Abstract TP221: Effect of Nurse-Driven Structured Early Phone Call on Clinic Follow-up and 30-day Readmission After Intracerebral Hemorrhage During the COVID-19 Pandemic

Background and Purpose: Intracerebral hemorrhage is a devastating type of stroke. Comprehensive care during hospitalization, early post-discharge clinic follow-up, and medication adherence may reduce 30-day readmission after ICH. In 2020, we noted decreasing outpatient clinic follow-up and increasing 30-day readmission rates after ICH at our stroke center between 2019 and 2020. In early 2021, we implemented a structured, nurse-led phone call within 7-14 days post hospital discharge to improve outpatient clinic follow-up, medication adherence and risk management after ICH. The goal of this study is to investigate the effect of structured early phone call on clinic follow-up and 30-day readmission. Methods: All the ICH patients who were discharged home received a phone call from stroke program nurses within 7–14 days post hospital discharge. Using a standardized script, nurses confirmed outpatient clinic appointment scheduling, educated on medication adherence, screened emotional well-being, and provided stroke-prevention education/resources. Up to three call attempts were made for each patient. Responses were documented in a secure database for care coordination and analysis. Statistical analysis included chi-square and t-tests. Results: Of the 154 ICH patients identified to be discharged home, 62 were in the control group (2019 – 2020) and 92 in the intervention group (2021 – 2024). The structured early phone calls significantly improved outpatient clinic follow-up rate (53% [49/92] vs. 20% [13/62], p < 0.05). Overall, the 30-day all-cause readmission rates only decreased slightly (r = –0.25, p = 0.63), partly due to small sample size. Conclusions: A structured, nurse-led post discharge phone call significantly improves outpatient clinic follow-up and potentially reduces 30-day readmission rates after ICH. Embedding this process into discharge protocols can enhance continuity of care. An additional large sample size study is warranted to prove the benefit of such intervention.