ACC Releases Expert Consensus Decision Pathway for Hospitalized Patients With Heart Failure

Discharge Day

Clinicians should plan for patient discharge upon their admission. They should consider long-term goals of care, gaps in patient understanding and adherence, and optimization of the chronic regimen. The ACC recommends consulting the checklist for Medicare patients (www.medicare.gov/pubs/ pdf/11376-discharge-planning-checklist.pdf) and the Target: HF program (www.heart. org/en/professional/quality-improvement/target-heart- failure).

Discharge should focus on 3 areas: (1) summary of the medical course, trajectory, and plans; (2) education of the patient and family; and (3) identification of the continuing care clinicians.

Focused Discharge Handoff

The ACC proposes that a focused distillation of crucial information should be created for patients with HF. It includes a summary of the patient’s HF type, condition at discharge, HF medications, GDMT, and follow-up plans. The sample document is available with the full guidelines.

Early Post-Discharge Follow-Up

Up to 25% of patients with HF will be readmitted, making the early stages after hospital discharge a particularly crucial time for care. Risk factors include incomplete recovery from acute illness, nutritional issues, sleep deprivation, and deconditioning.

1. Follow-Up Phone Call Within 48 to 72 Hours

The follow-up phone call should assess clinical signs of congestion, determine availability and affordability of medication, determine whether the patient understands and is adhering to their medical regimen, and ensure that follow-up appointments have been made.

2. First Post-Discharge Visit

At a patient’s first post-discharge appointment, clinicians should reassess clinical status, provide additional patient education, review and adjust medications, and address issues that could lead to hospital readmission or worsening HF. If a patient has comorbidities, these should be addressed as well.

Clinicians should perform laboratory testing including assessment of kidney function as well as monitoring of electrolytes and renal function.

If patients have symptoms and rapid disease progression, clinicians may refer patients to advanced HF specialists or consider palliative care.

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Palliative Care

The goals of palliative care are to assess and mitigate the burden of disease for patients, as well as their caregivers and loved ones.

Planning for palliative care should identify a surrogate decision maker for the patient. Clinicians should also consider the type and degree of care the patient would choose if they were to lose their capacity to make decisions.

It is important for clinicians to determine the patient’s understanding of their prognosis. The ACC recommends the following resources to use in these conversations: acc.org (www.cardiosmart.org/ Palliative-Care/Planning-Your-Care) and the HFSA Advanced Care Training Module (www.hfsa.org/ wp-content/uploads/2018/03/HFSA-Module-9-03.14.2018-LR. pdf).

Clinicians should consider the use of palliative care specialists, who can help patients and their families navigate the process.

Reference

Hollenberg SM, Stevenson LW, Ahmad T, et al. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized with Heart Failure [published online September 6, 2019]. J Am Coll Cardiol. doi:10.1016/j.jacc.2019.08.001