Quality of Heart Failure Care in the Intensive Care Unit

Abstract

Patients with heart failure (HF) who are seen in an intensive care unit (ICU) manifest the highest-risk, most complex and most resource-intensive disease states. These patients account for a large relative proportion of days spent in an ICU. The paradigms by which critical care is provided to patients with HF are being reconsidered, including consideration of various multidisciplinary ICU staffing models and the development of acute-response teams. Traditional HF quality initiatives have centered on the peri- and postdischarge period in attempts to improve adherence to guideline-directed therapies and reduce readmissions. There is a compelling rationale for expanding high-quality efforts in treating patients with HF who are receiving critical care so we can improve outcomes, reduce preventable harm, improve teamwork and resource use, and achieve high health-system performance. Our goal is to answer the following question: For a patient with HF in the ICU, what is required for the provision of high-quality care? Herein, we first review the epidemiology of HF syndromes in the ICU and identify relevant critical care and quality stakeholders in HF. We next discuss the tenets of high-quality care for patients with HF in the ICU that will optimize critical care outcomes, such as ICU staffing models and evidence-based management of cardiac and noncardiac disease. We discuss strategies to mitigate preventable harm, improve ICU culture and conduct outcomes review, and we conclude with our summative vision of high-quality of ICU care for patients with HF; our vision includes clinical excellence, teamwork and ICU culture.

Figure 1.. Heart failure syndromes in the Intensive Care Unit.

Heart failure presentations in the ICU are heterogeneous. Patients may present to the ICU for primary heart failure, secondary heart failure due to other cardiac disease, transplant or mechanical support related reasons or secondary to non-cardiac organ failure. Quality care and initiatives related to these patients must span several disease states and clinical teams in this context. HF: heart failure; ICU: intensive care unit; MCS: mechanical circulatory support.

Figure 2:

Phase of Care Mortality Analysis (POCMA) which is a tool to standardize the evaluation of cardiac ICU mortality, ensuring that all cases reviewed are subject to standardized analysis to identify quality improvement opportunities.

Central illustration:

Central tenants for ensuring quality of care for heart failure patients cared for in the intensive care unit (ICU) which include clinical excellence, staffing and teamwork and ICU culture.