45
Inpatient and Transitions of Care (see Table 26)
Î The use of performance improvement systems and/or evidence-
based systems of care is recommended in the hospital and early
postdischarge outpatient setting to identify appropriate HF patients
for GDMT, provide clinicians with useful reminders to advance GDMT,
and assess the clinical response. (I-B)
Î Throughout the hospitalization as appropriate, before hospital
discharge, at the first postdischarge visit, and in subsequent follow-up
visits, the following should be addressed (I-B):
a. Initiation of GDMT if not previously established and not contraindicated
b. Precipitant causes of HF, barriers to optimal care transitions, and limitations in
postdischarge support
c. Assessment of volume status and supine/upright hypotension with adjustment
of HF therapy, as appropriate
d. Titration and optimization of chronic oral HF therapy
e. Assessment of renal function and electrolytes, where appropriate
f. Assessment and management of comorbid conditions
g. Reinforcement of HF education, self-care, emergency plans, and need for
adherence
h. Consideration for palliative care or hospice care in selected patients
Î Multidisciplinary HF disease-management programs are
recommended for patients at high risk for hospital readmission,
to facilitate the implementation of GDMT, to address different
barriers to behavioral change, and to reduce the risk of subsequent
rehospitalization for HF. (I-B)
Î Scheduling an early follow-up visit (within 7–14 days) and early
telephone follow-up (within 3 days) of hospital discharge is
reasonable. (IIa-B)
Î Use of clinical risk-prediction tools and/or biomarkers to identify
patients at higher risk for postdischarge clinical events is reasonable.
(IIa-B)
