Successful Reduction in the Heart Failure Length of Stay through Standardized Management

Abstract

Background As the focus to decrease in-hospitalization medical expenses increases, length of stay (LOS) has become a focal point of analysis particularly in the heart failure (HF) population. This is a reasonable goal as HF is the leading cause of hospital admission in patients older than 65 years old and research has shown that shorter LOS is associated with better outcomes. The purpose of this project was to standardize the management of HF patients and to decrease the HF average length of stay (ALOS) by one day. Method In this single center observational study, five areas of potential improvement were identified: Initial Furosemide dosage, early involvement of cardiology team, utilization of a standardized HF order set, multi-disciplinary rounding and close monitoring from the nursing staff. The data showed that the majority of the HF patients were receiving Furosemide 40mg or less as the first dose in the Emergency Department (ED) which was associated with a two day increase in the length of stay, as compared to those receiving 60mg and higher. Furthermore, the data also showed low utilization of the HF order set, and lack of early cardiology consultation. Process benchmarking revealed an opportunity to restructure the multidisciplinary rounds to give focus on the progression of care. Review of literature uncovered the need to restructure the responsibilities of the HF nurse coordinator to support the initiative. Based on the identified opportunities, a HF management algorithm was created to standardize the approach. A HF nurse was appointed to oversee and promote these 5 key areas of focus. Results Improvements in the aforementioned processes, utilization of at least Furosemide 60mg in the ED increased from 22% to 67% in six months. Furthermore, order set utilization increased from 32% to 81% and cardiology consult increased from 75% to 95% both within a few months. These enhancements resulted in a 1.04 day reduction in the ALOS. In HF admissions, ALOS decreased from 7.72 days (2016) to 6.68 days (01/2017 - 07/2017). A true measure of this improvement is the LOS index which is the ratio of actual LOS over expected LOS. HF LOS index steadily trended down from 1.42 (01/2017) to 1.1 in (6/2017) (Vizient data). Conclusion In conclusion, the expansion of these five key milestones were the fundamental drivers in lowering the LOS by more than 1 day.