Reducing Readmission After CHF Hospitalization
To reduce readmission after CHF hospitalization, continue and optimize guideline-directed medical therapy (GDMT) during hospitalization, achieve complete decongestion before discharge, provide comprehensive discharge planning with clear transitional care instructions, and schedule early follow-up within 7 days of discharge. 1
Critical In-Hospital Interventions
Optimize GDMT During Hospitalization
Continue all existing GDMT medications (ACE inhibitors/ARBs/ARNi, beta-blockers, and mineralocorticoid receptor antagonists) throughout hospitalization unless truly contraindicated. 1 Discontinuing beta-blockers during hospitalization increases mortality risk, and withdrawal of ACE inhibitors/ARBs increases both post-discharge mortality and readmission rates. 1
Do not routinely discontinue GDMT for mild renal function decline or asymptomatic blood pressure reduction. 1 These are common pitfalls—small to moderate worsening of renal function (up to 20% decrease in eGFR) is not associated with acute kidney injury, and medications like spironolactone and beta-blockers may actually be protective. 1
Initiate new GDMT during hospitalization once clinical stability is achieved after effective diuresis. 1 The disease trajectory for HFrEF patients is markedly improved when GDMT is initiated or increased toward target doses during hospitalization. 1
If GDMT must be discontinued, reinitiate it as soon as possible before discharge. 1 Do not assume GDMT will be optimized after discharge—registry data shows 42% of patients receive no GDMT within 30 days post-hospitalization. 1
Achieve Complete Decongestion
Treat patients with significant fluid overload promptly with intravenous loop diuretics and titrate therapy until clinical evidence of congestion resolves. 1 Patients with residual congestion at discharge face higher risk for rehospitalization and death. 1
Include a discharge diuretic plan with clear instructions for adjustment based on weight and volume status. 1 This should specify target weight ranges and when to increase or decrease diuretic doses.
When diuresis is inadequate, intensify the regimen using either higher doses of intravenous loop diuretics or addition of a second diuretic. 1
Discharge Planning Requirements
Provide Comprehensive Transitional Care Instructions
Before discharge, provide patient-centered discharge instructions that clearly outline: 1
- Plans for addressing precipitating causes of worsening HF identified during hospitalization 1
- Specific diuretic adjustment instructions based on daily weights and volume status 1
- Coordination of safety laboratory checks (electrolytes, renal function) after GDMT initiation or intensification 1
- Detailed medication reconciliation with plans for resuming held medications, initiating new medications, and titrating GDMT to target doses 1
- Activity level, dietary sodium restrictions, and what to do if symptoms worsen 1
The 2009 ACC/AHA guidelines emphasize that failure of patients to understand compliance instructions is often a cause of HF exacerbation leading to readmission. 1 Education must address causes of HF, prognosis, therapy, dietary restrictions, importance of compliance, and signs of recurrent HF. 1
Schedule Early Follow-Up
Schedule follow-up within 7 days of hospital discharge to optimize care and reduce rehospitalization. 1 Early follow-up is reasonable based on guideline recommendations and is supported by research showing patients are at highest risk for decompensation in the days and weeks post-discharge. 1
- Studies demonstrate that early follow-up within 2 weeks reduces 30-day readmission rates by approximately 50% (from 28% to 14%). 2
- Early follow-up improves long-term prognosis and reduces HF readmissions even when medication adjustments are not made, suggesting benefit comes from early identification and modification of patient factors. 3
Post-Discharge Systems of Care
Refer to Multidisciplinary HF Disease Management Programs
For high-risk patients, particularly those with recurrent hospitalizations for HFrEF, refer to multidisciplinary HF disease management programs. 1 These programs reduce risk of hospitalization through case management or multidisciplinary approaches. 1
- Effective programs include cardiologists, primary care clinicians, HF nurses, pharmacists, dieticians, social workers, and community health workers. 1
- Components should include education, self-management, medication optimization, device management, weight monitoring, exercise and dietary advice, and facilitated access to care during decompensation episodes. 1
- Outpatient HF clinics with acute post-discharge visits, multiple medication adjustments, and ongoing telephonic follow-up can reduce 30-day readmissions by 69% and inpatient mortality from 11.6% to 1.2%. 4
Address High-Risk Characteristics
Identify and address factors associated with poor post-discharge outcomes: 1
- Comorbid conditions (renal dysfunction, pulmonary disease, diabetes, mental health, substance use disorders) 1
- Psychosocial limitations (impaired health literacy, cognitive impairment, inadequate social support) 1
- Medication noncompliance, which is independently associated with hospital readmission 5
Common Pitfalls to Avoid
Do not discharge patients before optimal volume status is achieved. Large registries show many patients are discharged with residual congestion or without life-saving therapies like ACE inhibitors/ARBs and beta-blockers. 1
Do not assume GDMT will be optimized after discharge. Most patients with HFrEF have no changes made to GDMT over 12 months despite being discharged on suboptimal doses. 1
Do not discontinue GDMT for mild blood pressure drops or small renal function changes. These medications should be continued unless true contraindications exist (advanced AV block without pacemaker, cardiogenic shock, angioedema). 1
Do not delay diagnostic testing or fail to control blood pressure/ventricular rate in atrial fibrillation before discharge. These oversights contribute to high readmission rates. 1