Dimissione e periodo vulnerabile: come evitare le reospedalizzazioni precoci.

Transcription

1 Scompenso Cardiaco Acuto Convention Centri Scompenso Dimissione e periodo vulnerabile: come evitare le reospedalizzazioni precoci. G. Di Tano Cardiologia, Cremona

2 Early Re-hospitalizations 30 days OHF - Chronic HF De novo HF Worsening HF ED Hospital Admission for AHF Early and Later Post-discharge period OHF - Chronic HF In-hospital Mortality Early Mortality The steps of Heart Failure patient s journey DT14

3 Rehospitalization is high in the early and later phase after hospitalization 30 days from discharge 1 patient out of 4 is readmitted

4 Progetto re-ospedalizzazioni precoci Area Scompenso The 30-day metric in Acute Heart Failure revisited. Data from IN-HF Outcome, an Italian Nationwide Cardiology Registry 1855 AHF enrolled 118 (6.4%) died in-hospital 159 transferred to other hospital 57 discharged to skilled nursing facilities 1 lost 1520 Discharged home 94 readmitted (6.1%) - 91% for CV causes - 42 dead (2.8%) 0 At 30 days from discharge 126 overall dead or readmitted (8.3%) At 30 days from 0 admission 7.6% dead G. Di Tano, R. De Maria et al. EJHF submitted

5 IN-HF 30 day outcome in 1520 discharged home 30-d read-free survivors 30-d readmitted or dead

6 Logistic regression independent predictors of death+ readmission or readmission at 30 days Combined death+read p 0R 95% Days Length of stay Worsening HF vs de novo Inotropes ACE/ARBs at discharge C statistic Days Length of stay Worsening HF vs de novo ACE/ARBs at discharge C statistic Il pz che muore/rericovera nelle Cardiologie a breve, ha SC cronico avanzato, disf renale, degenza lunga, con inotropi, meno RAS-inib.

7 Predictors of 30-Day Readmission in 412 Pts Hospitalized With Decompensated Heart Failure ( Hernadez MB et al, Clin. Cardiol )

8 TROPONIN, injury, cardiovascular events AST/ALT, organ damage

9 IN HOSPITAL Early HF readmission and 30-day mortality are associated with the process of inpatient care Meta-analysis of 13 studies: The risk of early readmission is increased by 55% when inpatient care is of relatively low quality... I was discharged early! They told me to just take these tablets!!! Ashton CM et al. Ann Intern Med. 2005;122:415. Ashton CM et al. Med Care. 2007;35:1044

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11 Valle R et al

12 Discharge and Follow-up: The beginning of the journey of a vulnerable patient For many if not most patients, hospitalization is just one step in chronic Heart Failure Once acute decompensation is stabilized we move quikly to optimize chronic therapy IN HOSPITAL to prevent rehospitalization. PRE-DISCHARGE therapy determines early outcome

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16 Hospital Discharge Recommendation or Indication COR LOE Performance improvement systems in the hospital and early postdischarge outpatient setting to identify HF for GDMT I B Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed: a) initiation of GDMT if not done or contraindicated; b) causes of HF, barriers to care, and limitations in support; c) assessment of volume status and blood pressure with adjustment of HF therapy; d) optimization of chronic oral HF therapy; e) renal function and electrolytes; f) management of comorbid conditions; g) HF education, self-care, emergency plans, and adherence; and h) palliative or hospice care. I B Multidisciplinary HF disease-management programs for patients at high risk for hospital readmission are recommended A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital discharge is reasonable Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is reasonable I IIa IIa B B B

17 Patient Care Plan Date of discharge Name and contact information for physician and DA Medications Pending tests and results Follow-up appointments Calendar Other orders (diet, activity, etc.) Information about disease or condition When to call physician or seek emergency care Form for writing down questions Map for locating appointments (optional) Other information about your center (optional)

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19 (52% of HF patients are not seen in the first 30 days after a hospitalization... Jencks et al. N Engl J Med 2009 )

20 First post-discharge assessment When?

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22 For a patient hospitalized due to AHF, pre-discharge phase is crucial for the optimal preparation to the vulnerable period of transition from in-patient to out-patient care. During this phase the following aspects should be addressed: Disease-modifying therapies should be initiated before discharge and carefully optimized during early post-discharge period. Comorbid conditions detected and managed. Patients at the highest risk identified and carefully followed. Potential precipitant causes of recurrent HF characterised. Patients enrolled in the multi-faced disease management projects.

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28 Circ Cardiovasc Qual Outcomes ) Partnering with community physicians or physician groups to reduce readmission (0.33 percentage point lower RSRRs; P=0.017) 1) Partnering with local hospitals to reduce readmissions (0.34 percentage point; P=0.020) 2) Having nurses responsible for medication reconciliation (0.18 percentage point; P=0.002) 3) Arranging a follow-up appointment before discharge (0.19 percentage point; P=0.037) 4) Having a process in place to send all discharge paper or electronic summaries directly to the patient s primary physician (0.21 percentage point; P=0.004), 5) Assigning staff to follow up on test results that return after the patient is discharged (0.26 percentage point; P=0.049)

29 Un MINIMAL DATA SET alla dimissione per il Medico di Famiglia

30 FOLLOW-UP DOPO LA DIMISSIONE OSPEDALIERA PZ A BASSO PROFILO DI RISCHIO Follow-up di 1-(3)-6 mesi presso l ambulatorio Scompenso Cardiaco per up-tritation della terapia, FU strumentale, valutazione devices, PZ AD ALTO PROFILO DI RISCHIO Decorso osp. BNP no - Re-ammissione - compliance Disf. Renale Comorbidità +++ Score +++ Visita precoce (< 7 gg) presso l Ambulatorio Scompenso Cardiaco Protocolli Terapeutici ambulatoriali Pz stabile Pz instabile Stretto monitoraggio telefonico domiciliare Reinvio e coinvolgimento del MMG - Follow-up telefonico Prosecuzione del Follow-up (tempi succ visita variabili ) ambulatoriale e telefonico

31 N Engl J Med 370;8, 2014