Download Heart Failure Order Sets

Heart Failure Order Sets
Standardizing Care for the Heart Failure
Patient
2012
Objectives:
 Standardize care for all heart failure patients in Legacy
 Base Practice on American Heart Association
Guidelines and Best Practice
 Improve the Continuum of Care for CHF patients
 Decrease length of stay and readmissions associated
with HF
March 19, 2013
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Co-Management Agreement
Focus Areas
 Legacy Cardiovascular Service Line across system
 Designate “Pillars” of cardiac care: Heart Failure, Rhythms,
Coronary Disease, and “General” Cardiology for initial
agreement
 Heart Failure Pillar mandate crosses through all aspects of
Legacy care
>
>
>
>
ED
Hospital Course
Discharge
Outpatient
What is Wrong With the Status Quo
 For CHF in-patients:
> 29% readmission rate within 30 days
 For CHF out-patients:
> Inadequate dosing of life saving drugs
 ACE Inhibitors
 Beta Blockers
Why CHF Pillar
 Heart failure is the most common hospital admission
diagnosis in patients age 65 or older
 Accounts for more than 700,000 hospitalizations
among Medicare beneficiaries every year
 Associated with severe functional impairments and
high rates of mortality and morbidity
 CMS target for quality initiatives and Core Measures
Legacy Medicare Vulnerability/Opportunity
 FY10 EMC $51,401,110
 FY11 EMC $54,988,087
 FY10 GS $70,777,895
 FY11 GS $70,521,181
 FY10 MP $33,419,171
 FY11 MP $34,779,386
 FY10 MH $17,775,619
 FY11 MH $17,574,637
 FY10 SC $39,315,706
 FY11 SC $40,494,024
 FY10 Total $212,689,501
 FY11 Total $218,357,315
$2,000,000-$6,000,000 Vulnerability plus
Opportunity for Bonus
From CHF readmissions
Why do CHF Programs work?
 They rescue the most vulnerable
> recently hospitalized patients
> Chronic NYHA Class 4 patients
 They titrate life saving drugs to full doses
> Some CHF patients are not on life prolonging drugs at all
> Of those who are, most are not on doses shown to provide the
life saving benefit
Heart Failure Pillar Performance Measures
• Heart Failure Readmission Rate
• Heart Failure Appropriate Care
Score
• Development of and Compliance
with System-wide, Quality-driven
Multidisciplinary Pathway
“Intake” Scope
• Determine disposition
• Medication List
• Medication Reconciliation
• Collection of baseline data
• Risk stratification / Risk
assessment
• Initiate HF education process
“Hospital Stay” Scope
• Multidisciplinary Rounds
• Medication reconciliation
• Continuing education
• Discharge planning /
organization of post d/c
services
• Accurate documentation / core
measures
• HF treatment per pathway
• Cardiac rehab referral
• Treatment goals per
HFSA/ACC/AHA guideline
• Evaluate specialist
consultation/ referral
“Discharge” Scope
• Discharge Criteria per
HFSA/ACC/AHA guideline /
readiness for discharge
• Medication reconciliation
• HF discharge instructions w pt
and family/ teach-back
• Documented d/c summary
• Ensure follow up scheduled
within 7 days
• Discharge checklist / Risk
Assessment
• Scale, blood pressure
machine, etc.
• PASS
• Provider notification of d/c
“Post-D/C” Scope
• Follow-up phone call
• Home visit
• PCP/Cardiologist/HF Clinic
visit
• Home tele-monitoring
• SNF/Home Health
coordination
• Disease Mgt / Case
Management
• Communication/Tracking/
Analysis of re-admissions
Team Members
Team Members
Team Members
Team Members
• Cardiologist
• Cardiologist
• Cardiologist
• Cardiologist
• ED physician
• Hospitalist
• Hospitalist
• Primary Care
• Hospitalist
• Inpatient Nurse / Nurse Mgr
• Inpatient Nurse / Nurse Mgr
• ED Nurse
• Cardiac Rehab Nurse
• Cardiac Rehab Nurse
• Nurse / HF Coordinator/ Home
Health/ Hospice
• ED Manager
• Care Management
• Care Management
• Inpatient Nurse
• Quality / Documentation
Specialist
•Pharmacy
• Care Management
• Care Management/quality
metrics management
•IT input
•Pharmacy
•Pharmacy
ED Visit
Admission
Who?
Ownership &
Accountability
Hospital Stay
Discharge
What?
Ambulatory F/U;
Post-discharge
Process, not
people
LEGACY HEALTH
Identifying Patients early in the ED
 If ED RNs note signs and
symptoms of dyspnea,
orthopnea, edema, weight
gain, or history of HF an
advisory will alert the use of
the “ED Protocol for Heart
Failure” with a decision tree
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HF patients who are discharged from the ED
 Standard HF teaching
instructions are given and
reinforced.
 HF Education from Exit Care
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Proper Identification if Heart Failure Patients
 HF Nurses/Case Mangers will run a workbench report each day
for “HF Admitted Patients”
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Order Set In Epic
 The “IP adult Heart Failure Order Sets” are in Epic and are based
on AHA guidelines and best practice. Use of these order sets are
essential to the success of the pathway
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LEGACY HEALTH
Multidisciplinary Rounds
 Multidisciplinary Rounds is alive at most sites and on the units
where HF patients are concentrated
 HF Nurses/Case managers will identify high risk patients during
rounds and actively work with the team to develop discharge plan
including:
>
>
>
>
3/19/2013
discharge medications
transportation home
follow up clinic appointments (coag clinic, PCP)
Teaching including documentation
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Daily Weights
 Standardize process for daily
weights
 Document time, charting
location
 Incorporate and document
teach back
 Utilize “Daily Weight Diary”
with patient involved in an
active roll in daily weight
management
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Discharge Instructions with Teach Back
 Standardization still in
process
 System-wide form utilization
will be based on community
standard and reviewed by
health literacy experts
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Teach-back Prompts
 I want to be sure that I explained your medication
correctly. Can you tell me how you are going to take
this medicine?
 We covered a lot today about your heart failure and I
want to make sure that I explained things clearly. What
are three things you can do that will help you control
your heart failure?
 What are you going to do when you get home?
 I shared a lot of information today. Could you share
with me what you heard?
 Can you show me how you are going to weigh yourself
when you get home?
What questions do you have?
LEGACY HEALTH
HF Basic Teach Back Questions
 What food are you to avoid?
 Name some salty foods you should not eat?
 How often should you weigh yourself?
 What time of day are you going to weight?
 What weight gain will your report to your care provider?
 How are you going to remember to take your medications?
 What pill/pills are you taking for your heart?
 What warning sign would prompt (cause) you to call the care
provider?
 Which provider would you call?
LEGACY HEALTH
Core Measure Documentation
 Physicians will use the IP Medicine Discharge summary
template the core measure check list is embedded in that
template and must be used to ensure 100% compliance with core
measure documentation
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Heart Failure Discharge
Guidelines-WORK IN PROGRESS (post Epic Upgrade)

Discharge expected today if clinically stable last 24 hours

Labs:

Discharge BNP is less than admit BNP (BNP decrease of at least 30%)

BUN/CR trending down

Electrolytes stable or improved

Respiratory status

O2 sat > 92% or baseline.
> Home oxygen therapy arranged as needed.

Activity tolerance- documented O2 saturation with activity.
> Activity level back to baseline
 Ambulation prior to discharge to assess functional capacity

Optimal Fluid status achieved
> Below baseline weight, if known. Aim net negative volume status if admission for volume overload.
> Discharge weight less than admit weight.

Pharmaceutical therapy near optimal> On oral medications for 24 hours; and stable for 24 hours.
> No IV vasodilators or inotropes for 24 hours

VS stable

T< 99.4 po ( 37.4 C )
> absence of orthostatic hypotension

Heart rate 50-100/min or baseline

Reminder: patient may meet these criteria but have different major diagnosis supporting continued IP stay.

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Post Discharge Follow-Up Appointments
 All High Risk
HF patients will
have follow-up
appointments
made before
discharge
 Each site will
identify the
appropriate
person and
work flow.
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Follow up phone calls-post discharge
 A follow up phone
call will be made
within 7 days post
discharge.
 Documentation will
be in a common
place under ”doc
flow sheets, Heart
Failure Follow up”
 This will allow all
clinicians, both out
patient and inpatient
to see note.
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Alert to Epic in-box for HF readmissions
 When patients are re-admitted with Heart Failure diagnosis an
alert will be sent to the Epic in-box of designated case
managers/HF Nurse Coordinator
 All patients with readmission alerts will be seen by case
managers/HF patients with in 24 hours of alert and discharge plan
reviewed for possible “misses”
 Care conferences will be planned for patient who have been
readmitted
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Readmission chart review
 Each readmission “fall out” will be reviewed by the respective
hospital committee
 A common process will be used and opportunities for improvement
will be identified (form to be developed)
 HF Pillar Medical Director will follow up on care issues
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HF Nurses at each site
 EH-Laura Wheeler, Lynn
Holter
 GS-Robin Klotz
 SC-Sue Frederick
 MP-Sue Willeson
 MH-Jill Sager, Bernadette
Hoover and Brenda
Grossnickle
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HF Volumes ‐ 12 month rolling averages
1050
1053
1079 1021 1014
1074
1036
1077
1144 1140
1097
1135 1208
1171 1168
LEH
LGS
LMP
LMH
Au
g‐ 1
2
‐1 2
J ul
‐1 2
J un
2
y ‐1
r ‐1
2
Ma
Ma
Ap
r‐ 1
2
2
b‐ 1
Fe
‐1 2
J an
De
c ‐1
1
1
No
v ‐1
1
t ‐1
Oc
Se
p‐ 1
1
1
g‐ 1
Au
‐1 1
J ul
‐1 1
J un
Ma
y ‐1
1
1200
1000
800
600
400
200
0
LSC
LEGACY HEALTH
HF Compliance, all measures/all sites
100
90
94 93
92 92
99 98 98
97
97
95
94
99
99 99
100!
97
99
98
99
80
70
Feb‐11
Apr‐11
Jun‐11
Aug‐11
Oct‐11
Dec‐11
Feb‐12
Apr‐12
Jun‐12
Aug‐12
LEGACY HEALTH
HF Inpatient Measure Compliance, August 2012
Top 10%
US Avg
LH
comp
num
den
EH
GS
MP
MH
SC
DC Instructions
100
93
96
80
83
100
98
94
93
100
LVF Assessment
100
98
100
95
95
100
100
100
100
100
ACE/ARB for LVSD
100
95
100
25
25
100
100
100
100
100
99
200
203
100
100
100
100
100
n=
39
52
44
15
53
Total fallouts
0
1
1
1
0
ACS (target 96.5)
100
96
96
86
100
n=
18
23
22
7
25
Overall compliance
LEGACY HEALTH
Legacy HF Pillar Dashboard
US Avg readmit rate for Medicare pt population = 24.8%
LEGACY HEALTH
HF 30 Day Observed/Expected Readmission Rate ‐ Medicare Pts
1.40
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Aug‐11 Sep‐11 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12
EH
GS
MP
MH
SC
LH
Linear (LH)
LEGACY HEALTH
1.40
HF 30 Day Observed/Expected Readmission Rate ‐ All Pts
1.20
1.00
0.80
0.60
0.40
0.20
0.00
Aug‐11 Sep‐11 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12
EH
GS
MP
MH
SC
LH
Linear (LH)
LEGACY HEALTH
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HF Mortality: All patient populations
EH
N u m b e r o f H F D e at h s
9
8
GS
7
6
MP
5
MH
4
SC
3
LH
2
1
0
Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12
LEGACY HEALTH
Next Steps
Medical Executive Committee Approval
JUNE/JULY
Quality Council Approval/Presentation
JUNE/JULY
Nurse Exec Committee Approval of Education Plan
JUNE/JULY
Education plan for Physicians roll out
AUG/SEPT
Education plan for nursing staff roll out
AUG/SEPT
Epic Projects testing completed and Operational
SEPT/OCT
Baseline data for HF order set compliance-Clarity report
SEPT
Audit for HF order set compliance
OCT/NOV
Tracking Implementation
 % Utilization of Heart Failure Admission Order Set
 % Utilization of Heart Failure Discharge Order Set
 30-day Readmission Rate
If Order Sets Followed, 100% Core Measurements
Will Be Reached
Summary
 Physician and Nurse Education is planned for fall
 All Epic pieces to be complete by fall
 Heart Failure Pillar will continue to adjust pathway to meet
American Heart Association guidelines as they are updated
 HF Nurses at each site will meet monthly for continuous process
improvement
 Heart Failure Joint Commission Accreditation
in 2013!
3/19/2013
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Any Questions?
 Lynn Pappas, Cardiovascular Service Line Director
> 503-415-5715
 Dr. Sandy Lewis, HF Pillar Medical Director
> 503-229-7559
 Desi Shubin, RN Manager
> 503-413-7299
 Mark Roady, CNS
> 503-413-3345
LEGACY HEALTH
LEGACY HEALTH
Questions?
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LEGACY HEALTH