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.

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.

Along with another clinical care manager, Kanat spends most of her mornings checking admitting records, clinical charts, and lab reports to find CHF cases that are harder to pinpoint than AMI patients. These cases are more difficult to identify because of associated medical conditions such as respiratory failure that can mask the heart failure symptoms. Once the cases are identified, a protocol of four core measures is triggered.

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.

Re-admissions drop

Margaret Simor, RN, BSN, CRN, director of cardiovascular service line clinical operations for John Muir Health, says heart failure re-admissions have dropped from 345 in 2004 to 301 last year at Walnut Creek and from 426 to 399 at the health system’s other campus in Concord, Calif.

“This is reflective of two things: the implementation of the CHF-cardiac educator positions on each campus and our increasing compliance with the medication best practices,” Simor says. “Many patients may not be on an ACE/ARB or Coreg on admit but most often go home on them.” (see sidebars)

Heart attack re-admissions are also lower at both campuses, she says. In addition, the Concord campus recently received the top VHA West Coast award for high reliability in AMI, achieving better than 90% compliance in all required performance measures from April 2005 through September 2006.

A multi-disciplinary committee reviews core measure data on a quarterly basis and brainstorms ways to improve the process. One strategy developed is a letter to inform physicians of any miscues in core measure performance, along with helpful hints on achieving compliance.

“We’re constantly looking at how we’re doing and seeking opportunities to improve compliance,” Simor says. “Once we hit 100% on a measure, we want to make sure we sustain it.”

Barriers overcome

An obstacle to demonstrating high-quality cardiac care has always been documentation, a hurdle that Simor says the nurse educators have helped overcome.

“They keep a focus on cardiac core measures by identifying patients who meet core measures criteria, looking for opportunities to apply best practice, and making sure physicians remember to document appropriately,” she says. The goal is 100% compliance so there is no room for a missed opportunity.

For example, one performance measure for both heart attack and heart failure is prescribing an ACE inhibitor at discharge, but some patients cannot tolerate the medication that treats left ventricular systolic dysfunction.

“When evaluating data, the fact an ACE inhibitor wasn’t prescribed would indicate the measure wasn’t performed, so the nurses will work to find out why the patient didn’t qualify for medication and have the physician enter the justification in the medical record,” Simor says.

She adds that the core measures criteria also 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.”

In the trenches

One significant change is a shift from retrospective chart review to real-time patient data collection. Nurses can use the data to guide patients toward healthier lifestyles and improved clinical outcomes while they are still in the hospital.

A multi-disciplinary committee also develops content for educational binders for patients based on the latest information on diet and weight management, as well as the latest instructions on when to seek medical attention, and includes a calendar of ongoing cardiac education classes. There is a heart failure binder, an MI binder, and an open-heart surgery binder.

“It’s real exciting to be down in the trenches and see good results that are above national benchmarks,” Kanat says. “Core measures are a fairly new process, so we try to keep everyone up-to-date and put the tools in place to get everything done.

RN teams assess patients

At the California Pacific Medical Center (CMPC) in San Francisco, advanced practice nurses lead team efforts to find patients in the cardiac core measures categories across a four-campus system.

“Patient education is a major part of a nurse’s role, so we want to identify these patients and educate them on risk factors, smoking cessation, and adherence to medications,” says Evelyn Taverna, RN, MS, CNS, CCM, a clinical nurse specialist in cardiology who, along with Aileen McAllister, RN, MS, helps coordinate the quality care efforts.

The core measures team checks each heart patient’s care plan to make sure all the steps are taken to comply with performance standards, Taverna says. Nurses also contribute to discharge instructions that contain components related to activity, diet, weight monitoring, medications, and recurring symptoms that signal the need to contact their doctor

Discharge goals

“With CHF, many patients have comorbidities and are quite ill, so a certain portion will be re-admitted,” Taverna says. “One goal is to focus on the discharge instructions and make sure follow-up appointments are set up. We also have a tele-management program to help them at home, which is a key to keeping them out of the hospital.”

Because CHF symptoms are subtle, patients must be monitored closely; a weight gain of only three pounds within two days after discharge is a signal to call their physician. Some patients wait too long and end up in the ED.

“One good thing about the core measures is they’ve created a lot of discussion around best practices and what impacts patient outcomes,” Taverna says. “We’re very process-oriented here and are always tweaking the discharge sheets, finding things that are most helpful to specific patients.”

Performance data from Medicare shows CMPC is doing a good job on the cardiac care guidelines, with scores above 90% in five of eight core measures for AMI patients and two of four core measures for CHF patients.

“The reality of health care is we’re being held to very high standards that take organizational commitment and a lot of support to be successful,” Taverna 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, a program that Muir and other hospitals have adopted.

Taverna adds that 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.

“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 & 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.

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.