Post-discharge Interviews Research Articles

A Mixed Methods Evaluation of a Pilot Multidisciplinary Breathlessness Support Service.

Breathlessness support services have demonstrated benefits for breathlessness mastery, quality of life and psychosocial outcomes for people living with breathlessness. However, these services have predominantly been implemented in hospital and home care contexts. This study aims to evaluate the adaptation and implementation of a hospice-based outpatient Multidisciplinary Breathlessness Support Service (MBSS) in Ireland. A sequential explanatory mixed methods design guided this study. People with chronic breathlessness participated in longitudinal questionnaires (n = 10), medical record audit (n = 14) and a post-discharge interview (n = 8). Caregivers (n = 1) and healthcare professionals involved in referral to (n = 2) and delivery of (n = 3) the MBSS participated in a cross-sectional interview. Quantitative and qualitative data were integrated deductively via the pillar integration process, guided by the RE-AIM framework. Integration of mixed methods data enhanced understanding of factors influencing the reach, adoption, implementation and maintenance of the MBSS, and the potential outcomes that were most meaningful for service users. Potential threats to the sustainability of the MBSS related to potential preconceptions of hospice care, the lack of standardized discharge pathways from the service and access to primary care services to sustain pharmacological interventions. This study suggests that an adapted multidisciplinary breathlessness support intervention is feasible and acceptable in a hospice context. However, to ensure optimal reach and maintenance of the intervention, activities are required to ensure that misconceptions about the setting do not influence willingness to accept referral to MBSS services and integration of services is needed to enable consistency in referral and discharge processes.

Maternal experiences of care following a stillbirth at Steve Biko Academic Hospital, Pretoria, South Africa


 Background. Despite improvements in obstetrics and neonatal care, the stillbirth rate remains high (23 per 1 000 births) in South Africa (SA). The occurrence of a stillbirth is a dramatic and often life-changing event for the family involved. The potential consequences include adverse effects on the health of the mother, strain on the relationship of the parents, and strain on the relationship between the parents and their other children. The standard of care in SA follows the Royal College of Obstetricians and Gynaecologists Green-top guidelines.Objectives. To explore maternal experiences of in-patient care received in cases of stillbirth.Methods. A descriptive phenomenological approach was performed in the obstetrics unit at Steve Biko Academic Hospital, Pretoria, SA. Post-discharge interviews were conducted with women who experienced a stillbirth. The healthcare workers in the obstetric unit were also interviewed on the care provided to these patients. Data analysis was performed using the Colaizzi’s method.Results. Data from the interviews with the 30 patients resulted in five themes relating to the maternal experience of stillbirth: ‘broken heart', ‘helping hand’, ‘searching brain’, ‘soul of service’ and ‘fractured system’. Healthcare worker participants emphasised the importance of medical care (the clinical guidelines) rather than maternal care (the psychosocial guidelines).Conclusion. While the medical aspects of the guidelines are adhered to, the psychosocial aspects are not. Consequently, the guidelines require adaptation, especially taking into consideration African cultural practices, and the inclusion of allocated responsibility regarding the application of the psychosocial guidelines, as this is the humanitarian umbilical cord between healthcare workers and those in their care.

Perinatal COVID-19 maternal and neonatal outcomes at two academic birth hospitals.

ObjectiveDescribe 1-month outcomes among newborns of persons with perinatal COVID-19.Study designProspective observational study of pregnant persons who tested positive for SARS-CoV-2 between 14 days before and 3 days after delivery and their newborns, from 3/2020 to 3/2021 at two urban high-risk academic hospitals. Phone interviews were conducted to determine 1-month newborn outcomes.ResultsAmong 9748 pregnant persons, 209 (2.1%) tested positive for perinatal SARS-CoV-2. Symptomatically infected persons were more likely to have a preterm delivery due to worsening maternal condition and their newborns were more likely to test positive for SARS-CoV-2 compared with asymptomatic persons. Six of 191 (3.1%) infants tested were positive for SARS-CoV-2; none had attributable illness before discharge. Of 169 eligible families, 132 (78.1%) participated in post-discharge interviews; none reported their newborn tested positive for SARS-CoV-2 by 1 month of age.ConclusionSymptomatic perinatal COVID-19 had a substantial effect on maternal health but no apparent short-term effect on newborns.

Association of Opioid Consumption Profiles After Hospitalization With Risk of Adverse Health Care Events

Although better pain management has guided policies for opioid use over the past few decades, evidence is limited regarding how patterns of use are associated with the risk of potentially avoidable opioid-related adverse events. To estimate the risk of harms associated with opioid dose and duration of use, and to ascertain whether the risk is modified by treatment indication and age. This ad hoc cohort study followed up patients who were enrolled in a cluster randomized trial of medication reconciliation between October 1, 2014, and November 30, 2016, 12 months after they were discharged from the McGill University Health Centre in Montreal, Quebec, Canada. To be eligible for this study, patients needed to have filled at least 1 opioid prescription 3 months after discharge. Patients with a history of using methadone or buprenorphine were excluded. Data analyses were performed between February 1, 2019, and February 28, 2020. Time-varying measures of opioid use included current use, daily morphine milligram equivalent (MME) dose, cumulative and continuous use duration, and type of ingredients in prescription opioids used. Hospitalization records, dispensed prescriptions records, and postdischarge interviews were used to evaluate adherence to the opioid prescriptions after discharge. Opioid-related emergency department visits, hospital readmissions, or all-cause death. Outcomes were ascertained using provincial medical services claims and hospitalization databases. Of 3486 participants in the cluster randomized trial (mean [SD] age of 69.6 [14.9] years; 2010 men [57.7%]), 1511 patients were included in this ad hoc cohort study. Among those with at least 1 opioid dispensation, 241 patients (15.9%) experienced an opioid-related emergency department visit, hospital readmission, or death. Results from marginal structural Cox proportional hazards regression models showed more than a 2-fold increase in the risk of opioid-related adverse events associated with a cumulative use duration of more than 90 days (adjusted hazard ratio, 2.56; 95% CI, 1.25-5.27) compared with 1 to 30 days. A 3-fold risk increase was found with a mean daily dose higher than 90 MME (adjusted hazard ratio, 3.51; 95% CI, 1.58-7.82) compared with 90 MME or lower. This study found an association between risk of adverse health care events and higher opioid doses and longer treatment duration. This finding can inform policies for limiting opioid duration and dose to attenuate the risk of avoidable morbidity.

Factors Affecting Infant Feeding Practices Among Women With Severe Mental Illness

Background: The health benefits of breastfeeding are well-established but for mothers with severe mental illness (SMI), the decision to breastfeed can be complex. Very few prior studies have investigated the infant feeding choices of women with SMI, or the factors associated with this. Our aims were to examine antenatal infant feeding intentions and infant feeding outcomes in a cohort of women admitted for acute psychiatric care in the first postpartum year. We also aimed to examine whether demographic and clinical characteristics associated with breastfeeding were similar to those found in previous studies in the general population, including age, employment, education, BMI, mode of delivery, smoking status, and social support.Methods: This study was a mixed-methods secondary analysis of a national cohort study, ESMI-MBU (Examining the effectiveness and cost-effectiveness of perinatal mental health services). Participants had been admitted to acute care with SMI in the first postpartum year. Infant feeding outcomes were retrospectively self-reported by women during a 1-month post-discharge interview. Free-text responses to questions relating to infant feeding and experience of psychiatric services were also explored using thematic analysis.Results: 144 (66.1%) of 218 women reported breastfeeding (mix feeding and exclusive breastfeeding). Eighty five percentage of the cohort had intended to breastfeed and of these, 76.5% did so. Factors associated with breastfeeding included infant feeding intentions, employment and non-Caucasian ethnicity. Although very few women were taking psychotropic medication contraindicated for breastfeeding, over a quarter (n = 57, 26.15%) reported being advised against breastfeeding because of their medication. Women were given this advice by psychiatry practitioners (40% n = 22), maternity practitioners (32.73% n = 18) and postnatal primary care (27.27% n = 15). Most women stopped breastfeeding earlier than they had planned to as a result (81.1% n = 43). Twenty five women provided free text responses, most felt unsupported with infant feeding due to inconsistent information about medication when breastfeeding and that breastfeeding intentions were de-prioritized for mental health care.Conclusion: Women with SMI intend to breastfeed and for the majority, this intention is fulfilled. Contradictory and insufficient advice relating to breastfeeding and psychotropic medication indicates that further training is required for professionals caring for women at risk of perinatal SMI about how to manage infant feeding in this population. Further research is required to develop a more in-depth understanding of the unique infant feeding support needs of women with perinatal SMI.

Electronic Cigarettes and Vaping-Associated Lung Injury (EVALI): A Rural Appalachian Experience

ABSTRACT Background: Electronic cigarette use has increased dramatically since their introduction in 2007. Respiratory complications, particularly lipoid pneumonia, have been reported as early as 2012. An outbreak of pulmonary injury in 2019 has been reported in patients using vaping products. Research Question: To describe a rural Appalachian tertiary center’s experience of EVALI and to identify novel mechanisms of pulmonary injury patterns. Study Design and Methods: We present a consecutive case series of 17 patients admitted to our rural, academic, tertiary care institution with EVALI from August 2019 to March 2020. Demographics, baseline characteristics, co-morbidities, vaping behavior, and hospital course were recorded. Broncho-alveolar lavage specimens were assessed for lipid-laden macrophages and hemosiderin-laden macrophages with stains for Oil-Red-O (n = 15) and Prussian Blue (n = 14) respectively. The patient volunteered e-liquid materials (n = 6), and vapors were analyzed using a proton transfer reaction time-of-flight mass spectrometer (PTR-TOF-MS) to describe the chemical profile. Post-discharge interviews were conducted. Results: The most common CT finding was bilateral ground-glass opacities with a predilection for lower lung zones. The most frequent pulmonary injury pattern was lipoid pneumonia. The majority of EVALI patients were critically ill requiring ventilation or ECMO. The most severely ill patients were noted to be positive for iron stains in macrophages and showed higher volatile organic compound (VOC) levels in chemical analysis. Interpretation: Based on our experience, EVALI in rural Appalachia presented with relatively severe respiratory failure. Worse outcomes appear to be correlated to high levels of VOCs, iron deposition in lungs, and concomitant infection.

Doing nothing? An ethnography of patients' (In)activity on an acute stroke unit.

Health research has begun to pay increasing attention to inactivity in its broadest sense as lack of meaningful activity and boredom. Few studies however have taken a critical look at this phenomenon. We explore (in)activity drawing on ethnographic data from observations in an acute stroke unit and post-discharge interviews with stroke survivors and their families. Four themes emerged that explain patients’ (in)activity: (i) planned activities; (ii) ‘doing nothing’, (iii) the material environment of the unit; (iv) interactions with staff. Considering these themes, we seek to problematise received conceptual and methodological approaches to understanding (in)activity. We argue that (in)activity is best conceived not as lack of action or meaning, but as a situated practice encompassing both bodily and mental activities that reflect and reproduce the way in which life is collectively organised within a specific healthcare setting.

0729 Sleep Apnea Diagnosis And Severity And Their Impact On Cognition After TBI: A VA TBI Model Systems Study

Abstract Introduction For persons with moderate-to-severe traumatic brain injury (TBI), chronic cognitive impairment contributes to long term disability. Health comorbidities may contribute to the neurologic burden in TBI. Indeed, obstructive sleep apnea (OSA) is associated with neuropathological and cognitive changes. The objective of this study was to examine the relationship between OSA and cognition after TBI. Methods Participants were prior inpatient rehabilitation patients drawn from the Tampa VA TBI Model Systems longitudinal study. Post-discharge interviews occurred 2 to 6 years post-TBI. Participants reported whether they were diagnosed with OSA and completed the Brief Test of Adult Cognition by Telephone (BTACT) which measures recall, working memory, processing speed, fluency, and reasoning. Participants with polysomnography (PSG) were separately analyzed to examine the impact of sleep apnea severity (i.e., Apnea-Hypopnea Index [AHI]) on cognition. Results Participants (N=104) were mostly male (95.2%), age M=37.7 (SD=12.5), Education M=13.6 years (SD=2.1), and 45.2% were diagnosed with OSA. Participants with and without OSA did not differ by age, education, gender, or time since injury at time of BTACT (ps > .05). ANCOVAs were conducted examining OSA diagnosis on BTACT subscale scores, covarying TBI severity level, but results did not reach statistical significance (ps > .05). A subset of participants with OSA had PSG (n=27), AHI score quartiles = 6.7/10.4/21.6. Higher AHI was associated with poorer reasoning (Spearman ρ = -0.45, p = .019). Nonsignificant results were found for word recall (Spearman ρ = -0.35, p = .074) and processing speed (Spearman ρ = -0.36, p = .069). Conclusion Severity of sleep apnea may influence aspects of cognition among persons with TBI, although these results are preliminary and need replication with a larger and more representative sample. Support This work was supported by the Veterans Health Administration Central Office VA TBI Model Systems Program of Research and subcontract from General Dynamics Information Technology [W91YTZ-13-C-0015, HT0014-19-C-0004] from the Defense and Veterans Brain Injury Center (DVBIC); and from the United States Department of Veterans Affairs [W81XWH-13-2-0095]; and from the United States Department of Defense Congressionally Directed Medical Research Programs; and from the Patient Centered Outcomes Research Institute (PCORI) [CER-1511-33005].

Impact of paediatric tonsillectomy perioperative management on pain, nausea and recovery: A prospective cohort study.

Tonsillectomy procedures are a core element of paediatrics; however, perioperative management differs. This study aimed to describe tonsillectomy management, including the burden of pain, nausea and delayed recovery. A prospective cohort study was undertaken through an audit of tonsillectomy perioperative practice and recovery and survey interviews with family members 7-14 days post-surgery. The study was undertaken at an Australian tertiary referral paediatric hospital between June and September 2016. The audit included 255 children undergoing tonsillectomy, with 127 family members interviewed. Most participants underwent adenotonsillectomy (n = 216; 85%), with a primary diagnosis of obstructive sleep apnoea (n = 205; 80%) and a mean age of 7 years (standard deviation; 3.9). A variety of intra-operative pain relief and antiemetics was administered. Pain was present in 29% (n = 26) of participants at ward return, increasing to 32-45% at 4-20 h and decreasing to 21% (n = 15) at discharge. A third of the children (32%; n = 41) had moderate to severe pain at post-discharge interview, and 30% (n = 38) experienced nausea at home. Most parents (82%; n = 104) were still giving regular paracetamol at 7 days post-operatively, and 31% (n = 39) had finished their oxycodone. Of the participants, 14% (n = 26) presented to the emergency department within 7 days of discharge; 8% (n = 20) of the total cohort were re-admitted. There was variety in perioperative and post-discharge care. Pain scores were infrequently documented post-tonsillectomy, and parents are generally dissatisfied with the management of post-operative pain and nausea. Further research is needed to provide a more consistent approach to perioperative management to promote recovery.

Changing Neonatal Nurses' Perceptions of Caring for Infants Experiencing Neonatal Abstinence Syndrome and Their Mothers

Neonatal intensive care units (NICUs) are caring for an increasing number of infants born with neonatal abstinence syndrome (NAS). The literature identifies the need for education for NICU nurses on NAS including skills for interacting with the mother with substance use disorder. An evidence-based practice project was developed to offer an educational presentation targeting these topics to 206 NICU participants (93% registered nurses, 1% licensed vocational nurses, and 6% nursing assistants) at a level IV NICU. A pretest/posttest was developed to assess knowledge of the participants prior to and after completion of the educational presentation. A posteducational questionnaire was developed to evaluate the skills learned for interacting with the mother with substance use disorder and the participant's professional readiness. The posttest demonstrated a statistically significant (P < .001) increase in knowledge of NAS. On the post-educational questionnaire, 96% of participants correctly identified 3 skills they would use clinically with mothers with substance use disorder and 84% of participants identified 2 personal strengths and 2 weaknesses that influence their care of infants with NAS and their families (professional readiness). These results demonstrate that this educational presentation was effective and should be replicated at other facilities to improve the knowledge and skills of NICU nurses to promote improved care for infants with NAS. Future studies should examine the impact on patient outcomes by preforming post-discharge interviews with the mothers of infants with NAS in the NICU pre- and post-educational intervention. Expanding the presentation into an interprofessional educational opportunity would promote increased knowledge and care by the entire multidisciplinary team.

First year post-stroke healthcare costs and fall-status among those discharged to the community.

Falls are common post-stroke events but their relationship with healthcare costs is unclear. The aim of this study was to examine the relationship between healthcare costs in the first year after stroke and falls among survivors discharged to the community. Survivors of acute stroke with planned home discharges from five large hospitals in Ireland were recruited. Falls and healthcare utilisation data were recorded using inpatient records, monthly calendars and post-discharge interviews. Cost of stroke was estimated for each participant from hospital admission for one year. The association of fall-status with overall cost was tested with multivariable linear regression analysis adjusting for pre-stroke function, stroke severity, age and living situation. A total of 109 stroke survivors with complete follow-up data (mean age = 68.5 years (SD = 13.5 years)) were included. Fifty-three participants (49%) fell following stroke, of whom 28 (26%) had recurrent falls. Estimated mean total healthcare cost was €20,244 (SD=€23,456). The experience of one fall and recurrent falls was independently associated with higher costs of care (p = 0.02 and p < 0.01, respectively). The observed relationship between falls and cost is likely to be underestimated as aids and adaptions, productivity losses, and nursing home care were not included. This study points at differences across fall-status in several healthcare costs categories, namely the index admission, secondary/tertiary care (including inpatient re-admissions) and allied healthcare. Future research could compare the cost-effectiveness of inpatient versus community-based fall-prevention after stroke. Further studies are also required to inform post-stroke bone-health management and fracture-risk reduction.

Lost workdays and healthcare use before and after hospital visits due to rotavirus and other gastroenteritis among young children in Norway

BackgroundCost-effectiveness of rotavirus vaccination is affected by assumptions used in health economic evaluations. To inform such evaluations, we assessed healthcare use before and after hospitalisations due to rotavirus and other acute gastroenteritis (AGE) among children <5years of age in Norway and estimated daycare and work absenteeism. MethodsWe conducted post-discharge interviews with caregivers of 282 children hospitalised with AGE at two hospitals in Norway during April 2014–February 2017. We collected data on healthcare use and absenteeism from daycare and work. We examined healthcare seeking and absenteeism patterns for RV-specific and other gastroenteritis. ResultsCaregivers of 485 (37%) of 1 298 hospitalised children were invited to participate, and 282 (58%) completed the questionnaire. Among these, 106 (38%) were rotavirus-positive, 119 (42%) were rotavirus-negative, and for 57 (20%) children no rotavirus testing was performed. Overall, 97% of children had been in contact with a healthcare provider before hospital admission and 28% had contacted a healthcare provider after discharge. Children that attended daycare were absent from daycare for a mean of 6.3days (median 5days). Caregivers of these children reported work absenteeism in 74% of cases. The mean duration of work absenteeism among caregivers was 5.9days (median 5days) both for RV-positive and RV-negative cases. ConclusionIn Norway, work absenteeism and healthcare use before and after hospitalisation due to rotavirus and non-rotavirus gastroenteritis are considerable and impose an economic burden on the healthcare system and society.

The breath of life. Patients’ experiences of breathing during and after mechanical ventilation

IntroductionBreathlessness is a prevalent and distressing symptom in intensive care, underestimated by nurses and physicians. Therefore, to develop a more comprehensive understanding of this problem, the study had two aims: to compare patients’ self-reported scores of breathlessness obtained during mechanical ventilation (MV) with experiences of breathlessness later recalled by patients and: to explore the lived experience of breathing during and after MV. MethodA qualitatively driven sequential mixed method design combining prospective observational breathlessness data at the end of a spontaneous breathing trial (SBT) and follow up data from 11 post-discharge interviews. FindingsFour out of six patients who reported breathlessness at the end of an SBT did not remember being breathless in retrospect. Experiences of breathing intertwined with the whole illness experience and were described in four themes: existential threat; the tough time; an amorphous and boundless body and getting through. ConclusionBreathing was not always a clearly separate experience, but intertwined with the whole illness experience. This may explain the poor correspondence between patients’ and clinicians assessments of breathlessness. The results suggest patients’ own reports of breathing should form part of nursing interventions and follow-up to support patients’ quest for meaning.

A Missed Opportunity to Improve Patient Satisfaction? Patient Perceptions of Inpatient Communication With Their Primary Care Physician.

Improving patient satisfaction is a major focus of hospitals. Patient satisfaction could be driven by patient perception of hospital team communication with their primary care physician (PCP). A retrospective mixed methods approach was used to characterize the relationship between patient satisfaction and patient perception of hospital team-PCP communication. Data were obtained through general medicine inpatient and postdischarge interviews, oversampling "vulnerable elders," and a faxed PCP survey. Among 1044 patients and their PCPs, 22.3% of PCPs were not aware of their patient's hospitalization. Among PCPs who reported that communication did not occur, half (49.2%) of their patients thought communication had occurred, implying a lack of patient awareness of discontinuity of care and possibly impeding safety. Patients who perceived that communication occurred were more satisfied with care (70.0% vs 53.1%, P < .001). Therefore, hospitals could potentially improve patient safety and satisfaction by seizing a missed opportunity to improve patient awareness of communication.

Characteristics and Outcomes of College-Age Adults Enrolled in Private Residential Treatment: Implications for Practice

Substance use among college-age adults is of interest due to high levels of use and low levels of treatment access and engagement relative to other adults. Data collected from 1,972 clients in residential services were analyzed to investigate differences in use patterns, treatment outcomes, and other life area problems. Participants completed an Addiction Severity Index (ASI) and the University of Rhode Island Change Assessment (URICA) at baseline, and an ASI and Treatment Services Review at 1-month and 6-month postdischarge interviews. Almost a quarter (24.1%) of participants were college age (18–25 years old). They were more likely to be White and male, and less likely to complete treatment although they had a longer average length of stay. College-age adults improved on all outcome measures, and posttreatment service use shows significant difference between college-age and older participants. Implications for practice are discussed.

Parental Language and Dosing Errors After Discharge From the Pediatric Emergency Department

Safe and effective care after discharge requires parental education in the pediatric emergency department (ED). Parent-provider communication may be more difficult with parents who have limited health literacy or English-language fluency. This study examined the relationship between language and discharge comprehension regarding medication dosing. We completed a prospective observational study of the ED discharge process using a convenience sample of English- and Spanish-speaking parents of children 2 to 24 months presenting to a single tertiary care pediatric ED with fever and/or respiratory illness. A bilingual research assistant interviewed parents to ascertain their primary language and health literacy and observed the discharge process. The primary outcome was parental demonstration of an incorrect dose of acetaminophen for the weight of his or her child. A total of 259 parent-child dyads were screened. There were 210 potential discharges, and 145 (69%) of 210 completed the postdischarge interview. Forty-six parents (32%) had an acetaminophen dosing error. Spanish-speaking parents were significantly more likely to have a dosing error (odds ratio, 3.7; 95% confidence interval, 1.6-8.1), even after adjustment for language of discharge, income, and parental health literacy (adjusted odds ratio, 6.7; 95% confidence interval, 1.4-31.7). Current ED discharge communication results in a significant disparity between English- and Spanish-speaking parents' comprehension of a crucial aspect of medication safety. These differences were not explained purely by interpretation, suggesting that interventions to improve comprehension must address factors beyond language alone.

Quality of Discharge Practices and Patient Understanding at an Academic Medical Center

With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding. To conduct a multifaceted evaluation of transitional care from a patient-centered perspective. Prospective observational cohort study, May 2009 through April 2010. Urban, academic medical center. Patients 65 years and older discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. Discharge practices, including presence of follow-up appointment and patient-friendly discharge instructions; patient understanding of diagnosis and follow-up appointment; and patient perceptions of and satisfaction with discharge care. The 395 enrolled patients (66.7% of those eligible) had a mean age of 77.2 years. Although 349 patients (95.6%) reported understanding the reason they had been in the hospital, only 218 patients (59.6%) were able to accurately describe their diagnosis in postdischarge interviews. Discharge instructions routinely included symptoms to watch out for (98.4%), activity instructions (97.3%), and diet advice (89.7%) in lay language; however, 99 written reasons for hospitalization (26.3%) did not use language likely to be intelligible to patients. Of the 123 patients (32.6%) discharged with a scheduled primary care or cardiology appointment, 54 (43.9%) accurately recalled details of either appointment. During postdischarge interviews, 118 patients (30.0%) reported receiving less than 1 day’s advance notice of discharge, and 246 (66.1%) reported that staff asked whether they would have the support they needed at home before discharge. Patient perceptions of discharge care quality and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear. However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor. Patient perceptions and written documentation do not adequately reflect patient understanding of discharge care.

Abstract WP327: Strategies for Improving Stroke Caregiver Readiness

Introduction: Stroke occurs suddenly causing significant residual impairment for stroke survivors requiring long-term assistance by family caregivers. Becoming a caregiver can be an overwhelming, difficult process and stroke caregivers often experience poorer health and higher mortality rates than non-caregivers. Methods: In this grounded theory study, we explored stroke caregivers’ needs and assessed their capacity and readiness to assume the caregiving role as the stroke survivor transitioned home from inpatient rehabilitation. Our sample included a comparison group (9 patient/family units) and an intervention group (10 patient/family units) for a total of 19 stroke survivors and 22 family caregivers. Participants were interviewed during inpatient rehabilitation, and at 1 and 3 months post-discharge. In the first interview, comparison group questions focused on understanding family members’ perceptions about how prepared they were to assume the caregiving role. In the intervention group we conducted 1 hour interviews to assess specific domains of caregiver capacity and readiness to assume the role and reported the findings to the stroke rehabilitation team prior to discharge. In the 2 post-discharge interviews in both groups, we explored caregivers’ perceptions about how prepared they were to manage the stroke survivors’ post-discharge needs. Interviews were analyzed using dimensional analysis and coded in NVivo data management software. Findings: Family members in both groups indicated they were not “ready” to assume the caregiving role and there was not enough time for them to prepare pre-discharge. Dimensions of readiness included having the commitment, resources, and ability to sustain the role. Pre-existing conditions, such as physical and mental health concerns, other roles/responsibilities, and home inaccessibility limited their caregiving capacity. Conclusions: In order to adequately prepare family caregivers, we must assess their caregiving capacity pre-discharge and develop plans to address gaps so that they will be ready to assume the role long-term. Rehabilitation lengths of stay are often insufficient to address these gaps requiring interventions to help caregivers bridge the gap as they transition home.

Abstract WP369: Doctorate of Nursing Practice-led Transitions of Care Model for Stroke and Transient Ischemic Attack

Background and Purpose: The chances of experiencing a second event are significantly increased in those with recent stroke or transient ischemic attack (TIA). Gaps in care due to the movement of patients between health settings and/or practitioners, also known as transitions of care (TOC), may contribute to secondary events. The impact of TOC on stroke/TIA outcomes has not been thoroughly examined. The Doctorate of Nursing Practice (DNP) is a relatively new role within the nursing profession that provides advanced practice nursing care, leadership and research expertise. As the first phase of a long term goal to evaluate a DNP-led TOC model specific to the stroke/TIA population in Southeastern Arizona, the purpose of this study was to identify the essential elements of a model specific for stroke/TIA using data from one urban primary stroke center. Methods: 1) Existing TOC models such as PRISMA, Hospital to Home, and STEPS were identified with applicability to the stroke/TIA patient. 2) Get With The Guidelines [GWTG®]-stroke database from a primary stroke center located in an urban setting in Southern Arizona was used to identify patient demographics and the essential elements that best reflect TOC. Results: We found 1) the Care Transitions Intervention model best suits a DNP-led TOC model for stroke-TIA. Key elements of this model include an interdisciplinary team approach utilizing case-management strategies, discharge planning, and patient self-management education. In addition, the advanced practice nurse has been found to be most successful in leading TOC models aimed at reducing readmissions. 2) Key outcome variables in a stroke specific TOC model include frequency of admission/readmission, patient demographics, prior hospitalizations, length of stay, discharge disposition, presence of stroke risk factors and urban vs. rural settings. 3) Post-discharge phone interviews may be needed to explore gaps in care not captured in GWTG. Conclusions: While TOC models have been described for other diagnoses, models for stroke/TIA are lacking. The use of the Care Transitions Intervention model for stroke/TIA could yield important reductions in the burden, morbidity, and mortality of stroke/TIA in Southeastern Arizona and thus, deserves further study.

Medication Reconciliation Accuracy and Patient Understanding of Intended Medication Changes on Hospital Discharge

Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding. To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications. Prospective cohort study Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home. We assessed medication reconciliation accuracy by comparing admission to discharge medication lists and reviewing charts to resolve discrepancies. Medication reconciliation changes that did not appear intentional were classified as suspected provider errors. We assessed patient understanding of intended medication changes through post-discharge interviews. Understanding was scored as full, partial or absent. We tested the association of relevance of the medication to the primary diagnosis with medication accuracy and with patient understanding, accounting for patient demographics, medical team and primary diagnosis. A total of 377 patients were enrolled in the study. A total of 565/2534 (22.3 %) of admission medications were redosed or stopped at discharge. Of these, 137 (24.2 %) were classified as suspected provider errors. Excluding suspected errors, patients had no understanding of 142/205 (69.3 %) of redosed medications, 182/223 (81.6 %) of stopped medications, and 493 (62.0 %) of new medications. Altogether, 307 patients (81.4 %) either experienced a provider error, or had no understanding of at least one intended medication change. Providers were significantly more likely to make an error on a medication unrelated to the primary diagnosis than on a medication related to the primary diagnosis (odds ratio (OR) 4.56, 95 % confidence interval (CI) 2.65, 7.85, p<0.001). Patients were also significantly more likely to misunderstand medication changes unrelated to the primary diagnosis (OR 2.45, 95 % CI 1.68, 3.55), p<0.001). Medication reconciliation and patient understanding are inadequate in older patients post-discharge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be disease-specific, but should be focused on the whole patient.