title: Critical pathway for the management of acute heart failure at the Veterans Affairs San Diego Healthcare System: transforming performance measures into cardiac care.
abstract: BACKGROUND
  Acute decompensated heart failure (ADHF) is a major public health problem and leading cause for hospitalization in people 65 years and older. Admission rates for ADHF, accounted for more than 1 million heart failure (HF) hospitalizations in 2004, and more than 6.5 million inpatient hospital days. Despite significant advances in HF management, including pharmacotherapy and devices; and extensive collaborative efforts of the American College of Cardiology, and American Heart Association to disseminate evidence-based practice guidelines for management of chronic HF in adults; 3 patients continue to present to the emergency departments in ADHF. The hospital treatment of HF frequently does not follow published guidelines, potentially contributing to the high morbidity, mortality, and economic cost of this disorder. This highlights an ongoing need for development of quality improvement programs that focus on delivering reliable, evidence-based care for patients with ADHF. Consequently, the development of clinical pathways has the potential to reduce the current variability in care, enhance guideline adherence, and improve outcomes for patients.
  
  
  METHODS
  The Veterans Affairs San Diego Healthcare System (VASDHCS) formed a multidisciplinary HF performance improvement team. 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 emergency department.
  
  
  RESULTS
  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. 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. The quality of the care is assessed by monitoring the nationally established performance measures for HF. Through the use of the HF computerized order sets, the VASDHCS currently achieves a performance level above most Joint Commission accredited organizations and in many areas achieves the best possible results compared with the top 10% of hospitals in the nation.
authors.affiliation: San Diego VA Medical Center, University of California, San Diego, CA, USA. gardetto.nancy@va.med
authors.forename: Nancy J
authors.initials: NJ
authors.lastname: Gardetto
authors.forename: Karen
authors.initials: K
authors.lastname: Greaney
authors.forename: Lisa
authors.initials: L
authors.lastname: Arai
authors.forename: April
authors.initials: A
authors.lastname: Brenner
authors.forename: Karen C
authors.initials: KC
authors.lastname: Carroll
authors.forename: Nancy M
authors.initials: NM
authors.lastname: Howerton
authors.forename: Melinda
authors.initials: M
authors.lastname: Lee
authors.forename: Laureen
authors.initials: L
authors.lastname: Pada
authors.forename: Marilynne
authors.initials: M
authors.lastname: Tseng
authors.forename: Alan S
authors.initials: AS
authors.lastname: Maisel
mesh_terms: D000208:Acute Disease; D002140:California; D003131:Combined Modality Therapy; D019091:Critical Pathways / Q000458:organization & administration*; D042241:Early Diagnosis; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D017052:Hospital Mortality / Q000639:trends; D006760:Hospitalization / Q000706:statistics & numerical data; D006787:Hospitals, Veterans / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008297:Male; D010348:Patient Care Team / Q000458:organization & administration*; D010359:Patient Readmission / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D013647:Task Performance and Analysis; D016896:Treatment Outcome; D014218:Triage