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Evidence based practice
Research
Improving discharge care: the potential of a new organisational intervention to improve discharge after hospitalisation for acute stroke, a controlled before–after pilot study
  1. Dominique A Cadilhac1,2,
  2. Nadine E Andrew1,
  3. Enna Stroil Salama3,
  4. Kelvin Hill4,
  5. Sandy Middleton5,
  6. Eleanor Horton6,
  7. Ian Meade7,
  8. Sarah Kuhle8,
  9. Mark R Nelson9,
  10. Rohan Grimley10,11
  11. On behalf of the Australian Stroke Clinical Registry Consortium
  1. 1 Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
  2. 2 Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, Australia
  3. 3 Queensland Cerebral Palsy and Rehabilitation Research Centre (QCPRRC), University of Queensland, Brisbane, Australia
  4. 4 Stroke Foundation, Melbourne, Australia
  5. 5 Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, Australia
  6. 6 School of Nursing, Midwifery & Paramedicine, University of the Sunshine Coast, Sunshine Coast, Australia
  7. 7 Acute Stroke Unit, The Townsville Hospital, Townsville, Australia
  8. 8 Redcliffe Hospital, Redcliffe, Australia
  9. 9 School of Medicine, University of Tasmania, Hobart, Australia
  10. 10 Sunshine Coast Clinical School, The University of Queensland, Nambour, Australia
  11. 11 Queensland Department of Health, Brisbane, Australia
  1. Correspondence to A/Prof Dominique A Cadilhac; dominique.cadilhac{at}monash.edu

Abstract

Objective Provision 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.

Setting Acute 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.

Participants Hospital clinicians involved in discharge care for stroke and patients admitted with acute stroke or transient ischaemic attack.

Intervention A four-stage, multifaceted organisational intervention that included data reviews, education and facilitated action planning.

Primary and secondary outcome measures Three 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).

Results Data 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).

Conclusion Discharge 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.

  • stroke
  • quality in health care
  • clinical audit
  • change management

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2017-016010

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    Footnotes

    • Contributors DAC: conceptualisation and design of the study, drafting of the manuscript and interpretation of the data. NEA: drafting of the manuscript, literature review, analysis of data and interpretation of the data. ESS: revisions to the manuscript, contribution to literature reviews, study coordination and interpretation of the data. KH: revisions to the manuscript, contribution to intervention design and methods, and interpretation of the data. SM: revisions of the manuscript, contribution to intervention design and methods, and interpretation of the data. EH: consumer representative, revision of the manuscript, contribution to intervention design and methods, and interpretation of the data. IM: revisions to the manuscript, contribution to intervention delivery and interpretation of the data. SK: revisions to the manuscript, contribution to focus group and interpretation of the data. MRN: revision of the manuscript, contribution to intervention design and interpretation of the data. RG: revisions to the manuscript, contribution to intervention design and methods, and interpretation of the data.

    • Funding The Nancy & Vic Allen Stroke Prevention Fund supported this project which was also supplemented by grant funds from the National Health and Medical Research Council (NHMRC; 1034415). DAC (1063761 co-funded Heart Foundation) and NEA (1072053) received Research Fellowship support from the NHMRC.

    • Competing interests None declared.

    • Ethics approval Metro North Hospital and Health Service, The Prince Charles Hospital, Human Research Ethics Committee (HREC/13/QPCH/279, November 2013).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Unpublished programme evaluation data from this study may be available for mutually agreed use by contacting the corresponding author.