Barriers of Successful Implementation of Discharge Criteria at a Tertiary Heart Function Clinic: A Retrospective Cohort Analysis

TL;DR

This study finds that many stable heart patients are not discharged from a clinic due to patient and provider barriers, limiting care for new patients.

Contribution

The study identifies specific clinical and provider-related barriers to discharging stable heart patients from a tertiary clinic.

Findings

Only 60.9% of eligible patients were discharged, with atrial fibrillation and low ejection fraction linked to discharge failure.

Provider experience under 10 years and delays in echocardiograms or care coordination were common reasons for not discharging patients.

Post-discharge adverse outcomes were low and mostly unavoidable, suggesting discharge is generally safe.

Abstract

Most heart function clinics cannot absorb their high volume of referrals. The effectiveness of clinic discharge protocols to offload stable patients is understudied. We examined predictors and barriers of implementing discharge criteria at our tertiary heart function clinic.

This is a retrospective analysis of discharge protocol implementation between August 1, 2023 and March 31, 2024. Outcomes were discharge and rates of acute care utilization within 6-months postdischarge.

Of 153 patients reviewed, 92 were suitable for discharge, but only 56 of 92 (60.9%) were discharged. Discharge failure was associated with the following: atrial fibrillation (66.7% not discharged vs 30.4% discharged; P < 0.001); ejection fraction < 50% at the last visit (77.8% not discharged vs 51.8% discharged; P = 0.012); worse kidney function (initial visit creatinine 101.0 vs 86.5 μmol/L for those discharged not discharged, respectively; and at last visit, 106.5 vs 99.0 μmol/L); and provider experience < 10 years (for 36.1% not discharged vs 16.1% discharged; P = 0.028). Reasons cited for discharge failure were that providers were awaiting an extra echocardiogram (48.6%) or coordinating with other cardiac care teams (27.0%). In the 6 months following discharge, 3 patients (5.4%) visited the emergency department for heart failure, 1 patient (1.8%) was hospitalized for heart failure, and 1 patient (1.8%) passed away from cancer. Three of 5 adverse outcomes were judged to be unavoidable even if clinic follow-up had been continued.

Discharge rate from our clinic is suboptimal, which impedes timely care for new referrals. We identified several patient- and provider-specific barriers to discharge. More studies are needed to explore this important area.

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