Transition to Nowhere
For a man with hypertension, prostate cancer, and chronic kidney disease hospitalized with acute kidney injury, discharge planning created numerous challenges. The inpatient team wanted a 1-week follow up, but the patient was new to this health system and had not yet seen a primary care provider. With the next available appointment in 6 weeks, the patient was instructed to call the urgent care clinic (which offered only same-day appointments) 1 week later. However, he never made it to the clinic and presented to the emergency department 2 weeks later with poorly controlled hypertension. In the accompanying commentary, Timothy W. Farrell, MD, of the University of Utah, discusses barriers to effective care transitions and outlines strategies to enhance care coordination for patients after hospital discharge.
Transition to NowhereCommentary by Timothy W. Farrell, MD
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital with anuric acute kidney injury in the setting of angiotensin receptor blocker overdose. The patient initially required intensive care unit admission for urgent hemodialysis before having a return of renal function to his previous baseline. Discharge planning efforts created a series of challenges.
The patient was new to this health system (having recently moved to the area), had no primary care provider established yet, and needed close follow-up care. The inpatient team desired a 1-week follow-up appointment to check renal function, potentially re-start medications held during hospitalization because of the renal failure, and ensure entry into the primary and specialty care systems. The next available primary care appointment was in 6 weeks, and the urgent care clinic only offered same-day appointments, leaving no way to schedule a visit there prior to discharge. The patient was instructed to call the urgent care clinic in 1 week for a same-day appointment. However, he never made it to the clinic. Nearly 2 weeks later, he presented to the emergency department with poorly controlled hypertension. Once his renal function was assessed and found to be back to baseline, his previously held antihypertensives were re-started, and he was sent home once again with the original primary care appointment now only a few weeks away.