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