Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2021


Doctor of Nursing Practice (DNP)

Primary Advisor

Joyce Knestrick, PhD, FNP-BC, FAANP, FAAN; Zurab Nadareishvili, MD, PhD; Benny Kim, MD


evidence-based practices; stroke; treatment; transitions of care programs


Background: Stroke is a leading cause of mortality in the U.S. Individuals who suffer from stroke or transient ischemic attack are at risk for further cerebrovascular events. Prevention requires thorough diagnostic evaluation and care coordination, particularly from inpatient to outpatient settings. Transition of Care programs are effective methods for developing long-term treatment, establishing follow-up, and preventing further complications.

Aims/Objectives: The project purpose was to integrate evidence-based recommendations into a Transitions of Care program for patients with ischemic stroke or transient ischemic attack. The aims were to evaluate whether implementation of Stroke Transitions of Care improved outpatient follow-up and stroke readmission rates.

Methods: This quality improvement project occurred in a Primary Stroke center and Neurology clinic. Participants were hospitalized individuals diagnosed with ischemic stroke or transient ischemic attack, assigned to the Neurology service, and discharged home. Process improvements included the nurse practitioner meeting with patients, establishment of a designated patient contact, scheduling follow-up, and performing a post-discharge call with medication reconciliation. Process measures were tracked with run charts over twelve weeks. Pre- and post-implementation data were collected.

Results: There were n=45 patients prior to intervention and n= 24 during intervention. There was a statistically significant 34% increase in proportion of patients attending clinic after intervention (83% vs 62%, p=0.012). Readmission rates were maintained at less than 10% post-implementation.

Implications/Conclusions: Overall, the process improvement measures led to an increase in outpatient follow-up. Adopting evidence-based practices in stroke transitions of care can lead to increased patient retention in the outpatient setting, which may improve overall patient care.

Open Access


Included in

Nursing Commons



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