From the Guidelines
Hospitalists commonly face diagnostic and treatment challenges, particularly with heart failure, where noncompliance with medical regimen, acute myocardial ischemia, and uncontrolled hypertension are common precipitating factors 1. The most common hospitalist problems with diagnosis and treatment plan include:
- Misdiagnosis or delayed diagnosis of conditions like heart failure, often due to nonspecific presentations or atypical symptoms
- Medication reconciliation errors, particularly with anticoagulants, insulin regimens, and antibiotics
- Treatment plan issues, such as inappropriate antibiotic selection and inadequate venous thromboembolism prophylaxis
- Communication breakdowns between providers during handoffs and insufficient discharge planning Some of the key factors that precipitate hospitalization for heart failure include:
- Noncompliance with medical regimen
- Acute myocardial ischemia
- Uncontrolled hypertension
- Atrial fibrillation and other arrhythmias
- Recent addition of negative inotropic drugs
- Pulmonary embolus
- Nonsteroidal anti-inflammatory drugs
- Excessive alcohol or illicit drug use
- Endocrine abnormalities, such as diabetes mellitus, hyperthyroidism, and hypothyroidism
- Concurrent infections, such as pneumonia and viral illnesses 1. To address these challenges, hospitalists should implement structured handoff protocols, utilize clinical decision support tools, perform thorough medication reconciliation at admission and discharge, engage multidisciplinary teams, and develop standardized protocols for common conditions, as recommended by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Key aspects of care for patients with heart failure include:
- Prompt treatment by expert staff in areas reserved for heart failure patients
- Early access to diagnostic procedures, such as echocardiography and coronary angiography
- A treatment plan that addresses the underlying cause of heart failure and any precipitating factors
- Follow-up care in a heart failure clinic program, when applicable
- Continuing professional education for heart failure staff nurses and cardiology/heart failure/intensive care specialists 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Common Hospitalist Problems with Diagnosis
- Acute heart failure (AHF) and sepsis are common challenges in hospital settings, with sepsis being a notable trigger for AHF decompensation 2
- Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant causes of inpatient morbidity and mortality, and can be challenging to diagnose promptly in intensive care units 3
- Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart, and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina 4
Common Hospitalist Problems with Treatment Plan
- Management of patients with AHF and sepsis is challenging due to potential contraindications between cornerstone interventions for AHF and sepsis 2
- Treatment of HAP and VAP requires prompt diagnosis and management, as well as prevention strategies to reduce the risk of these diseases 3
- Treatment of ACS involves rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes, or fibrinolytic therapy if PCI is not possible 4
- Community-acquired pneumonia (CAP) can lead to cardiovascular complications, including new or worsening heart failure, arrhythmias, myocardial infarctions, and strokes, which can affect treatment plans 5
- Readmissions after pneumonia hospitalization are common, with pneumonia, heart failure/cardiovascular causes, and chronic obstructive pulmonary disease/pulmonary causes being the most common reasons for early readmission 6
Diagnosis and Treatment Plan Considerations
- Electrocardiography should be performed immediately (within 10 minutes of presentation) to distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS) 4
- High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI 4
- Prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death for high-risk patients with NSTE-ACS 4