I have identified many problems in my workplace on a 9-bed stroke center. Stroke patients typically require comprehensive discharge instructions for safety, lifestyle changes, medication adjustments, and follow-up appointments (Wang et al., 2022). A post-stroke patient receiving complete and concise discharge instructions can be considered one of the most life-changing processes of their acute illness. Approximately 25% of our patients are readmitted within thirty days of discharge. After analyzing the data collected from these specific patients, the main issue identified is the inconsistency with discharge follow-ups including cardiology appointments, as well as misunderstandings of medication adjustments. Some of our patients have experienced embolic strokes, subsequently leading to a referral to a cardiologist to seek further workup. This workup involves medication adjustments and, most importantly, receiving and wearing a thirty-day Holter monitor. Some embolic strokes originate from undiagnosed atrial fibrillation, thus making it highly suggested to wear the monitor with hopes of finding any paroxysmal episodes. In most instances, the patients and/or caregivers don’t actually follow up with the suggestions; rather, it’s due to social determinants of health or a lack of full understanding of the importance of continuing the workup. The steps to be taken will follow as:

Identifying the problem, which has already been disclosed as frequent re-admissions of post-acute stroke patients,
Gathering all necessary data for evidence,
Preparing this information to disseminate to an interdisciplinary team in a conference,
Collaborating with team members and patients for feedback, specific to things that will help prevent or decrease frequent re-admissions back into the facility within thirty days
A solution to the issue is to perform discharge follow-up phone calls for our stroke patients who have been discharged back home into the community. A discharge advocate is essential to ensuring discharge instructions are understood beyond the hospital admission. It is also important to reiterate the necessity of following up with physicians and specialists, as noted. The SWOT tool is a strategic plan that will help any manager improve quality and safety within a workplace (Hollingworth & Reynolds, 2020). Using the SWOT method as an approach to this situation can help tremendously prevent such events from re-occurring. The SWOT method is perfect for identifying:

Strengths: our comprehensive stroke workup that is offered as a primary stroke center

Weaknesses: frequent readmissions, poor discharge teaching, lack of assessing social determinants of health on admission

Opportunities: to create a discharge advocate committee to reiterate all discharge instructions,

Threats: lack of access to community resources, barriers to learning, caregiver support

References

Hollingsworth, A., & Reynolds, M. (2020). The ED Nurse Manager’s Guide to Utilizing SWOT Analysis for Performance Improvement. Journal of Emergency Nursing, 46(3), 368–372. https://doi.org/10.1016/j.jen.2020.02.006

Wang, C., Yu, T., Luo, X., Zhou, C., You, C., Duan, L., Liu, S., Chen, Y., Jiang, Y., & Zhu, H. (2022). Protocol for the development of a clinical practice guideline for discharge planning of stroke patients. Annals of translational medicine, 10(17), 937. https://doi.org/10.21037/atm-22-3151