What is the appropriate review and management of this hospital visit's orders and recommendations?

Review and Management of Hospital Visit Orders and Recommendations

The hospital visit orders and recommendations should include a comprehensive discharge plan with specific attention to medication reconciliation, follow-up appointments within 7-14 days, and clear patient education regarding heart failure management.

Key Elements for Hospital Discharge Planning

Medication Management

• Medications should be reconciled for every patient and adjusted appropriately on admission to and discharge from the hospital 1
• Drugs required in the hospital to control ischemia should be continued after discharge in patients who do not undergo coronary revascularization, patients with unsuccessful revascularization, or patients with recurrent symptoms 1
• For heart failure patients, guideline-directed medical therapy (GDMT) should be continued except in cases of hemodynamic instability or contraindications 1
• Initiation of beta-blocker therapy at a low dose is recommended after optimization of volume status and discontinuation of intravenous agents 1

Follow-up Care Planning

• A follow-up visit within 7 to 14 days and telephone follow-up within 3 days of hospital discharge are strongly recommended for patients with heart failure 1
• Multidisciplinary heart failure disease-management programs are recommended for patients at high risk for hospital readmission 1
• Use of clinical risk-prediction tools and/or biomarkers to identify patients at higher risk for post-discharge clinical events should be implemented 1

Patient Education Requirements

• Before hospital discharge, patients and/or designated caregivers should receive clear instructions regarding medication type, purpose, dose, frequency, and potential side effects 1
• Patients should be informed about symptoms of acute myocardial infarction and instructed on how to seek help if symptoms occur 1
• All patients with cardiac conditions should be given sublingual or spray nitroglycerin with proper instructions for use 1
• Reinforcement of heart failure education, self-care, emergency plans, and the importance of adherence should be provided 1

Assessment Before Discharge

• The following should be addressed before hospital discharge, at the first post-discharge visit, and in subsequent follow-up visits 1:
  • Initiation of GDMT if not previously established and not contraindicated 1
  • Precipitant causes of heart failure, barriers to care, and limitations in post-discharge support 1
  • Assessment of volume status and blood pressure with adjustment of therapy 1
  • Optimization of chronic oral therapy 1
  • Assessment of renal function and electrolytes 1
  • Management of comorbid conditions 1
  • Consideration for palliative or hospice care in selected patients 1

Special Considerations for COVID-19 Patients

• For patients with COVID-19, special discharge protocols should be followed 1:
  • Patient should wear a surgical mask when leaving the operating room and during transport 1
  • Strict disinfection protocols should be followed for rooms and equipment 1
  • Family visits may need to be limited or prohibited depending on facility policies 1

Common Pitfalls to Avoid

• Failure to reconcile medications at discharge, which can lead to medication errors 2
• Inadequate communication about medication changes to patients, which contributes to poor adherence 1
• Insufficient follow-up planning, particularly for high-risk patients 1
• Lack of clear documentation regarding advance directives and goals of care 3
• Failure to provide patients with adequate information about their condition and warning signs that should prompt them to seek medical attention 4

Implementation of Performance Improvement Systems

• The use of performance improvement systems in the hospital and early post-discharge outpatient setting is strongly recommended to identify appropriate heart failure patients for GDMT, provide clinicians with useful reminders, and assess clinical response 1
• These systems should include protocols for medication reconciliation, structured discharge planning, and follow-up care coordination 1

Laboratory Assessment Before Discharge

• Serum electrolytes, urea nitrogen, and creatinine should be measured during titration of heart failure medications, including diuretics 1
• For patients with hyponatremia, appropriate management should be implemented before discharge, which may include water restriction and maximization of GDMT 1

By implementing these recommendations systematically, the quality of care and patient outcomes can be significantly improved while reducing the risk of hospital readmission.