February 2010

How to Identify Heart Failure Patients For Concurrent Abstraction

By Janet Whitesides, RN

Heart Failure (HF) is the end stage of several cardiac diseases. The diagnosis of HF for patients in acute care settings can be challenging, particularly with patients presenting with shortness of breath (SOB). Other physical signs of HF, such as rales, peripheral edema, or elevated jugular venous distension (JVD), may be absent depending on what drugs the patient is receiving. Restlessness during the physical exam (e.g. due to SOB or obesity) may also interfere with diagnosis. There are many ways to assess cardiac and pulmonary function, but there is no single diagnostic test for HF. The UNC Health Care Performance Improvement and Patient Safety Department has been concurrently abstracting for HF, pneumonia (PN), acute myocardial infarction (AMI), and surgical care infection prevention (SCIP) for Core Measures for the past two years. Our goal is to complete all four HF Core Measures indicators for each inpatient before discharge. Here is the process we use:

1. Each morning we review specific documentation for all adult admissions in the past twenty-four hours including:
   1. emergency room notes or History & Physical for any admission with a reason or diagnosis including any of the following phrases or acronyms, or any terms related to them: HF, congestive heart failure (CHF), right/left HF, cardiomyopathy or hypertensive cardiomyopathy, hypertensive urgency, non-ischemic cardiomyopathy (NICM), pulmonary edema, SOB, chest pain (CP), systolic or diastolic HF, vascular congestion, afibrillation (afib), dyspnea, respiratory failure/distress, end stage renal disease (ESRD), chronic kidney disease (CKD) or renal failure.
   2. radiology reports with clinical impressions which include HF-related terms, e.g. vascular congestion, pulmonary edema, or pleural effusion.
   3. lab reports for elevated brain natriuretic peptide (BNP) levels. BNP is the most widely used test to confirm the diagnosis of HF, especially with patients presenting with acute SOB. The efficacy of BNP measurements for HF diagnosis has been confirmed by many clinical studies since 2002. However, false-negative levels of BNP do occur in some cases of HF, e.g. patients with flash pulmonary edema or severe obesity.
   4. other clinical notes, such as consults or clinic notes, which may indicate that the patient has obvious symptoms of HF, such as bilateral peripheral edema, sudden weight gain in past two to three days, or a persistent cough.


2. The Centers for Medicare & Medicaid Services (CMS) requires four measures for treatment of HF identified patients: discharge instructions, evaluation of left ventricular systolic (LVS) function, administration of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) for left-ventricular systolic dysfunction (LVSD), and smoking cessation counseling. We make every effort to ensure these measures have been completed before inpatient discharge. Our process includes accurate and timely communication with clinicians to verify that each measure is complete and accurate. Sometimes we must confirm the diagnosis with the physician if the reason for admission is unclear.



3. Per CMS, only cases with codes prefixed "428" (the principal diagnosis code for HF) are chosen for concurrent or retrospective review. These codes include patients who may have hypertensive heart disease with HF or CKD or renal disease. The coding of complicated cases with combined diagnoses can be difficult to predict, so we follow all such patients to ensure required measures are completed.

Editor’s note: Janet Whitesides, is a Clinical Compliance, RN at UNC and guest contributor for Clinical-Insights.

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