Abstract NS21: Identification of Opportunities to Improve Stroke Patients Transitions of Care Among a Subset of Hospitals in the Michigan Coverdell Stroke Registry
Background: Stroke patients are at high risk for complications and hospital readmissions, ranging from 6.5% to 24.3% 30 days post-discharge. Evidence-based interventions for prevention of stroke readmissions are not clearly defined and surveillance data for transitions of care (TOC) are lacking. The Michigan Coverdell Stroke Registry is conducting surveillance to understand the current processes in order to assist hospitals to develop, implement and evaluate strategies to improve stroke TOC.
Methods: Data were collected from 395 cases from three hospitals from October 2013 to March 2014. Stroke nurses at each hospital collected data on selected transition of care elements via a combination of follow-up phone calls and chart review at different time intervals within 30 days of hospital discharge. Patients who died in-hospital or were discharged to a skilled nursing facility were excluded.
Results: Of the 395 cases, 357 (90.3%) of patients had a recorded history of high blood pressure.
A total of 19.0% (N=68) were not monitoring BP at home, 45.1% (N=161) were, and 35.9% (N=68) had an unknown monitoring status.
Among patients living at the time of follow up, 61.8% (N=240) were recorded as taking a medication post discharge. Only about half of patients who were taking medications responded as having understood how to take them, why they were taking them, and what to do when they ran out. Of note, a large proportion of the data was missing for each of those questions (44.6%, 45.8%, and 45.4% respectively).
A total of 149 patients were referred for follow-up at the time of the post-discharge call.
Conclusions/Discussion: TOC surveillance is a key component in the development and implementations of strategies to strengthen and evaluate the effectiveness of stroke care including: secondary adherence to prevention measures, patient/caregiver understanding of patient education, and hospital readmissions for complications following stroke. The data suggest that an there are opportunities to improve how patients are prepared for hospital discharge including teaching to monitor and report BP readings and prepare to manage medications after discharge. To our knowledge, this is the first multi-hospital stroke TOC surveillance program currently collecting data.
Author Disclosures: S.A. Roberts: None. A.V. Nickles: None. E. Siwiec: None. K. Glaza: None. C. Peplinski: None. M. Lange: None. M. Mitchell: None. T. Scorcia-Wilson: None. P. Mitsias: None.
- © 2015 by American Heart Association, Inc.