The Health Roundtable

Hospital 2 Home – Heart Failure Pathway, Reducing Readmissions

Presenter: Dr Stephen Jennison Whangarei NZ

Innovation Poster SessionHRT1215 – Innovation AwardsSydney 11th and 12th Oct 2012

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KEY PROBLEMBackgroundWhangarei Hospital readmission data – Heart failure and shock readmission rate is 27.3% This group of DRGs had 144 readmissions in the

2010/11 year, which cost the DHB $510,000 and consumed 460 patient bed days

Respiratory conditions readmission rate of 19.4% 209 readmissions in the 2010/11 year ALOS for these readmissions was 4.45 days (930 bed

days total), and cost to the hospital $872,000 90% of the patients readmitted lived within 30 minutes

from the hospital

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AIM OF THIS INNOVATION

Improvement Sought Reduce readmission rates for heart failure by 20%. Develop a patient focused, centred care approach with

the development of a Heart Failure Pathway that commences in the Emergency Department, and finishes with the transfer of patient care back to the GP.

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BASELINE DATAThe Issue Overall, the current rate of NDHB all acute readmissions uses up

considerable resource, i.e. total of 2,955 bed days over the 2010/11 year. This equates to 8 beds every day of the year, at an annual cost of $3.6m.

Reduction in readmission rates of 30 days or less (MoH target). NDHB currently has an overall readmission rate of 10.25%; an organisational driver, as well as an MoH driver, is to reduce this readmission rate to 9.95% for the FY 2011/12.

Areas of high readmissions are Cardiology and Respiratory patients, whose rates have been identified as being higher than we want, and the rates of readmission have significantly increased over the last 2 years.

Reduction in ED admissions is another key driver. The increase in ED presentations continue; several programmes are underway to attempt to reduce these presentations. The increasing volume plays a significant role in ED overload and evidence shows this increases patient mortality and morbidity.

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KEY CHANGES IMPLEMENTED dd Heart Failure pathway commenced

as soon as possible in the Emergency Department, ED call ext

8521 to notify CSN of patient

Cardiac Specialist Nurse (CSN) begins case managing patient

CSN visits patient at earliest opportunity

Ensure pathway documentation has

commenced

Physio:Review patient

functionality

Start education pack(kept on the ward)

Refer on to In-reach Team (Medical Outreach)

DischargeCheck List

q Meds checked/reconciled (contact ward pharmacist)q Can get meds (usual pharmacy preferred)q H2H appointmentSign off (if required) from q Physioq Social Workerq Dietitianq Occupational Therapistq Discharge summary/plan

complete and understood by patient and ‘key learner”

q Transport availableq 11am discharge plan in place

Key contact Ph ……………………..

On day of discharge ensure all above ticked off

Medical Outreach reinforce education pack with patient

and key learner

Day prior to discharge, make appointment for H2H

follow up, before patient leaves the hospital

Patient Diagnosed with Heart Failure, ED or Ward

Dietitian:Review

patient diet

Social: Review patient social

situation

Hospital pharmacist: Med reconciliation on admission and

discharge

Identify Key Learners, i.e. next of kin,

caregiver, family member

Hospital to home clinic appointment with Medical

Outreach Nurse.

Patient discharged back to GP care with

appointment

No intervention required? Intervention

Admission to Hospital Required. GP notified

Intervention required, then discharged back to GP care

with appointment

Community pharmacist: medicines

synchronisation and counselling

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OUTCOMES SO FARdd

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LESSONS LEARNED

What would you recommend to other organisations?

Start HF pathway ASAP: preferably in the E.D. The peak time for readmission is within 10 days

of discharge. Involvement of the hospital and community

pharmacist is key. The H2H visit is an excellent time to reinforce

hospital educational initiatives. Be clear about the scope