PurposeThere is an immediate need to establish a comprehensive continuum of care to address the various needs of stroke survivors, caregivers and society in secondary prevention.

IntroductionStroke is a major global health concern with 77 million deaths estimated to occur by 2030. The aim of this project is to enhance patient communication at discharge, supporting care transitions into the community and providing secondary stroke prevention intervention.

Objectives

MethodIn April 2018, the hospital implemented Vocera Care Inform technology to audio record care plans for patients with acute ischemic stroke. Prior to discharge, these patients met with nurse practitioners, who audio recorded personalized instructions and education. Using teach-back, nurse practitioners educated patients and family members about the discharge care plan. Nurse practitioners also created an electronic library with specific stroke care resources for each patient and their caregivers about the discharge care plan. Nurse practitioners also created an electronic library with specific stroke care resources for each patient and their caregivers. These educational resources, as well as the audio recorded discharge instructions, were securely and easily accessible to hear, read, or watch via telephone or computer at any time after discharge.

Enhance patient communication and education for stroke survivors and family members

Improve care plan compliance and patient accountability

Empower patients and caregivers to manage stroke recovery after hospital discharge

Reduce readmissions

ImpactBefore After

During our 7-day post discharge follow-up calls in 2017, we discovered:

After implementing the Vocera Care Inform solution, using teach back and recorded instructions:

Follow up with Primary Care Physician rates were low

Prescriptions were not filled

Patients were unable to recite signs and symptoms of stroke

Denial was high

7% more patients were compliant with medication

6% more patient could recite signs and symptoms of stroke

3% more patient with PMD made follow up appointments

2% more patients could recite personal risk factors

Post-Discharge Results

ResultsBetween April 2018 and Dec. 2018, 116 discharge plans were prepared and audio recorded by nurse practitioners at the bedside with patients and families using teach-back.

12-Month Trend: Decreasing Readmissions

ConclusionPoor patient communication can negatively impact transitions into community-based care environments, resulting in poor compliance, limited recovery, and potential re-admission. Access to recorded discharge instruction, educational resources, and continued support at home can positively impact recovery and reduce risk for re-admission.

*There are no relevant conflicts of interests to disclose.

References• Bettger, J., Alexander, K. (2012). Transitional care after hospitalization for acute stroke or myocardial

infarction: A Systematic Review. Ann Intern Med, 157(6), 407-416.

• Hayes, H. (2013). A doctor of nursing practice-led transition of care model for stroke and transient attack. Doctor of Nursing Practice, University of Arizona.

• Lindsay, MP., & Gilmore, P (2013).Managing stroke transitions of care: Best practice recommendations. Canadian Stroke Best Practices and Standards Working Group, Chapter 6. Retrieved from http://www.ontariostrokenetwork.ca/wp- content/uploads/2013/11/Ch6_SBP2013_Transitions-_28Oct13_Final_Post.pdf

• Shaw, Gina (2011). Transitions for stroke patients: how to reduce readmission rate. Neurology Today, 11(16).

• Wissel, J., Olver, J., Sunnerhagen, K. (2013). Navigating the poststroke continuum of care. Journal of Stroke and Cerebrovascular Disease. 22(1), 1-8.

25% of the patients who received the information accessed it

60% of accessed instructions were accessed more than once

50% decrease in readmissions

7.2%2017

3.6%2018

6.00%

6.20%

6.40%

6.60%

6.80%

7.00%

7.20%

7.40%

Year End 2017 Jan-April2018 April-Dec 2018 Jan-April 2019

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Personal risk factors Recite signs &symptoms

Medicationcompliance

PMD followup

2017 2018

Enhancing Stroke Care: Improving Discharge CommunicationJackie Dwyer, RN MSN, CNRN, Stroke Program Manager, Jersey Shore University Medical Center

Personal risk factors

Recite signsand symptoms

Medication compliance

PMD folow up

Year End 2017

Jan-April 2018

April-Dec 2018

Jan-April2019

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