3 Analysis of care pathways in patients admitted with acute decompensated heart failure (ADHF) shows a missed opportunity during the prehospital period to minimise the risk of admission. (28th September 2016) - McCambridge, J
Abstract : Introduction: Heart failure (ADHF) admission rates remain a major challenge. There is a paucity of data available relating to the pre-hospital phase of care prior to admission with ADHF. We aimed to achieve a more complete understanding of this period, which may allow for more effective pre-hospital intervention thereby preventing admission. Method: In an ongoing study analysing care pathways in patients admitted to St. Vincent's University Hospital with ADHF (de novo presentations, DN, and recurrent admitters, RA), focus was placed on the pre-hospital period to assess duration of symptoms, seeking of pre-hospital medical assessment, the nature of any intervention heart failure-directed (HFI) or otherwise and, in the case of RA, the effectiveness in reporting weight gain. This interim analysis includes 50 patients. Data was gathered from clinical patient surveys, conducted by a heart failure nurse specialist and completed by the patient and a designated family member. Result: Of a total of 50 patients, 30 (60%) were DN and 20 (40%) were RA. Median years since HF diagnosis for RA was 4.5 years. Median age was 72 years (69 for DN, 76 for RA). RA had a higher number of co-morbidities (4.5) compared to DN (3). More than 75% of patients in both groups reported a symptom duration of >3 days. Of RA, 90% (18) reported monitoring their weight and 72.22% (13 of 18) of those noted a weight gain of <2 kg over two days along with their symptoms. Of those who noted a weight gain, 76.92% (10 of 13) reported it to a doctor prior to admission. There was a high rate of patients seeking medical advice in the community (in a GP/HF/general cardiology clinic) prior to admission: 66.67% (20) of DN and 75% (15) of RA. Cardiology review (general or HF-specific) was more common in RA (50%, 10) compared to DN (3.33%, 1). 63.33% (19) of DN and 25% (5) of RA were reviewed by a GP only. Of the DN who were seen by a GP only, 15.79% (3 of 19) were prescribed an HFI (commencement of a diuretic or alteration of their established diuretic regimen), 31.58% (6 of 19) were prescribed another therapy (primarily antibiotics alone or with steroids) and in 52.63% (10 of 19) there was no intervention. Of the RA who were seen by a GP only, 0% (0 of 5) were prescribed an HFI, 20% (1 of 5) were prescribed another therapy and there was no intervention in 80% (4 of 5). Conclusion: Due to the prolonged duration of symptoms and the high rate of patients seeking medical advice in the community, there is both time and opportunity in which to implement a more effective HFI during the pre-hospital phase of care for patients presenting with ADHF. Improved patient education and improved recognition of HF features by GP's with streamlined access to outpatient specialist assistance may allow for earlier appropriately directed HFI, potentially reducing the risk of admission.