Pitfalls During HospitalPitfalls During Hospital
Discharges:Discharges:
Focus on CardiologyFocus on Cardiology
Presented b...
Components of HospitalComponents of Hospital
Discharge InstructionsDischarge Instructions::
 Activity restrictions/guidel...
How much time do you thinkHow much time do you think
a Physician should spenda Physician should spend
providing Dischargep...
What is Average AmountWhat is Average Amount
of Time MD spendsof Time MD spends
on Dischargeon Discharge
Instructions?Inst...
Most Common QuestionMost Common Question
Patients Ask UponPatients Ask Upon
Discharge?Discharge?
“When can I
Leave?”
Rates of CMS Rehospitalization WithinRates of CMS Rehospitalization Within
30 Days after Hospital Discharge30 Days after H...
ED Visits Post DischargeED Visits Post Discharge
 2.3 million visits from patients2.3 million visits from patients
discha...
1/3 chronically ill adults do not use1/3 chronically ill adults do not use
medications due to cost and do not tellmedicati...
MedicationMedication
Noncompliance orNoncompliance or
Mistakes Account forMistakes Account for
24% of Readmission Rate24% ...
 70% Patients Use Alternative Therapy70% Patients Use Alternative Therapy
 50 to 70% patients do NOT report50 to 70% pat...
 AntiplateletsAntiplatelets
 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 dischargeAsp...
What is the Most CommonWhat is the Most Common
Readmission Diagnosis?Readmission Diagnosis?
Background
• ACE-Inhibitors or angiotensin receptor blockers (ARBs) and
beta blockers reduce morbidity and mortality in pa...
Most Under-PrescribedMost Under-Prescribed
(or “forgotten”)(or “forgotten”)
Cardiac Meds onCardiac Meds on
Hospital Discha...
1990’s – Era of “Stent Mania”1990’s – Era of “Stent Mania”
JF
How long do Patients needHow long do Patients need
to take ASA & Plavix/Effientto take ASA & Plavix/Effient
after receivin...
 7,402 patients S/P DES did not fill7,402 patients S/P DES did not fill
clopidogrel prescription on day ofclopidogrel pre...
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 Coumadin
into the Mix…..into the Mix…..
 What to do with the patient on CoumadinW...
How many people areHow many people are
ACTIVELY involved inACTIVELY involved in
Hospital Discharging?Hospital Discharging?
Adverse Events after Discharge
 Telephone interviews with 400 patients
 76 (19%) had adverse events
 23 of these judged...
30-Day Hospital Re-Admit Rate30-Day Hospital Re-Admit Rate
Patients with identified medPatients with identified med
discre...
Medication reconciliation
ensures that patients receive
all intended medications and
no unintended medications
following t...
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
Pharmacy lecture: Hospital Discharge Pitfalls
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Pharmacy lecture: Hospital Discharge Pitfalls

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Pharmacy lecture: Hospital Discharge Pitfalls

  1. 1. Pitfalls During HospitalPitfalls During Hospital Discharges:Discharges: Focus on CardiologyFocus on Cardiology Presented by:Presented by: Carolyn StrimikeCarolyn Strimike Cardiology Nurse PractitionerCardiology Nurse Practitioner
  2. 2. Components of HospitalComponents of Hospital Discharge InstructionsDischarge Instructions::  Activity restrictions/guidelinesActivity restrictions/guidelines  Risk Factor ModificationRisk Factor Modification  Dietary restrictionsDietary restrictions  Home care/monitoring (dressings, BP, bloodHome 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)
  3. 3. How much time do you thinkHow much time do you think a Physician should spenda Physician should spend providing Dischargeproviding Discharge Instructions?Instructions?
  4. 4. What is Average AmountWhat is Average Amount of Time MD spendsof Time MD spends on Dischargeon Discharge Instructions?Instructions?
  5. 5. Most Common QuestionMost Common Question Patients Ask UponPatients Ask Upon Discharge?Discharge? “When can I Leave?”
  6. 6. Rates of CMS Rehospitalization WithinRates of CMS Rehospitalization Within 30 Days after Hospital Discharge30 Days after Hospital Discharge Jencks SF et al.Jencks SF et al. N Engl J MedN Engl J Med 2009;360:1418-14282009;360:1418-1428
  7. 7. ED Visits Post DischargeED Visits Post Discharge  2.3 million visits from patients2.3 million visits from patients discharged from hospital within 7 daysdischarged from hospital within 7 days  Uninsured 3 times more likely to visitUninsured 3 times more likely to visit EDED
  8. 8. 1/3 chronically ill adults do not use1/3 chronically ill adults do not use medications due to cost and do not tellmedications due to cost and do not tell cliniciansclinicians Arch Int Med 2004 (164) 1749-55Arch Int Med 2004 (164) 1749-55
  9. 9. MedicationMedication Noncompliance orNoncompliance or Mistakes Account forMistakes Account for 24% of Readmission Rate24% of Readmission Rate  Multidrugs/ multinames: “You meanMultidrugs/ multinames: “You mean WarfarinWarfarin andand CoumadinCoumadin are the same drug?”are the same drug?”  Use both generic and brands whenever possibleUse 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
  10. 10.  70% Patients Use Alternative Therapy70% Patients Use Alternative Therapy  50 to 70% patients do NOT report50 to 70% patients do NOT report herbal medication usage – MUST ASKherbal medication usage – MUST ASK PATIENTSPATIENTS
  11. 11.  AntiplateletsAntiplatelets  Beta-BlockersBeta-Blockers  ACEI/ARBsACEI/ARBs  StatinsStatins  CoumadinCoumadin
  12. 12. 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 systolicACE inhibitor or ARB for LV systolic dysfunctiondysfunction 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 minutesThrombolytic medication within 30 minutes  PCI within 120 minutesPCI within 120 minutes 7) Counseling smoking cessation7) Counseling smoking cessation 8) Cardiac rehab referral8) Cardiac rehab referral
  13. 13. What is the Most CommonWhat is the Most Common Readmission Diagnosis?Readmission Diagnosis?
  14. 14. 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
  15. 15. Most Under-PrescribedMost Under-Prescribed (or “forgotten”)(or “forgotten”) Cardiac Meds onCardiac Meds on Hospital Discharge??Hospital Discharge??
  16. 16. 1990’s – Era of “Stent Mania”1990’s – Era of “Stent Mania”
  17. 17. JF
  18. 18. How long do Patients needHow long do Patients need to take ASA & Plavix/Effientto take ASA & Plavix/Effient after receiving a coronaryafter receiving a coronary stent?stent?
  19. 19.  7,402 patients S/P DES did not fill7,402 patients S/P DES did not fill clopidogrel prescription on day ofclopidogrel prescription on day of dischargedischarge  Median time delay 3 days (range 1-23Median time delay 3 days (range 1-23 days)days)  1 in 6 patients delay filling clopidogrel1 in 6 patients delay filling clopidogrel prescriptionprescription Circ Cardiovasc Qual Outcomes 2010;3 261-266
  20. 20. Patients with any delay in filling prescription had Higher death/MI rates (14% versus 7.9% P<0.001)
  21. 21. Now Let’s Throw CoumadinNow Let’s Throw Coumadin into the Mix…..into the Mix…..  What to do with the patient on CoumadinWhat 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 eat Salad and Green Vegetables?
  22. 22. How many people areHow many people are ACTIVELY involved inACTIVELY involved in Hospital Discharging?Hospital Discharging?
  23. 23. 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.
  24. 24. 30-Day Hospital Re-Admit Rate30-Day Hospital Re-Admit Rate Patients with identified medPatients with identified med discrepanciesdiscrepancies 14.3%14.3% Patients withPatients with nono identified medidentified med discrepanciesdiscrepancies 6.1%6.1% P=0.041
  25. 25. Medication reconciliation ensures that patients receive all intended medications and no unintended medications following transitions in care locations.

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