1. 2
Reducing Stroke Readmissions in the Acute Care Setting
Michelle L Wallace
NUR 430
Professor Roberts

2. Introduction:
Cardiovascular diseases, obesity, cancer, and
stroke are some of the leading diseases in the world, and they
are the most frequent causes of death in recent past years.
Stroke is the condition when there is a blockage of blood
supply, and oxygen to any part of the brain. Unfortunately, his
will cause the death of brain cells. This capstone project is
about stroke readmissions that are increasing with passing time.
There are efforts being made to reduce stroke readmissions to
hospitals, and there are a lot of factors involved. Patients should
be given proper awareness, and nurses should be educated so
they may treat the patients with the appropriate care necessary.
According to the American Heart Association, 389 deaths occur
each day due to a stroke in 2016 (Sunil, 2013). This proposal
will discuss the different ways to reduce the stroke causes and
readmissions in the hospital.
Purpose:
The purpose of the project is to discuss the
different causes of stroke and other cardiovascular diseases and
further, it will discuss the ways of prevention and treatment as
well. It is a common observation that stroke readmissions are
increasing day by day, and patients are not getting enough care
and treatment in hospitals. It is observed that may stroke
patients are admitted to the hospital, go home after treatment;
and unfortunately, have to re visit hospitals again and again.
The awareness level has to be increased and the education level
has to be enhanced as well. The community should be engaged
in the different training sessions and proper guidance should be
given to them (Stephanie Rennke, 2015). There are different
strategies for reducing stroke readmissions in the hospitals.
First, it should be noticed that the immune system and nervous
system of the patients are weak, and they have to build
immunity and the concept of self-care should be introduced. The

3. families and peer groups should be supportive enough and diet
recommendations should be given to them. Subsequently, it
would be the duty of the nurses to provide education to patients
hopefully resulting in the reduction of stroke readmissions.
Personal Reflections:
There are different significant issues regarding
ailments and medical experts are presenting their strategies to
control these issues; however, I have selected stroke for the
proposal. Stroke and its incidence are increasing day by day,
and the western countries are most at risk. Sedentary lifestyles
are increasing, and the junk food prevalence is enhanced in
western countries as well. We as a people are so busy with jobs
and business, there is very little time to incorporate a healthy
lifestyle. Unfortunately, there is a lack of routine exercise as a
nation. On the other hand, the ratio of smokers is also
increasing, in which is a major contributor to stroke. The
awareness level has to be increased and nurses should be
educated as well (Hefzy, 2017). So, I am studying these risks to
assist in finding a solution.
Activities:
I have planned several steps and activities for
reducing the stroke readmissions in the hospitals. education
level to the nurses and to increase the awareness level to the
community. The first step is to engage with the stroke
coordinator for my facility. Fortunately, the stroke coordinator
is my preceptor. Together, we will attend the stroke alerts for
the hospital. We will also attend the stroke rounds with the
inpatient rehab physician, and therapy. When doing this, we
will be able to see what resources the patients are lacking that
may be causing the stroke. We will then begin to provide
information the patient will need to be successful. It is vital to
be aware of pertinent information such as family support. All of
this data will better allow staff to understand possible strategies
to reduce stroke readmissions. This will also give the nurse the
proper avenue to take in providing education to his or her

4. patient. The next step is to meet the families and peer groups of
the patients, as they will be involved in the care of the patient
as well. Together we will find out the triggers, and work as a
unit to prevent further readmissions. It is important to know
what issues they feel will lead them back to hospital. Lastly, the
final step will convince the patients to modify their lifestyle and
change their dietary intake. The dietary intake will be increased
in fruits, vegetables, and fiber and to reduce the extra fats and
cholesterol (Christina Condon, Sarah Lycan, & Pamela Duncan,
2015).
Outcomes: Planned
My planned outcomes are to show the decrease in
stroke readmission in hospitals and to increase the education
level and training of nurses. The stroke prevalence will be
reduced and people will try to modify their lifestyle and will
adopt a healthy diet to reduce the diseases. Some of the
literature is as follows. Clinics are tested with reconsidering
their medical clinic's transitional consideration rehearses, to
lessen 30-day readmission rates, forestall antagonistic
occasions, and guarantee protected progress of patients from
emergency clinic to home. Regardless of the expanding
consideration regarding transitional consideration, there are
hardly any distributed investigations that have indicated huge
decreases in readmission rates, especially for patients with
stroke and other neurologic findings. The fruitful emergency
clinic started transitional consideration programs incorporate a
"connecting" system with both pre-discharge and post-discharge
mediations and committed advances supplier required at
numerous focuses in time. In spite of the fact that multi-
component techniques including tolerant commitment,
utilization of a devoted change supplier, and assistance of
correspondence with outpatient suppliers require time and
assets, there is proof that neuro hospitalists can execute a
transitional consideration program with the point of improving
patient wellbeing over the continuum of care (Kristen, 2015).
Outcome: Evidence-Based Research

5. Centers are tried with rethinking their restorative
facility's transitional thought practices, to diminish 30-day
readmission rates, prevent adversarial events, and assure a
shielded advancement of patients from crisis facility to home.
Notwithstanding the extending thought in regards to transitional
thought, there are not really any conveyed examinations that
have shown enormous quantities in readmission rates,
particularly for patients with stroke and other neurologic
discoveries. Productive crisis facility began transitional thought
programs consolidate an "interfacing" framework with both pre-
discharge and post-discharge intercessions, and submitted
progresses provider required at various concentrations in time.
Notwithstanding the way that multicomponent systems
including tolerant responsibility, usage of a committed change
provider, and the help of correspondence with outpatient
providers require time and resources, there is evidence that
neuro hospitalists can execute a transitional thought program
with the purpose of improving patient prosperity over the
continuum of care.
Hansen and associates played out a methodical
audit of 43 intercessions to diminish 30-day medical clinic
readmission. Overall, the nature of concentrates was low, with
just 16 being randomized controlled preliminaries (RCTs). Most
examinations (56%) tried the impact of single-segment
mediations, while the rest of the groups. The creators portrayed
a scientific categorization of mediation parts including general
classes of pre-discharge intercessions (e.g., tolerant training,
release arranging, drug compromise, arrangement planned
before release); post-discharge intercessions (e.g., opportune
development, convenient PCP correspondence, follow-up call,
persistent hotline, home visit); and connecting mediations (e.g.,
change mentor, quiet focused release directions, supplier
progression). Of the 16 RCTs, just 5 yielded critical decreases
in clinic readmission. One of these gave early release arranging
(a solitary segment intercession) to high-chance patients. One
little pilot study and three bigger investigations actualized

6. multicomponent mediation packs, which brought about supreme
decreases in 30-day readmission of 3.6 to 28 rate focuses
(Sunil, 2013).
A special clinical requirement of the agency:
The patients need to have appropriate follow-up
appointments as ordered, the patients in turn need to modify
their lifestyle and take medications as ordered.
Proposed schedule/timeline:
The proposed time is 14 weeks to complete the
process, and all the six steps will be carried out without the
allotted time.
Collaboration with the preceptor:
The preceptor will continue to assist in providing
resources as gathered. Also giving insight as necessary. Lastly,
meeting to address concerns from preceptee. Preceptor also
provides extra support by permitting preceptee to attend stroke
alerts, and stroke rounds. Proposed evaluative
criteria:
It is necessary for patients to follow the discharge
instructions from the physician. This is to include a healthy
diet, and adequate exercise weekly. The patient will also begin
smoking cessation if necessary. Furthermore, the patient will
attend monthly stroke support groups, and take medications as
prescribed. These medications are to include blood pressure,
blood thinners, and cholesterol medications.
Evaluative criteria discussed:
The readmission of stroke patients will be observed
and monitored carefully; this is to reduce the instances of stroke
readmissions.
Conclusion
Stroke is the condition when blood supply to any part
of the brain. The capstone project is about reducing stroke
readmissions. This will occur by ensuring the patient knows the
risk factors, take the prescribed medications, following a heart
healthy diet, and exercising. The efforts are being made to
reduce the stroke readmissions to hospitals and it involves a lot

7. of factors. The patients should be given proper awareness and
nurses should be educated so they may treat the patients with
care. The strategies should be designed and should be followed
to reduce readmissions (Bumpus, 2017).
References
Bumpus, S. M. (2017). Transitional Care to Reduce Cardiac
Readmissions: 5-Year Results from the BRIDGE Clinic. Family
Medicine and Disease Prevention.
Christina Condon, M. N., Sarah Lycan, M. N., & Pamela
Duncan, P. P. (2015). Reducing Readmissions After Stroke With
a Structured Nurse Practitioner/Registered Nurse Transitional
Stroke Program. AHA .
Hefzy, H. K. (2017). A Transition of Care Program to Reduce
Stroke Related Hospital Readmissions. INTERNATIONAL
STROKE CONFERENCE MODERATED POSTER
ABSTRACTS.
Kristen. (2015). Reducing Stroke Readmissions in Hospitals.
Nursing Journal.
Stephanie Rennke. (2015). Transitional Care Strategies From
Hospital to Home. NCBI, 35-42.

8. I have to do a verbal engagement with my preceptor and
professor. I need to be able to explain …Where are the steps I
am taking for the project, and where we are now pertaining to
project?
Rubric for Written Project Paper
Content:
100 Excellent -- Quality information with all “required elements
included”. Quality denotes completeness, precision, clarity,
thoroughness, significance, relevance, accuracy, exhibits full
span of knowledge of a subject and specific topics are focused
upon, amplified and explored.
92 Good -- All “required elements” included. Information is
complete, precise, clear, thorough, significant, relevant and
accurate.
84 Average -- Accurate and complete information with all
“required elements” included.
77 Poor -- Information is inaccurate and/or incomplete with 1 or
more required elements omitted. Needs improvement.
0 Not done -- Did not do the required elements or
characteristics or submitted more than 3 days late.
Communication: Grammar, Punctuation and Format
100Excellent Rules of grammar, usage, and punctuation are
followed, spelling is correct. Language is clear and precise.
Sentences display consistently strong, varied structure.
92 Good Rules of grammar, usage and punctuation are followed;
spelling is correct. Language is clear. Sentences display varied
structure.
84 Average Paper contains few grammatical, punctuation and
spelling errors. Language lacks clarity or includes the use of
some jargon or conversational tone.
77 Poor Paper contains numerous grammatical, punctuation, and
spelling errors. Language uses slang or conversational tone
throughout.
0 Not done Did not do the required element or characteristics.

9. Required Elements
Levels of Achievement
Excellent
100
Good
92
Average
84
Poor
77
Not done
Issue: Discovery Research (10%)
· Describe the issue and explain the implications of the issue in
the context of holistic, comprehensive, effective, patient-
centered care.
Expected Outcomes: Discovery Research (5%)
· Develop specific, measurable, attainable, relevant project
outcomes that support your course outcomes.
Literature: Evidence Summary-Knowledge Generating Stage
(10%)
· Explain how literature supports or refutes the issue.
· Incorporate evidence-based practice (best practices).

10. Analysis: Translation into Guidelines (10%)
This section is based on your literature findings/review.
· Examine current nurses’ roles and participation regarding the
issue.
· Explain why the nurse’s involvement is important.
· Predict the short and long-term impact of these roles and
participation on the selected issue.
· - Consider ethical, legal, financial,
and social implications.
· Provide recommendations for improvement or sustaining of
nursing roles and participation in the issue.
Methodology for Implementation of the Project - (15%)
Describe what you did!
· Address what process was used in changing both individual
and organizational practices (What were the formal and
informal channels used)
Findings from what you implemented (15%)
Evaluation -Process and Outcome Evaluation (5%) Impact of

11. EBP ON
· Client health outcomes
· Provider/health setting and/or client’s satisfaction
· Economic impact
Summary: Practice Integration (10 %)
· Identify factors that affect the individual and organizational
rate of adoption of the innovation (e.g. your project)
· Discuss factors that affect integration of the change into
sustainable systems
Reflection- Curriculum Preparation (10 %)
· Discuss how curricular concepts (e.g., clinical judgment,
critical thinking, problem-solving, information/technology
literacy, knowledge of human diversity and social justice) have
prepared you to take a role in facilitating this change
· Discuss how this project prepared you for transition as a
baccalaureate professional nurse.

12. Communication: APA (2.5%): Same type of error is considered
as 1 error
0-2 errors
3 errors
4 errors
>4 errors
Communication: Scholarly references are used (2.5%): Same
reference is considered as 1 error
1 error
2 errors
3 errors
4 errors
> 4 errors
Communication : Grammar-punctuation and spelling
(2.5 %) – See above for grading criteria
Communication: Paper Length (2.5%) All 4 items must occur in
order to obtain the 2.5 %.
· Eight (8) to ten (10) pages max NOT including the title page
and the reference page(s).

13. · Double spaced
· Times New Roman
· 12 font
All 4 exist
3 exists
2 exists
1 exist
0 exist