Optimising transitional care after hospitalisation for heart failure

By Dr Emily Lathlean MB BS, FRACGP

Evidence-based guidelines on the transition of patients hospitalised with heart failure to community care have been developed by a multidisciplinary group of Australian healthcare professionals.

The guidelines, published in Heart, Lung and Circulation, noted that hospitalisations for heart failure were associated with high rates of readmission (of about 56%) and death (with an estimated all-cause mortality rate of 25%) one year after hospitalisation for heart failure in Australia, with even higher rates among Aboriginal and Torres Strait Islander people. According to the guidelines, about one-third of these hospital readmissions were considered potentially avoidable.

‘The most vulnerable period for patients with heart failure is within the first few weeks post-hospital discharge,’ the authors wrote, adding that ‘GPs have an important role in the management of patients with heart failure in the community and collaborative care is encouraged.’

The guidelines discussed the benefits of appropriate, timely and effective transfer of care between acute and community care, including minimisation of hospital readmissions and adverse events, creation of a more positive experience for patients, families and healthcare professionals, and minimisation of overall healthcare costs.

Key steps in transitional care following an admission for heart failure were outlined, from discharge planning to early follow up by the patient’s GP, cardiologist and/or heart failure nurse; facilitation of multidisciplinary management programs; long-term collaborative care between the GP, cardiology services and allied health professionals; and ongoing patient education.

Associate Professor Ralph Audehm, one of the guideline authors, said that early review of patients, within two weeks of discharge, following hospitalisation for heart failure was critical.

He recommended that GPs check that patients were taking all of the guideline-directed medical therapy, and, if not, to start the missing medications as soon as possible.

‘This will prevent patients being readmitted to hospital, make them feel better and prevent premature death,’ said Professor Audehm, who is also a GP in Melbourne.

Professor Audehm emphasised the importance of patients having ongoing two- to four-weekly reviews until taking the maximum tolerated guideline-directed heart failure therapy.

‘Patient engagement with medication titration, flexible diuretic therapy and referral to appropriate heart failure rehabilitation programs also improve survival and keep patients out of hospital,’ said Professor Audehm. ‘The [multidisciplinary] team should all be involved in this process – Home Medicines Reviews especially have shown to be of great value in keeping patients out of hospital [and] nurse clinics have also been shown to improve outcomes.’

Heart Lung Circ 2024; https://doi.org/10.1016/j.hlc.2023.11.029.