Digital Repository Doctoral Projects Spring 2021 Cerebrovascular Accident Education and Follow-up Care Roxanne Butterfield, MSN, RN, CRRN Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Butterfield, R. (2021). Cerebrovascular Accident Education and Follow-up Care Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Cerebrovascular Accident Education and Follow-up Care by Roxanne Butterfield A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 20, 2021 Mary Anne Hales Reynolds PhD, RN, ACNS-BC_ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 1 Cerebrovascular Accident Education and Follow-up Care Roxanne Butterfield, MSN, RN, CRRN Annie Taylor Dee School of Nursing, Weber State University CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 2 Acknowledgements I would like to give my thanks to those who have helped me along the academic journey in obtaining my Doctor of Nursing practice (DNP). I would first like to thank Dr. Mary Anne Reynolds for her encouragement, help, guidance, and unending patience with me. I would also like to thank the DNP faculty for making this degree possible and for the countless hours spent on teaching classes and grading papers as well as mentoring this first DNP cohort at Weber State University. I would like to acknowledge my wonderful co-workers and preceptors. Jamie D’Ausilio and Brandon Taylor have both been instrumental in helping me with my project and facilitating my progress, and the entire NSRU team who without their help this project would not have been possible. I am forever grateful for my fellow classmates and peers and they have been a source of inspiration and support throughout this entire program. Last and certainly not least, I would like to thank my children Lesley, Mikkal, Jenessa, and Jacob for their understanding and help. They have been such a resource and constant force in my life from the time I first started taking my first nursing classes 12 years ago. Also, thanks to my husband, Blake, who read and reread my papers. Thanks to all who have been involved and offered words of encouragement and praise. To my mom and dad who would be so proud of this educational pursuit, thank you. CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 3 Abstract Education and follow-up care after surviving a cerebrovascular accident or stroke can be disjointed and confusing for patients and families. Stroke patients admitted to St. George Regional Hospital Neuro Specialty Rehabilitation Unit require comprehensive stroke education, caregiver training, discharge teaching, and proper follow-up care to prevent costly hospital readmissions. The purpose of this DNP project was to implement an interdisciplinary stroke rehabilitation stroke program to reduce 30-day stroke readmissions and increase patient awareness of the importance of follow-up care. project included implementing a patient and family education program about stroke management, a standardized discharge process, and a post-discharge follow-up phone call. An interdisciplinary team developed the curriculum. The discharge checklist included what a patient or family member would need to know before discharging home. The post-discharge phone call was a reminder to the patient about following up care. Twenty-two had completed discharge checklists in their charts, and twenty-six patients received a follow-up phone call. Follow-up phone call attempts were made to twenty-six patients and reminded each patient about the importance of follow-up care. Patient satisfaction scores increased by 4%. Transitioning from rehabilitation to home is a critical time for stroke patients and their families. Properly educating the patient and family can help prepare them for life going forward following the stroke. The efficient/safe transition of care and standardized discharge teaching have the potential to improve post-discharge recovery and reduce costly readmissions. Keywords: stroke, rehabilitation, education, readmissions CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 4 Cerebrovascular Accident Education and Follow-up Care Nearly one-fifth of Medicare patients discharged from a hospital post cerebrovascular accidents or stroke are re-hospitalized due to an acute medical condition within 30 days (Slocum et al., 2015). Recently discharged patients are assumed to be more vulnerable to subsequent medical complications due to “post-hospital syndrome” resulting from additive effects of their original medical condition and stresses from hospitalization itself. Reasons for acute care readmission in the inpatient rehabilitation populace are complex and likely multifaceted (Fisher et al. 2016). Many readmissions can be prevented through proper education and continuing care along the continuum. There are several care barriers during the hospital to home transition phase that are associated with an unsatisfactory discharge planning process. Some of these barriers include not adequately preparing stroke patients and their caregivers with the education and skills to cope with the disability. This can threaten stroke survivors’ safety and significantly impact their rehabilitation (Chen et al., 2016). A stroke is a catastrophic event that may suddenly and completely change the lives of the stroke survivor and family, highlighting the need for a network of rehabilitation programs and services to support stroke survivors and caregivers through the stroke rehabilitation journey to home. Literature Review Search A comprehensive review of the literature for 30-day stroke readmissions, stroke outcomes, interdisciplinary education, and discharge transition of care was conducted. The databases used for conducting the search included CINAHL, MEDLINE, PubMed, and Nursing Reference Center Plus. Using search terms; stroke rehabilitation, stroke readmissions, CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 5 interdisciplinary teaching, discharge teaching, and follow-up care for stroke patients produced a rich variety of research articles and guidelines. Cerebrovascular Accident Cerebrovascular accident (CVA) or stroke affects approximately 795,000 people every year in the United States and roughly 140,000 per year will die as a result (Center for Disease Control and Prevention, 2021). For those who survive, the effects of the stroke vary but are often life-changing and costly. It is estimated that by 2030, an additional 3.4 million adults in the United States will have had a stroke. This is an increase of 20.5% from 2012 (Poston, 2018). According to Boehm et al (2017) a stroke can occur at any age but is more likely to happen in the older populations. Statistics indicate that about one in four stroke survivors will have another stroke. There are, however, many risk factors that can be addressed with more education and follow-up care (Stroke, 2019). There are modifiable and non-modifiable risk factors associated with stroke. Modifiable risk factors include hypertension, diabetes mellitus, hyperlipidemia, smoking, and previous stroke experience. Non-modifiable risk factors are sex, age, race, and genetics (Boehme et al, 2017). Women are more at risk than men for stroke because the incidence increases with age. African Americans are twice as likely to experience a stroke than the rest of the population. Managing modifiable risk factors, combined with more education are crucial elements in prevention and reducing re-admission for strokes. A stroke is a sudden interruption to the brain’s blood supply. Most strokes are caused by artery blockage within the brain and are called ischemic strokes. Hemorrhagic strokes occur when a blood vessel bursts and causes bleeding within the brain tissue. Both types of strokes require immediate treatments. Symptoms of stroke may be sudden weakness, loss of sensation, CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 6 trouble speaking, hearing, or walking, and or sudden severe headache, difficulty seeing, and confusion (Stroke Center, 2020). Various parts of the brain control certain areas and functions of the body. For this reason, the predictive expectations can be presumed as to which regions of the body may be affected. People with stroke sometimes get a mild headache as an initial symptom, but stroke can also be completely painless and often comes without warning. As the onset of stroke progresses, sudden eye, arm, or leg paralysis are common signs of ischemic stroke, particularly, if occurring on one side of the body. Confusion and trouble speaking or understanding speech are also common symptoms of stroke. The diagnosis of an acute stroke requires immediate emergency care and intervention to lessen its severity and stabilize the patient (Stroke Center, 2020). Physical Changes The effects of a stoke vary depending on severity and hemispheric location. The brain is divided into three major areas, cerebrum (right and left sides), cerebellum (top and front of the brain), and the brainstem (base of the brain). A stroke in the cerebrum can cause general impairment of movement, sensation, speech, language, eating, and swallowing. Also, vision, cognition perception, and orientation, bladder and or bowel control, and emotional stability can be adversely affected. Function that was normal prior to a stoke may be impacted by weakness or paralysis. A stroke in the cerebellum or brainstem elicits other types of impairments depending on the severity of the stroke such as balance, dizziness, headache, body temperature control, breathing, heart function, and in some cases even death (John Hopkins Health, n.d.). These changes of bodily physical and cognitive function can further lead to serious safety concerns related to swallowing, walking, and interfering with other activities of daily living. Psychological changes CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 7 Stroke effects can be both physical and psychological. Having a stroke can affect one’s personality. An individual may laugh or cry and not understand the reason behind the emotion. Emotional lability following stroke is considered quite normal for stroke victims although such responses may seem out of context or out of character for that individual. This is also referred to as the pseudobulbar effect. Depression and anxiety are common among stroke survivors (Stroke Foundation, 2020). It has been shown, however, that patients, who have depressed moods following stroke, have poorer outcomes during rehabilitation than patients who are not depressed. As expected, stroke survivors, who suffer from depression, have difficulty returning to their prior social activities compared to nondepressed survivors. The need to recognize and treat early post-stroke depression is important because it has been shown to help patients regain functional skills and return to social activity. In fact, there are several antidepressants and other medications used in treating post-stroke depression (Bilge et al, 2007). Because of the long physical recovery process of a stroke, additional components such as emotional recovery often come into play. A study, conducted by Taule et al. (2015) highlights the emotional toll that stroke has on survivors, and suggests why this must be dealt with for proper healing to occur. Stroke survivors often mourn the loss of the life they once had before the stroke, and hospital physicians are not always the best equipped to address this important aspect of healing. These patients express the need and desire to have empathetic professionals with understanding of the emotional and social concerns they now face going forward. Home health professionals need to have an individualized approach to each patient’s treatment plan that addresses the emotional impact as well as the physical barriers that each patient faces (Stroke, 2019). Care must include treating the emotional trauma along with physical disabilities. Not only does emotional trauma hinder healing, but it is also another risk factor in readmission. Education, CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 8 multidisciplinary team, and follow-up care both physical and emotional, are necessities to reduce readmissions and help patients live as independently and healthy as possible. Stroke rehabilitation can help patients gain function and improve post-stroke quality of life. Stroke Rehabilitation Once a patient is medically stabilized, stroke rehabilitation begins at the hospital or stroke center. The goal of stroke rehabilitation is to help a stroke survivor gain function that may have been lost due to the stroke. Using an interdisciplinary team approach, the stroke rehabilitation patient will work with a physical therapist to gain functional skills in mobility, and an occupational therapist to facilitation movement in activities of daily living such as bathing, dressing, toileting, eating, (American Stroke Association, 2019). Stroke patients also may need to work with a speech therapist to gain function in swallowing, cognition, word pronunciation, and problem solving. A team of rehabilitation nurses will teach the patient about bowel and bladder management, medication education, and how to adjust to life following the stroke. Even though severe disabilities and neurological impairments are quite evident during the early post-stroke phase, many stroke patients in comprehensive rehabilitation programs achieve significant degrees of function over time (Lee et al., 2015). Some stroke survivors may show early motor recovery function within a few months. Although the degree of paralysis is a major predictor, it cannot be used to precisely predict the rate of motor recovery function during the sub-acute stage of the stroke. Patients progress at their own rate and some recover function faster than others. Stroke recovery can be a long and difficult process, requiring an interdisciplinary approach whose focus is educating the patient and family or caregiver. Recovery takes time and will most likely happen if at all in the home after leaving the hospital (Delgado, 2018). Education CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 9 Once a patient is stabilized, they begin the road to recovery and rehabilitation. This includes education about prevention, function, and adjusting to a new normal. Education, discharge preparation, and follow-up care are key to reducing reoccurrence and readmissions. It is imperative to look at preventable measures along with the unpreventable risk factors to fully understand the significance of the problem (Nouh et al., 2017). For the best experience, education must include patients, families, and or caregivers. Education does not only focus on activities of daily living (ADL’s) as to how to function with this new disability, but it also addresses other factors, both physical and psychological, associated with stroke to alleviate concerns down the road. Providing stroke awareness education to patients and caregivers is required of hospitals that are certified Stroke Centers. Hospital environments, however, seldom have ideal conditions to facilitate learning. It is important to note that learning for a new stroke patient can be challenging because of fear, anxiety, and impairments caused by the stroke. Strategies capable of enhancing knowledge of stroke and self-management skills are essential to the prevention of secondary stroke, as well as detection and reaction to the new symptoms of stroke (Johnson et al., 2018). Education and follow-up care, both physically and emotionally, are necessary to help patients live as independently and healthy as possible while reducing readmissions to the hospital. Prevention The effect a stroke can have on a patient and their family/caregiver can be unpredictable or even unique, depending on the degree of impairment suffered. A patient who has been affected by a stroke is prone to other serious problems such as, urinary tract infections, pneumonia, pressure sores, and pulmonary embolism. Some of these can be life threatening. CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 10 Patients and caregivers will need to learn about medication management to make sure medications are administered correctly and compliance is maintained (Boehme et al., 2017). Diet and exercise are important factors that may lessen the chances of additional strokes. Other concerns, such as weight loss, glucose control, hypertension, hyperlipidemia, and being familiar with signs and symptoms of stroke are important for stroke survivors. As mentioned, modifiable risk factors such as hypertension, diabetes, atrial fibrillation, dyslipidemia, obesity, smoking, alcohol consumption, smoking, inflammation, and infection can be controlled to reduce possible recurrence (National Institute of Neurological Disorders and Stroke, 2020). Function Physical therapy and occupational therapy are important in helping a stroke survivor to adapt to their disability. Motor impairments are common for most stroke survivors. Because difficulty and loss of mobility are some of the most devastating aspects of a stroke, restoring gait function is often one of the primary goals of rehabilitation. A physical therapy team will work with the patient along with occupational therapy to restore mobility and purposeful movement (Nilsen & Geller, 2015). This may be done in several ways depending on the patient’s deficits. Some stroke survivors may require an adaptive device such as a walker or a cane to gain mobility while others may need the aid of a wheelchair to get around. Whatever the case may be, physical therapy will help the patients adapt (American Heart Association/American Stroke Association Guidelines, 2016). The occupational therapy team will work with the stroke survivor to gain function and facilitate movement in ADLs such as bathing, grooming, toileting, dressing, etc. Patients undergoing occupational therapy services are less likely to deteriorate and more likely to be confident of their capacity to carry out every day personal activities. Occupational therapy is CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 11 aimed at helping people reach their full degree of function and flexibility in all facets of daily life (Legg, et al. 2006). Occupational therapy specialists will work with the rehabilitation team to restore function to the patient and help make the necessary adaptations for the patient to obtain and maintain independence. Adaptation Stroke affects the ability of a person to engage in everyday life and is obviously an obstacle to living a normal life as compared to one’s peers. A neuropsychologist and or social worker will help the patient and family understand the emotional aspect of stroke. The social and emotional consequences of stroke for patients can include guilt, changes of temperament, and role change (Fens et al., 2015). For example, suddenly the husband or child becomes the caregiver. A stroke survivor may have a multitude of emotions such as shame, bitterness, and grief are often reported after a stroke. Some patients feel relief that their stroke was not worse, while others feel hopelessness, shame, and despair (Bucki et al., 2019). The overall goal is to improve quality of life by improving function and adaptation. Managing the emotional impact that stroke may have on a patient and their family is a big part of the rehabilitation experience and recovery. Outcomes Quality of Life Life following a stroke will look different for each stroke survivor. Overall, every stroke survivor is unique and will have different combinations of impairments. Function may return in certain patients while others will not regain much. Learning to cope with the new impairments can be challenging. A stroke often leaves a person with residual impairment of physical, psychological, and social function, thus undermining the ability to carry out daily activities. CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 12 According to Lo Buono et al., (2017) many patients report a reduction in quality of life after stroke including physical, emotional, and cognitive impairments with the most affected component of health-related quality of life being that of physical well-being. Even so, stroke survivors can often still lead a full life with the right support and rehabilitation. Decreased Readmissions Stroke patients typically have a high rate of 30-day readmission. Readmissions can be harmful to the patient and are costly to the hospital. Studies recently have estimated the cost of unplanned readmissions through Medicare and Medicaid services is about $17 billion annually in the United States (Reardon, 2015). As a result, hospitals have been tasked with reducing 30-day readmissions to avoid payment penalties. To reduce readmissions and have better patient outcomes, it is imperative to look at preventable measures and unpreventable risk factors to fully understand the significance of the problem (Nouh et al., 2017). Stroke awareness, and comprehension of stroke symptoms and risk factors are essential components of reducing recurrent stroke risk and hospital readmissions (Denny et al., 2017). The Joint Commission (2019) and other major quality improvement organizations have acknowledged the value of awareness enhancement, hence, the need for stroke education for patients and their families. Interdisciplinary Cerebrovascular Transition Program According to Polster (2015) as many as 79% of readmissions are preventable. The Joint Commission (2019) suggests a multifaceted approach that involves clarification of discharge instructions, self-care and emergency treatment, medication reconciliation, and clear guidance for patient and families. A well-orchestrated team of nurses, physicians, pharmacists, respiratory therapists, dieticians, and care managers all working together to provide the necessary education, can reduce readmissions and increase quality of life for the patient. CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 13 Clark and Forster, (2015) conducted a study on improving post-stroke recovery and multidisciplinary team approach versus an interdisciplinary team approach. Their findings show that collaboration between all health professionals is required and should extend the entire stroke pathway (the continuum of care). Compared to simple treatment regimens in lessor equipped institutions, a team working collaboratively that adapts an interdisciplinary approach is a superior contributor to quality care, and clearly benefits stroke patients receiving the training and skills needed to return home. Creating a culture, where all members of the team work together to ensure an interdisciplinary team approach, should be a fundamental part of a patient’s day. The entire team should be encouraging the patient to practice the skills learned and incorporate them into activities of daily living (Aries & Hunter, 2014). Individualized Plan of Care and Follow-up All patients should have an individualized plan of care (IPOC) documented in their medical chart. The Centers for Medicare and Medicaid Services require patients of inpatient. rehabilitation facilities to have a documented IPOC. These individualized plans include goals and outcomes that are uniquely tailored to the needs of each patient. A study by Mercer et al. (2015) showed that the quality improvement intervention using individualized treatment plans decreased hospital visits, 30-day readmissions, and hospital costs across the national health system for a diverse group of patients. As therapists work with patients, it is important for nurses to know how the therapist would like the patient transferred and attended to, and other interventions that will benefit the patient to gain movement and function. It is crucial that this information be passed on to those who work with the patient. This is best communicated through documentation in an electronic medical record. The electronic medical record also is used to track progress toward the patient’s rehabilitation goals and overall plan of care. CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 14 Condon et al., (2016) study indicated that 30-day stroke readmissions were reduced by as much as 48% for those patients who received a phone call from a registered nurse post-discharge and follow-up appointment at a stroke clinic. Supporting patients and caregivers to become involved allies and supporters of post-discharge care by education is essential. Identifying what patients can expect once they transition home can help to reduce hospital readmissions. Providing information and resources is part of the overall education for the patient and family member or caregiver (Poston, 2018). Theoretical Model To effectively implement a quality improvement project, it is important to fully understand the situation, need, or problem. Lewin’s force field model of change focuses on a team identifying a gap or change, analyzing, and adjusting as needed based on driving forces (Finkelman, 2018). Driving forces are those needing change and resistant forces are those that tend to keep the status quo. Lewin’s Change theory is constructed of three changes: unfreezing, planned change, and refreezing. Unfreezing is getting ready to make a change that deviates from the prior process. It can be classified as one of the most important stages of change. Purposeful change involves a clear purpose for the change and active involvement by an entire team. For the proposed change to be successful, it will require team commitment and involvement. Refreezing is establishing stability with the new process, getting comfortable, and making it the new norm. The forcefield model helps to guide the implementation of the stroke wellness program in an inpatient rehabilitation unit. Unfreezing involved preparing staff members for a change in the current process currently being followed for stroke patient education on the Neuro Specialty Rehabilitation Unit. Next, the staff was educated on the checklist and follow-up phone call process. Therapists were CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 15 also educated on the video that needed to be shown to stroke patients entering rehabilitation. Planned change included the implementation of the stroke wellness video, standardized discharge teaching checklist, and following up with the patient, once they were discharged home with a phone call. The planned phase or implementation stage took overseeing and reminding staff members of the new process. Change involves time and effort. Many people like the challenge of learning a new process, but there are those that do not see anything wrong with the old processes, and do not want to put any effort into the moving or change phase (Lorenzi & Riley, 2000). The re-freezing stage involved evaluating the quality improvement project and its effectiveness by looking at readmission and patient satisfaction data. If evidence indicates that the project has been successful, the process will be hardwired and become the new process for treating stroke patients. Summary Based on the literature review, strong evidence suggests a coordinated transition by an interdisciplinary team focusing on the patient, family/caregiver to include wellness education, detailed discharge checklist, and active patient involvement. Strokes are complex and recovery and rehabilitation can be a long process, so a team working interdisciplinary can help provide the tools necessary to regain function and ultimately allow the patient to live life to its fullest. Project Implementation Plan Goals The overall goal of this DNP project was to reduce 30-day stroke readmission rates on the Neuro Specialty Rehabilitation Unit at St. George Regional Hospital. The national average for 30-day stroke readmissions for ischemic stroke is 12% and expected to increase as the population ages (Poston, 2018). Reducing readmissions is not only a priority for hospital CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 16 administration, but a quality improvement initiative. The goal was accomplished by utilizing an interdisciplinary stroke wellness education program that included OT, PT, dietary, pharmacy, and social work for all stroke patients and caregivers. A detailed individualized discharge education and checklist was developed and implemented for transitioning to a home environment. A follow-up phone call by a registered nurse for all stroke patients was also implemented to ask the patient about medications, follow-up appointments, and any questions regarding care at home. Setting & Population The project was implemented at St. George Regional Hospital located in the city of St. George, Utah. St. George is a semi-retirement community with a population of approximately 90,000 consisting of about 30% senior citizens (World Population Review, 2020). St. George is one of the fastest-growing cities in the United States. St. George Regional Hospital is part of the Intermountain Healthcare system, a not-for-profit healthcare organization. The hospital is in the center of the city and is a level II trauma center. The hospital has a bed capacity of 332 with all ancillary services available. St. George Regional Hospital care covers a large rural area across portions of southern Utah and Nevada and northern Arizona. The Neuro Specialty Rehabilitation Unit where the project was implemented is a 20-bed unit housed in the hospital. In 2019 St. George Regional Hospital admitted 512 cerebrovascular accident, (CVA) patients and as of October 2020, 375 CVA patients have been admitted during 2020. St. George Regional Hospital treats CVA patients acutely and once they are stabilized, approximately 60% are discharged home with outpatient services and follow-up instructions. Approximately 7% are discharged to a skilled nursing facility. Roughly 26% of treated CVA patients will meet the criteria necessary for admission to an inpatient rehabilitation unit. This criterion includes a CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 17 medical need for nursing care, being able to participate in 3 hours of therapy with a need for physical therapy, and or occupational and speech therapy, and finally, insurance authorization. In 2019, St. George Regional Hospital inpatient rehabilitation unit admitted 170 stroke patients between the ages of 17-93. Prior to implementation of the project there was no organized CVA education on the inpatient rehabilitation unit that addressed overcoming stroke, discharge planning, and prevention of readmission to the hospital. The Neuro Specialty Rehabilitation unit has a staff compromised of a full-time physiatrist, physician assistant, nursing staff, social worker, nurse liaison, speech, and language pathologists, occupational therapy, physical therapy, dieticians, pharmacists, recreational therapists, and other ancillary staff. This team works interdisciplinary, and every discipline was involved in the DNP project. This unit maintains a 75% occupancy rate and admitting diagnosis include patients diagnosed with CVA, traumatic brain injuries, spinal cord injuries, multi-trauma, amputation, and a small population of disability patients. The project focused on CVA patients only but can be adapted to other diagnoses in the future if the evidence supports that the program has been successful in reducing 30-day readmission among CVA patients. Plan The identified gap that the DNP project focused on is patient education and standardized discharge teaching with a follow-up phone call for any questions the patient or family member may have, and a reminder to keep their stroke clinic appointment. A study by Ranner et al., (2018) found that implementation of a patient-centered approach to post-stroke recovery in rehabilitation inspired experiences of transparency in the rehabilitation process which contributed to a recognition of the patient’s own capability to perform activities of daily living and participation in everyday life. Being transparent also seemed to support the patient’s sense of CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 18 ownership in the rehabilitation process. The video that was implemented is centered around these principles. The video was viewed by five patients and 35 staff members, unfortunately the media platform that was used for patients to view the video was no longer supported by Intermountain Healthcare. Newly admitted CVA patients and their families were asked to watch this 13-minute video about CVA recovery, and their rehabilitation stay. The original DNP project included that patients and their families attend 30-minute classes addressing medication management, diet, physical and occupational therapy, and the psychosocial effects of CVA. Due to Covid-19 and the restrictions that were implemented to keep patients and staff safe, the classes had to be revised and the decision was made to record a video that the patient would watch as part of the admission process to rehabilitation. The video presentation included the physician talking to the patients about rehabilitation after a CVA and occupational therapy addressing activities of daily living including what to expect out of rehabilitation. Physical therapy then educated the patient and family on the importance of exercise and the skills needed to transition to home safely. Finally, the social worker spoke about psychosocial aspects of life following a CVA and a nurse about being active and engaged in all aspect of their rehabilitation journey. Learning was evaluated using the teach-back method. Teach-back has been reported to increase learning outcomes involving patients and families in a practical target setting for maximizing the use of health services. Teach-back implementation has been responsible for increasing successful discharge procedures, thereby ensuring smoother hospital-to-home transitions (Centrella-Nigro & Alexander, 2017). After the patient was taught about their medication, diet, exercise plan, etc. the nurse would have the patient or caregiver repeat or teach- CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 19 back the information that had been provided. The follow-up discharge phone call was also a tool used for teach-back. When the nurse called, she would ask the patient/caregiver if they had any questions or concerns on their discharge and if they understood the plan going forward for follow-up care. This was tracked on the follow-up phone call sheet. Patients and caregivers who have a better understanding of their post-discharge plan – including how to take their medications, signs, and symptoms to be aware of, and health lifestyle choices are 30% less likely to be readmitted or visit an emergency room than patients who have not received this information (Peter et al., 2015). A detailed discharge checklist was developed and implemented, and the nursing staff had the responsibility of educating the patient about discharge and transitioning to home. A charge nurse called the patient 48 hours after discharge to answer any questions the patient or family may have and to remind them of upcoming appointments.The discharge teaching checklist included discharge instructions, medication management and compliance, adaptive equipment use, follow-up appointments, labs, reviewing home exercise/activity program, information on community support resources, and support groups (Appendix A). A home evaluation was done before discharge if the patient lived within a 30-mile radius of the hospital. Recommendations from the home evaluation were reviewed with the patient upon discharge. A follow-up call was made by a charge nurse to clarify any questions and remind the patient for upcoming appointments (Appendix B). The charge nurse would make two attempts to reach the patient before declaring the patient unreachable. Education and training were provided to the nurses prior to implementation. This was done individually to the 20 nurses that would be discharging CVA patients. An additional training session was conducted for charge nurses who would be making follow-up phone calls to CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 20 newly discharged CVA patients. Nurse liaisons and therapists were trained on the video that was shown to CVA patients as part of their admission process to the Neuro Specialty Rehabilitation Unit. Issues The role of the DNP leadership student was instrumental in developing the video that was part of CVA rehabilitation and education. The DNP student worked with the rehabilitation team to develop a discharge checklist, educate the nurses on the new process, and evaluate the outcome of the discharge checklist. The follow-up phone call questionnaire was also developed by the DNP student. This was all done with input from the medical director. Budgetary costs included educational materials and minimal miscellaneous expenses. The DNP student serving as the project manager and facilitator donated time and therefore, no additional costs were incurred. There was not extra staff time required beyond regular shifts. Training was conducted and completed during scheduled working time. The data collection was provided partly by MedTel Outcomes which was already used by the facility. No extra costs were associated with data collection. The rehabilitation unit already employed a full-time prospective payment system (PPS) coordinator who entered data for payment. The DNP project was considered by Weber State University Internal Review Board to be a quality or process improvement project. There were no risks identified for patients participating in the process, and patients/families/caregivers had the option to refuse participation in the project. All data information collected and recorded on patients was confidential and only shared with key stakeholders. MedTel data is password protected and only available to those granted access. Timeline CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 21 The timeline for the implemented project was executed in phases. An interdisciplinary team consisting of occupational, physical, speech and language therapists, physician, and social work lead by the DNP student created an interdisciplinary educational video for stroke patients. The discharge checklist was developed and implemented simultaneously with the educational stroke wellness video. The follow-up phone call questionnaire was created and applied with the first discharged stroke patient. It was important for the DNP student to work with the entire team to coordinate the project. A few issues that arose were the extra workload on the nurses managing the discharge, filling out the checklist, and making follow-up phone calls. Evaluation The impact of the program was evaluated by comparing readmission data before and after the intervention to see if it was related to a smoother transition for stroke patients, as indicated by a lower readmission rate, compliance to follow-up care, and or patient satisfaction. Through conducting chart reviews pre and post implementation, data was collected for follow-up care appointments. Patient satisfaction scores were gathered and compared as well. Readmission rates were collected through a national database programs, MedTel Outcomes and Uniform Data Systems for Medical Rehabilitation. MedTel and Uniform Data Systems are used by rehabilitation hospitals to compare characteristics of stroke (gender, age, severity, type of stroke, demographics, etc.) and benchmark rehabilitation outcomes against other hospital comparison groups. Such things as readmissions, falls, length of stay, mobility and self-care were just a few things used as comparisons. The information was collected on all stroke patients who had been discharged in January 2020 through January 2021. Admission, discharge, and readmission data were reviewed for this project. Data Analysis and Results CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 22 Pre-implementation data was collected from January – March 2020 (quarter 1) and post-implementation data was collected from October 2020 – February 2021 (quarter 4). During quarter one of 2020, 37 stroke patients were admitted and discharged from the rehabilitation unit with an average length of stay of 15.3 days. During the fourth quarter 32 were admitted and discharged with an average length of stay of 12.8 days. The national average length for stroke patients admitted to an inpatient rehabilitation facility is 15.4 days. The average age of stroke patients for both quarters was approximately eighty years old. The interdisciplinary education video was shown to five patients. Also, a discharge checklist was implemented during the fourth quarter. Of the 32 patients admitted, an accurate and completed checklist was obtained on 22 patients or 69%. Some of the nurses neglected to fill out the checklist or only partially completed the list which accounted for the deficit. A follow-up phone call was attempted on all 32 patients, and contact was made with 28 patients to remind them of follow-up care. Chart reviews for quarter one indicated that 20/37 patients or 60% had follow-up appointments prior to interventions. After implementation of the educational video, discharge checklist, and follow-up phone call during the fourth quarter, 22/32 patients or 62% had follow-up appointments. The data reported on 30-day stroke readmissions concluded that during the first quarter 30-day readmission was 3% or about one patient. The fourth quarter 30-day readmission rate was 6% or about two patients. The increase in readmission rates may have been influenced by the Covid-19 outbreak. St. George Regional Hospital was not experiencing a Covid-19 surge during the first quarter of 2020. Patients with Covid-19 were on the rise during the fourth quarter which led to both a shorter length of stay and admitting patients that may have been better served at a skilled nursing facility rather than an intense rehabilitation unit. CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 23 Findings The objective of the DNP project was to decrease 30-day readmissions for stroke patients discharged from an inpatient rehabilitation unit and to increase participation in follow-up stroke clinic appointments. Improving the transition process to home through education and training was also part of the overall stroke improvement plan. The data suggests that although there was a slight increase in compliance to follow-up appointments there was also an increase in 30-day readmissions. The population targeted for this project were stroke patients admitted to an inpatient rehabilitation unit located in the southern part of Utah. Perhaps this study does give some hope for improving the lives of stroke victims after discharge from the unit, but it strongly suggests continued pursuit for more confirmatory data as the future unfolds. The findings indicated that a standardized checklist helped with the education and assuring that the patients had what they needed prior to going home. Following up with a post-discharge phone call can lead to increased compliance in follow-up care and increase patient satisfaction. An additional finding that was discovered through MedTel data was that falls with injuries post-discharge were reduced. Recommendations When the quality of care and patient outcomes are improved, a project will most likely be considered a success. However, to be considered impactful in how healthcare is delivered, it must be tried and tested for a longer period than just comparing one quarter against another. It is recommended that collecting data for at least a year would give a fairer representation of the project. It has been recommended that the stroke education classes be continued in person with family members present and where dialogue can take place rather than just viewing a video. The recommendation would be for a standard checklist to be implemented for a more extended CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 24 period, and a post-discharge follow-up protocol to be instituted along with creating a standardized checklist for other diagnoses. Contacting the patient after discharge can be another touchpoint along the continuum of care. Conclusion Transitioning from the hospital to home can be complex and confusing for patients and their families. Stroke is a significant cause of impairment and fatality and puts a heavy burden on healthcare systems. For treatment and rehabilitation, prompt admission of a stroke patient to a hospital is recommended, though recovery is often still left incomplete upon discharge. Transitional treatment models have proven to be useful for chronically ill patients, although their success in helping stroke patients remains inconsistent (Wang et al. 2017). This project successfully developed an interdisciplinary approach to patient education and discharge documentation. The team of occupational, physical, and speech therapists along with nursing and physiatry worked together to better educate stroke patients and their families. There is evidence here to conclude that care across the continuum is going to improve stroke patient outcomes and reduce readmissions and improve the quality of life for these patients. Healthcare systems may potentially benefit by recognizing this emerging fact and work on continuously improving the discharge process and follow-up care for patients. Healthcare is continuously changing to improve the patient experience and drive better patient outcomes. The purpose of this DNP project was to decrease 30-day stroke readmissions, provide interdisciplinary stroke education, and improve post-discharge follow-up care. It was targeted to patients admitted to an inpatient rehabilitation setting. 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Washington country, Utah population 2020. https://worldpopulationreview.com/us-counties/ut/washington-county-population/ CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 31 Appendix A Date/Initials ____________ Talk with social worker to ensure that patient is ready for discharge ____________ Equipment ordered if needed ____________ PICC lines, IV’s removed ____________ Caregiver training is completed ____________ Review discharge instructions with patient/family ____________ Have patient/family “teach back” discharge instructions ____________ Reconciliation of medications ____________ Obtain medication prescriptions if needed ____________ Review follow-up appointments with patient/family ____________ Provide a copy of home exercises from therapy ____________ Diabetic education is completed (if needed) ____________ Signs and symptoms of stroke are reviewed ____________ Provide listing of community resources: Support group, etc. ____________ Review what to do if a fall were to occur ____________ IMM letter signed (Medicare patients only) ____________ Oxygen ordered if needed Reason Item(s) were not completed: EACH ITEM NOT COMPLETED MUST BE CODED NSRU Checklist for Discharge Transition to Home CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 32 1 - - - - - Not applicable 2 - - - - - Patient refused 3 - - - - - Other (please explain) ____________ Follow-up phone call completed CEREBROVASCULAR ACCIDENT EDUCATION AND FOLLOW-UP 33 Appendix B