Background: Prolonged hospital lengths of stay increase costs, delay rehabilitation, and expose acute ischemic stroke patients to hospital-acquired infections. We designed and implemented a nurse-driven transitions of care coordinator (TOCC) program to facilitate the transition of care from the acute care hospital setting to rehabilitation centers and home.Methods: This was a single-blinded, prospective, randomized pilot study of 40 participants to evaluate the feasibility of implementing a TOCC program led by a stroke nurse navigator in hospitalized acute ischemic stroke patients. The intervention consisted of a stroke nurse navigator completing eight specific tasks, including meeting with stroke patients and their families, facilitating communication between team members at multi-disciplinary rounds, assisting with referrals to rehabilitation facilities, providing stroke education, and arranging stroke clinic follow-up appointments, which were confirmed to be completed by independent study personnel. The primary outcome was to assess the feasibility of the program. The secondary outcomes included comparing hospital length of stay (LOS) and patient satisfaction between the TOCC and usual care groups. We also explored the association between patient-level variables and LOS.Results: The TOCC program was feasible with all pre-specified components completed in 84.2% (95% CI: 60.4–96.6%) and was not significantly different from the assumed completion rate of 75% (p = 0.438). There was no significant difference in median LOS between the two groups [TOCC 5.95 days (4.02, 9.57) vs. usual care 4.01 days (2.00, 10.45), false discovery rate (FDR)-adjusted p = 0.138]. There was a trend toward higher patient median satisfaction in the TOCC group [TOCC 35.00 (33.00, 35.00) vs. usual care 30 (26.00, 35.00), FDR-adjusted p = 0.1] as assessed by a questionnaire at 30 days after discharge. The TOCC study allowed us to identify patient variables (gender, insurance, stroke severity, and discharge disposition) that were significantly associated with longer hospital LOS.Conclusion: A TOCC program is feasible and can serve as a guide for future allocation of resources to facilitate transitions of care and avoid prolonged hospital stays.

Introduction: Prolonged hospital stays expose stroke patients to hospital-acquired infections, increase overall cost of care, and delay the initiation of rehabilitation therapies. We sought to examine the factors associated with length of stay (LOS) in acute ischemic stroke (AIS) patients at a comprehensive stroke center (CSC) in an urban center. We hypothesized that patients being discharged to subacute rehabilitation (SAR) or nursing home facilities would have longer LOS. Methods: Consecutive patients admitted to our stroke service from April to July 2018 with a principal diagnosis of AIS were included. Patients with transient ischemic attack, intracerebral hemorrhage or subarachnoid hemorrhage were excluded. Demographics, admission NIHSS, baseline modified Rankin Scale (mRS), discharge mRS, and discharge disposition were collected. LOS was calculated from date/time of patient registration to discharge. Results: Baseline characteristics are shown in table 1. LOS and NIHSS were significantly correlated ( r s 0.745, p <0.001). Medicaid as primary insurance on admission was associated with longer LOS (21.9 days) as compared to Medicare (6.5 days) or commercial insurance (2.6 days) [p=0.017]. Higher discharge mRS was associated with longer LOS [p=0.002]. Discharge to SAR was associated with longer LOS (22.9 days) as compared to acute rehab (8.8 days), home with home health (3.2 days), or home (2.6 days) [p = 0.001]. There was no difference in LOS according to baseline mRS, age, gender, or race. Conclusions: Higher admission NIHSS, Medicaid insurance on admission, discharge to SAR, and discharge mRs &gt4 were significantly associated with longer LOS in AIS patients. Systems of care interventions are needed to address disparity in LOS for Medicaid patients.

Introduction: Transitions of care from the acute hospital to other medical facilities and home is a national health care priority. We designed a randomized pilot study to assess the feasibility of a Transitions of Care Coordinator (TOCC) program led by a nurse navigator. We hypothesized that the navigator would complete all portions of TOCC program in at least 75% of acute ischemic stroke (AIS) pts. Methods: Consecutive AIS patients admitted from April to July 2018 were randomized to TOCC group or usual care group. Pts discharged to subacute rehab, nursing home and hospice or died during hospitalization were excluded. In TOCC, the navigator met patient/caregiver on admission, followed up discharge pending diagnostics, attended multi-disciplinary rounds, facilitated rehab referrals, provided stroke education, and arranged clinic follow-up. Demographics, NIHSS, mRS and discharge disposition were collected. Hospital length of stay (LOS) was calculated from date/time of patient registration to discharge. Patient satisfaction questionnaire and readmission rate was assessed at 30 days by phone. Continuous variables were analyzed using Wilcoxon rank-sum and categorical variables using Fisher’s exact test. Results: TOCC pts were older, but other demographics were well matched (table 1). The navigator completed all portions of the TOCC program in 80% of pts. The mean time spent by the navigator per TOCC pt was 111 minutes (SD 23). There was no difference in distribution of LOS between the TOCC and usual care groups (5.7 vs. 5.1 days, p=0.51). There was no difference in the mean patient satisfaction scores between TOCC and usual care groups (30.3 vs. 29.6, p=0.66). There were no 30-day readmissions or ER visits in TOCC group vs. 3 and 2 in the usual care (p=0.25, p=0.50). Conclusion: A nurse navigator-led TOCC program is feasible and may be associated with decreased 30-day readmissions. The ongoing TOCC study will assess any association with LOS and patient satisfaction.

Background/ Issue: Epidemiologically, pediatric strokes are rare; therefore, index of suspicion is low and many cases are not recognized early enough to qualify for acute treatment. With this small patient population, many regions have yet to develop protocols and policies for acute pediatric stroke response. In the District of Columbia, MedStar Georgetown University Hospital (MGUH) is the only Joint Commission Accredited Comprehensive Stroke Center with a pediatric intensive care unit. Purpose: The purpose of our program was to develop institutional protocols for pediatric stroke patients who are candidates for hyper-acute treatment. Protocols focused on pediatric patients who presented through our emergency department or were transferred from other facilities within the time window for acute treatment. The protocols were established to ensure a clear process for physicians and staff to follow. Methods: An interdisciplinary group met to discuss modification of our current Adult Ischemic Stroke Code Protocol needed for a coordinated approach to pediatric stroke patients. The team members included the Stroke Coordinator, Stroke Nurse Navigator, Stroke Nurse Practitioner, Pediatric Neurologist, Medical Director of the Pediatric ICU, Manager of the Pediatric ICU, Pediatric Anesthesia, Medical Director of the Stroke Program, and the Emergency Department Team. Results: The interdisciplinary team was able to adapt a protocol using the Adult Ischemic Stroke Code Protocol. Key differences between the adult and pediatric stroke code work-flow consisted of including pediatric neurologists early in the decision process, pediatric nurses to assist with monitoring children, and pediatric anesthesia for assistance with imaging and/or endovascular intervention. The order sets were adjusted to include weight- based calculations for medications, age-based monitoring parameters, and specific pediatric needs. Conclusion: It is possible to develop a Pediatric Stroke Code Protocol based on the Adult Ischemic Stroke Code Protocol to include all modifications appropriate for pediatric care and still maintain the rapid work-flow that everyone is familiar with. It is essential to include all key stakeholders to ensure a smooth and safe process.