Heart failure (HF) occurs when the heart can’t pump enough oxygenated blood to perfuse body organs. This condition is the primary cause of more than 55,000 deaths each year in the United States. The most common signs and symptoms of HF are shortness of breath on exertion; orthopnea; weight gain with edema in the feet, legs, or lower back; fatigue; and weakness. Major causes of HF are coronary artery disease, high blood pressure, and diabetes.

According to the Centers for Disease Control and Prevention (CDC), HF is diagnosed in 670,000 new persons annually. Currently, about 5.8 million persons in the United States are living with HF.
In women, HF incidence has dropped by about 30% due to earlier diagnosis and treatment. In men, the number of new cases remains unchanged. The annual economic toll of HF is about $34.5 billion.

As with most diseases, the earlier HF is diagnosed and treated, the greater the chance for improving the patient’s quality of life and increasing life expectancy. Over the past 50 years, scientists and healthcare providers have made great strides in treatment and patient outcomes by examining best practices for patients with HF.

Core measures

The Joint Commission introduced four initial core measurement areas for hospitals in May 2001; HF was one of these areas. The Joint Commission worked with the Centers for Medicare and Medicaid (CMS) on HF core measure sets. Standardized and renamed National Hospital Quality Measures, these core measure sets are expected to improve the quality of care for hospital patients while promoting examination of results of the care provided.

Currently, core measures for HF include:

• use of an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
• left ventricular function (LVF) assessment
• smoking cessation counseling
• HF discharge instructions.

The Joint Commission uses these four items as hospital inpatient quality measures. In 2009, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) proposed new focused guidelines, which include measurement of natriuretic peptides (BNP and NT-proBNP) when the diagnosis of HF is uncertain. The Joint Commission and CMS have yet to officially adopt this recommendation into the National Hospital Quality Measures.

Core measure: ACEI or ARB

ACEIs reduce the risk of HF-associated deaths by 15% to 25%. (An ARB may be substituted in patients with ACEI allergies). ACEIs include captopril (Capoten), lisinopril (Prinivil or Zestril), enalapril (Vasotec), and ramipril (Altace). ARBs include losartan (Cozaar), valsartan (Diovan), and irbesartan (Avapro). These drugs continue to decrease both mortality and the number of re-admissions among HF patients.

Core measures: LVF assessment

Evaluation of LVF guides treatment for HF patients and must be documented in the patient’s medical record. Ideally, the best time to evaluate LVF is during the patient’s initial evaluation. However, many patients with longstanding HF have never had LV assessment. Currently, proof of LV assessment must be documented on every hospital admission.

Two-dimensional echocardiography with Doppler is used to assess left ventricular ejection fraction (EF), left ventricular size, wall thickness, and valve function. EF indicates HF severity, guides treatment, and correlates mortality and morbidity risks. Normal EF values range from 50% to 70%.

Core measure: Smoking-cessation counseling

HF patients who have quit smoking report improved quality of life. Clinicians should recognize the value of smoking cessation for all patients, but especially for HF patients because it decreases their comorbidity risks.

Core measure: Discharge instructions

Discharge instructions for HF patients should include diet, daily weight measurement, medication use, signs and symptoms that their condition is worsening, and follow-up plans. In conjunction with electronic medical records, medication reconciliation on admission and discharge has streamlined medication changes. In outpatient settings, physicians provide slightly different patient education, including the definition of HF and risk-factor modification. Patient and family teaching must be adapted to their level of understanding.

Implementation

Hospitals report all patients diagnosed or treated for HF to CMS, along with the National Hospital Quality Measures guidelines implemented or continued during the inpatient visit by staff physicians. These guidelines include LVF assessment and testing, weight measurement, patient education, beta-blocker drugs for left ventricular systolic dysfunction, and ACEIs or ARBs for patients with EFs less than 40%. Patient education provided by healthcare professionals should include HF definition, how to recognize worsening HF symptoms and appropriate treatment for these symptoms, indications for and use of all prescribed drugs, importance of modifying risk factors, specific dietary recommendations (including low-sodium diets and alcohol-intake restrictions), and activity and exercise guidelines. To optimize patient outcomes, physicians should implement these guidelines in both the hospital and clinic settings.

Before 2009, discharge instructions for HF patients included the simple statement, “Watch for worsening symptoms.” However, many patients weren’t able to determine what “worsening symptoms” meant, so healthcare professionals now provide the more specific instructions below:

• “Call your physician if you gain more than 2 lb.”
• “Go to the emergency department if you experience a problem breathing.”
• “Call the physician, nurse practitioner, or physician assistant if edema recurs.”
• “Make an appointment if your heart failure symptoms return.”

Hospitals initiated the use of core-measure checklists and core-measure specialists to implement proper requirements for each core measure. Larger facilities may use one specialist per core measure. In smaller facilities, a single specialist may be responsible for all core measures; in this case, staff nurses are responsible for implementation, with the help of the specialist and checklist.

Medical records departments use International Classification of Diseases (ICD) coding for all patients. When a patient is coded ICD-9-CM with HF, core measures must be completed; otherwise, The Joint Commission and CMS deem it a “fallout,” which affects the hospital’s Medicare and Medicaid reimbursement.

HF is one of the most common reasons for hospital readmissions. Starting October 2012, CMS changed its reimbursement for 7-day, 15-day, and 30-day re-admissions. Nationally, these changes will reduce costs by an estimated $1 billion to $2.5 billion annually.

Success or failure?

Hospitals report patient outcome data to the TJC; these reports are available online by request. Florida was used as a sample state to review data collection. (See HF core measures: Florida vs national average.)

HF core measures: Florida vs national average

From September 2009 through October 2010, 159 Florida hospitals reported patient outcome data to The Joint Commission. Each of these hospitals fell into the top 10% in maintaining core measures for heart failure treatment, but only 13% reported 100% compliance on all four core measures. Florida falls below the national average for each heart failure core measure in the lowest percentage. However, compliance with core measures is a problem in many states—one that nurses can help improve

Room for improvement

Even with core measures for HF in place, re-admissions continue to remain high, calling for tighter control of HF patients. A review of new best practices suggests the value of investing in high-quality care through in-hospital treatment and follow-up care, integration of electronic medical records among hospitals and providers, stronger discharge planning on admission, better teaching of the HF disease process to patients and families at their level of understanding, follow-up phone calls by nurses to high-risk patients, and more collaboration between hospitals and providers.

Hospitals seek to deliver the best quality of care and improve patient outcomes so as to better their standing in the community and obtain maximum reimbursement. By following the TJC/CMS core measure sets, hospitals can maximize reimbursements while helping ensure that patients receive the best quality of care and better outcomes. In this win-win scenario, all parties benefit from best practices.

Nonetheless, statistics continue to show room for improvement. Nurses need to stand up to the challenge of providing evidence-based and clinically based care for all patients. Are we up to the challenge? I believe we are. Speak up for your patients’ benefit. Advocate for revamping of HF teaching materials and initiating phone calls by nurses to high-risk HF patients 2 to 3 days after discharge to help avert the need for readmission.

Lucy Baccus Stella is an assistant professor at South University School of Nursing in Tampa, Florida.

Selected references

American Medical Association. 2010 Physician Quality Measurement Reporting. www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician-quality-reporting-system.page.

Averill RF, McCullough EC, Hughes JS, et al. Redesigning the Medicare inpatient PPS to reduce payments to hospitals with high readmission rates. Health Care Financ Rev. 2009;30(4):1-15.

Bonow RO, Ganiats TG, Beam CT, et al; American College of Cardiology Foundation; American Heart Association Task Force on Performance Measures; American Medical Association-Physician Consortium for Performance Improvement. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with heart failure: a report of the American College Of Cardiology/American Heart Association Task Force on Performance Measures and the American Medical Association-Physicians Consortium For Performance Improvement. Circulation. 2012;125(19):2382-401.

Centers for Disease Control and Prevention. Heart Failure Fact Sheet. Last updated October 17, 2012. www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm. Accessed December 23, 2012.

Centers for Medicare & Medicaid. Physician Quality Reporting System. 2012. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html. Accessed December 23, 2012.

Hsich E, Wilkoff B. Understanding your ejection fraction. Reviewed December 2011. http://my.clevelandclinic.org/heart/disorders/heartfailure/ejectionfraction.aspx. Accessed December 23, 2012.

Masica AL, Richter KM, Convery P, Haydar Z. Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Proc (Bay Univ Med Cent). 2009;22(2):103-11.

Silow-Carroll S, Edwards JN, Lashbrook A. Reducing hospital readmissions: Lessons from top-performing hospitals. The Commonwealth Fund. April 6, 2011. http://www.commonwealthfund.org/Publications/Case-Studies/2011/Apr/Reducing-Hospital-Readmissions.aspx. Accessed December 23, 2012.

The Joint Commission. Core Measure Sets: Heart Failure. February 7, 2011. http://www.jointcommission.org/core_measure_sets.aspx. Accessed December 23, 2012.