Chapter 17: Transitions of Care

TRANSITIONS OF CARE AND PATIENT SAFETY IN OB/GYN PATIENTS

In the era of quality-of-care improvement and healthcare reform, transitional care has been the focus of increased scrutiny. There is a large body of evidence suggesting that current medical care is not coordinated with quality problems for patients undergoing transitions across sites of care.¹ For obstetric and gynecologic (OB/GYN) hospitalists’ patients, and medical patients in general, multiple transitions of care occur frequently: by shift within the same level of care, by level of care within the same location, and between locations, including the patient's home. In general, transitions of care are defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.² In other words, it involves the movement of patients between healthcare practitioners, settings, and home as their condition and care needs change. The current fragmentation of care in our healthcare system makes transitions a vulnerable period for patients.^3,4

The OB/GYN hospitalist model is no exception.⁵ Although the hospitalist may help improve the quality and safety of OB/GYN services and reduce the incidence of adverse events, poor coordination of care may lead to delays in diagnosis and treatment, increased length of stay, increased risk of readmission, and increased costs.^2,6 Consequently, a fundamental component of the OB/GYN hospitalist program is the establishment of a well-structured program of transitions of care, with clear communication between OB/GYN hospitalists and primary healthcare providers, effective patient handoffs, regular updates on progress, and detailed follow-up instructions.⁷

The impact of poor coordination across the healthcare continuum has been clearly documented. Multiple deficiencies have been identified in the transition process: barriers in communication, lack of accountability by providers, poor or inexistent medication reconciliation, and incomplete, inaccurate, or delayed information transfer, among others.² In addition to significant patient safety and satisfaction, poor transitions have a significant economic impact on patients, insurers, and taxpayers. For instance, hospital readmissions, which are frequently linked to poor transitions, cost the US healthcare system approximately $15 billion a year.⁸ Further costs occur as a result of unnecessary physician visits; the use of medication for preventable conditions; duplication of laboratory, imaging, or other tests; loss of productivity; and other aspects. The immediate implementation of strategies to improve the transition of care is needed.

A prospective cohort study assessing the safety of transitions found that one in five patients discharged from the hospital experienced adverse effects related to medical care.⁴ In approximately two-thirds of these cases, the adverse events were considered preventable or ...