HF Readmission Risk Flagged by Nurses’ Bedside Lung ScansJuly 25, 2022
Nurses could be quickly trained to use handheld ultrasound to identify whom among patients nearing discharge for acute decompensated heart failure (HF) were at greater risk of poor outcomes, an Australian group reported.
HF nurses at four hospitals were taught how to perform a pre-discharge combined lung and inferior vena cava (IVC) assessment (LUICA) and apply the 10-point cutoff for vertical B-lines that indicate greater lung density, and point to congestion.
Patients they identified as congested had a significant 3.42-fold higher odds of HF readmission or mortality within 90 days (37% vs 14% with lower B-line scores), independent of demographics, HF characteristics, comorbidities, and event risk score, according to Thomas Marwick, MBBS, PhD, MPH, of the Baker Heart and Diabetes Institute in Melbourne, Australia, and colleagues.
The difference between congested and non-congested groups was significant for both readmissions and deaths alone as well. Moreover, non-congested patients spent more days alive out of hospital (85.5 vs 78.3 days, P<0.01), study authors reported in the Aug. 2 issue of the Journal of the American College of Cardiology.
“Noninvasive assessment of congestion is easy to implement and provides a path to guided volume management during the hospital course. Additional value may be obtained by the addition of a nursing LUICA in postdischarge disease management to detect and manage early evidence of congestion,” Marwick’s group suggested.
“Nonetheless, it should be acknowledged that the presence of B-lines in this setting identifies risk of readmission, and does not necessarily indicate congestion. Clinical judgement is always needed before initiating diuresis,” the investigators cautioned.
Marwick and colleagues noted that short-term readmissions for acute decompensated HF remain a major health and socioeconomic problem. Total annual cost of care for HF is forecasted to reach $70 billion by the year 2030, up from $31 billion in 2012, due to the aging population.
Meanwhile, physicians remain in shortage — with estimates of a shortfall of about 40,000 to 122,000 doctors over the next decade. Thus, there is growing interest in the role of allied health professionals stepping in to perform imaging and other duties.
In Marwick and colleagues’ study, nurses with limited or no previous ultrasound scanning experience were trained on a nine-zone LUICA protocol that was done a median 2 days before discharge for each participant. Images were later reviewed by nurses blinded to patient characteristics and outcomes.
The study nurses’ “success with limited training further highlights the universality of LUS [lung ultrasound] as an examination that does not require physician expertise to be effective,” according to an accompanying editorial led by Brandon Wiley, MD, of the Mayo Clinic in Rochester, Minnesota.
“The novel findings … remind us that HHU [handheld ultrasound] should not be confined to the ‘black bag’ of physician experts. The potential of these devices to elevate the physical examination and change the delivery of health care can only be realized by placing them in the hands of a broad array of health care providers,” the editorialists argued.
The present study had 240 patients with acute decompensated HF who were discharged after admission to the ICU or the internal medicine or cardiology wards at four hospitals in Australia. Median age was 77 years, and 56% were men.
Lung scans split patients into groups of those congested (n=115) and not congested (n=125). Congested patients were more likely to have previous cardiac operations, HF duration of more than 6 months, and renal impairment.
Marwick’s team noted that IVC congestion or effusion did not correspond with 90-day readmissions or mortality. However, IVC ultrasounds had been successfully performed in less than half of the cohort.
“Although IVC assessment was not predictive of 90-day outcomes, we continue to advocate predischarge assessment of the IVC using bedside HHU [handheld ultrasound]. We also raise the need for more extensive training in IVC assessment by nurses to provide strong evidence about the combined LUICA,” the authors wrote.
Wiley’s group noted that some HHU devices already offer automatic B-line identification and IVC measurements.
Next-generation devices using artificial intelligence (AI) could make diagnostic efficacy even better, they said. One study had shown that nurses were capable of acquiring diagnostic-quality transthoracic echocardiography images with help from AI software.
The study was supported by grants from Australia’s Medical Research Future Fund and National Health and Medical Research Council Partnership.
Marwick and Wiley had no disclosures.