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Assessment of a Heart Failure
30-Day Readmission Risk Tool
Joyce Putnam DNP, RN, ACNP-BC, CCRN
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Acknowledgements
I must thank my committee
Chair, Dr. Kenneth Lowarance
Committee member, Dr. Melissa Sherrod
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Objectives
Discuss the evidence regarding the 30-day
readmission tool.
Describe the implementation of the tool using the
Iowa model.
Discuss the findings of the project with implications
for practice.
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Purpose
The goals of this project were to identify heart failure
patients at risk for 30-day readmission, to provide a
smooth transition from hospital to home, to improve
the patient’s quality of life, and to reduce healthcare
costs by decreasing the readmission rates for this
patient population.
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Background
Heart Failure (HF) affects more than five million Americans
HF is the #1 reason for hospital admissions in people over age 65
Annual cost of HF hospitalizations $34.8 billion
Approximately 25% are readmitted within 30 days
Readmissions cost an estimated $17 billion a year
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Background
Target of legislative action
Readmissions rates of hospitals are posted on
Hospital Compare website (CMS)
Fall 2012 Medicare payments will be reduced to
hospitals with high readmission rates
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Background
It is not just about cost, there is a human
factor
Loss of independence for HF patients
Quality of life decreases with each HF
hospital readmission
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All-Cause Mortality After Each
Subsequent Hospitalization for HF
Time since admission
0.0
0.2
0.8
1.0 HF
1st admission (n = 14,374)
2nd admission (n = 3,358)
3rd admission (n = 1,123)
4th admission (n = 417)
1st hospitalization: 30-day mortality = 12%; 1-year mortality = 34%
0.6
0.4
0.0 0.5 1.0 1.5 2.0
Setoguchi S, et al. Am Heart J. 2007;154:260-266.
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Guiding Framework
Iowa Model of Evidence-Based Practice to Promote Quality Care
Priority to organization
Team development
Relevant research
Pilot the change
Evaluation and outcomes
Dissemination of results
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Synthesis of Literature
30-Day HF readmission risk models
Transition from hospital discharge to home
Lack of social support
Cognitive dysfunction
HF mortality risk models
HF survival models
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Intervention
ESCAPE Risk Model (Evaluation Study of Congestive Heart
Failure and Pulmonary Artery Catheterization Effectiveness)
Age > 70 years
BUN > 40 mg/dl
BUN > 90 mg/dl
Six minute walk test less than 300 feet
Sodium < 130mEq/l
CPR/mechanical ventilation
Furosemide dose > 240 mg at discharge
BNP level > 500 pg/dl
BNP level > 1300 pg/dl
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Intervention
Added features to ESCAPE Risk Tool
Inadequate support systems
Living alone
Being homebound
No family available
Cognitive dysfunction
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Implementation
Identify patients on admission
BNP levels
List of possible HF admission diagnoses
Identified patients by number on tool
Discharge list compared to admission data
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Data Collection
BNP Levels
Admitting and discharge diagnoses
ESCAPE Risk tool with modifications implemented
and scored
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Results
Total of 51 patients evaluated
3 removed due to lack of BNP level
22 patients with low risk
13 patients with moderate risk
13 patients with high risk
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Results
Readmission results
8 patients identified in October as high
risk for readmission
2 of those patients were readmitted in
November
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48% n=23
52% n= 25
Age Demographics
Age ≤ 70 years
Age > 70 years
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56% n= 27
44% n= 21
Gender Demographics
Male
Female
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0
1
2
3
4
5
6
7
4
5
7
Days by Risk Group
Median Length of Stay in Days
Low Risk
Moderate Risk
High Risk
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0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
11.10%
6.45%
Comparison of Readmission Rates
Plaza Medical Center Readmission Rates
Nov 2010
Nov 2011
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Conclusions
ESCAPE tool with modifications did identify 2
patients as high risk who were readmitted
6 other patients were identified as high risk but were
not readmitted
High risk group had the longest length of stay
Tool can potentially be used for risk assessment
Further study is needed to establish validity and
reliability
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Lessons Learned
BNP levels are not always drawn on HF patients
Including the BNP level as part of the ESCAPE tool
is a strength but also a limitation
Serial BNP levels are not recommended, admission
and discharge BNP levels only
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Lessons Learned
Cognitive dysfunction is a common problem with HF
patients
Few clinicians document this finding on the inpatient
medical record, only dementia is documented
This became a limitation of the tool to accurately
assess cognition
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Lessons Learned
One aspect of the tool evaluated the six minute walk
test less than 300 feet
Author was dependent on nurses’ documentation of
activity level
This was a limitation to correctly asses the patient’s
ability to perform the walk test
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Future Directions
First step to enhance tool development is to
establish validity and reliability of the modified
ESCAPE risk tool
Current risk models available all need further study
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Future Directions
Lack of social support described as living alone,
homebound or lack of family support benefit from a
smooth transition to home
Early follow-up by the practitioner within 4-5 days of
discharge is essential
Use of the virtual ward described by Lewis (2010)
Follow-up phone calls within 2-3 days of discharge
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Future Directions
Cognitive dysfunction is a complex problem and is prevalent in the HF population
Cognitive dysfunction is underappreciated by healthcare clinicians
Lack of documentation in the pilot study seems to confirm this
Nurses must be aware to adjust education based on cognition and include the home caregiver
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Future Directions
Risk assessment for readmission is the first step
Transitioning from hospital to home is critical
Practitioners must see HF patients within 5-7 days
post discharge
Institute for Healthcare Improvement (2007) set forth
a solid plan: enhanced admission assessment,
enhanced teaching and learning, patient/family-
centered handoff communication, and post acute
care follow-up
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Dissemination
Share information with colleagues
Poster/oral presentations
Written articles
Further study – planning the next step