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Barriers of Successful Implementation of Discharge Criteria at a Tertiary Heart Function Clinic: A Retrospective
Rami Idris1, Ansh Patel2,3, Dhruv Srikanth1
1Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada.
Insights
Heart failure clinic discharge rates are low, hindering new patient care. Patient factors like atrial fibrillation and provider inexperience impede discharge, requiring further study.
Area of Science:
- Cardiology
- Healthcare Management
Background:
- High referral volumes challenge heart failure clinics.
- Effectiveness of discharge protocols for stable patients is understudied.
Purpose of the Study:
- Examine predictors and barriers to implementing discharge criteria in a tertiary heart failure clinic.
- Identify factors contributing to suboptimal patient discharge rates.
Main Methods:
- Retrospective analysis of discharge protocol implementation (August 2023 - March 2024).
- Assessed patient discharge rates and 6-month acute care utilization post-discharge.
Main Results:
- Only 60.9% of suitable patients were discharged.
- Discharge failure associated with atrial fibrillation, reduced ejection fraction, poorer kidney function, and less experienced providers.
- Common reasons for discharge failure included awaiting echocardiograms and care coordination.
Conclusions:
- Suboptimal discharge rates impede timely care for new referrals.
- Identified patient and provider-specific barriers to discharge.
- Further research is needed to address these barriers and improve clinic efficiency.
Background:
Most heart function clinics cannot absorb their high volume of referrals. The effectiveness of clinic discharge protocols to offload stable patients is understudied. We examined predictors and barriers of implementing discharge criteria at our tertiary heart function clinic.
Methods:
This is a retrospective analysis of discharge protocol implementation between August 1, 2023 and March 31, 2024. Outcomes were discharge and rates of acute care utilization within 6-months postdischarge.
Results:
Of 153 patients reviewed, 92 were suitable for discharge, but only 56 of 92 (60.9%) were discharged. Discharge failure was associated with the following: atrial fibrillation (66.7% not discharged vs 30.4% discharged; P < 0.001); ejection fraction < 50% at the last visit (77.8% not discharged vs 51.8% discharged; P = 0.012); worse kidney function (initial visit creatinine 101.0 vs 86.5 μmol/L for those discharged not discharged, respectively; and at last visit, 106.5 vs 99.0 μmol/L); and provider experience < 10 years (for 36.1% not discharged vs 16.1% discharged; P = 0.028). Reasons cited for discharge failure were that providers were awaiting an extra echocardiogram (48.6%) or coordinating with other cardiac care teams (27.0%). In the 6 months following discharge, 3 patients (5.4%) visited the emergency department for heart failure, 1 patient (1.8%) was hospitalized for heart failure, and 1 patient (1.8%) passed away from cancer. Three of 5 adverse outcomes were judged to be unavoidable even if clinic follow-up had been continued.
Conclusions:
Discharge rate from our clinic is suboptimal, which impedes timely care for new referrals. We identified several patient- and provider-specific barriers to discharge. More studies are needed to explore this important area.
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