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

Abstract

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. © 2010 Society of Hospital Medicine.

Copyright © 2010 Society of Hospital Medicine

Patients with acute coronary syndrome (ACS) are a challenge for the hospitalist, as they require substantial coordination of care and support during hospitalization and in the transition back into primary care. ACS accounted for 733,000 discharge diagnoses in 2006 (inclusive of unstable angina or acute myocardial infarction [MI]), and the American Heart Association considers this a conservative estimate.1 Readmission of these patients occurs with some frequency and expends healthcare resources. A multiemployer claims database showed a 20% rehospitalization rate for patients with ischemic heart disease within 1 year of discharge after ACS.2

Implementation of evidenced‐based care for patients with ACS and an emphasis on preventive measures for coronary heart disease (CHD) have improved CHD‐related outcomes. A 2007 study revealed that almost one‐half of the 40% decrease in CHD‐related mortality between 1988 and 2000 was directly attributable to therapeutic interventions and prevention and treatment of recognized risk factors for CHD. However, this news was tempered by the effect of 2 risk factors, increased body mass index and diabetes, which accounted for additional CHD‐related deaths in 2000.3

The Society of Hospital Medicine (SHM) has established core competencies for hospitalists who manage patients with ACS, defining the scope of interactions between the hospitalist, patient, and other clinicians such as specialists and primary care providers (PCP).4, 5 Several competencies focus on ACS and transitions in care, requiring the hospitalist to demonstrate the skills and attitudes outlined in Table 1. Of concern is the risk for adverse events associated with medication errors and lack of follow‐up related to diagnostic tests during the postdischarge period, which in turn raises the risk of readmission.6 The hospitalist is in a unique position to have a positive impact on the transition from inpatient to primary care by proactively addressing patient‐specific issues through careful planning and coordination with the patient, the PCP, and other stakeholders. The hospitalist cannot be accountable for all elements of the transition process, but can be proactive, working with hospital leadership and allied health professionals to promote systems that support safe transitions in care.

Core Hospitalist Competencies for ACS Relative to Transitions in Care
  • Related data were reported by the Society of Hospital Medicine.5

  • Abbreviation: ECG, electrocardiogram.

Knowledge Explain goals for hospital discharge, including specific measures of clinical stability for safe care transition
Skills Synthesize patient history and the results of physical examination, ECG, laboratory, and imaging studies, using risk stratification tools to determine therapeutic options, formulate an evidence‐based treatment plan, and determine the level of care required
Assess patients with suspected ACS in a timely manner, identify the level of care required, and manage or co‐manage the patient with the primary requesting service
Attitudes Communicate with patients and their families to explain the history and prognosis of the patient's cardiac disease
Communicate patient risk factors and educate patients in ways to reduce risk
Communicate with patients and their families to explain the goals of the care plan, discharge instructions, and management after hospital discharge; include information about medications, diet, and physical activity
Recognize indications for early specialty consultation, including cardiology and cardiothoracic surgery
Initiate secondary prevention measures prior to discharge including, as appropriate, smoking cessation, dietary modification, and evidencebased medical therapies
Use a multidisciplinary approach in the care of patients with ACS that begins at admission and continues through all care transitions; members of the multidisciplinary team may include nurses, nutritionists, and rehabilitation and social services
Communicate to outpatient providers the notable events of the patient's hospitalization and postdischarge needs, including new therapies, duration of treatment, and outpatient cardiac rehabilitation
Provide and coordinate resources that will help patients make a safe transition from the hospital to arranged follow‐up care and tests

Case Study

Jose is a 66‐year‐old retiree recovering on the medical floor after diagnosis of an ST‐segment elevation myocardial infarction (STEMI) and implantation of a drug‐eluting stent (DES). Jose and his family were poor historians on admission and it is unclear whether his medical and medication history are accurate. Jose is anxious to get out of here and thinks this is no big deal. Upon admission Jose was hypertensive and mildly obese. He denies smoking and exercises once in awhile by working in his yard. His lipid profile on admission indicated elevated low‐density lipoprotein (LDL) and total cholesterol.

You decide to address several issues during Jose's hospital stay. These include contacting Jose's PCP to obtain a complete medical and medication history, and educating Jose about his cardiac disease, his risk of future events, and strategies for risk reduction.

Continuity of Care: Key Information Exchange Between the Hospitalist and the Primary Care Physician

Prehospitalization and Hospitalization

Prehospitalization and hospitalization are critical times for the patient with ACS: decisions not only affect the inpatient course but lay the groundwork for care after discharge. For ACS in particular, early identification and understanding of a patient's risk for further ischemic events is critical to determining the therapeutic course, and evidence shows that timely intervention decreases morbidity and mortality.7, 8 Notably, the evaluation and risk stratification of patients with ACS are hospitalist core competencies (Table 1); the initiation of a beta blocker and antiplatelet therapy are considered by the Center for Medicare and Medicaid Services (CMS) to be core measures by which to measure the quality of hospital care. The hospitalist may provide oversight and assure that care is coordinated and patients are assessed and triaged in a timely manner according to recommended guidelines.

Information‐gathering and evaluation begins in the emergency department (ED)9 (Table 2) and continues after admission9 (Table 3), when the hospitalist may need to seek additional medical and medication history to inform risk assessment. In fact, risk assessment should continue throughout the hospital stay as additional diagnostic information is acquired and consultations are provided. Medication reconciliation started during prehospitalization may be complicated by the lack of a reliable source of medication history and should be reevaluated 24 hours after the patient is admitted. Contact with the PCP is appropriate during the hospital stay, with the hospitalist apprising the PCP of diagnoses, interventions, and major clinical events during hospitalization. The PCP may offer valuable insight about issues related to discharge planning.

Prehospitalization Measures for ACS
  • Related data were reported by the Society of Hospital Medicine Acute Coronary Syndrome Advisory Board.9

  • Abbreviations: ACE, angiotensin‐converting enzyme; ACS, acute coronary syndrome; CBC, complete blood count; CK‐MB, creatinine kinase‐MB; CMP, comprehensive metabolic panel; ECG, electrocardiogram; INR, international normalized ratio; Mg, magnesium; TIMI, thrombolysis in myocardial infarction.

  • Core measure, CMS.

History
Signs and symptoms of current event
When available:
Prior ECGs
Prior related hospitalizations
Relevant labs and diagnostics
Diagnostics, Laboratory
Stat ECG
CBC, CMP, INR, Mg, CK‐MB, troponins
Fasting lipids, stool guaiac
Medication Reconciliation
Start beta blocker*
Start antiplatelet therapy*
Start ACE inhibitor when indicated
Statin
Evaluation
Risk assessment, TIMI score
Request cardiology consult if indicated
Admission and Hospitalization Measures for ACS
  • Related data were reported by Society of Hospital Medicine Acute Coronary Syndrome Advisory Board.9

  • Abbreviations: ACE, angiotensin‐converting enzyme; ACS, acute coronary syndrome; CBC, complete blood count; CK‐MB, creatinine kinase‐MB; ECG, electrocardiogram; ECHO, echocardiogram; LMWH, low molecular weight heparin; PCP, primary care provider; PTT, partial thromboplastin time; UFH, unfractionated heparin; VTE, venous thromboembolism.

  • Core measure, CMS.

History (if incomplete from prehospitalization)
Baseline ECG
Relevant medical history
PCP
Patient, family
Diagnostics, Laboratory
Serial ECG, if indicated
CBC, if LMWH or UFH; or PTT if heparin
CK‐MB, troponins, serial if indicated
VTE prophylaxis
Renal function for contrast studies
Medication Reconciliation
Start beta blocker*
Start antiplatelet therapy*
Start ACE inhibitor when indicated
Statin
Evaluation
Continuing risk assessment
ECHO
Stress test
Outpatient exercise prescription from physical therapist
Cardiology consults
Other consults as needed
Begin Discharge Planning

Discharge planning ideally begins soon after admission in order to adequately address issues which may complicate recovery. Medication reconciliation continues during discharge planning, and CMS core measures still apply relative to the use of beta blockers and antiplatelet therapies. Confirming the accuracy of the patient's medication history during hospitalization is an important step in medication reconciliation to ensure that therapies are appropriate and to avoid discrepancies in discharge medications.

A particular challenge of ACS care is the extensive amount of complex information which must be shared quickly and accurately with all stakeholders. The risk of miscommunication is real, but systems and tools are available to lower this risk. At this juncture, technology‐based resources can be especially useful for obtaining and organizing information. Standardized order entry programs or order sets are a reliable method that clinicians can use to meet quality standards during the patient's hospitalization and are highly recommended for patient safety. The SHM ACS Transitions Workgroup has also developed an adaptable multidisciplinary tracking tool that can be used to monitor a patient with ACS through the anticipated transitions in care. This tool tracks key pieces of clinical information throughout the hospital stay and facilitates communication between clinicians. The tool is detailed to include quality measures such as the CMS core measures and can serve as documentation to measure compliance.10 The tracking tool and examples of order sets for patients with ACS are available from the SHM in the Clinical Tools section of the ACS Quality Improvement (QI) Resource Room available at: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_ACS/ACS_Home.cfm.

Discharge and Postdischarge

Discharge is one of the most crucial transitions in care, with potential impact on patient outcomes postdischarge, including readmission. In the past decade, initiatives to improve the discharge process, particularly discharge summaries,11 have yielded standards and tools to improve the process. Current standards for a safe discharge12, 13 are summarized in Table 4. Generally, standards address the need for delivery of a written discharge summary to the clinician who is assuming care after discharge; educating patients about their diagnosis, hospital course, and future medical needs; medication reconciliation; and, arrangement of postdischarge services such as follow‐up appointments. Additionally, the SHM has developed a discharge checklist14 (Table 5) and a template15 for the discharge summary, each to facilitate communication between stakeholders. The discharge summary is an obvious target for QI, as it is the most common vehicle for sharing patient information with the PCP and other healthcare providers. Essential elements of a discharge summary are content (Is key information captured?); format (Is content clear, concise, and accurate?); and delivery (Does the discharge summary reach the right people in a timely manner?).

Components of a High‐Quality Discharge System
Project RED (Re‐Engineered Discharge)* 2009 National Quality Forum (NQF)
  • Abbreviation: PCP, primary care provider.

  • The Re‐Engineered Discharge Project. Related data were reported by Clancy.12

  • National Quality Forum. Related data were reported by the National Quality Forum.13

Educate the patient about diagnosis during hospitalization Prepare a written discharge plan
Make appointments for clinician follow‐up and postdischarge testing; identify and resolve barriers to follow‐up care Prepare a written discharge summary
Talk to the patient about testing done in the hospital and who will follow up on results Provide a discharge summary to a licensed clinician who will provide care after discharge
Organize postdischarge services; identify and resolve barriers to receiving services Develop an institutional system to confirm receipt of the discharge summary by a licensed clinician
Medication reconciliation: counsel the patient about medications and identify barriers to adherence and compliance
Reconcile the discharge plan with evidence‐based guidelines
Educate the patient on problem‐solving strategies, including contacting the PCP
Expedite transmission of the discharge summary to a licensed clinician and services that will be involved with the patient's care postdischarge
Assess the patient's understanding of the discharge plan; ask patients to explain in their own words; identify and resolve barriers to understanding
Provide the patient with a written summary detailing clinical course, follow‐up, and medication instructions
Telephone the patient 2 to 3 days after discharge to review the plan and address problems
Components of a Discharge Summary, Adapted from the SHM
  • Related data were reported by Halasyamani et al.14

  • Abbreviations: ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker; ECG, electrocardiogram; ECHO, echocardiogram; ETT, exercise tolerance test; INR, international normalized ratio; LDL, low‐density lipoprotein; LFTs, liver function tests; MI, myocardial infarction; NTG, nitroglycerin; SHM, Society of Hospital Medicine.

Diagnoses
Detail location of MI and complications
Comorbidities
Note diabetes, results of lipid panel, hypertension, renal disease
Medications
Medication reconciliation
Note reason if core measure medications are not prescribed (beta blockers, antiplatelet therapies)
ACE/ARB, aspirin, beta‐blockers, statin, sublingual NTG, clopidogrel (include duration of therapy)
Titration of any medications
Procedures
Type, location of stent
Complications
If ECHO, include type, ejection fraction; provide copy of ECG if available
Follow‐up appointment
PCP, cardiologist, others such as cardiac rehab
Follow‐up testing
ETT (type, timeframe); ECHO; required lab work
Code status
Activity
Diet
Wound care (eg, groin)
Treatment course
Cognitive level
Discharge LDL
Discharge creatinine
INR if on warfarin
LFTs if on statin
Copy all providers

Evidence indicates that the danger for patients at discharge is often related to medication reconciliation, adverse drug events (ADEs), and pending test results or testing needed after hospitalization.6 Errors affect a sizable proportion of patients, with 49% of patients in 1 study subject to at least 1 medical error within 2 months of discharge. This error was directly attributed to discontinuity during the transition from hospitalist care to the affiliated PCP practice. Errors were related to discharge medications, test results, or lack of PCP follow‐up on testing recommended by the inpatient provider (a work‐up error). Patients with a work‐up error were 6 times more likely to be rehospitalized in the 3 months following the first outpatient visit.16 Another study found that 41% of discharged patients had inhospital test results return after they were discharged and that PCPs were often unaware of these results. In some of these cases, test results required action, sometimes urgently.17

Most adverse events after discharge appear to be ADEs, with up to two‐thirds identified as preventable or ameliorable.1820 In a general medical population, Forster et al.20 found that ADEs resulted in significant injury in 71% of patients, serious injury in 13%, and life‐threatening injury in 16%. ADEs also resulted in 27% of patients requiring emergency care or readmission. Anticoagulants and cardiovascular medications were ranked high among medications associated with an ADE; failure to monitor medications was the most common cause of a preventable or ameliorable ADE, suggesting that ACS patients may be particularly at risk for an ADE following discharge. Patients had good recall of general drug information provided at discharge; patients who could not recall receiving specific information about ADEs were more likely to have an ADE. This is an area of opportunity for the hospitalist to improve patient safety during the transition to primary care. It is also of special concern for patients with ACS, given the complexity of medication regimens and the potential for serious drug reactions.

The risk of adverse events after discharge is higher in certain populations such as the elderly. Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a QI initiative to improve patient care during discharge.21 BOOST aims to reduce 30‐day readmission rates for general medicine patients (especially older adults), improve patient satisfaction, improve communication between the institution and the PCP, identify high‐risk patients and mitigate risk, and improve patient and family education with a focus on patient‐specific risk factors.

BOOST uses a multidisciplinary 7P Screening tool to identify high‐risk patients, specifically through discharge planning and risk stratification.21 Seven areas are assessed: Problem medications, Punk (depression), Principal diagnosis, Polypharmacy, Poor health literacy, Patient support, and Prior hospitalization. For each, specific interventions are recommended to lower the risk of untoward events. 7P Screening applies to patients with ACS and can be an important step in identifying concerns at discharge, with the goals of promoting recovery and reducing the risk of readmission. The BOOST tool also includes a Universal Patient Discharge List reflective of those proposed by Project RED (Re‐Engineered Discharge) and the SHM. However, BOOST suggests additional steps to enhance communication: multidisciplinary rounds at discharge, direct communication with the PCP before discharge, phone contact with the patient or caregiver within 3 days of discharge, and phone numbers for hospital personnel familiar with the patient if the patient is unable to reach the PCP about an issue before the patient's first scheduled follow‐up visit. These steps recognize the value of direct communication between the hospitalist, the patient, and the PCP.

Overcoming Barriers to Communication Between the Hospitalist and the PCP

A successful transition from the hospital to primary care rests largely on the quality of communication between the hospitalist and the PCP. However, only 56% of PCPs expressed satisfaction with the communication they have with hospitalists22 and direct communication is infrequent.11 The PCPs surveyed desired direct and frequent communication, with three‐quarters preferring to speak with the hospitalist by phone at both the patient's admission and discharge.22

PCPs deemed discharge medications and discussion of the reasoning for medication changes and duration of treatment, diagnoses, physical findings, test results, follow‐up needs and plan details, and pending test results to be the most important shared information,11, 22 but this information is frequently unavailable. Details about pending test results at discharge were missed in 65% of summaries, followed by inhospital test results in 33% to 63%, discharge medications in 2% to 40%, and a description of the follow‐up plan in 2% to 43%. Late discharge summaries, some arriving after the first follow‐up visit, are also a barrier to quality care.11, 22, 23 Structured discharge summaries can yield organized and easily retrievable information, with the structure providing cues to include all necessary details.11 These may be computer‐generated vs. traditional dictated or handwritten summaries.6

Use of standardized instruments such as the SHM transitions tool can also help facilitate communication between providers. This tool provides a detailed checklist of recommended diagnostics and therapeutics for patients with ACS that should be considered when the patient is transferred and during discharge. This type of tool has been shown to enhance communication and alert multidisciplinary providers to address issues prior to discharge. A standardized toolkit consisting of a standard admission form, a facsimile to the PCP at admission, a worksheet to identify barriers at discharge, pharmacistphysician medication reconciliation, and predischarge planning appointments reportedly reduced the number of return visits to the ED within 3 days of discharge in an elderly general medicine population; at 30 days there were fewer ED visits and readmissions.24

It is worth noting that patients and their caregivers also have barriers to communication that hospitalists may be able to help address by discharge. These barriers include poor literacy, poor English proficiency, poor understanding of medical jargon, inadequate time with the clinician for questions and answers, poor cognition, highly complex information, and a diagnosis the patient may consider overwhelming.6 Specifically, patients with ACS demonstrated a poor comprehension of their medication regimen after discharge, manifested as either a delay or not filling of prescriptions, followed by poor adherence to the regimen.25 It is also helpful if financial barriers to medication use, either because of direct cost or restriction in outpatient formularies, are identified prior to discharge. Patients report that a follow‐up call from the clinician after discharge or pharmacist counseling before discharge, and use of a pillbox would remove some barriers to adherence. In teach‐back, patients are asked to repeat instructions in their own words, avoiding yes or no answers, thereby revealing gaps in understanding. This strategy checks patient comprehension and provides an opportunity for dialog if it is apparent that patients do not understand information related to their disease and recovery.

Case Study (cont)

Jose's PCP provided more information about his medical and medication history. His father died of a heart attack at 62 years old. Jose has smoked on and off for several years and has been poorly compliant with measures to reduce his risk for CHD such as diet, exercise, and taking statins. Jose may not comprehend the seriousness of his heart disease and how secondary preventive measures may reduce his risk of further events. His history of poor compliance raises concern that he will not persist with recommended ACS medications or antiplatelet regimens after discharge.

Impact of the Hospitalist on Long‐Term Outcomes

Evidenced‐based guidelines stress the need for aggressive modification of risk factors and treatment with antiplatelet, antihypertensive, and lipid‐lowering agents started during hospitalization and continued long‐term as part of secondary prevention strategies.7, 8 There is a missed opportunity for improving patient outcomes after ACS,26, 27 shown by the underuse of guideline‐recommended therapies (antiplatelet therapies such as clopidogrel and aspirin, beta blockers, angiotensin‐converting enzyme [ACE] inhibitors, and statins).28 More than one‐half of patients stopped evidence‐based medications without input from their providers, partly attributed to patients' perception that medication was not needed.26, 27, 29 In another study, 1 in 6 patients who received a DES delayed filling their antiplatelet prescription following discharge (median, 3 days; range, 1‐23 days). Patients who delayed filling the prescription were at increased risk of death or MI compared with patients who filled the prescription on the day of discharge. These findings underscore the importance of discharge planning and patient counseling to improve adherence to medications given at discharge.30 Through education, the hospitalist can directly influence patient and caregiver understanding of the benefit of ACS medications and their effect on long‐term outcomes.

Educating the patient and family about the nature, prognosis, and treatment of cardiac disease is equally important, and secondary prevention measures should be addressed prior to discharge. Prevention includes urging the patient to make therapeutic lifestyle choices such as smoking cessation (a core measure), maintaining a healthy diet, and regular exercise. Addressing these issues is important for the hospitalist and reinforced by the PCP, because adherence to behavioral changes after ACS has been shown to be poor and to directly impact outcomes. In 1 study, one‐third of smokers continued to smoke after 1 month and about one‐third of patients did not adhere to a recommended diet or exercise regimen. At 6 months, those patients who did quit smoking had a 43% lower risk of MI; compliance with the diet and exercise regimen lowered their risk of MI by 48%. Persistent smoking and nonadherence to diet and exercise resulted in an almost 4‐fold increased risk of MI, stroke, or death vs. never‐smokers who adhered to diet and exercise recommendations.31 This presents a clear opportunity for the hospitalist to intervene and affect change. Assessment of needed secondary prevention measures should occur in preparation for discharge, and an emphasis on patient teaching and communicating the plan to the PCP may overcome patient barriers to adhering to recommended lifestyle changes.

Case Study (cont)

After verbally describing his discharge medications to Jose and his family, and providing written patient materials, you ask Jose to explain why his prescribed dual antiplatelet therapy is important. He states it will help his occasional arthritis, because aspirin is one of the drugs, revealing that Jose lacks understanding of why he is taking the antiplatelet therapies or why they are important. A consult is requested from pharmacy for additional counseling. Because you have been in direct contact with the PCP, you call now to express your concerns, in addition to noting Jose's poor comprehension in the discharge summary.

Conclusion

Timely and accurate communication between the hospitalist and the PCP is a vital component of a safe transition from inpatient to primary care. This communication directly impacts the continuity of care, patient outcomes, patient and caregiver satisfaction, and use of healthcare resources. The role of the hospitalist is still evolving. Hospitalists will continue to have a pivotal role in transitions of care, and have a direct impact on the quality of the transition at discharge and patient outcomes after ACS. Hospitalists should be cognizant of gaps in care related to how information is generated, recorded, and shared between the inpatient setting and primary care, and should be proactive in identifying barriers and facilitating solutions. The hospitalist's responsibility for the patient does not end at the time of discharge but extends until the PCP assumes responsibility for patient care following hospitalization. We must make every reasonable effort to assure that our patients and their outpatient providers and caregivers are given all the tools necessary to complete and maintain the patient's therapy.

Acknowledgements

The author thanks Denise Erkkila, RPh for her editorial assistance in preparation of this manuscript.

References

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