# Presentation: 579011

## VA Heart Failure and IHI’s Five Million Lives Campaign

- Paul Heidenreich MD, MS
- Barry Massie MD
- Anju Sahay PhD
- Robert Jesse MD, PhD
- 7/9/2007

## The Institute for Healthcare Improvement (IHI)

- Save 100,000 lives campaign
- Reduce hospital mortality
- Rapid response teams
- Better acute MI Care
- Prevent adverse drug events
- Prevent central line infections
- Prevent ventilator-associated pneumonia
- Prevent surgical site infections

## 100K Lives Campaign

- 3100 Hospitals participated
- 18 months
- 124,000 lives saved

## VA Members

_**VA Members**_
- West Roxbury
- Tampa
- VISN 23

## Slide 5

## The Institute for Healthcare Improvement

- Many more patients are _**harmed**_ than killed
- 37 million hospitalizations/year in the US
- 40-50 injuries/100 admissions
- 15 million are harmed/year in US hospitals
- 40,000 / day
**Goal:  ****	****Eliminate harm to 5 million ****	****	****	****	****patients over the next two years**

## IHI Definition of Medical Harm

- 	Unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.

## IHISave 5 Million Lives From Harm 

- Prevent pressure ulcers
- Reduce MRSA
- Prevent harm from high-alert medications
- Reduce Surgical Complications
**Deliver reliable **_**evidence**_**-**_**based**_** care for heart failure**
- Get boards on board

## Goal:  Deliver reliable evidence-based care for congestive heart failure ... to reduce admissions.
Reduce the readmission rate by 50% by December 2008

- Goal:  Deliver reliable evidence-based care for congestive heart failure ... to reduce admissions.
- Reduce the readmission rate by 50% by December 2008

## Measure Left Ventricular Ejection Fraction (EF)
ACE inhibitor or ARB at Discharge if EF<40%
Anticoagulation if Atrial Fib. at Discharge
Influenza vaccine
Pneumoccocal vaccine
Smoking Cessation counseling
Discharge instructions

- Measure Left Ventricular Ejection Fraction (EF)
- ACE inhibitor or ARB at Discharge if EF<40%
- Anticoagulation if Atrial Fib. at Discharge
- Influenza vaccine
- Pneumoccocal vaccine
- Smoking Cessation counseling
- Discharge instructions

**CMS: in 2005 only 54% of eligible patients received all interventions**

**IHI 5 Million Lives Campaign**

## Beta-Blocker at Discharge if EF<40%
Discharge Contract
Statins for coronary disease
Spironolactone for certain high risk patients

- Beta-Blocker at Discharge if EF<40%
- Discharge Contract
- Statins for coronary disease
- Spironolactone for certain high risk patients

## Form a team
Focus on a specific cohort (e.g. those being discharged home)
Standardize Protocols
Nursing
Discharge
Link treatment orders to results of EF testing
Need to capture the LVEF numerically
Use Case Managers

- Form a team
- Focus on a specific cohort (e.g. those being discharged home)
- Standardize Protocols
- Nursing
- Discharge
- Link treatment orders to results of EF testing
- Need to capture the LVEF numerically
- Use Case Managers

**IHI 5 Million Lives Campaign**

## Reconcile Medications
Teach Back
Follow up phone call in 48 hours
Medication check
Physician visit
1 week for average risk patients
48 hours for high risk patients
Case management for high risk patients

- Reconcile Medications
- Teach Back
- Follow up phone call in 48 hours
- Medication check
- Physician visit
- 1 week for average risk patients
- 48 hours for high risk patients
- Case management for high risk patients

**IHI 5 Million Lives Campaign**

## IHI:  Recommended Actions

- Identify population of patients with CHF
- Develop standard order sets/protocols
- Implement process for reliably providing automatic smoking cessation counseling for all patients identified on admission with smoking history
- Implement process for automatically providing pneumococcal and influenza vaccine

## IHI:  Recommended Actions

- Begin discharge assessment and teaching on admission
- Standardize CHF teaching elements and ensure skill of staff who are teaching patients
- Use “Ask Me 3” and Teachback methods to ensure “same pageness” with patient
- Establish linkages with home health and primary care for each patient
- Assess each patient’s situation for ability to follow through on discharge instructions and ensure barriers are addressed

## Process of Care VA and CMS

## LVEF Measurement

**% of  Heart Failure Patients**

**LVEF Measurement**

**Top 10%**

## ACE Inhibitors or ARBs (EF<40%)

**% of  HF Low EF  Patients**

**ACE Inhibitors or ARBs (EF<40%)**

**Top 10%**

## Discharge Instructions

**% of  Heart Failure Patients**

**Discharge Instructions**

- Hospital Compare 10/2005 to 9/2006,  U. Michigan N=549, Ann Arbor VA N=89

**Top 10%**

## VA CHF Performance 2004-2005 

**% of Heart Failure Patients**

**VA CHF Performance 2004-2005 **

## Outcome: VA and CMS

## Mortality Rating: CMS

|  | Number of Hospitals |  |  |
| --- | --- | --- | --- |
| Heart Failure | Below | Average | Above |
| U.S. (30d 11%) | 35 | 4734 | 38 |
| Acute MI |  |  |  |
| U.S. (30d 16%)  | 7 | 4453 | 17 |

## VA Trends

- VA Admissions with principal diagnosis of heart failure.
- 1998-2005

## VA Heart Failure 30-Day Readmission

## VA Heart Failure 30-Day Mortality

**CMS 11%**

## Summary

- Process of care is good compared to CMS, but has room for improvement.
- Difficult to judge outcome measures.
- Focus area: discharge-handoff
- Patient contract
- Early Follow-up