Heart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient followup improve patient outcomes and reduce morbidity.
AimTo implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care.
MethodsTo address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called "power plan"), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative.
ResultsOur intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our "power plan" promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management.
ConclusionThe management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.
Esophageal foreign body ingestion is a cause of non-cardiac chest pain and can be associated with significant mortality. Typically, esophageal foreign body ingestion is managed with endoscopic retrieval to prevent complications. The most commonly ingested foreign bodies in adults are food boluses. However, sometimes we see patients after the ingestion of more atypical and dangerous objects. Here, we present a case of a 66-year-old female who presented to the emergency department with chest pain. Quickly after admission to the emergency department, the patient was noted to have an esophageal foreign body on the chest radiograph. The patient was subsequently taken for endoscopic management of the foreign body and intubated for airway protection. With careful manipulation of the mystery object, the foreign body was removed and the patient was able to be discharged safely from the hospital without complications. This case emphasizes the importance of keeping a broad differential for one of the most commonly seen chief complaints in the emergency department to ensure timely triage of patients.
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