From the 2019 HVPAA National Conference
Mrs. Kimberly Cuomo (Johns Hopkins University School of Medicine), Mrs. Abby Cummings (Johns Hopkins School of Medicine), Ms. Kathryn Menzel (Johns Hopkins School of Medicine), Ms. Amy Cammer (Johns Hopkins School of Medicine), Ms. Tina Vest (Johns Hopkins School of Medicine), Ms. Diane Lepley (Johns Hopkins School of Medicine), Dr. Mustapha Saheed (Johns Hopkins University School of Medicine), Dr. Nisha Gilotra (Johns Hopkins School of Medicine)
Background
Heart failure (HF) is a costly burden to our healthcare system. Of the approximately 1 million annual Emergency Department (ED) visits for acute decompensated heart failure (ADHF), over 80% result in hospitalization. Outpatient diuresis clinics provide a unique opportunity to potentially avoid hospitalization; however, the incorporation of these clinics into the ED management algorithm of ADHF has not been studied. The Johns Hopkins Heart Failure Bridge Clinic (HFBC) is a nurse practitioner managed outpatient clinic with ability to provide same day or scheduled heart failure care, including intravenous diuretic administration, laboratory assessments, medication management and heart failure education. Patients seen in the HFBC after a heart failure hospitalization have a significantly lower 30-day readmission rate than those not seen in the clinic (11% vs 36% in 2017).
Objective
We developed a pilot program to study an intervention between the Johns Hopkins ED and HFBC to connect eligible patients with the HFBC and reduce ED and hospital utilization.
Methods
HFBC providers and ED clinical case managers participated in a daily “touch-base.” Patients appropriate for transfer from the ED to the HFBC based on established eligibility criteria (Table) were identified. In the HFBC, patients underwent outpatient intravenous diuresis, HF education and management, and were set up with follow up HF care.
Results
During the pilot program, 29 encounters (26 unique patients) were discussed. Patients average age was 58, 11 (42%) were female, and 13 (48%) had HF with preserved ejection fraction.
Thirteen (48%) patients had previously been to the HFBC. Of the 29 encounters, 8 (7 unique patients) resulted in transfer from ED to HFBC, 11 in hospital admission (length of stay 9.8 + 8.8 days), and 10 were discharged directly home with 3 of those patients given appointments for follow up in the HFBC within one week. Of the 8 transfers to HFBC, 5 visits included IV furosemide administration (average dose 96 + 23 mg) and all included extensive HF education. Four patients were scheduled to follow up in the HFBC within 1 week, 2 patients were scheduled with close follow up with their primary care provider, and 1 patient declined a follow up appointment. After transfer from ED to HFBC, 5 patients remained out of the ED for greater than 30 days. One patient returned to the ED 7 days later with non heart failure symptoms and 1 patient continued to have very frequent ED visits due to psychosocial circumstances. None of the patients transferred to the HFBC experienced adverse events and all were discharged home in stable condition directly from the clinic.
Conclusion
We demonstrate feasibility and efficacy of a collaborative effort between the ED and outpatient diuresis clinic to reduce admissions for HF.
Clinical Implications
Incorporation of outpatient HF clinics into an ED HF clinical care pathway may have significant downstream implications for both improving HF care coordination as well as reducing healthcare utilization in an at risk patient population.
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