Abstract TP208: Stroke Nurse Navigators and Coordinated Actions for Results and Excellence (CARE)

Background and Purpose: Stroke causes approximately 165,000 deaths each year, making it the 5th leading cause of death contributing to an economic burden averaging $59,900 per patient annually. 80% of strokes are preventable through management of modifiable risk factors such as hypertension, diabetes, and smoking. Stroke Nurse Navigators (SNNs) were introduced in November 2020 as part of the hospital’s preparation for achieving Comprehensive Stroke Center designation. Since their implementation, the stroke program has grown from 299 stroke alerts annually to over 1,300. The SNN roles are to assist with stroke alerts, timely interventions, ensure inpatient stroke metrics are met using “Get With The Guidelines®” (GWTG), educating patients, families, and staff on modifiable risk factors and ensure secondary stroke prevention measures are addressed prior to discharge. Methods: All patients admitted with a diagnosis of ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), or stroke rule-out are actively followed and audited by SNNs. Stroke order sets in both the Emergency Department and inpatient units include a consultation to the SNN, which automatically populates a patient list within the Electronic Medical Record (Epic). This ensures consistent tracking throughout the hospital stay. Regardless of final discharge coding, all patients are treated as potential stroke or TIA cases to ensure comprehensive evaluation, education, and adherence to stroke care protocols. Results: The national 30-day readmission rate for ischemic stroke in the U.S. is around 12-13%. For the time period of January 2025 - May 2025, our 30-day readmission rate is at 5.9%. In 2025, we achieved the GWTG Gold Plus with Target: Stroke Honor Roll Elite Plus with Advanced Therapy with Target: Type 2 Diabetes Honor Roll. This was our first time receiving the Advanced Therapy award since becoming a Comprehensive Stroke Center in June 2022. Conclusion: The addition of SNNs has significantly enhanced the quality of stroke care, even amid a substantial increase in stroke volume. By collaborating closely with staff and providers to emphasize the importance of GWTG and Quality Measures, SNNs ensure that patients receive timely interventions and appropriate secondary prevention strategies. Their involvement is instrumental in reducing stroke recurrence and improving long-term patient outcomes.