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Discharge Care Planning For Survivors of Stroke in
Australia: Patient Perceived Quality and a Novel
Intervention to Improve Hospital Adherence
Nadine Andrew
NHMRC Research Fellow
Translational Public Health Division, Stroke & Ageing Research
Monash University
Translational Public Health DivisionStroke & Ageing Research, School of Clinical Sciences, Monash University
Our team works collaboratively with a number of policy and
research partners to provide the evidence needed to improve
the prevention, clinical care and outcomes of stroke
Measuring the quality of stroke care: The
Australian Stroke Clinical Registry (AuSCR)
• National collaborative effort to monitor and improve acute
stroke care in Australia (established 2009)
• Data on all stroke and TIA admissions (52 hospitals)
• Quality of care indicators:
1) admitted to a stroke unit
2) given thrombolysis if an ishaemic stroke
3) prescribed antihypertensive medication at discharge
4) received a care plan in consultation with the patient and
their family if discharged to the community
• Outcome data at 90-180 days following stroke
AuSCR
• Monitoring tool
– State governments (e.g. Victoria and Queensland)
– Site/hospital level
• Large amount of data (>25,000 registrants) for
examining variations in care for sub-groups
e.g. young stroke patients, in-hospital stroke
• Quality improvement research
– Data on program performance
– Recruiting research participants
AuSCR related projects
• Stroke123 (NHMRC Partnership Grant)
– Queensland sub-study / StrokeLink
• Improving discharge from hospital after stroke (Nancy and Vic Allen stroke prevention fund)
• The impact of discharge planning on post-
discharge stroke outcomes (NSF project grant)
Stroke care in Australia
• Over 50,000 strokes per year
• Leading cause of adult disability
• Most (88%) are eventually discharged home
• 5 year risk of recurrent stroke:
– women 24%
– men 42%
• Discharge care planning is important for:
– successful integration back into the community
– secondary prevention of stroke
Evidence to practice gaps
• Evidence of poor adherence to acute care practices
recommended in the national clinical guidelines
• NSF Audit 2013 data
– 50% of patients received a care plan on discharge
– 46% received behaviour change education
– 77% were prescribed antihypertensive medication at discharge
• AuSCR 2013 data
– 55% of patients received a care plan on discharge
– 71% were prescribed antihypertensive medication at discharge
2009-2013 data
9%
6%
24%
23%
25%
8%5%
Discharge destination from acute
care
Died in hospital
Residential care
Home with supports
Home without supports
Rehabilitation (Inpatient)
Hospital
Other
.85
.9.9
5
1
Surv
ival
0 30 60 90 120 150 180 200
Days post-discharge
Discharged on an antihypertensive medication
Not discharged on an antihypertensive medication
Cox proportional hazards regression
Survival at 180 days following stroke
Impact of discharge planning on
outcomes
AIMS
1) To describe patients’ perceptions of their
discharge planning process from the acute
hospital setting
2) To understand the relationship between: the
quality of stroke discharge planning; post-
discharge quality of life; and unmet needs
Funded by: National Stroke Foundation Small Project Grant
PI: Nadine Andrew, CIs: Dominique Cadilhac, Monique Kilkenny
Methods
Participants were:– Recruited through AuSCR
– Discharged to home from acute care hospitals
– Approximately 6 months post-stroke
Surveys:– PREPARED (Grimmer et al 2001)
– Long Term Unmet Needs following Stroke
(LUNS)
– Questions about stroke specific information
Methods
Survey data were linked to AuSCR data to
provide information on:
(i) Clinical characteristics– Stroke severity
– Stroke type
– Previous history of stroke
– Demographics
(ii) Outcomes– Quality of life (EQ-5D)
– Living situation
Proportion of respondents who were fully
satisfied for each PREPARED domain
N=218
0
10
20
30
40
50
60
70
80
90
100
Support structures Medicationmanagement
Communitymanagement/coping
Control of discharge Prepared overall
Factors associated with discharge
quality
• Receiving hospital specific information was
associated with satisfaction with:
– support structure information (p=0.001)
– medication management (p=0.01)
• Being young (<65 years) was associated with
reduced satisfaction with community management
(i.e. not coping) (p=0.005)
• Being discharged in the afternoon was associated
with increased control of discharge (p=0.006)
Multivariable results – PREPARED survey scores and outcomes at 3-6 months following stroke
Models were adjusted for ability to walk on admission, age, gender, in-hospital stroke, stroke type, previous stroke and socioeconomic position
Improving discharge from hospital
after stroke
Aim
To designed and pilot a program to support clinical
practice improvement targeting discharge care
planning
Funded by: Nancy and Vic Allen stroke prevention fund
PI: Dominique Cadilhac, CIs: Nadine Andrew, Enna Salama
Improving discharge from hospital
after stroke
• AuSCR Queensland data from January 2012 to
July 2013 were used to select:
2 top performing hospitals to identify
enablers
2 hospitals with less than average
performance considered suitable for trialling
a quality improvement intervention
Improving discharge from hospital
after stroke
Intervention development
– Focus groups with exemplar hospitals
– Evidence from the literature
– Expert Working Group, which included
consumer representatives, guided design and
delivery
– Evidence based implementation using the
Theoretical Domains Framework (Grimshaw et al)
Intervention delivery: Workshop 1
Participants: Staff involved in delivering discharge
processes e.g. medical, nursing, pharmacy, allied
health and administrative staff
• Dissection of the sites AuSCR data
• Review of current practices and systems
• Discussion re. facilitators and barriers to
changing practice based on working group data
• Gap analysis of best practice vs current practice
Intervention delivery: Workshop 2
• Clinical champion presented objectives and evidence
• Presentation of current quality improvement practices
and how to build on these
• Discussion of implementation strategies deemed
feasible by the sites in Workshop 1
• Development of local action plans (based on methods
by Grimshaw and Michie)
• Clear goals were outlined and key stakeholders and
timeframes were agreed upon
Michie S et al, Ann Behav Med. 2013;46:81-95
Grimshaw J, et al. Implementation Science. 2012;7:1-17
Ongoing support
• Project officer helped sites work towards
the agreed goals
– email contact
– face-to-face visits with staff
• Performance monitoring and feedback
using AuSCR data
Results: expert working group
Patient factors
• A multidisciplinary approach to education and
communication
• Opportunities for doctors to undertake education
with patients and families at outpatients
• Empowering patients through the use of consumer
developed discharge tools
Results: expert working group
Clinician factors
• Multidisciplinary team approach
• Willingness to review and improve practice
• Social work and discharge coordinators were key
• Other disciplines provided backup if something
was missed prior to discharge
• Regular formal and informal communication
• Ongoing education especially for new staff
Results: expert working group
System factors
• Discharge planning starts at admission
• Dedicated Discharge Officers (administrative
staff) and a discharge room/space
• Effective use of electronic automated systems
Enterprise Discharge Summary (EDS)
• Good systems of documentation to monitor
processes
• Strong ties with local community and services
Action areas - pilot hospital 1
• Interdisciplinary care
• Consistent use of eLMS (Enterprise Liaison Medication
Summary) and EDS (Enterprise Discharge Summary)
• Consistent prescriptions of discharge medication
• Staff education
• Developing consistent discharge processes
• Improve procedural knowledge
• Quality control of discharge process
• Consistent documentation
• Data Quality including reliability of AuSCR data
Action areas - Pilot Hospital 2• Pharmacy involvement at ASU meetings / increased
pharmacy resources
• Consistent use of eLMS (Enterprise Liaison Medication
Summary)
• Training for new staff
• Awareness of practice gaps
• Consistent discharge processes
• Improve knowledge about discharge plan eligibility
• Role definition / designated roles
• Inconsistent documentation
• Data Quality including (reliability of AuSCR data), data
recording when medical charts unavailable
Hospital 1 Site 2
Pre-
intervention
adherence
Post-
intervention
adherence
P-
value
Pre-
intervention
adherence
Post-
intervention
adherence
P-
value
Discharge care plan 67/126
(53%)
10/10
(100%)0.004
6/31
(19%)
9/11
(82%)<0.001
Antihypertensive
medication149/230
(65%)
20/29
(69%)0.66
22/42
(52%)
16/20
(80%)0.04
Results: Pre intervention vs
post intervention
Pre-intervention period: January 2014 to June 2014
Post-intervention period: October 2014 to November 2014
Discharge care plan
adherence
Pre-Intervention
Post-Intervention
0
10
20
30
40
50
60
70
80
90
100
15 25 35 45 55 65
% Care plan
Hospital ID
Results: Pre intervention vs
post intervention
Site 1
Site 2
Conclusion
• Good discharge planning can improve patient
outcome and reduce unmet needs
• Discharge planning is often sub-optimal
• Key factors for improving discharge planning:
– Multi disciplinary team approach
– Dedicated discharge staff
– Effective use of existing systems
– Performance monitoring and documentation
– Strong engagement with patients, family and community