discussion w6 635

DQ-1

Congestive Heart Failure is considered as one of the most frequent causes of readmission in the hospital that accounts for more than 700,000 hospital admissions per year and approximately 174,000 readmitted within 30 days (Mirklin et al., 2017). The readmission cost burden accounts for more than 10 billion dollars spent each year (Mirklin et al., 2017). Hospitals who have an excessive amount of hospital readmissions received less payment from CMS due to the Readmission Reduction Program that was approved in 2012.

One of the programs that I will implement is the use of the home telehealth program named CARDIOCOM Telehealth. It is a comprehensive health system setting that aims to reduce the readmission in patients with CHF. It is first introduced in the Heart Hospital Baylor Plano’s Center for Advanced Cardiovascular Care (CACC) in collaboration with Medtronic that delivers a 30-day advanced monitoring program called CARDIOCOM in patients with CHF (Garcia & Bradford, 2017). First, I will inform the staff nurses, managers and directors in the inpatient and outpatient heart failure unit about this program. I will also invite some representatives from Medtronic to discuss how the program works and what services do they offer. Then, next we will have a pilot stage and will get a survey done after to see if we can make a practice change. If approved, I will explain to the patient about the program and will inform them that this program is a voluntary support and not a replacement of treatment plan. I will educate the patient and their family that through the use of this technology, data collection, patient management and RN coordinators will be assign to the patient and will evaluate the patient’s risk in order to keep the patient out of the hospital. If I have a newly diagnosed patient with CHF or those patients who have frequent readmission due to CHF exacerbation within the last 90 days. I will refer them to the comprehensive care managers that can provide an education about the CARDIOCOM program. This comprehensive manager also identifies patients who have CHF in the hospital and will call the provider or the patient and their families to offer their services. Once the patient agrees to the program, I will encourage the patient to call into the program on their first day post discharge. Also, I will ensure that the patient and their family is educated and trained on how to manage the patient’s condition paying close attention to the diet, exercise, self-monitoring, self- management and methods on how to communicate and collaborate with their coordinators and physician as well as using home telecommunication technologies such as CARDIOCOM. According to Garcia and Bradford (2017), this program decreased a hospital admission, length of stay and reduce the cost of care in approximately 70% of patients with CHF (Garcia & Bradford, 2017).

References:

Garcia, Marie & Bradford, Monique. (2017). Improving CHF Re-Admission Rates through CARDIOCOM Telehealth Program: 4. Heart & Lung: Journal of Acute & Critical Care, 46, 213. Retrieved from https://doi.org/10.1016/j.hrtlng.2017.04.016

Mirkin, K., Enomoto, L., Caputo, G. & Hollenbeak, C. (2017). Risk factors for 30-day readmission in patients with congestive heart failure. Heart & Lung: Journal of Acute & Critical Care, 46, 357-362. Retrieved from https://doi.org/10.1016/j.hrtlng.2017.06.005

DQ-2

The Inpatient Quality Indicators provides an insight on hospital quality of care using hospital administrative data. One of the inpatient quality indicators (IQI) identified in Agency for Health Research and Quality (AHRQ), (2015) is percutaneous coronary intervention volume. Evidence-based practice is now widely recognized as the key to improving healthcare quality and patient outcomes. Percutaneous coronary intervention (PCI) has matured from a pioneering adventure focused on feasibility to a major sub-specialty delivering real clinical results to patients. Despite delivering reductions in mortality and morbidity in the field of acute coronary syndrome and overcoming in-stent restenosis, several challenges still remain. Firstly, we need to adhere to practices supported by established trials: data relating to PCI in stable angina and late reopening of occluded infarct-related vessels suggest that this is not always the case. Secondly, we must develop new trials asking clinically relevant questions in 'real-world' populations that are focused on patient-based outcomes. Finally, given the current global financial crisis, it is now more important than ever that we demonstrate cost-effectiveness in our clinical practice. In these turbulent times, we discuss the challenges ahead for PCI in its journey towards evidence-based practice (Calvert & Steg, 2018).

 

Agency for Health Research and Quality (AHRQ). (2015). Inpatient Quality Indicators. Retrieved from:

https://www.qualityindicators.ahrq.gov/Downloads/Modules/IQI/V50/IQI_Brochure.pdf

Calvert, P. A., & Steg, P. G. (201*). Towards evidence-based percutaneous coronary intervention. European Heart Journal, 33(15), 1878–1885. https://doi.org/10.1093/eurheartj/ehs151

DQ-3

One of the inpatient quality indicators the Agency for Healthcare Research and Quality (AHRQ) identifies is the pneumonia mortality rate. Pneumonia affects all populations, especially the young, the elderly, and the immunocompromised. It is the world’s leading cause of death among children under 5 years of age, the most common cause of hospital admissions for U.S. adults, and is the most common cause of sepsis and septic shocks (Metlay et al., 2019). Pneumonia related mortality in those admitted to the ICU is about 30% (Nair & Niederman, 2020). The benefits of admission include improved diagnostic tests and respiratory support. The most common bacterial pathogen responsible for CAP is S. pneumoniae; however, due to the recent pandemic of COVID-19, most pneumonia has been viral in which antibiotics are ineffective unless bacterial co-infection. Therefore, it is important to initiate empirical antibiotics if there is clinical suspicion of bacterial infection, including characteristic symptoms and localized chest findings. It is important to consider a chest X-ray when acute cough in addition to abnormal vital signs is present as the gold standard for diagnosis of pneumonia is infiltrates on a chest x-ray. Recognizing severe signs/symptoms of CAP and the need for ICU level of care with mechanical ventilation can impact patient outcomes. There are several prognostic scoring systems, such as the Pneumonia Severity Index (PSI) and the CURB-54, that can be useful for predicting mortality with CAP patients. Evidently, there’s a mortality advantage with community-acquired pneumonia (CAP) patients who required mechanical ventilation with 72 hours of the onset of CAP (28%) compared to those who required ventilation 4 or more days after the onset of CAP (51%) (Nair & Niederman, 2020).

After establishing a diagnosis of pneumonia, empirical antibiotic treatment should be initiated within 4 hours and within 1 hour if the patient has suspected sepsis. According to American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines, there is strong evidence that inpatient adults with non-severe CAP without risk factors for MRSA and P. aeruginosa should be treated with either monotherapy with a respiratory fluoroquinolone, levofloxacin 750 mg daily, or combination therapy with a beta-lactam, such as ampicillin-sulbactam 1.5 to 3g every 6 hours, ceftriaxone 1-2g daily, or ceftaroline 600 mg every 12 hours, and a macrolide, azithromycin 500 mg daily or clarithromycin 500 mg twice daily (Metlay et al., 2019). For severe CAP, inpatient adults should be treated with a beta-lactam and macrolide or beta-lactam and fluoroquinolone. If risk factors for MRSA or P. aeruginosa are present, providers should add treatment. Early initiation of appropriate antibiotics is the key element in reduction of adverse outcomes in patients with CAP, and tt is important to implement guideline recommendations that are evidence-based to decrease the mortality rate of pneumonia.

 

References

Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., … Whitney, C. G. (2019). Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Disease Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7). doi:10.1164/rccm.201908-1581ST

Nair, G. B., & Niederman, M. S. (2020). Updates on community-acquired pneumonia management in the ICU. Pharmacology & Therapeutics. doi:10.1016/j.pharmthera.2020.107663