Evaluation of rural stroke services: does implementation of coordinators and pathways improve care in rural hospitals?
OBJECTIVE
The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes.


METHODS
A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented.


RESULTS



METHODS
pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66).


CONCLUSIONS
Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.
From the Translational Public Health Unit, Stroke and Ageing Research Centre, Department of Medicine, Southern Clinical School, Monash University, Clayton, Australia (D.A.C., T.P., M.K.); Stroke Division, Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia (D.A.C., T.P., M.K.); Stroke Services New South Wales, New South Wales Agency for Clinical Innovation, New South Wales, Australia (M.L.); Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia (K.M.); Hunter Stroke Service, Hunter New England Area Health, Rankin Park Centre, New South Wales, Australia (M.P.); Centre for Brain and Mental Health Research, University of Newcastle and Hunter Medical Research Institute, New Lambton, New South Wales, Australia (C.L.); and John Hunter Hospital, Newcastle, New South Wales, Australia (C.L.).
Dominique A
DA
Cadilhac
Tara
T
Purvis
Monique F
MF
Kilkenny
Mark
M
Longworth
Katherine
K
Mohr
Michael
M
Pollack
Christopher R
CR
Levi
D054869:Clinical Audit; D003695:Delivery of Health Care / Q000458:organization & administration / Q000592:standards / Q000639:trends; D017598:Efficiency, Organizational / Q000592:standards / Q000639:trends; D017408:Guidelines as Topic; D006782:Hospitals, Special / Q000458:organization & administration / Q000592:standards / Q000639:trends; D006801:Humans; D009517:New South Wales; D012189:Retrospective Studies; D019035:Rural Health Services / Q000458:organization & administration / Q000592:standards / Q000639:trends; D020521:Stroke / Q000628:therapy*
coordinator; quality; stroke care; stroke delivery; stroke units