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DNP Project: Scholarly Product for Dissemination

For this assignment you will prepare a scholarly product that reports your progress (or results) and implications of your DNP project to a designated audience. If you are not in the implementation or evaluation phases of your DNP project you may report on a project that you have worked on during your practicum experiences with the practicum site. While you are not required to actually present your work it will be beneficial for you to prepare your product for dissemination now while you can receive feedback from your peers and faculty committee.

Your scholarly product may be in the form of a manuscript for publication, project summary and evaluation report, conference proceedings, poster presentation, program evaluation report, grant proposal, media or technology-based deliverable, or a different faculty approved product. The scholarly product is due to your Instructor by Day 7 of Week 10 so you may receive feedback on it before finalizing your DNP Project Paper (a DNP program requirement). Unless otherwise arranged with your Project committee, your final product must include the following information, and must be written in a style appropriate for your intended audience:

Background, Purpose, and Nature of the Project
Describe the larger problem or issue you explored in your DNP Project. Explain how this problem or issue affects nursing practice and the overall health care system, and describe how your DNP Project explored possible strategies for addressing the problem or issue.
Research Design, Setting, and Data Collection
Briefly explain the methods you used to carry out your DNP Project, including any relevant theoretical frameworks or models. Identify the practice setting and context in which you conducted your project, as well as the sample/population as applicable. Outline your data collection methods and justify why you chose these methods.
Presentation of Results
Explain the results of your DNP Project. Include any relevant graphs, tables, charts, models, or other visual representations of your data/results. Include a short description of each visual, what it displays, and how it relates to your project.
Interpretation of Findings, and Implications for Evidence-Based Practice
Share the results of your DNP Project, and provide an interpretation of your findings. Describe how the results can be translated into evidence-based practice. Explain how this would impact the main problem or issue you explored in your DNP Project.

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Abstract

Impact of Nurse Education Program on 30-Day Readmissions among Ischemic Stroke Patients

Mariana Tsucuneli

MS, Walden University, 2018

BS, Davenport University, 2014

Mariana Tsucuneli

Proposal Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Nursing Practice

Walden University

May 2020

Abstract

Unplanned 30-day readmissions among patients diagnosed with Ischemic stroke (IS) is a major public health problem in the United States (US). The Affordable Healthcare Act introduced financial penalties and incentives for facilities to encourage care plans aimed to reducing 30-day readmissions rates for stroke and other five illnesses. Facilities with high rates of 30-day readmissions for IS patients, are therefore penalized by the centers for Medicare and Medicaid services in addition to receiving poor scores on the quality of care they provide. The proposed project will be a staff education program aimed to improve post-acute stroke transitional care to reduce 30-day readmission rates. The project will be guided by the question; among nurses caring for IS patients, does an educational program focused on active engagement and caring for patients compared to standard practice, reduce the 30-day readmission rates? The design of the educational intervention, its implementation, and evaluation will be guided by the competency, outcomes, and performance assessment (COPA) model focused on the integration of interactive learning, practice-based outcomes, and competency assessment.

Keywords: 30-day readmissions, care bundle, ischemic stroke, educational program.

Impact of a Nurse Education Program on 30-Day Readmissions among Ischemic Stroke Patients

by
Mariana Tsucuneli
MS, Walden University, 2018
BS, Davenport University, 2014

Project Submitted in Partial Fulfillment

of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
May 2020

Table of Contents

Section 1: Nature of the Project

Introduction

Problem Statement

Purpose

Nature of the Doctoral Project

Significance

Summary

Section 2: Background and Context

Introduction

Concepts, Model and Theories

Model

Theory

Concepts

Relevance to Nursing Practice

Local Background and Context

Role of the DNP Student

Summary

Section 3: Collection and Analysis of Evidence

Introduction

Practice-focused Question

Sources of Evidence

Nature of the Data

Participants

Procedures

Ethical Considerations

Analysis and Synthesis

24
Summary

References

Appendix: Educational Program

Section 1: Nature of the Project

Introduction

Patient readmission within 30 days following initial stay and discharge is a common problem in the United States (US) occurring at an estimated 14% of all hospital admissions (Hughes & Witham, 2018). The 30-day readmission rates in US hospitals are used as quality measures, and the hospital readmission reduction program (HRRP) established in the Affordable Care Act provides financial incentives to healthcare facilities with lowered readmission rates (Centers for Medicare and Medicaid [CMS], 2019). The CMS also fines hospitals with high 30-day readmission rates relative to other healthcare facilities under the HRRP (CMS, 2019). Using 30-day readmission rates as a quality measure also affects facilities with high re-hospitalization frequency and is used as an indicator of inadequate care provision (Vahidy et al., 2017). Hospital readmission is also associated with other problems for the facility, including longer stays and a higher risk of complications for the patient (Hughes & Witham, 2018).

Ischemic stroke (IS) is one of the health conditions whose 30-day readmission is monitored by the CMS under the HRRP (CMS, 2019). Approximately 12% of IS patients are readmitted to hospitals within 30 days of discharge in the US (Vahidy et al., 2017). Readmissions due to IS are considered high risk and the use of the readmission rates as a measure of quality is prioritized at the national level (Andrews & Freburger, 2015). The type of post-acute stroke care has been associated with transitional care outcomes including 30-day readmissions and recovery (Poston, 2018). Educational interventions for nurses have been associated with improved patient and quality of healthcare outcomes in stroke care (Jones et al., 2018). The proposed DNP project will involve developing a nurse educational program focused on transitional care for IS patients associated with reducing 30-day readmissions. The developed program will be implemented to all the nursing staff working at post-acute IS ward in a rehabilitation center in the north-eastern US. The expected social change will be in transitional behaviors among the nurses to include checking for risk factors for post-acute stroke disorders. The anticipated implications for social change will be the reduction of risk of post-acute stroke disorders and 30-day readmissions among stroke survivors.

Problem Statement

The target healthcare facility is an inpatient rehabilitation facility with a stroke unit which has prevalent unplanned 30-day readmissions. Up to 60% of the patients admitted at the facility have more than one comorbidity. Among patients with stroke, comorbidities such as respiratory diseases and urinary tract infections are associated with high risk of 30-day readmissions (Poston, 2018). Inadequate transitional care including failure to identify post-stroke disorders, risk factors, and lack of social engagement among IS patients have also been associated with increased rates of 30-day readmissions (Poston, 2018). A brief needs assessment established that there was a gap in adequate transitional care knowledge among the nurses as well as harmonization of the care procedures among all post-acute stroke patients.

Stroke is among the leading causes of mortality and long-term disability (Poston, 2018). With the aging population rising, IS prevalence is expected to increase with projections of up to 20.5% surge by 2030. Improving the quality of transitional care in healthcare facilities is expected to help prevent the occurrence of post-stroke conditions requiring hospital readmissions (Poston, 2018). Additionally, understanding IS, and its risk factors could lead to a more focused quality of care, potentially reducing the risk of readmissions (Andrews & Freburger, 2015). In a facility with high 30-day readmission rates among IS patients, a staff educational intervention aimed to improve the understanding of post-acute stroke readmission risk factors would be helpful in reducing the prevalence of re-hospitalizations.

The nursing workforce is the most involved of all healthcare providers in patient care (American Association of Colleges of Nursing [AACN], 2019). In the treatment of IS, up to 60% of the survivors require post-acute care services in rehabilitation, skilled nursing facilities, and in-home healthcare; services that are primarily provided by nurses (Poston, 2018). Nurses, therefore, have the ability to transform the quality and type of healthcare provided to post-acute stroke patients. With improved awareness, the nurses will be able to identify post-transition issues early enough and address them to avoid re-hospitalizations (Poston, 2018). A nurse educational program on patient engagement and risk factors for post-stroke disorders requiring acute care is significant and would improve prevention of 30-day readmissions, (Nakibuuka et al., 2016). The project will, therefore, contribute to the nursing practice by adding to the existing knowledge of evidence-based nursing practices such as patient engagement. The project will contribute evidence in support of nursing practices aimed to improve the quality of care as well as patient and facility outcomes. Patients whose risk factors for post-stroke readmissions will be identified and addressed at an early stage will benefit from the prevention strategies by improving their recovery and health outcomes (Porter, 2018).

Purpose

The gap in nursing practice this proposed staff education doctoral project will address is the lack of adequate knowledge related to post-acute stroke transitional care. The aim of implementing the project will be to address the lack of adequate knowledge on active engagement of patients and early identification of risk factors for post-stroke readmissions. The purpose of the DNP project will be to develop and implement a nurse educational program on post-acute stroke transitional care to reduce 30-day readmission rates among IS patients. The DNP staff education project will be guided by the following practice-focused question: Among nurses caring for IS patients, does an educational program focused on active engagement and caring for patients compared to standard practice, reduce the 30-day readmission rates?

The project will be a staff education program focusing on active patient engagement and identification of post-stroke readmission risk factors with the aim of decreasing 30-day readmission rates at the facility. The quality of care provided during the transitional period from hospital to a rehabilitation facility has a significant effect on the readmission rates of IS patients (Hudali, Robinson, & Bhattarai, 2017). Evidence has also shown that most of the post-stroke disorders requiring readmissions are preventable (Poston, 2018). Providers who are more knowledgeable of the type of care to offer patients during transition and rehabilitation period will be able to identify the predictors of readmissions and address them at an early stage. The staff education will be focused on addressing the gap in knowledge of the nursing staff working at the rehabilitation facility and enable them to identify and address risk factors for post-stroke disorders that might lead to unplanned hospital readmissions.

Nature of the Doctoral Project

The proposed project will involve the development and implementation of a nurse education program on the care of IS patients in an inpatient rehabilitation facility located in the Northern United States (US). The focus of the project will be on the development of an educational program on a post-acute stroke transition care plan for nurses, its implementation, and evaluation of its effectiveness on reducing 30-day readmission rates in the IS unit. The educational program will be developed from reviewed literature and validated by an expert panel at the facility of implementation. The transition care plan will involve a patient engagement focused-care, identification, and addressing of preventable post-stroke disorders. The nursing staff working at the unit will be educated to improve their knowledge on the type of care to provide to IS patients before discharge to prevent unplanned 30-day readmissions. The education program will be designed with input from an expert panel and based on the review and synthesis of the literature on the appropriate transitional care for IS patients to avoid 30-day readmissions. The de-identified data to support the effectiveness of the staff education program post–implementation will be obtained by the staff from the hospital electronic health records (EHR) and analyzed by the DNP student to determine the rate of 30-day readmissions in patients diagnosed with IS.

Project data will be organized into pretest and post-intervention columns. Pre-intervention data on the number of readmissions recorded eight weeks before the project implementation will be obtained from EHR by the staff. Post-intervention data will be the number of readmissions associated with IS diagnosis recorded eight weeks after the staff education program is implemented. Analysis of the outcome by the DNP student will be done by comparing the pretest and post-intervention data to determine significant differences. Reduction in readmissions after the intervention will indicate the effectiveness of the staff education program. The eight-week timeframe for pre and post-intervention data collection is selected in order to get sufficient population data for evaluating the project outcomes. The outcomes of interest are the 30-day readmission rates; the staff education program will be conducted in two to four sessions, held once a week. Post-intervention data will be collected eight weeks after the intervention is implemented.

The aim of conducting the Doctor of Nursing practice (DNP) project is to improve the knowledge of nurses on post-acute stroke transitional care. The purpose of the DNP project will be to develop and implement a nurse educational program on post-acute stroke transitional care to reduce 30-day readmission rates among IS patients. The project’s objective will be to improve the knowledge of the nursing staff on the care of IS patients to reduce 30-day readmission rates.

Significance

The primary stakeholders for this DNP project are the IS patients, administrative staff, and nurses working at the stroke rehabilitation unit in the healthcare facility. Patients’ recovery and post-discharge progress will be dependent on the type and quality of care provided to them before leaving the hospital. The quality of care that nurses provide to these patients will be affected by the educational intervention presented in the scholarly DNP project. The intervention is the first of the kind to be implemented at this specific facility, thus it will be an update on the current evidence best practice knowledge for the nursing staff. Other stakeholders of the project include the nursing manager and the administrators of the facility. The nursing manager supervises the nurses, and any improvement in the type of care provided will reflect their superior’s commitment to quality improvement within the facility. The facility administrators will also benefit from improved IS patient outcomes, reducing the rates of 30-day readmission, thus allowing the hospital to qualify for CMS incentives. Given that the IS 30-day readmission rates are used as quality measures by the CMS, an observed reduction would positively reflect on the type of care provided at the facility.

A positive outcome of the project will provide evidence on the effectiveness of a staff educational program focused on discharge and transitional care for IS patients. The evidence will contribute to available nursing practices supporting quality improvement in healthcare facilities (Poston, 2018). Nurses have been urged to embrace evidence-based practice as they pursue their quest to improve healthcare outcomes (ACCN, 2019). If the staff educational program is found to be effective, a need for regular training programs for the nurses will be confirmed in addition to identifying and improving areas in care delivery where they lack current knowledge.

Similar educational programs can contribute to nursing staff working with patients requiring care bundles for improved health outcomes such as sepsis. Programs can be adopted where a care bundle can be designed, and training conducted for the nursing staff to understand and implement the recommended evidence-based practices, thus resulting in early identification of sepsis and improving the overall health outcomes. Other scenarios where nurse educational programs can be adopted include the prevention 30-day readmission rates among patients with the conditions that are monitored by the CMS, such as myocardial infarction, chronic pulmonary disorders, and pneumonia, among others (CMS, 2019). These conditions require appropriate monitoring and care during the transitional period and before discharge to prevent chances of readmission, thus reducing the financial expenditure.

The potential implications for positive social change involve equipping nurses with the evidence- based knowledge and skills to adequately care for IS patients before discharge to prevent readmissions. The hospital should benefit from the reduced rates by gaining relief from previous financial penalties imposed on the facility by CMS for having high rates of 30-day readmissions. If the 30-day readmission rates are reduced compared to the other facilities within the region, the facility will receive financial incentives from CMS. Reduced rates of readmissions are also an indication of the quality of care offered at the hospital, thus attracting more patients.

Summary

Unplanned patient readmission rates are costly for healthcare facilities and negatively impact the rankings of the hospital-based on care quality (Hughes & Witham, 2018). High 30-day readmission rates in IS patients are among the most prevalent problems faced by healthcare facilities in the US. Patients with IS are at a high risk of mortality and long-term disability, which increases significantly with every hospitalization (Poston, 2018). With the population of IS patients expected to increase, it is imperative that the problem of 30-day readmission rates among hospital clients be addressed. The purpose of the DNP project will be to develop and implement a nurse educational program on post-acute stroke transitional care to reduce 30-day readmission rates among IS patients. In the inpatient rehabilitation facility where the project will be implemented, it was established that the nurses lack adequate knowledge on early identification of post-stroke disorders symptoms leading to frequent unplanned readmissions. The facility has, in the recent past, experienced increased 30-day readmission rates in patients with IS.

The project will involve educating all the nursing staff working at the IS unit on the use of a post-acute stroke transitional care plan. The care plan will focus on patient engaging care that involves early identification of post-stroke disorders associated with possible readmissions. The post-implementation outcome to be evaluated in the project will be the 30-day readmission rates among IS patients observed eight weeks prior and after the implementation of the educational program. The outcome data will be obtained from patient charts by the records staff at the facility. The first section has introduced the DNP project and its relevance to the facility of implementation and nursing practice. Section 2 presents the background and contextual information on the project.

Section 2: Background and Context

Introduction

In a healthcare facility located in the northwestern region of the US, 30-day readmission rates are a concern. The CMS often ranks the facility’s performance as below average in its attempts of reducing 30-day readmission rates in IS patients. The proposed project will involve developing and implementing an educational program for the nursing staff working at the facility’s stroke unit to improve their knowledge on the best evidence-based post-acute stroke transitional care. The DNP student will develop the educational program based on literature review on nursing practices involving patient engagement and identification of post-acute stroke risk factors and comorbidities. The developed educational program will be reviewed and validated by an expert panel before implementation. The DNP project will be guided by the practice focused question: Among nurses caring for IS patients, does an educational program focused on active engagement and caring for patients compared to current standard of practice, reduce the 30-day readmission rates? The purpose of the DNP project will be to develop and implement a nurse educational program on post-acute stroke transitional care to reduce 30-day readmission rates among IS patients.

This section presents the background and contextual information on the project. The concepts, theories, or models to be used in the project will be reviewed in the first subsection. The relevance of the project to nursing practice as well as the local background information on the problem and intervention will be presented. The role of the DNP student and the project teams will also be reviewed in this section.

Concepts, Model and Theories

Model

The model to be used in the project will be the competency, outcomes, and performance assessment (COPA) model, which will inform the design and implementation of the educational program. The COPA model was developed by Lenburg (1999) in the 1990s following extensive educational work with the New York Regents College Nursing Program. The COPA is a learning model focused on the integration of interactive learning, practice-based outcomes, and competency assessment (Lenburg, 1999). The COPA model identifies the critical skills needed for practice, the most effective way to integrate those skills, and the most efficient methodology to teach these skills so that staff integrates them into practice (Chianchana & Wichian, 2016). The COPA approach also requires that the educators evaluate the relevant environmental needs in order to identify the content and competencies to be achieved in the teaching program (Lenburg, 1999).

The COPA model is comprehensive and requires the educator and other stakeholders to address the four essential questions; (a) what are the essential competencies and outcomes for contemporary practice? (b) what are the indicators that define those competencies? (c) what are the most effective ways to learn those competencies? and (d) what are the most effective ways to document that practitioners have achieved the required competencies? The DNP student will respond to each of the four questions during the designing of the evidence-based intervention and the evaluation plan.

The COPA model has been proven as valid in its application in best-evidence nursing practice. According to Lazarte (2016), the COPA model can be used to evaluate a wide range of nursing practice core competencies. The educational program on IS care bundle will be integrated into the COPA concepts to promote nurses’ knowledge gain and its transference to practice. The COPA model has been used in other educational programs for nurses, including the training of novice nurses to gain practice experience. Lin, Wang, and Ye (2015) also utilized the COPA model to explore various methods of injection and intravenous infusion among animals, and how they can be used to improve the core professional nursing competencies. In another study, Manojlovich, Lee, and Lauseng (2016) demonstrated the efficacy of using the COPA model to address core competencies of patient care such as safety and care quality offered by nurses and other healthcare professionals. De Stampa et al. (2014) also evaluated the impact of the COPA model on hospital admissions. The study used the COPA model to provide integrated primary care with intensive case management for community-dwelling, frail elderly patients (Den Stampa et al., 2014).

Theory

Kurt Lewin (1951) theorized change in three steps; unfreeze, change, refreeze. Lewins theorized the unfreeze-change-refreeze change model as requiring participants to discard their previous knowledge and learn the new one (Cummings, 2016). The unfreeze-change-refreeze model is focused on identifying the influencing forces to change, hence knowing which ones to strengthen or weaken for new behavior to be adopted (Ellis & Abbot, 2018). Both driving and restraining forces are responsible for any equilibrium to take effect and the Lewin’s theory of change states that when the former is strong and/or the latter weak, then change is guaranteed to occur (Lewin, 1951).

The first step of change, unfreezing, involves individuals rejecting their old behavior and overcoming the resistance and conformity (Cummings, 2016). The driving and restraining forces for the change are identified at this stage, and the former can be strengthened in preparation for change (Lewn, 1951). In the proposed project, the unfreezing stage will involve educating nurses working at the target facility of the current status regarding the preventable readmission rates and the potential benefits of introducing the proposed change in improving the desired patient outcomes. Informing nurses about the high rates of 30-day readmissions will help in increasing the driving force for accepting the proposed change.

The second step, moving or change, involves the process of altering individuals’ feelings, thoughts, and behaviors (Lewin, 1951). Change can be facilitated by challenging the status quo and providing a fresh perspective or finding new information to influence the preferred change (Ellis & Abbot, 2018). In the proposed project, the second step of the change theory will involve conducting a staff education on the IS care bundle. Educating the nurses on the IS care bundle will provide them with a fresh perspective on the type of care to offer to their patients, thus prompting its use and the attainment of the desired patient outcomes.

The final step is the refreezing and involves ensuring the sustainability of the adopted new habit. Lewin (1951) theorized that the refreezing stage is fundamental in ensuring that the change introduced will be sustained as the new equilibrium. The final stage in the project will involve informing the nurses regarding the evaluation outcome and the facility’s reaffirmation that the care bundle will be adopted as the new standard of care practice. The DNP student will provide recommendations for sustaining the IS care bundle in the facility to the nursing manager.

Lewin’s change theory has been validated in its application in care practice modifications. Gupta, Boland, and Aron (2017) supported the change theory in their study findings that clinical practice constantly requires unlearning and learning. Ellis and Abbot (2018) also supported the application of the change model as essential in healthcare because change is inevitable in the practice. Ellis and Abbot (2018) specifically supported the application of the model in implementing change in a kidney care unit. Similarly, Bender (2016) supported the application of the model in nursing practice in introducing and implementing a clinical nurse leader role. Therefore, the change theory can be effectively used to implement practice change in the proposed project.

Concepts

· Client is used in this project to represent a patient receiving care at the inpatient rehabilitation unit. The term resident may also be used to refer to the patients receiving care at the unit.

· Caregiver is used in this project to refer to any healthcare provider providing care to the patients/ residents at the rehabilitation unit, or at home after discharge. A caregiver may also be used to refer to the patient’s family or any other person caring for them at home after discharge.

· The term care bundle is used to refer to the type of care nurses will be educated on to offer to IS patients. The care bundle will involve active engagement of patients in their care, and communication with their caregivers and family on their care needs after discharge.

· Active engagement in patient care is used to refer to the type of care where the patient is involved, such as asking about how they feel, talking to them about their symptoms, etc. Active engagement is a type of care advocated in the care bundle, and it is expected to help providers to identify and address stroke risk factors at an early stage before adverse events occur.

· 30-day readmissions in this project refer to the unplanned cases where patients have to be sent back to the hospital for acute care; 30 days after admission at the rehabilitation unit. Unplanned readmission cases maybe due to sudden illness requiring in acute care, or stroke reoccurrence within 30 days of admission in the rehabilitation unit. All occurrences where residents have to be sent back to the hospital either for acute care or for scheduled check-up are recorded. All readmissions requiring acute-care within 30-days of prior hospitalization will be referred as 30-day readmission rates.

Relevance to Nursing Practice

A hospital’s ability to reduce adverse effects likely to cause unplanned admissions after initial diagnosis is used as the quality indicator of its providers (Kim et al., 2015). Hospitals unable to reduce its 30-day readmissions pay financial penalties to the CMS in additional to scoring poorly its quality rankings (Kim et al., 2015). Stroke, a leading cause of mortality, is one of the health conditions associated with a high prevalence of unplanned 30-day readmissions (Lichtman, Leifheit-Limson, & Goldstein, 2015). A recent study found that up to 12.4% of IS patients are re-hospitalized within 30-days of initial discharge in the US (Bambhroliya et al., 2015; Vahidy et al., 2017).

The goal of primary care providers is to provide quality care to their patients (Hudali et al., 2017). Primary care providers are focused to address the issues that reduce the quality of care they aspire to provide to their patients (Hudali et al., 2017). With stroke certified a major public health problem, the focus on reducing adverse effects that cause unplanned 30-day readmissions in IS patients has shifted to primary healthcare providers (Lichtman et al., 2015). Through evidence-based practices, research has established that the most prevalent causes of 30-day readmission of IS patients include infection, falls, electrolyte abnormalities, cardiovascular events, and recurrent stroke (Mittal, Rabinstein, Mandrekar, Brown, & Flemming, 2017). The project will focus on preventable and controllable causes such as electrolyte imbalance, infections, and cardiovascular events. Electrolyte imbalance can be prevented with attentive caregivers and infections can be controlled if detected early; similarly, the risk factors for recurrent stroke and cardiovascular events can be identified in some cases, and measures put in place to reduce likelihoods of unplanned readmissions (Mittal et al., 2017). In addition, 30-day readmission rates can be prevented with adequate discharge planning, effective communication, and efficient follow-up of patient’s condition (Andrews, Li, & Freburger, 2015). With the causes of 30-day readmissions identified, the focus of improving the quality of care is now on the prevention of these adverse events before occurrence.

The identification of risk factors associated with infections or cardiovascular events is important and ensures that the symptoms are addressed before they occur (Poston 2018). Nurses and other primary care providers striving to improve the quality of care offered to their clients can utilize the findings of evidence-based research to understand the role they have to play. For example, improving communication and discharge planning has been found to improve the health outcome of discharged patients, which is likely to reduce 30-day readmissions (Andrews et al., 2015). Providing an actively patient engaging care will also allow nurses to identify the symptoms of infections before they occur and address them, accordingly, reducing the likelihood of 30-day readmission rates (Poston, 2018). Actively engaging IS patients will also help in the prevention of falls and management of electrolyte abnormalities and cardiovascular events before they advance to adverse events also reducing the likelihood of unplanned 30-day readmission (Mittal et al., 2017).

Nurse’s knowledge of the appropriate care to offer is an important indicator of patient outcomes (Wu et al., 2018). According to Poston (2018), the first step to improving health outcomes for stroke survivors in the knowledge gain among nurses on the appropriate level of care they need to offer. Educational interventions for nurses have been found effective in improving their knowledge regarding the type of care they have to offer (Jones et al., 2018). Educational programs for nurses have also been associated with their improved adoption of evidence-based practices (Melender Mattila, & Häggman-Laitila, 2016). Nurse targeted education interventions on evidence-based practices have also shown promising results direct improvement of patient outcomes (Jones et al., 2018; Wu et al., 2018).

Local Background and Context

Hospitalizations related to stroke are costly for both the hospitals and the CMS whereby, it is estimated to cost between 18,963 and $21,454 per patient (Poston, 2018). Unplanned readmissions have been known to result in more adverse health outcomes than the initial hospitalization (Hughes & Witham, 2018). The cost of treatment as a result of readmission is expected to be more expensive compared to the initial hospitalization. Patient outcomes also decrease considerably lowering their quality of life (Poston, 2018). The hospitals also face financial consequences as the CMS declines to reimburse for preventable readmissions (Hughes & Witham, 2018). Unplanned 30-day readmissions due to IS are considered to be preventable, therefore, financial penalties are inflicted on hospitals with relatively higher than average rates (CMS, 2019). The HRRP launched in the Affordable Care Act insists on the penalization of hospitals with high rates of 30-day readmission rates as an attempt to reduce public spending related to re-hospitalizations and improve the quality of care patients receive.

At the target facility, there is a need to conduct staff education on patient engagement and early identification of the risk factor of acute post-stroke disorders to minimize the 30-day readmission rates among patients. The hospital has scored higher than average in facilities with high 30-day readmission rates related to stroke. According to the Agency for Healthcare Research and Quality [AHRQ] (2019), providing ongoing patient engaging care for IS clients would ensure that they understand their diagnoses, follow-up needs, and the person to contact in the occurrence of the problem after being discharged. This would reduce the occurrence of adverse events requiring unplanned hospitalizations within 30 days of discharge. Therefore, the objective of the proposed DNP project will be to improve the knowledge of nurses regarding the transitional care requirements of post-acute stroke patients. The project will involve developing and implementing a nurse educational program on post-acute stroke transitional care for nurses to reduce 30-day readmission rates among IS patients. Nurses will be expected to provide patient-engaging transitional care for their patients following the implementation of the educational program.

The target facility is a rehabilitation unit within a larger healthcare system. The unit serves stroke and cancer patients, among others requiring health with their daily living activities during recovery from a major illness. The unit has a post-stroke rehabilitation department, which is where the project will be implemented. Readmissions at the facility are classified as either planned or planned. The focus of the project will be on unplanned 30-day readmission rates. All readmissions are recorded at the facility including the cause and time the patient was sent to hospitals. In the local context, readmissions refer to the events where patients have to leave the rehabilitation unit for acute care services at a hospital or emergency care department.

Role of the DNP Student

As a DNP nursing student, my role in the facility will be to serve as team leader for the project. I work as a patient care coordinator at the facility which allows me to have firsthand knowledge of the systems and the type of care provided. However, I have no personal relationships with any of the nurses and patients at the facility. I have also never been in contact with patient EHR records regarding readmissions or IS diagnoses at the facility. I will also not have access to the patient EHR records during the course of the project but will have medical records personnel at the facility abstract and de-identify the data before I handle it.

My role in the project will be to develop the educational program under guidance from an expert panel, and to direct its implementation. I will develop the educational intervention based on evidence-based literature regarding the transitional care for IS patients to prevent adverse events leading to readmissions (Mittal et al., 2017). I will hand over the developed educational program to the facility for implementation. My roles will be to develop the educational program utilizing an expert panel from the facility for review and validation, provide guidance on its presentation and collection of de-identified data from patient charts, and analyze the received data to determine its effectiveness on reducing 30-day readmissions. I will meet with two personnel from the medical records department who will collect and provide the de-identified data from the EHRs. The meeting will be to review with the staff regarding the type of data to collect and how to present it de-identified.

My motivation to conduct this project is the low rankings the facility has continually received from CMS regarding its inability to reduce 30-day readmissions. As a nurse practitioner, I observe and understand the hard work other nurses put in caring for patients. Low rankings and frequent unplanned patient readmissions tend to demoralize nurses who often feel they are not doing enough. I hope to provide the nurses here with additional evidence-based knowledge on transitional care for stroke survivors. I do not believe I have any biases that could affect the project outcome. I will not come into contact with the EHRs and will only receive de-identified data for analysis.

Summary

Unplanned 30-day readmissions in IS patients are a major public health problem (Kim et al., 2015). However, research has established that the adverse events associated with readmissions in patients with IS can be prevented (Mittal et al., 2017). The project will focus on educating nurses on offering active patient engagement care allowing for the symptoms of such adverse events to be identified and addressed in advance. The COPA model which is focused on the integration of interactive learning, practice-based outcomes, and competency assessment will be utilized in the design, implementation, and evaluation of the project outcomes (Lenburg, 1999). The Lewin’s theory will guide the practice change among the nurses to adopt the care bundle for the IS patients. The healthcare facility of implementation has frequently featured in below-average rankings regarding 30-day readmission reduction and quality of care. The motivation for the project will be the high prevalence of 30-day readmissions in IS patients at the rehabilitation facility. The role of the DNP student will be to develop the educational program and present it for implementation as well as educate records personnel on data abstraction to help in evaluating the project outcome. The next section explores the methods used in implementing and evaluating the project.

Section 3: Collection and Analysis of Evidence

Introduction

Frequent patient readmission after initial diagnosis and treatment is a common problem in the US (Hughes & Witham, 2018). Unplanned 30-day readmission rates in patients diagnosed with IS is an indicator of the quality of care provided in a healthcare facility (Vahidy et al., 2017). The CMS monitors the readmission rates of IS among other fatal health conditions penalizing and offering financial incentives to the hospitals with relatively high and low rates respectively (CMS, 2019). Many of the post-stroke disorders responsible for 30-day readmission rates are preventable when identified and addressed early enough. This doctoral project will focus on educating nurses how to implement a pre-discharge care by engaging patients in their care and the ability to identify and address post-stroke disorders. The purpose of the DNP project will be to develop and implement a nurse educational program on post-acute stroke transitional care to reduce 30-day readmission rates among IS patients. The project’s objective will be to improve the knowledge of the nursing staff on the care of IS patients to reduce 30-day readmission rates. The project implementation will be guided by the COPA model from design to evaluation.

Section 3 presents the methodology utilized to design, implement, and evaluate the educational intervention. An in-depth discussion on the practice-focused question, sources of evidence, implementation, and evaluation stages will be conducted. The steps for analysing and synthesizing the evidence collected will be discussed as well.

Practice-focused Question

The local problem to be addressed is the high rates of 30-day readmission in IS patients. The facility where the project will be implemented has been found to have poor transitional care pre and during IS patients’ discharge to either go home or continue rehabilitative care. Communication among nurses, with caregivers, patients, and their families has been found to be low in the project. The gap in practice to be addressed by the project is lack of adequate knowledge related to post-acute stroke transitional care including identification of the risk factors of post-stroke disorders leading to 30-day readmissions. The high rate of 30-day readmissions among these patient populations is the problem to be addressed by the project. The project will be guided by the practice focused question: Among nurses caring for IS patients, does an educational program focused on active engagement and caring for patients compared to standard practice, reduce the 30-day readmission rates? The purpose of the DNP project will be to develop and implement a nurse educational program on post-acute stroke transitional care to reduce 30-day readmission rates among IS patients. The post-acute stroke care will be patient involving including routinely discussing patient symptoms, and feelings regarding the care approach taken compared to the current practice where the patients are not engaged regarding their condition and care.

Based on the practice-focused question, nurses will be educated to follow new protocols in caring for IS patients during rehabilitative care and the transition to recovery from acute stroke. The content of the educational program will be derived from empirical research on nurse-targeted interventions for improving post-stroke transitional care health outcomes. The care plan will involve an active engagement patient care including identification and addressing of the risk factors for post-stroke conditions that could lead to 30-day readmissions. Thirty-day readmissions will be used to refer to unplanned re-hospitalizations in patients diagnosed with IS due to stroke-related conditions within 30 days after initial discharge. The educational program will refer to the intervention that involves educating nurses on how to care for IS patients.

Sources of Evidence

The source of evidence used in the project will be the hospital health records for IS patients regarding 30-day readmissions before and after implementation of the educational program. Evidence will be the 30-day readmissions data of IS patients obtained from health records at the facility. Patients being admitted at the facility will be questioned regarding prior hospitalizations and their responses compared to the patient health records. Patients previously admitted due to IS will be compared to determine the length of time between the admissions. Patients who had been discharged within 30-days of the current hospitalization will be recorded. The number of 30-day readmissions eight weeks before the educational program is implemented will be collected and compared to the same time after the intervention.

The de-identified data, collected by the medical records staff, from patient charts will be the number of patients admitted within 30-days of discharge, which relates to the purpose of the project. The data collected pre- implementation of the educational program will be compared to that collected after. The two datasets will be compared for significant differences. A study by Lichtman et al. (2015) established that 11.9% of IS readmissions among Medicare patients were as a result of preventable causes. A 10% reduction in 30-day readmissions in the data collected eight weeks after the educational intervention will be anticipated in the proposed project and will be associated with the project intervention. Comparing 30-day readmissions pre and post implementing the educational program will be useful in establishing its effectiveness.

Collecting the de-identified data and its analysis will enable the comparison of the impact of the care provided by nurses after the educational program in comparison to usual practice. The data collected before the implementation of the educational program will be representative of the outcome of usual care practices. The data collected after the education program is presented will be the true reflective of the impact of the intervention on 30-day readmission outcomes. A 10% reduction is expected. Comparing the data will align with the practice-focused question of the comparison between usual care to the one focused on active patient engagement. The processes of collecting and analyzing the evidence for the project, therefore, align with the practice-focused question.

Nature of the Data

Data will be collected every 24 hours from the EHRs during the timeline of the project. Pre-intervention data will be collected by abstracting the EHRs to generate reports on the number of 30-day readmissions recorded every day for the eight weeks preceding the intervention. The data will be abstracted by trained medical record officers working at the facility. The collected data are relevant to the practice problem because of their direct portrayal of the 30-day readmission circumstances at the facility before and after the implementation of the intervention. Data recorded on the EHRs are available every 24 hours, thus the collected evidence was relevant to the project.

All cases of 30-day readmissions are recorded at the facility. Data recorded in EHRs is usually accurate, complete, and comparable boosting the validity and reliability of the project evidence (Chan, Fowles, & Weiner, 2010). Data from EHRs have also been validated for use as quality measures and improvement purposes further supporting its use in the current project (Chan et al., 2010). Access to the data for the doctoral student will be granted by the facility administrator. The student will not be involved in collecting the data; rather two trained medical records personnel working at the facility will extract the data from the EHRs. Data will be abstracted from 30-day readmission records for only the stroke unit. The reason for admission will also be collected, as well as whether it was planned or not. The doctoral student will receive de-identified data and conduct analysis using only the unplanned cases.

Participants

The project participants will include all the nursing staff working at the inpatient stroke rehabilitation unit at the healthcare facility located in the northwestern US. The nursing staff comprises of registered nurses (RNs), licensed vocational nurses (LPNs), and nurse practitioners (NPs). The target will be all the staff who provide direct care to patients at the stroke unit. All the nursing staff at the unit will be targeted to attend the educational program. Having all the nurses trained will be a helpful, making the outcome a reflection of the impact of the training. Training all the nursing staff at the unit will ease the process of evaluating the effectiveness of the educational intervention on patient outcomes for the ward.

Procedures

The first step will involve a comprehensive literature synthesis on post-IS care. Review of previous literature on caring for IS patients to prevent 30-day readmissions will help the doctoral student to design the educational program based on active patient-engaging care (Appendix). The intervention will then be presented to the nursing manager and expert panels at the facility for review. After the nursing manager is satisfied with the educational program, it will be presented to the nursing staff at the unit. The approved educational plan will then be presented to the nurses, educating them on post-acute stroke transition with the goal of reducing the rate of readmission. The nurse manager at the facility will determine the number of sessions held to ensure that all nurses working at the stroke unit are educated. The DNP student will recommend attending at least one 60-minute session for each nurse.

The Doctoral student will meet with the medical records team to review the data abstraction process. The data will be abstracted and presented to the student within eight weeks after the project implementation. De-identified data on the patients’ frequency of readmissions for the 30 days’ period before and after the staff education project will be collected. The readmission rates will be evaluated using percentages and frequencies to determine whether there is an improvement.

Ethical Considerations

The proposed project will adhere to all requirements pertaining to the protection of human subjects. The DNP student will seek approval from the Walden’s Institutional Review Board (IRB) before initiating the project. Authorization from the target setting to use patient data from the facility’s EHR database will also be sought. After getting approval, the student will provide assurances for confidentiality and anonymity of patient data. Confidentiality will be addressed by storing the provided data on a password-protected laptop. Anonymity will be addressed by de-identifying all patient data.

Analysis and Synthesis

Data will be abstracted by hand by two trained records personnel within the unit, handed over to the DNP student and stored in a Microsoft Excel file. The analysis will involve a comparison a comparison of pre and post -intervention data using percentages and tables. A Pearson’s chi-squared test (χ2) will also be used to determine if the changes observed in the 30-day readmission rates pre and post the intervention were as a result of the educational program and care bundle. Comparison using the χ2 test will be done to establish the significance of the relationship between the observed change and the intervention. Findings will be interpreted at 0.05 level of significance. Percentage change in overall number of readmissions 8 weeks before and after the interventions will also be computed.

Summary

The purpose of the proposed project will be to evaluate the impact of the staff education program on 30-day readmission rates in patients with IS. The source of evidence to evaluating the project will be EHRs where patient diagnosis, admission, and discharge data are recorded and made available within 24 hours. The evidence required to evaluate the project outcome will be the 30-day readmission rates in IS patients observed eight weeks before and after implementation of the educational program. Permissions for implementing the project and collecting the data will be requested from both the Walden University IRB and the facility administrator. The intervention will be designed by the DNP student and implemented by the nursing manager to all the nursing staff including the RNs, LPNs, and NPs working at the stroke rehabilitation unit. Trained medical records personnel will abstract the data and de-identify it before presenting it to the DNP student for analysis. The analysis of the obtained data will involve the use of a χ2 test interpreted at 0.05 level of significance and computing of percentage changes in readmission rates. The next section will present the results obtained from the analysis.

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Appendices

Appendix A: Educational Program

Learning Objectives

1. Nurses should be able to list the major risk factors for 30-day readmissions in post-stroke patients

2. Nurses should be able to list the causes of unplanned 30-day hospital readmissions post-acute stroke.

3. Nurses should be able to list strategies for reducing 30-day readmission rates in ischemic stroke patients

4. Nurses should be able to describe sample approaches for addressing the risk factors for post-stroke disorders

Educational Content

Up to 12.1% of ischemic stroke patients are readmitted within 30 days of discharge, were 89.6% of the readmission cases are unplanned (Poston, 2018; Vahidy et al., 2017). Rates for 30-day readmissions are used as quality measures, and the hospital readmission reduction program (HRRP) established in the Affordable Care Act provides financial incentives to healthcare facilities with lowered readmission rates (Centers for Medicare and Medicaid [CMS], 2019). The CMS also fines hospitals with high 30-day readmission rates relative to other healthcare facilities under the HRRP (CMS, 2019).

Risk Factors for Readmissions

· High comorbidity score (Fehnel et al., 2015; Nouh, McCormick, Modak, Fortunato, & Staff, 2017; Okere, Renier, & Frye, 2016).

· Age 75 years and above (Fehnel et al., 2 015; Nouh et al., 2017; Okere et al., 2016).

· Living in a nursing facility prior to stroke (Okere et al., 2017)

· Some comorbidities, such as previous stroke, diabetes, renal failure, heart failure, hypertension, and atrial fibrillation (Condon, Lycan, Duncan, & Bushnell, 2016; Fehnel et al., 2015; Nouh et al., 2017).

· Admission to a non-neurology service (Okere et al., 2016).

· Untreated high cholesterol (Fehnel et al., 2015).

· Low social engagement in the rehabilitation facility (Okere et al., 2017).

· Poor social support (Condon et al., 2016).

Identified Cause of Readmissions

· Respiratory diseases such as pneumonia and influenza (Fehnel et al., 2015).

· Urinary tract or respiratory infections (Nouh et al., 2017).

· Recurrent stroke or transient ischemic attack (Nouh et al., 2017).

· Gastrointestinal complications (Okere et al., 2017)

· Injuries such as those originating from falls (Okere et al., 2 017).

Preventing 30-day Readmissions

Involving patients in decisions on care and treatment and having health services needs met in areas such as falls, fatigue, emotion, memory, speaking, and reading (Kristensen, Tistad, Koch, & Ytterberg, 2016). Frequent contact and communication with patients will help identify and address needs such as poor medication adherence, and risk of infections (Poston, 2018). Identify and stratify patients depending on the risks they have for 30-day readmissions, then address each risk separately (Condor et al., 2016; Kristensen et al., 2016; Poston, 2018).

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(HRRP). Retrieved from

https://www.cms.gov/medicare/medicare-fee-for-service-

payment/acuteinpatientpps/readmissions-reduction-program.html