Improving discharge planning after stroke

The head of the stroke unit selected discharge planning as a priority after a patient was readmitted with a second stroke following discharge without secondary prevention medication.

Apart from reducing the risk of another stroke, formal discharge planning can improve the coordination of services and reduce long-term unmet needs for people who have had a stroke. It is also part of the Clinical Guidelines for Stroke Management and the Acute Stroke Clinical Care Standard, so improving practice in this area would help the hospital meet Action 1.27 of the NSQHS Clinical Governance Standard. 

The hospital already contributes to the Australian Stroke Clinical Registry (AuSCR), so no new data collection would be needed. Benchmark, national and state data are also available for comparison, from sources including AuSCR and The Stroke Foundation.

The Stroke Unit’s Head of Department and Clinical Nurse Consultant decided to review the hospital’s AuSCR data for the previous year, along with national and state data. They chose two of the indicators related to discharge planning as their initial focus:

• Care plan provided at discharge
• Discharged on an antihypertensive medicine.

The Clinical Nurse Consultant generated a report from the online AuSCR portal. The hospital was close to average for most indicators but performed poorly on the measures of discharge planning. 

Only 49% of patients had a care plan on discharge after a stroke, compared to the national average of 59% and the benchmark of 95%. And 60% were discharged on antihypertensive medication, compared to the national average of 70%.

After ruling out data errors as a factor, the Clinical Nurse Consultant presented the results at a meeting of clinical staff who contribute to discharge planning for stroke patients. The group included medical, nursing, pharmacy and allied health staff.

The group decided differences in case mix, structure or resources of the hospital did not explain the poor results. They identified several aspects of processes and practice that were contributing to inconsistent discharge care planning:

• Lack of awareness, compounded by rotation of staff
• Lack of an appropriate template
• Inconsistent prescribing of secondary prevention medication.

At a follow up meeting to discuss strategies to improve discharge planning, the group agreed to a range of changes:

• Senior medical, nursing and allied health staff to raise discharge care planning for stroke patients on all ward rounds over the following two weeks, and to lead education sessions on the importance of discharge care planning in the following month
• Discharge care planning to be included in orientation of new staff
• The checklist for leaving hospital in the Stroke Foundation booklet ‘My stroke journey’ to be used as a template for discharge planning
• Recommendations and evidence for secondary prevention medication to be added to bedside charts as a reminder
• Pharmacy staff to alert the medical team if secondary prevention medications are not included in discharge medications.

Follow up after three months showed a small improvement in both indicators, but the hospital was still below the national averages. To improve discharge planning further, a stroke ‘in-reach’ team of medical and allied health practitioners was formed to review all stroke patients before discharge.

Review after a further three months showed that the hospital had reached the national averages for percentage of stroke patients with a discharge plan and for prescription of secondary prevention medication. Results for all indicators from the registry are reviewed every quarter at a multidisciplinary stroke meeting. Priorities for new quality improvement initiatives are also discussed in light of the hospital’s performance in comparison to national and state data.