Improving Post-Stroke Outcomes With Personalized Discharge Instructions

Marian LaMonte, MD, MSN, FAAN

Implementing simple educational and decision-support interventions improved physician compliance with providing patient-specific stroke discharge instructions (DCI) in a recent study conducted at Ascension Saint Agnes Hospital. The findings were presented virtually by Marian LaMonte, MD, MSN, FAAN, chief of neurology, at the 2021 American Academy of Neurology (AAN) Annual Meeting, April 17-22.

LaMonte and colleagues implemented an intervention bundle that consisted of simple educational activities, reminders, and decision-support tools in the hospital’s electronic medical records (EMR) system. This intervention increased compliance in providing stroke-specific DCI by 38.6%, from 51.9% pre-intervention to 90.5% within 4 months. More than a 30% and 60% improvement in compliance was seen in the teaching service (from 60.0% to 90.5%) and non-teaching service (from 25.0% to 87.5%), as well.

NeurologyLive spoke to LaMonte to learn more about what prompted the need for the intervention and the importance of providing dedicated stroke DCI. She detailed how specific DCI can help patients during their rehabilitation and lower their recurrent stroke risk.

NeurologyLive: What prompted the study? Can you expand on the need for dedicated stroke DCI?

Marian LaMonte, MD, MSN, FAAN: So, part of the American Heart Association and Stroke Association’s mission is to provide as much education to stroke patients as possible prior to their leaving the hospital and being able to look at that information once they get home and review it. That being said, at our hospital and at many hospitals, it turns out we have a very difficult time ensuring that patient DCI are specific to an individual patient's risk factors, rather than just general information about stroke that might not pertain directly to issues they personally need to address for future health. So, we recognized that that was happening and we produced a set of DCI that could be electronically added to the patient's discharge paperwork and printed out for the patient, and the nurses go over that information for the patient. So, it's individualized, but it also includes some general measures such as adequacy of sleep, possibly advising an evaluation for obstructive sleep apnea. These are things that we can't do in the hospital while they're acutely ill. So, it has mainly their individual risk factors, but then also some general issues that happen to stroke patients that they should be aware of and have their doctors follow up on.

We were having a problem with getting this electronic information given to most of our stroke patients, so we decided to use the electronic system that we have to see if there were any simple maneuvers in the EMR to assist physicians and make sure they click on and provide those instructions for their patient. We found a relatively simple work around. We have an older EMR system here at St. Agnes called MEDITECH, which is still widely used in the US. It has some features that allowed us to block the incorrect general DCI that we found was mostly being used and only allowed for the individual stroke DCI. This brought the compliance rate up dramatically. It was one of those simple fixes that provides such a great difference in a patient's life. It was very satisfying.

How could dedicated stroke DCI improve patient care and rehab?

We provide, in writing, to a patient and their family, the specific risk factors that we uncovered while they've been in the hospital that we think are associated with their stroke, how you can treat them, and what medicine exactly you should be on for these risk factors. We provide a medication list and what each medicine is used for to combat your risk factors for stroke and what you can do, generally, to have a healthier lifestyle to reduce your risk of stroke. This includes stopping smoking; we provide a lot of information on many places that they can get help with smoking cessation, alcohol abuse, or drug use, which is, unfortunately, prevalent in our society. So, the DCI includes this in simple and straightforward terms. The nurses go over the DCI individually with the patient and their family before they leave. We ask them to bring the DCI to their rehabilitation evaluation and to their first follow-up doctor's appointment. That's how we help communicate what happened in the hospital with their outpatient doctors and therapists.

Transcript edited for clarity. For more coverage of AAN 2021, click here.

REFERENCE

Asfaw M, LaMonte M. Improving stroke patient discharge instructions use. Presented at 2021 American Academy of Neurology Annual Meeting; April 17-22, 2021. Abstract P5 119