Abstract 268: Multidisciplinary Approach to the Heart Failure Patient Significantly Improves Adherence to Evidence-Based Medicine Beyond Core Measures

Background: Adherence to heart failure core measures has been a focus of all hospitals in the past several years and has become even more important with the advent of pay for performance. Core measures address basic heart failure care, but do not include utilization of all evidence-based therapies which improve long term outcomes. We hypothesized that an in-hospital multidisciplinary heart failure (HF) management program could improve adherence to evidence-based guidelines beyond core measures. Methods: As a quality improvement initiative, we formed a multidisciplinary team to improve compliance with HF evidence-based therapy. Interventions included multiple educational sessions, discharge and post-discharge transition improvements, concurrent and post-discharge chart abstraction, revised patient education, and real-time provider education. Charts were abstracted in 525 consecutive HF inpatients between Jul 2010 and Mar 2011. Data was collected in the GWTG-HF (Outcome Inc) Registry. Pre-intervention compliance data (Jul-Sep) was compared to post-intervention (Nov-Mar) data with a paired t test and the Mann-Whitney rank sum test. Direct variable cost was analyzed for defect-free cases versus cases with defects. Results: Baseline Demographics: Mean age was 69 years, 42% female, 20% black, 55% ischemic etiology, mean LVEF=37%. Prior to the multidisciplinary intervention, overall defect-free care was excellent at over 89% (see figure) but there was a relative underutilization of aldosterone antagonists, hydralazine/nitrate therapy, CRT-D and anticoagulation for AF. Post-intervention, adherence improved to over 90% for all 8 evidence based therapies including: evidence-based beta-blocker (p=0.002), aldosterone antagonist (p<0.001), hydralazine nitrate (p=0.04), ICD placed or prescribed (p<0.001), CRT-D (p=0.002), anticoagulation for afib (p=0.04), and DVT prophylaxis (p=0.04). Mean direct variable cost per case was higher at $8249 in defect cases versus $6951 in defect-free cases. Conclusions: In this single center experience, interventions led by a HF multidisciplinary team can significantly improve adherence to evidence-based therapies, beyond core HF measures. A multidisciplinary approach to inpatient HF care has the potential to decrease HF related costs.

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Care transition from rehabilitation to home: A QI project using the RED Toolkit to decrease readmission rates

Journal of Hospital Administration ◽

10.5430/jha.v10n1p46 ◽

2021 ◽

Vol 10 (1) ◽

pp. 46

Author(s):

Jennifer R. Bernard ◽

Eileen L. Creel ◽

Rhonda K Pecoraro

Keyword(s):

Quality Improvement ◽

Hip Fracture ◽

Healthcare Providers ◽

Inpatient Rehabilitation ◽

Care Plan ◽

Quality Improvement Initiative ◽

Evidence Based ◽

Discharge Process ◽

Post Discharge ◽

Post Intervention

Objective: This quality improvement (QI) project’s aim was to lower 30-day healthcare reutilization for patients aged 50 or older with hip fracture using an evidence-based discharge process method, the Re-Engineered Discharge (RED) Toolkit.Methods: The QI project of a revised patient discharge process to lower healthcare reutilization of Baton Rouge Rehabilitation Hospital (BRRH) hip fracture patients was implemented as an evidence-based quality improvement initiative. Inpatient and outpatient discharge process revisions were implemented at an inpatient rehabilitation facility (IRF) based on Re-Engineered Discharge (RED) Toolkit recommendations. Inpatient revisions included patient barrier identification with associated documentation changes to the IRF interdisciplinary team form. Outpatient modifications consisted of an After-Hospital Care Plan (AHCP), and two post-discharge Telephone Follow-Up (TFU) calls.Results: Healthcare reutilization and thirty-day hospital readmission for this project were measured at 8.5% and 5.7%, respectively. A decrease in healthcare reutilization of at least 1.6% was observed for the IRF. Most participants scored at a high level (88.6%) of “patient knowledge of self-management” post intervention. Out of participants who did not attend their first Primary Care Provider (PCP) appointment, 33.3% experienced healthcare reutilization. This result emphasized the importance of seeing one’s PCP post-discharge. Patient satisfaction increased by 5% and 6.73%, measured by Hospital Consumer Assessment of HealthCare Providers and Systems (HCAHP) scores for nursing care and physician care, respectively.Conclusions: Implementation of a RED Toolkit-based discharge process at an IRF positively impacted all three study outcomes and associated healthcare costs in lowering preventable readmissions.

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Abstract P164: Reduction of Heart Failure Readmissions Through an Enhanced Internal Medicine Residency Curriculum

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_2.ap164 ◽

2011 ◽

Vol 4 (suppl_2) ◽

Author(s):

Mercy P Chandrasekaran ◽

Janice Barry ◽

Barbra White ◽

Paula L Eryazici ◽

Sorin C Danciu

Keyword(s):

Internal Medicine ◽

Heart Failure ◽

Internal Medicine Residency ◽

Post Discharge ◽

Post Intervention ◽

Statistical Comparison ◽

Residency Curriculum ◽

Core Measures ◽

The Impact

Background: Heart failure (HF) carries a significant economic burden and hospitalizations account for 70% of the total costs of heart failure. Rehospitalizations are particularly costly and potentially avoidable. As part of the National Initiative for Alliance of Independent Academic Medical Centers, we aimed to decrease the HF readmissions by 5% through enhancements in the Internal Medicine Residency Curriculum. Methods: Between 7/10-2/11, we implemented a HF lecture series, multidisciplinary rounds, article and case reviews. Cardiac Rehabilitation, Information Systems, HF Team, Case Managers/Social Work and Nursing staff collaborated to develop better documentation and discharge protocols. To determine the impact of our intervention, the change in 30-day readmission and pre and post questionnaire about HF knowledge/attitudes were statistically analyzed. Results: The pre test questionnaire showed: 1) Residents felt more confident in treating/ counseling patients with HF and were not as confident in identifying precipitants of readmissions or applying core measures. 2) Most residents felt the key factors to preventing readmissions were close post-discharge follow up and patient education. Post intervention questionnaire showed: 1) More residents were confident about the core measures, quality indicators, appropriate documentation of HF. 2) More residents were satisfied with the Internal Medicine Residency Curriculum. The average HF readmission rate reduced from 24.6% to 20.9% between 7/10-11/10 (above goal). January - August 2010 (Before Intervention) September - November 2010 (After Intervention) All HF Admissions 1178 464 All HF Readmissions 292 (24.8 %) 103 (22.2%) Primary HF Admissions 167 63 Primary HF Readmissions 40 (24.0%) 12 (19.0%) Statistical comparison of All HF p=0.483, OR 1.339, 95% CI 0.656-2.727 Statistical comparison of Primary HF p=0.276, OR 1.155 95% CI 0.895-1.491 Conclusions: A 6-month resident-oriented multidisciplinary intervention improved patient care, documentation, and resident understanding of HF syndrome. This led to promising trends towards a significant decrease in 30-day HF readmissions. Further improvement in outcomes should be evident at the completion of 12-month follow-up.

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Heart Failure Core Measures-A Multidisciplinary Approach

Heart & Lung ◽

10.1016/j.hrtlng.2009.03.028 ◽

2009 ◽

Vol 38 (3) ◽

pp. 277

Author(s):

C. Hinojosa ◽

J. Giardina ◽

K. Radtke ◽

C. Vournazos

Keyword(s):

Heart Failure ◽

Multidisciplinary Approach ◽

Core Measures

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Abstract 214: Multidisciplinary Approach to Improve Process Measures and Prevent Heart Failure Readmissions

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.5.suppl_1.a214 ◽

2012 ◽

Vol 5 (suppl_1) ◽

Author(s):

George Syros ◽

Mitesh Kabadi ◽

Sarah Blanchard ◽

Kristin Aviles ◽

Claire Melvin ◽

...

Keyword(s):

Heart Failure ◽

Performance Measures ◽

Multidisciplinary Approach ◽

High Risk Patient ◽

Care Staff ◽

Rank Test ◽

Fluid Restriction ◽

Post Discharge ◽

Readmission Rates ◽

Process Measures

Background: Approximately 5.2 million Americans have heart failure (HF). HF morbidity and mortality is high, and 27% of patients are readmitted at 1 month and 50% at six months. Objective: To determine the effect of a multidisciplinary approach on Hospital Quality Alliance (HQA) performance and 30-day HF readmission rates. Methods: A one year, prospective, observational study on the effect of a multidisciplinary approach on 30-day HF readmissions was performed and compared to the prior year’s readmission rate at a University affiliated community hospital. HF patients were identified by case and unit nurse managers, who also screened for intravenous diuretic use to determine if patients had HF but were admitted under another diagnosis. HF patients were clustered geographically where daily multidisciplinary rounds with the unit nurse and care manager, pharmacist, social worker, nutritionist, medical and nursing staff took place. The goal was to ensure compliance with the established HQA Performance Measures, initiate appropriate discharge planning, and assess functional status. Patients were educated on 2 gram sodium diet, 2 liter fluid restriction, daily weight monitoring, and smoking cessation. Follow-up appointments with their PCP or cardiologist were scheduled. Upon discharge, nursing and medical staff provided medication and home management instructions. The patient’s PCP was called by the attending physician or cardiovascular fellow as well as the Skilled Nurse Facility, Rehabilitation, and Home Care staff, when applicable. Targeted in-home support immediately following discharge from the hospital was provided. High risk patient had an in-home 2-3 day post discharge visit by VNA and a Pharmacist to access their weight, medications, and physical activity progress. Results: During the intervention year, 355 CHF patients were discharged and compared to 318 patients in the year prior. The 30 day readmissions were reduced from 79 (24.8 %) to 64 (18.03%), p = 0.04 by Wilcoxon Signed-Rank Test. The Heart Failure National Inpatient Quality Measures performance increased from 95% ± 3.8% (2010) to 99.6% ± 0.5% (2011) - p = 0.008 . Conclusions: With implementation of penalties by Medicare in 2013 for 30 day HF readmissions, strategies to reduce them are critical. A comprehensive intervention involving multiple specialties and appropriate patients’ disposition can reduce 30-day readmission rates as well as improve Heart Failure National Inpatient Quality Performance Measures. Further evaluation of this treatment approach, including an assessment of cost-effectiveness, is warranted.

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Implementation of an Evidence-Based Practice Discharge Medication Protocol for Heart Failure Patients to Reduce 30-Day Readmissions

10.46409/sr.qtur9486 ◽

2021 ◽

Author(s):

◽

Dawn Onstott

Keyword(s):

Heart Failure ◽

Evidence Based Practice ◽

Statistical Significance ◽

Heart Association ◽

Evidence Based ◽

Post Intervention ◽

Healthcare Budget ◽

Discharge Medication ◽

Intervention Protocol ◽

The One

Practice Problem: An estimated 6.5 million American adults ≥20 years of age have heart failure (HF) and worldwide 1 to 2% of the total healthcare budget is spent on HF. To improve outcomes and streamline the treatment of HF patients, The American Heart Association (AHA) joined with the American College of Cardiology (ACC) and created the Get With The Guidelines Program (GWTG). PICOT: The PICOT question that guided this project was in adult HF patients admitted to the cardiovascular unit under the care of the hospitalist service, does implementing an evidence-based practice (EBP) discharge medication protocol for physician use based on the AHA GWTG program’s HF discharge medication protocol, compared to no standardized discharge protocol, improve patients’ 30-day readmission rate, in 12 weeks? Evidence: Evidence from 10 studies supported implementing an evidence-based GDMT tool into a standardized HF discharge medication protocol for this project. Intervention: Education and encouragement of use of the AHA GWTG discharge medication protocol for HF in the electronic health record (EHR) was provided to a group of physicians on a cardiovascular unit. The intervention was over a four-week period and pre- and post-intervention protocol use was observed with specific measures analyzed for observation of improvement. Outcome: The results determined there was minimal statistical significance, however, there was a decrease in the financial measure of the cost of HF readmissions denoting a clinical significance. Conclusion: Continued use of a guideline-based discharge medication protocol, such as the one utilized in this project, is recommended based on the results and evidence provided in this project.

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Abstract 14370: Rapidly Improving Adherence to Guideline-Directed Medical Therapies in Metropolitan Heart Failure Systems of Care

Circulation ◽

10.1161/circ.142.suppl_3.14370 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jacqueline Tomei ◽

Robin Y Kiser ◽

Lynn Mallas-Serdynski ◽

Michelle Scharnott ◽

Michele M Bolles ◽

...

Keyword(s):

Heart Failure ◽

Patient Outcomes ◽

Professional Education ◽

Systems Of Care ◽

Beta Blockers ◽

Primary Diagnosis ◽

Evidence Based ◽

Aldosterone Antagonists ◽

Aldosterone Antagonist ◽

The Mean

Background: The 2017 AHA/ACC/HFSA Focused Update of the 2013 ACC/AHA Guidelines for the Management of Heart Failure provided additional support for the clinical use of ACEI, ARBs or ARNIs in conjunction with Evidence-Based Beta Blockers and Aldosterone Antagonists in HFrEF, otherwise known as Guideline-Directed Medical Therapy (GDMT). Although these updates clarified the benefits of GDMT to patient outcomes, low rates of adherence at the provider level for both hospitalized and ambulatory patients continue to be seen. Methods: With the objective of rapidly improving GDMT utilization, as well as improving patient outcomes, the American Heart Association initiated a multidisciplinary collaborative in three metropolitan markets - Chicago, Milwaukee, and St. Louis. Utilizing Get With The Guidelines®-Heart Failure (GWTG-HF), 40 hospitals tracked patients discharged with a primary diagnosis of heart failure and entered data from their inpatient and 30-days post-acute record. An initiative benchmark group was created to track progress and revisions were made to the post-acute care form. Hospitals were provided targeted consultation using hospital-specific data compared to regional and initiative benchmarks. The initiative provided exclusive professional education, including webinars, collaboration meetings, and best-practice recommendations. Results: Between January 1, 2019 and December 31, 2019, 10,532 patients with a primary diagnosis of heart failure, were entered into GWTG-HF from the 40 initiative hospitals, in which 3807 had an EF of <40%. A comparison from Q1 to Q4, 2019 of the mean adherence for GDMT was performed at discharge and yielded the following results: ACEI/ARB or ARNi from 89.3% to 91.6%, Evidenced-Based Beta Blockers from 90.3% to 94.2% and Aldosterone Antagonist from 53.6% to 64.7%; At 30-Days the mean adherence for Q1 and Q4 were calculated as follows: ACEI/ARB or ARNi from 60.4% to 72.9% and Aldosterone Antagonist from 28.2% to 55.3%. Evidence-Based Beta Blocker was only captured for Q3 and Q4, 2019 and the mean adherence improved from 70.3% to 73.8%. Conclusions: The multi-city quality initiative early results show a positive correlation in improving adherence to GDMT in both the hospital and ambulatory setting.

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CLABSI reduction using evidence based interventions and nurse empowerment: a quality improvement initiative from a tertiary care NICU in Pakistan

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-318779 ◽

2020 ◽

pp. archdischild-2019-318779

Author(s):

Ali Shabbir Hussain ◽

Anjum Mohyuddin Ahmed ◽

Saba Arbab ◽

Shabina Ariff ◽

Rehan Ali ◽

...

Keyword(s):

Quality Improvement ◽

Neonatal Intensive Care ◽

Fungal Infections ◽

Tertiary Care ◽

Central Line ◽

University Hospital ◽

Quality Improvement Initiative ◽

Evidence Based ◽

Post Intervention ◽

Nurse Empowerment

ObjectiveCentral line associated bloodstream infection (CLABSI) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). We designed a CLABSI Prevention Package (CPP) to decrease NICU CLABSI rates, using evidence-proven interventions.DesignThis was a quality improvement (QI) project. Data collection was divided into three phases (pre-implementation, implementation and post implementation). SQUIRE2.0 guidelines were used to design, implement and report this QI initiative.SettingA tertiary care level 3 NICU at the Aga Khan University Hospital (AKUH), Karachi, Pakistan.PatientsAll patients admitted to the AKUH NICU from 1 January 2016 to 31 March 2018 who had a central line in place during their NICU admission.InterventionsCPP used evidence-based interventions focusing on hand hygiene, aseptic central line insertion techniques and central line care, prevention of fungal infections and nurse empowerment.Main outcome measuresCLABSI rates pre and post intervention were recorded. Secondary outcomes were risk factors for CLABSI, device (central line) utilisation ratio, CLABSI related mortality and micro-organism profile.ResultsCLABSI rates decreased from 17.1/1000 device days to 5.0/1000 device days (relative risk (RR)=0.36, CI=0.17–0.74). Device (central line) utilisation ratio declined from 0.30 to 0.25. Out of 613 patients enrolled in our study, 139 (22.7%) died. Mortality was higher in CLABSI group (n=20, 44%) as compared with non CLABSI group (n=119, 21.1%) (p<0.001). Gestational age of <27 weeks was an independent risk factor for CLABSI (RR=4.45, CI=1.10–18.25, p=0.03). A total of 158 pathogens were isolated among which 68 were associated with CLABSI. Gram-negative bacteria 31 (47.7%) were the most common cause of CLABSI. Ninety-seven (61%) micro-organisms were multi-drug resistant.ConclusionsCPP was effective in decreasing NICU CLABSI rates and can be used as a model to decrease NICU CLABSI rates in low or middle-income countries.

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Aldosterone Antagonists: Evidence-Based Yet Underutilized Effective Heart Failure Therapy

Congestive Heart Failure ◽

10.1111/chf.12022 ◽

2013 ◽

Vol 19 (3) ◽

pp. 105-106 ◽

Cited By ~ 3

Author(s):

Carl J. Lavie ◽

James J. DiNicolantonio ◽

James H. O'Keefe ◽

Hector O. Ventura

Keyword(s):

Heart Failure ◽

Evidence Based ◽

Heart Failure Therapy ◽

Aldosterone Antagonists

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Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data

BMJ Open ◽

10.1136/bmjopen-2017-018243 ◽

2017 ◽

Vol 7 (11) ◽

pp. e018243 ◽

Cited By ~ 8

Author(s):

Vera Maria Avaldi ◽

Jacopo Lenzi ◽

Stefano Urbinati ◽

Dario Molinazzi ◽

Carlo Descovich ◽

...

Keyword(s):

Heart Failure ◽

Observational Study ◽

Administrative Data ◽

Hospital Readmission ◽

Patient Adherence ◽

Angiotensin Receptor Blockers ◽

Secondary Outcome ◽

Evidence Based ◽

Aldosterone Antagonists ◽

Β Blockers

ObjectivesTo evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF).DesignRetrospective observational study based on administrative data.SettingLocal Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants.ParticipantsAll patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015.Primary and secondary outcome measuresMultivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge.ResultsThe study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (–53% and –28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (–28%).ConclusionsCompared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.

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