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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
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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
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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
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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
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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)
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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
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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
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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
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.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
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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
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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
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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
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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
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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)
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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