Reduced Poststroke Complications after Combination of Multidimensional Nursing Interventions and Antiplatelet Therapy

Summary

This retrospective single-center study investigates whether structured post-discharge nursing follow-up reduces short-term complications in ischemic stroke patients receiving antiplatelet therapy, reporting fewer 30 day complications and improved complication-free survival.

Abstract

Stroke survivors remain at high risk of recurrent events and complications despite standard antiplatelet therapy. Multidimensional nursing interventions may improve outcomes by addressing the medical, functional, and psychosocial needs that conventional care often overlooks during the recovery period. This retrospective, single-center study included 120 ischemic stroke patients discharged on antiplatelet therapy. Patients were divided into an intervention group receiving multidimensional nursing care and a control group receiving conventional care. The primary outcome was the incidence of post-stroke complications within 30 days of discharge. The secondary outcome was complication-free survival over 12 months of follow-up. Logistic regression was used to assess the intervention effect on the primary outcome, and Kaplan–Meier survival analysis was used to evaluate the secondary outcome.

For the primary 30-day outcome, the incidence of complications was significantly lower in the intervention group (11.7% vs. 35.0%, P < 0.01). Multivariable logistic regression, adjusting for age, stroke severity (NIHSS score), and BMI, identified the nursing intervention as an independent protective factor against 30-day complications (adjusted odds ratio [AOR] = 0.267, 95% CI: 0.108–0.658, P = 0.005). For the secondary 12-month outcome, Kaplan–Meier analysis demonstrated significantly prolonged complication-free survival in the intervention group compared with the control group (log-rank P = 0.0042).

These findings suggest that a multidimensional nursing intervention combined with standard antiplatelet therapy may reduce the incidence and delay the onset of post-stroke complications in patients with ischemic stroke. However, due to the retrospective, non-randomized design and potential residual confounding, these findings should be considered hypothesis-generating and confirmed in prospective randomized trials.

Introduction

Stroke remains a formidable global health challenge, persisting as the second leading cause of death and a major contributor to long-term adult disability worldwide¹. For the millions who survive, the journey to recovery is fraught with significant hurdles. The standard of care for secondary prevention in ischemic stroke patients is long-term antiplatelet therapy. However, despite this pharmacological intervention, the risk of recurrent vascular events and medical complications remains substantial, with approximately 10–11% of survivors experiencing another stroke within the first year². Beyond recurrence, survivors are highly susceptible to a cascade of complications, including aspiration pneumonia, deep vein thrombosis, urinary tract infections, depression, and falls. These events, often arising from immobility, dysphagia, and psychological distress, can derail recovery, leading to functional decline, increased mortality, and soaring healthcare costs.

This persistent vulnerability highlights a critical gap: effective post-stroke care requires more than medication alone. It necessitates a holistic, proactive approach that addresses the complex, multifactorial needs of stroke survivors during the critical transition from hospital to home and beyond³. The period following discharge is particularly perilous, marked by fragmented care, patient and caregiver unpreparedness, and a high risk of preventable complications. To bridge this gap, multidisciplinary and multidimensional care models have been advocated, integrating medical management with coordinated rehabilitation, nursing, and psychosocial support³.

Within this framework, specialized stroke nursing has emerged as a pivotal, yet often underutilized, component. Through evidence-based practice, vigilant monitoring, patient education, and psychosocial support, stroke nurses are uniquely positioned to mitigate complications and foster recovery^1,4. For instance, a standardized nursing intervention model (SNIM) implemented in Chinese hospitals demonstrated a significant reduction in immobility-related complications such as pneumonia and pressure sores⁵. However, the evidence base is not uniformly robust. Systematic reviews indicate that while individual studies show benefits, the overall effect of nursing interventions on long-term outcomes remains mixed, and further high-quality evidence is needed to define optimal care models⁴.

This study aims to directly address this evidence gap by rigorously evaluating a specific, structured model of care. Our primary objective is to determine the efficacy of a multidimensional nursing intervention—when combined with routine antiplatelet therapy—in reducing post-stroke complications. We define "multidimensional nursing interventions" as a holistic care model that systematically addresses multiple facets of a patient's recovery. This includes but is not limited to: (1) patient and caregiver education on stroke, risk factors, and medication adherence; (2) guidance on rehabilitation exercises, mobility training, and complication prevention (e.g., swallowing assessments, early mobilization); (3) psychological counseling and support; and (4) structured, regular follow-up monitoring.

While prior research, such as the STROKE-CARD trial in Austria, has shown that intensive, clinic-based multidisciplinary follow-up can reduce major cardiovascular events⁶, such programs can be resource-intensive. Our proposed method differs by focusing on a nurse-led, continuous care model that extends throughout the first year post-discharge, providing more frequent and personalized patient contact. This approach contrasts with less intensive conventional care, which typically consists of brief discharge instructions and routine, physician-led outpatient visits. We hypothesize that this proactive, nurse-driven strategy will be more effective in the early detection and prevention of complications, thereby improving short-term outcomes.

Therefore, the scientific question we address is: In ischemic stroke patients discharged on antiplatelet therapy, does the addition of a structured, multidimensional nursing program to conventional care reduce the 30-day incidence of post-stroke complications and prolong complication-free survival compared to conventional care alone? By answering this question, our study seeks to provide robust clinical evidence on how integrated nursing care can complement pharmacotherapy to enhance secondary prevention and improve patient outcomes, ultimately informing best-practice guidelines for post-stroke management.

Protocol

Study design and participants
This retrospective, single-center observational study was approved by the Ethics Committee of Hunan Brain Hospital (approval number: HBH-2021-045; date of approval: March 15, 2021). Given the retrospective nature of the research, the requirement for informed consent was waived. The study was conducted in the stroke unit of a tertiary hospital in Changsha, China, between January 2021 and December 2023. The reporting of this study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Eligibility criteria
Patients were eligible for inclusion if they met all of the following criteria: age 18 years or older; confirmed diagnosis of acute ischemic stroke within 30 days prior to hospital discharge; prescribed long-term antiplatelet therapy at discharge (aspirin 100 mg daily, clopidogrel 75 mg daily, or both); diagnosis of ischemic stroke confirmed by computed tomography or magnetic resonance imaging performed within 24 h of admission.

Patients were excluded if they met any of the following criteria: hemorrhagic stroke (intracerebral hemorrhage or subarachnoid hemorrhage) or hemorrhagic transformation of ischemic stroke; terminal illness with life expectancy less than 12 months (based on physician documentation in the medical record); severe cognitive impairment (Montreal Cognitive Assessment score < 18 documented in the medical record) that would preclude participation in educational interventions or telephone follow-up; current participation in other disease management programs or clinical trials; residence outside the hospital's primary catchment area (defined as >50 km from the hospital), which would preclude complete follow-up and access to medical records; incomplete medical records precluding assessment of baseline characteristics or outcomes.

Participant identification and screening
Potential participants were identified through a systematic search of the hospital's electronic medical record system for all patients discharged from the stroke unit with a primary diagnosis of ischemic stroke (ICD-10 code I63) during the study period (January 2021 to December 2023). A total of 312 consecutive patients were initially identified.

Two trained research assistants independently reviewed the medical records of all 312 patients against the eligibility criteria. Disagreements were resolved by consensus or by referral to a third reviewer (the principal investigator). The screening process and reasons for exclusion were documented on a standardized case screening form.

Participant flow
Of the 312 patients initially identified, 192 patients were excluded for the following reasons: hemorrhagic stroke or hemorrhagic transformation (n = 48); terminal illness with life expectancy < 12 months (n = 23); severe cognitive impairment (MoCA <18) (n = 31); participation in other disease management programs (n = 17); residence outside catchment area (>50 km) (n = 42); incomplete medical records (n = 31).

This left 120 patients who met all eligibility criteria and were included in the final analysis. Based on a review of nursing documentation from the study period, these 120 patients were categorized into two groups: an intervention group, 60 patients who received the multidimensional nursing program in addition to standard antiplatelet therapy, and a control group, 60 patients who received conventional care with antiplatelet therapy alone. Group assignment was determined by the care documented in the medical records, reflecting routine clinical practice during the study period. No patients were excluded after initial group assignment.

Missing data and follow-up completion
For the primary 30-day outcome, 115 of 120 patients (95.8%) had complete 30-day follow-up data (all three scheduled telephone calls completed and full EMR review possible); 5 patients (4.2%) were missing the day 30 telephone call but had complete EMR data through day 30 and were included in the primary analysis (complications captured through record review). No patients were excluded from the primary analysis due to missing data.

For the secondary 12-month outcome, 108 of 120 patients (90.0%) had complete 12-month follow-up data (all scheduled telephone calls completed through day 365); 7 patients (5.8%) had partial follow-up (completed calls through at least 6 months but missing some later calls); 5 patients (4.2%) were lost to follow-up during months 2-12 (3 in control group, 2 in intervention group) and were censored at the time of last contact in the survival analysis. A detailed participant flow diagram is provided in Figure 1.

Standardization and fidelity monitoring
To ensure consistent delivery, the intervention was manualized with detailed protocols for each component. All patient interactions were documented using standardized case report forms. A random sample of 20% of telephone encounters was audited by the supervising neurologist for adherence to the protocol. Monthly team meetings were held to review protocol adherence and address any deviations. Fidelity metrics, including the percentage of scheduled calls completed and the completeness of documentation, were tracked throughout the study period.

Component 1: Education and self-management (in-hospital)
The educational component consisted of two structured 45–60-min one-on-one sessions conducted by a stroke nurse specialist during the 72 h prior to hospital discharge. Sessions followed a standardized curriculum and were guided by a 12-item educational checklist. Topics covered included stroke pathophysiology and warning signs of recurrence (using visual aids and a standardized handout); medication education: indication, dosage, timing, and potential side effects for antiplatelet therapy (aspirin/clopidogrel), antihypertensives, and statins; risk factor management targets: blood pressure < 130/80 mmHg, HbA1c < 7.0% (if diabetic), LDL cholesterol < 1.8 mmol/L; early recognition of complications: recurrent stroke (FAST signs), infection (fever, dysuria, skin changes), and falls; when and how to seek medical attention (emergency department vs. outpatient clinic). Patients and caregivers received a standardized 24-page educational booklet and a medication reminder chart. Completion of the educational sessions was documented in the electronic medical record, and the checklist was signed by both the nurse and the patient/caregiver.

Component 2: Rehabilitation and physical support (in-hospital and post discharge)
Prior to discharge, each patient underwent a standardized functional assessment by the rehabilitation therapist, including water swallow test for dysphagia screening (3-ounce water swallow test); Berg Balance Scale for fall risk assessment; assessment of mobility and transfer status.

Based on this assessment, a personalized rehabilitation plan was developed and documented on a standardized template. The plan included range-of-motion exercises for affected limbs (specific exercises, repetitions [10 reps], frequency [3x daily]); mobility training based on ambulatory status (e.g., transfers, gait training with assistive devices); swallowing exercises and dietary modifications for patients with dysphagia (e.g., chin-tuck maneuver, thickened liquids, pureed diets); positioning techniques to prevent pressure injuries (specific turning schedules: reposition every 2 h while in bed). Caregivers received hands-on training in assisting with these exercises during a single 60-minute session prior to discharge, with a return demonstration required to confirm competency. The rehabilitation plan was reviewed and reinforced during each follow-up call.

Component 3: Psychosocial support (in-hospital and post discharge)
All patients in the intervention group were screened for emotional distress using the Hospital Anxiety and Depression Scale (HADS) administered at discharge and again at each follow-up contact (via telephone). The HADS consists of 14 items (7 anxiety, 7 depression) with scores ranging from 0 to 21 per subscale: Scores 0–7: Normal range; Scores 8–10: Mild symptoms (supportive counseling from nurse); Scores 11–21: Moderate to severe symptoms (referral to clinical psychologist).

Patients with scores ≥ 8 received a structured 15–20 min supportive counseling session from the stroke nurse during the follow-up call, focusing on coping strategies, stress management, and problem-solving. Patients with scores ≥ 11 or those expressing suicidal ideation were referred to the clinical psychologist for formal assessment and intervention within 72 h. Caregiver stress was assessed informally during follow-up contacts using a single screening question ("How are you coping with the caregiving responsibilities?"), with referrals to social services as needed.

Component 4: Follow-up monitoring protocol (post discharge)
Structured telephone follow-up was conducted by the same stroke nurse specialist throughout the study period to ensure continuity. Calls followed a standardized 18-item script and were documented on a structured case report form. The follow-up schedule was:

Month 1: Weekly calls on days 7, 14, 21, and 28 (±1 day)
Months 2–3: Biweekly calls on days 42, 56, 70, and 84 (±2 days)
Months 4-12: Monthly calls on days 112, 140, 168, 196, 224, 252, 280, 308, and 336 (±3 days)

Each call lasted approximately 20–30 min and covered medication adherence assessment using 3-day recall (asked to name medications, doses, and times); review of any new symptoms or warning signs (using a symptom checklist); blood pressure and glucose self-monitoring results (if applicable); reinforcement of lifestyle modifications (diet, exercise, smoking cessation); rehabilitation plan adherence and any barriers encountered; HADS administration (monthly); scheduling of any necessary follow-up appointments.

Completion criteria: A follow-up call was considered "completed" if the nurse successfully spoke with the patient or primary caregiver and completed at least 80% of the scripted items. If a patient was unreachable, the call was reattempted within 48 h up to three attempts before being recorded as "missed."

Escalation rules: During any follow-up contact, if the patient reported symptoms concerning for recurrent stroke (sudden weakness, speech difficulty, facial droop); chest pain or shortness of breath; fever > 38.3 °C (101 °F); or falls with injury; suicidal ideation, the nurse followed a standardized escalation protocol, which included instructing the patient to seek immediate emergency care and notifying the on-call neurologist. For non-urgent concerns (e.g., medication questions, scheduling issues), the nurse coordinated with the appropriate provider and documented the action taken.

Adherence and fidelity: Throughout the study period, the following fidelity metrics were tracked: percentage of scheduled calls completed: 94.3% (range by patient: 82-100%); mean call duration: 24.6 min (SD ± 4.2); percentage of patients with complete documentation: 100%; percentage of calls requiring escalation: 3.2%; inter-rater reliability on a random sample of 20 calls: 92% agreement on key data elements.

Component 5: Care coordination
Weekly 30 min multidisciplinary team meetings were held to review patients in the intervention group. During these meetings, the stroke nurses presented updates on patient status, including any complications, medication changes, hospitalizations, or psychosocial concerns identified during follow-up calls. The team discussed and documented a coordinated plan, which was communicated to the patient by the nurse within 48 h. Referrals to outpatient services (e.g., home health, physical therapy, social work) were processed through a standardized referral form.

Control group: Conventional care
Patients in the control group received the standard in-hospital nursing care and discharge planning routinely provided at the institution. This included brief verbal instructions (approximately 10–15 min) from the discharging nurse on medication schedules, general rehabilitation recommendations, and dietary advice at the time of discharge. Patients were provided with a standardized discharge summary for their primary care physician and instructed to schedule a follow-up outpatient visit with the neurology clinic at approximately 30 days post discharge. No structured telephone follow-up, individualized education materials, psychosocial screening, or multidisciplinary care coordination was provided to this group beyond standard clinical practice.

Data collection and outcome measures
Baseline demographic and clinical data were extracted from electronic medical records by two trained research assistants working independently, with discrepancies resolved by consensus. Data extracted included: age (years); sex (male/female); body mass index calculated as weight in kilograms divided by height in meters squared (kg/m²); stroke severity assessed by the NIHSS score at admission (range 0 to 42, with higher scores indicating greater severity); stroke type (ischemic or hemorrhagic); antiplatelet regimen (aspirin 100 mg daily, clopidogrel 75 mg daily, or dual therapy); and comorbidities including hypertension (systolic blood pressure ≥ 140 mmHg or on antihypertensive medication), diabetes mellitus (fasting glucose ≥ 7.0 mmol/L or on hypoglycemic medication), and hyperlipidemia (LDL cholesterol ≥ 2.6 mmol/L or on lipid-lowering medication).

Outcomes and follow-up

Primary and secondary outcomes
The primary outcome of this study was the incidence of any post-stroke complication occurring within 30 days of hospital discharge. The secondary outcome was complication-free survival over 12 months of follow-up. For both outcomes, complications were classified into five predefined categories, each with specific diagnostic criteria requiring confirmation by objective evidence.

Diagnostic criteria for each complication type
Recurrent stroke (ischemic or hemorrhagic): Defined as a new focal neurological deficit of sudden onset lasting >24 h, not attributable to another cause, with confirmatory evidence on neuroimaging (computed tomography or magnetic resonance imaging) demonstrating a new infarct or hemorrhage corresponding to the clinical findings. Transient ischemic attacks (symptoms resolving within 24 h without imaging evidence of new infarction) were not counted as recurrent stroke events. Confirmation required review of imaging reports and neurological consultation notes.

Seizures: Defined as any clinically apparent seizure event (generalized or focal) documented by a physician in the medical record, or a seizure event reported by the patient/caregiver that was confirmed by review of emergency medical services records, emergency department records, or neurology consultation notes. Events described as "possible seizure" or "seizure-like activity" without physician confirmation were not counted unless subsequently confirmed by electroencephalography or specialist evaluation.

Deep vein thrombosis (DVT): Defined as a thrombus in the deep venous system of the upper or lower extremities confirmed by compression ultrasound (venous duplex) demonstrating non-compressibility of a venous segment or intraluminal filling defect. Clinical suspicion without ultrasound confirmation was not sufficient. Pulmonary embolism was not included as a separate outcome but was recorded if it occurred concurrently with DVT or as an isolated event; however, no isolated pulmonary emboli occurred in this cohort.

Urinary tract infection (UTI): Defined as the presence of both urinary symptoms (dysuria, frequency, urgency, suprapubic pain, or new onset incontinence) OR fever (>38.0°C) with no other identified source; AND positive urine culture with ≥10⁵ colony-forming units/mL of a uropathogenic organism (or ≥10³ CFU/mL with symptoms and a positive urinalysis). Asymptomatic bacteriuria (positive culture without symptoms) was not counted as a UTI. For patients with indwelling urinary catheters, UTI was defined as fever (>38.0 °C) with no other identified source and a positive urine culture (≥10³ CFU/mL) from a catheter specimen.

Bedsore infection (pressure injury infection): Defined as any pressure injury (Stage 2 or higher) with clinical signs of infection requiring systemic antibiotic therapy, as documented by a physician, wound care nurse, or in the medical record. Clinical signs included erythema, warmth, induration, purulent drainage, or foul odor. Superficial colonization without systemic antibiotic treatment was not counted. Confirmation required review of wound care documentation or physician notes.

Outcome ascertainment process
Data on complications were obtained through a rigorous multi-stage ascertainment process designed to maximize completeness and accuracy.

Stage 1: Electronic medical record review
For all patients, regardless of group assignment, the complete electronic medical record was systematically reviewed by two trained research assistants working independently. Records reviewed included inpatient admission notes and discharge summaries from the index stroke hospitalization; all subsequent inpatient admissions to any hospital within the healthcare system; all outpatient clinic notes (neurology, primary care, rehabilitation, wound care); emergency department records; radiology reports (CT, MRI, ultrasound); laboratory results (urine cultures, blood cultures); microbiology reports; consultation notes. Any potential complication identified by either reviewer was flagged for adjudication. Inter-reviewer agreement on initial record review was 96.2% (kappa = 0.89), indicating excellent reliability.

Stage 2: Structured telephone interviews
For the primary 30-day outcome assessment, standardized telephone interviews were conducted by trained stroke nurses on day 7, day 14, and day 30 post discharge (±1 day). For the secondary 12-month outcome assessment, additional telephone interviews were conducted monthly from month 2 through month 12 (at days 60, 90, 120, 150, 180, 210, 240, 270, 300, 330, and 365, each ±3 days).

Each interview followed a structured 18-item script (see Supplemental File 1, section 1) with questions relevant to complication ascertainment. Patients who reported any potential complication were asked for permission to contact the treating facility or physician to obtain records. Verbal consent was obtained and documented in the call record.

Stage 3: Confirmation and source documentation
For any potential complication identified through either EMR review or telephone interview, the following confirmation process was followed:

For events occurring within the hospital system, the research team obtained and reviewed the full medical record, including admission notes, discharge summaries, imaging reports, laboratory results, and consultation notes. A standardized case report form was completed for each event, documenting the date, diagnostic criteria met, and source documentation.

For events occurring outside the hospital system, if a patient reported hospitalization, emergency department visit, or new diagnosis at an outside facility, the research team requested records from that facility. Written authorization was obtained from the patient (or legally authorized representative) for the release of records. Once received, records were reviewed using the same criteria as for in-system events.

For events reported by telephone but without available outside records: If records could not be obtained (e.g., facility non-response, patient unable to provide authorization), the event was classified as "suspected but unconfirmed" and was not counted as a complication in the primary analysis. A sensitivity analysis including suspected events was planned but not performed due to the low number of such cases (n = 2).

Outcome adjudication
All potential complications identified through either EMR review or telephone interview were reviewed by an independent outcome adjudication committee consisting of one stroke neurologist (not involved in patient care during the study period); one senior stroke nurse (not involved in intervention delivery or follow-up calls); one internist (for review of infections and medical complications).

The committee reviewed de-identified case summaries and source documentation for each potential event. Adjudication was performed using a standardized form that required the committee to confirm that the event met the predefined diagnostic criteria; assign the event date (date of symptom onset or date of diagnosis if onset unclear); classify the event type; determine whether the event should be counted in the final analysis. Disagreements were resolved by consensus, with a third reviewer (a second neurologist) consulted if consensus could not be reached. Inter-rater reliability for adjudication was 98.5% (kappa = 0.94).

Handling of missing follow-up data
Patients were considered lost to follow-up if they could not be reached by telephone after three attempts over a 10-day period at any scheduled follow-up time point. For the primary 30-day outcome, patients were included in the primary analysis if they had complete follow-up through day 30 or were missing the day 30 call but had complete EMR data through day 30 (complications captured through record review). Patients were excluded from the primary analysis if they lacked day 30 call and had incomplete EMR data (e.g., moved out of system).

For the secondary 12-month outcome, patients were censored at the time of the last completed follow-up contact. Patients with <6 months of follow-up data were excluded from the 12-month survival analysis. In this study, 115 of 120 patients (95.8%) had complete 30-day follow-up data; 108 of 120 patients (90.0%) had complete 12-month follow-up data (all 8 scheduled calls completed); 5 patients (4.2%) were lost to follow-up during months 2–12 (3 in control group, 2 in intervention group). No patients were excluded from the primary 30-day analysis due to missing data.

Statistical analysis
All statistical analyses were performed using statistical software with the following packages: a package for baseline table generation, a package for survival analysis, and a package for data visualization. Continuous data were assessed for normality using the Shapiro-Wilk test. Continuous variables with a normal distribution were expressed as mean ± standard deviation and compared between groups using independent-samples t-tests. Continuous variables that were not normally distributed were expressed as median with interquartile range and compared using Mann–Whitney U tests. Categorical variables were expressed as frequencies and percentages and were compared using chi-square tests or Fisher’s exact tests when the expected cell counts were <5.

Analysis of primary outcome (30-day complication incidence): For the primary outcome, a chi-square test was used to compare the crude incidence of complications between groups within the first 30 days post-discharge. The relative risk with 95% confidence interval was calculated. A multivariable logistic regression analysis was conducted to identify independent predictors of 30-day complications and to estimate the intervention's effect, adjusting for potential confounders. Variables included in the model were: group assignment (intervention vs. control), age (continuous, years), sex (male vs. female), hypertension (present vs. absent), diabetes (present vs. absent), BMI (continuous, kg/m²), and NIHSS score (continuous). Variables were selected for inclusion based on clinical relevance and previous literature, regardless of univariate significance. Adjusted odds ratios (AORs) with 95% confidence intervals were calculated by exponentiating the regression coefficients. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test. An odds ratio of 0.267 indicates that patients in the intervention group had approximately one-quarter the odds of experiencing a complication within 30 days compared to patients in the control group, equivalent to a 73.3% reduction in the odds of an event.

Analysis of secondary outcome (12-month complication-free survival): For the secondary outcome, time-to-event analysis was performed using the Kaplan-Meier method, with time zero defined as the date of hospital discharge and follow-up continuing through 365 days. Patients were censored at the time of first complication, death, loss to follow-up, or at 365 days, whichever occurred first. Survival curves for the intervention and control groups were compared using the log-rank test. A Cox proportional hazards model was used to estimate the hazard ratio for time to first complication over the full 12-month period, adjusting for the same covariates as the logistic regression model. The proportional hazards assumption was evaluated using Schoenfeld residuals and was confirmed for all variables (global test P > 0.05). All statistical tests were two-sided, and a P-value < 0.05 was considered statistically significant. No adjustment was made for multiple comparisons in this exploratory analysis.

Sample size consideration
Because this study was retrospective in design, no formal a priori sample size calculation was conducted. The sample size of 120 patients (60 per group) was determined by the number of eligible patients with complete data available during the study period who met the inclusion criteria. A post-hoc power calculation indicated that with 60 patients per group and an observed complication rate of 35% in the control group versus 11.7% in the intervention group, the study had 89% power to detect this difference at a two-sided alpha level of 0.05.

Results

Participant flow and baseline characteristics
A total of 312 patients with ischemic stroke were screened for eligibility during the study period. Of these, 192 patients were excluded for the following reasons: hemorrhagic stroke or transformation (n = 48), terminal illness with life expectancy <12 months (n = 23), severe cognitive impairment (n = 31), participation in other disease management programs (n = 17), residence outside the catchment area (n = 42), and incomplete medical records (n = 31)....

Discussion

This retrospective analysis found that a multidimensional nursing intervention, when added to standard antiplatelet therapy, was associated with improved outcomes for post-stroke patients. For the primary 30-day outcome, patients who received comprehensive nursing care had a significantly lower incidence of early complications compared to those receiving conventional care (11.7% vs. 35.0%, P = 0.005). After adjusting for age, stroke severity, and BMI in multivariable logistic regression, the intervention remained indepen...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Aspirin	Bayer AG	N/A	Antiplatelet medication, 100 mg tablets
Clopidogrel	Sanofi	N/A	Antiplatelet medication, 75 mg tablets
Electronic medical record system	Winning Health Technology Group	N/A	Hospital information system used for data extraction
Hospital Anxiety and Depression Scale (HADS)	Mapi Research Trust	N/A	Psychometric instrument for screening emotional distress
Montreal Cognitive Assessment (MoCA)	MoCA Clinic	N/A	Cognitive screening tool, version 8.1
National Institutes of Health Stroke Scale (NIHSS)	National Institutes of Health	N/A	Standardized neurological examination for stroke severity
R package: ggplot2	R Foundation	N/A	Data visualization package, version 3.4.2
R package: survival	R Foundation	N/A	Survival analysis package, version 3.5-5
R package: tableone	R Foundation	N/A	Baseline table generation package, version 0.13.2
R software	R Foundation for Statistical Computing	N/A	Statistical analysis software, version 4.3.0
Water swallow test	N/A	N/A	Bedside screening tool for dysphagia
Zenodo	CERN	N/A	General-purpose data repository, DOI: 10.5281/zenodo.10839456