Cardiovascular Admissions, Readmissions, and Transitions of Care

Abstract

Hospital 30-day readmissions have become a major priority for hospitals. Hospitals face penalties for excessive readmissions for acute myocardial infarction (AMI) and heart failure (HF). Thus, it is important for hospitals to understand the transitions of care that occur for both of these conditions, and what tools are available to guide the processes involved. A multi-disciplinary team including Emergency Medical Service providers, Emergency Medicine providers, cardiologists, hospitalists, pharmacists, nurses, case managers, and outpatient physicians can all be involved in the process of safely transitioning a patient between care settings. Small-scale studies in the geriatric population have shown improved transitions of care and decreased readmissions with these care teams. The emergency department is a key transition point for patients with AMI and HF, yet it is rarely identified and utilized as such in transitions of care interventions. Future research and implementation projects will need to refine and expand the role of the emergency department in the process.

Introduction

Reduction of hospital readmissions has become a major priority for most hospitals, likely in large part due to the readmission penalty implemented by the Centers for Medicaid and Medicare Services (CMS) in October 2012. As a result of this legislation, hospitals are now penalized up to 1% of Medicare payments for excessive 30-day readmissions of patients with the primary diagnoses of acute myocardial infarction (AMI), heart failure (HF), and pneumonia.[1] “Excessive readmissions” are determined by calculation of the excess readmission ratio, which is calculated separately for each condition and is a comparison of each hospital’s measured 30-day readmission rate for that condition to the national “expected” rate, based on an average hospital with similar patients. The penalty increased to 2% in October 2013, and is expected to increase again to 3% in October 2014. In addition to increasing the penalty rate, there are discussions of increasing the number of conditions included in this program in future years as well.[2] It is estimated that 30-day mortality and readmission rates from 2005 to 2008 were 16.60% and 19.94% for AMI and 11.17% and 24.56% for HF, respectively.[3]

Though the emergency department (ED) has mostly been left out of initial interventions to reduce readmissions, this focus on preventing readmissions will inevitably have a trickle-down effect to the ED as it is the entry point for the majority of hospitalizations[4] and thus many potential readmissions. Recent work has found that patients who return to the ED after a prior inpatient discharge are re-admitted about 50% of the time.[5] As hospitals develop means of proactively identifying patients who would qualify as a 30-day readmission case, EDs will likely be pushed to work with hospital case managers and discharge planners to determine if there are safe care settings for discharging these patients as an alternative to hospitalization.

This paper reviews data regarding care coordination and care transitions spanning from pre-hospital to post-discharge for acute MI and heart failure, highlighting ongoing coordination projects as well as potential strategies to be employed in future work.

Definitions

There are two terms used in this article that require clear definition: “transitions of care” and “care coordination”. “Transitions of care” includes a broad range of time-limited services designed to ensure health care continuity, avoid preventable poor outcomes among at-risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another.[6]These transitions can occur at any health care exchange point, including from ED to inpatient status. “Care coordination”, in contrast, is ideally an ongoing process defined as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services”. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.[7] These concepts have become so widespread that there is a National Transitions of Care Coalition (http://www.ntocc.org) that has support guides and tools to assist health care professionals in executing effective transitions of care.

Acute Myocardial Infarction and Transitions of Care

In 2006, acute coronary syndrome (ACS) was the primary diagnosis for over 700,000 discharges.[8] There are several transitions of care to be addressed and potentially improved within the realm of ACS, especially regarding management of ST-Elevation Myocardial Infarction (STEMI).

Emergency Medical Services to Hospital

For patients who call 911 and activate Emergency Medical Services (EMS), direct care begins at the time at which the EMS provider arrives at the patient’s side, and thus the initial transition of care is from the pre-hospital to hospital setting. The 2013 American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines for the management of STEMI recommend a regionalized medical system to enable rapid recognition and timely reperfusion of patients with STEMI.[9] According to the guidelines, EMS personnel should be accountable for obtaining a pre-hospital electrocardiogram (ECG), making the diagnosis of STEMI, activating the in-hospital response system, and deciding whether to transport the patient to a hospital that is capable of performing percutaneous coronary intervention (PCI). In addition, the guidelines suggest that “consideration should be given to the development of local protocols that allow preregistration and direct transport to the catheterization laboratory of a PCI-capable hospital (bypassing the ED) for patients who do not require emergent stabilization upon arrival”.[9]

Despite establishment of these guidelines, a recent study from the AHA Mission: Lifeline Program showed ED bypass occurring in only about 11% of STEMI cases. This poor adherence to these guidelines is likely a result of numerous factors, including multiple, separate EMS providers across the U.S. healthcare system with different individual protocols; ambulances without physician staffing; significant variation in geographic areas and terrain throughout the country; lack of a consistent information technology infrastructure to support the routine digital transmission of ECGs for physician review to minimize false catheterization laboratory activations; and dispersal of primary PCI services across a large number of hospitals.[10]

An effective transition of care in the pre-hospital setting would include streamlined, standardized protocols for rapid transfer and transport of patients, as recommended by the AHA.[11] These protocols would include standing orders for the care of STEMI patients with a well-defined care pathway, as well as a clearly defined plan for communicating vital information to in-hospital providers. For example, the D2B alliance (www.d2balliance.org) is an American College of Cardiology-sponsored initiative to achieve a door-to-balloon time of less than 90 minutes for at least 75% of non-transfer primary PCI patients. The DB2 alliance website includes such items as a STEMI alert checklist and a standard order set.[12] These resources may be helpful for providers and hospitals to initiate their process of standardizing and streamlining the process for STEMI patients.

Emergency Department to Hospital Admission

Moving beyond the pre-hospital setting, EDs and hospitals can also use standardized protocols as guides in helping transition patients from the ambulance into the ED and subsequently to the cardiac catheterization lab, ensuring clear communication of care that has been provided and what is still required.

In a time-sensitive and crucial condition such as ACS, it is important to clearly communicate between providers. Interviews with providers have identified numerous contributors to errors, from inaccurate to incomplete information, ED crowding and high workload, difficulty accessing information such as vital signs, and ambiguous responsibility for sign out and follow up.[13] It is crucial to have a way to deliver consistent, concise, and clear information, such as a checklist. Surgical safety checklists have been shown to decrease complication rates globally [14], and such checklists incorporated into the transfer of patients with ACS and STEMI may also improve the timeliness and quality of care delivered.

A number of tools have been developed from the inpatient side to encourage the initiation of as many lifesaving therapies as possible before patient discharge, including preprinted orders, care maps, discharge forms, physician/nursing education plans, and treatment utilization reports.[15] These tools are designed to identify guideline-recommended treatments and encourage proper administration in appropriate patients. Often these tools help to prospectively identify major comorbidities and other factors that may be exacerbated as a result of a patient’s MI and/or HF exacerbation, with the goal of being able to address these potential problems early in the process.

Inpatient to Discharge

Patient education and discharge planning as well as timely follow-up and outpatient monitoring have significant room for improvement. The Society of Hospital Medicine has established core competencies for hospitalists who manage patients with ACS. [16] According to these competencies, discharge planning and care coordination should begin as soon as the patient is admitted to the hospital. Regarding the discharge process itself, the ACC/AHA guidelines recommend that prior to hospital discharge, patients and caregivers should be provided with well-understood instructions for medications and follow-up appointments. In addition, they should all be provided with instructions on behavioral changes such as smoking cessation, weight management and exercise, blood pressure, cholesterol, and diabetes control.[9,17,18] In addition to acute rehabilitation, many patients may also benefit from coordination of rehabilitation for secondary prevention.[19] Despite these guidelines for in-hospital and discharge-specific care, almost one third of patients in one study reported receiving less than one day’s advance notice of discharge, and although one third of patients were discharged with a scheduled appointment, less than half could accurately recall details of the appointment.[13] In addition, cardiac rehabilitation programs remain underutilized across the United States, with an estimated participation rate of only 10% to 20% of eligible patients per year who experience an acute MI.[19]

Congestive Heart Failure and Transitions of Care

An estimated 5.1 million Americans 20 years and older have HF, which is projected to increase 25% by 2030.[8] There are over 650,000 ED visits per year for acute HF exacerbations, and about 80% of these visits result in admission to the hospital.[20] In addition, 25% of hospital discharges for HF will result in a thirty-day readmission, a rate which has been relatively stable for the past years.[21-23]

EMS to Hospital

The ACC / AHA and European College of Cardiology have jointly established guidelines for the management of acute HF patients. These guidelines do not, however, contain specific recommendations on early management. Thus, a multi-national group of experts convened in 2006 specifically to develop recommendations for early management of acute HF exacerbations, acknowledging “all acute heart failure syndrome patients should have appropriate goal-directed treatment started as early as possible.” Pre-hospital recommendations included rapid establishment of the diagnosis, transfer as quickly as possible to a hospital (preferably with cardiology service and cardiac care unit [CCU]), establishment of communication between EMS personnel and the receiving hospital, and consideration of use of continuous positive airway pressure (CPAP).[24]

Emergency Department to Hospital Admission

The ED is the primary point of admission for patients with HF exacerbations, and should be a pivotal player in discussions regarding improving care transitions and reducing subsequent recurrent care utilization. In addition, as placement in the observation unit (OU) does not count as an admission (or a readmission), providers are likely to receive increasing pressure to place patients in the OU as opposed to inpatient whenever possible. At this time, however, there are limited studies assessing ED transitions for HF patients, largely because the vast majority of patients are admitted to the hospital and the focus of studies has been on transitions home from the inpatient setting. Currently 4 out of every 5 patients presenting to the ED with HF are admitted to the hospital, though studies have suggested that up to 50% of patients may be safe for a shorter observation stay or even for discharge home.[20,25] One study raises “the need for skillful coordination of the transition of care” as a “significant hurdle” in placing patients in the observation unit or discharging them home from the ED instead of admitting them to the hospital.[25] Increased efforts on establishing clear communication pathways with outpatient cardiologists and a mechanism by which patients can be scheduled for an outpatient follow-up visit within the following 1-2 days may assist ED providers in safely discharging a set of HF patients home.[20]

Inpatient to Discharge

The time of transition home from the hospital, referred to by some as the “vulnerable phase”[26] has received significant focus in efforts for reducing readmissions for HF, in large part because of the significant amount of care coordination that needs to take place. This coordination ideally involves detailed communication between multiple sources, including the patient and family, inpatient and outpatient providers, pharmacists, and other case managers, and has historically varies widely between hospitals.

There have been a number of studies of innovative approaches to reducing 30-day readmission rates for HF that have addressed different aspects of the discharge process and have shown improved outcomes including reduced 30-day readmissions and/or improvement in other measures of morbidity and mortality. While the details of these interventions vary, they generally are aimed at addressing one or more of the following categories: improved discharge instructions,[27] patient empowerment/motivation,[28] comprehensive medication reconciliation,[27] assistance with linkage to short-term outpatient follow-up providers,[29] and the provision of various home health services.[30]

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has established 3 performance measures specific to the discharge of patients with HF, one of which mandates the administration of discharge instructions to all patients with HF, as follows (HF-1): “Heart failure patients discharged home with written instructions or educational materials given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.”[31] Despite having identified hospital discharge as a critical time for care coordination, recent studies have identified many areas of shortfall in communication and post-discharge planning.

One study of early outpatient follow-up found that only 38% of patients had follow-up within 7 days of discharge.[32] Bradley et al performed a comprehensive review of multiple components of the discharge processes for patients with HF or AMI. They received response from 537 hospitals, 87% of which reported having a QI team devoted to reducing preventable admissions for patient with CHF, and found that close to 50% of hospitals discharged CHF patients without a plan for managing changes in their condition and less than half gave patients who received home health services an inpatient point of contact for questions. In addition, less than 55% of hospitals “usually” or “always” discharged patients with an outpatient follow-up appointment, only 37% alerted the outpatient provider of a patient discharge within 48 hours, and less than 65% sent a discharge summary to outpatient providers “most” or “all” of the time. Only 20% of hospitals gave patients a discharge summary, and less than 70% had a discharge summary ready for viewing within 7 days after discharge. In cases of discharge to a skilled nursing facility, 61% ensured nurse-to-nurse report prior to transfer and only 47% always provided a discharge summary.[21]

There is a multi-rung ladder of responsibility at the time of discharge home. Patients and families must have a clear understanding of the disease process, including early signs of decompensation such as subtle weight increases. Inpatient providers must provide timely and complete discharge information to the outpatient providers as well as assisting in setting up a follow-up appointment for the patient shortly after discharge. Outpatient providers, in return, must put processes in place to allow for timely scheduling of patients both after discharge and for urgent appointment as needed.

The OPTIMIZE-HF program was developed to help hospitals improve their systems for treating HF patients, and includes provision of a number of standardized pathways and checklists for hospitals. Studies of hospitals enrolled in this program have shown increases in adherence to all 4 JCAHO measures of quality in HF patients, thought likely attributable both to improved measurement of performance and availability of standardized tools.[33] Thus, a reasonable step forward in ensuring best practices across the nation may be universal implementation of these checklists to facilitate streamlined and comprehensive discharge of HF patients. Once home, patients may also benefit from improved mechanisms for receiving remote care and monitoring. A recent review of structured telephone support and telemonitoring as a means of caring for HF patients at home found that both methods were effective in reducing the overall risk of all-cause mortality and HF-related hospitalizations as well as in improving general quality of life and reducing healthcare costs. Considering these findings, there may be an increasing role for telehealth in facilitating continued care coordination and monitoring at home.

DO TRANSITIONAL INTERVENTIONS WORK?

In a recent meta-analysis of interventions to decrease 30-day readmissions, the authors created a taxonomy of the interventions, including pre-discharge interventions, post-discharge interventions, and interventions bridging the transitional gap.[34] Overall, there were 12 categories of interventions that were evaluated, and there was significant variation in the components of the bundles. Only 16 of the 43 studies utilized a randomized controlled trial design.

Several key projects and initiatives have focused on patient transitions to the outpatient setting, a few of which are highlighted here. Project RED (Re-Engineered Discharge) was designed by researchers at Boston University Medical Center with funding from the Agency for Healthcare Research and Quality.[35] The intervention includes a toolkit to help train staff on 12 discrete components of the discharge process, including items such as planning for follow-up visits, reconciling medications, and reviewing discharge planning with patients. Results of a randomized controlled trial showed that those patients in the intervention group had lower rates of hospital utilization than those in the usual care group.[35] Project BOOST (Better Outcomes by Optimizing Safe Transitions), sponsored in part by the Society for Hospital Medicine, identifies general medicine high-risk patients at the time of admission with the goal of reducing 30-day readmission rates.[36] This program helps identify patients at risk of readmission early, and assists the site in developing tools to optimize discharge process. The teach-back process is utilized to ensure patients understand care plans, self-care instructions, and follow-up appointments. Preliminary data from sites that implemented Project BOOST had a reduction in their 30-day readmission rates from 14.7% to 12.7% at 12 months after implementation.[36] The Care Transitions Intervention was developed by a team led by Eric Coleman in Colorado, and decreased rehospitalization rates at both 30 and 90 days.[37-40] This intervention focuses on the utilization of a “transitions coach” to encourage the patient and family to take a more active role in his health. Finally, Naylor et al. developed a nurse-led transitional care model that was found to decrease readmissions specifically in the elderly population.[6,41,42]

These relatively small-scale studies have shown the efficacy of transitional care tools, with the next step that these tools need to be further disseminated and implemented in a broad population. In addition, it may be helpful to further test the tools for specific disease entities such as acute coronary syndrome and heart failure. Cardiovascular patient care requires a multidisciplinary approach. Decreasing readmissions is only one part of the pathway.