student research day - Case Western Reserve University School of ...

Craig Lance
QI in Heart Failure for VA Cleveland Facilities: An Implementation Plan
Craig Lance, Aron, David, MD, MS, Schaub, Kimberly, PhD, Gee, Julie, RN,MSN,CNP, Hitch, Jeanne, MA, M.Ed, LPC,
Bruckman, David, MS, MT(ASCP) and Ileana Piña, MD, FACC
Cardiology Department
Cleveland VAMC
Objective: To improve heart failure (HF) practice quality by decreasing diuretics and increasing neurohormonal
inhibition in outpatients at the VA Cuyahoga County facilities with a diagnosis of HF secondary to systolic
dysfunction. Angiotensin converting enzyme inhibition (ACEI) and/or angiotensin II receptor blocker (ARB)
administration is part of the evidenced-based HF Guidelines and a performance measure for HF.
Rationale: Among the arguments for controlling diuretic use is the increase in the renin-angiotensin-aldosterone
system (RAAS) as a result of diuresis. Although a therapeutic goal is to achieve euvolemia, the ADHERE (acute HF)
Registry has pointed to a higher mortality associated with higher diuretic use. Whether the association is truly
causal is uncertain at this time. The use of ACEI/ARB for reduction in the RAAS cascade has been well documented
in the literature and serves as a performance measure which is linked to a favorable outcome and quality care.
Aims: To decrease loop diuretic to the lowest necessary level in the Cleveland VAMC, Brecksville and McCafferty
and institute a flexible diuretic regimen as recommended in the HF Guidelines. To maximize ACEI/ ARB use to
tolerability.
Methods and Intervention: NHeFT (National Heart Failure Training Program) of Case is a multi-site, nation-wide
HF training CME program. The mission of NHeFT is to disseminate best practices in HF care for health care
practitioners to change practice patterns. The typical program includes ½ day of didactics followed by a
preceptorship with the instructors at the attendees site seeing HF patients. The program stresses the appropriate
use of Guideline-driven therapy with emphasis on RAAS inhibition and lowering diuretics to optimally needed doses
with a flexible diuretic regimen. Health care providers will be enrolled in the NHeFT programs at all 3 facilities after
the baseline data collection.
Results: Research is ongoing.
Supported by Health Services R&D department of the VAMC
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