(P253) EVALUATION OF TRANSITIONAL CARE PROCESSES FROM CARDIAC SURGERY DISCHARGE TO COMMUNITY

Background: Caring for patients after cardiac surgery has evolved significantly with rising complexity of surgical procedures, increasingly frail patients with multiple comorbidities, and the aim of decreasing days in hospital. Cardiac surgery Nurse Practitioners (NP) at our site provide post-procedure care and management in the cardiac ward setting including the dictation summary and plan of care upon discharge. In recent years, our team noted an increase in phone calls from primary care providers (PCP) with inquiries about various components of follow-up including medical management, potential surgical complications, diagnostic results, and hemodynamic concerns. Our study aimed to evaluate the PCPs self-reported knowledge in providing early post-operative follow-up and explore their perception of gaps in transition of care.

METHODS AND RESULTS: Survey questionnaires were distributed to PCPs in conjunction with the patients’ discharge summary after cardiac surgery. Surveys were distributed retrospectively to PCPs who provided follow-up care to cardiac surgery patients in the 6-months prior to study onset. Questionnaires were completed by 40 participants (General Practitioners 87.5% and 12.5% NPs), 50% female, N=20) with a median practice size of 1206 patients (range 200-3200), 29% (N=11) practice in a rural location, 68% (N=26) urban and 3% (N=1) remote settings. Self-reported competencies were reported highest in assessing fluid status, titrating diuretic therapies, and interpreting diagnostic tests. Participants reported least competence in managing surgical sites and anticoagulation management. Respondents mostly reported that discharge summaries provided information that prepared providers to adequately provide continuity of care. Feedback received in the open-ended questions was mainly positive relating to the detail and timeliness of discharge summaries and access to specialized cardiac surgery knowledge through a rapid access line. Improved standardization of discharge summary and coordination of time-sensitive diagnostics by the discharge team were reported as being areas for improvement.

Conclusion: PCP’s experience of delivering early postoperative care is not well explored, and existing evidence is outdated. Results of our study identified gaps in transition of care for PCPs in various practice settings. Strategies to improve transition from the acute setting to community include implementation of a transitional care program such as discharge clinics and coordination of early diagnostic testing by acute programs on discharge to lessen the burden on primary care providers with limited capacity and access to resources. Improving access to specialized cardiac surgery follow-up could address the limited capacity reported by community providers and improve patient outcomes.