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'Core Measures' Help RNs Ensure Top Cardiac Care

Monday July 30, 2007
(Photo by Morgan Lavin.)
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The hands-on approach that Nancy Kanat, RN, takes in tracking heart patients has helped John Muir Medical Center in Walnut Creek, Calif., become a top-performing hospital in complying with national cardiac care guidelines.

Core Measures for Congestive Heart Failure

    ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

    • Assessment of Left Ventricular Function (LVF)

    • Discharge Instructions

    • Smoking Cessation Advice/Counseling

Source: Centers for Medicare & Medicaid Services

On the cover: Diane Reiner, RN, quality coordinator, Providence Heart and Vascular Institute, Portland, Ore., and patient Mildred Wells.
Kanat, a clinical care manager and patient educator, makes sure patients with acute myocardial infarction (AMI) or congestive heart failure (CHF) receive prompt attention. This includes adherence to a set of evidence-based cardiac core measures adopted by Medicare. Medicare adopted the measures to create an online "scorecard" that compares hospital performances on the gold-standard protocols.

"We try to find patients with heart disease as soon as they walk in the door," Kanat says. If a heart attack patient is admitted to the emergency department, a charge nurse alerts Kanat, who takes quick action, visiting the patient and making sure the caregiving team initiates and documents eight core measures required under AMI guidelines. The measures range from being given an aspirin on arrival to extensive preventive care instructions at discharge. (see sidebars)

Compliance on selective core measures fulfills hospital participation requirements for full Medicare reimbursement and positions them to cash in on pending pay-for-performance incentives for meeting quality care standards.

The cardiac core measures were chosen by The Joint Commission (formerly called the Joint Commission on Accreditation of Healthcare Organizations) in collaboration with the American Heart Association (AHA), and have been endorsed by the National Quality Forum.

Margaret Simor, director of cardiovascular service line clinical operations for John Muir Health, says the core measures criteria set an aggressive baseline for treatment of cardiac disease regardless of a patient's race, gender, or cultural background.

"There's no opportunity to exclude," says Simor, who has participated in women's heart programs and in local health fairs for a diverse regional population. "The core measures help assure there's no disparity in the quality of patient care."

ED jump-start

Ginny Posey, RN, MSN, director of emergency services at Salem Hospital Regional Health Services in Salem, Ore., says experienced nurses helped drive successful implementation of core measures for some 100 heart attack patients who showed up at the ED last year: "Patients don't come in with the label 'having a heart attack,' but usually state they have chest pain, arm pain, or abdominal pain. So it takes an expert nurse to differentiate the kind of pain and put the picture together to initiate the performance protocols."

She says that while identifying heart attack patients is easier than pinpointing some 332 congestive heart failure cases a year, the diagnosis isn't always clear-cut.

On a daily basis, there might be 25 patients with chest pain and only two having a heart attack, Posey says. "So we initiate the protocols 25 times to be successful and not have any core measure patients slip through the cracks."

Real-time feedback

Roberta Vanscoyk, RN, a cardiac educator, says development of a rapid-cycle system for daily auditing of patient data on a case-by-case basis is making a huge difference in improving performance scores at the Salem hospital.

"If feedback isn't early enough, it's kind of like chasing your tail," says Vanscoyk, who tracks nurses' contribution to achieving high scores on eight MI and four CHF measures. In the past, she says, performance results were shared at staff meetings weeks or even months after patient discharges, which often made it hard to pinpoint problems.

"Now we can interview those involved with core measure patients to identify reasons for performance failures and make corrections immediately in real time," Vanscoyk says.

She reports that within six weeks of launching the rapid-cycle project in mid-May of 2006, performance compliance on cardiac core measures jumped from 36% to 100% and stood at 86% as of mid-January 2007.

"We occasionally still have failures, such as a patient not getting to the cath lab in less than 90 minutes," she says. "We review each case to find the cause."

AHA guidelines

At Providence Heart and Vascular Institute in Portland, Ore., Diane Reiner, RN, quality coordinator for core measure compliance, credits the early implementation of AHA guidelines with achieving a top-performance ranking in the AMI category.

"I don't do data abstraction or footwork, but I'm involved in looking at outcomes and getting them in front of the appropriate clinicians," says Reiner, a cardiac nurse manager.

"We've made a very concerted effort to comply with these measures, which have been a priority with us for many years," she says. For example, all cardiac patients who are smokers are counseled to quit, which is documented in their files. They're also given smoking cessation resources when discharged.

Reiner says highly skilled cardiac nurses abstract and review patient data for core measure compliance for the Providence network that includes three hospitals in the Portland area, including flagship Providence St. Vincent Medical Center.

Staff nurses are responsible for educating patients and their families on the importance of medications, quitting smoking, and following physician orders, says Reiner, who adds that RNs also monitor charts of core measure patients to make sure each procedure is documented.

Defining benefits

Gayla Nielsen, RN, MSN, manages a 71-bed cardiac-telemetry unit at Providence St. Vincent Medical Center, where the staff of 110 nurses plays a central role in assuring compliance to core measure procedures.

Nielsen says the nurses regularly do chart reviews to identify whether core measures are met. If there's an omission, the nurses confer with the physician or patient to remedy the problem or document why a step wasn't done.

The growing emphasis on core measure performance benefits both patients and the hospital system, she says: "The measures are indicators of the highest-quality patient care that can lead to improved outcomes. It's important to demonstrate this for people [such as patients and their friends and family members] who are doing their homework and becoming much more informed about selecting facilities and treatments."

Recipe for success

Posey says Salem adopted evidence-based protocols for trauma care 20 years ago that generated a systematic approach to improving care for groups of patients with certain symptoms.

"The core measures mirror our philosophy that a systematic approach improves patient care," she says. "They take variability away and lead to more successful outcomes."

Adhering to a set of standardized core measures may be considered "cookbook medicine" in some settings, but to Posey, they contain the right mix of ingredients for optimal patient care.

"I'd call it a recipe for success, based on the cookbook for core measures," she says.

Measuring outcomes

While Medicare is fueling the trend of comparing the quality of care among hospitals, a lingering question is whether compliance to core measures improves cardiac patient outcomes, including mortality.

A recent study published in the Journal of the American Medical Association (JAMA) found no significant effect on patient outcomes or death rates in hospitals that were focusing on five core measures for heart failure care.

Simor says the study, based on 2003-04 data on heart failure, represents a time when most hospitals were struggling to comply with the standards.

"I don't really agree with the study based on our own experiences," says Simor, who adds that heart failure patient re-admission rates within 30 days of discharge at Muir's hospitals are lower than those reported in the literature. The study also preceded the American Heart Association's Get With The Guidelines program for heart attacks and CHF, which Muir and other hospitals have adopted.

New research studies show that compliance to core measures is having a positive impact on patient outcomes. One example, also in JAMA, was that prescribing an ACE inhibitor for CHF patients improves clinical outcomes during the first 60 to 90 days after discharge, she says.

The AHA says more than 450,000 people suffer recurrent heart attacks annually and 25% of men and 38% of women will die within a year. Within six years after an attack, approximately 22% of men and 46% of women will be disabled with heart failure.

Get With The Guidelines For AMI and CHF are web-based programs created to help hospitals improve the quality of care for cardiac patients. The programs align treatment with the most current scientific guidelines. The programs also provide participating hospitals with a robust database and real-time benchmarking capabilities toward enhancing patient outcomes and saving lives.

According to the AHA, nationwide implementation of cardiovascular disease secondary prevention guidelines — including compliance to core measures — could result in saving more than 80,000 lives each year.

"Collecting patient data for core measure reporting is now part of everyday hospital routine," Simor says. "Like other institutions, we are exploring telemonitoring as a mechanism to further reduce re-admission rates. A national database for evaluating best practices in heart attack care is also in the works so Centers [for Medicare and Medicaid Services (CMS)] can better evaluate patient outcomes."

On Jan. 10, 2007, CMS announced it would abstract data from 2005-06 on 30-day death rates for heart attack and heart failure patients from some 4,000 hospitals and post the results on its hospital compare website. In preparation for the June launch of the consumer-oriented information, CMS sent hospitals data in December on how their 2003 cardiac mortality rates compared to the national Medicare average of 17.8% for heart attacks and 11.8% for heart failure.

Rather than posting actual death rates, Medicare will compare hospitals and let patients know if a particular hospital performs better, worse, or on par with the national average. CMS hopes posting the data will be a wake-up call to under-performing hospitals.

Posey at Salem Hospital adds that even if there is difficulty correlating the quality care guidelines to improved patient outcomes, complying to core measures brings efficiency to the cardiac care process.

"If we have all the standards in place and know that aspirin works and beta-blockers work, we're not going to have people fall through the cracks and not receive the best care for the problem they came in with," she says. "We just believe very strongly that this is about patient safety and doing the right thing."

John Leighty is a freelance writer for NurseWeek. To comment on this story, send e-mail to editormtw@nurseweek.com.

For further study, read our CE module, "Getting to the Heart of MI — and STEMI," on www.nurse.com.

Core Measures for Acute Myocardial Infarction

    ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)

    • Aspirin at Arrival

    • Aspirin at Discharge

    • Beta Blocker at Arrival

    • Beta Blocker at Discharge

    • PCI Within 120 Minutes of Arrival
    (Percutaneous coronary intervention)

    • Smoking Cessation Advice/Counseling

    • Thrombolytic Medication Within 30 Minutes of Arrival

Source: Centers for Medicare & Medicaid Services