Hospital Admission from the Emergency Department for Patients Diagnosed with Heart Failure

Approximately 25% of those hospitalized with congestive heart failure are readmitted within 30 days after discharge. Because researchers and policy makers consider hospital readmission within 30 days for patients with heart failure to be a quality of care issue, the Centers for Medicare and Medicaid Services has imposed financial penalties of up to 3% of a hospital\u27s Medicare revenue for 1 year for excessive readmissions, potentially impacting the financial sustainability of some organizations. The purpose of the study was to address the research gap regarding the outcome quality measure of hospital admissions from the emergency department (ED) and 2 each process and structure variables. The Donabedian conceptual framework was used to assess quality of care through the triad of structure, process, and outcome. The quantitative study comprised analysis of cross-sectional archival data from the 2015 National Hospital Ambulatory Care Survey using cross-tabulations with chi-square followed by multiple logistic regression analysis. Findings showed that process quality measures of being seen in the ED within 72 hours and total laboratory tests obtained in the ED were predictive of lower likelihood of admission. The structure quality measure of insurance was not predictive; however, being seen by provider type consulting physician was predictive of higher likelihood of admission, whereas being seen by a nurse practitioner was predictive of lower likelihood of hospital admission. The implications of this study for social change are helping hospitals maintain financial stability through avoidance of financial penalties for heart failure readmission, supporting access to care for patients by avoiding hospital closures

Assessing Prevalence of Known Risk Factors in a Regional Central Kentucky Medical Center Heart Failure Population as an Approach to Assessment of Needs for Development of a Program to Provide Targeted Services to Reduce 30 Day Readmissions

Abstract Objectives: Determine demographic, physiologic, and laboratory characteristics at time of admission of the heart failure (HF) population in a regional acute care facility in Central Kentucky through review of patient electronic medical records. Determine which HF population characteristics are significantly associated with readmissions to the hospital. Provide identification of the statistically significant common characteristics of the HF population to this facility so that they may work towards development of an electronic risk for readmission predictive instrument. Design: Retrospective chart review. Setting: Regional acute care facility in Central Kentucky. Participants: All patients (n = 175) with a diagnosis or history of HF (to include diagnosis related group (DRG) codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.1, 428.41, 428.23, 428.43, 428.31, 428.33, 428.1, 428.20, 428.22, 428.30, 428.32, 428.40, 428.40, 428.42, 428.0, and 428.9; The Joint Commission, 2013) admitted to the acute care setting of a regional hospital in the Central Kentucky area between the dates of January 1, 2013 and July 31, 2013. Eligible participants were identified via an electronic discharge report listing all patients discharged during the study time period with a HF code. Main Outcome Measure: A chart review was performed to define the HF population within the regional acute care facility. Abstracted information was collected on data instruments (Appendices A,B, and C) and analyzed to define the overall HF population (n = 175). The data was then analyzed to determine significance between patient characteristics (demographic, physiologic, and laboratory) and 30 day readmissions. The data was examined both on the individual patient level and independent of patient level looking at each admission independently. Results: An in depth description of the HF patient population in this facility was obtained. Several patient characteristics including a history of anemia, COPD, ischemic heart disease, diabetes, and the laboratory values creatinine and BNP outside of the reference range were found to have a significant association with 30 day readmissions. Discharge to a skilled nursing facility (SNF) was also found to be a significant predictor of 30 day readmissions. Some social variables such as marital status were not found to have a significant relationship to 30 day readmissions. Conclusion: This investigation is a stepping stone to creating an electronic tool designed to reflect the characteristics of HF population admitted to a single facility and predict risk of HF readmissions within 30 days at the time of admission. Implementation of a plan of care designed to meet the needs of this HF population as well as identify those patients at high risk for will allow for provision of a comprehensive and timely individualized plan of care to reduce the incidence of 30 day readmissions

Bioimpedance-Based Heart Failure Deterioration Prediction Using a Prototype Fluid Accumulation Vest-Mobile Phone Dyad: An Observational Study

BACKGROUND: Recurrent heart failure (HF) events are common in patients discharged after acute decompensated heart failure (ADHF). New patient-centered technologies are needed to aid in detecting HF decompensation. Transthoracic bioimpedance noninvasively measures pulmonary fluid retention. OBJECTIVE: The objectives of our study were to (1) determine whether transthoracic bioimpedance can be measured daily with a novel, noninvasive, wearable fluid accumulation vest (FAV) and transmitted using a mobile phone and (2) establish whether an automated algorithm analyzing daily thoracic bioimpedance values would predict recurrent HF events. METHODS: We prospectively enrolled patients admitted for ADHF. Participants were trained to use a FAV-mobile phone dyad and asked to transmit bioimpedance measurements for 45 consecutive days. We examined the performance of an algorithm analyzing changes in transthoracic bioimpedance as a predictor of HF events (HF readmission, diuretic uptitration) over a 75-day follow-up. RESULTS: We observed 64 HF events (18 HF readmissions and 46 diuretic uptitrations) in the 106 participants (67 years; 63.2%, 67/106, male; 48.1%, 51/106, with prior HF) who completed follow-up. History of HF was the only clinical or laboratory factor related to recurrent HF events (P=.04). Among study participants with sufficient FAV data (n=57), an algorithm analyzing thoracic bioimpedance showed 87% sensitivity (95% CI 82-92), 70% specificity (95% CI 68-72), and 72% accuracy (95% CI 70-74) for identifying recurrent HF events. CONCLUSIONS: Patients discharged after ADHF can measure and transmit daily transthoracic bioimpedance using a FAV-mobile phone dyad. Algorithms analyzing thoracic bioimpedance may help identify patients at risk for recurrent HF events after hospital discharge. Sert Kuniyoshi, Joseph Rock, Theo E Meyer, David D McManus. Originally published in JMIR Cardio (http://cardio.jmir.org), 13.03.2017

Adult Postoperative Open-Heart Patients: Anemia and 30-Day Hospital Readmission

Background. In 2013 alone, more than 4% (3.9 million) of patients discharged from a hospital were readmitted. Anemia following a surgical procedure is associated with early hospital readmission. Purpose/Aims. The following were specific aims of this dissertation: Aim 1. To develop an operational definition of the term condition-based maintenance as applied to health care and discuss the applicability and effectiveness of condition-based maintenance within health care. Aim 2. To identify the number of adult patients undergoing elective open-heart surgery with preoperative anemia. Aim 3. To examine the relationship between preoperative anemia, sociodemographics, and 30-day hospital readmission rates among postoperative open-heart adult patients. Aim 4. To explain the development and impact of the Hospital Readmissions Reduction Program (HRRP) and discuss the political, social, and economic implications of CABG as a newly targeted condition within the HRRP. Approach. To address aim 1, the Walker and Avant model for concept analysis was used to review and analyze relevant literature, create a basic operational definition, and clarify related concepts. To address aims 2 and 3, a retrospective cross‐sectional study was conducted using the STS Database to identify 1,353 surgical cases between August 2014 and July 2018. Cross-tabs and multivariable logistic regression analysis were used to assess the prevalence of preoperative anemia and association with 30-day hospital readmission. To address aim 4, a policy analysis was performed in accordance with Bardach and Patashnik’s procedure. Findings. From the concept analysis process, the notion of condition-based maintenance emerged, holding promise in advancing symptom science through development of personalized strategies to treat and prevent adverse symptoms of illness. The prevalence of preoperative anemia was 43.7% (n = 591), and 177 (13%) had a 30-day hospital readmission. Patients with preoperative anemia had 1.88 (95% CI 1.36, 2.58) times higher odds of being readmitted. Through policy analysis, a correlation between insurance and 30-day hospital readmission following a CABG procedure was identified. Currently, penalty programs may be adjusted to better capture sociodemographic differences. Implications. The findings from this study suggest preoperative anemia is associated with increased risk for 30-day hospital readmission. These results provide a basis for further risk reduction strategies and preoperative optimization

Impact of Congestive Heart Failure Discharge Planning on Congestive Heart Failure Re-Admission Rates

Background: Congestive Heart Failure (CHF) is the most common diagnosis accounting for more healthcare costs than any diagnosis. CHF readmissions contribute significantly to this expenditure. Quality of care in heart failure is linked to process based performance measures. This study evaluated the relationship between adherence to performance metrics and 30 day readmission rates. Methods: This was a single center case-control study that evaluated 6063 consecutive patients admitted with CHF from December 2001 through December 2008. Data was collected for readmission to the hospital within 30 days and compliance to the heart failure performance measures at discharge. Results: The rate of readmission for CHF increased steadily from 16.8% in 2002 to 24.8% in 2008. Adherence to CHF performance measures increased concurrently during the same time frame from 88.7% to 98.9%.Except for left ventricular function (LVF) assessment, 30 day readmission rate was not associated with adherence to performance measures. Readmitted patients had twice the odds of not having their LVF assessed (OR: 2.0; p Conclusions: Heart failure performance measures, except for the assessment of left ventricular function have little relationship with 30 day hospital readmissions after discharge. More studies need to be done to identify performance measures that correlate with quality of care in heart failure patients

Pilot Study: Avoiding Readmissions of Heart Failure Patients Across Transitions of Care

Background: A major problem facing the U.S. healthcare system is avoidable hospital readmissions. Patients with Heart Failure (HF) face variety of barriers to health care and are at higher risk for readmissions. To address this problem, evidence-based interventions focused on safe transition from hospital to home are needed. Methods: A quality improvement pilot project was implemented to evaluate the feasibility of evidence based interventions in preventing avoidable readmissions. The project setting was in a 900 bed health care system. The descriptive statistical methods were means and frequencies. The Transition Coordinator (TC) enrolled a convenience sample of 30 participants. The evidence based interventions were Project RED (Re-Engineered Discharge) and the TC Advocacy Plan. Project RED has 12 elements to improve the hospital discharge process by reducing rehospitalization rates, promoting safety, and increasing patient satisfaction. The TC Advocacy Plan consisted of screening tools, HF education, teamwork, collaboration, and use of resources. It offered different strategies and interventions that strengthen the initiatives in avoiding readmissions. This initiative was supported by a collaborative team that included physicians, nurses, social workers, and pharmacists. Results: Project RED 12 elements and the TC Advocacy Plan were all implemented. The identified trends in data were presented to key stakeholders. This possibly led to an enhanced multidisciplinary collaboration creating continuity of care in patient\u27s seamless transition from inpatient to outpatient settings. Conclusion: An intervention that incorporates Project RED and the TC Advocacy Plan may be effective in preventing avoidable readmissions, but further investigation is needed