Abstract DP087: Bridging the Stroke Care Gap: A Nurse-Led Approach to Better Outcomes

Background: One of the leading causes of death in the United States is from a cerebrovascular accident, otherwise known as a stroke. Strokes are preventable by 80%; however, there is limited education and follow-up support. Patients are responsible for following up with their primary care provider after discharge. This poses challenges for the patient since they may not have family support. The role of a Stroke Nurse Navigator (SNN) is to provide education, address barriers, and provide support to the patient’s post-stroke recovery. Currently, SNN’s are not fully adopted as the standard of practice across all hospitals. Purpose: A SNN was introduced at a hospital in Northern California to explore the effectiveness in reducing 30-day readmission rates and 72-hour emergency room bounce backs, increasing follow-up adherence, and improvement of overall patient outcomes. Methods: Baseline data was collected from August 2024 through December 2024 (n=98) and again after implementation of a SNN (January 2025 through April 2025; n=87). Data included all patients admitted with either a cerebrovascular accident or transient ischemic attack. Data was collected based on 30-day readmission rates, 72-hour bounce-back rates, follow-up appointment adherence with their primary care physician, and patient satisfaction scores. Admission data, appointment attendance and survey scores were utilized to evaluate the effectiveness of the SNN. Results: When compared to pre-implementation numbers, the 30-day readmission rate was reduced by 49%. The 72-hour emergency room bounce back numbers decreased by 53%. Follow-up adherence increased by 56%. Patient experience surveys revealed that patients had a greater understanding of their diagnosis (previous average of 4.25 out of 5 to 4.61out of 5). Additionally, patients reported feeling more supported (previous average of 4.15 out of 5 to 4.83 out of 5). Conclusion: The introduction of an SNN reduced 30-day readmission rates and 72-hour bounce backs, increased follow-up adherence, and improved patient satisfaction scores. Findings from this study highlight the critical need of implementing SNNs across the nation.