6/1/18 LEARNING OBJECTIVES PATIENT POPULATION PRESENTATIONS

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1 PREVENTING HOSPITAL READMISSIONS IN CARDIOVASCULAR PATIENTS Christina Cortez Perry, MSN, FNP-C, CCCC Cardiology Coordinator- Corpus Christi Medical Center 1

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3 LEARNING OBJECTIVES Identify the target patient population Identify different types of interventions in the cardiac arena Identify in-hospital pharmacotherapies Identify at-home pharmacotherapies Recognize the importance of pharmacotherapies in preventing hospital readmissions PATIENT POPULATION Leading cause of death 630,000 US deaths every year (1 in 4) Heart disease costs the US $200 billion annually (including health care services, medications, and lost productivity) PRESENTATIONS Arresting or return of spontaneous circulation (ROSC) S-T elevation myocardial infarction (STEMI) Non S-T elevation myocardial infarction (NSTEMI) Atypical presentations Out-patient diagnostic catheterizations 3

4 DON T BE FOOLED Who do you picture in your mind when you think of a cardiac patient? INTERVENTIONS Surgical Coronary artery bypass On-pump Off- pump Open chest Minimally invasive With concomitant valve repair or replacement Endarterectomy Percutaneous coronary intervention (PCI) Angioplasty Stenting Bare-metal Drug-eluting Thrombectomy Rotational atherectomy INTERVENTIONS 4

5 Class I Antiplatelet therapy Aspirin mg daily IN-HOSPITAL PRE-OPERATIVE Discontinue clopidogrel and ticagrelor at least 5 days prior to surgery Discontinue prasugrel at least 7 days prior to surgery Discontinue short-acting IV glycoprotein IIb/ IIIa inhibitors (eptifibatide, tirofiban) at least 2-4 hours prior to surgery Discontinue short-acting IV glycoprotein IIb/ IIIa inhibitors (abciximab) at least 12 hours prior to surgery Statin therapy All patients should receive adequate statin therapy to reduce LDL cholesterol to less than 100 mg/dl and to achieve at least a 30% lowering Class I cont. Beta Blockers IN-HOSPITAL PRE-OPERATIVE Should be administered for at least 24 hours prior to CABG for all patients without contraindications to reduce post-op AF Class III- Harm Discontinuation of statin or other dyslipidemic therapy is not recommended before or after CABG without adverse reactions Postmenopausal hormonal therapy should NOT be administered to women undergoing CABG IN-HOSPITAL POST-OPERATIVE Class I Antiplatelet therapy Aspirin mg daily indefinitely Statin therapy All patients should receive adequate statin therapy to reduce LDL cholesterol to less than 100 mg/dl and to achieve at least a 30% lowering Hormonal manipulation Intravenous insulin should be given to achieve and maintain an early post-operative glucose less than or equal to 180 mg/dl while avoiding hypoglycemia 5

6 Class I cont. Beta Blockers IN-HOSPITAL POST-OPERATIVE Beta Blockers should be reinstituted as soon as possible after CABG to reduce post-op AF ACE Inhibitor/ ARBs ACE inhibitors and ARBs given before CABG should be reinstituted postoperatively once the patient is stable, unless contraindicated ACE inhibitors or ARBs should be initiated postoperatively and continued indefinitely in CABG patients who were not receiving them preoperatively, who are stable, and who have an LVEF less than or equal to 40%, hypertension, diabetes mellitus, or CKD, unless contraindicated IN-HOSPITAL POST-OPERATIVE Class III- Harm Discontinuation of statin or other dyslipidemic therapy is not recommended before or after CABG without adverse reactions Postmenopausal hormonal therapy should NOT be administered to women undergoing CABG AT-HOME Class I Antiplatelet therapy Aspirin mg daily indefinitely Statin therapy All patients should receive adequate statin therapy to reduce LDL cholesterol to less than 100 mg/dl and to achieve at least a 30% lowering of LDL Beta Blockers Beta blockers should be prescribed to all CABG patients with no contraindications at time of discharge 6

7 AT-HOME Class I cont. ACE Inhibitors/ ARBs ACE inhibitors or ARBs should be continued indefinitely in CABG patients who are stable, and who have an LVEF less than or equal to 40%, hypertension, diabetes mellitus, or CKD, unless contraindicated Class III- Harm Discontinuation of statin or other dyslipidemic therapy is not recommended before or after CABG without adverse reactions Postmenopausal hormonal therapy should NOT be administered to women undergoing CABG Class I Oral Antiplatelet therapy PERCUTANEOUS INTERVENTION: IN-HOSPITAL PRE-PROCEDURE Patients already taking daily aspirin therapy should take 81 mg to 325 mg before PCI Patients not on aspirin therapy should be given nonenteric aspirin 325 mg before PCI A loading dose of a P2Y12 receptor inhibitor should be given to patients undergoing PCI with stenting Class II Administration of a high-dose statin is reasonable before PCI to reduce the risk of periprocedural MI PERCUTANEOUS INTERVENTION: IN-HOSPITAL PERI-PROCEDURE Other meds used in-hospital Heparin Bivalirudin IV antiplatelets 7

8 Class I Antiplatelet therapy Aspirin mg should be continued indefinitely PERCUTANEOUS INTERVENTION: IN-HOSPITAL POST-PROCEDURE In patients receiving a stent (BMS or DES) during PCI for ACS, P2Y12 inhibitor therapy should be given for at least 12 months In patients receiving DES for a non-acs indication, clopidogrel 75 mg/d should be given for at least 12 months if patients are not at high risk of bleeding PPIs should be used in patients with a history of prior GI bleeding who require DAPT Statin therapy All patients should receive adequate statin therapy to reduce LDL cholesterol to less than 100 mg/dl and to achieve at least a 30% lowering of LDL PERCUTANEOUS INTERVENTION: IN-HOSPITAL POST-PROCEDURE Class I cont. Blood pressure control with a goal of >140/90mm Hg Diabetes management WHAT DO THEY NEED? Case studies 8

9 WHY DO PATIENTS GET READMITTED? Avoidable vs. unavoidable readmissions Progression in disease process New and separate problem Lack of patient follow-through ED decision making regarding readmission Lack of hand-off to outpatient providers Too-soon discharge Lack of goal discussion MEDICATION ERRORS 20% of patients have a medication related adverse effect- 2/3 of which could have been prevented Sent home without necessary medications Sent home with prescriptions that duplicate ones at home (generic vs. brand) Inadequate monitoring/ teaching about possible side effects WHAT CAN WE DO? Accurate home medication reconciliations at admission Telephone call Home visits Telemonitoring Medication management Patients who received medication management by a pharmacist were less likely to be readmitted or seen in the emergency department within 30 days of discharge 9

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11 THANK YOU. Questions? 11

12 REFERENCES Alper, E., O Malley, T., & Greenwald, J. (2017). Hospital discharge and readmission. In J.A. Melin (Ed.), UpToDate. Retrieved December 15, 2017, from andreadmission?search=hospital+readmission&anchor=h10&language=en- US&source=preview&selectedTitle=1~150#H19 Guidelines and Clinical Documents. ( ). Retrieved December 15, 2017 from 12

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