n January 2013, RN.com introduced the concept of Core Measures to our readers as a part of a new educational series. Every two months, RN.com will explore a specific Core Measure. Each article will take a comprehensive, in-depth approach to a specific health-related condition. Our aim is to increase our readers’ understanding, while communicating the importance of adhering to these measures as a standard of care to improve patient safety. The Centers for Medicare and Medicaid (CMS) and The Joint Commission (TJC) collaborated to define a set of criteria to be used by both organizations to measure quality of patient care. These evidence-based criteria, the Core Measures, are indicators of timeliness and effectiveness of care for certain specific conditions. They state key actions which have contributed to successful outcomes for these conditions.

The most recent Specifications Manual for National Hospital Inpatient Quality Measures contains categories of Core Measures including acute myocardial infarction (AMI), heart failure, pneumonia, surgical care improvement, immunization, prevention, and other categories. In January, we delved into acute myocardial infarction (AMI) measures. This month, we will examine core measures relating to heart failure.

The Heart Failure (HF) Measures

The three heart failure measures which MUST BE DOCUMENTED are:

• Discharge instructions
• Evaluation of left ventricular systolic (LVS) function
• ACE inhibitor or angiotensin receptor blocker (ARB) for LVS dysfunction (LVSD)

Discharge Instructions:

By the time of discharge, heart failure patients or their caregivers MUST receive written instructions or educational materials that include all of the following aspects:

• Activity level
• Diet
• Discharge medications
• Follow-up appointment
• Weight monitoring

What to do if symptoms worsen: Non-compliance with follow-up care threatens the patient’s status and also increases the likelihood of readmission and mortality. In addition to data related to Core Measures, CMS collects readmission and mortality data.

Left Ventricular Systolic (LVS) function:

LVS function is the single most important diagnostic test in the management of all patients with heart failure. The heart failure patient’s record must document that LVS function was evaluated before arrival, during hospitalization, or is planned after discharge.

Angiotensin Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blockers (ARB) therapy:

For the LVSD patient, the patient’s record must document a prescription for an ACEI or ARB at hospital discharge. LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. ARBs are recommended for patients who are ACEI intolerant.

Examples of ACEIs:

• benazepril (Lotensin®, Lotensin Hct®)
• captopril (Capoten®)
• enalapril (Vasotec®)
• fosinopril (Monopril®)
• lisinopril (Prinivil®, Zestri®)
• moexipril (Univasc®)
• perindopril (Aceon®)
• quinapril (Accupril®)
• ramipril (Altace®)
• trandolapril (Mavik®)

Examples of ARBs:

• candesartan (Atacand®)
• eprosartan (Teveten®)
• irbesartan (Avapro®)
• losartan (Cozaar®)
• olmesartan (Benicar®)
• telmisartan (Micardis®)
• valsartan (Diovan®)

The Nurse’s Role

• Provide and document patient teaching of all six required aspects. Use a “teach back” method to assure that the patient or caregiver has learned the information and can state it to you.
• Assure that LVS function or plan for evaluation is documented.
• Assure that an ACEI or ARB is ordered. During hospitalization, administer the medications as ordered. Document and provide patient teaching concerning these medications.

Adherence to the Core Measure standards, along with patient satisfaction data reported on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, impact an organization’s reimbursement for care and accreditation status. Therefore, knowledge about the Core Measures, what each one entails, and how the standards are satisfied, is critical to the organizations for which you work. Support your healthcare organization’s achievement of high ratings on Core Measures.

The public may compare specific healthcare organizations’ results on Core Measures at the TJC website and at the U.S. Department of Health and Human Services (USDHHS) Hospital Compare website.

Biography: Bette Case Di Leonardi, PhD, RN-BC has worked in nursing, education and healthcare administration for more than 40 years and was among the first group of nurses certified in Nursing Professional Development. Today, Di Leonardi is an independent consultant who publishes and presents on a variety of professional and educational topics.