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Transitions of Care-A Hot topic and need for uniform guidelines
Hello All,
Your thoughts on the need for Guidelines for Transitions of Care from the LTC setting to home, hospital, etc. Did not know that a new Transitions of Care Guideline was just published by the AMDA. Jim Lett was the lead physician on the guideline. one of the big issues has to do with medication reconciliation, especially such drugs as the low molecular weight agents. On the other hand, some drugs tend to be left off the Hospital Discharge form due to oversight or just the fact that they were not continued during the hospitalization, examples-cholinesterace inhibitors. Can you think of others?
Your comments!
Dr. Cefalu
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Posted by Charles A. Cefa... on June 9, 2010 at 6:06 pm
To Ed Davidson PHarm D, MPH
HI Ed, I apologize for not responding quicker. Yes, we need safeguards on both ends of the spectrum (receiving and discharging). There is also a real educational/communication gap when patients go to to the hospital and are not continued on drugs that the Hospitalist feels is not a priority such as the acetyl cholinesterace inhibitors and thus the reason sometimes they come back with worsening cognitive decline. Thank you for your comments,
the best,
Charles
Posted by Charles A. Cefa... on June 9, 2010 at 6:06 pm
To Kevin O'Neill MD, FACP, CMD
HI Kevin,
Yes, that is very unfortunate that that happened to a family member like your mother. Very scary. Not an uncommon occurence for patients being discharged form the Hospital. Needless to say, the more reason for a universal protocol for Transitions of Care and Discharge Planning.
Thank you for your comment. the best,
Charles
Posted by Anonymous on May 3, 2010 at 9:05 pm
Hi Charles:
My mother has been on Coumadin for atrial fib, She underwent ORIF for a left hip fracture and subsequenlty was sent to a rehab hospital. Her Coumadin was held due to slight prolongation of her INR, and no one thought to mention it on discharge nor was it noted on her discharge medication sheet. She was in an assisted living community for a few days when I got a call from my sister, "Didn't you say that Mom needs to be on Coumadin...Well she isn't getting it." I am sure if we experienced this oversight, it is not an uncommon occurrence.
Kevin O'Neil, MD, FACP, CMD
Posted by Anonymous on January 13, 2010 at 4:01 pm
Dr. Cefalu,
Couldn't agree more. Other examples I have seen in post-acute rehab settings include: incorrect opiod dosage coversions, duplicate drugs in the same therapeutic class (due to formulary change during hospitalization), antiipsychotics prescribed for delirium in the hospital not reconciled, and therefore continued long term in the nursing facility. Antiplatelet agents (for stroke/MI prevention) are also often discontinued during hospitalization, especially if surgery is performed, due to risk of bleeding, and not reinstated post-discharge. We need better commuication on the sending and receiving sides, on this issue.
Ed Davidson, PharmD, MPH
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