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Critical Pathway for the Management of Acute Heart Failure at the Veterans Affairs San Diego Healthcare System

Transforming Performance Measures Into Cardiac Care

Gardetto, Nancy J. MSN, FNP-c; Greaney, Karen MN, ANP; Arai, Lisa PharmD; Brenner, April MBA, BSN; Carroll, Karen C. MS, CCNS; Howerton, Nancy M. MSN, MBA; Lee, Melinda RD; Pada, Laureen MSN; Tseng, Marilynne BSN; Maisel, Alan S. MD, FACC

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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine: September 2008 - Volume 7 - Issue 3 - p 153-172
doi: 10.1097/HPC.0b013e31818207e4



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Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older.1 Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million in-patient hospital days.2 Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology (ACC), and American Heart Association (AHA) to disseminate evidence-based practice guidelines for management of chronic HF in adults;3 patients continue to present to the emergency departments (EDs) in ADHF.

The consequent health care burden of delivering care to the 5 million Americans with HF is tremendous. ADHF is a complex and costly clinical syndrome, carrying high in-hospital mortality (4.1%), and substantial hospital readmission rates.2 The estimated direct and indirect cost annually for HF management in 2006 was $29.6 billion dollars.2 The acute decompensated heart failure national registry, documents HF care practices and treatment patterns throughout the United States, for hospitalized patients with ADHF.1 Findings from acute decompensated heart failure national registry showed low adherence to published guidelines, and suboptimal conformity to the Joint Commission (JC) core HF performance measures, suggesting persistent gaps in the quality of care being delivered to HF patients.4

This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. In 2003, the Department of Veterans Affairs, Blue Ribbon Panel outlined its plan to Improve Cardiac Care. The objective of the Veterans’ Health Administration (VHA) Cardiac Care Initiative was to identify, catalogue and disseminate readily-usable quality improvement tools and strategies for acute coronary syndrome (ACS) and HF for ED field implementation. The Veterans Affairs San Diego Healthcare System (VASDHCS) is well suited to champion evidence-based performance improvement programs; and formed a multidisciplinary ACS/HF performance improvement team that met weekly to review the ACC/AHA Task Force Practice Guidelines and the JC performance measures. In 2006, the ACS ED menu was implemented and published5 and the team set forth on the task of developing standard order sets for patients with ADHF. After analyzing local care processes, reviewing evidence of best care practices, and defining appropriate goals to satisfy the multidimensional needs of HF patient; the team developed a computerized pathway in a user-friendly format that is simple, yet comprehensive; and focuses on early stages of HF evaluation and treatment for patients presenting to the ED.

Diagnosing HF

When a patient presents with shortness of breath, and HF is suspected, the ED HF Clinical Decision Menu is selected from the main HF order set, and the screen shown in Figure 1 is displayed.

ED HF Clinical Decision Menu.

In Figure 1, arrow 1 directs the user to an Online Clinical Guidelines link, which when clicked displays an overview of the HF treatment pathways (Fig. 2) available within the Veterans Affairs computerized patient record system.

HF treatment pathway.

Arrow 2 directs the triage nurse to the individual HF order sets, utilizing policy based, standardized, preliminary diagnostic and laboratory testing, which prompts rapid assessment and evaluation of HF in the ED. Included in these order sets are complete blood counts, urinalysis, serum electrolytes (creatinine and urea nitrogen), cardiac markers, B-type natriuretic peptide (BNP),6 electrocardiography, and chest radiography (Fig. 3). The ultimate goal is that results of preliminary tests and physical examination be available within 1 hour of the patient's initial presentation.

ED order set.

When the initial triage orders are completed, the reason for request and dialogue preview screen prompts notification of the MD that preliminary tests are pending, and that patient is in need of immediate evaluation; arrow 3 in Figure 4 directs providers to step 2 of the Clinical Decision Guide, the MD Initial Treatment pathway (Fig. 4). This pathway provides a systematic approach to a diagnosis-based order set that allows providers to differentiate between severe respiratory failure, and shortness of breath with or without chest pain (Fig. 4). The order sets are built to facilitate rapid assessment and accelerate the treatment of HF in the ED setting; taking into consideration, different management needs and the spectrum of diseases contributing to HF.

ED HF Clinical Decision Menu: step 2 MD initial treatment pathway.

Risk Stratification

The clinical decision guide assists the health care provider to immediately risk stratifies the patient in such a way that facilitates the determination of need for either admission and/or further treatment in the ED. This strategy is based on information obtained from clinical assessment of hemodynamics (signs of congestion/perfusion), and preliminary diagnostic and laboratory testing, heavily weighting the BNP level.6 By selecting the range that corresponds to a patients BNP level, the resulting decision menu guides the user to stratify the patient into high versus moderate risk, and triage accordingly.

If patients present with acute HF and evidence of acute myocardial injury (positive cardiac markers and/or electrocardiogram), providers click Yes to shortness of breath with chest pain and are immediately directed to the specialized ACS treatment menu (Fig. 5), which guides critical treatments that meets the goals and indications prescribed by the ACC/AHA, and the JC for rapid management of ACS in the ED.5 If the patient has shortness of breath, but no chest pain; at a glance the provider is presented with a review of other causes of dyspnea and ACS signs and symptoms. If none are present, clicking No (arrow 4, Fig. 5), directs the user to the HF symptom order sets that provide treatment algorithms for HF management to further assist with medical stabilization, early initiation of diuretics and accelerate the triage process.

ACS treatment menu.

The provider is prompted by a series of questions surrounding the presence or absence of HF symptoms; by clicking on Yes (arrow 5), the order sets assist providers who have identified the cold-wet or hemodynamically unstable HF patient, to expedite treatment and patient triage. The critical pathway for the severe HF patient calls for immediate attention, aggressive treatment and admission to the intensive care unit (ICU) (Fig. 6).

HF ICU admission menu.

For ADHF requiring admission, the computerized menu provides a series of critical pathways that follow good clinical practice guidelines for management of hemodynamically unstable HF patients in the ED setting, through admission to the ICU including; observation, monitoring (Fig. 7) and treatment for severe HF (Fig. 8).

HF treatment menu.
Medication treatment menu for severe HF.

As seen in Figure 7, the dialogue box carries the user through the management of ADHF in the ED. Built into the decision guides is the option for step 3: MD reassessment and second trial treatment order sets, displayed in Figure 13 and provides options for aggressive medical management in the ED setting.

HF assessment menu.

If the patient's condition warrants immediate pharmacologic management, the pathway guides users to a clinical decision menu for treatment of severe HF (Fig. 8). This is based on Advanced Cardiac Life Support guidelines and incorporates use of vasodilators, inotropic infusions, diuretics, and respiratory orders.

The ICU/Direct Observation Unit HF order menus can be used throughout the hospital course (Fig. 9).

ICU/DOU HF menu.

The availability of the ICU / Direct Observation Unit HF menu throughout the hospital course has a 3-fold benefit: (1) it provides a systematic approach to HF management; (2) as the patient progress from the acute in-patient hospital phase, it provides a segue toward outpatient HF management; and (3) it assists providers with core HF measures/indicators by providing a menu with standard HF medications, consults, patient education, and HF discharge instructions.

Going back to the initial assessment in the ED (Fig. 4), instead of a BNP of >500 pg/mL; the patient has a BNP of 100 to 500 pg/mL (indicative of moderate HF). The treatment algorithms shown in Figure 10 provide an overview of pathway options in the HF menu.

Overview of HF treatment algorithm.

If BNP 100 to 500 is selected, the menu options in Figure 12 become available.

HF treatment menu.

The pathway is built to be intuitive and flows as HF treatment is initiated and the patient's condition is monitored in the ED setting (Fig. 12).

Healthcare providers are cued to re-evaluate patients based on HF criteria (Fig. 13).

Pathways options (Fig. 14) include admit or treat in ED and phase 2 HF treatment in ED.

HF treatment decision options in ED.

Built into the pathway (Fig. 15) is a strategy for effective management, timely reassessment, and appropriate disposition of the HF patient.

HF evaluation and discharge criteria in ED.

If further treatment is warranted, the provider is taken back to earlier pathway options found in Figures 13 and 14; if admission is warranted the option in Figure 16 is provided.

HF evaluation and discharge criteria in ED, continued.

If a patient's symptoms have improved; and providers determine the patient meets discharge criteria (Fig. 14), by selecting Yes, on the HF DC from ED Criteria menu, menu options for discharge become available, as shown in Figures 17 to 19.

HF discharge medication menu.
HF discharge ED dialogue and medication reconciliation.
HF discharge ED criteria menu.

Successful strategies to improve care for HF patients need to assist health care providers with rapid recognition and early aggressive treatment, while creating a reliable process that ensures continuity of care.7 This critical pathway for management of Acute HF at the VASDHCS provides computerized order sets that guide health care providers through accepted treatment regimens, providing documentation of treatment and assists with compliance data collection. Obviously, comorbidities and individual patient events may force health care providers to deviate from the pathway; however, once the diagnosis of HF is made, risk stratification occurs using clinical signs and symptoms along with laboratory values discerning BNP levels and renal function. Implementation of a critical pathway and HF algorithm aimed at rapid evaluation and treatment of patients presenting to the ED with shortness of breath, will facilitate effective patient triage, which will not only benefit the patient, but will ease crowding of the ED. Finally, the algorithm provides documentation for health care providers and patients and assists as a measuring tool in tracking adherence.

As a healthcare leader and proponent of putting quality first and building healthier communities, the VHA participates in publicly shared “national” performance initiatives. There are now several web sites that provide hospital quality data. The intent of these Websites is to make it easier for the consumer to make informed healthcare decisions and to support efforts to improve quality in US hospitals. The Centers for Medicare & Medicaid Services, an agency of the US Department of Health and Human Services along with the Hospital Quality Alliance created the Hospital Compare Website. Hospital Compare has quality measures on how often hospitals provide recommended care for adults being treated for a heart attack, HF, or pneumonia. These same measures are also a part of the JC and VHA's current performance measurement programs. Through the use of the ACS and HF computerized order sets as presented in this document, the VASDHCS currently achieves a performance level above most JC accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation (Table 1).

The Joint Commission Quality Check: Hospital-Reporting Period: October, 2006–September, 2007
Medication treatment menu for HF.


1. Fonarow GC. Overview of Acutely Decompensated Congestive Heart Failure (ADHF): a report from the ADHERE Registry. Heart Fail Rev. 2004;9:179–185.
2. American Heart Association. Heart disease and stroke statistics: 2005 Update. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113:e85–e151. Available at:
3. Hunt SA. ACC/AHA 2005 guideline update for diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology & American Heart association Task Force on Practice Guidelines (Committee to Revise the 2001 Guidelines for the Evaluation and Management of Chronic Heart Failure). J Am Coll Cardiol. 2005;47:e3–e362. Available at:
4. Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Intern Med. 2005;165:1469–1477.
5. Larson R, Brenner A, Greaney K, et al. Acute Coronary Syndrome: the time is life campaign at the veterans administration medical center San Diego. Crit Pathw Cardiol. 2006;5:46–58.
6. Maisel AS, Krishnaswamy P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161–167.
7. Sevin E, Jacobsen D. Improved care for patients with congestive heart failure. Jt Comm J Qual Patient Saf. 2008;34:13–19.

Acute Decompensated Heart Failure (ADHF); implementation of clinical pathway; performance improvement; evidence-based guidelines and HF core measures

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