Barriers Of Successful Implementation Of Discharge Criteria At A Tertiary Heart Function Clinic

Abstract

Introduction

Most multidisciplinary heart function clinics cannot absorb the high volume of referrals they receive. The effectiveness of discharge protocols to offload stable patients from HF clinics has been poorly studied. We aimed to examine the predictors and barriers of implementing discharge criteria at a tertiary HF clinic.

Methods

We reviewed patients with ≥3 visits to our heart function Clinic between Aug 1st and Feb 29th, 2024. We extracted patient-related and provider-related characteristics at initial and most recent clinic visits. The clinic's established discharge algorithm (Figure 1), was used to categorize patients as eligible or ineligible for discharge. The primary outcome was rate of successful discharge (defined as actual discharge of patients deemed suitable for discharge according to the protocol).

Results

Of 144 patients reviewed (mean age 71± 13 yrs, 65% men, and 8% HFpEF), 60 patients (41.7%) were deemed suitable for discharge, however, only 25/60 (41.7%) were actually discharged.Failure to discharge was associated with atrial fibrillation (AF) (20.8% of patients with AF were discharged vs 55.6%; p-value 0.009), having a HF hospitalization within 12 months (28.6% vs 53.1%; p-value 0.054), and those with improved EF to less than 50% (33.3% vs 64.7%; p-value 0.027). For provider-specific characteristics, there was a trend towards an association between having a cardiologist (discharge rate 100% among patients with a cardiologist vs 38.6%; p-value 0.067); whereas having a primary care provider did not correlate with discharge success (p-value >0.05). As for heart function providers’ characteristics, low clinical experience (defined as <5 years in practice) was associated with a low rate of successful discharge (10.5% vs 52.6%; p-value 0.002).Thematic analysis revealed the desire to re-repeat the echocardiogram to confirm consistent improvement in ejection fraction (14/34, 41.7%), and to follow-up on non-heart failure consultants’ opinions (arrhythmia, surgery, structural heart team; 9/34. 26.5%), to be the most common reasons for failure to discharge.

Conclusion

The rate of successful discharge from our clinic is suboptimal (41.6%) which impedes timely care for new referrals. We identified several patient-related characteristics and provider-specific barriers for successful discharge. More studies are needed to explore this important area.