Background: Prolonged hospital lengths of stay increase costs, delay rehabilitation, and expose acute ischemic stroke patients to hospital-acquired infections. We designed and implemented a nurse-driven transitions of care coordinator (TOCC) program to facilitate the transition of care from the acute care hospital setting to rehabilitation centers and home.Methods: This was a single-blinded, prospective, randomized pilot study of 40 participants to evaluate the feasibility of implementing a TOCC program led by a stroke nurse navigator in hospitalized acute ischemic stroke patients. The intervention consisted of a stroke nurse navigator completing eight specific tasks, including meeting with stroke patients and their families, facilitating communication between team members at multi-disciplinary rounds, assisting with referrals to rehabilitation facilities, providing stroke education, and arranging stroke clinic follow-up appointments, which were confirmed to be completed by independent study personnel. The primary outcome was to assess the feasibility of the program. The secondary outcomes included comparing hospital length of stay (LOS) and patient satisfaction between the TOCC and usual care groups. We also explored the association between patient-level variables and LOS.Results: The TOCC program was feasible with all pre-specified components completed in 84.2% (95% CI: 60.4–96.6%) and was not significantly different from the assumed completion rate of 75% (p = 0.438). There was no significant difference in median LOS between the two groups [TOCC 5.95 days (4.02, 9.57) vs. usual care 4.01 days (2.00, 10.45), false discovery rate (FDR)-adjusted p = 0.138]. There was a trend toward higher patient median satisfaction in the TOCC group [TOCC 35.00 (33.00, 35.00) vs. usual care 30 (26.00, 35.00), FDR-adjusted p = 0.1] as assessed by a questionnaire at 30 days after discharge. The TOCC study allowed us to identify patient variables (gender, insurance, stroke severity, and discharge disposition) that were significantly associated with longer hospital LOS.Conclusion: A TOCC program is feasible and can serve as a guide for future allocation of resources to facilitate transitions of care and avoid prolonged hospital stays.
Introduction: Prolonged hospital stays expose stroke patients to hospital-acquired infections, increase overall cost of care, and delay the initiation of rehabilitation therapies. We sought to examine the factors associated with length of stay (LOS) in acute ischemic stroke (AIS) patients at a comprehensive stroke center (CSC) in an urban center. We hypothesized that patients being discharged to subacute rehabilitation (SAR) or nursing home facilities would have longer LOS. Methods: Consecutive patients admitted to our stroke service from April to July 2018 with a principal diagnosis of AIS were included. Patients with transient ischemic attack, intracerebral hemorrhage or subarachnoid hemorrhage were excluded. Demographics, admission NIHSS, baseline modified Rankin Scale (mRS), discharge mRS, and discharge disposition were collected. LOS was calculated from date/time of patient registration to discharge. Results: Baseline characteristics are shown in table 1. LOS and NIHSS were significantly correlated ( r s 0.745, p <0.001). Medicaid as primary insurance on admission was associated with longer LOS (21.9 days) as compared to Medicare (6.5 days) or commercial insurance (2.6 days) [p=0.017]. Higher discharge mRS was associated with longer LOS [p=0.002]. Discharge to SAR was associated with longer LOS (22.9 days) as compared to acute rehab (8.8 days), home with home health (3.2 days), or home (2.6 days) [p = 0.001]. There was no difference in LOS according to baseline mRS, age, gender, or race. Conclusions: Higher admission NIHSS, Medicaid insurance on admission, discharge to SAR, and discharge mRs >4 were significantly associated with longer LOS in AIS patients. Systems of care interventions are needed to address disparity in LOS for Medicaid patients.
Introduction: Delay in discharge of acute stroke patients considered medically ready for discharge increases costs and exposure to nosocomial infections, and is frustrating for patients. We evaluated factors associated with delays in discharge in acute ischemic stroke (AIS) patients in a Transitions of Care Coordination (TOCC) study. Methods: From April to July 2018, 29 AIS patients (pts) were randomized to TOCC (n=13) or usual care (n=16) groups. Intracerebral hemorrhage, transient ischemic attack and subarachnoid hemorrhage pts were excluded. In TOCC, a nurse navigator met patient/family, identified barriers to discharge, checked status of diagnostics, attended multi-disciplinary rounds to facilitate rehab referrals, provided stroke education, and coordinated clinic follow-up. Delayed length of stay (dLOS) was defined as the difference between date/time medically ready for discharge and date/time of actual discharge. Demographic variables, NIHSS, mRS and discharge disposition were collected. Continuous variables were analyzed with Wilcoxon rank-sum or Kruskal-Wallis test, and categorical variables with Fisher’s exact test. Results: Pts in the TOCC group were older, but other baseline characteristics were well matched (Table 1). dLOS was significantly correlated with NIHSS ( r s 0.65, p=0.00037. There was a difference in dLOS by insurance type (Medicare 4.05 d vs. Medicaid 17.7 d vs. Commercial 3.0 days, p=0.0250). There was a difference in mean dLOS by discharge disposition (acute rehab 6.5 d, home 1 d, home with home health 1.4 d, subacute rehab 17 d, (and patient death 9 d), p=0.007. There was a difference in distribution of dLOS by distance from home zip code to hospital but no difference was found in the post-hoc analysis. There was no difference in mean dLOS between TOCC and usual care groups (6.5 vs. 4.5 days, p=0.256). Conclusion: Higher NIHSS, Medicaid insurance, and discharge to acute rehab were significantly associated with dLOS in AIS patients.
Background: A critical component in preventing Cerebral Vascular Accidents (CVA) and Transient Ischemic Attacks (TIAs) is knowledge of risk factors and, signs and symptoms of a stroke, and follow-up care with a neurologist and primary care provider. To prevent readmission to the hospital for a second CVA, a large hospital system outside the District of Columbia has implemented a Nurse-led Stroke Education program. Purpose: Introduction of a full-time Stroke Navigator will improve patient education for Ischemic and TIA patients, through a nurse-led Stroke Education program. Methods: Phase 1: The Stroke Navigator in conjunction with the bedside RN will provide personalized stroke education to patients who suffer from a CVA or TIA. Phase II: The Stroke Navigator will conduct a follow-up phone call of patients discharged with a diagnosis of stroke or TIA within seven days. The phone call will assess patient’s knowledge of their risk factors, the symptoms and symptoms associated with a stroke, medication compliance, and follow-up medical appointment compliance with a Primary Care Provider (PCP) and Neurologist. Results: Data was reviewed from January –May 2021(n=87) prior to the implementation of the stroke navigator role, and from June –July 2021(n=57) after integration of the role. Patients’ follow-up compliance with their PCP increased from 34% to 68%. Follow-up with a neurologist increased from 8% to 44%. Medication Compliance decreased from 99% to 89%. Patients’ knowledge of signs and symptoms of stroke increased from 8% to 18%. Patients’ knowledge of their personal risk factors for stroke decreased from 45% to 35%. Conclusion: Data surrounding implementation of a full time Stroke Navigator has made a positive impact on patient’s post-stroke knowledge and care surrounding follow-up with providers and knowledge of signs/symptoms of stroke. The Stroke Coordinator and Stroke Navigator will continue to measure quality outcomes over time to determine if the stroke education program is continuing to positively impact post-discharge patient care.
Background/ Issue: Epidemiologically, pediatric strokes are rare; therefore, index of suspicion is low and many cases are not recognized early enough to qualify for acute treatment. With this small patient population, many regions have yet to develop protocols and policies for acute pediatric stroke response. In the District of Columbia, MedStar Georgetown University Hospital (MGUH) is the only Joint Commission Accredited Comprehensive Stroke Center with a pediatric intensive care unit. Purpose: The purpose of our program was to develop institutional protocols for pediatric stroke patients who are candidates for hyper-acute treatment. Protocols focused on pediatric patients who presented through our emergency department or were transferred from other facilities within the time window for acute treatment. The protocols were established to ensure a clear process for physicians and staff to follow. Methods: An interdisciplinary group met to discuss modification of our current Adult Ischemic Stroke Code Protocol needed for a coordinated approach to pediatric stroke patients. The team members included the Stroke Coordinator, Stroke Nurse Navigator, Stroke Nurse Practitioner, Pediatric Neurologist, Medical Director of the Pediatric ICU, Manager of the Pediatric ICU, Pediatric Anesthesia, Medical Director of the Stroke Program, and the Emergency Department Team. Results: The interdisciplinary team was able to adapt a protocol using the Adult Ischemic Stroke Code Protocol. Key differences between the adult and pediatric stroke code work-flow consisted of including pediatric neurologists early in the decision process, pediatric nurses to assist with monitoring children, and pediatric anesthesia for assistance with imaging and/or endovascular intervention. The order sets were adjusted to include weight- based calculations for medications, age-based monitoring parameters, and specific pediatric needs. Conclusion: It is possible to develop a Pediatric Stroke Code Protocol based on the Adult Ischemic Stroke Code Protocol to include all modifications appropriate for pediatric care and still maintain the rapid work-flow that everyone is familiar with. It is essential to include all key stakeholders to ensure a smooth and safe process.
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