Background: Patients who experience acute stroke often have complex discharge planning needs that impact transitions of care. The hectic acute care hospital environment is not always conducive to addressing these needs in a standardized fashion.
Purpose: To improve communication among team members and identify potential post-acute needs early in the hospital stay. Ultimately we hoped to have a positive impact the readmission rate and the patient experience.
Methods: We designed a structure for daily rounds, identifying who would attend, setting clear expectations, and having a consistent schedule. We piloted a paper based check list that would serve as a guide to the dialogue during daily rounds to ensure that the team addressed key issues in a step wise, standardized fashion. This process also included the patients and families and their goals of care.
Results: Readmissions were reduced from 15.4% to 10.9%. HCAHPS scores improved, specifically "Discharge Information" from 70% to 94% and "Communication with Nurses" from 46% to 83%.
Conclusions: For a patient population with complex discharge needs, transitions of care can be improved by implementing a daily rounding checklist. This could positively impact the readmission rate and the patient experience.