Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Lower CHF 30-day readmits: When do "we" start?Mar 25, 2012 15:25 EDT
It's Sunday, the second day of the ACC 2012 meeting, and Dr Harlan Krumholz is trying something different. He's put together some of the best folks in the business of treating heart failure in coordination with the Hospital to Home (H2H) initiatives driven by the ACC for a "conversation" rather than a series of lectures. He's given the speakers free rein and the best of all platforms to roll out their successful innovations. These experts want to help us to "not" reinvent the wheel, because most of these folks have pioneered the toughest, roughest, and most rugged terrain in the medical arena successfully. They have the right to brag. Their patients return to the hospital in heart failure in under 30 days only 8% to 19% of the time.
We began with Dr Larry Allen and Colleen Rohrer RN from the University of Colorado. "The admit diagnosis is often inaccurate and the claims codes delayed," said Dr Allen. They simplified things by identifying patients with a BNP >100 or who received an IV loop diuretic. They excluded patients with ESRD, cirrhosis, or cancer. They tried to determine the readmit risk by utilizing the LACE model at first, but it didn't work for their point of assessment early in the admission rather than at discharge. They found the UT Southwestern model published in Medical Care in 2010 worked well, employing its 27 variables extracted from the electronic medical records. Nurse Rohrer receives "an email at 4:00 am every morning of patients ranked by risk score." It took them long 1.5 years to generate the email and get the risk scores generated, but it was worth it. "None of this is cheap or free, but it has been good for our institution," added Dr Allen.
Next we heard from Dr Adrian Hernandez from Duke University and Dr John Heitzer from the NY Methodist Hospital. Dr Hernandez began by saying, "At Duke, we think we are number one in everything, and when readmit rates started 'getting out' in MI and heart failure . . . we were worse than average. The administration," he joked, "went through five stages of grief: denial—'It's not possible,' followed by anger—'Why are people doing this to us?' Then on to bargaining by thinking, 'Maybe we can have some special consideration; after all it's the fault of all the people who are sent here who are very complex'; then depression—'Yes, this is really a problem,' and finally, acceptance—'Yes, it's a problem, and it will not go away.' " He then rhetorically asked, "Will it mean something? Will it actually change the patient's journey?"
Dr Heitzer discussed "The utility of volunteers to reduce hospital CHF readmission" program. They targeted two areas by acknowledging that 50% of readmits are due to pharmacologic and dietary noncompliance and admitted the inability of doctors to spend the time needed for discharge. Their innovation utilized premed students, who contacted CHF patients on the day of discharge and at 24 to 48 hours postdischarge with education on their disease process, a med review, and emphasis on daily weights and fluid restriction. They also encouraged regular follow-up. The volunteers were trained with a one-hour course on CHF info and given an educational handout. Of the 137 patients, 70 were in the intervention group. At 30 days, the readmit rates for a population with an average EF of 35% was nearly 50% lower in the intervention arm.
Next Dr Ileana Piña and Dr Vivek Bhati from Montefiore Medical Center in New York presented their "Brown-bag-clinic" approach. Dr Piña stated, "Before you do anything, you start looking first. Where are the patients coming from? Are ACOs sending people in? Don't believe all the administrative data you get. Out of 50 charts, 30 had no evidence of heart failure anywhere." She noted that skilled nursing facilities "had readmit rates as high as 40%."
Dr Bhati then outlined her "brown-bag-clinic" approach, which requires each patient "to bring in every med in their cabinet." Nurses and pharmacists counseled their patients on side effects and utilization. "If you do low-hanging fruit first, it doesn't take long to produce results. At the VA hospital, they reduced hospital readmits to 8%", said Dr Piña. Dr Bhati quipped, "One brown bag, 50 cents. Saving heart-failure admits, $17 billion."
Last, we heard from Dr Mary Walsh and Mary Fischer MSN, from St Vincent Hospital, in Indianapolis Indiana. They discovered that at the skilled nursing facilities, "there was a culture of not wanting patients to lose weight. Skilled nursing facilities are monitored on patient satisfaction, so they were concerned about providing a lower-sodium diet," said Nurse Fischer. They even invited nursing assistants to participate in their ANEWLEAF program, where they reported:
A—acute agitation or anxiety.
N—nighttime shortness of breath or increased nighttime urination.
E—extreme shortness of breath lying down.
A—abdominal symptoms, nausea, pain, decreased appetite, distention.
They recently worked with a Jewish skilled nursing facility that is required to serve kosher food but committed to providing a 2-g sodium option. Another "high-end skilled nursing facility is now engaged in complying with our CHF protocols," said Nurse Fischer.
Few presentations at major meetings are as "real" as this one this morning. One could almost feel the cool clammy skin, hear the rales . . . and see the panic in the faces of drowning and failing hearts begging to be saved. Dr Krumholz put it best: "Really, the success is about not hitting home runs. It's about small ball; inexpensive, thoughtful interventions that involve better communication and take into account what it feels like to be a patient. These things can effect change everywhere."
Indeed it can. . . . So when and how do the rest of us start? Check out the ACC's H2H program to learn more.