Improving discharge care: the potential of a new organisational intervention to improve discharge after hospitalisation for acute stroke, a controlled before–after pilot study

Abstract

ObjectiveProvision of a discharge care plan and prevention therapies is often suboptimal. Our objective was to design and pilot test an interdisciplinary, organisational intervention to improve discharge care using stroke as the case study using a mixed-methods, controlled before–after observational study design.SettingAcute care public hospitals in Queensland, Australia (n=15). The 15 hospitals were ranked against a benchmark based on a composite outcome of three discharge care processes. Clinicians from a ‘top-ranked’ hospital participated in a focus group to elicit their success factors. Two pilot hospitals then participated in the organisational intervention that was designed with experts and consumers.ParticipantsHospital clinicians involved in discharge care for stroke and patients admitted with acute stroke or transient ischaemic attack.InterventionA four-stage, multifaceted organisational intervention that included data reviews, education and facilitated action planning.Primary and secondary outcome measuresThree discharge processes collected in Queensland hospitals within the Australian Stroke Clinical Registry were used to select study hospitals: (1) discharge care plan; (2) antihypertensive medication prescription and (3) antiplatelet medication prescription (ischaemic events only). Primary measure: composite outcome. Secondary measures: individual adherence changes for each discharge process; sensitivity analyses. The performance outcomes were compared 3 months before the intervention (preintervention), 3 months postintervention and at 12 months (sustainability).ResultsData from 1289 episodes of care from the two pilot hospitals were analysed. Improvements from preintervention adherence were: antiplatelet therapy (88%vs96%, p=0.02); antihypertensive prescription (61%vs79%, p<0.001); discharge planning (72%vs94%, p<0.001); composite outcome (73%vs89%, p<0.001). There was an insignificant decay effect over the 12-month sustainability period (composite outcome: 89% postintervention vs 85% sustainability period, p=0.08).ConclusionDischarge care in hospitals may be effectively improved and sustained through a staged and peer-informed, organisational intervention. The intervention warrants further application and trialling on a larger scale.

Use of audit, feedback and education increased guideline implementation in a multidisciplinary stroke unit

“…This drop in compliance has been observed in other stroke implementation research and is described as a ‘decay effect’. 30 …”

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread

“…Within stroke, there is variability. Sustained improvement in the provision of discharge care processes was evident 9 months post-implementation in one study [7]; however, in another multi-centre trial, improvements after the initial quality improvement effort were not sustained at 12 months [38]. Given the difficulties and variability in achieving knowledge translation and the considerable length of time it takes to embed evidence into standard practice [39], the results from the current study are notable indicating scale up and spread ‘at pace’ and provide insight into knowledge transfer in this context.…”

“…No single approach is successful for all healthcare settings. Strategies that have taken into account contextual issues and barriers and facilitators to their implementation have had success in changing clinician behaviours and closing the evidence-practice gap [4–7].…”

How to do health services research in stroke: A focus on performance measurement and quality improvement

“…Termed ''facilitation,'' these include strategies such as audit and feedback, consensus building and reminders or more comprehensive quality improvement systems such as the plan-do-study-act cycle. 29 For examples see the Stroke 123 study protocol and pilot study of an organization intervention to improve discharge care by Cadilhac et al 34,35…”

“…29 For examples see the Stroke 123 study protocol and pilot study of an organization intervention to improve discharge care by Cadilhac et al. 34,35…”