by Carolyn Thomas ♥ @HeartSisters
After I was discharged from the Coronary Care Unit following my heart attack, I felt overwhelmed because, other than some reading material about heart-healthy eating and wound control, I was pretty well booted out the door with virtually no follow-up care plan once I got home.
So when my friend Viv’s daughter Kate phoned me a few days later (Kate happens to be a cardiac nurse), I had an endless list of panicky questions for her about my surprisingly distressing ongoing chest pains along with dozens of other issues. I was convinced that another heart attack was imminent – an extremely terrifying prospect for a freshly diagnosed heart patient. She was able to answer my questions (“Sounds like what we call post-stent stretching pain – very common!”) and reassured me that I just might live through another day.
Canadian researchers in Ottawa have developed a simple tool for hospital staff to predict the probability that patients like me, discharged directly from hospital back to the community, will be readmitted – or die – within 30 days.
The study, published in the Canadian Medical Association Journal, could help identify patients who may benefit from closer monitoring and care so that serious health problems can be prevented.
The tool was developed by a group of Canadian researchers led by Dr. Carl van Walraven of the Ottawa Hospital Research Institute, the University of Ottawa and the Institute for Clinical Evaluative Sciences.
The group examined detailed medical records from 4,812 people discharged from 11 Ontario hospitals, and found that four factors could predict the risk of re-admission or even death. They called the tool LACE to coincide with the factors, which are:
- Length of stay in hospital
- Acuity of the admission (whether or not it was through the emergency department)
- Comorbidity of the patient (a score based on what chronic diseases the patient has)
- Emergency room utilization (number of visits in the previous six months)
For example, let’s say you are a person with multiple chronic disease diagnoses like diabetes, heart disease and severe asthma. One night, you’re brought into your local hospital’s Emergency Department by ambulance with unusual chest pressure and extreme weakness – your third ambulance ride to Emergency in as many months. You undergo a number of tests this time, but are discharged within a day or two.
Each of these four LACE factors is assigned a number of points based on its value. When these points are added together, they form your total LACE score.With a possible LACE score of 19 points (the highest), medical staff now know that you have a 44% chance of re-admission to hospital or death.
Researchers found that people with a score of zero had only a 2% risk of re-admission or death.
The researchers obtained similar results when testing the LACE tool using records from 1 million Ontario hospital patients discharged between 2004 and 2008, as Dr. van Walraven explained:
“Our hospitals provide exceptional care, but many patients still face serious health challenges in the weeks following a hospital discharge. This research is an important step towards identifying those who are most at risk, so that we can address their health problems earlier and prevent serious complications.”
This study is part of a larger program that is using Ontario health records to find novel ways to improve health.
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NOTE FROM CAROLYN: I wrote more about hospital stays and discharge planning in my book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University, 2017). You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon. If you order it directly from Johns Hopkins University Press, you can use their code HTWN to save 20% off the list price.
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Q: Have you ever left the hospital without a discharge plan?
Heart Sisters 
After a STEMI heart attack, 4 days, I was discharged…I was only given a follow up appointment a few days later and a number to call if I had a problem. I had been put on 5 new meds at max doses including coumadin. I encountered many issues from the meds – not the heart attack – including asthma, fluid on the lungs, diarrhea, extreme muscle pain and an INR of 8! (acceptable range for those taking coumadin: 2.0 to 3.0). Once I was taken off some of the drugs or the doses adjusted, I finally got better!
There was no plan of care but my GP straightened it all out because the cardiac docs are so hard to get ahold of….
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Thank goodness for competent GPs, Chris! I often think of my family doc as the quarterback keeping all the complicated plays in order.
I also think of what a shock our poor bodies go through after a heart attack. Not only have we survived this traumatic event, but now our bodies have to adjust to this whole new world as a patient, not to mention adjusting emotionally and psychologically! (overnight! – there’s no gradual adaptation period to monitor which if any of the new meds might be having a distressing effect on us). It must have been a huge relief to finally get your meds adjusted appropriately…
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Carolyn, Sandy and Stephen, what Hospital were you discharged from? It is important to find out if it was in proximity of the study that was carried out and in what year (date) that happened. Thank you for the additional info.
Best regards and hope you are all doing well now.
Anna
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Both Stephen and I were discharged from hospitals far away from Ottawa.
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Yes, I too was surprised at how quickly I was discharged from the hospital with very little information and absolutely no follow up.
You would think that making a 30 minute DVD would not be that difficult, nor would a once a week telephone call. The LACE criteria don’t seem to take into account any psychological factors — yet the presence of a major depression after a heart attack is a major risk factor for dying within the year.
I think once again the cardiology profession is focusing on physical rather than emotional, psychological, or spiritual elements.
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I agree, Steve. Neither do the LACE criteria factor in one’s home situation at all: are you living on your own? do you have family and friends close by to help you during the early weeks post-discharge? what kind of social supports do you have? what about work or financial pressures?
But at least the four LACE factors are steps in the right direction.
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The emotional and psychological issues have been big for me. I don’t feel that I’m depressed, but I am definitely sad. I guess knowing that my heart now has been damaged is the major reason why I feel this way.
Sometimes I wonder if the doctors see so many heart attacks that they just don’t think about what it really does to us. I am in Cardiac Rehab and that has helped with getting my strength back, but they are not addressing the emotional part we go through at all.
Perhaps they think we should seek help on our own. I see my cardiologist this week and I am going to ask him why this is overlooked.
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Very interesting. I guess if they would have used the “LACE” with me they would have known they would be seeing me again in two weeks after being discharged with a heart attack. I will say that my doctor wanted me to stay a few days longer but I was feeling good and wanted to get home to my children. Maybe next time it would be best for “me” to listen to the doctor.
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Was it in Canada? There are a couple of studies published in medical journals that suggest that the LACE index is not reliable. For example, in May 2012 Age and Ageing published and article by P. Cotter at al. showing that in a study in the UK done in an elderly population, the results were 57% good predictor (c statistic of 0.57), namely 43% of the time wrong (with a specificity of 0.47, namely 47% only)! Also there are other studies that show most of these predictors are very very poor and by the way, a c statistic in the 0.5 range is no better than a flip of a coin, in terms of probability and accuracy. In Medscape Multispecialty of October 18, 2011, James Brice discusses this in his article called “Tools to predict Hospital Readmissions perform poorly”.
There are other fallacies with the LACE predictor that I am aware of, but first, let me ask you, are you under, at or above the middle-age range? That being said it is negligent care to send patients home without follow-up plans and without ensuring that they are being looked after while they still need it.
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Thanks Anna. I’m aware of the U.K. study, which pointed out (accurately) that the LACE tool research was limited to patients without cognitive impairment and excluded nursing home residents. I’ve added an UPDATE with this study’s findings on the accuracy of using LACE in patients age 85 and older. You are absolutely correct: it IS negligent to discharge patients (of any age) with no follow up discharge plans – yet sadly, it remains a pervasive practice. This report from The Center For Advancing Health suggests that as many as 91% of patients with chronic illness continue to be sent home negligently like this.
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