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03/27/2014 Objectives A Novel Method to Reduce Heart Failure Readmissions Rebecca C. Swierz, RPh, PharmD PGY-1 Pharmacy Resident Southwest General Health Center Pharmacist Objectives: Explain the basics of the Heart Failure Exacerbation Rescue Kit Discuss workflow for administering a Rescue Kit from admission to discharge in a hospital system Describe the cost‐benefit analysis of a Heart Failure Exacerbation Rescue Kit Technician Objectives: Explain the preparation of the Heart Failure Exacerbation Rescue Kit Kit Basics Objectives Medications Information for Physicians HEART FAILURE EXACERBATION KIT Education for Nurses THE BASICS Education for Patients Kit Basics Objectives Medications For MDs For RNs For Pts Reduce hospital readmission by early recognition and treatment of heart failure symptoms Dispense to all Heart Failure patients under the care of SWG Home Health Care unless contraindicated Kit Basics Objectives Loop Diuretic: – Torsemide 20 mg # 10 Medications For MDs For RNs For Pts Thiazide Related Diuretic: – Metolazone 5 mg # 2 Electrolyte Supplement(s): – Potassium Chloride 20 mEq # 6 – Magnesium L-lactate # 6 1 03/27/2014 Kit Basics “Dear Physician” Letter How to order the Rescue Kit Visual materials Objectives Medications For MDs – Poster board – Mock kit For RNs Inform PCP For Pts Objectives Medications For MDs For RNs For Pts Kit Basics Objectives Objectives Medications Medications For MDs For MDs For RNs For RNs For Pts For Pts Objectives Medications In services Educational materials **Vital to the success of the Kit!** Objectives Medications For MDs For MDs For RNs For RNs For Pts For Pts 2 03/27/2014 Objectives Objectives Medications Medications For MDs For MDs For RNs For RNs For Pts For Pts Kit Basics Objectives Medications For MDs For RNs For Pts Patient must be HF SWG HHC Discharge counseling required – Address four main questions • • • • WHEN to use it? WHAT is it for? WHAT is in it? HOW much does it cost? Kit Basics Warning Labels on Kit – Do not open unless instructed by your Home Health Nurse or Physician – Do not use past – Not for daily use – Yellow Zone use only HEART FAILURE EXACERBATION KIT WORKFLOW 3 03/27/2014 Workflow Workflow HHC Liaison is alerted of SWG HHC patient Patient is discharge with SWG HHC and HF Kit and closely monitored by HHC RN for yellow zone symptoms HHC Liaison contacts HF team to evaluate patient for appropriateness of Kit Once Kit is ready, it is brought to patient’s floor where Discharge RPh or HF team member will counsel patient After hours? Weekends? Kit Rxs are printed and signed by MD then faxed to SWG Community Pharmacy and filled by technicians Workflow Workflow HHC Liaison is alerted of SWG HHC patient HF Exacerbation: Patient is discharge with SWG HHC and HF Kit and closely monitored by HHC RN for yellow zone symptoms HHC Liaison contacts HF team to evaluate patient for appropriateness of Kit Once Kit is ready, it is brought to patient’s floor where Discharge RPh or HF team member will counsel patient – Unrelieved shortness of breath – Worsening edema • Swelling in the legs, ankles, or abdomen – Weight gain of 2 pounds in one day or 5 pounds in one week Kit Rxs are printed and signed by MD then faxed to SWG Community Pharmacy Workflow ! Workflow Exacerbation Day 1 Exacerbation Day 2 IF NOT RETURNED TO BASELINE Loop Diuretic: Torsemide Loop Diuretic: Torsemide – If the patient is taking torsemide as a routine home med, the regular dose is doubled in the morning – If the patient is taking furosemide as a routine home med: • Furosemide morning dose is replaced with the same mg dose of torsemide in the morning • The patient’s normal evening dose of furosemide is still taken if applicable – Max torsemide dose is 200 mg PO daily – Repeat torsemide using exacerbation day 1 dose Thiazide Related Diuretic: Metolazone – Add metolazone 5 mg 30 minutes prior to torsemide Electrolyte supplements: KCl, Mg – Administered if potassium levels < 3.5 mEq/L or magnesium levels are < 1.7 mEq/L – Max KCl is 60 mEq per dose 4 03/27/2014 Workflow Exacerbation Day 3 – If weight not back to baseline or weight increased, refer to emergency department for review of systems HEART FAILURE EXACERBATION KIT COST BENEFIT Cost Benefit Cost of Heart Failure Readmission – Considerations: $$$ • Average LOS: 5.8 days • Average Cost/Day: $1200-2000 • Average Medicare Readmittance: 27% in 30 days Cost of Heart Failure Kit – Supplies: ~$2/kit • • • • Labels Bags Bottles Tamper Tape – Medications: ~$6/kit Conclusions The Heart Failure Rescue Kit is piloted in a closely monitored group of patients Education to all members of the patient’s care team is vital for the Rescue Kit’s success Dispensing workflow – a work in progress Opportunities for decreased readmission rates and decreased hospital cost are possible with the Heart Failure Rescue Kit Bogaev R. Cost Considerations in the Treatment of Heart Failure. Texas Heart Institute Journal. 2010: 37, 557-558 Ross J.S., Chen J., Lin Z., Recent national trends in readmission rates after heart failure hospitalization. Circ Heart Fail. 2010;3:97-103. Acknowledgements Stacey Zorska, PharmD Director of Pharmacy Southwest General Heath Center Dave Ferris, PharmD Residency Program Director Southwest General Health Center [email protected] QUESTIONS? 5 03/27/2014 References Douban S, Brodsky MA, Whang DD, Whang R.Significance of magnesium in congestive heart failure Am Heart J. 1996 Sep;132(3):664-71. Ross J.S., Chen J., Lin Z., Recent national trends in readmission rates after heart failure hospitalization. Circ Heart Fail. 2010;3:97-103. Gheorghiade M, Gattis W, O’Connor C, Adams K, Elkayam U, Barbagelata A, et al. Effects of Tolvaptan, a Vasopressin Antagonist, in Patients Hospitalized With Worsening Heart Failure:A Randomized Controlled Trial. JAMA. 2004; 291(16): 1963-1971. Bogaev R. Cost Considerations in the Treatment of Heart Failure. Texas Heart Institute Journal. 2010: 37, 557-558 http://h2hquality.org/. Multidisciplinary care for people with chronic heart failure. Principles and recommendations for best practice. Heart Foundation 2010 1-48. Hunt SA, Abraham WT, Chin MH, et al, “2009 Focused Update Incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation,” CIrculation, 2009, 119(14):e391-479 Koniari K, Parissis J, Paraskevaidis I, Anastasiou-Nana M. Treating volume overload in acutely decompensated heart failure: established and novel therapeutic approaches. Europ Heart J Acute Cardiovasc Care. 2012 Sep;1(3):256-68. Kramer WG, Smith WB, Ferguson J, Serpas T, Grant AG, Black PK, Brater DC. Pharmacodynamics of torsemide administered as an intravenous injection and as a continuous infusion to patients with congestive heart failure. J Clin Pharmacol. 1996 Mar;36(3):265-70. Murray MD, Deer MM, Ferguson JA, Dexter PR, Bennett SJ, Perkins SM. Open-label randomized trial of torsemide compared with furosemide therapy for patients with heart failure. Am J Med. 2001 Nov;111(7):513-20. www.americanheart.org. Get with the Guidelines Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, et al., 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013. 1524-4539 6