As a veteran home care cardiovascular nurse, I have been very perturbed that OASIS completely ignores my area of expertise and patients' basic health care deficits. As the 11 national home care quality indicators were released by CMS I saw there are no quality indicators that measure "Improvement in Hemodynamic Stability." A patient with a Foley catheter who uses a walker would appear, according to OASIS, to require more nursing time and resources than a patient subsisting on a left ventricular assist device.

This is troubling because CMS data indicate that cardiovascular diagnoses are the most frequently referred set of problems seen in home care patients, accounting for 57.9% of all Medicare home health use. In addition, heart failure as a primary referral diagnosis is second only to rehabilitation (HHS, 2001).

Although OASIS may not specifically account for cardiovascular status by monitoring improvement in cardiac signs and symptoms, the functional outcomes of patients who exhibit extreme changes in blood pressure are affected. Examples include:

* Patients living with heart failure are constantly battling fluid retention and anemia, which can quickly diminish cognitive function.

* Recovering from cardiothoracic surgery at home, patients report elevated levels of anxiety, which is reflected in OASIS data.

* Changes in cardiovascular status can directly or indirectly affect every quality indicator, including "Improvement in Toileting."

Because home care clinicians do not simply check one OASIS item to address the entire needs of patients with cardiovascular problems, they must be astute to identify early status changes that can negatively impact on care outcomes. In addition, a broad evidence-based knowledge set regarding assessment criteria, nutrition, medications must also be present to be effective instructors that facilitate a safe and efficient discharge to self-care. Thus, it is imperative that all home care clinicians, not just cardiovascular specialists, have a solid understanding of cardiovascular care.

This special issue of HHN has provided information crucial for quality management regarding:

* improvement in medication management,

* improvement in dyspnea status, and

* emergent care and acute hospitalization.

More importantly, this month's HHN provides an update of clinical issues and best practices for providing care to cardiovascular patients in their home, affecting all patient outcomes. We continue to wait for researchers and CMS to conduct studies that will identify which cardiovascular measurements are necessary so a quality indicator for "Improvement in Hemodynamic Stability" can be added.

Until then, we must commit ourselves to assuring that our knowledge base is current and accurate. All the authors involved in this issue are dedicated home care professionals and expert practitioners. Every reader can have the greatest confidence knowing that the information provided is peer reviewed, based in the science and on the literature, making it accurate and timely. The collective expertise shared in these pages has the potential to greatly impact patient outcomes and the Federal Government's quality health initiative. It is because cardiovascular status directly affects every system and a person's functional abilities and limitations that this issue is so important.

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