To address quality and cost-effective outcomes for major diagnoses necessitating hospital admission, a large Midwestern health system formed an interdisciplinary care management committee. Care management encompasses the development and use of tools that reflect existing knowledge of best practice, proactive measures to address consumption of health services, and quality management. The first disease condition addressed by the care management committee was congestive heart failure (diagnosis related group 127), which represented the primary reason for medical admission to the acute care hospitals in the health system and offered an excellent opportunity to address quality and resource utilization issues.
To formulate guidelines for management of patients with congestive heart failure, an interdisciplinary expert panel was assembled. The panel developed a clinical algorithm, standing admission orders, and a clinical pathway for acute heart failure care, along with a set of key recommendations. Protocols later were designed for ambulatory care, home care, and the long-term care setting. The goals for the initiative (Sidebar) included prevention of early readmission to the hospital, an important reflection of quality of life, and symptom management, particularly pertinent to the home care and longterm care protocols.
This article describes the heart failure protocol developed and implemented in one of the health system's long-term care facilities located in close proximity to one of the health system's tertiary care hospitals. The facility is a combined senior community that includes 68 assisted living and 150 nursing home beds, 61 of which are skilled care. During the past year, the facility has averaged 30 skilled care admissions per month, with a median length of stay of 20 days (mean length of stay, 30 ± 47 days). The recent changes in Medicare reimbursement guidelines have led to an increased turnover of nursing home residents.
The prevalence of heart failure increases with age, with approximately 85% of heart failure cases occurring in adults age 65 and older (Kannel, Ho, & Thorn, 1994). Heart failure is the leading principal diagnosis for hospitalization among Medicare beneficiaries, and readmission rates are significant (Krumholz et al., 1997).
For patients hospitalized with new-onset heart failure, mortality has been estimated to range between 75% and 84% (Croft, Giles, Pollard, Keenan, & Anda, 1999). Although morbidity and mortality have been reduced by the use of ACE inhibitors and other medications (Havranek, Abrams, Stevens, & Parker, 1998; Luzier et al., 1998; Stevenson et al., 1995), heart failure ranked fourth in a list of target conditions for quality of care improvement in vulnerable older adults (Sloss et al., 2000).
Consensus recommendations for the diagnosis and management of chronic heart failure have been disseminated (Consensus Recommendations for the Management of Chronic Heart Failure, 1999; Hunt et al., 2001). In 2002, the American Medical Directors Association (AMDA), representing medical directors of longterm care facilities, updated its Heart Failure Clinical Practice Guideline (AMDA, 2002).
One guide to the diagnosis and therapy of heart failure is the ejection fraction of the heart, which can be measured with a two-dimensional echocardiogram. A normal ejection fraction, but findings of heart failure on chest radiograph (e.g., pleural effusion, vascular congestion) indicates diastolic dysfunction, which may be found in 50% of nursing home residents (AMDA, 2002). Although there is no standardized treatment for diastolic failure, digoxin should be avoided and systolic blood pressure should be lowered to the greatest degree possible without causing adverse symptoms.
An ejection fraction «a 40% indicates systolic dysfunction, for which the treatment of choice is an ACE inhibitor. This class of medications has been shown to reduce rehospitalizations and prolong life. In the presence of symptoms of New York Heart Association class III or IV heart failure, spironolactone should be added to therapy for its life-prolonging advantage.
An ejection fraction < 20% and a history of repeated hospitalizations may indicate end-stage cardiac disease. The nursing home provides an environment where residents and their families can assess expectations and reflect about prognosis with endstage heart failure. Often, a hospice approach can be selected for these residents and further hospitalizations are declined.
Because ACE inhibitors have been shown to prolong survival and improve quality of life in patients with systolic dysfunction, regulatory agencies such as the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission for Accreditation of Health Care Organizations (JCAHO) monitor the use of this class of medication in patients with a diagnosis of congestive heart failure as an indicator of quality of care. In at least one state, health plan and employer consortiums recently have targeted ACE inhibitor use and linked it to hospital financial incentives.
Although there are some exceptions to ACE inhibitors (e.g., hypotension, renal failure), generally most patients with congestive heart failure should be able to tolerate these medications. The presence of a disabling cough would prompt discontinuation of an ACE inhibitor and consideration of an alternate medication category such as angiotensin receptor blockers.
Experience suggests individuals who have an understanding of their chronic illness and who self-monitor specific parameters for worsening, improvement, or stabilization of their illness are less anxious and more likely to maintain control. Successful examples of this strategy have been demonstrated with hypertension and diabetes. Individuals who monitor their blood pressure or blood glucose at home are more likely to take their medications and bring their illness under control if the parameters become abnormal (Roter et al., 1998).
The parameter monitored for congestive heart failure is an individual's weight (Consensus Recommendations for the Management of Chronic Heart Failure, 1999). As the heart fails, it becomes a weaker pump and is unable to push fluid through the kidneys to be eliminated, leading to fluid accumulation in the body. This can result in shortness of breath, which frequendy is a cause for return to the hospital setting (Tsuyuki et al., 2001).
Ideally, by monitoring weight gain, individuals with heart failure can keep their illness under control in the outpatient setting or receive acute care at an earlier stage of decompensation with resultant shorter hospital stays (Miranda et al., 2002). Similarly, consistent monitoring of residents' weight by nursing staff in long-term care facilities could lead to early recognition and management of decompensation, avoiding returns to the hospital and thus improving overall quality of life and care for residents.
As the incidence of heart failure increases and the length of acute care stays decrease, the prevalence of heart failure can be anticipated to increase in all levels of long-term care. Skilled nursing and subacute care programs can be developed to serve &s a link in the continuum between an acute episode of debilitating illness and home (Lewis, 2002).
The role of residents and their family in self-managing chronic illness cannot be underestimated. The importance of complying with sodium restrictions and medications as well as regular weight monitoring should be regular components of education in the care plan. When residents are unable to participate in education, family or significant others should be considered as they can influence resident compliance and outcomes.
Elderly individuals and those with chronic illnesses including heart failure are at higher risk for morbidity and mortality with influenza and pneumonia (Centers for Disease Control, 1991, 1997). Currendy, CMS, state peer review organizations, and JCAHO monitor hospitals and other care facilities for the administration of influenza and pneumococcal pneumonia vaccines. Vaccination history should be assessed at the time of long-term care admission and tracked during the course of stay.
The protocol for monitoring congestive heart failure in the long-term care setting targeted two groups: nursing home and assisted living residents. Nursing home residents consisted of recent skilled care admissions from the hospital who required close monitoring to prevent worsening of their illness and thus early hospital readmission. The second group, assisted living residents, were medically stable but could benefit most from education and prevention of complications. The protocol was formulated by an interdisciplinary team that included the facility's medical director, director of nursing, and key nursing unit leaders. Nursing staff then received education regarding the specifics of the protocol.
The protocol is initiated at admission or readmission from acute care for those with a diagnosis of heart failure. Admissions personnel play a key role in early recognition of potential cases by requesting supportive diagnostic information such as echocardiogram and cardiology consult reports from discharging hospitals and admitting physicians. Recent weight information is requested along with immunization history.
Heart failure is verified at the time of admission by nursing staff through several methods such as:
* Review of hospital or outpatient records for history of congestive heart failure.
* Admission chest radiograph report showing changes of congestive heart failure.
* Echocardiogram report indicating cardiac dysfunction or an ejection fraction =s 40%.
* Medications used to treat congestive heart failure.
The medications prescribed for residents with congestive heart failure may be reviewed by the consulting pharmacist and the medical director of the facility for evidencebased care. In questionable cases, the diagnosis is confirmed by a physician.
Weight Monitoring Regimen
Once the diagnosis of congestive heart failure has been verified, residents are placed on a weight regimen by the nursing staff. Residents are weighed three times per week until their weight has been evaluated as stable, defined as a weight gain < 2 lb for three measurements. After their weight has been determined to be stable, residents are weighed weekly. Residents with a weight increase Ss 2 lb receive a standardized nursing assessment. The assessment includes auscultation for breath sounds that do not clear with coughing as well as evaluation for:
* Shortness of breath.
* Inability to breathe while lying flat.
* Night cough.
* Fluid in the legs.
* Change in vital signs.
Residents' physicians are called if the nursing assessment findings after a 2-Ib weight gain were positive or if the nursing assessment findings were negative but the weight gain was 4 lb. If the physician's response is appropriate, the resident should improve and hospitalization should be prevented.
Preventive Vaccination Policy
The nursing home had been targeting preventive vaccinations as a quality initiative for 10 or more years. Efforts were made to obtain vaccination history at the time of admission, and residents or their families were asked each fall for permission to administer influenza and pneumococcal vaccinations. However, quality monitoring data showed this was an ineffective strategy because opportunities for pneumococcal vaccination throughout the year were missed and families frequently failed to return the signed permission forms.
After the heart failure protocol was implemented, the vaccination policy was revised so vaccines were administered automatically when indicated unless specifically refused by residents or their family. Notice of this new vaccination policy was provided to the families of all current residents and on admission to all new residents.
A heart failure education booklet was developed for use across the continuum of care. It included information about the causes of fluid retention, dietary intervention (such as salt restriction), the need for continued monitoring of residents' weight, and the purposes of their medications. The booklet provided a basis for education in the long-term care facility.
Dietary and nursing staff developed a strategy for education. Stable assisted living residents received education including how to weigh themselves and follow their weight as a sign of worsening of their illness. Those admitted to the nursing home following hospitalization were targeted for education as part of the plan for discharge.
Health system care management initiatives are monitored for impact on quality and utilization. Indicators for the heart failure initiative were based on the national CMS Sixth Scope of Work heart failure initiative. These indicators were adopted by JCAHO as part of its quality care Core Measures. Applicable indicators for the long-term care heart failure protocol that were tracked and compared over time were:
* Inclusion of a current echocardiogram report or ejection fraction in residents' clinical record. Hospitals throughout the health system established the availability of echocardiogram results as one of their key quality indicators for congestive heart failure. The emphasis on monitoring echocardiogram results in the nursing home provided the opportunity to assess thoroughness in obtaining clinical data from the acute care setting and provided improved coordination of long-term care with acute inpatient treatment.
* Use of ACE inhibitors in appropriate residents with heart failure. This indicator was monitored in residents with systolic dysfunction. In a large long-term care study, Gambassi et al. (2000) demonstrated only 25% of residents with congestive heart failure received ACE inhibitors. The goal at the facility was to optimize the use of ACE inhibitors or alternatively the use of angiotensin receptor blockers if an ACE inhibitor was contraindicated. The health system goal for this indicator was 80% use of ACE inhibitors or documented exception to use of the drug.
* Use of a standardized nursing assessment. This indicator was developed locally for the long-term care facility to monitor effective use of the weight and assessment portions of the protocol. It encompassed weight monitoring, nursing assessment for symptoms of congestive heart failure, and the reporting of weight changes and symptoms to residents' attending physicians. It was anticipated that standardized assessment parameters, agreed on collaboratively in advance, would increase staff confidence in their clinical skills and the validity of reporting to attending physicians.
* Effective treatment for congestive heart failure symptoms. This indicator was developed locally to measure the response of physicians to weight changes and the presence of congestive heart failure symptoms with the result that ^hospitalization for treatment is avoided.
* Attainment of a 90% immunization rate for influenza and pneumococcal vaccines. The target for each type of immunization was set at 90% rather than 100% as there were still residents and families who feared these injections and continued to refuse them.
* Education for residents and their families regarding heart failure. For the nursing home program, this indicator measured whether residents received information on medications, diet, weight monitoring, and smoking cessation (if applicable) prior to discharge. Those in assisted living received education while in the facility. The target rate was set at 100%.
The protocol for congestive heart failure was introduced in March 2001. A total of 17 residents (9 skilled nursing and 8 assisted living residents) were identified as having potential to be enrolled in the protocol. It took approximately 2 months for the nursing staff to become familiar with identifying appropriate residents and monitoring for weight gain and symptoms of heart failure.
Progress with the protocol was assessed in May (n = 12 for skilled nursing home and ? = 8 for assisted living residents), September (n = 18 skilled nursing home and ? = 8 assisted living residents), and November (n = 6 skilled nursing home residents). The May assessment is referred to as the baseline period because this was when the protocol was first fully implemented. The assisted living residents were not included in the third assessment period because the initial residents stabilized and continued in the residential setting without difficulty by the second assessment period.
At baseline, the first quality indicator, echocardiogram availability, was not met well in either setting. By September, echocardiograms were included in the records of 66% of residents with heart failure in the nursing home and 55% of those in assisted living. This was achieved by calling the hospital inpatient units and asking for reports to be faxed to the long-term care facility. In November, there was a slight decrease to 50% of those in the nursing home while echocardiograms for those in assisted living remained unchanged (Figure 1).
The notable turnover in skilled nursing home residents presents an ongoing challenge to obtain current pertinent clinical information, particularly from the hospital setting. Echocardiogram use improved to 67% (n = 18) 5 months following the initial three assessment periods. Access to the health system reporting information system aided in obtaining results if not provided by the feeder hospitals when residents were transferred to the long-term care facility.
Figure 1 . Graph depicting documented echocardiogram report or ejection fraction in residents' clinical records.
Figure 2. Graph depicting ACE inhibitor use in appropriate residents with heart failure.
Use of ACE Inhibitors
The second indicator, use of ACE inhibitors for appropriate cases of heart failure, increased in both settings from the baseline calculations (Figure 2). By the third assessment period, this group of medications was prescribed for 66% of assisted living and 50% of nursing home residents with systolic heart failure. This increase reflected a successful effort by the health system's care management committee to improve the use of ACE inhibitors in the acute setting, from which most of the nursing home admissions had come.
Figure 3. Graph depicting effective symptom management.
Figure 4. Graph depicting influenza immunization.
Improvements also reflected concerted efforts by the medical director to educate attending physicians at the facility through presentations at monthly staff meetings. In a révaluation 5 months following the initial three measurement periods, ACE inhibitor use improved even further to 83% in the skilled nursing residents n = 1 8).
Nursing Assessment and Response of Physicians
Nursing assessment and the response of physicians were not assessed at baseline. This was one of the most difficult areas of the protocol to implement. During the first 2 months after the protocol was introduced, the medical director ascertained the nursing staff did not understand why they were monitoring residents' weight, how they needed to assess for the presence of symptoms of heart failure, and how they needed to contact residents' attending physicians to receive changes in medication orders. This observation necessitated staff education and reinforcement.
By baseline, the nursing staff was more able to respond to the parameters in the protocol, and symptom management improved (Figure 3). In the assisted living section, 66% of residents with heart failure were being appropriately weighed by September, and reports to physicians were made in an appropriate manner. The success rate was not 100% because two residents were not compliant with their self -medication regimen.
By November, there was 100% success in both the nursing home and assisted living with monitoring residents' weight, reporting outcomes to attending physicians, and obtaining an appropriate physician response. During the November monitoring, none of the residents had worsened heart failure symptoms sufficient to require acute inpatient treatment; instead, all were treated in the longterm care setting.
Five months after the third measurement period, a review of skilled nursing residents showed that of 18 heart failure residents, 1 1 were identified by staff as having episodes of clinical deterioration (n = 22 episodes), but only one episode led to acute hospitalization. In addition, improved nursing assessment has benefited residents with pneumonia, chronic lung disease, and renal failure because these conditions also result in shortness of breath, weight gain, or both.
The percent of residents who had influenza vaccination (Figure 4) was low at baseline and at the second assessment period because data were based on the prior year vaccination season (usually October through February). By the third assessment period in November, after the new vaccination policy was in place at the facility, the influenza vaccination rate improved to 90% in both the residential and nursing home settings. Families were provided with written information on vaccinations and notified that vaccinations would be administered to all eligible residents unless there was a specific refusal from residents or their guardian.
Similarly, the pneumonia vaccination rate at baseline also was low (Figure 5). Efforts were made to vaccinate residents against pneumococcal pneumonia at admission or on return from the hospital. The assisted living section achieved 100% compliance; the nursing home compliance with this indicator was 30%. The higher rate of resident turnover in the nursing home section requires continued diligence in obtaining vaccination histories and pursuing follow up when indicated.
Resident and Family Education
Resident education was not assessed at baseline (Figure 6) as no formal program had been in place prior to implementation of the protocol. Again, this was something more difficult and complex to implement. Dietary and nursing staff designed a resident education guideline for use in the facility. The assisted living section reached 100% compliance with resident education by the September assessment, but during the November assessment, there was still only 30% achievement of resident education in the nursing home.
Education was planned for the nursing home residents and families near the time of discharge. Unfortunately, the prospective payment system implemented by Medicare for reimbursement to skilled nursing facilities resulted in shorter lengths of stay with less advance planning time regarding the exact day of discharge.
An assessment conducted 5 months after the November assessment showed no improvement in the area of resident education. An interdisciplinary planning committee whose purpose has been to clarify and coordinate the roles of various providers in the nursing home discharge planning process has now addressed this problem. A standardized resident discharge instruction tool has been developed for use in the nursing home. Education of residents and their families is expected to be better planned ior, implemented, and documented.
Figure 5. Graph depicting pneumococcal immunization.
Figure 6. Graph depicting resident education.
Although all of the goals were not met, the protocol and use of identified quality indicators has driven the facility toward better resident care. The specific aspects of care were defined and agreed on by both medicine and nursing. Indicators enabled monitoring of care over time. Care that needed to be addressed therefore could be evaluated and improved on collaboratively by the disciplines involved. The indicators selected provided direction for specific strategies. These quality indicators are comparable to those recommended by Fonarow (2001) for heart failure in vulnerable elder adults.
Heart failure is a chronic disease, frequently characterized by exacerbations and remissions. Current strategy in the treatment of chronic illness is to teach residents and caregivers how to monitor for signs of early decompensation and initiate timely action based on these findings when indicated.
The parameter for monitoring worsening of heart failure is weight gain and resulting increase of adverse symptoms (e.g., shortness of breath, congestion, edema). By self-monitoring, residents can be more in control of their illness and better able to prevent exacerbations and hospitalization.
In the long-term care setting, nursing plays a major role in identifying residents with heart failure, monitoring their condition, and providing resident and family education. Use of quality indicators can help long-term care facilities systematically monitor specific care processes and improve clinical outcomes.
This protocol for congestive heart failure in a long-term care facility has strengthened the continuum of care between inpatient and post-acute settings. A more comprehensive, standardized set of diagnostic data is now pursued when residents are admitted or transferred to long-term care. Standardized heart failure management is emphasized for inpatient long-term care and post-discharge care.
The protocol also has strengthened the role of nursing through a greater understanding of the pathophysiology of illness, the role of nursing assessment, and the value of resident education. Resident education for self-management has received increased focus in both the assisted living and nursing sections. The protocol also helped shape a new policy for vaccination, and the development and use of the discharge planning document were direct outgrowths from this initiative.
Finally, the protocol provided a tool for monitoring a specific outcome over time so that deficits are detected and improvements are achieved. Data were especially helpful in modifying physician practice patterns and educating facility administration by providing messages about current performance.
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