Patients admitted to the ED for stroke and other neurological conditions have better functional outcomes and quality of life when enrolled into a nurse-led post-discharge service, a WA study shows.
The intervention also brought substantial cost savings, with patients who opted into the service reporting fewer ED and hospital readmissions saving the hospital an estimated A$101,639 per annum or A$275 per patient annually, compared to standard post discharge care.
Amid heavy demand for Perth hospital neurology services the team behind the program – Neurological Change and Development Nurse at the Neurological Council of Western Australia, Dr Judith Pugh and colleagues from the Fiona Stanley Hospital – said high 28-day readmission rates prompted their investigation into alternative routes of post discharge care.
Writing in Health and Social Care, the group revealed that unpublished data between 2014–2018 showed 62% of the hospital’s adult neurology patients were readmitted within 28 days of discharge.
These were patients with a primary diagnosis of stroke, epilepsy, migraine/headache or functional neurological disorders (FND) and approximately half were readmitted for non- neurological reasons. Some, like falls, pneumonia, and urinary tract infections, were potentially preventable said investigators – and potentially responsive to timely, community-based nursing intervention they added.
Recognising the role of community neurology nurses (CNN) Dr Pugh and colleagues looked at integrating the specialist nurses into the unit’s multidisciplinary teams at the discharge planning stage.
Supporting discharge home the community neurology nurse helped with coordination of care, neurological nursing assessment and home based care including home visits, Telehealth, and maintaining communication post discharge through text messages and email.
“The [community neurology nurse] provides a bridge between hospital inpatient care and community care seeding a therapeutic relationship with patients before their discharge,” investigators said of the important role.
High risk for readmissions
The service, called Neurocare, was offered to 177 acute care adult patients admitted to the neurology ward of a WA hospital with a diagnosis of stroke, epilepsy, migraine/headache or FND and discharged home.
Of the patients offered the service, identified by clinicians for being at high risk for readmission, 81 patients enrolled into Neurocare. Just under half of the patients who turned down the service cited managing well with informal supports and other services.
A retrospective group of 740 patients who received the previous model of care made up the comparator group.
Alongside nursing clinical assessment and arranging referrals, the CNN role was far-reaching: undertaking comprehensive needs/wellness assessments including assessing and establishing support systems, and monitoring patient health and functional status, which enabled early identification of risk for clinical deterioration .