Does Implementation of Coordinators and Pathways Improve Care in Rural Hospitals?

Stroke is a leading cause of death and major cause of disability. Inconsistent access to evidence-based interventions, such as stroke units (SUs), has been shown to have detrimental effects on patient outcomes. Being able to provide evidence-based stroke care consistently remains a challenge, particularly in rural locations. This is because rural hospitals are less likely to offer coordinated and dedicated services for stroke care in comparison with metropolitan hospitals. Geographic location may also influence patient outcomes, with greater levels of death or dependency reported for patients with stroke in rural communities. Australia is geographically a large continent with a population of ≈22 million who reside mostly along the eastern seaboard. In 2011, it was estimated that ≈9% of acute stroke admissions in Australia were treated in rural hospitals (eg, hospitals where the population was <25 000 people). Furthermore, only 4% to 5% of the 91 rural hospitals that responded to a national survey had an SU or access to neurologists, <50% used a care pathway, and only 32% had a clinical nurse specialist for stroke. With ≈7 million residents, New South Wales (NSW) is the most populated state in Australia, and almost a third of this population live in rural areas. Similar to many locations, variability in the provision Background and Purpose—The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. Methods—A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. Results—Sample: pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34–2.66). Conclusions—Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home. (Stroke. 2013;44:2848-2853.)