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ICS I
I NSTITUTE FOR C LINICAL S Y S T E M S I M P ROV E M E N T
Health Care Order Set:
Emergent Orders for Heart Failure
Fourth Edition December 2009

The information contained in this ICSI Health Care Order Set is intended primarily for health professionals and the following expert audiences: physicians, nurses, and other health care professional and provider organizations; health plans, health systems, health care organizations, hospitals and integrated health care delivery systems;
health care teaching institutions; health care teaching institutions;
health care information service departments; health care information technology departments; medical specialty and professional societies; researchers;
federal, state and local government health care policy makers and specialists; and employee benefit managers.
This ICSI Health Care Order Set should not be construed as medical advice or medical opinion related to any specific facts or circumstances. If you are not one of the expert audiences listed above you are urged to consult a health care professional regarding your own situation and any specific medical questions you may have. In addition, you should seek assistance from a health care professional in interpreting this ICSI Health Care Order Set and applying it in your individual case. This ICSI Health Care Order Set is designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a Order Set for all patients with a particular condition. An ICSI Health Care Order Set rarely will establish the only approach to a problem. Copies of this ICSI Health Care Order Set may be distributed by any organization to the organization's employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Order Set may be used by the medical group in any of the following ways: copies may be provided to anyone involved in the medical group's process for developing and implementing clinical guidelines; the ICSI Health Care Order Set may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents; and copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Order Set is incorporated into the medical group's clinical guideline program.
All other copyright rights in this ICSI Health Care Order Set are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adaptations or revisions or modifications made to this ICSI Health Care Order Set.
ICS I
I NSTITUTE FOR C LINICAL S Y S T E M S I M P ROV E M E N T
Health Care Order Set:
Fourth Edition December 2009
Annotation Table
Topic
Pre-Checked Orders Admitting Data Diagnosis Nursing Orders Medications Patients with SBP Less than 70 mmHg Diuretic Nitroglycerin Nesiritide Laboratory/Diagnostic Tests
Annotation
1 2 3 4 5
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Copyright 2009 by Institute for Clinical Systems Improvement 1
Fourth Edition/December 2009
Table of Contents
Work Group Leader
Stephen Kopecky, MD Cardiology, Mayo Clinic
Algorithms and Annotations ....................................................................................... 1-11
Work Group Members
Cardiology Tarek Mahrous, MD North Central Heart Clinic Charles Pinkerman, MD Park Nicollet Health Services Emergency Medicine Peter Smars, MD Mayo Clinic
Internal Medicine Ashok Ojha, MD Hutchinson Medical Center Shama Raikar, MD HealthPartners Medical Center
Supporting Evidence.................................................................................................... 12-14

Brief Description of Evidence Grading ............................................................................ 13 References ........................................................................................................................ 14
Annotation Table ................................................................................................................ 1 Foreword Scope and Target Population......................................................................................... 3 Clinical Highlights and Recommendations .................................................................. 3 Priority Aims ................................................................................................................. 3 Key Implementation Recommendations ....................................................................... 3 Related ICSI Scientific Documents ........................................................................... 3-4 Disclosure of Potential Conflict of Interest................................................................... 4 Introduction to ICSI Document Development .............................................................. 5 Description of Evidence Grading.................................................................................. 5 Order Set.......................................................................................................................... 6-9 Annotations ..................................................................................................................10-11
Nursing Bernadette Beining, RN Marshfield Clinic Mary Jo Macklem, RN Park Nicollet Health Services Pharmacy Joshua E. Breeding, PharmD, BCPS Fairview University Medical Center Robert Straka, PharmD University of Minnesota Physicians
Support for Implementation ..................................................................................... 15-22
Priority Aims and Suggested Measures ............................................................................ 16 Measurement Specifications .................................................................................. 17-19 Key Implementation Recommendations .......................................................................... 20 Knowledge Resources ...................................................................................................... 20 Resources Available..................................................................................................... 21-22
Physician Assistant Angela Turner, PA-C Park Nicollet Health Services Facilitator Myounghee Hanson ICSI Kari Retzer, RN ICSI
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Institute for Clinical Systems Improvement 2
Foreword
Scope and Target Population
This order set pertains to the acute measures initiated in the emergency department only and does not include orders for admission to intensive care, telemetry or medical/surgical units.
Clinical Highlights and Recommendations

Evaluate patients presenting with heart failure for exacerbating and underlying causes, including coronary artery disease, hypertension, valvular disease and other cardiac and non-cardiac causes. (Annotation #3) Studies show that the distinction between systolic dysfunction and preserved systolic function is important because the choice of therapy may be quite different, and some therapies for systolic dysfunction may be detrimental if used to treat preserved systolic function. (Annotation #3) Brain natriuretic peptide (BNP) and NTproBNP are useful in the diagnosis and prognosis of heart failure in patients with dyspnea of unknown etiology. (Annotation #6)
Priority Aims
1. Decrease the readmission rate within 30 days of discharge following hospitalization for heart failure. 2. Improve the use of diagnostic testing in order to identify and then appropriately treat adult patients with heart failure.
Key Implementation Recommendations

The following system changes were identified by the order set work group as key strategies for health care systems to incorporate in support of the implementation of this order set. 1. Hospitals should develop and implement ED critical pathways and consider standard orders to accomplish rapid evaluation and treatment of heart failure patients. Standard discharge orders/instructions should also be considered.
Related ICSI Scientific Documents

Guidelines Antithrombotic Therapy Supplement Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS) Hypertension Diagnosis and Management Lipid Management in Adults Major Depression in Adults in Primary Care Palliative Care Stable Coronary Artery Disease Venous Thromboembolism Diagnosis and Treatment Venous Thromboembolism Prophylaxis
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Institute for Clinical Systems Improvement
Foreword Order Sets Admission for Heart Failure Order Set Discharge for Heart Failure Order Set
Venous Thromboembolism Prophylaxis for the Medically Ill Patient Order Set
Disclosure of Potential Conflict of Interest
ICSI has adopted a policy of transparency, disclosing potential conflict and competing interests of all individuals who participate in the development, revision and approval of ICSI documents (guidelines, order sets and protocols). This applies to all work groups (guidelines, order sets and protocols) and committees (Committee on Evidence-Based Practice, Cardiovascular Steering Committee, Women's Health Steering Committee, Preventive & Health Maintenance Steering Committee and Respiratory Steering Committee). Participants must disclose any potential conflict and competing interests they or their dependents (spouse, dependent children, or others claimed as dependents) may have with any organization with commercial, proprietary, or political interests relevant to the topics covered by ICSI documents. Such disclosures will be shared with all individuals who prepare, review and approve ICSI documents. Robert Straka, PharmD has received honoraria from Pfizer, Novartis and Schering-Plough in the amounts of $2,000, $1,500, and $2,000. The only engagement for which a marketed product was involved was Novartis Aliskiran. Mr. Straka served one time as a consultant to ARCA Pharmaceuticals for a product that is not currently on the market; he received honoraria in the amount of $1,500. Stephen L. Kopecky, MD is a consultant for and has received honoraria in the amount of $1,500 from Glaxo Smith Kline. Dr. Kopecky is on the advisory board for Biophysical. No other work group members have potential conflicts of interest to disclose.
Introduction to ICSI Document Development

This document was developed and/or revised by a multidisciplinary work group utilizing a defined process for literature search and review, document development and revision, as well as obtaining input from and responding to ICSI members. For a description of ICSI's development and revision process, please see the Development and Revision Process for Guidelines, Order Sets and Protocols at http://www.icsi.org.
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Foreword
Evidence Grading System

A. Primary Reports of New Data Collection: Class A: Class B: Class C: Randomized, controlled trial Cohort study Non-randomized trial with concurrent or historical controls Case-control study Study of sensitivity and specificity of a diagnostic test Population-based descriptive study Cross-sectional study Case series Case report Meta-analysis Systematic review Decision analysis Cost-effectiveness analysis Consensus statement Consensus report Narrative review Medical opinion
Class D:
B. Reports that Synthesize or Reflect Upon Collections of Primary Reports: Class M:
Class R:
Class X:
Citations are listed in the guideline utilizing the format of (Author, YYYY [report class]). A full explanation of ICSI's Evidence Grading System can be found at http://www.icsi.org.
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Order Set
This order set pertains to the acute measures initiated in the emergency department only and does not include orders for admission to intensive care, telemetry or medical/surgical units.
Legend: ! Open boxes are orders that a clinician will need to order by checking the box Pre-checked boxes are those orders with strong supporting evidence and/or regulatory requirements that require documentation if not done. (See Annotation #1)
Patient Information (Two are required.) Last Name: First Name: Date of Birth:___/___/_____ Patients age: ID #:
Admitting Data (See Annotation #2)

Attending physician: How to contact: Primary care physician: How to contact:
Diagnosis (See Annotation #3)

Admitting Dx: Heart Failure New onset Acute exacerbation Class II (slight limitation of activity) Class III (marked limitation of activity) Class IV (severe to complete limitation of activity) Secondary Dx:
Condition
Stable Unstable Other
Code Status
Full code DNR/DNI Comfort care Not discussed
Vitals
Vital signs every minutes Oximetry - continuous ECG monitor - continuous
Allergies/Adverse Drug Reactions

None Yes, Name: Type of reaction: Type of reaction: Type of reaction:
Nursing Orders (See Annotation #4)

Oxygen L/min (2-4 L/min) by nasal canula to keep SaO2 greater than 92 Catheter Input and output
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Order Set
Airway/Respiratory Management Consults: Respiratory therapy Advanced airway protocol: CPAP Patient Admission Plan ED observation bed Procure inpatient bed: Patient weight: Patient height: kg cm
Anesthesia BiPAP
Intubation
Short-stay bed ICU Telemetry
Medical
IVs
Establish IV saline lock with flush every day as needed. Check IV fluid if appropriate: Normal saline D5 0.45% NaCl with 20 mEq/L KCl at mL/hour D5 0.45% NaCl at mL/hour Lactated Ringers at mL/hour at
mL/hour
Medication (See Annotation #5)

Patients with SBP less than 70 mmHg (signs/symptoms of shock) Norepinephrine continuous IV infusion. Start at 0.03-0.1 mcg/kg/min. Titrate by 0.03-0.1 mcg/kg/min every 5-10 minutes to keep MAP and/or BP of _______ mmHg (max. of 0.4 mcg/kg/min). Patients with SBP 70-100 mmHg (signs/symptoms of shock) Dopamine continuous IV infusion. Start at mcg/kg/min (2-5 mcg/kg/min). Titrate by mcg/kg/min (1-2.5 mcg/kg/min) every 5-10 minutes to keep MAP and/or BP of ______ mmHg (max. of 20 mcg/kg/min). Patients with SBP greater than 160 mmHg OR SBP greater than 120 mmHg AND heart rate greater than 100 beats per minute (bpm) Labetalol mg IV (5-10 mg IV bolus) once, repeat times for target SBP greater than 120 and heart rate greater than 60 bpm Esmolol mcg/kg IV (500 mcg/kg IV bolus) once Esmolol maintenance IV drip mcg/kg/min (50-300 mcg/kg/min) Patients with SBP greater than 100 mmHg (without signs/symptoms of shock) Diuretic (hold if SBP less than mmHg) Furosemide mg (10-40 mg) by mouth every hours starting at hours (max. 600 mg daily) Furosemide mg (0.5-1 mg/kg) IV now and mg IV every hours (max. 400 mg daily) Furosemide (Lasix) continuous IV infusion mg/hour (1-5 mg/hour) (max. 400 mg daily) Torsemide mg (10-20 mg/day) by mouth every hours starting at hours Torsemide mg IV now and mg IV every hours Torsemide continuous IV infusion mg/hour (max. 200 mg daily) Metolazone mg by mouth every hours. Give 30 minutes BEFORE loop diuretics.
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Order Set
Nitroglycerin (hold if SBP less than mmHg) Tablet 0.4 mg sublingual every 5 minutes as needed for chest pain Notify MD if no relief after 3 doses Nitroglycerin continuous IV infusion. Start at mcg/kg/min (0.07-0.15 mcg/kg/min). Titrate by 0.1 mcg/kg/min every 5 minutes to maintain SBP between ______ - ______ mmHg (max. 2 mcg/kg/min). Nesiritide (hold if SBP less than 90 mmHg) ______ mcg IV loading dose over 1 minute (2 mcg/kg IV) 0.01mcg/kg/min continuous IV infusion. Titrate by 0.005 mcg/kg/min every 3 hours (max. 0.03 mcg/kg/min) (Central line including PICC recommended for dobutamine or dopamine) Inotrope Dopamine continuous IV infusion. Start at mcg/kg/min (2-5 mcg/kg/min). Titrate by mcg/kg/min (1-2.5 mcg/kg/min) every 5-10 minutes to keep MAP and/pr BP of ________ mmHg (max. 20 mcg/kg/min). Dobutamine continuous IV infusion (refractory cases, SBP greater than 100 mmHg). Start at mcg/kg/min (2-5 mcg/kg/min). Titrate by mcg/kg/min (1-2.5 mcg/kg/min) every 5-10 minutes (max. 20 mcg/kg/min). Milrinone 50 mcg/kg IV loading dose over 10 minutes Continuous IV infusion. Start at 0.25 mcg/kg/min. Titrate by 0.1 mcg/kg/min every 3 hours (max. 0.75 mcg/kg/min). Digoxin (for patients in atrial fibrillation with rapid ventricular response) 500 mcg loading dose once by mouth IV (max. 1 mg/day) (Adjust dose if renal dysfunction present.) Notify MD if SBP below mmHg, HR less than _______, or arrhythmia occurs
Laboratory/Diagnostic Tests (See Annotation #6)

Electrolytes, bun, creatinine Glucose Mg++, Ca++ CBC, platelets Digoxin level Urinalysis PT/INR PTT Cardiac markers (CKMB, Troponin) BNP or NTproBNP Arterial blood gases Chest x-ray AP portable Standard PA and lateral 12-lead ECG Echocardiogram
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Order Set

Arterial line Echocardiogram PA catheter Balloon pump
Set up for: Other
Other
Other orders
Consults
Cardiology Pulmonary
Authorized Prescriber Signature: ____________________________________________________ Printed Name:____________________________________________________________________ Date & Time of Orders: / / :
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Annotations
1. Pre-Checked Orders
ICSI order sets utilize two types of boxes for orders. One is the open box that clinicians will need to check for the order to be carried out. The second box is a pre-checked box and are those orders that have strong evidence and/or are standard of care and require documentation if the clinician decides to "uncheck" the order. There is increasing evidence that pre-checked boxes are more effective in the delivery of care than physician reminders, even within the computerized medical record environment (Dexter, 2004 [A]). Organizations are recognizing the benefit of using pre-checked boxes for other orders to promote efficiency. Organizations are encouraged, through a consensus process, to identify those orders to utilize pre-checked boxes to increase efficiency, reduce calls to clinicians, and to reduce barriers for nursing and other professionals to provide care that is within their scope.
2. Admitting Data
Patient information would be part of the medical record in electronic ordering. Institutions will need to add this section per their organization's policy. Physician information would not be necessary in electronic ordering. How to contact would not be actionable in electronic ordering.
3. Diagnosis
The diagnosis of heart failure should not be a single diagnosis. It is important to identify the etiology or precipitating factors as a cause of heart failure. It is important to determine whether ventricular dysfunction is systolic or diastolic because therapies are quite different. Some therapies for systolic dysfunction may even be harmful if used to treat preserved systolic function (Topol, 1985 [C]). Ischemia is responsible for the majority of cases of heart failure. Two-thirds of systolic heart failure is due to ischemic heart disease. Identifying ischemia as a cause of heart failure is important, because a majority of these patients would benefit from revascularization.
4. Nursing Orders
Patients who stabilize may be admitted to an observation unit or monitored. Observation units provide a cost-effective alternative to hospitalization for select patients. Patients for whom an observation unit would not be appropriate include: Unstable vital signs ECG or serum markers of myocardial ischemia Decompensation (concomitant end-organ hypofusion, volume overload and systemic vasoconstriction) Requiring continuous vasoactive medication (e.g., nitroglycerin, nitroprusside, dobutamine or milrinone) to stabilize hemodynamics Non-sustained ventricular tachycardia not caused by electrolyte imbalance Acute mental status abnormality Severe electrolyte imbalances
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Institute for Clinical Systems Improvement
Annotations
5. Medications
Patients with SBP Less than 70 mmHg (Signs/Symptoms of Shock)

Norepindphrine might also be preferable to dopamine if tachycardia is an issue.
Diuretic
Furosemide is the most commonly used loop diuretic, with the dose adjusted upward if the patient is currently on oral doses. Diuretic effect occurs in 30 minutes, with peak effect in one to two hours. The pharmacologic characteristics of all loop diuretics are similar. Therefore, a lack of response to adequate doses of one loop diuretic mitigates against the administration of another loop diuretic. A combination of diuretics with different mechanisms of action should be given instead (Brater, 1998 [R]).
Nitroglycerin
Vasodilators should be given concurrent with diuretic therapy. Nitroglycerine is considered first-line therapy, and many patients will improve symptomatically and may be transferred to an observation or inpatient bed (Jain, 2003 [R]; Marx, 2002 [R]). Initial therapy consists of 0.4 mg sublingual or paste. Patients not improving will need more aggressive therapy. Begin nitroglycerin infusion at 10-20 mcg/min and increase by 10-20 mcg/min every 3.5 minutes until the desired effect is achieved. Maximum dose is 300 micrograms per minute.
Nesiritide
There is little experience with infusions of nesiritide for more than 48 hours. Nesiritide should be reserved for patients who fail to improve with the maximum infusion dose of nitroglycerin. Nesiritide should be initiated with a 2 mcg IV bolus followed by 0.01 mcg/kg/min IV infusion (Burger, 2001 [A]; Burger, 2002 [A]; Colucci, 2000 [A]).
6. Laboratory/Diagnostic Tests
Brain natriuretic peptide (BNP) and NTproBNP assays have been found useful in the diagnosis of patients with dyspnea of unknown etiology. BNP is helpful in ruling out a cardiac cause when the BNP is less than 100 pg/mL. BNP is also used as a risk stratification technique. Persistent elevation of plasma BNP prior to discharge from the hospital despite medical therapy is predictive of death or readmission (McCord, 2004 [C]). NTproBNP is helpful in excluding a cardiac cause in patients receiving BNP as a therapy. The levels for NTproBNP are age and sex dependent. NTproBNP less than 125 pg/mL for people less than 75 years old or a NTproBNP less than 450 pg/mL for people older than 75 helps exclude a cardiac cause of dyspnea.
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ICS I
I N ST IT U TE FO R C L I N I C AL S YST EMS I MP ROVEMEN T
Supporting Evidence:
Document Drafted Oct Mar 2004 First Edition Aug 2005 Second Edition Aug 2006 Third Edition Sep 2007
Joshua E. Breeding, PharmD, BCPS Pharmacy Fairview Health Services Rufino Festin, MD Cardiology Park Nicollet Health Services Penny Fredrickson Measurement/Implementation Advisor ICSI Sai Haranath, MD Internal Medicine MeritCare Bryan Hoff, MD Internal Medicine Allina Medical Clinic
Contact ICSI at: 8009 34th Avenue South, Suite 1200; Bloomington, MN 55425; (952) 814-7060; (952) 858-9675 (fax) Online at http://www.ICSI.org
Copyright 2009 by Institute for Clinical Systems Improvement 12
Fourth Edition Begins Jan 2010
Released in December 2009 for Fourth Edition. The next scheduled revision will occur within 12 months.
Original Work Group Members

Rhonda Ketterling, MD Internal Medicine MeritCare Stephen Kopecky, MD Work Group Leader, Cardiology Mayo Clinic Ann-Marie Landin, BS, RHIT Facilitator ICSI Mary Jo Macklem, RN Nursing Park Nicollet Health Services
Ashok Ojha, MD Internal Medicine Hutchinson Medical Center Sharmishtha Raikar, MD Internal Medicine HealthPartners Medical Group Robert Straka, PharmD Pharmacy Regions Hospital Angela Turner, PA-C Physician Assistant Park Nicollet Health Services
Brief Description of Evidence Grading

Individual research reports are assigned a letter indicating the class of report based on design type: A, B, C, D, M, R, X. A full explanation of these designators is found in the Foreword of the order set.
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References
Brater DC. Diuretic therapy. N Engl J Med 1998;339:387-95. (Class R) Burger AJ, Elkayam U, Neibaur MT, et al. Comparison of the occurrence of ventricular arrhythmias in patients with acutely decompensated heart failure receiving dobutamine versus nesiritide therapy. Am J Cardiol 2001;88:35-9. (Class A) Burger AJ, Horton DR, LeJemtel T, et al. Effect of nesiritide (B-type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated heart failure: the precedent study. Am Heart J 2002;144:1102-08. (Class A) Colucci WS, Elkayam U, Horton DP, et al. Intravenous nesiritide, a natriuretic peptide, in the treatment of decompensated heart failure. N Engl J Med 2000;343:246-53. (Class A) Dexter PR, Perkins SM, Maharry KS, et al. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 2004;292:2366-71. (Class A) Jain P, Massie BM, Gattis WA, et al. Current medical treatment for the exacerbation of chronic heart failure resulting in hospitalization. Am Heart J 2003;145:S3-17. (Class R) Marx JA, Hockberger RS, Walls RM, et al. In Rosen's Emergency Medicine: Concepts and Clinical Practice. St. Louis, MO. Mosby, Inc. 2002. (Class R) McCord J, Mundy BJ, Hudson MP, et al. Relationship between obesity and B-type natriuretic peptide levels. Arch Intern Med 2004;164:2247-52. (Class C) Topol EJ, Traill TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 1985;312:277-83. (Class C)
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I NSTI T U T E F O R C LIN IC A L S YSTEMS I MP ROV E ME N T
Support for Implementation:
This section provides resources, strategies and measurement specifications for use in closing the gap between current clinical practice and the recommendations set forth in the order set. The subdivisions of this section are: Priority Aims and Suggested Measures - Measurement Specifications Key Implementation Recommendations Knowledge Resources Resources Available
Copyright 2009 by Institute for Clinical Systems Improvement
15
Priority Aims and Suggested Measures

1. Decrease the readmission rate within 30 days of discharge following hospitalization for heart failure. Possible measure for accomplishing this aim: a. Percentage of adult patients with a primary discharge diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge. (See Priority Aims and Suggested Measures from the ICSI Heart Failure in Adults guideline.)
2. Improve the use of diagnostic testing in order to identify and then appropriately treat adult patients with heart failure. Possible measure for accomplishing this aim: a. (inpatient): Percentage of adult patients with a primary discharge diagnosis of heart failure with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization or is planned for after discharge. (CMS/The Joint Commission quality measure) (See Priority Aims and Suggested Measures from the ICSI Heart Failure in Adults guideline.)
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Measurement Specifications
Possible Success Measure #1a
Percentage of adult patients with a primary discharge diagnosis of heart failure who are readmitted for heart failure within 30 days of discharge.
Population Definition Data of Interest
Adult patients with a primary discharge diagnosis of heart failure who were discharged alive
Numerator: Number of adult patients with a primary discharge diagnosis of heart failure who were readmitted for heart failure within 30 days of discharge. Denominator: Number of adult patients with a primary discharge diagnosis of heart failure who were discharged 30 days from the measurement period. ICD-9 codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9. (See ICD-9 Code Descriptions table at the end of the measurement section.) Exclusions: Patients who are less than 18 years of age Patients who died prior to discharge Patients who were transferred to another hospital Patients who left against medical advice Patients discharged to hospice
Readmission rate = Number of patients readmitted within 30 days of discharge. Number of patients discharged 30 days from measurement period.
Measurement Period
There are two possible periods of evaluations: measuring admission that occurs 30 days prior to a discharge and measuring readmission that occurs 30 days following discharge. For the first option, a hospital would start with the discharges for March and then look at the previous 30 days to see whether any of these discharges were readmissions from a previous hospital stay for heart failure. For the second option, a hospital would start with the discharges for February and track for the next 30 days whether any of these patients are readmitted to the hospital. Monthly data will be submitted quarterly.
Suggested Sample Size
The suggested sample size is 20 patients per month.
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Possible Success Measure #2a
Percentage of adult patients with a primary discharge diagnosis of heart failure with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization or is planned for after discharge.
Population Definition Data of Interest
Adult patients with a primary discharge diagnosis of heart failure.
Numerator: Number of adult patients with a primary discharge diagnosis of heart failure with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge. Denominator: Number of adult patients with a primary discharge diagnosis of heart failure. ICD-9 codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9. (See ICD-9 Code Descriptions table at the end of the measurement section.) Exclusions: Patients who are less than 18 years of age Patients who died prior to discharge Patients who were transferred to another hospital Patients who left against medical advice Patients discharged to hospice Patients with reason(s) documented by a physician, nurse practitioner, or physician assistant for no LVS function assessment
Measurement Period
The period for assessment is during the hospital stay and at discharge. Monthly data will be submitted quarterly.
Definition of Terms
The most useful evaluation of left systolic ventricular function is the comprehensive two-dimensional echocardiogram coupled with Doppler flow studies. Radionuclide ventriculography can also be performed. To assess left ventricular ejection fraction and volume. Description of left ventricular systolic function may be quantitative (i.e., ejection fraction) or qualitative (e.g., "moderately depressed" or visually estimated ejection fraction).
Suggested Sample Size
The minimum sample size is 20 patients per month.
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Descriptions of ICD-9 Codes

ICD-9-CM Code 402.01 402.11 402.91 404.01 404.03 404.11 404.13 404.91 404.93 428.0 428.1 428.20 428.21 428.22 428.23 428.30 428.31 428.32 428.33 428.40 428.41 428.42 428.43 428.9 Description Malignant, hypertensive heart disease with heart failure Benign, hypertensive heart disease with heart failure Unspecified, hypertensive heart disease with heart failure Malignant, hypertensive heart and renal disease with heart failure Malignant, hypertensive heart and renal disease with heart failure and renal failure Benign, hypertensive heart and renal disease with heart failure Benign, hypertensive heart and renal disease with heart failure and renal failure Unspecified, hypertensive heart and renal disease with heart failure Unspecified, hypertensive heart and renal disease with heart failure and renal failure Unspecified congestive heart failure Left heart failure Unspecified, systolic heart failure Acute systolic heart failure Chronic systolic heart failure Acute or chronic systolic heart failure Unspecified, diastolic heart failure Acute diastolic heart failure Chronic diastolic heart failure Acute or chronic diastolic heart failure Unspecified, combined systolic and diastolic heart failure Acute combined systolic and diastolic heart failure Chronic combined systolic and diastolic heart failure Acute or chronic combined systolic and diastolic heart failure Unspecified, heart failure
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Key Implementation Recommendations

The following system changes were identified by the order set work group as key strategies for health care systems to incorporate in support of the implementation of this order set. 1. Hospitals should develop and implement ED critical pathways and consider standard orders to accomplish rapid evaluation and treatment of heart failure patients. Standard discharge orders/instructions should also be considered.
Knowledge Resources
Criteria for Selecting Resources
The following resources were selected by the Emergent Orders for Heart Failure order set work group as additional resources for providers and/or patients. The following criteria were considered in selecting these resources. The site contains information specific to the topic of the order set. The content is supported by evidence-based research. The content includes the source/author and contact information. The content clearly states revision dates or the date the information was published. The content is clear about potential biases, noting conflict of interest and/or disclaimers as appropriate.
Resources Available to ICSI Members Only

ICSI has a wide variety of knowledge resources that are only available to ICSI members (these are indicated with an asterisk in far left-hand column of the Resources Available table). In addition to the resources listed in the table, ICSI members have access to a broad range of materials including tool kits on CQI processes and Rapid Cycling that can be helpful. To obtain copies of these or other Knowledge Resources, go to http://www.icsi.org/knowledge. To access these materials on the Web site you must be logged in as an ICSI member. The Knowledge Resources list in the table on the next page that are not reserved for ICSI members are available to the public free-of-charge.
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Resources Available
* Author/Organization Title/Description Audience Web Sites/Order Information http:// www.AAHFN.org American Association of Specialty organization dedicated to Health Care Heart Failure Nurses advancing nursing education, clinical Professionals practice and research, to improve heart failure patient outcomes. American College of Cardiology American Heart Association Channing L. Bete, Co. Heart Failure Society of America Offers clinical statements and guidelines to help address contemporary practice issues within the field of cardiology.
Health Care Professionals
http://www.acc.org
"Go Red for Women" Physician Tool Health Care Kit Professionals Learning to Live with Heart Failure; 31-pg handbook Patients and Families
http:// www.americanheart.org http://www.channing-bete.com item #93612 Spanish 93628
Heart Failure Society of America Modules on Education Krames Communications Mayo Clinic
The Heart Failure Society of America, Health Care Inc. (HFSA) represents the first orga- Professionals nized effort by heart failure experts from the Americas to provide a forum for all those interested in heart function, heart failure and congestive heart failure research and patient care. Go to the Web site for more information. Patients and Caregivers
http://www.hfsa.org http://www.hfsa.org/journal.asp
http://www.hfsa.org/heart_failure_education_modules.asp http://wwww.krames4heart.com 800-333-3032 #11468 http://www.mayoclinic.com/ health/heart-failure/DS00061
Krames: Cardiac Resynchronization Therapy; 16-pg booklet Heart failure, also known as congestive heart failure (CHF) means your heart can't pump enough blood to meet your body's needs. Any number of underlying heart conditions can lead to heart failure. Over time, conditions such as coronary artery disease or high blood pressure gradually sap your heart of its strength, leaving it too weak or too stiff to fill and pump efficiently. Information at this site include: signs and symptoms, causes, risk factors, when to seek medical advice, screening and diagnosis, complications, treatment, prevention, self-care, coping skills.
Patients and Families Health Care Professionals; Patients and Families
* Available to ICSI members only.
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Resources Available

Title/Description Audience Web Sites/Order Information
http://www.nlm.nih.gov/ medlineplus/tutorials/ congestiveheartfailure.html
* Author/Organization
NIH Medline Plus * North Clinic Park Nicollet
Interactive patient tutorial. Also for print. Patients and Families Tobacco Cessation Program Hypertension, Understanding Health Care Professionals Health Care Professionals; Patients and Families Health Care Professionals; Patients and Families Health Care Professionals; Patients and Families
Call ICSI to order: 952-814-7060
Download from ICSI Web site: http://www.icsi.org Download from ICSI Web site: http://www.icsi.org Download from ICSI Web site: http://www.icsi.org http:// www.p-h.com
Park Nicollet
Lipids, Understanding
Park Nicollet
Triglycerides, Facts About
* Prichett and Hull Associates, Inc.
Pamphlet: A Stronger Pump
Health Care Professionals
* Available to ICSI members only.
www.icsi.org

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ICS I

I NSTITUTE FOR C LINICAL S Y S T E M S I M P ROV E M E N T

Health Care Order Set:

Emergent Orders for Heart Failure

Fourth Edition December 2009

health care teaching institutions; health care teaching institutions;

Health Care Order Set:

Emergent Orders for Heart Failure

Fourth Edition December 2009

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Algorithms and Annotations ....................................................................................... 1-11

Work Group Members

Supporting Evidence.................................................................................................... 12-14

Support for Implementation ..................................................................................... 15-22

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Clinical Highlights and Recommendations

Key Implementation Recommendations

Related ICSI Scientific Documents

Institute for Clinical Systems Improvement

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Disclosure of Potential Conflict of Interest

Introduction to ICSI Document Development

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Evidence Grading System

B. Reports that Synthesize or Reflect Upon Collections of Primary Reports: Class M:

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Admitting Data (See Annotation #2)

Diagnosis (See Annotation #3)

Allergies/Adverse Drug Reactions

Nursing Orders (See Annotation #4)

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Short-stay bed ICU Telemetry

Medication (See Annotation #5)

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Laboratory/Diagnostic Tests (See Annotation #6)

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Set up for: Other

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Institute for Clinical Systems Improvement

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Patients with SBP Less than 70 mmHg (Signs/Symptoms of Shock)

Emergent Orders for Heart Failure

Fourth Edition Begins Jan 2010

Original Work Group Members

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Brief Description of Evidence Grading

Emergent Orders for Heart Failure

Fourth Edition/December 2009

Support for Implementation:

Emergent Orders for Heart Failure

Copyright 2009 by Institute for Clinical Systems Improvement