The Problem: Heart failure, a condition in which the heart can't pump enough blood to the body's other organs, is a major health risk for the mostly Latino population living in El Paso, Texas, near the border between the United States and Mexico.
At Del Sol Medical Center, a 336-bed community hospital in El Paso where three-quarters of the patient population is Latino, heart failure was the most common cardiovascular diagnosis. Yet heart failure patients were not receiving care in compliance with national guidelines, and they had high rates of hospital readmission.
Grantee Background: In an effort to improve care for heart disease patients, Del Sol Medical Center conducted an intensive review of its cardiovascular services, including an external audit, which provided a clear road map for improvement. With input from an interdisciplinary task force, the hospital initiated standardized procedures for diagnosing and treating heart attacks (e.g., dispensing aspirin and a beta-blocker at arrival and discharge) and other cardiovascular diagnoses.
Del Sol Medical Center also established a heart failure center intended to provide a bridge from inpatient to outpatient care. "We wanted to be more proactive in helping heart failure patients manage their disease so we didn't have a constant flow of patients being discharged and coming back again," said Jennifer Suitonu, MBA-HCM, MSN, RN, NEA-BC, administrative director of cardiovascular services. She also served as project director for Del Sol's project, funded by the Robert Wood Johnson Foundation (RWJF) under its national program: Expecting Success: Excellence in Cardiac Care.
A nurse practitioner ran the heart failure center, assisted by a nurse. Each day, the nurses reviewed hospital admissions to identify heart failure patients and begin educating them about the need to track their symptoms, control their diet, monitor their weight and blood pressure and take prescribed medications on an ongoing basis. The nurses also described the heart failure center and followed up within a few weeks after discharge to schedule a visit. Del Sol encouraged patients to bring family members and anybody else involved in their care to medical appointments.
The Project: Del Sol Medical Center improved its patient chart review and discharge processes, and enhanced its heart failure center, with support from Expecting Success. The initiative lasted from 2005 to 2008.
While working on Expecting Success, the Del Sol team:
- Hired a nurse with a strong cardiology background to review charts and determine whether heart attack patients were receiving care in compliance with evidence-based national guidelines (hospital funding was used for this). In contrast to the previous system for assessing quality, where staff reviewed charts after patient discharge, this "real-time" review enabled clinicians to take appropriate steps to improve care immediately. '"This gave us the opportunity to make a difference in the care we were providing,'" said Suitonu.
- With RWJF funding, purchased a patient education software system, called KRAMES on Demand. The software allows staff to print out information about heart failure and heart attacks in multiple languages, including Spanish, for patient use.
- Developed standardized cardiovascular discharge orders, also in compliance with guidelines. A single discharge form now guides clinicians in dispensing aspirin and beta-blockers, reviewing additional medication needs, and offering smoking cessation counseling and other patient education. The document also includes perforated prescription forms. Previously, the process for discharging heart patients had been fragmented, requiring nurses and physicians to remember everything they were supposed to do.
- Educated and motivated clinicians with such strategies as grand rounds lectures, report cards measuring physician performance and buttons for staff that read, "I saved a life today."
- Provided scales to patients to improve compliance with daily weight monitoring.
The heart failure center:
- Held focus groups with heart failure patients to identify barriers to compliance, such as transportation and language issues, and access to care.
- Offered group nutrition and education classes, produced a "heart healthy cookbook" and developed bilingual calendars and diaries allowing patients to document their weight and blood pressure and monitor any changes in signs and symptoms. Patients received a scale on their first visit to the center.
- Provided timely access to care for heart failure patients.
Results: Del Sol Medical Center reported the following results from its Expecting Success project:
- Heart failure patients who received all of the care recommended in core national guidelines increased from 15 percent to 94 percent over two years (2005 to 2007).
- Heart attack patients who received all recommended care increased from 17 percent to 89 percent over two years (2005 to 2007).
- Readmissions for heart failure within 30 days decreased from 16 percent to 7 percent over two years (2005 to 2007).
- The Expecting Success project has changed the way Del Sol provides care for cardiac patients, according to the project director, Jennifer Suitonu. The hospital continues to use the standardized cardiovascular discharge orders and real-time review of care (as of December 2009).
The heart failure center closed in 2009 due to a decline in the number of heart failure patients utilizing the services offered. Although the outpatient component of the program has been discontinued, a nurse still identifies and visits heart failure patients in the hospital to provide inpatient education.
- Building on the approach used in cardiology, Del Sol has implemented real-time chart review and standardized discharge orders for patients with pneumonia and for surgical patients.
RWJF Perspective: RWJF is committed to ensuring that all Americans receive quality health care. Racial and ethnic disparities were especially likely to occur in treating heart disease, according to the Institute of Medicine. RWJF's Expecting Success national program engaged 10 acute-care hospitals in identifying cardiac care disparities and developing and sharing tools to improve care for African-American and Latino patients. RWJF focused Expecting Success on cardiac care because disparities are well documented and the recommended standard of care is widely accepted and easily measured.
"These hospitals courageously led the way in using data to discover and correct their own racial and ethnic gaps in care. Their hard work demonstrates that we cannot have high quality of care for all until providers see eliminating disparities in care as an essential function of mainstream quality improvement," said Pamela S. Dickson, MBA, assistant vice president for RWJF's Health Care Group.