Abstract 197: Root Cause Analysis of 30-day Heart Failure Readmission Elucidates Acute Kidney Injury as a Common Offender

Background: Hospitalization for heart failure (HF) and heart transplant is associated with a high likelihood of readmission within 30 days of discharge. Our study objective was to identify risk factors and causes for readmission at a high acuity tertiary academic medical center in order to develop targeted interventions aimed at HF readmission reduction. Methods: We retrospectively reviewed 49 sequential cases of patients readmitted within 30 days of hospitalization for HF (41) or heart transplant (8) between Q3-Q4 2014. Two unblinded reviewers determined the root causes of readmission, likelihood of readmission prevention, and interventions most likely to prevent similar readmissions from recurring. Results: HF exacerbation was the primary reason for readmission in 47% (23/49) of cases. Also in 47% (23/49) of the readmissions, the possibility for preventing the readmission had an appropriate intervention been implemented was determined to be at least 50%. The other 53% (26/49) of readmissions were considered unlikely to have been readily preventable. Medical complications were the primary cause of readmission in 14% (7/49) of cases, of which acute kidney injury (AKI) was the most common. Over one-fourth (13/49) of all readmissions were found to have at least a 15% increase in creatinine level from time of discharge to time of readmission. Dietary indiscretion (8% i.e. 4/49), psychosocial factors (8%), and progression of disease (8%) were other notable root causes for readmission. When assessing the most likely part of patient care to address to prevent readmission, more proactive follow-up/monitoring was considered to be the most high-yield intervention in 14% of cases i.e. 7/49. Also of note, reclassifying admissions as observation status based on length of stay would have prevented 33% (16/49) of cases from meeting readmission criteria. Conclusion: Our study supports a multifaceted, multidisciplinary approach to reducing HF readmissions, given the array of readmission causes and targeted areas for intervention identified. It also demonstrates that AKI may be an underappreciated cause for readmission, with 28% of all-cause readmissions presenting with creatinine elevations of at least 15%. Therefore, in addition to a multidisciplinary approach to discharge planning, we recommend institutions implement specific strategies to reduce AKI.