The Joint Commissions Core Measures serve as a standardized assessment measure for care given in specific areas. Despite widespread dissemination of the core measures, safety goals, and related quality guidelines, there is significant variation in their application across hospitals. The reasons for this are varied but include differences in guideline familiarity, provider training, and tools and systems to ensure that recommended care is provided and documented. Also hospital type, size, and location have been found to correlate with compliance rates. Other hospital characteristics such as physician leadership and organizational support also appear to contribute to the consistent use of evidence-based processes of care. (Andrew L. Masica, Richter, MS, MFA, ELS, Convery, MD, MMM, CPE, & Haydar, MD, MBA, 2009)
We will now look at the evidence behind the Core Measure Set for Heart Failure
Heart failure management
- The strongest evidence for the core measures is found in patients with systolic dysfunction and EF <40%.
- Left ventricular EF should be documented. EF results indicate severity of heart failure, help determine treatment, and correlate with mortality and morbidity risk. Measurement of EF is also useful at times of change in clinical status.
- Beta-blockers (e.g., bisoprolol, metoprolol XL, carvedilol) reduce the risk of death by 30% to 35%. Note: As of 2009, this has not been officially designated as a core measure despite endorsement by specialty societies and high levels of evidence support.
- ACE inhibitors reduce the risk of death by 15% to 25%. Angiotensin-receptor blockers (ARBs) may be used in patients who are allergic to ACE inhibitors.
- Smoking cessation improves heart failure patients’ self-reported quality of life.
- Discharge instructions with specific information about diet, daily weight measurements, medication use, and detailed follow-up planning reduce the risk of rehospitalization by up to 25% and the risk of mortality by up to 10% (Andrew L. Masica M. M., Richter, MS, MFA, ELS, Convery, MD, MMM, CPE, & Haydar, MD, MBA, 2009).
HEART FAILURE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES
|HF-2||Evaluation of LVS (left ventricular systolic) Function|
|HF-3||ACEI or ARB for LVSD (left ventricular systolic dysfunction)|
HF-1: Discharge Instructions
Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
- Patient non-compliance with medication and diet is an important reason for changes in clinical status. Discharge instructions, given appropriately, help ensure that patients and their families understand their dietary restrictions, activity recommendations, prescribed medication regimen, and the signs and symptoms of worsening heart failure (Jessup M, Casey, Feldman, Francis, & Ganiats, 2009).
- The following should be included in the discharge instructions:
- Activity level.
- Discharge medications.
- Follow-up appointment.
- Weight monitoring.
- What to do if symptoms worsen.
HF-2: Evaluation of LVS (Left Ventricular Systolic) Function
Heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge.
- Identification of patients with impaired left ventricular systolic function is necessary for the appropriate selection of medications to reduce morbidity and mortality. National guidelines advocate the evaluation of left ventricular systolic function as the single most important diagnostic test in the management of all patients with heart failure (Jessup M, Casey, Feldman, Francis, & Ganiats, 2009).
HF-3: ACEI or ARB for LVSD (left ventricular systolic dysfunction)
Heart failure patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.
- ACE inhibitors reduce mortality and morbidity in patients with heart failure and left ventricular systolic dysfunction. Clinical trials have also established ARB therapy as an acceptable alternative to ACEI, especially in patients who are ACEI intolerant. National guidelines strongly recommend ACEIs for patients hospitalized with heart failure (Jessup M, Casey, Feldman, Francis, & Ganiats, 2009). Guideline committees have also supported the inclusion of ARBs in performance measures for heart failure (Lindenfeld, Albert, Boehmer, Collins, Ezekowitz, & Givertz, 2004).
When reviewing a case involving Heart Failure I utilize the Joint Commission Core Measures to determine if there was any lack of following these measures with this particular patient. If I find that the Core Measures were not adhered to I may then ask for the hospitals education files for the staff involved regarding Joint Commission Core Measures. Nurses should be proactive with the patients in their care in making sure that appropriate discharge instructions are given and that the patient/family understand these instructions; that appropriate diagnostic testing is performed during the hospitalization to ensure that the most appropriate medications are prescribed; and that the patient is discharged on those medications that have been deemed necessary for their disease entity.
If you have a case involving an Acute Myocardial Infarction Alvin & Associates, Legal Nurse Consultants would be happy to assist you with a review of your case.
Andrew L. Masica, M. M., Richter, MS, MFA, ELS, K. M., Convery, MD, MMM, CPE, P., & Haydar, MD, MBA, Z. (2009, April). Linking Joint Commission inpatient core measures and National Patient Safety Goals with evidence. Retrieved September 5, 2014, from PubMed: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2666853/
Jessup M, A. W., Casey, D. E., Feldman, A. M., Francis, G. S., & Ganiats, T. G. (2009). ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol., 1343-82.
Lindenfeld, J., Albert, N. M., Boehmer, J. P., Collins, S. P., Ezekowitz, J. A., & Givertz, M. M. (2004). Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Failure, 475-539.