Post-discharge Clinic Research Articles

Leveraging machine learning to enhance appointment adherence at a novel post-discharge care transition clinic

Abstract Objective This study applies predictive analytics to identify patients at risk of missing appointments at a novel post-discharge clinic (PDC) in a large academic health system. Recognizing the critical role of appointment adherence in the success of new clinical ventures, this research aims to inform future targeted interventions to increase appointment adherence. Materials and Methods We analyzed electronic health records (EHRs) capturing a wide array of demographic, socio-economic, and clinical variables from 2168 patients with scheduled appointments at the PDC from September 2022 to August 2023. Logistic regression, decision trees, and eXtreme Gradient Boosting (XGBoost) algorithms were employed to construct predictive models for appointment adherence. Results The XGBoost machine learning model outperformed logistic regression and decision trees with an area under the curve (AUC) of 72% vs 65% and 67%, respectively, in predicting missed appointments, despite limited availability of historical data. Key predictors included patient age, number of days between appointment scheduling and occurrence, insurance status, marital status, and mental health and cardiac disease conditions. Discussion Findings underscore the potential of machine learning predictive analytics to significantly enhance patient engagement and operational efficiency in emerging healthcare settings. Optimizing predictive models can help balance the early identification of patients at risk of non-adherence with the efficient allocation of resources. Conclusion The study highlights the potential value of employing machine learning techniques to inform interventions aimed at improving appointment adherence in a post-discharge transition clinic environment.

The First Observational Study of Acute Medical Unit in Qatar

Abstract Background Acute medical unit (AMU) is a dedicated facility to treat patients with acute medical conditions requiring a short hospital stay (< 72 hours) with the support of a multidisciplinary team led by a medical consultant. We aim to present a study of the AMU model of care from Qatar to provide insight into its effects on patient care and management. Methods Retrospective data from AMU facility at Hamad General Hospital (HGH), Doha, Qatar, was collected from January 2019 to December 2020 from the electronic patient record. The data were analyzed for demographic characteristics of the patients, length of stay (LOS), readmission rate, and postdischarge follow-up. The effectiveness of the AMU system was studied closely from this data. An extensive literature search was also performed for comparative results analysis in other AMU facilities outside Qatar. Results Total admissions under the AMU facility were 8,371 from january2019 to December 2020. The 28 days readmission rate was 10.25 and 9.9% in 2019 and 2020, respectively. The average LOS was approximately 3.2 days. Around 88.7% of the patients were discharged home, 7.8% were admitted to medical wards due to longer stays, and 0.5% left against medical advice. Most of the patients admitted under AMU were 18 to 60 years old. The top primary diagnoses of admissions were minor stroke, transient ischemic attack, chest infection, urinary tract infections, and gastrointestinal and liver diseases. The most common comorbidities were hypertension, diabetes, acute kidney injury, and chronic kidney disease. A total of 2,858 patients were booked for a follow-up visit in the postdischarge clinic on discharge from the AMU for the year 2019 and 2020. The analysis of these followed up patients showed 73% of patients were discharged from clinic after first visit while the readmission from clinic was on only 1% (28 patients for year 2019 and 2020). Conclusion Attentive patient care under AMU with a designated multidisciplinary medical team led by an internal medicine consultant is the cornerstone for the success of the AMU unit. This unit has proven very helpful for the smooth disposition of patients from the emergency department with reduced LOS, readmission rate, and overall mortality.

Transitional care clinics for patients discharged from hospital without a primary care provider: A systematic review.

The transition from hospital to home is a high-risk period. Timely follow-up care is essential to reducing avoidable harms such as adverse drug events, yet may be unattainable for patients who lack attachment to a primary care provider. Transitional care clinics (TCCs) have been proposed as a measure to improve health outcomes for patients discharged from hospital without an established provider. In this systematic review, we compared outcomes for unattached patients seen in TCCs after hospital discharge relative to care as usual. We searched the following bibliographic databases for articles published on or before August 12, 2022: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PsycINFO, and Web of Science. Five studies were identified that examined the effects of a dedicated postdischarge clinic on emergency department (ED) visits, readmissions, and/or mortality within 90 days of discharge for patients with no attachment to a primary care provider. Studies were heterogeneous in design and quality; all were from urban centers within the United States. Four of the five studies reported a reduction in either the number of ED visits or readmissions in patients seen in a TCC following hospitalization. TCCs may be effective in reducing hospital contacts in the period following hospital discharge in patients with no established primary care provider. Further studies are required to evaluate the health benefits attributable to the implementation of TCCs across a broad range of practice contexts, as well as the cost implications of this model.

Criteria for discharge of preterm infants from Canadian neonatal intensive care units.

Initial discharge from a neonatal intensive care unit (NICU) to home is a crucial milestone that impacts preterm infants, their families, and NICUs. Standardized discharge programs individualized for family needs can ensure a safe transfer of care to parents, decrease the length of stay and hospital costs, and improve parents' satisfaction. To assess the degree of variability in the current discharge criteria of preterm infants less than 34weeks' gestation among Canadian NICUs, explore different institution-specific guidelines and degree of adherence to the Canadian Paediatric Society (CPS) guidelines. A clinical representative of each of the 117 level 2-4 Canadian NICUs was contacted via email to participate in an anonymous survey link regarding the discharge criteria of preterm infants. Responders from ninety-eight NICUs (84%), representing all Canadian provinces, completed the survey. Most were nurse practitioners (43%) and neonatologists (31%) with > 5years of experience (87%). Level 3 and 4 NICUs represented 63% of responses. Units varied widely in many discharge criteria and in their adherence to CPS guidelines. Most of the units (81%) lack written discharge guidelines; 60% do not have a dedicated discharge coordinator, and 45% do not have a post-discharge clinic. Only 25% routinely teach parents CPR and only half of the surveyed units provide parental support programs. Conclusion: There is a significant heterogeneity in discharge practices of preterm infants among Canadian NICUs. This survey provides a basis for benchmarking and knowledge sharing. What is Known: • Discharging preterm infants from the NICU impacts preterm infants, their families, and NICUs. • All efforts should ensure a safe transfer of care to parents, decrease the length of stay, better utilize resources, and improve parents' satisfaction. What is New: • The discharge criteria of preterm infants vary widely among NICUs. • This survey provides benchmark information and exposes the need to better standardize discharge practices and the subsequent support for infants and parents.

Novel, nurse-led early postdischarge clinic is associated with fewer readmissions and lower mortality following hospitalisation with decompensated cirrhosis

ObjectivePatients hospitalised with decompensated cirrhosis have high rates of early unplanned readmission. Many readmissions are avoidable with secondary preventative strategies, but patients are often readmitted prior to outpatient review. To...

72 Criteria for Discharge of Preterm Infants in Canadian Neonatal Intensive Care Units

Abstract Background Discharging to home is a milestone that impacts preterm infants, their parents, and the neonatal intensive care units (NICU). Standardized discharge programs that are individualized for family needs can ensure a safe transfer of care to parents, decrease the length of hospital stay and costs, and improve parental satisfaction. Objectives To assess the degree of variability in discharge criteria for preterm infants <34 weeks’ gestation across Canadian NICUs, explore different institution-specific guidelines, and evaluate the degree of adherence to Canadian Paediatric Society (CPS) guidelines. Design/Methods A clinical representative for each of 117 level 2, 3 and 4 Canadian NICUs was contacted via email to participate in an anonymous survey link (OPINIO) regarding their discharge criteria for preterm infants. French and English versions of the survey were available. Results Ninety-eight respondents (83.7%), representing all Canadian provinces and the NWT, completed the survey (Figure 1). The majority of the responders were nurse practitioners (42.8%) and neonatologists (30.7%) with >5 years of experience (87%). 63% of responses came from level 3 and 4 NICUs. Most respondents (80.6%) lacked written guidelines in their units for discharging preterm infants. 60.2% did not have a dedicated discharge coordinator, and 45% did not have a post-discharge clinic. Table 1 summarizes the different discharge practices. Conclusion There is a significant heterogeneity in discharge practices for preterm infants in Canadian NICUs, despite the presence of CPS guidelines. This survey provides a basis for benchmarking and knowledge-sharing, but more research is needed to guide best evidence-based practice. Potential competing interests Dr. El-Naggar served as a consultant for Aerogen Pharma Limited and is a site investigator of its funded study: A Partially-Blind, Randomized, Controlled, Parallel-Group, Dose-Ranging Study to Determine the Efficacy, Safety and Tolerability of AeroFactTM (SF-RI 1 surfactant for inhalation combined with a dedicated drug delivery system) in Preterm Infants at Risk for Worsening Respiratory Distress Syndrome.

The impact of hospital-based post-discharge pharmacist medication review on patient clinical outcomes: A systematic review

BackgroundClinical pharmacists have been shown to identify and resolve medication related problems post-discharge, however the impact on patient clinical outcomes is unclear. AimsTo undertake a systematic review to identify, critically appraise and present the evidence on post-discharge hospital clinics that provide clinical pharmacist medication review; report the patient clinical outcomes measured; and describe the activities of the clinical pharmacist. MethodsPublished studies evaluating a patient clinical outcome following a post-discharge hospital clinic pharmacy service were included. All studies needed a comparative design (intervention vs control or comparator). Pubmed, Embase, CINAHL, PsycnINFO, Web of Science, IPA and APAIS-Health databases were searched to identify studies. The type of clinic and the clinical pharmacist activities were linked to patient clinical outcomes. ResultsFifty-seven studies were included in the final analysis, 14 randomised controlled trials and 43 non-randomised studies. Three key clinic types were identified: post-discharge pharmacist review alone, inpatient care plus post-discharge review and post-discharge collaborative clinics. The three main outcome metrics identified were hospital readmission and/or representation, adverse events and improved disease state metrics. There was often a mix of these outcomes reported as primary and secondary outcomes. High heterogeneity of interventions and clinical pharmacist activities reported meant it was difficult to link clinical pharmacist activities with the outcomes reported. ConclusionsA post-discharge clinic pharmacist may improve patient clinical outcomes such as hospital readmission and representation rates. Future research needs to provide a clearer description of the clinical pharmacist activities provided in both arms of comparative studies.

Symptom severity trajectories and distresses in patients undergoing video-assisted thoracoscopic lung resection from surgery to the first post-discharge clinic visit.

This study aimed to characterize patients' symptom severity trajectories and distresses from video-assisted thoracoscopic lung resection to the first post-discharge clinic visit. Seventy-five patients undergoing thoracoscopic lung resection for diagnosed or suspected pulmonary malignancy prospectively recorded daily symptom severity on a 0-10 numeric scale using the MD Anderson Symptom Inventory until the first post-discharge clinic visit. The causes of postoperative distresses were surveyed, and symptom severity trajectories were analyzed using joinpoint regression. A rebound was defined as a statistically significant positive slope after a statistically significant negative slope. Symptom recovery was defined as symptom severity of ≤3 in two contiguous measurements. The accuracy of pain severity on days 1-5 for predicting pain recovery was determined using area under the receiver operating characteristic curves. We applied Cox proportional hazards models for multivariate analyses of the potential predictors of early pain recovery. The median age was 70 years, and females accounted for 48%. The median interval from surgery to the first post-discharge clinic visit was 20 days. Trajectories of several core symptoms including pain showed a rebound from day 3 or 4. Specifically, pain severity in patients with unrecovered pain had been higher than those with recovered pain since day 4. Pain severity on day 4 showed the highest area under the curve of 0.723 for predicting pain recovery (P = 0.001). Multivariate analysis identified pain severity of ≤1 on day 4 as an independent predictor of early pain recovery (hazard ratio, 2.86; P = 0.0027). Duration of symptom was the leading cause of postoperative distress. Several core symptoms after thoracoscopic lung resection showed a rebound in the trajectory. Specifically, a rebound in pain trajectory may be associated with unrecovered pain; pain severity on day 4 may predict early pain recovery. Further clarification of symptom severity trajectories is essential for patient-centered care.

Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic.

Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.

ODP236 Reducing length of Hospital Stay and Mortality in COVID-19 Patients with Diabetes

Abstract Introduction: & Background Diabetes in COVID-19 patients is individual risk factor and documented in worldwide studies to contribute to disease severity, increased length of stay and higher mortality (fig-1). Aggressive management of blood sugars and acute diabetic complications reduce the length of stay and mortality. Methods Randomly selected 200 patients admitted with diabetes and COVID-19 studied. The unified treatment protocol (fig-2) applied for all patients and blood sugars monitored closely and optimized. Data collected on bimonthly basis and analyzed. Patients’ characteristics taken from data extraction tool (Oasis) of hospital. Median values for length of stay and post discharge FBS and RBS were calculated Microsoft Excel tool. Mortality rates calculated by percentages. Results 200 patients studied in the 4 months study period. The median length of stay was 3 days. The mortality rate was 2.5% (fig-3,4). The median FBS and RBS in the patient group monitored in the post discharge clinic was 130 mg/dl and 170 mg/dl respectively. The results compared with the standard international studies. Discussion Diabetes in COVID-19 patients posed great challenge as increased severity and mortalities reported compared to non-diabetic. Taking a pre-emptive strategy to combat this problem by aggressively manage diabetes help in reducing length of stay and morbidity. The length of stay in studded population was 3 days as compared to 13 days in a major international study(Ref: 1) . Financial saving come from rapid turnover of beds. The mortality was 2.5% compared to reported 7.3% in a major study (Ref: 2), reflecting the implications of aggressive management of diabetes. Regular follow-up and support by running post-discharge clinic definitely help reducing readmissions and acute complications of uncontrolled diabetes. Conclusion Aggressive management of diabetes in COVID-19 patients by tailored treatment protocols and dedicated teams will help to decrease the morbidity and mortality. Presentation: No date and time listed

Early Exercise-Based Rehabilitation for Patients with Acute Decompensated Heart Failure: A Systemic Review and Meta-Analysis.

Cardiac rehabilitation is an important part of the therapeutic regimen for chronic heart failure. Acute decompensated heart failure (ADHF) in hospitalized patients were usually excluded from cardiac rehabilitation programs. The initiation of cardiac rehabilitation with ADHF usually occurs after hospital discharge. This study included recent clinical trials in patients beginning early exercise-based rehabilitation during their hospitalization and compared the efficacy and safety of early cardiac rehabilitation to ADHF patients who didn't receive cardiac rehabilitation. Clinical trials were searched from the EMBASE, PubMed, CENTRAL, and WAN FANG. We included randomized controlled trials (RCTs) in which early exercise-based rehabilitation started during the index hospitalization, from the establishment of the database to July 2022. RevMan 5.4 was used for the statistical analysis. Six studies, with a total of 668 patients were included; 336 patients in the early rehabilitation group and 332 patients in the control group. Exercise capacity was significantly improved in the 6-minute walk distance [mean difference (MD): 32.97, 95% CI: 31.03 to 34.90, p 0.00001], and the Short Physical Performance Battery (MD: 1.40, 95% CI: 1.35 to 1.44, p 0.00001). The rate of all-cause rehospitalization was significantly decreased in the early rehabilitation group (OR: 0.67, 95% CI: 0.45 to 0.99, p = 0.04). Early exercise-based rehabilitation for eligible ADHF in-patients starting during, or early after, hospitalization could significantly improve exercise capacity. A transitional, individualized, progressive, exercise-based rehabilitation program during hospitalization combined with post-discharge clinic rehabilitation is an integrated rehabilitation strategy for acute decompensated heart failure.

Retention of discharge instructions using an interdisciplinary model for at-risk children with cancer: A quality improvement initiative.

We sought to improve caregiver retention of critical initial hospital discharge instructions using a multidisciplinary, team-based intervention for newly diagnosed pediatric cancer patients at high risk for unfavorable outcomes. A multidisciplinary team of pediatric residents, nurses, social workers, pharmacists and hematology/oncology faculty implemented practices to optimize teaching of key discharge material as part of four Plan-Do-Study-Act intervention cycles. An 11-question survey distributed at the first post-discharge clinic visit assessed the efficacy of the intervention, as defined by caregiver retention of critical home instructions. Thirty-nine caregivers of pediatric cancer patients in an urban academic tertiary-care children's hospital took part in this project. Overall retention of key discharge information was greater in the post-intervention cohort compared to the baseline cohort (median total scores: 89 and 63, respectively; p=.001). Improvements in the proportions of correct responses post-intervention were also observed across all subject matters: from 0.57 to 0.88 for fever guidelines (p=.059), from 0.71 to 0.78 for signs of sepsis (p=.65), from 0.57 to 1.00 for accurate choice of on-call number (p=.004), and from 0.71 to 0.94 for antiemetic management (p=.14). Initiation of our comprehensive cancer-specific program to improve caregiver retention of discharge instructions at the first post-hospitalization clinic visit has been successful and sustainable. This project demonstrated that a multi-disciplinary collaborative team effort increases caregiver retention of critical health information, and this has potential to lead to improved outcomes for patients.

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

Latest in Resuscitation Research: Highlights From the 2021 American Heart Association's Resuscitation Science Symposium.

Outpatient clinic attendance and outcomes among patients hospitalized with diabetic foot ulcers

BackgroundThere are limited data on post-hospital discharge clinic attendance rates and outcomes among patients with diabetic foot ulcers (DFUs). MethodsRetrospective study of patients hospitalized with a DFU from 2016 to 2019 in a large public hospital. We measured rates and predictors of clinic attendance with providers involved with DFU care within 30 days of hospital discharge (“30-day post-discharge clinic attendance”). Log-binomial regression was used to estimate risk ratios (RR) and 95 % confidence intervals (CI). ResultsAmong 888 patients, 60.0 % were between 45 and 64 years old, 80.5 % were Black, and 24.1 % were uninsured. Overall, 478 (53.8 %) attended ≥1 30-day post-discharge clinic appointment. Initial hospital outcomes were associated with clinic attendance. For example, the RR of 30-day post-discharge clinic attendance was 1.39 (95%CI 1.19–1.61) among patients who underwent a major amputation compared to patients with DFUs without osteomyelitis and did not undergo an amputation during the initial hospitalization. Among 390 patients with known 12-month outcome, 71 (18.2 %) had a major amputation or died ≤12 months of hospital discharge. ConclusionWe found a low post-discharge clinic attendance and high post-discharge amputation and death rates among patients hospitalized with DFUs. Interventions to increase access to outpatient DFU care are needed and could prevent amputations.

Inpatient CPAP adherence may predict post-discharge adherence in hospitalized patients screened high risk for OSA.

Despite increased recognition of sleep disordered breathing in hospitalized patients, studies are lacking on the impact of inpatient adherence with positive airway pressure (PAP) therapy on post-discharge adherence. To assess the predictive value of inpatient adherence to PAP therapy on post-discharge compliance and adherence. We reviewed data on individuals as part of a registry of a hospital-based sleep medicine program between August 2019 and December 2020. Consecutive patients identified as high risk for sleep disordered breathing based on our 2-tier screening process and initiated on Auto-PAP (APAP) therapy were included. Their adherence and post-discharge course were recorded. Primary objectives were polysomnography (PSG) compliance, sleep medicine clinic follow-up compliance, and 30-day adherence to PAP therapy if indicated by PSG. In total, 900 individuals were screened during the study period. Of these, 281 were offered inpatient PAP therapy. Patients on bilevel PAP therapy (88 patients) were excluded due to lack of objective compliance recording. Final analysis was performed on 193 patients. Of the 193 patients placed on inpatient APAP, 140 (73%) were adherent to the therapy with average usage of 367min per day versus 140min per day in the non-adherent (p < 0.001). There was no significant difference in oxygen desaturation index between the adherent and non-adherent groups (32.4 ± 21.9 events per hour and 34.5 ± 21.9 events per hour consistent; p = 0.5). No demographic and anthropometric characteristics or comorbid conditions were noted. Those who were adherent to PAP therapy in-hospital 47/140 (34%) underwent ambulatory PSG post-discharge compared to 7/53 (13%) of those non-adherent in-hospital (p = 0.002). The adherent group also had significantly higher likelihood for post-discharge clinic follow-up (p = 0.01) and adherence to outpatient PAP therapy (p = 0.01). Hospitalized patients identified as high risk for sleep disordered breathing have high adherence to PAP therapy during hospitalization and inpatient adherence predicts outpatient follow-up (both PSG testing and sleep clinic) and home PAP adherence.

A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care.

Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6months. Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

Rapid Adaptation Of Televists In The Post Hospital Discharge Heart Failure Clinic: Impact On 30 Day Readmissions During The Pandemic

<h3>Introduction</h3> Early follow-up within 7 to 14 days after a hospitalization has been recommended as a measure to reduce 30-day readmission. While the cost of US hospital readmission that is avoidable is estimated at 25 billion per year and the Hospital Reduction Readmission Program (HRRP) was implemented with accountability and penalty on the discharging hospital, the practical aspects of a patient returning within a week back to a clinic has not been addressed. With the surge of Covid-19 pandemic, Televisits have become the norm rather than an exception. We report a single center experience of rapid adaptation of such technology with the onset of the pandemic. <h3>Methods</h3> Deidentified data was obtained from administrative and quality reports of the Houston Methodist Hospital. The Heart failure clinic at our institution is staffed by a heart failure disease management (HFDM) service. Televisit platforms existed in our electronic medical record in the HF clinic in 2018. Heart failure patients would be referred inpatient and scheduled with the HF clinic within 7 days post discharge with a focus on medication reconciliation, self-reported vital monitoring, identification of care resources and barriers to compliance would also be identified during the visit. Plan of care, and changes in the medical regimen were done in collaboration with the patients primary cardiologist. Identified gaps were addressed and referred to community and resources. Community and Home health collaboration were conducted to achieve best outcome and continuity of care. Future appointments were established to ensure follow ups and no gaps in care. <h3>Results</h3> Despite EMR availability of televisit platform in our clinic since 2018, there was no adaptation until the onset of the pandemic. With in-person visits in 2019, the overall all cause readmissions were slightly higher compared to during the pandemic when televisit utilization was to the maximum. As for the HF cause for readmission, the in person visits had a similar slighty lower 30 day readmission rate as compared to the Televisits. <h3>Conclusion</h3> Like in the rest of the areas of outpatient practice, televisit adaptation has been rapid in the HF post discharge clinic. While it seems obvious that many of the logistics and objectives of the post discharge visit can be successfully implemented in a virtual visit, there might be certain limitations like assessing volume status as the HF related readmission seem to have marginally increased.

Abstract 56: Predictors Of Post Stroke Discharge Follows-ups In The Stroke Clinic And Role Of A Stroke Navigator To Improve Follow-ups

Objective: We aimed to evaluate which factors contributed to acute ischemic stroke (AIS) following up in stroke clinic post hospitalization. Methods: Single center retrospective analysis of AIS patients from January 2016 to April 2021. Patients were excluded if: died during index hospitalization, discharged to hospice or had incomplete data. We evaluated our primary outcome: factors contributing to patients attending post-discharge appointments and secondary outcome: factors contributing to patients scheduling post-discharge appointments utilizing binomial stepwise logistic regression models. Subgroup analysis compared latency to be seen in follow-up clinic between patients who had an appointment scheduled at discharge compared to those who did not using a Mann-Whitney test. Results: Out of 7960 AIS patients, 2734 were included in this study, 2130 (77.9%) of those patients scheduled an appointment post-discharge, whereas 1649 (60.3%) attended an appointment post-discharge. Patients were more likely to attend a follow-up appointment if scheduled while hospitalized, OR=3.48 [95%CI, 2.94-4.14], p&lt;0.001 and less likely if: older OR=0.98 [95%CI 0.97-0.98], p&lt;0.001; admitted for a longer duration, OR=0.98 [95%CI, 0.96-1.00], p=0.05; lived farther away OR=0.99 [95%CI, 0.96-0.99], p&lt;0.001 or had higher modified Rankin Scale (mRS) at discharge OR=0.73 [95%CI, 0.69-0.79], p&lt;0.001. Patients were more likely to schedule a follow-up appointment after initiation of the AIS navigator program, OR=8.52 [95%CI, 6.59-10.57], p&lt;0.001.Patients with follow-up appointments scheduled during their initial hospitalization were seen in clinic sooner; 27 days (IQR 19-36) versus 37 days (IQR 22-61), p&lt;0.001. Conclusion: Patients with AIS were more likely to schedule an appointment after initiation of a nurse navigator program. Patients were also more likely to attend post-discharge stroke clinics if their appointments were scheduled during index hospitalization.

606. Implementation of a Telehealth-based OPAT Early Post-Discharge Clinic May Reduce Hospital Readmission

BackgroundRecent studies suggest that early post-discharge follow-up for patients receiving outpatient parenteral antimicrobial therapy (OPAT) reduces readmission rates. We report our experience implementing a telehealth-based clinic to facilitate early (1-2 week) follow-up for selected OPAT patients perceived to be at high risk for readmission.MethodsWe identified patients who met criteria for and completed a supplemental OPAT telehealth visit following the initial seven months after implementation of this clinic (11/1/20 – 5/31/21). Clinical criteria triggering intake of patients for these visits included: endovascular or cardiac device-related infection; treatment with vancomycin, oxacillin/nafcillin, or aminoglycosides; ≥2 prior hospitalizations within past 1 year; treating Infectious Disease or OPAT team’s subjective assessment of high readmission risk. Patients planned for < 14 days of OPAT therapy were excluded. Categorical variables were compared using a Chi-square test at the α=0.05 level of significance.ResultsA total of 49 patients completed a telehealth visit; mean time from discharge to telehealth visit was 12.1 days (SD +/- 3.9). An intervention was made in 27% of these visits (13 of 49 patients), most commonly involving attempted mitigation of an adverse event or line-related complication (7 cases). The all-cause, 30-day readmission rate for this cohort was 6.1% (3 of 49 patients), while the rate for OPAT patients who did not receive an early telehealth visit during the same period was 22.7% (52 of 229 patients) which was statistically significant (p=0.008). This association of benefit was also found when comparing infection-related, 30-day readmission rates (0% vs 7.4%, p=0.049).ConclusionImplementation of OPAT telehealth encounters for high-risk patients resulted in a high rate of intervention to mitigate adverse events of OPAT therapy. Readmission occurred less than one-third as frequently in the telehealth group compared to patients with no early follow-up visit. Telehealth-based encounters appear comparable in effectiveness to those previously reported utilizing in-person visits, introducing efficiencies that may allow for broader implementation of this intervention.Disclosures Nicolas W. Cortes-Penfield, MD, Nothing to disclose Bryan Alexander, PharmD, Astellas Pharma (Advisor or Review Panel member)

"Brown Bag Clinic": A Pharmacist-led Approach to Reduce Heart Failure Hospital Readmission.

Objectives: Heart failure (HF) affects approximately 6 million in the United States and despite guideline-directed medical therapy (GDMT), still more than 20% of patients are readmitted within 30 days.1,2 This study evaluated the impact of a "pharmacist-led HF Brown Bag Clinic" (BBC) on HF patient outcomes including readmissions and mortality. Methods: This retrospective study, conducted at an academic medical center, included adult patients 18 to 89 years old with HF presenting to the BBC 7-14 days post HF hospitalization. Those failing to attend the BBC within 30 days of hospital discharge were in the control group. Our electronic medical records were used to capture patients' baseline characteristics and describe pharmacists' interventions. Thirty- and ninety-day post-discharge HF readmission and all-cause mortality were evaluated. Results: A total of 32 patients met the inclusion criteria; 15 receiving intervention and 17 controls. A total of 18 HF hospital readmissions occurred, 4 (22%) readmissions in the intervention group and 14 (78%) in the control group (p= 0.06). Hospital readmissions within 30 days and 90 days were greater in the control group compared with the intervention group (18% vs. 7% and 41% vs. 21% respectively). Conclusion: A pharmacist-led post-discharge clinic demonstrated numerically fewer HF hospital readmissions compared with a scheduled but "no show" control group.