The document discusses various pitfalls that can occur during hospital discharges, with a focus on cardiology. It notes that common components of discharge instructions include activity restrictions, risk factor modification, dietary restrictions, and medication information. However, studies have shown that on average, physicians spend very little time providing discharge instructions. Some key risks that can lead to hospital readmissions include medication noncompliance, alternative therapy use, and lack of follow-up after discharge. The document emphasizes the importance of thorough discharge education to reduce readmission rates.

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. 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. How much time do you thinkHow much time do you think
a Physician should spenda Physician should spend
providing Dischargeproviding Discharge
Instructions?Instructions?

4. What is Average AmountWhat is Average Amount
of Time MD spendsof Time MD spends
on Dischargeon Discharge
Instructions?Instructions?

5. Most Common QuestionMost Common Question
Patients Ask UponPatients Ask Upon
Discharge?Discharge?
“When can I
Leave?”

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. 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. 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. 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.  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

12.  AntiplateletsAntiplatelets
 Beta-BlockersBeta-Blockers
 ACEI/ARBsACEI/ARBs
 StatinsStatins
 CoumadinCoumadin

13. 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

14. What is the Most CommonWhat is the Most Common
Readmission Diagnosis?Readmission Diagnosis?

15. 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

18. Most Under-PrescribedMost Under-Prescribed
(or “forgotten”)(or “forgotten”)
Cardiac Meds onCardiac Meds on
Hospital Discharge??Hospital Discharge??

19. 1990’s – Era of “Stent Mania”1990’s – Era of “Stent Mania”

21. JF

28. 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?

29.  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

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

31. 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?

32. How many people areHow many people are
ACTIVELY involved inACTIVELY involved in
Hospital Discharging?Hospital Discharging?

33. 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.

34. 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

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