Post Discharge Research Articles

Dengue Cardiomyopathy Treatment Strategy Optimisation by Integrating Point-of-Care Ultrasound with VExUS

Dengue fever is an arthropod-borne viral disease that is widespread throughout the world. Herein, we report a case of dengue cardiomyopathy that was detected and treated to best effect using point-of-care ultrasound (POCUS) and the VExUS score. A 75-year-old lady with no known comorbidities presented with a 10-day history of fever, vomiting, loose stool, and poor appetite. Upon arrival, she was febrile and hypotensive. Bedside POCUS showed poor left ventricular systolic function, inferior vena cava measuring 2.27cm and VExUS grading of 2 to 3. Dengue serology IgM and IgG were positive and NT-proBNP raised at 12500pg/ml. Instead of fluid resuscitation, diuretic and inotropes were initiated along the line of cardiogenic shock secondary to dengue cardiomyopathy. Serial normal cardiac enzymes and electrocardiogram excluded acute coronary syndrome. She was discharged well, and repeated echocardiography one-month post discharge showed normal left ventricular systolic function with no clinical signs or symptoms of heart failure.

Smoking cessation and prognosis during long-term follow-up after stroke, TIA, and acute coronary syndrome-results from the randomized controlled NAILED trial.

About 50% of patients continue to smoke after stroke and myocardial infarction. We aimed to assess the effect of a multiple risk factor intervention on long-term smoking cessation and to explore a possible association between early smoking cessation and long-term prognosis. Consecutive patients with stroke/TIA/acute coronary syndrome (ACS) at Östersund Hospital during 2010-2014 were included, randomized to intervention or usual care (1:1), and followed through 2017. This substudy included participants that reported current smoking during hospitalization and were alive at 1 month post discharge when the intervention began (n = 321). The smoking cessation intervention was part of a telephone-based, multiple risk factor intervention delivered by a nurse and consisted of brief advice delivered annually. Smoking cessation at the last follow-up was analyzed as the primary outcome. Smoking cessation at other time points and association between early smoking cessation and prognosis (CV events, survival) were secondary outcomes. After a mean follow-up of 4.2 years, 171 participants reported nonsmoking, with no significant difference between the intervention and control group (50.3% vs. 56.3%, absolute difference 5.9%, 95% CI -5.0 to 16.7, p = 0.286). Of these, 80.7% had stopped smoking within 1 month after discharge. The intervention did not improve smoking cessation proportions in the long or short term, and there was no apparent effect on smoking cessation attempts or sustained abstinence. Smoking cessation within 1 month was associated with lower all-cause mortality (HR 0.52, 95% CI 0.32-0.87), and there was a nonsignificant trend towards a lower incidence of CV events (HR 0.71, 95% CI 0.45-1.12). Annual brief advice by a nurse as part of a multiple risk factor follow-up did not improve long-term smoking cessation after stroke/TIA/ACS. Continued smoking past 1 month was associated with worse prognosis. ISRCTN registry ISRCTN96595458, ISRCTN23868518, ISRCTN30433343.

The burden of all-cause mortality following influenza-associated hospitalizations, FluSurv-NET, 2010-2019.

While the estimated number of U.S. influenza-associated deaths is reported annually, detailed data on the epidemiology of influenza-associated deaths, including the burden of in-hospital versus post-hospital discharge deaths are limited. Using data from the 2010-11 through 2018-19 seasons from the Influenza Hospitalization Surveillance Network, we linked cases to death certificates to identify patients who died from any cause during their influenza hospital stay or within 30 days post discharge. We described demographic and clinical characteristics of patients who died in hospital versus post discharge and characterized locations and causes of death (COD). Among 121,390 cases hospitalized with laboratory-confirmed influenza over 9 seasons, 5.5% died; 76% of deaths were in patients ≥65 years, 71% were non-Hispanic White, and 34% had ≥4 underlying medical conditions. Among all patients with an influenza-associated hospitalization who died, 48% of deaths occurred after hospital discharge; the median days from discharge to death was 9 days (IQR 3-19 days). Post-discharge deaths more often occurred in older patients and among those with underlying medical conditions. Only 37% of patients who died had "influenza" as a COD on their death certificate. Influenza was more frequently listed as a COD among persons who died in-hospital compared with cardiovascular disease among those who died after discharge. All-cause mortality burden is substantial among patients hospitalized with influenza, with almost 50% of deaths occurring within 30 days after hospital discharge. Surveillance systems should consider capture of post-discharge outcomes to better characterize the impact of influenza on all-cause mortality.

Family Care Partner's Preparedness in Caring for Hospitalized Persons With Dementia.

To examine care partner preparedness in caring for recently hospitalized persons with dementia and care partner characteristics associated with preparedness at discharge, 2months, and 6months post discharge. Stepwise regression in a sample of 461 care partners of hospitalized persons with dementia who participated in the Fam-FFC clinical trial. On average, care partners were 61.81years old (SD=14.19) and primarily female (n=334, 72.5%). Care partners reported having some preparedness in general and it increased from discharge (23.75, SD=6.78) to 2months (24.5, SD=6.49) and 6months (26.35, SD=6.73). Multiple care partner characteristics were associated with preparedness at discharge [age (b=-0.071; p<0.001), burden (b=-0.283; p<0.001), and depression (b=-0.284; p<0.01)], 2months [burden (b=-0.226; p<0.001), strain (b=-0.144; p<0.05), depression (b=-0.185; p<0.05)] and 6months [burden (b=-0.164; p<0.01), strain (b=-0.183; p<0.05), depression (b=-0.279; p<0.01)] post discharge. While care partners' feelings of greater burden and depression were associated with lower preparedness at all time points, care partners' higher age was associated with lower preparedness at discharge only and care partners' feelings of higher strain was associated with lower preparedness at two and 6months post discharge. Findings suggest the need to address care partners' feelings of burden, strain, and depression with tailored interventions and programs to optimize their preparedness in meeting unique care needs of hospitalized persons with dementia. Resilience-based interventions and programs can be useful to manage feelings of burden, strain, and depression and optimize preparedness.

Open versus minimally invasive hepatic and pancreatic surgery: 1-year costs, healthcare utilization and days of work lost

IntroductionUtilization of minimally invasive surgery (MIS) has become increasingly popular due to its potential benefits such as earlier recovery and reduced morbidity. We sought to characterize differences in 1-year healthcare costs and missed workdays among patients undergoing MIS and open surgery for a hepatic or pancreatic indication. MethodsData on patients who underwent hepatic and pancreatic resection were obtained from the IBM Marketscan database. Generalized linear models were utilized to compare healthcare costs and missed workdays among patients undergoing MIS versus open surgery. ResultsAmong 8705 patients, 85.0 % (n = 7399) and 15.0 % (n = 1306) patients underwent an open or MIS HP procedure, respectively. In the unmatched cohort, patients who underwent MIS were more likely to be female (62.7 % vs. 54.6 %) and were less likely to have a Charlson Comorbidity Index score >2 (34.5 % vs. 49.6 %) (both p < 0.05). After entropy balancing, multivariable analysis revealed that MIS was associated with lower 1-year post discharge expenditures (mean difference -$9,739, 95%CI-$12,893, -$6585) and fewer missed workdays at 1-year post-discharge (IRR 0.84, 95%CI 0.81–0.87) (all p < 0.001). DiscussionAt index hospitalization and 1-year post-discharge, an HP MIS approach was associated with lower healthcare expenditures versus open surgery for hepatic and pancreatic resection, as well as fewer missed workdays.

The association of physical resilience and post-discharge adverse events among older adults with dementia

Objectives Post-discharge adverse events, such as falls, hospitalizations, and death, are more prevalent among older adults with dementia, compared to their cognitively intact counterparts. This study aimed to test the association between physical resilience and post discharge adverse events in a sample of older adults with dementia. Method Through phone calls with caregivers over one year, we obtained data on physical resilience and post-discharge adverse events through caregiver report among a sample of 314 recently discharged older adults with dementia. We performed negative binomial regression (falls and hospitalizations) and logistic regression (death), controlling for covariates. Results Greater physical resilience at one month post discharge was significantly associated with less falls, hospitalizations, and death within one year. Conclusion This study highlights a particular patient profile, recently discharged older adults living with dementia who have low physical resilience, that could be targeted for intervention when discharged from the hospital.

Independent risk factors of ejection fraction deterioration post discharge in hospitalized heart failure patients with mildly reduced ejection fraction

Abstract Background The identification of independent risk factors for left ventricular ejection fraction (LVEF) deterioration is of clinical importance in patients diagnosed heart failure with mildly reduced ejection fraction (HFmrEF). This study aimed to determine the independent risk factors of LVEF deterioration post discharge among hospitalized HFmrEF patients. Methods This retrospective study analyzed data from 807 HFmrEF patients admitted to our hospital between January 2015 and August 2020. LVEF values were assessed by echocardiography between 6 months and 1 year after discharge. Patients were followed up to a mean of 33 months. The primary endpoint was disease progression expressed as heart failure with reduced ejection fraction (HFrEF) between 6 months and 1 year post discharge. The secondary endpoint was all-cause death. Multivariate logistic regression analysis was conducted to identify independent risk factors associated with LVEF deterioration. Results There were 225 patients progressed to HFrEF between 6 months and 1 year post discharge. All-cause death was significantly higher in HFrEF patients (43%) compared to patients with stable LVEF (unchanged or improved, 24%, P&amp;lt;0.001). Multivariate logistic regression analysis showed that the independent risk factors associated with worsening LVEF in patients with HFmrEF were: female (OR=1.71, 95% CI 1.14 to 2.57, P=0.009), higher NT-proBNP (≥2312 pg/ml, OR=1.71, 95% CI 1.14 to 2.57, P=0.010), higher uric acid (≥318 µmol/L, OR=11.63, 95% CI 7.89 to 17.15, P&amp;lt;0.001), and larger end-diastolic left ventricular dimension (OR=1.05, 95% CI 1.02 to 1.08, P&amp;lt;0.001). Conclusion Results of this study might help risk stratification to identify hospitalized HFmrEF patients with increased risk of progression to HFrEF post discharge. Patients with above clinical features should undergo more intensively monitoring and enhance care adherence to HF guideline medications. Future studies are needed to validate if tailored guideline adherence management strategies for post-discharged HFmrEF patients based on personalized risk stratification could mitigate LVEF progression and improve survival of these patients.

Development and validation of a predicting model for risk of mortality in heart failure patients with mildly reduced ejection fraction post discharge

Abstract Background Prognostic prediction for heart failure with mildly reduced ejection fraction (HFmrEF) patients remains challenging. We aimed to create and validate a mortality risk prediction model for HFmrEF patients at 6-month, 1-year, and 3-year post discharge. Methods Clinical data of 1691 HFmrEF patients registered in the heart failure registry from 2015 to 2020 at the Heart Center of our hospital were analyzed. Patients were assigned into a training (1183 patients) and validation cohort (508 patients) at 7:3 ratio. Predictive variables for mortality at various period post discharge were identified by the Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis. The predicting model was then established based on these variables. Model performance was evaluated with ROC curve and Decision Curve Analysis (DCA). Results Eight predictors were identified including age, NT-proBNP, hemoglobin levels, use of beta-blockers, ACEI/ARB, invasive ventilation, PCI procedures, and pulmonary artery systolic pressure values. The model achieved a C-index of 0.748 (training set) and 0.755 (validation set). Area Under the Curve (AUC) for training set at 6 months, 1 year, and 3 years were 0.813, 0.784, and 0.774, and AUC for validation set were 0.775, 0.744, and 0.770, respectively. The DCA analysis confirmed the favorable net benefit of the established nomogram model. Conclusion This predicting model might be used for post-discharge risk stratification and individual decision-making of post-discharge management in HFmrEF patients.

The mortality implications of increasing and decreasing sST2 levels during acute decompensated heart failure

Abstract Introduction Soluble Suppressor of Tumorigenicity (sST2), a marker of cardiac remodelling and fibrosis, has demonstrated promises in prognostication of heart failure (HF) and therefore recommended as an additional test for risk stratification of HF in the 2017 ACC/AHA/HFSA guidance. It is well investigated as single measurements in acute and ambulatory settings. Data regarding sST2 level changes during acute decompensated heart failure (ADHF) and its potential in providing additional prognostic information is however sparse. We therefore sought to evaluate changes in sST2 and its prognostic implications in hospitalized patients during ADHF. Methods Between December 2019 and February 2022, consecutive patients with ADHF and reduced ejection fraction (EF&amp;lt;50%) presenting to our University Hospital were recruited as part of the Investigating the soluble ST2 biomarker in addition to Natriuretic peptides in managing patients with Heart Failure and a Reduced Ejection Fraction (INST2ANT-HF) study (REC Reference: 19/EE/0269). Serum samples were taken at clinician determined decompensation and recompensation in all participants, who were then followed up for one year post discharge. The study primary end point was all-cause mortality at one year. A 2x2 contingency table was constructed to display the relationship between the frequency of unchanged/increased or decreased sST2 levels at recompensation and the frequency of mortality at one year (Table 1). A Kaplan-Meier curve was plotted to display the survival probability of the two groups during one-year follow up (Figure 1), and log-rank test applied to evaluate for significant difference in the survival distributions. Results In 169 patients with paired sST2 samples, median age (IQR) was 72 (62-80.8), 39 (23.2%) were female and 160 (95.2%) were ethnically white. 158 (94.1%) presented with NYHA class II-IV and the median (IQR) EF was 26% (17.5-32.5). Median (IQR) length of stay in hospital was 8 days (5-13). Median (IQR) sST2 level at decompensation and recompensation were 60ng/ml (40-93.3) and 39.5ng/ml (24-64.8) respectively. At clinician determined recompensation, sST2 level decreased in 136 (81%) patients while 32 (19%) had unchanged/increased sST2 levels. One-year mortality was 37.5% in patients with unchanged or increasing sST2 levels during ADHF, compared to 16.2% in those with decreased sST2 levels. The mean (SE) survival time was 332 (7) days for patients with unchanged/increasing sST2, and 274 (22.5) days for patients with decreasing sST2 at HF recompensation (p=0.003). Conclusion Our data demonstrates that there was a downward trend in sST2 in most patients during recovery from an ADHF episode. Importantly, a static or increasing sST2 level from HF decompensation to recompensation was associated with a significantly higher risk of mortality at one year. Further research may ascertain if the mortality risk is also dependent on the percentage changes in sST2 concentrations.Table 1:2x2 contingency tableFigure 1:Kaplan-Meier curve

Effect of a cardiovascular post discharge sms support program on healthcare utilisation - the hearthealth program

Abstract Background Cardiovascular disease (CVD) is a leading cause of mortality worldwide[1]. Targeting modifiable risk factors is key to primary and secondary prevention of CVD but many barriers to good risk factor control exist[2]. SMS message programs have shown to be an efficient modality to deliver information to improve knowledge and risk factor profiles for CVD patients[3]; however, their impact on healthcare utilisation has not been thoroughly examined. The HeartHealth program is a text message post-discharge support program delivered to CVD patients. It comprised regular semi-personalised text messages providing CVD information, advice, and support to patients over a 6-month period. Purpose This study aimed to examine the impact of the Heart Health program on healthcare service utilisation. Methods Patients ≥18 years old who recently attended cardiology clinics or were discharged from a cardiology unit, between April 2020 and April 2022 were invited to the program. We compared healthcare utilisation rates in patients who enrolled into the HeartHealth text program (intervention group) to contemporaneous patients who did not enrol in the program (control group). The primary outcome was the incidence rate of all-cause healthcare utilisation events (composite of ED presentations and/or hospital admissions for any medical cause) in the 6 months post-discharge. The secondary outcomes were incidence rates of CVD events and unplanned CVD events. All analyses were adjusted for demographic and co-morbidity variables. Results 11542 patients were included in analysis (intervention: 4324, control: 7218), mean age 58.8 years, 60.7% were male, and 78.3% with English as their preferred language. HeartHealth Intervention participants had lower rates of the primary outcome of healthcare service events compared to control participants (mean number of events 0.43 intervention vs 0.52 control, adjusted rate ratio [RR], 0.91 [95% CI, 0.83-0.99], p=0.033, Table 1). The intervention was significantly more effective in older patients compared to younger patients (RR, 0.82, [95% CI, 0.72-0.93] in patients aged ≥65 years, compared to patients &amp;lt;65 years, RR, 0.98, [95% CI, 0.87-1.10]; p-value for interaction =0.043, Figure 1). The subset of CVD events and unplanned CVD events were numerically lowering in the intervention group compared to the control, but the risk ratio not statistically significantly different in adjusted models (Table 1). Conclusion This analysis demonstrates that a text message post-discharge support program for CVD patients decreased the need for healthcare service utilisation for all medical causes. Future randomised controlled trials are required to further support these findings.Figure 1:Adjusted interaction analysisTable 1:Adjusted Incidence of events

Long-term clinical outcomes and patterns of follow-up after cardiogenic shock: insights from an advanced heart failure referral center registry

Abstract Background Inpatient mortality of patients with cardiogenic (CS) has been reported as high as 50%. Those who present in CS are at high risk of having recurrent admissions to hospital or requiring advanced heart failure (HF) therapies. The Toronto General Hospital (TGH) is a quaternary cardiac center, providing mechanical circulatory support (MCS) and heart transplantation (HT), serving as a regional CS transfer hub for a population of over 8 million people. While inpatient management of CS patients has been studied extensively, there is little data on where or how these patients are followed after their discharge. We aimed to determine the long-term clinical outcomes and nature of follow up after a CS admission. Methods This was a retrospective cohort study of CS patients admitted to TGH between 2014 and 2023. We collected data regarding survival to discharge and the type of follow up patients received after their index CS admission. Survival was compared using Kaplan-Meier methods. Results 1582 patients were admitted during the study. The mean age was 59.9 + 16.1 years, including 474 (30.0%) females and 335 (21.2%) patients with acute myocardial infarction CS. In-hospital mortality was 32.4%, with a further 17 (1.8%) patients transferred to palliative care during their index CS admission. After excluding patients who underwent heart transplantation (HT) or durable MCS implant, 679 patients were discharged alive, with median follow-up of the 307 (range 0 – 3436) days. Overall mortality was 57.0%. Among discharged patients, 396 (56.8%) were followed at the regional hub hospital. A further 54 (8.0%) patients were followed by a cardiology provider at a referring community center. A total of 202 (29.7%) patients did not have outpatient follow up arranged at the time of their discharge and no details of further care were available. Median survival during follow-up was higher among patients with confirmed follow-up at the time of their discharge, but not statistically significant (1798 vs 1775 days, p=0.067). There was a significant survival benefit among CS patients followed at a heart function clinic compared with those who were not, (1821 vs. 1775 days, p= 0.020). In terms of candidacy for advanced therapies, having outpatient follow up was associated with receiving durable MCS or HT (6.3% vs. 0.5%, p=0.003). Conclusion Despite advances in the management of CS, overall mortality remains high at 57.0%. Follow-up after CS admission is of essential importance- both in improvement of long-term outcomes, and access to advanced heart failure therapies. There was a survival benefit among patients who were followed in a specialized heart function clinic. Additionally, having outpatient follow up was significantly associated with receiving advanced therapies. Further research is needed to identify the barriers to accessing post discharge follow-up care.

The cost-effectiveness of a digitally enabled telerehabilitation program delivered nationally to patients in Australia

Abstract Introduction Traditionally delivered cardiac rehabilitation (CR) programs have considerable benefits, yet access and participation remains low. Emerging digital health models offer promise in healthcare delivery, but their benefits and impact on healthcare utilization and cost-effectiveness are uncertain. We conducted a cost-effectiveness analysis of a telehealth program with a CR mobile app for post-hospitalization coronary heart disease (CHD) patients. Purpose To assess whether a digitally enabled CR program is cost-effective compared with a propensity matched usual care control group in the Australian health system. Methods Patients were recruited nationally, through a health insurer, following hospitalization for CHD. Participants received weekly telehealth consultations for up to 8 weeks, supplemented by use of an mHealth app. Using administrative private health insurance claims data, we assessed differences in hospital costs, mortality rates and bed days at 12-months post discharge. Incremental cost effectiveness ratios (ICERS) were calculated to determine the cost per deaths prevented and cost per bed days saved for the digital-CR group (n=133) compared with usual care (n=266). Results Among the cohort, 36% lived in regional/rural areas, 70% were male and the mean age was 68 years. The mean total hospital all cause readmission costs at 12-months were $1,488 AUD less in the digital-CR group ($16,411) compared to the usual care group ($17,899). Digital-CR had fewer total hospital days relative to the usual care group (median of 2 vs 3 days) and patients in the digital-CR group had a significantly lower mortality rate at 12-months post discharge. The ICERs were -$337 per 100 patient deaths prevented and -$3,033 per median bed days saved. Conclusion The implementation of a digital-CR program demonstrates cost-effectiveness for patients with CHD when compared to usual care. Thus, advocating for the widespread availability of digital-CR programs as an option for CHD patients following hospital discharge is warranted.

A practical risk score for prediction of 6-month mortality in patients with acute heart failure: CHAM2P2

Abstract Background Admission with acute heart failure carries a poor prognosis. Multiple predictive risk scores exist in heart failure presentation, however the utility of these scores in acute heart failure setting among older adults is limited. Aim The purpose of this study was to develop a practical risk score to predict 6-month mortality in patients presenting with acute heart failure. Methods Between January-August 2020, 474 consecutive patients (mean age 80 ± 11 years) admitted with acute heart failure to a large tertiary hospital in the South-West of England were identified. Data was retrospectively collected on admission bloods, comorbidities, imaging, echocardiography and post discharge mortality. Prediction modelling with multivariate Cox regression was then used to identify clinically relevant predictors of six-month mortality. Continuous variables were dichotomised around the mean/median for simplification. Variables were assigned points proportional to hazard ratios on Cox regression. Results Mortality at six months was 34% (161/474). Cox regression identified five significant (p&amp;lt;0.05) predictors of mortality: C: Clinical Frailty Score&amp;gt;5, H: hospital stay &amp;gt;10 days, A: age &amp;gt;80yrs, M: malignancy (current or previous) history and P: NT pro-BNP&amp;gt;4500pg/ml. In our final model, malignancy and NT pro-BNP were assigned two points with the remainder being assigned one. In total, 304 patients had data available to generate CHAM2P2 scores. Mortality increased sequentially from 16.0% in patients with CHAM2P2 0-2, 44.4% in patients with CHAM2P2 scores of 3-5 and 94.1% in patients with CHAM2P2 scores of 6 or 7 (log rank &amp;lt;0.01). AUC demonstrated good discriminatory value of the CHAM2P2 score in predicting six-month mortality (AUC 0.74). Conclusion The CHAM2P2 score is a readily available and simple tool to predict 6-month mortality in patients admitted with acute heart failure.

Patient control preferences prior to discharge after cardiac surgery

Abstract Background The impact of patient preferences and participation in the acute recovery period prior to discharge after cardiac surgery is not well understood. Although there is a plethora of literature describing pre and post discharge interventions to support patients’ recovery there is minimal evidence demonstrating the effectiveness of specific interventions that optimise recovery or patient preferences for participation in decision making related to this period of transition from hospital to home. Purpose The aim of this study was to explore patient preferences for participation in discharge planning. Methods This study took place in a major metropolitan hospital in Victoria, Australia with a population base of over 1 million people that provides over 100,000 episodes of care and approximately 850 cardiothoracic procedures annually. We recruited consecutive adult patients, able to understand and speak English who were being discharged home after cardiac surgery. Prior to discharge, a Registered Nurse conducted a semi-structured interview following patient consent where patients were asked to complete the 5 item Control Preferences Scale (CPS) in relation to 3 discharge planning questions. With each question patients were asked to rate their preferred and actual role in the decision-making process. The CPS has 5 cards each portraying a role in treatment decision making; active (1-2), collaborative (3) or passive (4-5) participation to determine what level of control patients’ desire in relation to their care. Results From 196 patients undergoing cardiac surgery 63 (32.1%) were eligible and agreed to participate. When asked about making plans for discharge 9 (14.3%) patients’ preference was to have an active role in this process, 25 (39.7%) preferred a collaborative approach and 29 (46.1%) a passive approach. Patients perceived their actual role was active (n = 10, 15.9%), collaborative (n = 17, 27.0%) or passive (n = 36, 57.1%). When asked about deciding when to go home 9 (14.3%) patients’ preference was to have an active role in this process, 18 (28.6%) preferred a collaborative approach and 36 (57.1%) preferred a passive approach. Patients perceived their actual role was active (n = 8, 12.7%), collaborative (n = 13, 20.6%) or passive (n = 42, 66.6%). When asked about their preferred role in deciding where they go when discharged 21 (33.4%) patients’ preference was to have an active role in this process, 19 (30.2%) preferred a collaborative approach and 23 (36.5%) a passive approach. Patients perceived their actual role was passive (n = 24, 38.1%), collaborative (n = 16, 25.4%) or passive (n = 23, 36.5%). Conclusion Patient preferences for control were congruous with their perceived experience of involvement in decision making which indicates patients’ preference for control is taken into account by clinicians managing the discharge planning process in this setting.

Closing the loop: Utilizing advanced practice providers for a 7-day post hospital discharge follow-up of GI oncology patients at an academic cancer center.

304 Background: Acute care visits for oncology patients may be preventable, especially for high-risk patients with a recent hospitalization. During our 2023 Fiscal Year, we observed an approximate 22% rate for 30 day readmissions for oncology patients, with our gastrointestinal (GI) oncology patients having the most readmissions, at Stanford Cancer Center. Readmission review through clinician surveys suggested that about 28% of unplanned admissions may have been preventable, with root cause analysis identifying timely access to ambulatory symptom management as a major driver. Methods: We established a cancer transitional care (CTC) clinic to provide consistent and timely post-discharge follow-up for oncology patients. We initiated a pilot program for GI oncology patients (chosen due to high acuity and readmission rate) who had an unplanned admission to Stanford Hospital. We aimed to schedule a visit with an advanced practice provider (APPs) within 7 days of discharge. The A3 problem solving process was implemented weekly by a multidisciplinary team. We created a referral in our electronic medical record. Inpatient oncology teams were instructed to place this referral within 3 days before discharge, allowing for adequate patient and family education regarding the goals of CTC visits and ample time for the post-discharge CTC visit to be scheduled prior to patient discharge. Prior to CTC visits, pharmacists performed outreach to reconcile medications to reduce medication errors. Eight oncology APPs were trained regarding the focused nature of a CTC visit, including symptom management, medication reconciliation, and goals of care discussions. Results: At baseline, from June 1 and November 30th, 2023, 61% of patients had follow-up within 7 days of discharge and 12% of patients with none. Between December 13, 2023 and April 19, 2024, CTC implementation resulted in a total of 220 referrals for GI oncology discharges, yielding 144 CTC clinic visits. Resulting in 66.1% of patients having follow up within 7 days of discharge and 9% of patients had no follow up scheduled. 79% of visits were within 7 days of discharge, representing a 29% increase in our goal scheduling timeline. The average time between discharge date and CTC visit was 6.2 days. Sixty six patients also received detailed pharmacy reviews with medication reconciliation and addressing medication access issues. Conclusions: Through our CTC clinic, we standardized post-discharge follow-up access for GI oncology patients, reducing variability in follow up. We plan to disseminate this model across medical oncology subspecialty clinics. Barriers included standardization of follow up with clinical team and expectations for the visit for both patients and clinicians. Future directions include integrating same day symptom management and urgent care access.

Mortality and Place of Residence One Year Post Stroke in an Irish Cohort

Abstract Background Transition from hospital to community post stroke is a critical period in a patient's recovery. Understanding where post-stroke patients are living a year after discharge can provide valuable insights into the effectiveness of discharge planning and rehabilitation strategies. We aimed to identify location of patients one year post stroke and examine the influences on that location. Methods We performed a retrospective cohort study of stroke patients admitted to an acute hospital over a one-year period. Data on demographics, function, length of stay, stroke severity, mortality and discharge location were obtained from the in-hospital stroke registry. Patients were interviewed one year post stroke and follow up data on place of residence obtained. Results 260 strokes occurred during the 1-year period. 11% died as inpatients and 5% were uncontactable leaving 206 stroke patients included in this study. Twenty-five patients (12%) died between discharge and 1 year follow up. 150 (73%) returned home post discharge rising to 157 (76%) one year post stroke. 32 (16%) were discharged to nursing homes falling to 22 (11%) at one year. Patients in nursing homes were older (80 vs 68 years, p = 0.001), had longer inpatient stays (37 vs 9 days, p = 0.000) and had higher Modified Rankin Scores (5 vs 2, p=0.0001). Conclusion Almost one in four stroke patients died within the first year of stroke consistent with international data. Mortality was highest in the acute post stroke period, but half of all deaths occurred post hospital discharge highlighting the importance of secondary vascular prevention and advanced care planning in this population. Older age, higher functional dependence and longer length of hospital stay were all associated with nursing home admission. Post stroke morbidity and mortality remains high after hospital discharge. Further study is needed to understand cause of death in the post discharge period in this population.

EDAPT: The Development And Implementation Of A Novel Referral Pathway From The Emergency Department

Abstract Background The Emergency Department Admission Prevention Therapy (EDAPT) service was developed by Therapy staff of the Pathfinder team in order to facilitate timely and appropriate discharges from the Emergency Department (ED) and to maximise capacity for the follow-up team. The aim of this pilot is to provide rapid access to therapy post discharge from ED for older adults with acute decline in function in order to prevent hospital admission. The service provides a short-term reablement approach within the home aiming to facilitate patients to regain pre-acuity baseline. EDAPT was modelled from an existing service but has now been expanded to accepting direct referrals from ED Medical Staff and Advanced Nurse Practitioners (ANPs) outside of standard working hours. Methods The pilot was introduced following collaboration and consultation with a number of key stakeholders including respective Therapy Managers, ED Consultants, ANPs and ED Therapists. A new EDAPT referral pathway was created, and documentation including specific referral and assessment forms. A designated area for receipt of referrals in the ED department was chosen and checked daily. Results 64 patients with a mean age of 80.5 years were referred to the EDAPT service from November ’23 to April ’24. 53 of those patients received face-to-face input and had a mean Clinical Frailty Scale score of 5. 27% (n=17) of referrals were initiated out-of-hours via Medical and ANP staff and 48% (n=31) of referrals were falls related. Patients received an average of 2 follow-up visits during EDAPT involvement. Conclusion The EDAPT pilot is successfully facilitating timely and appropriate discharges from the ED, improving patient experience and patient flow from ED to their own home. The pilot integrates acute hospital care and community services, supporting a person-centred approach of the right care, at the right time and in the right place.

Estimating Patient Eligibility And Benefit Of Intravenous Zolendronic Acid In Hip Fracture Patients: A Service Evaluation

Abstract Background Low trauma hip fractures are serious and carry an estimated re-fracture rate of 10.6%, leading increased morbidity, mortality and healthcare cost. Intravenous Zolendronic Acid (IVZ) administration following hip fracture reduces re-fracture risk by approximately 23% and is recommended yearly for three years by National Osteoporosis Guidelines Group (NOGG) 2021. However, a significant treatment gap remains with only one-fifth of patients receiving IVZ pre-discharge, due to implementation challenges, such as suboptimal Vitamin D levels and lack of resources for yearly infusions. Recently published consensus guidelines offer practical advice as to how to overcome these barriers. This service evaluation estimates the proportion of hip fracture patients eligible for IVZ; as well as the re-fracture rate, prior to the introduction of a local IVZ pathway. Methods Approval from local Quality and Patient Safety Department was received. Low trauma hip fracture patients were identified from the local Orthogeriatric database (October 2019 to January 2021). Hospital electronic laboratory and radiology software were used to identify renal function on discharge and evidence of further fractures (at six months, 1 year and 3 years). Subjects were deemed potentially eligible for IVZ if they had an estimated glomerular filtration rate (eGFR) of ≥50 mls/min (a proxy for calculated creatinine clearance ≥30mls/min in this patient cohort). Results Of 463 subjects, 384 (82.9%) had an eGFR ≥50. Re-fracture data was collected for 263 eligible subjects. Seventeen (6.5%) re-fractured within six months, 21 (8%) re-fractured within a year and 45 (17.1%) re-fractured at any stage post discharge. Conclusion IVZ treatment is the most efficacious secondary fracture prevention post-hip fracture, and most patients are eligible for this treatment. Implementing IVZ pathways for hip fracture patients may significantly reduce re-fracture rate, however expansion of resources allocated to Orthogeriatrics and Fracture Liaison teams is required to successfully implement inpatient pathways and ongoing care.

Adding a Mobility Champion to an Existing Progressive Mobility Protocol: An Evidence-Based Initiative.

This evidence-based initiative assessed the effect of adding a mobility champion to an existing progressive mobility protocol on functional decline in hospitalized older adults as evidenced by recommended discharge to home versus an inpatient rehabilitation facility. Older adults admitted from home to a 47-bed medical-surgical telemetry unit who were assessed as ambulatory, either independently or with assistance (Level 5), and with a progressive mobility order in the electronic health record were included in the initiative. Patient care associates who volunteered to be mobility champions were trained how to safely ambulate patients. Patients who worked with a mobility champion were less likely to be referred to inpatient rehabilitation post discharge for further care due to functional decline. Mobility has a critical role in the maintenance of hospitalized older adults' functional abilities and is a determinate of their post discharge disposition. [Journal of Gerontological Nursing, xx(x), xx-xx.].

Applying Clinical Practice Guidelines on Chronic Headaches, Neck Pain, and Chest Symptoms: A Single Case Report

BACKGROUND: Neck pain and headaches are common conditions in physical therapy practice. Clinical practice guidelines (CPG’s) are forms of evidence designed to decrease practice variability and guide care. CPG recommendations are general, with few specific tactics recommended, which could be a factor in their limited adoption and poor application. This case report demonstrates an example of implementing the Academy of Orthopedic Physical Therapy (AOPT) Neck Pain Revision CPG while also highlighting limitations and areas lacking specificity. CASE PRESENTATION: The patient was a 37-year-old female with neck pain, chest pain, and headaches. She was treated following the recommendations within the AOPT CPG along with psychologically informed practice. The Neck Disability Index (NDI), Patient Specific Functional Scale (PSFS), Fear Avoidance Beliefs Questionnaire (FABQ), symptoms, and impairments were measured at evaluation, discharge, and 2 months post discharge. OUTCOMES: Clinically meaningful improvements in NDI and PSFS scores, improved cervical endurance, scapular strength, and cervical motor control were observed at discharge. Additional improvements in NDI scores were seen at 2-months post discharge. DISCUSSION: While the CPG promotes the use of manual therapy, exercise and general screening, the authors demonstrate specific techniques for identifying and managing fear avoidance behavior with cognitive and graded exposure techniques.