Background
Cognitive impairment is common in older patients with heart failure (HF), leading to higher 30-day readmission rates than those without cognitive impairment.
Objectives
The aim of this study was to determine whether increased readmissions in older adults with cognitive impairment are related to HF severity and whether readmissions can be modified by caregiver inclusion in nursing discharge education.
Methods
This study used prospective quality improvement program of cognitive testing and inclusion of caregivers in discharge education with chart review. Two hundred thirty-two patients older than 70 years admitted with HF were screened for cognitive impairment using the Mini-Cog; if score was less than 4, nurses were asked to include caregivers in education on 2 cardiovascular units with an enhanced discharge program. Individuals with ventricular assist device, transplant, or hospice were excluded. Measurements include Mini-Cog score, 30-day readmissions, readmission risk score, ejection fraction, brain natriuretic peptide, and medical comorbidities.
Results
Readmission Risk Scores for HF did not correlate with Mini-Cog scores, but admission brain natriuretic peptide levels were less abnormal in those with better Mini-Cog scores. Only for patients with cognitive impairment, involving caregivers in discharge teaching given by registered and advanced practice nurses was associated with decreased 30-day readmissions from 35% to 16% (P = .01). Readmission rates without/with cognitive impairment were 14.1% and 23.8%, respectively (P = .09). Abnormal Mini-Cog screen was associated with a significantly increased risk of 30-day readmission (odds ratio, 2.23; 95% confidence interval, 1.06–4.68; P = .03), whereas nurse documentation of education with family was associated with a significantly decreased risk of 30-day readmission (odds ratio, 0.46; 95% confidence interval, 0.24–0.90; P = .02).
Conclusions
Involving caregivers in discharge education significantly reduced 30-day readmission rates for patients with HF and cognitive impairment. The Readmission Risk Score was similar between patients older than 70 years with and without cognitive impairment. We have hypothesis-generating evidence that identification of cognitive impairment and targeted caregiver engagement by nurses may be critical in the reduction of readmission rates for older patients with HF.
The deep space's coldness (∼4 K) provides a ubiquitous and inexhaustible thermodynamic resource to suppress the cooling energy consumption. However, it is nontrivial to achieve subambient radiative cooling during daytime under strong direct sunlight, which requires rational and delicate photonic design for simultaneous high solar reflectivity (>94%) and thermal emissivity. A great challenge arises when trying to meet such strict photonic microstructure requirements while maintaining manufacturing scalability. Herein, we demonstrate a rapid, low-cost, template-free roll-to-roll method to fabricate spike microstructured photonic nanocomposite coatings with Al 2 O 3 and TiO 2 nanoparticles embedded that possess 96.0% of solar reflectivity and 97.0% of thermal emissivity. When facing direct sunlight in the spring of Chicago (average 699 W/m 2 solar intensity), the coatings show a radiative cooling power of 39.1 W/m 2 . Combined with the coatings' superhydrophobic and contamination resistance merits, the potential 14.4% cooling energy-saving capability is numerically demonstrated across the United States.
Background: Hospitalized heart failure remains a major driver of cost, healthcare utilization, and morbidity. Diagnosis-related groups (DRGs) have commonly been used to estimate hospitalized heart failure incidence. Furthermore, payors use DRGs as the basis for novel reimbursement models, such as the Bundled Payments for Care Improvement (BPCI). However, DRGs group payments, not diagnoses, and thus are inherently limited as a tool for ascertainment of incidence. Therefore, relying upon DRG data alone could lead to significant underestimates of the burden of hospitalized heart failure. Objective: To prospectively compare the incidence of hospitalized heart failure as detected by DRG data to expert chart review of algorithmically detected cases. Methods: Hospitalized heart failure cases were detected using a sensitive enterprise data warehouse query, which identified patients based on clinical and diagnosis-related parameters, including BNP level and administration of intravenous diuretics. The EDW query was run daily; expert clinicians verified hospitalized heart failure based on comprehensive chart review. During the same study period, the number of patients coding into heart failure DRGs (291, 292, or 293) was compiled. Results: During the study period of 207 days, a total of 6915 charts were screened (33.4 charts per day). A total of 1010 patients were identified by chart review as having heart failure requiring active management. During the study period, only 334 patients (33%) received a heart failure DRG, while the remainder received 1 of 146 other DRGs. Of the patients not coding into a heart failure DRG, 362 received another cardiac DRG, of which 256 were procedural DRGs. Pulmonary DRGs accounted for 86/1010 cases (8.5%), while renal DRGs accounted for a further 70/1010 cases (6.9%). Conclusions: Hospitalized heart failure is a common clinical syndrome, but relying solely on DRG data leads to large underestimates of disease burden. Conversely, because of clinical co-morbidities and the intricacies of the DRG grouping algorithm, clinically apparent heart failure can code into an astonishing number and variety of DRGs. A more comprehensive estimate of hospitalized heart failure incidence has broad process of care, workflow, and public health implications.
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