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.	江滨. 中国人群卒中防治现状、成就与国家行动方略. 国际脑血管病杂志, 2021, 29(9): 641-645.
2.	《中国脑卒中防治报告》编写组. 《中国脑卒中防治报告 2019》概要. 中国脑血管病杂志, 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.	Gonçalves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital. Cochrane Database Syst Rev, 2022, 2(2): CD000313.
7.	唐丽, 李建军, 高峰, 等. 出院计划的国际实施进展及认识. 中国康复理论与实践, 2015, 21(6): 634-641.
8.	赵岳. 探讨连续护理过程中出院计划模式的应用. 中国护理管理, 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.	段丽娟, 侯尚妍, 樊朝凤, 等. 基于质量效益的出院计划护理模式构建及优化思考. 中华现代护理杂志, 2020, 26(29): 4123-4126.
14.	马梦真, 杜星斌, 范燕燕. 护士主导出院计划的工作内容及应用现况. 护理研究, 2021, 35(4): 661-664.
15.	中国老年护理联盟. 老年患者出院准备服务专家共识(2019 版). 中华护理杂志, 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.	段丽娟, 樊朝凤, 朱伟, 等. 我国脑卒中患者出院计划的文献计量学分析. 中华现代护理杂志, 2019, 25(9): 1066-1072.
29.	董艳平, 周萍, 吴丽红, 等. 护士主导出院计划对造口术后患者出院准备度和造口心理适应的影响. 中国实用护理杂志, 2022, 38(1): 25-31.
30.	时玉婷, 蒋红, 刘华华, 等. 脑卒中病人出院计划应用及启示. 护理研究, 2015(11): 1288-1290.
31.	张淑芳, 赵素琴. 基于适时干预模式的出院计划在缺血性脑卒中患者中的应用研究. 神经损伤与功能重建, 2021, 16(5): 277-279, 282.
32.	粟艺红, 唐景峰. 出血性脑卒中后遗症期病人出院计划方案的构建及应用. 护理研究, 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.	刘凌, 付伟. 患者出院计划指南 5W1H 分析. 中国实用护理杂志, 2012, 28(35): 53-56.
40.	孟苗苗, 罗旭飞, 倪小佳, 等. 脑卒中临床实践指南和专家共识的质量评价与优化建议. 中国循证心血管医学杂志, 2020, 12(11): 1316-1323.
41.	贾俊海, 张元元, 刘爱萍, 等. 脑卒中临床实践指南质量评价. 中国医药导刊, 2018, 20(10): 577-583.

1. 江滨. 中国人群卒中防治现状、成就与国家行动方略. 国际脑血管病杂志, 2021, 29(9): 641-645.
2. 《中国脑卒中防治报告》编写组. 《中国脑卒中防治报告 2019》概要. 中国脑血管病杂志, 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. Gonçalves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital. Cochrane Database Syst Rev, 2022, 2(2): CD000313.
7. 唐丽, 李建军, 高峰, 等. 出院计划的国际实施进展及认识. 中国康复理论与实践, 2015, 21(6): 634-641.
8. 赵岳. 探讨连续护理过程中出院计划模式的应用. 中国护理管理, 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. 段丽娟, 侯尚妍, 樊朝凤, 等. 基于质量效益的出院计划护理模式构建及优化思考. 中华现代护理杂志, 2020, 26(29): 4123-4126.
14. 马梦真, 杜星斌, 范燕燕. 护士主导出院计划的工作内容及应用现况. 护理研究, 2021, 35(4): 661-664.
15. 中国老年护理联盟. 老年患者出院准备服务专家共识(2019 版). 中华护理杂志, 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. 段丽娟, 樊朝凤, 朱伟, 等. 我国脑卒中患者出院计划的文献计量学分析. 中华现代护理杂志, 2019, 25(9): 1066-1072.
29. 董艳平, 周萍, 吴丽红, 等. 护士主导出院计划对造口术后患者出院准备度和造口心理适应的影响. 中国实用护理杂志, 2022, 38(1): 25-31.
30. 时玉婷, 蒋红, 刘华华, 等. 脑卒中病人出院计划应用及启示. 护理研究, 2015(11): 1288-1290.
31. 张淑芳, 赵素琴. 基于适时干预模式的出院计划在缺血性脑卒中患者中的应用研究. 神经损伤与功能重建, 2021, 16(5): 277-279, 282.
32. 粟艺红, 唐景峰. 出血性脑卒中后遗症期病人出院计划方案的构建及应用. 护理研究, 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. 刘凌, 付伟. 患者出院计划指南 5W1H 分析. 中国实用护理杂志, 2012, 28(35): 53-56.
40. 孟苗苗, 罗旭飞, 倪小佳, 等. 脑卒中临床实践指南和专家共识的质量评价与优化建议. 中国循证心血管医学杂志, 2020, 12(11): 1316-1323.
41. 贾俊海, 张元元, 刘爱萍, 等. 脑卒中临床实践指南质量评价. 中国医药导刊, 2018, 20(10): 577-583.

West China Medical Journal

Research progress on discharge planning for stroke patients

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