Acute Stroke Patients’ Transition: Study Design


Increased rates of patient readmissions are one of the biggest problems for modern healthcare. Often, a patient is unprepared to take the matters of personal healthcare back into their own hands, which is associated with increased re-hospitalization rates. As it stands, transitional care is not standard practice in most healthcare facilities. The transition of care is known to improve the quality of care for patients as well as decrease readmission rates (Reeves et al., 2017). This design proposal suggests the establishment of a health transition clinic for first-time stroke patients to decrease the chances of re-hospitalization.

Change Model Overview

The ACE Star model Evidence-Based Practice Process is a model used by nurses in evidence-based practice. It helps in understanding the cycles, nature, and characteristics of knowledge, which provides a framework for various interventions. The ACE star describes five main stages of knowledge transformations, which are knowledge discovery, synthesis of the available evidence, development of practice recommendations, integration into practice, and evaluation of the results. It is a simple, easy-to-understand framework that can be applied to nearly any practical intervention, which is why it is recommended for evidence-based practice and nursing research.

Define the Scope of the EBP

The purpose of this EBP research is to address the needs of stroke patients and reduce readmission rates. According to Reeves et al. (2017), about 33-35% of stroke patients have recurring episodes within 90 days after being released from the hospital. Post-discharge transitional care is stated to be able to reduce the risks of repeating strokes followed by re-hospitalization. Within the scope of this intervention, transitional care is to be administered to first-time stroke patients.


Relevant stakeholders in this research will include the doctors and nurses operating the transitional care center, the patients, and myself as the leader of the project. Patients are included in the stakeholder list as they are the primary recipients of care. It is estimated that the transitional care center will require five general practice nurses, one doctor, one pharmacist, and two members of support staff. The maximum estimated capacity for the transitional care center is 10 patients.

Determine Responsibility of Team Members

Since I am the leader of the project, my duties will be to coordinate the project, offering initial training and instructions to nursing professionals involved in the experiment, as well as compiling and analyzing data from research. The responsibilities of nurses, the doctor, and the pharmacist would be to facilitate transitional care and prepare the patients for discharge. Support staff would be needed to provide materials and equipment when necessary.


Summarize the Evidence

There are many factors contributing to re-hospitalization rates in stroke patients. Strowd et al. (2015) state that the most influential factors in determining the potential for follow-up readmission are high National Institute of Health Stroke Scores (NIHSS) and previous re-hospitalizations. Leppin et al. (2014) state that post-discharge and transitional care are associated with a low hospitalization rate.

However, they do not provide any information on the use of dedicated transitional care clinics, which indicates the novelty of the proposed intervention. Gray and Hickenbottom (2018) find that transitional care is associated with decreases in readmission rates by 8-12%. The proposed interventions include standardizing transitional care and focusing on stroke patients discharged to home care.

Develop Recommendations for Change Based on Evidence

Based on the evidence provided above, the recommendation is to develop a dedicated transitional care center for first-time stroke patients. This center will provide the patients with all the necessary assistance and information to transition from the hospital to home care. An emphasis will be made on self-care habits, self-monitoring, and knowledge of resources available in the community.


Action Plan

The specific steps for implementing the proposed intervention would include gaining support from the local hospital, recruiting other nurses and doctors to participate in the research, finding volunteers to participate in the project, and conducting the intervention. The timeline for this project is 3 months. Evaluation of the outcomes will include examining the readmission rates for the patients and comparing them with the hospital average.

Process, Outcomes Evaluation, and Reporting

Desired outcomes include lower readmission rates, increased satisfaction from treatment, and better healthcare outcomes. These results will be measured by calculating the percentage of readmissions among the patients who have undergone the intervention. These results will be compared to the control group, which would not receive the same treatment and adhere to standard hospital discharge guidelines. The results will be reported to all relevant stakeholders via a report.

Identify Next Steps

The results of the intervention will be applicable to other heart stroke units and, partially, to the facility as a whole. There is the potential of implementing the plan on a larger scale by utilizing larger hospitals as platforms for experimentation. In order for the intervention to become standard practice, it would be required to propose the intervention through various legislative channels with the aid of the American Nursing Association (ANA)

Disseminate Findings

Findings will be communicated externally on all stages of research through internal reports. These reports will have all the necessary data pertaining to the research, but will not contain the entire picture, as it would be our job to assemble the pieces together. Externally, findings will be communicated to the rest of the world through publications in various academic journals.


Stroke-related readmissions present a serious healthcare problem. The proposed intervention seeks to reduce the number of readmissions by providing a transitional care clinic to first-time stroke patients. The design proposal utilizes the ACE Star model as a framework for this intervention. The effectiveness of training and impressive results would guarantee the continuation of the intervention after the active part of the research is over.


Gray, K., & Hickenbottom, S. (2018). Abstract WP325: Transitional care interventions result in statistically significant reduction in stroke readmission rate. Stroke, 47, supplement 1.

Leppin, A. L., Gionfriddo, M. R., Kessler, M., Brito, J. P., Mair, F. S., Gallacher, K.,… Montori, V. M. (2014). Preventing 30-day hospital readmissions. JAMA Internal Medicine, 174(7), 1095. Web.

Reeves, M. J., Hughes, A. K., Woodward, A. T., Freddolino, P. P., Coursaris, C. K., Swierenga, S. J., … Fritz, M. C. (2017). Improving transitions in acute stroke patients discharged to home: The Michigan stroke transitions trial (MISTT) protocol. BMC Neurology, 17, 115. Web.

Strowd, R. E., Wise, S. M., Umesi, U. N., Bishop, L., Craig, J., Lefkowitz, D., … Bushnell, C. D. (2015). Predictors of 30-day hospital readmission following ischemic and hemorrhagic stroke. American Journal of Medical Quality, 30(5), 441-446.

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NursingBird. "Acute Stroke Patients' Transition: Study Design." November 6, 2023.