In 2001, The Joint Commission (TJC) and Centers

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1 Hosp Phrm 2014;49(11): Thoms Lnd Publishers, Inc. doi: /hpj Originl Article Phrmcist Involvement t Dischrge with The Joint Commission Hert Filure Core Mesure: Chllenges nd Lessons Lerned Holly Herring, PhrmD, BCPS * ; Winter Smith, PhrmD, BCPS ; Toni Ripley, PhrmD, BCPS, AQ-Crdiology ; nd Kevin Frmer, PhD ABSTRACT Bckground: Phrmcists re vitl helth cre providers to ptients with hert filure (HF), but their complince to the HF core mesure hs not been clerly defined. Objective: The objective of this study ws to mesure the impct of phrmcist involvement t dischrge on complince with The Joint Commission HF core mesure. Methods: This prospective study ws conducted t 361-bed cdemic teching institution. A phrmcist performed chrt reviews just prior to dischrge on dult ptients with preliminry dignosis of HF (ie, clinicl suspicion) to evlute complince with the HF core mesure. The phrmcist then intervened s needed to ensure complince. The primry outcome ws HF core mesure complince rtes with phrmcist involvement t dischrge compred to rtes during the sme 3-month period during the previous yer (without phrmcist involvement). Results: Of 92 ptients dmitted with clinicl suspicion of HF, the phrmcist ws ble to review 45 ptient chrts t dischrge (49%). The mjority of interventions mde by the phrmcist were due to mediction discrepncies within the dischrge instructions found during mediction reconcilition. Rtes of complince with the HF core mesure did not differ between the period with phrmcist involvement t dischrge nd the previous period (without phrmcist involvement, P =.39). However, brriers to complince relted to dischrge mediction documenttion, interdisciplinry communiction, nd mnpower were identified through the process. Conclusion: Although phrmcist involvement t dischrge did not trnslte into improved complince with the HF core mesure, systemtic brriers to complince were identified nd re currently being ddressed. Key Words core mesures, hert filure, performnce mesures, phrmcist, The Joint Commission Hosp Phrm 2014;49: In 2001, The Joint Commission (TJC) nd Centers for Medicre nd Medicid Services (CMS) developed evidence-bsed performnce mesures, termed core mesures or qulity mesures, for hospitls to comply with in order to improve sfety nd qulity of cre for ptients with hert filure (HF). 1 Hospitls should strive for 100% complince to ech of the 4 criterions of the HF core mesure: (1) dischrge instructions, (2) evlution of left ventriculr (LV) systolic function, (3) ngiotensin-converting * Phrmcist, Integris Helth Edmond, Edmond, Oklhom; Associte Professor, Professor, Deprtment of Phrmcy: Clinicl nd Administrtive Sciences, University of Oklhom College of Phrmcy, Oklhom City, Oklhom. Corresponding uthor: Holly Herring, PhrmD, BCPS, Integris Helth Edmond, 4801 Integris Prkwy, Edmond, OK 73034; e-mil: holly.herring22@yhoo.com Hospitl Phrmcy 1017

2 enzyme inhibitor (ACEI) or ngiotensin receptor blocker (ARB) therpy for ptients with left ventriculr (LV) systolic dysfunction or documenttion of contrindiction to such therpy, nd (4) smoking cesstion dvice/counseling. 2 To be included in the HF core mesure, ptient must be dmitted to the hospitl with principl dignosis of HF. Severl prctices must tke plce to meet these stndrds nd be in complince with the HF core mesure criteri. For the dischrge instruction criteri, ptients must receive instructions regrding specific symptoms tht wrrnt tretment, diet nd weight mngement, nd ctivity level. Ptients must lso be given complete dischrge mediction instructions tht include documenttion of home medictions nd new medictions to be continued following dischrge. LV systolic function must be recorded in the ptient s medicl record s n ejection frction (EF). Ptients with LV systolic dysfunction nd n EF less thn 40% should receive ACEI or ARB therpy, unless contrindiction is documented. Finlly, ptients who smoke must be given dvice or counseling on smoking cesstion. All elements of these 4 criteri must be clerly documented in the ptient s medicl record. TJC recognizes phrmcists s helth cre professionls who id in the implementtion of core mesures. Beginning in 2008, TJC llowed documenttion of LV systolic function nd contrindictions to ACEI or ARB therpy by phrmcist to meet the HF core mesure criteri. 2 Further, phrmcists cn id in the mediction reconcilition process to help ensure tht ptients receive complete list of dischrge medictions. 3 With this uthoriztion from TJC, phrmcists could potentilly hve discrete role in chieving complince with the HF core mesure. The OU Medicl Center is 361-bed dult cdemic teching institution serving centrl Oklhom. Historiclly, HF core mesures hve lrgely been mnged by OU Medicl Center nursing ledership nd stff. Rtes of complince with the HF core mesure t OU Medicl Center from Jnury 2009 to Mrch 2009 were s follows: 80.6% of HF ptients were given complete dischrge instructions, 100% hd documenttion of LV systolic function, 93.3% were prescribed n ACEI or ARB for LV systolic dysfunction or contrindiction to therpy ws documented, nd 100% were provided smoking cesstion counseling. At tht time, nurse leder, the medicl stff, nd nursing stff were ultimtely responsible for complince to the core mesure for ech ptient with principl dignosis of HF. The nurse leder worked to ensure documenttion of LV systolic function, pproprite drug therpy (if indicted for n EF <40%), or documenttion of contrindiction to therpy. Prior to dischrge, home mediction orders were completed by the physicin. Then, the nursing stff trnscribed the mediction orders to dischrge instruction sheet tht ws given to the ptient, which lso included counseling on diet nd weight mngement, ctivity level, nd specific symptoms tht wrrnt further tretment. Written smoking cesstion counseling for ptients with smoking history ws lso included on the dischrge instruction sheet. Finl dignostic codes were ssigned fter dischrge. A qulity nurse nlyst reviewed ech ptient chrt coded with principl dignosis of HF for complince with the HF core mesure nd entered complince sttus (complint vs noncomplint) into dtbse. This informtion is submitted to nd publicly reported by the CMS nd the US Deprtment of Helth nd Humn Services ( hospitlcompre.hhs.gov). In Fll 2009, opportunities for improvement in complince with 2 of the HF core mesure criteri were identified: proportion of ptients receiving complete dischrge instructions nd n ACEI/ARB for LV systolic dysfunction. Therefore, phrmcist joined the nurse leder nd ptient cre tem (nurses nd physicins) to help improve complince to the HF core mesure. The purpose of this study ws to mesure the impct of phrmcist involvement t dischrge on complince with the overll HF core mesure. METHODS Study Design This ws prospective study conducted t dischrge on ptients with principl dignosis of HF from Jnury 2010 through Mrch Ptients between the ges of 18 nd 100 yers dmitted with n initil principl dignosis of HF were included. Of note, becuse the finl coding of dignosis occurs fter ptient dischrge, ll ptients with preliminry dignosis code (ie, clinicl suspicion of HF) were included for the initil chrt review. Ptients were excluded if they were trnsferred to other fcilities prior to dischrge. The study protocol ws reviewed nd pproved by the locl institutionl review bord. Informed consent ws wived on the bsis tht the reserch involved no more thn miniml risk to the prticipnts Volume 49, December 2014

3 Intervention The phrmcist ws notified by the nurse of ptients with HF who were being dischrged. The phrmcist performed chrt reviews 1 to 3 hours prior to dischrge to evlute complince with the HF core mesure. The phrmcist then intervened s needed bsed on this chrt review to ensure complince with the HF core mesure. The specific interventions re defined in Tble 1. Outcomes Mesured The primry outcome ws HF core mesure complince rtes with phrmcist involvement t dischrge compred to rtes during the sme 3-month period during the previous yer (Jnury 2009 to Mrch 2009, without phrmcist involvement). Electronic medicl records nd hrdcopy medicl chrts served s principl dt sources. The qulity nurse nlyst reported complince rtes to study personnel for sttisticl nlysis. Complince rtes were then collected s nominl vribles nd compred using the chi-squre test. RESULTS During the study period (Jnury 2010 to Mrch 2010), 92 ptients were dmitted with clinicl suspicion of HF. Of these 92 ptients, the phrmcist reviewed 45 ptient chrts t dischrge (49%). Thirty-one of the 45 ptients reviewed by the phrmcist were excluded from finl nlysis due to the correction of the coded medicl dignosis fter dischrge, leving 14 ptients for finl nlysis (14/45; 31%) (Figure 1). The complince rtes to the TJC HF core mesure with phrmcist involvement from Jnury 2010 to Mrch 2010 were reported s follows: 78.9% were given complete dischrge instructions, 100% hd documenttion of LV systolic function, 100% were prescribed n ACEI or ARB for LV systolic dysfunction, nd 100% were provided smoking cesstion counseling. No difference in these rtes ws found compred to the control period of Jnury 2009 to Mrch 2009 without phrmcist involvement (P =.39) (Tble 2). Tble 1. Phrmcist interventions performed HF core mesure criteri Intervention description No. of study ptients who received intervention (n = 9) Dischrge instructions Reconciled home nd inptient medictions to: 0 Identify nd resolve mediction discrepncies in collbortion with dischrging physicin 0 Ensure complete dischrge mediction list ws provided to ptient 7 (78%) Evlution of LV systolic function ACEI/ARB for LV systolic dysfunction (EF <40%) Smoking cesstion If not recorded, reported EF in medicl record (from recent echocrdiogrm) If no EF vilble for documenttion, recommended echocrdiogrm If not prescribed, recommended therpy If contrindiction existed, documented this in medicl record 0 Hypersensitivity to ACEI or ARB 0 Moderte/severe ortic stenosis 0 Renl rtery stenosis 0 Hyperklemi 0 Hypotension 0 Renl dysfunction Written mterils given with dischrge instructions to ll ptients; no phrmcist intervention Note: ACEI = ngiotensin-converting enzyme inhibitor; ARB = ngiotensin receptor blocker; EF = ejection frction; LV = left ventriculr. 1 (11%) 1 (11%) 0 (0%) Exmples of mediction discrepncies identified nd resolved: therpeutic dupliction, mediction omission, incorrect dose nd/or intervl, unintended drug continution/discontinution. Hospitl Phrmcy 1019

4 31 ptients (69%) excluded did not hve principl dignosis of HF 45 ptients (49%) reviewed by phrmcist 92 ptients dmitted with clinicl suspicion of HF 14 ptients included tht met study criteri 11 ptients (79%) complint with HF core mesure 47 ptients (51%) not reviewed by phrmcist (ll with HF principl dignosis) 38 ptients (81%) complint with HF core mesure Figure 1. Phrmcist review of ptients nd hert filure (HF) core mesure complince (Jnury-Mrch 2010). Coded fter dischrge. Five of the 14 (36%) ptients reviewed by the phrmcist were complint with ll 4 criteri of the HF core mesure; therefore, no intervention ws necessry. The phrmcist performed interventions on the remining 9 ptients, nd the types of interventions re summrized in Tble 1. The mjority of interventions (77.8%) were due to mediction discrepncies within the dischrge instructions tht were found during mediction reconcilition. The most common mediction discrepncy ws the omission of medictions from the physicin dischrge orders to the dischrge instructions t the time of trnscription. Discussion Phrmcist involvement did not trnslte into improved complince with the HF core mesure. There were no dditionl process chnges tht would hve ffected the results during or between study periods. The smll smple size of ptients included in the finl nlysis my hve impcted these dt. In spite of this limittion, the study provided insight into brriers tht exist to meeting the core mesure nd into the fesibility of utilizing phrmcists to improve dherence. Brriers to meeting the core mesure mnifested primrily in dischrge instructions. Completeness of dischrge instructions ws the lowest re of complince during both timefrmes, with complete dischrge mediction instructions being the principl component of noncomplince. Physicins often dictted dischrge summries fter ptients were relesed from the hospitl, nd the dictted summries were often inconsistent with the dischrge orders provided for trnscription t the time of dischrge. Medictions were not reconciled between the originl dischrge orders nd dictted summries, becuse the dicttion ws done fter dischrge; therefore, medictions were often omitted from the ptient s dischrge instructions. Such discrepncies re unlikely to be voided without chnge in this process. These findings re similr to study in which complince with dischrge instructions remined lower thn nticipted becuse of documenttion issues within the mediction reconcilition process. 4 Chnges in the dischrge mediction trnscription process t our institution re currently in process to ddress this systemtic problem. Another brrier to complince ws the lck of stremlined process t dischrge. During the study, 3 people were involved in the review nd reporting process for HF ptients (nurse leder, qulity nurse Tble 2. The Joint Commission hert filure core mesure complince rtes before nd fter phrmcist involvement t dischrge HF core mesure criteri Complince rtes Jnury-Mrch 2009, % Complince rtes Jnury-Mrch 2010, % HF ptients given complete dischrge instructions Evlution of LV systolic function Given ACEI/ARB for LV dysfunction or documenttion of contrindiction to therpy Smoking cesstion dvice/counseling Note: ACEI = ngiotensin-converting enzyme inhibitor; ARB = ngiotensin receptor blocker; HF = hert filure; LV = left ventriculr. P =.39 for comprison of 2 time periods overll (ll 4 criteri combined) Volume 49, December 2014

5 nlyst, nd phrmcist) s described erlier. With so mny helth cre professionls involved, notifiction of HF ptients being dischrged ws inconsistent nd the phrmcist ws not lwys notified of dischrge ptients for review. Also, the mnpower needed for review of ll HF ptients t the time of dischrge ws greter thn wht one phrmcist could ccommodte; one phrmcist ws llocted 30% time to ssume this responsibility. This ppered to be insufficient, becuse the phrmcist ws only ble to review hlf of the ptients (45/92) with clinicl suspicion of HF. Furthermore, since the phrmcist relied on preliminry dignosis codes (ie, clinicl suspicion of HF) to identify HF ptients, the mjority of the phrmcist s effort ws spent on review of ptients without finl primry dignosis of HF. The fesibility of routinely including phrmcists t the point of dischrge for ech HF ptient would likely require multiple phrmcists dedicted to evluting complince with the core mesure, including evenings nd weekends. Given the high bseline complince with the HF core mesure, the dded vlue of dditionl helth cre professionls is uncertin. The current process hs been stremlined such tht one person, HF qulity nurse coordintor (0.5 full-time equivlent) is solely responsible for the review HF ptients nd complince to TJC HF core mesure. Prior to this study, HF qulity nurse coordintor ws not prt of our institution s helth cre tem. This hs led to more efficient pproch tht focuses on HF ptients from dmission to dischrge, ultimtely reducing unnecessry review nd improving communiction. Future reserch should focus on interventions to improve the mediction reconcilition process for HF ptients. A study is currently evluting the role of phrmcists in the dischrge mediction reconcilition process nd the reduction of unintentionl mediction errors t dischrge. 5 This tril my provide insight into the vlue of phrmcists in the mediction reconcilition process, but future studies should focus on the role of phrmcists in the mediction reconcilition process t dischrge for HF ptients nd complince with TJC HF core mesure. CONCLUSION In this investigtion, ddition of phrmcist to multidisciplinry tem did not improve complince to TJC HF core mesure. However, systemtic issues contributing to noncomplince were identified. Qulity improvement mesures re plnned or in plce to ddress these issues. ACKNOWLEDGMENTS The uthors hve no finncil or institutionl conflicts of interest to report. Holly Herring ws previously Clinicl Assistnt Professor, University of Oklhom College of Phrmcy, Oklhom City, Oklhom. REFERENCES 1. The Joint Commission on the Accredittion of Helthcre Orgniztions. Comprehensive review of development nd testing for ntionl implementtion of hospitl core mesures. Accessed September 27, Qul ity Net. Specifictions mnul for ntionl hospitl inptient qulity mesures. Version 2.5b. org. Accessed September 20, Hinojos C, Girdin J, K Rdtke, Vournzos C. HF core mesures multidisciplinry pproch [bstrct]. Hert Lung: J Acute Crit Cre. 2009;38: Coons J, Fer T. Multidisciplinry tem for enhncing cre for ptients with cute myocrdil infrction or HF. Am J Helth Syst Phrm. 2007;64: AHS Cncer Control Albert. The impct of phrmcist dischrge mediction reconcilition on unintentionl mediction discrepncies from inptient dischrges t the Albert Cncer Bord Cross Cncer Institute. CliniclTrils.gov Accessed My 26, Hospitl Phrmcy 1021