Discharge Planning and Transition of Care in HE

Arun Jesudian, MD: Jim, I want to close by discussing how patients are discharged, which is usually outside your purview. I don’t anticipate you discharge many of these patients, but I want to talk about the admission fully. If a patient who is admitted with HE [hepatic encephalopathy] is nearing discharge, some things that are important to keep in mind are how we can strategize for them to get appropriate, follow-up, treatment, and hopefully not end up back in the emergency department [ED] within a month or so. At my institution [Weill Cornell Medical College], we try and educate the patient about the disease. It’s not necessarily straightforward for them to understand why their brain is affected by cirrhosis and how that has a lot to do with bacteria in their intestines. The medications lactulose and rifaximin help prevent that, but we try to discuss the basics of the pathophysiology of hepatic encephalopathy, how ammonia plays a role in having adequate bowel movements, and how taking this antibiotic can help prevent them from ending up back in the hospital.

We prescribe them the medications they need. Rifaximin often requires prior authorization, so we want to make those prescriptions clear in terms, saying that the indication is overt hepatic encephalopathy and they were hospitalized with it. If they’re intolerant of lactulose or if they failed lactulose, it’s important to include the right ICD-10 [International Classification of Diseases, Tenth Revision] code. We try to start that process early so that they don’t run into a lapse in medications. That brings up a question for you. Do you see patients whose major reason for coming in is that they didn’t have access to medication?

James Williams, DO, MS, FACEP: That’s a challenge for a lot of patients, particularly those living on their own. Perhaps they don’t have a strong support network. Maybe they did have a strong support network, but recurrent HE sometimes exhausts family members and leaves patients on their own. It’s a challenge if they can’t get support, don’t know how to get it, or won’t get it. The No. 1 thing we can do is provide good follow-up for these patients.

I imagine you have a great case manager network at your facility. We have it at our facility too, although I don’t discharge most of these patients. On the backside, when hospitalists discharge them, we have case managers calling these patients to make sure they’re getting their medication and to see how they’re doing. Those 2 open-ended questions—are you getting your medications? How are things going?—are helpful to minimize progression for relapse.

In the emergency department, the most important thing we can do to help with this continuity of understanding of HE and ongoing treatment is to diagnose HE. Rather than admitting the patient with a diagnosis of a generic altered mental status, which doesn’t help much, try to refine it: yes, they did have a GI [gastrointestinal] bleed plus or minus SBP [spontaneous bacterial peritonitis], but also mention hepatic encephalopathy explicitly because that will help them then get the medication as an inpatient but also as an outpatient.

Arun Jesudian, MD: Such important points. I completely agree with the case-management aspect. We can prevent a significant subset of admissions by someone just calling them and picking up on early encephalopathy that can be managed at home. For example, sometimes patients need to take a little extra lactulose. That could avoid an emergency department visit or an admission that can be costly in a number of ways: outcome, days in the hospital, dollars spent. Sometimes they need a sooner follow-up appointment than what’s been scheduled for them. If someone is checking in the first few days and they recognize that, that can potentially be a way of keeping them out of the hospital. Thank you for bringing that up and the importance of attaching that diagnosis to their hospitalization, even though they might have several diagnoses. These patients are medically complex, but in terms of access to medications, having that HE diagnosis—both in the hospitalization and potentially on the prescription—is important.

James Williams, DO, MS, FACEP: We learned this decades ago with congestive heart failure as it proliferated: when we have close follow-up with case management, we can minimize any recurrence of ED visits or hospitalizations and access to medications. That’s key. No. 1 you have to make the diagnosis, and No. 2, you have to take your medication to treat it.

Arun Jesudian, MD: Exactly. If we can do that reliably or achieve that on behalf of our patients, we’ll be taking much better care of them and preventing a lot of admissions, or at least the preventable ones.

James Williams, DO, MS, FACEP: Absolutely.

Arun Jesudian, MD Thank you for this rich and informative discussion. Before we conclude, I’d like to get final thoughts from you. Dr Williams, is there anything you want to add?

James Williams, DO, MS, FACEP: It’s been a pleasure having this conversation with you and our colleagues. Thank you for the opportunity. My final thought is that in the emergency department, when you have complex patients with altered mental status, you have to at least consider hepatic encephalopathy, as not just the sole diagnosis but often a joint diagnosis. You have to treat both aggressively and start early just as you would any other patient in the emergency department. Remember, it’s not a unifying diagnosis of a singular diagnosis of sepsis. We typically have to treat sepsis and HE aggressively. Even if it’s subtle, if it’s not over. With HE, which is easy to diagnose, you want to start treatment early and don’t want to depend on your serum ammonia level. It’s a clinical diagnosis.

Arun Jesudian, MD I like that as a closing thought: don’t depend on your serum ammonia level. Thank you. To our viewing audience, we hope you found this Peer Exchange to be useful and informative. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content in your in-box.

Transcript Edited for Clarity