Abstract WP290: Stroke 90 Program

Abstract

Background: Despite tremendous scientific advancements in acute stroke care, post-stroke management can be challenging. Information overload and a lack of post-discharge understanding can lead to potential stroke readmissions. Purpose Patients with a history of stroke have a significantly higher risk of readmission. Neuro-telemetry nurses designed Stroke 90 as a follow-up outreach program to reduce the stroke readmission average by 2% over six months and address knowledge gaps. After completing the program, patients will have the education and resources to prevent readmission. Methods: Neuro-telemetry nurses call stroke patients three weeks post-discharge to determine baseline knowledge of their stroke. The next six weeks reinforce individualized stroke education and reassess for continued post-discharge needs. The Plan Do Study Act (PDSA) cycle was implemented May 2021 for 11 months and only included acute ischemic or hemorrhagic stroke patients (n=154) discharged home from the Neuro-Telemetry Unit. A second PDSA cycle began in September 2022, including patients (n=356) discharged with a diagnosis of Transient Ischemic Attack, Ischemic, or Hemorrhagic Stroke from the Emergency Department, Intensive Care Unit, and Neuro-Telemetry Unit. Data is collected retrospectively by identifying patients with a final stroke diagnosis 30 days post-discharge. Outpatient visits and procedural admissions were excluded. 90-day readmissions only included inpatient hospital stays with another stroke diagnosis. Results: From September 2022 to December 2022, 6.25 patients were readmitted per month with a diagnosis of acute stroke, making the readmission average 16%. From January 2023 to June 2023, 4 stroke patients were readmitted per month, yielding a readmission average of 12%. The program demonstrated a monthly acute stroke patient reduction of 2.25 with a 3-day average length of stay (total savings of 6.75 hospital days). Conclusion: Overall, there was a 4% decrease in the readmission average, which exceeded the goal of a 2% decrease. The teach-back method is valuable for addressing knowledge gaps and decreasing post-stroke readmissions. The Stroke 90 Program significantly benefits stroke survivors as they navigate recovery.