Performance Measurement, Staffing, and Facilities Requirements for Observation Unit Heart Failure Management

Nancy M. Albert

When planning to open a heart failure (HF) management program in a chest pain center (also known as a short stay or observation unit), there are behind-the-scenes aspects to consider that promote optimal patient outcomes. Even though emergency care quality indicators are not specific to HF management, a substantive HF program should meet performance standards deemed important to inpatient and ambulatory HF care. Thus, the purpose of this chapter is to discuss performance measurement specific to HF care. Staffing and facilities requirements are discussed because they provide the structure and process aspects of a quality HF program that advances performance scores to improve patient quality of life, decrease morbidity, and reduce the quantity and length of hospitalization episodes.

Performance Management

No specific HF performance measures exist for a HF management program in a short stay unit setting. Performance measures were developed for hospitalized and ambulatory patients with HF by national organizations (Table 8-1) to improve the quality and consistency of care that hospitalized patients receive and to provide expectations of quality ambulatory care for programs that wish to be certified as a HF disease management program.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) developed the HF Core Measure Set in 2002 as one of four initial priority focus areas for hospital core measure development. Measuring the processes and outcomes of hospital care for patients with HF increases health care provider awareness that HF is a highly prevalent condition, uses more Medicare dollars for diagnosis and treatment than any other diagnosis, and is a common Medicare diagnosis-related group, reflecting

frequent hospitalizations.¹ The four standardized core measures set for hospitalized patients are discharge instructions, assessment of left ventricular function, use of an angiotensin-converting enzyme inhibitor (ACEI) in patients with left ventricular dysfunction, and smoking cessation advice and counseling. These measures provide a starting point for addressing key aspects of HF care.

TABLE 8-1 Performance Measures in Heart Failure

Measure O = Outpatient I = Inpatient	Source	Description	Rationale
Patient education—predischarge [I] or during an ambulatory visit [O] including drug doses and frequency [O]	ACC/AHA; JCAHO	Documentation that patients received written instructions or educational materials that includes content on activity level, diet, medication administration, follow-up appointment, weight monitoring, and understanding symptoms and what to do if they worsen	Nonadherence to HF therapies and selfcare is often a cause of rehospitalization. Knowledge of HF prognosis and care expectations is a prerequisite to self-care and therapy adherence.22,23 An effective management strategy is close attention and follow-up of prescribed medications to proactively recognize potential interactions and minimize adverse effects.22
Assessment of left ventricular systolic function—I and O	ACC/AHA; JCAHO	Documentation that left ventricular function was previously assessed, assessed in hospital, or there are plans to assess postdischarge—I	Other assessment methods, in combination (history, physical exam, chest x-ray, and ECG), are unreliable for distinguishing between left ventricular systolic dysfunction, preserved left ventricular function, or a noncardiac etiology.22
Use of ACEI or ARB in patients with left ventricular systolic dysfunction—I and O	ACC/AHA—ACEI or ARB; JCAHO—ACEI	Documentation of prescribing an ACEI or ARB in patients with systolic HF (prior to discharge—I) when there are no contraindications documented	Multiple large, randomized studies of ACEIs in patients with systolic HF showed that it alleviated symptoms, improved clinical status, enhanced quality of life, and reduced the risk of death and hospitalization.22
Use of betablocker in patients with left ventricular systolic dysfunction—I and O	OPTIMIZEHF researchers	Documentation of prescribing a betablocker with known benefit in patients with systolic HF (prior to discharge—I) when there are no contraindications documented	Multiple large, randomized studies of beta-blockade in patients with systolic HF showed that it alleviated symptoms, improved clinical status, enhanced quality of life, and reduced the risk of death and hospitalization.22
Smoking cessation counseling and advice—I and O	ACC/AHA; JCAHO	In adults with a history of smoking cigarettes (defined as smoking in the last 1 year prior to admission), documentation of smoking cessation counseling or advice (prior to discharge—I)	Smoking has cardiotoxic effects.22 Many deaths in the United States are attributed to a smoking-related illness. Additionally, up to one half of patients with cardiovascular disease begin smoking again within 12 months of their diagnosis.24
Use of warfarin in patients with HF and atrial fibrillation —I and O	ACC/AHA	In patients with chronic or recurrent (persistent, permanent, or paroxysmal) atrial fibrillation, documentation of prescribing warfarin (prior to discharge —I) when there are no contraindications documented	Stasis of blood in the fibrillating atria may predispose patients to systemic or pulmonary emboli. Prevention of thromboembolic events is an essential element of HF treatment.25
Initial laboratory tests—O	ACC/AHA	Initial laboratory evaluation to include urinalysis and serum testing for complete blood count, basic serum electrolytes (including serum creatinine), calcium, magnesium, blood lipids, glycohemoglobin, and thyroid stimulating hormone	Hyper- and hypothyroidism can be a primary or contributing cause of HF. Other laboratory tests can reveal illnesses or disorders that exacerbate or cause HF.22
Weight measurement —O	ACC/AHA; JCAHO	Obtain a weight at each visit; assess for weight change, reflecting a change in volume status	Provides clues about volume status that is essential in determining sodium status (excess or deficiencies) that may precipitate the need for diuretic therapy, self-care knowledge/adherence in low-sodium diet and fluid management (in volume overload) or changes in drug therapies (hypovolemia).22
Blood pressure measurement—O	ACC/AHA; JCAHO	Obtain a blood pressure at each visit	Elevated systolic and diastolic blood pressure is a risk for development of HF,22 and high blood pressure in HF portends worse outcomes (due to worsened left ventricular remodeling).22
Assessment of clinical symptoms of (excess) volume overload—O	ACC/AHA	Assess for dyspnea, fatigue, and orthopnea at each visit	Same rationale as weight monitoring.
Assessment of clinical signs of (excess) volume overload—O	ACC/AHA	Assess for peripheral edema, rales, hepatomegaly, ascites, S₃ or S₄ gallop, and elevated jugular venous pressure at each visit	Same rationale as weight monitoring.
Assessment of activity level—O	ACC/AHA	Assess level of activity using a standardized scale or tool at every visit to evaluate the impact of HF on activity level (functional status)	Questions about level of activity might provide greater insight into functional limitations than asking about symptoms experienced because many patients curtail activities when symptoms interfere.22
Assessment of return for emergency care or admission to the hospital—O	JCAHO^a	90-day return for emergency care or hospitalization for HF after the index emergency care discharge for HF	Hospital discharges for HF rose 157% from 1979 to 2002.24 Risk of hospitalization, return emergency care visit, and death within 3 months of discharge from emergency care for HF was high: 61% of patients, in a single-center study.26
Screened for or given influenza vaccination—O	JCAHO^a	The number of patients with HF who are screened for or given an influenza vaccination	In patients with HF, influenza can lead to a complex HF decompensation and death. Influenza is a serious concern for patients with HF because there is a high risk for complications, hospitalization, and worse outcomes. A vaccination may prevent needless illness and hospitalization.5
Screened for or given pneumococcal vaccination—O	JCAHO^a	The number of patients with HF who are screened for or given a pneumococcal vaccination	Same rationale as influenza vaccine; high rate of death from a preventable bacterial disease. Pneumococcal infection can increase HF exacerbation, hospitalization, morbidity, and mortality.5
ACC, American College of Cardiology; ACEI, angiotensin-converting enzyme inhibitor; AHA, American Heart Association; ARB, angiotensin receptor blocker; ECG, electrocardiography; HF, heart failure; JCAHO, Joint Commission on Accreditation of Healthcare Organizations. ^aThese standardized HF measurements are exclusive to JCAHO as part of their disease-specific care certification. They have been posted for public comment (now closed to comments) but have not been finalized.

In addition to the four JCAHO core measures, researchers from the Organized Program to Initiate Lifesaving Treatment in Hospitalized patients with Heart Failure (OPTIMIZE-HF), a registry and performance improvement program for patients hospitalized with HF, found that discharge use
of a beta-blocker was safe and well tolerated, improved treatment rates, and was associated with lower risk of mortality.² Researchers concluded that the data were compelling enough to warrant adding discharge use of a beta-blocker as an HF performance measure.²

The American College of Cardiology (ACC) and American Heart Association (AHA) developed performance measures for chronic HF. In addition to the four JCAHO core predischarge hospital measurements, a fifth measure was applied: use of an anticoagulant in patients with atrial fibrillation. In these performance measures, use of an ACEI was expanded to include angiotensin receptor blockade as an equivalent drug class.³

Although the JCAHO and ACC/AHA HF core measures and OPTIMIZE-HF beta-blocker measure were developed for patients hospitalized with HF, they should be applied in a short stay HF management program. These six core measures are easy to assess and implement when facility planning includes the resources necessary for patient education, left ventricular function assessment, and ordering of core HF medications. Of note, in a study of JCAHO core measures applied at a two-campus university hospital health care system, availability of standardized order forms, computer discharge instructions, and education materials did not lead to improvement in core measures scores; however, a dedicated nurse practitioner implementing resources led to rapid and sustained improvements.⁴ Clearly, having a champion to develop, implement, and continually monitor the quality of care patients receive is an asset to HF management program success. In a short stay unit setting that does not use a dedicated advance practice nurse, nursing and physician personnel who make up the team must understand the importance of consistent application of core performance measures to achieve outcomes consistent with long-term goals of HF management: to cause reversal or prevent progression of left ventricular remodeling.

Performance measures have been developed for ambulatory HF management programs by ACC/AHA³ and JCAHO.⁵ Table 8.1 includes 15 performance measures, many of which are essential to both inpatient and outpatient HF care. There is not 100% agreement in stated performance measures by ACC/AHA and JCAHO; however, each measure is an essential element in improving specific clinical HF care. Because a short stay unit visit is uniquely different from an in-patient hospital stay or a chronic ambulatory visit, the 15 ACC/AHA and JCAHO performance measure profiles should be applied in a short stay HF management program but require some revision to fully apply. In Table 8-2, four measures from Table 8-1 were modified for use in a short stay HF management program. Rationale for the suggested changes is provided in Table 8-2.

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