1. CHF Team Approach Peter Carson, MD Jacqueline Gannuscio, MSN, ACNP RN Washington DC

2. Performance Measures Improvement: A Team Approach to Acute Hospital Management of CHF ABSTRACT: Congestive Heart Failure is a prevalent problem in this country with nearly 5 million patients diagnosed. It is the most common DRG in hospitalized patients, with hospital discharges for heart failure (HF) rising 179% from 1979 to 2003. Readmission rates are as high as 50% within 6 months. There have been positive outcomes for hospital readmission, adherence to guideline based therapy, costs, and quality of life, in outpatient HF programs. However little is known about the impact Heart Failure Teams on outcomes in the hospital. The Washington DC Veteran’s Administration (VA) Medical Center tracks quality in the outpatient and inpatient settings by the use of Performance Measures. For heart failure, use of Angiotensin Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARB) discharge instruction for diet, weight and medications are followed. In the last quarter of 2005 compliance with the last two measures met or exceeded the VA goal of 90%. Use of ACEI or ARB however was 75%. In the fall of 2005 a team approach was initiated for management of patients hospitalized with HF, which included a Cardiologist and an Acute Care Nurse Practitioner. Each of the five medical teams were contacted daily and asked about new patients admitted with HF. Consult orders were also placed to Cardiology Heart Failure Team. These were completed by the NP within 24 hours, and diagnostic and treatment recommendations were made to the medical team. Ongoing education of medical residents and interns is an integral part of the process. There was an improvement in ACEI/ARB use during the period from 10/05 to 6/06 with 100% compliance noted at the latest review. Use of NP’s as members of HF teams improves outcomes as measured by improvement in HF Performance Measures.

3. RESEARCH Washington DC VA Medical Center Heart Failure Program OUTPATIENT CLINIC INPATIENT MANAGEMENT

4. JCAHO Heart Failure Measure Trends 04.01.2004-03.31.2005 33

5. Discharge Medications The percentages for Aldosterone Receptor Antagonist and Subcutaneous Erythropoietin may be under-reported in the cumulative columns since these medications were added to the case report form in Q1 2004, and therefore were not available options to the total benchmark population. LAST QUARTER n=1474 01.01.2006- 03.31.2006 LAST 12 MONTHS n=13210 04.01.2005- 03.31.2006 CUMULATIVE n=140841 01.01.2001-03.31.2006 ACEi or ARB (%) ACE Inhibitor (%) Angiotensin II Receptor Blocker (%) Aldosterone Receptor Antagonist (%) 67 51 19 22 67 53 16 20 67 54 15 9 Aspirin (%) Beta-blocker (%) Digoxin (%) Diuretic (%) 56 76 25 84 54 74 26 82 49 64 32 85 Lipid-Lowering (%) Nitrate (%) Subcutaneous Erythropoietin (%) Warfarin (%) 49 25 4 30 47 26 3 28 39 29 1 28 52

6. Performance Measures for HF 10/04-8/05 VISN 5

7. HF-Inpt on ACEI/ARB FY05

8. VAMCDC Inpatient HF Program Components of Program: Medical Teams – Primary Providers CHF MD and NP – Medical Consultants Nursing – Bedside Care and Education Case Management – Discharge Planning Dietary – Dietary Education PT – Mobility and Functional Improvement Tools EMR CHF Order Set CHF Consult Discharge Instructions Advanced Clinic Access

10. CHF Orders

11. Select Components of Discharge Instructions

12. VAMCDC ACEI/ARB 12/05-6/06