Research progress on discharge planning for stroke patients_West China Medical Journal

Authors：

WANG Cong ^1,2 ,  JIANG Yan ^1,3 , DUAN Lijuan ¹ , LIU Shanshan ^1,2 , SUN Wenjing ² , SONG Yuanyuan ²

1. Department of Neurosurgery, West China Hospital, Sichuan University / West China School of Nursing, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Evidence-based Nursing Center, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
3. Nursing Department, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding?author：

JIANG Yan, Email: hxhljy2018@163.com

Keywords：

Discharge planning; stroke; review

DOI：

10.7507/1002-0179.202205026

Video：

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Due to the high incidence rate, high mortality rate, high disability rate, high recurrence rate and many complications of stroke, patients are easily re-admitted after discharge, which seriously affects their quality of life. A scientific and standardized discharge plan can ensure continuous medical care for stroke patients, reduce readmission rates, and improve patient outcomes, which is of great significance for reducing the burden of stroke. This paper reviewes the development and connotation, the nursing model and the implementation status of the discharge planning among stroke patients at home and abroad, and makes recommendations on the opportunities and challenges of implementing the stroke discharge plan, in order to provide a reference for scientific and standardized stroke disease management.

Citation： WANG Cong, JIANG Yan, DUAN Lijuan, LIU Shanshan, SUN Wenjing, SONG Yuanyuan. Research progress on discharge planning for stroke patients. West China Medical Journal, 2023, 38(10): 1601-1606. doi: 10.7507/1002-0179.202205026 Copy

1.	江濱. 中國人群卒中防治現狀、成就與國家行動方略. 國際腦血管病雜志, 2021, 29(9): 641-645.
2.	《中國腦卒中防治報告》編寫組. 《中國腦卒中防治報告 2019》概要. 中國腦血管病雜志, 2020, 17(5): 272-281.
3.	Zhong W, Geng N, Wang P, et al. Prevalence, causes and risk factors of hospital readmissions after acute stroke and transient ischemic attack: a systematic review and meta-analysis. Neurol Sci, 2016, 37(8): 1195-1202.
4.	Bristow O, Stickney C, Thompson S. Discharge planning for continuity of care. League Exch, 1976(112): i-viii, 1-144.
5.	Chen L, Xiao LD, Chamberlain D, et al. Enablers and barriers in hospital-to-home transitional care for stroke survivors and caregivers: a systematic review. J Clin Nurs, 2021, 30(19/20): 2786-2807.
6.	Gon?alves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital. Cochrane Database Syst Rev, 2022, 2(2): CD000313.
7.	唐麗, 李建軍, 高峰, 等. 出院計劃的國際實施進展及認識. 中國康復理論與實踐, 2015, 21(6): 634-641.
8.	趙岳. 探討連續護理過程中出院計劃模式的應用. 中國護理管理, 2007, 7(7): 78-80.
9.	Hu R, Gu B, Tan Q, et al. The effects of a transitional care program on discharge readiness, transitional care quality, health services utilization and satisfaction among Chinese kidney transplant recipients: a randomized controlled trial. Int J Nurs Stud, 2020, 110: 103700.
10.	Chen Y, Zhu L, Xu F, et al. Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project. JBI Database System Rev Implement Rep, 2016, 14(2): 322-336.
11.	Zarle NC. Continuity of care. Balancing care of elders between health care settings. Nurs Clin North Am, 1989, 24(3): 697-705.
12.	Yam CH, Wong EL, Cheung AW, et al. Framework and components for effective discharge planning system: a Delphi methodology. BMC Health Serv Res, 2012, 12: 396.
13.	段麗娟, 侯尚妍, 樊朝鳳, 等. 基于質量效益的出院計劃護理模式構建及優化思考. 中華現代護理雜志, 2020, 26(29): 4123-4126.
14.	馬夢真, 杜星斌, 范燕燕. 護士主導出院計劃的工作內容及應用現況. 護理研究, 2021, 35(4): 661-664.
15.	中國老年護理聯盟. 老年患者出院準備服務專家共識(2019 版). 中華護理雜志, 2020, 55(2): 220-227.
16.	Sinclair AJ, Dashora U, George S, et al. Joint British Diabetes Societies for Inpatient Care (JBDS-IP) clinical guideline inpatient care of the frail older adult with diabetes: an executive summary. Diabet Med, 2020, 37(12): 1981-1991.
17.	Mennuni M, Gulizia MM, Alunni G, et al. ANMCO Position Paper: hospital discharge planning: recommendations and standards. Eur Heart J Suppl, 2017, 19(Suppl D): D244-D255.
18.	Blaylock A, Cason CL. Discharge planning predicting patients’ needs. J Gerontol Nurs, 1992, 18(7): 5-10.
19.	van Walraven C, Dhalla IA, Bell C, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ, 2010, 182(6): 551-557.
20.	CMS proposes prioritizing patient preferences, linking patients to follow-up care in discharge planning process. ED Manag, 2016, 28(3): 30-32.
21.	Sorkin DH, Amin A, Weimer DL, et al. Hospital discharge and selecting a skilled nursing facility: a comparison of experiences and perspectives of patients and their families. Prof Case Manag, 2018, 23(2): 50-59.
22.	Holland DE, Hansen DC, Matt-Hensrud NN, et al. Continuity of care: a nursing needs assessment instrument. Geriatr Nurs, 1998, 19(6): 331-334.
23.	Holland DE, Bowles KH. Standardized discharge planning assessments: impact on patient outcomes. J Nurs Care Qual, 2012, 27(3): 200-208.
24.	Mountain A, Patrice Lindsay M, Teasell R, et al. Canadian Stroke Best Practice Recommendations: rehabilitation, recovery, and community participation following stroke. Part two: transitions and community participation following stroke. Int J Stroke, 2020, 15(7): 789-806.
25.	Andrew NE, Busingye D, Lannin NA, et al. The quality of discharge care planning in acute stroke care: influencing factors and association with postdischarge outcomes. J Stroke Cerebrovasc Dis, 2018, 27(3): 583-590.
26.	Mitchell SE, Martin J, Holmes S, et al. How hospitals reengineer their discharge processes to reduce readmissions. J Healthc Qual, 2016, 38(2): 116-126.
27.	Gesell SB, Bushnell CD, Jones SB, et al. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res, 2019, 19(1): 978.
28.	段麗娟, 樊朝鳳, 朱偉, 等. 我國腦卒中患者出院計劃的文獻計量學分析. 中華現代護理雜志, 2019, 25(9): 1066-1072.
29.	董艷平, 周萍, 吳麗紅, 等. 護士主導出院計劃對造口術后患者出院準備度和造口心理適應的影響. 中國實用護理雜志, 2022, 38(1): 25-31.
30.	時玉婷, 蔣紅, 劉華華, 等. 腦卒中病人出院計劃應用及啟示. 護理研究, 2015(11): 1288-1290.
31.	張淑芳, 趙素琴. 基于適時干預模式的出院計劃在缺血性腦卒中患者中的應用研究. 神經損傷與功能重建, 2021, 16(5): 277-279, 282.
32.	粟藝紅, 唐景峰. 出血性腦卒中后遺癥期病人出院計劃方案的構建及應用. 護理研究, 2021, 35(9): 1667-1669.
33.	Biley A. National Service Framework for Older People: promoting health. Br J Nurs, 2002, 11(7): 469-476.
34.	Mayo NE, Nadeau L, Ahmed S, et al. Bridging the gap: the effectiveness of teaming a stroke coordinator with patient’s personal physician on the outcome of stroke. Age Ageing, 2008, 37(1): 32-38.
35.	Purvis T, Kilkenny MF, Middleton S, et al. Influence of stroke coordinators on delivery of acute stroke care and hospital outcomes: an observational study. Int J Stroke, 2018, 13(6): 585-591.
36.	Pellett C. Discharge planning: best practice in transitions of care. Br J Community Nurs, 2016, 21(11): 542-548.
37.	Laver KE, Adey-Wakeling Z, Crotty M, et al. Telerehabilitation services for stroke. Cochrane Database Syst Rev, 2020, 1(1): CD010255.
38.	van den Berg M, Crotty M, Liu E, et al. Early supported discharge by caregiver-mediated exercises and e-health support after stroke: a proof-of-concept trial. Stroke, 2016, 47(7): 1885-1892.
39.	劉凌, 付偉. 患者出院計劃指南 5W1H 分析. 中國實用護理雜志, 2012, 28(35): 53-56.
40.	孟苗苗, 羅旭飛, 倪小佳, 等. 腦卒中臨床實踐指南和專家共識的質量評價與優化建議. 中國循證心血管醫學雜志, 2020, 12(11): 1316-1323.
41.	賈俊海, 張元元, 劉愛萍, 等. 腦卒中臨床實踐指南質量評價. 中國醫藥導刊, 2018, 20(10): 577-583.

1. 江濱. 中國人群卒中防治現狀、成就與國家行動方略. 國際腦血管病雜志, 2021, 29(9): 641-645.
2. 《中國腦卒中防治報告》編寫組. 《中國腦卒中防治報告 2019》概要. 中國腦血管病雜志, 2020, 17(5): 272-281.
3. Zhong W, Geng N, Wang P, et al. Prevalence, causes and risk factors of hospital readmissions after acute stroke and transient ischemic attack: a systematic review and meta-analysis. Neurol Sci, 2016, 37(8): 1195-1202.
4. Bristow O, Stickney C, Thompson S. Discharge planning for continuity of care. League Exch, 1976(112): i-viii, 1-144.
5. Chen L, Xiao LD, Chamberlain D, et al. Enablers and barriers in hospital-to-home transitional care for stroke survivors and caregivers: a systematic review. J Clin Nurs, 2021, 30(19/20): 2786-2807.
6. Gon?alves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital. Cochrane Database Syst Rev, 2022, 2(2): CD000313.
7. 唐麗, 李建軍, 高峰, 等. 出院計劃的國際實施進展及認識. 中國康復理論與實踐, 2015, 21(6): 634-641.
8. 趙岳. 探討連續護理過程中出院計劃模式的應用. 中國護理管理, 2007, 7(7): 78-80.
9. Hu R, Gu B, Tan Q, et al. The effects of a transitional care program on discharge readiness, transitional care quality, health services utilization and satisfaction among Chinese kidney transplant recipients: a randomized controlled trial. Int J Nurs Stud, 2020, 110: 103700.
10. Chen Y, Zhu L, Xu F, et al. Discharge planning for heart failure patients in a tertiary hospital in Shanghai: a best practice implementation project. JBI Database System Rev Implement Rep, 2016, 14(2): 322-336.
11. Zarle NC. Continuity of care. Balancing care of elders between health care settings. Nurs Clin North Am, 1989, 24(3): 697-705.
12. Yam CH, Wong EL, Cheung AW, et al. Framework and components for effective discharge planning system: a Delphi methodology. BMC Health Serv Res, 2012, 12: 396.
13. 段麗娟, 侯尚妍, 樊朝鳳, 等. 基于質量效益的出院計劃護理模式構建及優化思考. 中華現代護理雜志, 2020, 26(29): 4123-4126.
14. 馬夢真, 杜星斌, 范燕燕. 護士主導出院計劃的工作內容及應用現況. 護理研究, 2021, 35(4): 661-664.
15. 中國老年護理聯盟. 老年患者出院準備服務專家共識(2019 版). 中華護理雜志, 2020, 55(2): 220-227.
16. Sinclair AJ, Dashora U, George S, et al. Joint British Diabetes Societies for Inpatient Care (JBDS-IP) clinical guideline inpatient care of the frail older adult with diabetes: an executive summary. Diabet Med, 2020, 37(12): 1981-1991.
17. Mennuni M, Gulizia MM, Alunni G, et al. ANMCO Position Paper: hospital discharge planning: recommendations and standards. Eur Heart J Suppl, 2017, 19(Suppl D): D244-D255.
18. Blaylock A, Cason CL. Discharge planning predicting patients’ needs. J Gerontol Nurs, 1992, 18(7): 5-10.
19. van Walraven C, Dhalla IA, Bell C, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ, 2010, 182(6): 551-557.
20. CMS proposes prioritizing patient preferences, linking patients to follow-up care in discharge planning process. ED Manag, 2016, 28(3): 30-32.
21. Sorkin DH, Amin A, Weimer DL, et al. Hospital discharge and selecting a skilled nursing facility: a comparison of experiences and perspectives of patients and their families. Prof Case Manag, 2018, 23(2): 50-59.
22. Holland DE, Hansen DC, Matt-Hensrud NN, et al. Continuity of care: a nursing needs assessment instrument. Geriatr Nurs, 1998, 19(6): 331-334.
23. Holland DE, Bowles KH. Standardized discharge planning assessments: impact on patient outcomes. J Nurs Care Qual, 2012, 27(3): 200-208.
24. Mountain A, Patrice Lindsay M, Teasell R, et al. Canadian Stroke Best Practice Recommendations: rehabilitation, recovery, and community participation following stroke. Part two: transitions and community participation following stroke. Int J Stroke, 2020, 15(7): 789-806.
25. Andrew NE, Busingye D, Lannin NA, et al. The quality of discharge care planning in acute stroke care: influencing factors and association with postdischarge outcomes. J Stroke Cerebrovasc Dis, 2018, 27(3): 583-590.
26. Mitchell SE, Martin J, Holmes S, et al. How hospitals reengineer their discharge processes to reduce readmissions. J Healthc Qual, 2016, 38(2): 116-126.
27. Gesell SB, Bushnell CD, Jones SB, et al. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res, 2019, 19(1): 978.
28. 段麗娟, 樊朝鳳, 朱偉, 等. 我國腦卒中患者出院計劃的文獻計量學分析. 中華現代護理雜志, 2019, 25(9): 1066-1072.
29. 董艷平, 周萍, 吳麗紅, 等. 護士主導出院計劃對造口術后患者出院準備度和造口心理適應的影響. 中國實用護理雜志, 2022, 38(1): 25-31.
30. 時玉婷, 蔣紅, 劉華華, 等. 腦卒中病人出院計劃應用及啟示. 護理研究, 2015(11): 1288-1290.
31. 張淑芳, 趙素琴. 基于適時干預模式的出院計劃在缺血性腦卒中患者中的應用研究. 神經損傷與功能重建, 2021, 16(5): 277-279, 282.
32. 粟藝紅, 唐景峰. 出血性腦卒中后遺癥期病人出院計劃方案的構建及應用. 護理研究, 2021, 35(9): 1667-1669.
33. Biley A. National Service Framework for Older People: promoting health. Br J Nurs, 2002, 11(7): 469-476.
34. Mayo NE, Nadeau L, Ahmed S, et al. Bridging the gap: the effectiveness of teaming a stroke coordinator with patient’s personal physician on the outcome of stroke. Age Ageing, 2008, 37(1): 32-38.
35. Purvis T, Kilkenny MF, Middleton S, et al. Influence of stroke coordinators on delivery of acute stroke care and hospital outcomes: an observational study. Int J Stroke, 2018, 13(6): 585-591.
36. Pellett C. Discharge planning: best practice in transitions of care. Br J Community Nurs, 2016, 21(11): 542-548.
37. Laver KE, Adey-Wakeling Z, Crotty M, et al. Telerehabilitation services for stroke. Cochrane Database Syst Rev, 2020, 1(1): CD010255.
38. van den Berg M, Crotty M, Liu E, et al. Early supported discharge by caregiver-mediated exercises and e-health support after stroke: a proof-of-concept trial. Stroke, 2016, 47(7): 1885-1892.
39. 劉凌, 付偉. 患者出院計劃指南 5W1H 分析. 中國實用護理雜志, 2012, 28(35): 53-56.
40. 孟苗苗, 羅旭飛, 倪小佳, 等. 腦卒中臨床實踐指南和專家共識的質量評價與優化建議. 中國循證心血管醫學雜志, 2020, 12(11): 1316-1323.
41. 賈俊海, 張元元, 劉愛萍, 等. 腦卒中臨床實踐指南質量評價. 中國醫藥導刊, 2018, 20(10): 577-583.

West China Medical Journal

Research progress on discharge planning for stroke patients

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