicator definitions. Definitional Issue: Severity of Heart Failure Discussion: • Currently the indicators do not adjust for severity of heart failure. • Outcomes for Class I and II (mild) Heart Failure patients are very different from Class III (moderate) and Class IV (severe) Heart Failure patients. • Indicator definition is unable to adjust for end stage (Stage IV) heart failure as severity is unable to be identified from data collection. • Investigations found that proxy measures for severity of heart failure can not be used as exclusion criteria as they are not targeted proxies given that they are distributed across heart failure groups. • The use of cardiogenic shock was investigated as a proxy measure for high severity. It was found that due to the number of cases of cardiogenic shock for the Readmission and Longstay indicators being too low it can not be used in risk adjustment Decision: • Severity of Heart Failure can not be adjusted for. • It is acknowledged that this is a limitation of the proposed indicator definitions. Definitional Issue: Palliation Discussion: • Palliative patients should be excluded from the current definition as the indicators only include acute patients. • Documentation and coding of palliative status is not consistent • Some facilities manage patients in the palliative phase within the acute unit rather than transfer to a Palliative Care Unit (PCU). It was suggested that these units may be penalised in the current indicator definition as these patients will be included in their data set. Decision: • Palliative patients should continue to be excluded. • It is acknowledged that documentation and coding palliative care status is a limitation of the proposed indicator definitions. Definitional Issue: Nursing Home Patients Discussion: • It was suggested that the management of patients admitted from Nursing Homes is different from other and so should be excluded from the definition. • Analysis o Small numbers were admitted directly from a nursing home o Readmission rate is lower than other sources VLAD Heart Failure Working Group Summary of Activities Page 8 of 16 o
Long stay rates are similar to patients from other sources. Decision: • Nursing Home patients to continue to be included. Definitional Issue: Age Discussion: • Current lower cut off for age is 30 years • The older ages are more likely to have co‐morbidities impacting on the outcomes. Should all be included and rely on risk adjustment or should these ages (> 80 years) be excluded? • It was thought that ages 18 years and above be included • Analysis of the data indicates the outcome rates for long stay increase with age. For readmissions the outcome rate is the same across age groups. • It was thought that the older ages should be included given that one aim is to reduce the unplanned readmissions and the elderly are a target group for this. Decision: • It was agreed to include ages 18 years and higher Definitional Issue: Risk adjustment model Discussion: • The risk adjustment co‐morbidities for the current indicator definitions were considered for clinical relevance and suggestions for other co‐morbidities to be considered. • The statistical relevance on readmission and longstay outcomes rates was then determined for all individual co‐morbidities. • The impact on facility flagging patterns for both revised definitions was subsequently assessed. Decision: • A revised list of risk adjustment co‐morbidities were agreed upon and are documented in the proposed indicator definition (see Appendix B). • Changes to risk adjustment co‐morbidities include: o Readmission ƒ Removal of Age and Sex ƒ Inclusion of Renal Failure o Longstay ƒ Removal of Malignancy ƒ Inclusion of Diabetes and Pulmonary Hypertension VLAD Heart Failure Working Group Summary of Activities Page 9 of 16 Heart Failure Readmission Indicator •
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The Working Group agreed that there is value in continuing this indicator, as it has the potential to identify patient safety and quality issues. The Working Group recommended that some modification was required to improve the indicator clarity. o Readmission admissions must be emergency admissions (see Definitional Issue: Removal of planned readmissions p11)
o Changes to readmission Principal Diagnoses, age inclusion criteria and risk adjustment criteria were made.
Table 3: Old and Proposed Heart Failure Readmission Definitions Old Definition
Patients readmitted to any Queensland hospital within 30 days of discharge to home / usual residence with a principal diagnosis of heart failure (I50).
Inclusion and Exclusion Criteria Principal Diagnosis Code Separation date State of usual residence Episode type Overnight stay patients Age Length of stay Admission source Separation mode Risk Adjustment Criteria Selected co‐morbidities (see Appendix B) VLAD Heart Failure Working Group Summary of Activities New Definition
Patients readmitted to any Queensland hospital within 30 days of discharge to home / usual residence with an emergency admission and
for a condition that could be
considered a consequence of
the initial treatment received (see Appendix C for a full list).
I50
1 July 2006 to most recent
Queensland
Acute
Must have spent at least one night in hospital
30 – 89 years
1 – 30 patient days
Excludes transfers in
Excludes transfers out and deaths
Unchanged
1 July 2009 to most recent
Unchanged
Unchanged
Unchanged
18+ years
Unchanged
Unchanged
Unchanged
Age, Sex
Renal Failure
Page 10 of 16 Definitional Issue: Removal of planned readmissions Discussion: • It was acknowledged that planned readmissions form part of best practice heart failure treatment and so these patients should be excluded from the definition wherever possible. It was thought that the inclusion of planned readmission would penalise best practice. • The working group agreed to automatically exclude patients with an elective episode of care. • In addition, a list of procedures conducted on the readmission episodes of care was reviewed. This failed to identify procedures that would uniquely identify planned admissions. Decision: • Change definition to include only emergency re‐admissions and therefore exclude elective re‐admissions. Definitional Issue: Readmission Interval Discussion: • The group discussed whether the current 30 day time period for readmission be reduced to 14 days to bring in line with national/international benchmarks. • It was decided to retain the 30 day time period but to include another field in the data provided that flags whether the readmission occurred within 14 days. This would aid investigation of flags by quickly determining the percentage of patients that were readmitted within 14. This would inform the review as to whether the rate of readmission is, in fact an issue of concern. Decision: • Continue with the current readmission interval of 30 days. Definitional Issue: Transplant patients Discussion: • The Prince Charles Hospital performs assessments on Heart Failure patients awaiting a transplant. The inclusion of these patients may unfairly penalise the hospital as the admission is planned. • No codes were identified for being on transplant waiting list. • A workup code is available but this would only apply for the initial admission for transplant admission and not for subsequent admissions awaiting transplant. This workup code is currently not used consistently. • A manual list of these patients is kept at the hospital which records the UR number, date of birth and assessment start date. • The process of excluding these patients manually through the use of this list was explored. A labour intensive manual process would be required to exclude these patients from the VLAD dataset. • Given the small number of readmissions identified, the risk of error from a the manual process required to remove transplant patients and the minor impact they would have on the overall outcome rate it was agreed not to exclude transplant patients. Decision: • Include transplant patients VLAD Heart Failure Working Group Summary of Activities Page 11 of 16 Heart Failure Longstay Indicator •
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The Working Group agreed that there is value in continuing this indicator, as it has the potential to identify patient safety and quality issues and efficiency issues. The Working Group recommended that some modification was required to improve the indicator clarity. o Changes to long stay point, age inclusion criteria and risk adjustment criteria were made.
Table 4: Old and proposed Heart Failure Longstay definitions Old Definition New Definition Patients with length of stay longer than 14 days Patients with length of stay longer than 15 days with a with a principal diagnosis of heart failure (I50). principal diagnosis of heart failure (I50). Inclusion and Exclusion Criteria Principal Diagnosis Code I50 Unchanged Separation date 1 July 2006 to most recent 1 July 2009 to most recent State of usual residence Queensland Unchanged Episode type Acute Unchanged Overnight stay patients Must have spent at least one night in hospital Unchanged Age 30 – 89 years 18+ years Length of stay 1 – 30 patient days Unchanged Admission source Excludes transfers in Unchanged Separation mode Excludes transfers out Unchanged Risk Adjustment Criteria Selected co‐morbidities Age, Septicaemia, Malignancy, Anaemia, Age, Septicaemia, Anaemia, Diabetes, Hyponatremia, (see Appendix B) Hyponatremia, Valvular Disorders, Dysrhythmias, Valvular Disorders, Pulmonary Hypertension, Dysrhythmias, Cerebrovascular Disease, Hypotension and Shock, Cerebrovascular Disease, Hypotension and Shock, Acute Acute LRTI and Influenza, Other Chronic Obstructive LRTI and Influenza, Other Chronic Obstructive Pulmonary Pulmonary Disease, Intestinal disorders, Liver Disease, Intestinal disorders, Liver Disease, Cellulitis, Ulcer Disease, Cellulitis, Ulcer of lower limb or decubitus of lower limb or decubitus ulcer, Renal Failure, Urinary Tract ulcer, Renal Failure, Urinary Tract Infection (site not Infection (site not specified), Other urinary symptoms, specified), Other urinary symptoms, Oedema Oedema VLAD Heart Failure Working Group Summary of Activities Page 12 of 16 Definitional Issue: Longstay Point Discussion: • Previously the point for long stays has been where there is a long stay rate of 10% • Under the existing definition the long stay point is 14 days • Analysis revealed that the point at which a long stay rate is 10% is now 15 days Decision: • The long stay point be changed to 15 days. VLAD Heart Failure Working Group Summary of Activities Page 13 of 16 APPENDICES Appendix A ‐ Indicator Review Working Group Terms of Reference TERMS OF REFERENCE Variable Life Adjusted Display Heart Failure Indicator Working Group Role The primary role of the Variable Life Adjusted Display (VLAD) Heart Failure Indicator Working Group is to provide expert opinion and evidence‐based advice regarding current and future indicators to be monitored using the VLAD or other statistical monitoring methodologies. Scope of activity/responsibility The Working group brings together expert health professionals, system administrators and data analysts to review the current Heart Failure indicators monitored with the VLAD (and propose any future indicators). The group will ensure that the indicators are: ƒ clinically significant (for individual patient/s and the health system as a whole) ƒ clearly defined ƒ statistically reliable (suitable volume of patients) ƒ responsive to changes in processes or clinical practice In the context of reviewing the clinical usefulness of indicators, clinical experts within the group may also be required to review VLAD responses and provide advice regarding the dissemination of findings from such responses. Representatives from clinical networks and other professional groups are responsible for providing a summary of discussions and decisions made back to the group they represent. Membership Name Position Dr George Javorsky Clinical Director Advanced Heart Failure and Cardiac Transplant Unit TPCH Director Internal Medicine PAH Nursing Director Institute of Cardiac Services CNC Heart Failure Services TPCH Clinical Nurse Information Manager‐ Cardiology GCH Safety and Quality Nurse Manager Innisfail Health Service CNC Quality Data RBWH Safety & Quality Unit Convenor Queensland Coding Committee Coding Quality Coordinator Health Information Services RBWH Dr Ian Scott Donna Brown Maria Podger Amy Sweeny Andrea Shang Kirsty Calabro Corrie Martin Derelle Pratt VLAD Heart Failure Working Group Summary of Activities Page 14 of 16 N.B. Staff from the Clinical Monitoring Team within Patient Safety and Quality Improvement Service (PSQIS) will attend the meetings to facilitate and provide technical advice regarding VLAD or other statistical methodologies and to assist in the development of indicators. Frequency of meetings, Quorum and secretariat The VLAD Heart Failure Indicator Working Group is scheduled to meet approximately monthly for three meetings. Secretariat will be provided by Clinical Monitoring Team, PSQIS. A quorum of half the membership is required. If a member is unable to attend, the secretariat should be advised 1 week prior to the scheduled meeting date. A proxy may attend on behalf of a member, but must be able to make decisions on behalf of the member. Documents for review prior to the meeting will be sent by email 7 days prior to the meeting. It is the responsibility of members to regularly check email and have reviewed all necessary documentation prior to the meeting. Reporting/governance Significant changes to Indicator definitions will also need to be ratified by the Patient Safety and Quality Executive Committee VLAD Sub‐committee. Appendix B ‐ Risk Adjustment Co‐morbidities Co‐morbidity Septicaemia ICD codes A40 – A41 (2007/2008 – 2009/2010) A40 ‐ A41; R57.2; R65 (2010/2011 – ) Anaemia D50 – D64 Diabetes E10 – E14 Hyponatremia E87.1 Dementia F00 – F03; G30 – G31.1 Valvular Disorders I05 – I08; I33 – I39 Pulmonary Hypertension I27 Dysrhythmias I46 – I49 Cerebrovascular Disease I60 – I69 Hypotension and Shock I95; R57 Acute LRTI and Influenza J09 – J22 Other COPD J49 – J44; J47 Intestinal Disorders K21; K52 – K59 Liver Disease K70 – K77 Cellulitis L03 Ulcer of lower limb or decubitus ulcer L89; L97 Renal Failure N17 – N19; R34 (2007/2008) N17; N18.3 – N18.5; N18.9; N19; R34 (2008/2009 – ) Urinary Tract Infection (site not specified) N39.0; T83.5 Other urinary symptoms R30 – R39 Oedema R60 VLAD Heart Failure Working Group Summary of Activities Page 15 of 16 Appendix C ‐ Full List of Readmission Principal Diagnoses
ICD‐10‐AM Code E86 E87.0 E87.1 E87.2 E87.3 E87.4 E87.5 E87.6 E87.7 I13.0 I13.2 I25.5 I42.0 I42.1 I42.2 I42.5 I42.6 I42.7 I42.8 I42.9 I50 I95.0 J81 J90 N17 N19 R00 R18 R57.0 R60.1 Description Volume depletion Hyperosmolality and hypernatraemia Hypo‐osmolality and hyponatraemia Acidosis Alkalosis Mixed disorder of acid‐base balance Hyperkalaemia Hypokalaemia Fluid overload Hypertensive heart and kidney disease with (congestive) heart failure Hypertensive heart and kidney disease with both (congestive) heart failure and kidney failure Ischaemic cardiomyopathy Dilated cardiomyopathy Obstructive hypertrophic cardiomyopathy Other hypertrophic cardiomyopathy Other restrictive cardiomyopathy Alcoholic cardiomyopathy Cardiomyopathy due to drugs and other external agents Other cardiomyopathies Cardiomyopathy, unspecified Hear failure (Includes: Congestive heart failure; Left ventricular failure; and, Heart failure, unspecified) Hypotension (Includes: Idiopathic hypotension; Orthostatic hypotension; Hypotension due to drugs; Other hypotension; and, Hypotension, unspecified) Pulmonary oedema Pleural effusion, not elsewhere classified Acute kidney failure (Includes: Acute kidney failure with tubular necrosis; Acute kidney failure with acute cortical necrosis; Acute kidney failure with medullary necrosis; Other acute kidney failure; and, Acute kidney failure, unspecified) Unspecified kidney failure Abnormalities of heart beat (Includes: Tachycardia, unspecified; Bradycardia, unspecified; Palpitations; and, Other and unspecified abnormalities of heart beat) Ascites Cardiogenic shock Generalised oedema VLAD Heart Failure Working Group Summary of Activities Page 16 of 16