You’d be mad at having to return your car to the mechanic within a month, yet rehospitalization after people get their hearts repaired too often is treated as business as usual, laments Dr. Ricardo Bello, a cardiac surgeon at New York’s Montefiore Medical Center.
Heart surgeons try to prevent that by re-examining patients two to three weeks after they go home. But Montefiore patients tend to be readmitted sooner than that.
So last fall, Bello’s team began a special clinic where nurses check heart surgery patients about a week after they go home, at no extra charge — and have a chance to re-teach those discharge instructions when people are more ready to listen.
Plus, for that first month at home, patients are supposed to wear a bracelet with a phone number to reach Montefiore’s cardiac unit 24 hours a day with any worries.
“It changed my conception of dealing with a doctor,” said Michael Lee, 60.
Montefiore surgeons repaired a life-threatening crack in Lee’s aorta, the body’s main blood vessel, but his recovery derailed days after getting home. He quit some medications. He was scared to wash the wound that ran from chest to navel, an infection risk. He developed a scary cough and called that special clinic in a panic.
It turned out the cough was a temporary nuisance — but nurses discovered a real threat: Lee’s blood pressure was creeping up, a risk to his healing aorta. Those pills Lee quit were supposed to keep it extra low, a message he’d missed. And some hands-on instruction reassured Lee that he could handle his wound without tearing it.
Without the clinic, “he’s definitely somebody we would have been called to see in the emergency room,” said physician assistant Jason Lightbody.
In heart failure, a weakly pumping heart allows fluid to build up until patients gasp for breath. Spotting subtle early signs like swelling ankles or creeping weight gain is crucial. But at the Oregon Health & Science University, nurse practitioner Jayne Mitchell spied as patients were told what to watch for as they were discharged — and they barely paid attention.
The new plan: Learn by doing.
Every morning, hospitalized patients weigh themselves in front of a nurse, record the result and get quizzed on what they’d do at home. Gained 2 pounds or more? Call the doctor for fast help. Lots of day-to-day fluctuation? A weekly log can help a doctor tell if a patient is getting worse or skipping medication or having trouble avoiding water-retaining salty food.
Step 2: These patients need a check-up a week after they go home. The hospital makes the appointment with a primary care doctor before they’re discharged, to ensure they can get one.
And for some high-risk patients who live too far away to easily track, Mitchell is pilot-testing whether a high-tech option helps them stick with care instructions.
During that first vulnerable month at home, those patients record their morning weight, blood pressure and heart rate on a monitor called the Health Buddy. It automatically sends the information back to Mitchell’s team at OHSU and also will flash instructions to the patient if it detects certain risks.
In Sun River, Ore., Richard W. Pasmore’s phone rang one morning. Nurses three hours away in Portland saw that his weigh-in was high and adjusted his medications over the phone.
The 67-year-old Pasmore thinks it prevented a return to the hospital: “It kept them totally abreast of everything that was happening with me.” And by the end of the month, he says he’d gotten in the habit of his morning heart failure checks.