Transitioning the patient with acute coronary syndrome from inpatient to primary care

Abstract

Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of the hospitalist in facilitating the continuity of care and as a key link between the patient and the primary care provider (PCP). Core competencies address key decision points and processes that occur during hospitalization for ACS including the initial evaluation and risk stratification, medication reconciliation, and discharge planning. Discharge is a crucial transition and one where hospitalists can both facilitate the transition to primary care and improve adherence to quality measures established for ACS. Poor communication during discharge reportedly results in postdischarge adverse events, most often related to medications and lack of follow-up related to pending test results. Standards for a safe discharge such as Project RED (Re-Engineered Discharge), initiatives to improve outcomes after discharge like Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), and adaptive tools including the ACS Transitions Tool support timely and accurate communication of complex information between the hospitalist, the PCP, and the patient. While the role of hospitalists is evolving, it is clear that they have a central role in ensuring safe transitions in care for ACS. Journal of Hospital Medicine 2010;5:S8-S14.

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“…46,51 The nurse may also be mindful of wider socioeconomic/psychosocial challenges, including increased risk of depression and imbalance in health care provision or access that may necessitate individualization of the care plan.…”

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“…A hospitalist's responsibility to a patient does not end at patient discharge but, rather, extends until a patient's PCP assumes responsibility for post-hospital care. Every reasonable effort should be made to ensure that patients and their outpatient providers and caregivers receive all the information and tools they need to deliver appropriate care [8].…”

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