A Multi-Component Transition of Care Improvement Project to Reduce Hospital Readmissions Following Ischemic Stroke

Ischemic stroke (IS) is a common cause of hospitalization which carries a significant economic burden and leads to high rates of death and disability. Readmission in the first 30 days after hospitalization is associated with increased healthcare costs and higher risk of death and disability. Efforts to decrease the number of patients returning to the hospital after IS may improve quality and cost of care.

Improving care transitions to reduce readmissions is amenable to quality improvement (QI) initiatives. A multi-component QI intervention directed at IS patients being discharged to home from a stroke unit at an academic comprehensive stroke center using IS diagnosis-driven home care referrals, improved post-discharge telephone calls, and timely completion of discharge summaries was developed. The improvement project was implemented on July 1, 2019, and evaluated for the 6 months following initiation in comparison to the same 6-month period pre-intervention in 2018.

Following implementation, a statistically significant decrease in 30-day all-cause same-hospital readmission rates from 7.4% to 2.8% (p = .031, d = 1.61) in the project population and from 6.6% to 3% (p = .010, d = 1.43) in the overall IS population was observed. Improvement was seen in all process measures as well as in patient satisfaction scores.

An evidence-based bundled process improvement intervention for IS patients discharged to home was associated with decreased hospital readmission rates following IS.