Evaluation and Management of Patients with Acute Decompensated Heart Failure

Hospital Discharge

Recommendation

12.25

It is recommended that criteria in Table 12.7 be met before a patient with HF is discharged from the hospital. (Strength of Evidence = C)

In patients with advanced HF or recurrent admissions for HF, additional criteria listed in Table 12.7 should be considered. (Strength of Evidence = C)

Background

Criteria for determining the optimal length of stay for individual patients admitted with ADHF remains to be established by rigorous clinical studies. Care must be taken to avoid premature discharge of patients with decompensated HF. The discharge criteria recommended here balance the need for adequate symptom relief and acceptably low readmission rates against the need for economical care.

Timing of discharge is further complicated by the fact that assessment of volume status can be difficult. As a result, patients with persistent volume overload are sometimes released prematurely. Patients who require several days of intravenous medications need a period of observation free of such support before discharge. In most cases, stability for 24 hours after discontinuation of intravenous therapy is sufficient to assess the likelihood that the patient will continue symptomatic improvement on oral medications alone. Meeting all criteria for discharge should be more stringently enforced in patients with advanced HF, especially the elderly, because they are at highest risk for readmission. Observation for a period of 24 hours after discontinuation of vasoactive or inotropic support is ideal, but shorter periods may suffice for patients whose symptoms have significantly improved and who tolerate weaning of intravenous support well.

Recommendation

12.26

Discharge planning is recommended as part of the management of patients with ADHF. Discharge planning should address the following issues:

  • Details regarding medication, dietary sodium restriction, and recommended activity level
  • Follow-up by phone or clinic visit early after discharge to reassess volume status
  • Medication and dietary adherence
  • Alcohol moderation and smoking cessation
  • Monitoring of body weight, electrolytes and renal function
  • Consideration of referral for formal disease management. (Strength of Evidence = C)

Background

The risk of readmission is highest just after hospitalization. Careful monitoring of patients soon after discharge may be useful in limiting the likelihood of readmission. Some patients have a tendency to become rapidly congested following discharge. Follow-up soon after discharge, either by phone or clinic visit, provides the opportunity to rapidly reevaluate the patient's volume status and to modify therapy to maintain control of congestion. It may be difficult to discharge patients on the dose of diuretic they probably need to maintain a euvolemic state after discharge when they have experienced a significant loss of fluid and have been maintained on a low sodium diet while in the hospital.

Table 12.7: Discharge Criteria for Patients With HF

Recommended for all HF patients
  • Exacerbating factors addressed.
  • Near optimal volume status observed.
  • Transition from intravenous to oral diuretic successfully completed.
  • Patient and family education completed, including clear discharge instructions
  • LVEF documented
  • Smoking cessation counseling initiated
  • Near optimal pharmacologic therapy achieved, including ACE inhibitor and beta blocker (for patients with reduced LVEF), or intolerance documented (Sections 7 and 11)
  • Follow-up clinic visit scheduled, usually for 7-10 days
Should be considered for patients with advanced HF or recurrent admissions for HF
  • Oral medication regimen stable for 24 hours
  • No intravenous vasodilator or inotropic agent for 24 hours
  • Ambulation before discharge to assess functional capacity after therapy
  • Plans for postdischarge management (scale present in home, visiting nurse or telephone follow up generally no longer than 3 days after discharge)
  • Referral for disease management, if available