Abstract WMP18: Stroke Nurse Navigator Team Utilization Towards Reduction Of Unplanned 30-day Readmissions Following Stroke

Background: Unplanned 30-day hospital readmissions following a stroke is recognized as a serious quality and safety issue in the United States. The transition period from the hospital discharge is recognized as a vulnerable period in which medication errors and loss of ambulatory follow-ups can potentially occur. There, we sought to determine if 30-day stroke readmission can be prevented with utilization of a stroke nurse navigator team. Our secondary outcome of interest was 90-day outcome events. Methods: We first retrospectively analyzed 1657 consecutive patients presenting with ischemic or hemorrhagic strokes, included in an institutional stroke registry between January 2018 and August 2020, the time before the utilization of stroke nurse navigator teams. The stroke nurse navigator interventions included medication reviews, hospitalization course review, stroke education, and establishment of outpatient follow-ups within 3 days following the discharge. Following the stroke nurse navigator team phone checks ins in September 2020, we then retrospectively analyzed 851 consecutive patients presenting with stroke, included in the registry between September 2020 and December 2021. Results: Baseline 30-day stroke readmission rate was 11.7% (194/1657) before nurse navigator team. The Readmission rate reduced to 8.2% (71/870), which was statistically significant (p<0.05) following the period that utilized stroke nurse navigator team. Baseline 90-day death and cardiovascular events before the stroke nurse intervention was 5.4% (89/1657) and 8.1% (134/1657), respectively. Following the intervention, there was also no statistical difference in the 90-day outcome events of death and cardiovascular event 6.2% (27/433) and 7.3% (32/433), p>0.05. Conclusion: Utilization of the Stroke nurse navigator team can reduce unplanned 30-day stroke readmissions, but it did not have an impact on 90-day clinical outcome. Further studies are warranted to study the relationship between resource utilization during transition period from discharge and quality outcome in stroke.