Heart failure decompensations accounts for over one million hospitalizations annually and are the most common cause of US hospital admission in patients over 65. While this results in a reduced quality of life for patients, hospital admissions within 30 days of discharge for heart failure are not reimbursed, making this patient population incredibly expensive for hospitals to treat. US expenditure on heart failure exceeds $30 billion annually and is projected to rise by 127% to nearly $70 billion by 2030 as the population ages. Scheduling a follow up appointment within one week of discharge has been shown to reduce rates of readmission. This quality improvement initiative is aimed at improving post-discharge follow up rates in a tertiary referral hospital. The affiliated follow up clinic uses a different electronic medical record (EMR) system, so a system of cross-communication is key. The initial intervention introduced an EMR order that, once placed in the inpatient setting, created an appointment request in the follow up clinic. The cardiology consult nurse practitioner was assigned and educated about the task of entering this follow up order. With this intervention, an increase the number of confirmed follow up appointments scheduled by discharge for patients admitted with acute decompensated heart failure was expected. The initial intervention of introducing an EMR order resulted in a median of 18 patient referrals per month over a period of 5 months. The intervention of introducing a dedicated nurse practitioner the task of placing the order resulted in an increase to 25 orders in the next month. Similarly, the percentage of completed referrals increased from 29% over 5 months to 44% in the last month when a dedicated nurse practitioner was tasked with placing the order for follow up. In recognizing the delicate process of discharging patients with heart failure decompensations, a unified process to organize follow up in a tertiary referral hospital was necessary to communicate with the affiliated clinic. This initial intervention shows promise that continuity of care can be established in an intricate medical system. Further interventions include better equipping the cardiology clinic with personnel to accommodate for the bolus of new post-discharge follow up appointments.
Elevated aortic valve gradients are common after transcatheter aortic valve implantation for degenerated surgical aortic valve replacement bioprostheses, but their clinical impact is uncertain.
Because of the diverse etiologies of community-acquired pneumonia (CAP) and the limitations of current diagnostic modalities, serum procalcitonin levels have been proposed as a novel tool to guide antibiotic therapy. Outcome data from procalcitonin-guided therapy trials have shown similar mortality, but the essential question is whether the sensitivity and specificity of procalcitonin levels enable the practitioner to distinguish bacterial pneumonia, which requires antibiotic therapy, from viral pneumonia, which does not. In this meta-analysis of 12 studies in 2408 patients with CAP that included etiologic diagnoses and sufficient data to enable analysis, the sensitivity and specificity of serum procalcitonin were 0.55 (95% confidence interval [CI], .37-.71; I2 = 95.5%) and 0.76 (95% CI, .62-.86; I2 = 94.1%), respectively. Thus, a procalcitonin level is unlikely to provide reliable evidence either to mandate administration of antibiotics or to enable withholding such treatment in patients with CAP.
