1. Fischer, Mary MSN, RN, CCRN

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December of 2005, St. Vincent Hospital created a 20-bed Heart Failure Unit dedicated to providing evidence-based care to allpatients-a clinical nurse specialist was hired to drive this initiative.



To date, no published studies have evaluated these measures as part of a multidisciplinary inpatient heart failure unit.



Heart failure (HF) affects over 5 million people in the United States. Its incidence has doubled in the last 10 years resulting in 6,500,000 hospital admissions annually. Patients are prone to frequent exacerbations often resulting in readmission. Recent advances in pharmacological and nonpharmacological treatment have improved HF outcomes. In 2005, JCAHO identified core measures essential to treatment (left ventricular dysfunction (LVSD) assessment, ACEI or ARB for LVSD, smoking cessation counseling, discharge instructions for activity level, diet, discharge medications, follow-up appointment, weight monitoring, and steps to take for worsening symptoms).



Upon admission to the unit with a preprinted order set, the patient automatically receives a cardiac rehabilitation consult and is begun on an evidence-based clinical pathway. Daily (M-F) multidisciplinary patient rounds are conducted under the direction of a Cardiology Clinical Nurse Specialist along with a Case Manager-RN, Cardiac Rehabilitation RN, Pharmacist, Primary Care RN, and Cardiology Clinical Nurse Specialist; the team is joined weekly by a palliative care physician. The focus of rounds includes daily physical assessment of the patient, weight trend, laboratory results, and current concerns. Core measures are confirmed or addressed; education and activity progress are provided; medications are reviewed; the patient's home situation and need for home healthcare are evaluated; telehealth in-home monitoring is arranged to monitor selected patients. Patients unable to return home are assisted with placement in a long-term assisted care (LTAC), short-term nursing facility (SNF), or hospice (if end-stage). An outpatient HF clinic is available for patient referral. At discharge, the physician's nurse reinforces patient education and arranges outpatient follow-up, and the patient is provided preprinted discharge instructions. Data on the impact of these interventions were abstracted from hospital medical records.



Results at 3 months into the intervention indicate significant improvement in discharge instructions (72% up to 92%), LVSD assessment (92% to 96%), ACE/ARB use (82% to 92%), and smoking cessation counseling (84% to 100%) compared with the 3 months prior to the intervention. Unit tracking of home healthcare referrals, outpatient heart failure clinic referrals, physician compliance with admission, and discharge summary instructions show a trend toward improvement.



Patient-specific measures tied to direct patient quality of life and mortality measures improved.


Implications for Practice:

In summary, a multidisciplinary disease-specific unit improves patient-specific outcomes as indicated by JCAHO core measures. Further research is needed to evaluate the impact on cost of care and length of stay.