A Phased Cluster-randomized Trial of Rural Hospitals Testing a Quality Collaborative to Improve Heart Failure Care

Nurse staffing stability associated with improved performance measures in heart failure care in rural hospitals.

The Joint Commission—the organization that accredits and certifies health care organizations—requires hospitals to report on four heart failure performance measures:

  1. Assessment of left ventricular ejection fraction
  2. Use of angiotensin converting enzyme inhibitor/angiotensin receptor blockers
  3. Discharge instructions
  4. Smoking cessation counseling

While heart failure care remains suboptimal, smaller hospitals (< 200 beds), including rural hospitals, are less likely than others to provide the recommended care.

In this randomized trial, investigators tested a rural hospital quality collaborative for improving heart failure patient care through nursing in 23 rural hospitals. One group of hospitals received the intervention, while another served as the control group receiving the intervention six months later. The intervention consisted of a two-day in-person meeting; a heart failure toolkit with resources tailored to the hospital; and monthly group teleconferences with the study team. In addition to the four measures, the study also looked at the nurse staffing, skill mix, and the practice environment.

There were no significant differences between the two groups at baseline. There also were no statistically significant improvements in any of the four measures after the intervention. Improvements in performance measures were seen, however, in the hospitals with less nurse turnover, indicating a stable practice environment.