Health care professionals in Canadian emergency departments are treating an increasing number of frail, elderly patients. A significant number of these patients will have heart failure, and these patients are at risk for readmission to hospital. As return hospital visits are associated with increased morbidity and health care costs, it is important to help reduce readmissions. Optimizing self-care tools has been shown to reduce readmissions for patients with heart failure, but it is still unclear if these tools can be used for the frail elderly.
We have proposed a prospective randomized single centre pilot study to help reduce 90 day readmissions to hospital for frail elderly patients with heart failure. Patients who are over the age of 70 with a frailty index score ≥ 3/18 presenting with symptoms of heart failure will be included. Patients with active delirium, severe dementia, or who are being discharged to rehabilitation centres will be excluded. Patients randomized to the intervention group will receive a telephone call approximately 5 days post-discharge. A heart failure nurse will administer the heart failure self care questionnaire. If any deficiencies in the patient’s ability to recognize or treat symptoms of worsening heart failure are identified, the nurse will provide structured responses. The nurse will also confirm any upcoming appointments. Finally, patients will be referred to a geriatrics clinic for frailty assessment. Targeted interventions regarding nutrition, physical activity and caregiver support will be provided. Patients in the control group will be contacted 5 days after discharge to confirm outpatient follow-up, but otherwise will have the care as prescribed by their treating physician at discharge from hospital.
The primary clinical outcome of interest will be readmission to hospital for any diagnosis after 90 days from hospital discharge. Secondary outcomes will include improvement in quality of life scores, frailty index, and readmissions in 1 year. In addition, we will collect the number of patients that are screened, eligible, enrolled, and complete follow-up. Data will be gathered on any issues that hinder enrollment or the completion to follow-up.
Approximately 41% of elderly patients who were discharged from our ER with acute decompensated heart failure returned with dyspnea within 30 days and 11% presented more than three times in a year. By reducing readmissions, we will be able to free valuable resources in both the ED and the wards. In addition, we expect that patients should report improvement in quality of life scores, report improved symptom control, experience fewer medication side effects, and feel more capable to manage their symptoms from home.