Closing the Loop: Streamlining Stroke Discharge to Enhance Continuity of Care
Rani Priyanka Vasireddy1, Margie Campbell2, Ronald Adams1, Jessica Lee1
1Neurology, University of Kentucky, 2Neurology, UK HealthCare
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.
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