Discharge & Transitions

Discharge and Transition Guidelines

More than 30% of discharged patients do not understand their discharge instructions on returning home. Careful and well-thought-out transitioning of care from the different settings of the hospitalized patient with ACS is a vital component of optimizing treatment in both inpatient and, eventually, outpatient settings. Although communication during transitions of care is important for all hospitalized patients, it is particularly important for those admitted with ACS. During hospitalization, risk stratification, medications, and interventions initiated in one setting (such as the ED) drive important medical decisions in other areas (such as the CCU). In addition, in many components of ACS care, timing is essential. Without seamless transitions, accurate timing can become problematic and interfere with ACS care being outstanding. All transitional communications should be done in a manner that allows an opportunity for questions and review of the data. Knowledge of a patient’s TIMI score is optimal during all phases of patient care to facilitate treatments and observe for any comorbidities. All stakeholders involved in the treatment of the patient in outpatient or inpatient settings must be included in the transition. Taking into consideration that communication is a competency of hospital medicine; the following team members and areas must have an integral role:

• EMS;
• ED;
• Attending physician/hospitalist;
• Cardiology;
• Invasive cardiologist;
• Key test results
• Patient and/or primary caregiver;
• PCP;
• Nursing.

Hospitalization

• Attending physician/hospitalist;
• Cardiology;
• PCP;
• Patient and/or primary caregiver;
• Cardiac rehab;
• Nutritionist;
• Case management/ social worker;
• Nursing;
• Key test results.

Additional comorbidities may require:

• Nephrology;
• Gastroenterology;
• Intensivist/pulmonologist.
• Thoracic surgery;

Discharge

• Attending physician/hospitalist;
• Cardiology;
• PCP;
• Medication reconciliation;
• Patient and/or primary caregiver;
• Key test results;
• Cardiac rehab;
• Nutritionist;
• Case management/ social worker;
• Nursing;
• Accepting physician if patient
is transitioning toward a SNF/Rehab.

Prehospitalization

Whether or not the patient will require immediate coronary intervention, the following information will be required while transitioning care from the ED and/or outpatient center (please see the attached flow sheet).

• Stat ECG;
• CBC;
• INR;
• Mg;
• CK-MB, troponins;
• Fasting lipid;
• Electrolytes;
• Glucose;
• Stool guiac;
• Old ECG;
• Records;
• Medication reconciliation. Initiation of:
  • Beta-blockers (core measure),
  • Antiplatelets (core measure),
  • Statins,
  • ACE inhibitors when indicated;
• Risk assessment;
• TIMI score;
• Cardiac consult.

Hospitalization

During patients’ hospitalizations and transitions through different levels of care, it is recommended that stakeholders share the following information. Patients and their caregivers must communicate throughout their hospitalization. In addition, a patient’s condition must be communicated with that patient’s primary care physician. Medication reconciliation is also vital to patient safety during the transition of care. Discharge planning should be initiated soon after admission, including identification of the needs or limitations that patients or their families may have at discharge.

• ECG (serial if indicated);
• CBC (if LMWH or UFH is in use for treatment) or PT/PTT (if anticoagulation is required);
• CK-MB, troponins (serial if indicated);
• Renal functions (if contrasted studies performed);
• VTE prophylaxis;
• Old ECG;
• Cardiology consultant;
• Additional consultants;
• Medication reconciliation
  • Beta-blockers (core measure),
  • Antiplatelets (core measure),
  • Statins,
  • ACE inhibitors when indicated;
• Cardiac rehab;
• Echo
  • Type,
  • Result;
• Stress test
  • Type,
  • Result.

Discharge

The optimal time to educate patients and their caregivers about their disease process and treatment is during the discharge process. The date of discharge and necessary ancillary services should be identified to patients and caregivers well in advance of discharge. Detailed instructions in both the discharge summary and patient instructions should be reviewed with and provided to patients. Outpatient follow-up arrangements should be made prior to discharge. Outpatient follow-up appointments with a PCP, if patient does not have one, and subspecialists must be provided. Although verbal communication is the standard of care when transitioning a patient’s care to the outpatient arena, the discharge summary is often the only tool available to communicate the patient’s hospital course and outpatient treatment plan. Go to the Clinical Tools section for an example of a discharge summary template.

Discharge Summary

• Diagnoses (elaborate)
  MI — location, complications (heart failure, arrhythmias, hematomas, and potential EF%)
• Comorbidities — DM, lipids, hypertension, renal disease
• Medications
• Core measures (reason not prescribed)
• ACE/ARB
• ASA
• Beta-blockers
• Statin
• Medication RECONCILIATION
• SL NTG:
• Plavix: how long? (review literature)
• Titration of appropriate medications
• Procedures
• Type of stent (metal versus drug-eluting), location
• Complications (hematoma, transfusion)
• If echo
  • Type
  • EF%
  • copy of his/her ECG
• Follow-up appointment
  • PCP
  • Cardiologist
  • Appropriate other consultants — cardiac rehabilitation
• Follow-up testing
  • ETT
    • Type
    • Time frame
  • Echo — if indicated after NSTEMI and STEMI
  • Pertinent lab work (hemoglobin, INR, LFT if on statin at 4 weeks, creatinine)
• Code status
• Activity
• Diet
• Wound care
  • Groin wound
• Treatment course
  • Include patient’s cognitive level
  • Discharge LDL
  • Discharge creatinine
  • If on coumadin, INR
  • If on statin, LFTs
• [CC to all providers, including home health care]

A detailed explanation of the patient’s clinical course, complications, recommended follow-up care for these complications, and procedures performed should be included in the discharge summary. If coronary intervention was done, listing the location of stent(s) and the type used is also recommended.

All supporting tests and their results should be added. The results of echocardiogram and stress testing performed during the hospitalization should be included.

The patients’ cognitive status should be included.

Medication reconciliation is a major patient safety goal, in addition to a Joint Commission standard. Instructions on titration and duration of these medications should be included in the summary. The following medications should be part of the patient’s regimen and discussed in the discharge summary:

1. Beta-blockers
2. ACE/ARB for blood pressure control and EF% less than 40.
3. ASA between 81 and 162 mg per day.
4. STATIN titration to LDL less than 80.
5. Sublingual NTG.
6. Plavix: 75 mg per day for 1 year on all drug-eluting stents, and a minimum of 1 month, but 1 year is recommended.

It is highly recommended that physician appointments be made for the patient prior to discharge. Follow-up instructions should be provided in detail, including any necessary follow-up studies to be performed in the outpatient setting. Groin or sternum wound care instructions should also be provided. Lifestyle changes should be included in the summary (see ACS Specific Discharge Planning Checklist in the clinical tools section for an example discharge summary template).