Abstract T MP104: Stroke Transition of Care: Preventing a Second Event
Background: In the United States stroke is the leading cause of long-term disability leaving over six million stroke survivors. In 2009, the indirect and direct cost in the U.S. was $38.6 billion dollars. If modifiable risk factors were controlled, up to 80% of strokes could be prevented. There is no current recommended transition of care approach or algorithm to track and follow-up on acute ischemic stroke or transient ischemic attack patients post discharge from the hospital for secondary stroke prevention.
Purpose: The purpose of this exploration is to perform a gap analysis of programs/trials for transition of care in order to prevent a secondary stroke event.
Methods: Eight secondary stroke prevention program/trials were evaluated to provide hospitals with evidence-based tools to start to address the wide gap in post-discharge transition of care.
Results: Several areas were identified as potential starting points for a healthcare organizations transition of care program. They include an educator/coordinator role, follow-up time frames, and validated tools for assessment pre/post discharge. Significant gaps exist for those who are unable to be discharged to the community; this population is largely excluded in transition of care programs.
Conclusion: There is not a program/trial with a holistic approach regardless of discharge disposition. Future studies are needed to centralize the qualities found in this review that are ideal for any program: Pre-set physician appointments, follow up phone calls pre/post doctor appointments, series of classes in-hospital with topics on nutrition, exercise regimen, cardiac and neurologic event education and prevention, psychological support with referral, caregiver and community licensed personnel education/training, algorithms with evidence based literature regarding follow up and secondary prevention provided to primary physicians, and social worker community resources. The utilization of the advanced practice nurse and the holistic approach of the Roy Adaptation Model and theory as an assessment and intervention conduit can begin to bring current evidence for transition of care.
Author Disclosures: K. Valdez: None.
- © 2015 by American Heart Association, Inc.