Pitfalls During Hospital Pitfalls During Hospital Discharges:Discharges:

Focus on CardiologyFocus on Cardiology

Presented by:Presented by:Carolyn StrimikeCarolyn Strimike

Cardiology Nurse PractitionerCardiology Nurse Practitioner

Components of Hospital Components of Hospital Discharge InstructionsDischarge Instructions::

Activity restrictions/guidelinesActivity restrictions/guidelines Risk Factor ModificationRisk Factor Modification Dietary restrictionsDietary restrictions Home care/monitoring (dressings, BP, blood Home care/monitoring (dressings, BP, blood

sugar, weights)sugar, weights) Physician Follow-up (routine, problems – Physician Follow-up (routine, problems –

who and when to contact)who and when to contact) Follow-up testingFollow-up testing Medications (existing and new)Medications (existing and new)

How much time do you think How much time do you think a Physician should spenda Physician should spend

providing Discharge providing Discharge Instructions?Instructions?

What is Average AmountWhat is Average Amountof Time MD spendsof Time MD spends

on Dischargeon DischargeInstructions?Instructions?

Most Common QuestionMost Common QuestionPatients Ask UponPatients Ask Upon

Discharge?Discharge?

“When can I Leave?”

Rates of CMS Rehospitalization WithinRates of CMS Rehospitalization Within30 Days after Hospital Discharge30 Days after Hospital Discharge

Jencks SF et al. Jencks SF et al. N Engl J MedN Engl J Med 2009;360:1418-1428 2009;360:1418-1428

ED Visits Post DischargeED Visits Post Discharge

2.3 million visits from patients 2.3 million visits from patients discharged from hospital within 7 daysdischarged from hospital within 7 days

Uninsured 3 times more likely to visit Uninsured 3 times more likely to visit EDED

1/3 chronically ill adults do not use 1/3 chronically ill adults do not use medications due to cost and do not tell medications due to cost and do not tell

clinicians clinicians

Arch Int Med 2004 (164) 1749-55Arch Int Med 2004 (164) 1749-55

Medication Medication Noncompliance or Noncompliance or

Mistakes Account for Mistakes Account for 24% of Readmission Rate24% of Readmission Rate

Multidrugs/ multinames: “You mean Multidrugs/ multinames: “You mean WarfarinWarfarin and and CoumadinCoumadin are the same drug?” are the same drug?” Use both generic and brands whenever possible Use both generic and brands whenever possible

when teaching ptswhen teaching pts Discharge medication lists need to be explicitDischarge medication lists need to be explicit Check on patient’s system for taking medicationsCheck on patient’s system for taking medications Seven day/ 4 compartment per day pill boxes are helpfulSeven day/ 4 compartment per day pill boxes are helpful A home visit or f/u phone call is VERY helpfulA home visit or f/u phone call is VERY helpful

70% Patients Use Alternative Therapy70% Patients Use Alternative Therapy 50 to 70% patients do NOT report 50 to 70% patients do NOT report

herbal medication usage – MUST ASK herbal medication usage – MUST ASK PATIENTSPATIENTS

Antiplatelets Antiplatelets Beta-BlockersBeta-Blockers ACEI/ARBsACEI/ARBs StatinsStatins CoumadinCoumadin

Acute MI Quality MeasuresAcute MI Quality Measures 1) Aspirin at arrival1) Aspirin at arrival 2) 2) Aspirin at dischargeAspirin at discharge 3) 3) ACE inhibitor or ARB for LV systolic dysfunctionACE inhibitor or ARB for LV systolic dysfunction 4) Beta-blockers at arrival4) Beta-blockers at arrival 5) 5) Beta-blockers at dischargeBeta-blockers at discharge 6) STEMI6) STEMI Thrombolytic medication within 30 minutes Thrombolytic medication within 30 minutes PCI within 120 minutes PCI within 120 minutes 7) Counseling smoking cessation7) Counseling smoking cessation8) Cardiac rehab referral8) Cardiac rehab referral

What is the Most CommonWhat is the Most CommonReadmission Diagnosis?Readmission Diagnosis?

Background

• ACE-Inhibitors or angiotensin receptor blockers (ARBs) and beta blockers reduce morbidity and mortality in patients with heart failure (HF) and left ventricular systolic dysfunction (LVSD).

• The use of evidence-based therapies such as ACE-Inhibitors, ARBs and beta blockers with HF and LVSD is significantly lower in patients with increased risk.

• In order to optimize the use of evidence based therapies and improve HF outcomes, more data is needed to assess how to safely treat high risk patients with contraindications.

Peterson PN, et al. CIRCULATIONAHA/2009/879478

•18,307 patients with LV systolic dysfunction surviving hospitalization between January 2005 & June 2007

•From 194 GWTG-HF participating hospitals

•GWTG-HF risk prediction score used to categorize patients according to their estimated in-hospital mortality risk

Most Under-PrescribedMost Under-Prescribed(or “forgotten”)(or “forgotten”)

Cardiac Meds onCardiac Meds onHospital Discharge??Hospital Discharge??

1990’s – Era of “Stent Mania”1990’s – Era of “Stent Mania”

JF

How long do Patients needHow long do Patients needto take ASA & Plavix/Effientto take ASA & Plavix/Effientafter receiving a coronary after receiving a coronary

stent?stent?

7,402 patients S/P DES did not fill 7,402 patients S/P DES did not fill clopidogrel prescription on day of clopidogrel prescription on day of dischargedischarge

Median time delay 3 days (range 1-23 Median time delay 3 days (range 1-23 days)days)

1 in 6 patients delay filling clopidogrel 1 in 6 patients delay filling clopidogrel prescriptionprescription

Circ Cardiovasc Qual Outcomes 2010;3 261-266

Patients with any delay in filling prescription had Higher death/MI rates (14% versus 7.9% P<0.001)

Now Let’s Throw CoumadinNow Let’s Throw Coumadininto the Mix…..into the Mix…..

What to do with the patient on Coumadin What to do with the patient on Coumadin who gets a stent?who gets a stent? Aspirin doseAspirin dose Risk of BleedingRisk of Bleeding

Dietary restrictionsDietary restrictions

Can I eatSalad and

Green Vegetables?

How many people areHow many people areACTIVELY involved inACTIVELY involved inHospital Discharging?Hospital Discharging?

Adverse Events after Discharge

Telephone interviews with 400 patients 76 (19%) had adverse events 23 of these judged preventable

“The most common deficit in the provision of

discharge care was poor communication

between the hospital caregivers and either

the patient or the primary care physician.”

Ann Intern Med 2003;138:161-7.

30-Day Hospital Re-Admit Rate30-Day Hospital Re-Admit Rate

Patients with identified med Patients with identified med discrepanciesdiscrepancies

14.3%14.3%

Patients with Patients with nono identified med identified med discrepanciesdiscrepancies

6.1%6.1%

P=0.041

Medication reconciliation ensures that patients receive all intended medications and no unintended medications following transitions in care

locations.