Abstract Details

Title Closing the Loop: Streamlining Stroke Discharge to Enhance Continuity of Care

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P6 - Poster Session 6 (11:45 AM-12:45 PM)

Poster/Presentation
Number 13-002

Objective We present a quality improvement project implemented at the University of Kentucky stroke unit that reduced post-discharge issues, nurse navigator time, streamlined transitions of care, improved medication management, and ultimately lowered hospital readmissions.

Background Patients discharged home from the Stroke Neurology Service at the University of Kentucky are experiencing difficulties related to follow-up appointments and medication management. These challenges require significant time and support from stroke nurse navigators and residents, affecting approximately 10% of patients discharged to home.

Design/Methods FOCUS-PDSA (Find a problem, Organize, Clarify, Understand, select intervention; Plan-Do-Study- Act) methodology was used for this project. In a one-year analysis of home discharge calls, we identified patient issues and tracked nurse navigator time per call prior to initiating PDSA cycles. Over two PDSA cycles between March 1 to April 30 of 2024 we implemented two interventions. Firstly, we educated senior residents on the stroke service to sign discharge summaries instead of interns, reducing nurse navigator time spent on provider tracking. Second, we launched the "ASK me 3" campaign, encouraging patients to inquire about their care via displayed placards and signs in patient rooms and corridors.

Results

During initial PDSA cycle, we were able to achieve only 50% of compliance in signing discharge summaries and there was no significant improvement in nurse navigator call time. After revising our intervention to mandate the name of the senior resident on discharge summaries, we achieved 100% compliance and nurse navigator time has been reduced by 30% over a two-month period along with reduction of patient issues from 10% to 6%.

Conclusions

Our data suggested that system-based changes, such as mandating provider names on discharge summaries and implementing the "ASK me 3" campaign, may be more reliable than provider-dependent interventions. If effectively utilized, these tools could be scaled to broader settings, potentially encompassing entire department or multiple departments.

Authors/Disclosures
Rani Priyanka Vasireddy, MBBS PRESENTER	Dr. Vasireddy has nothing to disclose.
Margie Campbell (UK HealthCare)	Margie Campbell has nothing to disclose.
Ronald F. Adams Jr, RN	Mr. Adams Jr has nothing to disclose.
Jessica D. Lee, MD, FAAN (University of Kentucky)	Dr. Lee has received personal compensation for serving as an employee of ��ɫ��. The institution of Dr. Lee has received research support from Janssen.

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