Efficient and effective care depends on continuity of communication between nurses and physicians and adequate access to patients' medical history, laboratory results, and ECGs. The following operational strategies may help institutions reduce potentially preventable hospitalizations: ensure effective communication between nursing staff and physicians regarding patients' condition; provide physicians with easy access to stat laboratory results in less than 4 hours on weekends and adequate access to the patient's medical history, laboratory results, and ECGs; and motivate physicians to treat residents within the nursing home whenever possible.

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Background: Although designated stroke centers (DSCs) improve the quality of care and clinical outcomes for ischemic stroke patients, less is known about the benefits of DSCs for patients with intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Hypothesis: Compared to non-DSCs, hospitals with the DSC status have lower in-hospital mortality rates for hemorrhagic stroke patients. We believed these effects would sustain over a period of time after adjusting for hospital-level characteristics, including hospital size, urban location, and teaching status. Methods and Results: We evaluated ICH (International Classification of Diseases, Ninth Revision; ICD-9: 431) and SAH (ICD-9: 430) hospitalizations documented in the 2008-2012 New York State Department of Health Statewide Planning and Research Cooperative System inpatient sample database. Generalized estimating equation logistic regression was used to evaluate the association between DSC status and in-hospital mortality. We calculated ORs and 95% CIs adjusted for clustering of patients within facilities, other hospital characteristics, and individual level characteristics. Planned secondary analyses explored other hospital characteristics associated with in-hospital mortality. In 6,352 ICH and 3,369 SAH patients in the study sample, in-hospital mortality was higher among those with ICH compared to SAH (23.7 vs. 18.5%). Unadjusted analyses revealed that DSC status was related with reduced mortality for both ICH (OR 0.7, 95% CI 0.5-0.8) and SAH patients (OR 0.4, 95% CI 0.3-0.7). DSC remained a significant predictor of lower in-hospital mortality for SAH patients (OR 0.6, 95% CI 0.3-0.9) but not for ICH patients (OR 0.8, 95% CI 0.6-1.0) after adjusting for patient demographic characteristics, comorbidities, hospital size, teaching status and location. Conclusions: Admission to a DSC was independently associated with reduced in-hospital mortality for SAH patients but not for those with ICH. Other patient and hospital characteristics may explain the benefits of DSC status on outcomes after ICH. For conditions with clear treatments such as ischemic stroke and SAH, being treated in a DSC improves outcomes, but this trend was not observed in those with strokes, in those who did not have clear treatment guidelines. Identifying hospital-level factors associated with ICH and SAH represents a means to identify and improve gaps in stroke systems of care.

Our analysis showed that communication and consensus are important factors in the hospital transfer decision and that the discord in perceptions among MDs and DONs may complicate interventions to reduce preventable hospitalization.