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.

Advances in adult learning theory and instructional technologies provide opportunities to improve neurology knowledge acquisition. This scoping review aimed to survey the emerging landscape of educational innovation in clinical neurology. With the assistance of a research librarian, we conducted a literature search on November 4, 2021, using the following databases: PubMed, Embase, Scopus, Cochrane Library, Education Resources Information Center, and PsycINFO. We included studies of innovative teaching methods for medical students through attending physician-level learners and excluded interventions for undergraduate students and established methods of teaching, as well as those published before 2010. Two authors independently reviewed all abstracts and full-text articles to determine inclusion. In the case of disagreement, a third author acted as arbiter. Study evaluation consisted of grading level of outcomes using the Kirkpatrick model, assessing for the presence of key components of education innovation literature, and applying an author-driven global innovation rating. Among 3,830 identified publications, 350 (175 full texts and 175 abstracts) studies were selected for analysis. Only 13 studies were included from 2010 to 2011, with 98 from 2020 to 2021. The most common innovations were simulation (142), eLearning, including web-based software and video-based learning (78), 3-dimensional modeling/printing (34), virtual/augmented reality (26) podcasts/smartphone applications/social media (24), team-based learning (17), flipped classroom (17), problem-based learning (10), and gamification (9). Ninety-eight (28.0%) articles included a study design with a comparison group, but only 23 of those randomized learners to an intervention. Most studies relied on Kirkpatrick Level 1 and 2 outcomes—the perceptions of training by learners and acquisition of knowledge. The sustainability of the innovation, transferability of the innovation to a new context, and the explanation of the novel nature of the innovations were some of the least represented features. We rated most innovations as only slightly innovative. There has been an explosion of reports on educational methods in clinical neurology over the last decade, especially in simulation and eLearning. Unfortunately, most reports lack adequate assessment of the validity and effect of the respective innovation's merits, as well as details regarding sustainability and transferability to new contexts.

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Introduction: Delay in discharge of acute stroke patients considered medically ready for discharge increases costs and exposure to nosocomial infections, and is frustrating for patients. We evaluated factors associated with delays in discharge in acute ischemic stroke (AIS) patients in a Transitions of Care Coordination (TOCC) study. Methods: From April to July 2018, 29 AIS patients (pts) were randomized to TOCC (n=13) or usual care (n=16) groups. Intracerebral hemorrhage, transient ischemic attack and subarachnoid hemorrhage pts were excluded. In TOCC, a nurse navigator met patient/family, identified barriers to discharge, checked status of diagnostics, attended multi-disciplinary rounds to facilitate rehab referrals, provided stroke education, and coordinated clinic follow-up. Delayed length of stay (dLOS) was defined as the difference between date/time medically ready for discharge and date/time of actual discharge. Demographic variables, NIHSS, mRS and discharge disposition were collected. Continuous variables were analyzed with Wilcoxon rank-sum or Kruskal-Wallis test, and categorical variables with Fisher’s exact test. Results: Pts in the TOCC group were older, but other baseline characteristics were well matched (Table 1). dLOS was significantly correlated with NIHSS ( r s 0.65, p=0.00037. There was a difference in dLOS by insurance type (Medicare 4.05 d vs. Medicaid 17.7 d vs. Commercial 3.0 days, p=0.0250). There was a difference in mean dLOS by discharge disposition (acute rehab 6.5 d, home 1 d, home with home health 1.4 d, subacute rehab 17 d, (and patient death 9 d), p=0.007. There was a difference in distribution of dLOS by distance from home zip code to hospital but no difference was found in the post-hoc analysis. There was no difference in mean dLOS between TOCC and usual care groups (6.5 vs. 4.5 days, p=0.256). Conclusion: Higher NIHSS, Medicaid insurance, and discharge to acute rehab were significantly associated with dLOS in AIS patients.

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.