From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

Machine learning decision support model for discharge planning in stroke patients

BACKGROUND/AIM

Efficient discharge for stroke patients is crucial but challenging. The study aimed to develop early predictive models to explore which patient characteristics and variables significantly influence the discharge planning of patients, based on the data available within 24 h of admission.

DESIGN

Prospective observational study.

METHODS

A prospective cohort was conducted at a university hospital with 523 patients hospitalised for stroke. We built and trained six different machine learning (ML) models, followed by testing and tuning those models to find the best-suited predictor for discharge disposition, dichotomized into home and non-home. To evaluate the accuracy, reliability and interpretability of the best-performing models, we identified and analysed the features that had the greatest impact on the predictions.

RESULTS

In total, 523 patients met the inclusion criteria, with a mean age of 61 years. Of the patients with stroke, 30.01% had non-home discharge. Our model predicting non-home discharge achieved an area under the receiver operating characteristic curve of 0.95 and a precision of 0.776. After threshold was moved, the model had a recall of 0.809. Top 10 variables by importance were National Institutes of Health Stroke Scale (NIHSS) score, family income, Barthel index (BI) score, FRAIL score, fall risk, pressure injury risk, feeding method, depression, age and dysphagia.

CONCLUSION

The ML model identified higher NIHSS, BI, and FRAIL, family income, higher fall risk, pressure injury risk, older age, tube feeding, depression and dysphagia as the top 10 strongest risk predictors in identifying patients who required non-home discharge to higher levels of care. Modern ML techniques can support timely and appropriate clinical decision-making.

RELEVANCE TO CLINICAL PRACTICE

This study illustrates the characteristics and risk factors of non-home discharge in patients with stroke, potentially contributing to the improvement of the discharge process.

REPORTING METHOD

STROBE guidelines.

Benefits of a family-based care transition program for older adults after hip fracture surgery

BACKGROUND

Hip fracture (HF) in older adults is strongly associated with a greater decline in their activities of daily living (ADLs) and health-related (HRQoL). The present study aimed to evaluate the effects of a family-based care transition program (FBCTP) on ADLs, HRQoL and social support in this age group after HF surgery.

METHODS

A quasi-experimental design was conducted on 100 older adults who had undergone HFS and were selected by convenience sampling and allocated to the IG (n = 50) and the CG (n = 50). Data were collected utilizing the Barthel Index, the 12-item Short Form Health Survey (SF-12), and the Multidimensional Scale of Perceived Social Support. The FBCTP was delivered in-hospital education sessions, home visit, and a follow-up and telephone counselling session. The data were collected at three stages, including the baseline, four weeks after discharge, and eight weeks later. The level of statistical significance was set at 0.05.

RESULTS

The results of the study indicated that the effects of time and group on the increase in ADLs were 15.2 and 36.69 (p < 0.000), respectively, following the completion of the FBCTP. Furthermore, time and group were found to have a positive effect on HRQoL, with an increase of 2.82 and 5.60 units, respectively (p < 0.000). In this context, time and group also interacted in the IG compared to the CG, with scores increasing by 1.86 units over time (p < 0.000). Although the study results indicated that social support improved by 1.98 units over time (p < 0.000), the effects of group alone and the time × group interaction were not statistically significant. This indicates that the program was not effective in accelerating social support.

CONCLUSION

Consequently, nurses, policymakers, and planners engaged in geriatric healthcare may utilize these results to enhance the health status of this age group following HFS.

Transitioning to home and beyond following stroke: a prospective cohort study of outcomes and needs

INTRODUCTION

Understanding of the needs of people with stroke at hospital discharge and in the first six-months is limited. This study aim was to profile and document the needs of people with stroke at hospital discharge to home and thereafter.

METHODS

A prospective cohort study recruiting individuals with stroke, from three hospitals, who transitioned home, either directly, through rehabilitation, or with early supported discharge teams. Their outcomes (global-health, cognition, function, quality of life, needs) were described using validated questionnaires and a needs survey, at 7-10 days, and at 3-, and 6-months, post-discharge.

RESULTS

72 patients were available at hospital discharge; mean age 70 (SD 13); 61% female; median NIHSS score of 4 (IQR 0-20). 62 (86%), 54 (75%), and 45 (63%) individuals were available respectively at each data collection time-point. Perceived disability was considerable at hospital discharge (51% with mRS ≥ 3), and while it improved at 3-months, it increased thereafter (35% with mRS ≥ 3 at 6-months). Mean physical health and social functioning were "fair" at hospital discharge and ongoing; while HR-QOL, although improved over time, remained impaired at 6-months (0.69+/-0.28). At 6-months cognitive impairment was present in 40%. Unmet needs included involvement in transition planning and care decisions, with ongoing rehabilitation, information, and support needs. The median number of unmet needs at discharge to home was four (range:1-9), and three (range:1-7) at 6-months.

CONCLUSION

Stroke community reintegration is challenging for people with stroke and their families, with high levels of unmet need. Profiling outcomes and unmet needs for people with stroke at hospital-to-home transition and onwards are crucial for shaping the development of effective support interventions to be delivered at this juncture.

ISRCTN REGISTRATION

02/08/2022; ISRCTN44633579.

A person-centred care transition support for people with stroke/TIA: A study protocol for effect and process evaluation using a non-randomised controlled design

INTRODUCTION

Care transitions following a stroke call for integrated care approaches to reduce death and disability. The proposed research described in this study protocol aims to evaluate the effectiveness of a person-centred multicomponent care transition support and the process in terms of contextual moderators, implementation aspects and mechanisms of impact.

METHODS

A non-randomized controlled trial design will be used. The intervention includes person-centred dialogue intended to permeate all patient-provider communication, various pedagogical modes of information, a person-centred care and rehabilitation plan, and a bridging e-meeting to prepare patients for homecoming. Patients with stroke or TIA who are to be discharged from the participating hospitals to home and referred to a neurorehabilitation team for continued rehabilitation will be included. Follow-ups will be conducted at one week, 3 months and 12 months. Data will be collected on the primary outcome of perceived quality of the care transition, and on the secondary outcomes of health literacy, medication adherence, and perceived person-centeredness. Data for process evaluation will be collected through semi-structured interviews, focus groups, participatory observations, and the Normalisation Measure Development Questionnaire.

DISCUSSION

The study will provide insights on implementation, mechanisms of impact, contextual moderators, and effectiveness of a care transition support, targeting a poorly functioning part of the care trajectory for people with stroke and TIA.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05646589.

Experience of Transitional Care Among Thai-Isan Older Stroke Survivors and Their Family Caregivers

The transitional care model for people who have suffered brain injuries is a relatively recent addition to the Thai healthcare system. The aim of this study was to explore experience of Thai Isan older stroke survivors and their family caregivers across different points of transition from hospital to home. Fifteen dyads of older stroke survivors and their family caregivers were recruited following the inclusion and exclusion criteria. Data were collected through participant observations and semi-structured interviews. Forty-seven participation observation field notes and twenty-four interview transcriptions were analyzed using the Four Phases of the Data Analysis Enabler and the Leininger-Templin-Thompson Ethnoscript Coding Enabler. Three themes emerged: I feel lost with managing care at home; it has been challenging for our family to maintain continuity of care; and it is a matter of who fits in and is convenient for family care responsibilities. The findings of this study have highlighted the dispersion of care among Thai-Isan people during the patient's transition to home. Therefore, a transitional care plan should be developed that specifies who is responsible for monitoring and supporting patients and families throughout this period.

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England

BACKGROUND

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives.

METHODS

Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners.

RESULTS

Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward.

CONCLUSIONS

Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

Participation in daily life activities at two months after stroke predicts long-term health-related quality of life

BACKGROUND

After stroke, many patients experience problems with participation in daily activities. Improving participation is the main goal in stroke rehabilitation. However, the longitudinal relationship between participation and health-related quality of life (HRQoL) remains unclear.

OBJECTIVES

This study aimed to examine (1) the predictive value of participation at two months on long-term HRQoL and (2) the longitudinal relationship between participation and HRQoL.

METHODS

In this multicenter, prospective cohort study, patients were assessed at two and 12 months after stroke. Participation was measured with the Restriction subscale of the Utrecht Scale for Evaluation of Rehabilitation - Participation. HRQoL was assessed with the three-level version of the EuroQoL five dimensions questionnaire index score.

RESULTS

This study included 291 patients. Mean age was 66.6 ± 12.4 years, 64.3% were male and mean National Institutes of Health Stroke Scale (NIHSS) was 2.5 ± 2.9. Multivariable linear regression, adjusted for demographic characteristics, stroke characteristics, physical and cognitive impairment, showed that a higher level of participation at two months correlated with a higher HRQoL at one year (B = .004; 95% CI =.002-.005). Patients whose participation improved had a greater increase in HRQoL, compared to patients without improvement (0.080 ± .21 versus -.054 ± .21; p < .001).

CONCLUSIONS

The level of participation at two months post-stroke predicts HRQoL at one year. Improvement in participation during the first year after stroke is associated with improvement in HRQoL. We recommend including the assessment of participation in daily activities at follow-up visits.

Study on self-management of real-time and individualized support in stroke patients based on resilience: a protocol for a randomized controlled trial

BACKGROUND

The transitional period from hospital to home is vital for stroke patients, but it poses serious challenges. Good self-management ability can optimize disease outcomes. However, stroke patients in China have a low level of self-management ability during the transitional period, and a lack of effective support may be the reason. With the rapid development of technology, using wearable monitors to achieve real-time and individualized support may be the key to solving this problem. This study uses a randomized controlled trial design to assess the efficacy of using wearable technology to realize real-time and individualized self-management support in stroke patients' self-management behavior during the transitional period following discharge from hospital.

METHODS

This parallel-group randomized controlled trial will be conducted in two hospitals and patients' homes. A total of 183 adult stroke patients will be enrolled in the study and randomly assigned to three groups in a 1:1:1 ratio. The smartwatch intervention group (n = 61) will receive Real-time and Individualized Self-management Support (RISS) program + routine care, the wristband group (n = 61) will wear a fitness tracker (self-monitoring) + routine care, and the control group (n = 61) will receive routine stroke care. The intervention will last for 6 months. The primary outcomes are neurological function status, self-management behavior, quality of life, biochemical indicators, recurrence rate, and unplanned readmission rate. Secondary outcomes are resilience, patient activation, psychological status, and caregiver assessments. The analysis is intention-to-treat. The intervention effect will be evaluated at baseline (T0), 2 months after discharge (T1), 3 months after discharge (T2), and 6 months after discharge (T3).

DISCUSSION

The cloud platform designed in this study not only has the function of real-time recording but also can push timely solutions when patients have abnormal conditions, as well as early warnings or alarms. This study could also potentially help patients develop good self-management habits through resilience theory, wearable devices, and individualized problem-solution library of self-management which can lay the foundation for long-term maintenance and continuous improvement of good self-management behavior in the future.

TRIAL REGISTRATION

The ethics approval has been granted by the Ethics Committee of West China Hospital, Sichuan University (2022-941). All patients will be informed of the study details and sign a written informed consent form before enrollment. The research results will be reported in conferences and peer-reviewed publications. The trial registration number is ChiCTR2300070384 . Registered on 11 April 2023.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke

OBJECTIVE

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals.

METHOD

A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis.

RESULTS

Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD.

CONCLUSION

The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Putting music to trial: Consensus on key methodological challenges investigating music-based rehabilitation

Major advances in music neuroscience have fueled a growing interest in music-based neurological rehabilitation among researchers and clinicians. Musical activities are excellently suited to be adapted for clinical practice because of their multisensory nature, their demands on cognitive, language, and motor functions, and music's ability to induce emotions and regulate mood. However, the overall quality of music-based rehabilitation research remains low to moderate for most populations and outcomes. In this consensus article, expert panelists who participated in the Neuroscience and Music VII conference in June 2021 address methodological challenges relevant to music-based rehabilitation research. The article aims to provide guidance on challenges related to treatment, outcomes, research designs, and implementation in music-based rehabilitation research. The article addresses how to define music-based rehabilitation, select appropriate control interventions and outcomes, incorporate technology, and consider individual differences, among other challenges. The article highlights the value of the framework for the development and evaluation of complex interventions for music-based rehabilitation research and the need for stronger methodological rigor to allow the widespread implementation of music-based rehabilitation into regular clinical practice.

Primary care practitioners' perspectives of discharge communication and continuity of care for stroke survivors in Australia: A qualitative descriptive study

Discharge communication is an important component of care transition between hospitals and community care, particularly for the complex needs of stroke survivors. Despite international research and regulation, ineffective information exchange during care transitions continues to compromise patient outcomes. Primary care practitioners are increasingly responsible for the provision of stroke care in the community, yet it is not known how their role is supported by discharge communication. The aim of this qualitative study was to describe the primary care practitioner perspective of discharge communication, identifying the barriers and enablers relative to continuity of care for stroke survivors. Semi-structured telephone interviews were conducted with primary care practitioners across Australia, between April and September 2020. Data were analysed using thematic analysis with a constant-comparison approach. The findings suggest that discharge communication is often inadequate for the complex care and recovery needs of stroke survivors. The challenges in accessing care plans were noted barriers to continuity of care, while shared understandings of stroke survivors' needs were identified as enablers. As discharge communication processes were perceived to be disconnected, primary care practitioners suggested a team approach across care settings. It is concluded that initiatives are required to increase primary care collaboration with hospital teams (which include stroke survivors and their caregivers) to improve continuity of care after stroke.

Interventions within the Scope of Occupational Therapy in the Hospital Discharge Process Post-Stroke: A Systematic Review

Stroke is one of the main causes of disability in adulthood. Its rehabilitation is a complex process that requires a multidisciplinary team of specialised professionals. The main goal of this review was to determine the impact of occupational therapy intervention post-stroke on the home discharge process. A systematic search was carried out of the following databases: Pubmed, Web of Science, PsycINFO, Scopus, Otseeker, and Dialnet. A screening was performed taking into account the type of article, including exclusively RCT, and type of intervention, only including interventions within the scope of occupational therapy that take place during the process of hospital discharge post-stroke. A total of 2285 citations were identified in the search from which 13 articles met the inclusion criteria. Comparisons of the groups indicated that early occupational therapy intervention during the process of hospital discharge can be effective in terms of functional recovery and can lead to the caregiver seeing improvements in self-efficacy and fatigue. In addition, the inclusion of a caregiver in the intervention influences the patient’s adherence to treatment, leading to a reduction in the cost of treatment and rehabilitation.

Effectiveness of interventions to support the transition home after acute stroke: a systematic review and meta-analysis

Background

Effective support interventions to manage the transition to home after stroke are still mostly unknown.

Aim

The purpose of this systematic review was to investigate the effectiveness of support interventions at transition from organised stroke services to independent living at home.

Methods

The Cochrane Central Register of Controlled Trials, six databases including MEDLINE and Embase, trial registries, grey literature, and Google Scholar were all searched, up to June 2021.

We included randomised controlled trials enrolling people with stroke to receive either standard care or any type of support intervention from organised stroke services to home. The primary outcome was functional status.

Two authors determined eligibility, extracted data, evaluated risk of bias (ROB2), and verified the evidence (GRADE). Where possible we performed meta-analyses using Risk Ratios (RR) or Mean Differences (MD).

Results

We included 17 studies. Support interventions led to important improvements in functional status, as determined by the Barthel Index up, to 3-months (MD 7.87 points, 95%CI:6.84 to 19.16; 620 participants; five studies; I2 = 77%). Results showed modest but significant functional gains in the medium to long-term (6–12 month follow up, MD 2.91 points, 95%CI:0.03 to 5.81; 1207 participants; six studies; I2 = 84%). Certainty of evidence was low.

Support interventions may enhance quality of life for up to 3-months (MD 1.3,95% CI:0.84 to 1.76), and reduce depression (SMD -0.1,95% CI:-0.29 to − 0.05) and anxiety (MD -1.18,95% CI:-1.84 to − 0.52) at 6–12 months. Effects on further secondary outcomes are still unclear.

Conclusions

Incorporating support interventions as people who have experienced a stroke transition from hospital to home can improve functional status and other outcomes. Due to study heterogeneity, the essential components of effective transition of care interventions are still unknown. Adoption of core outcome sets in stroke research would allow for greater comparison across studies. Application of a development and evaluation framework engaging stakeholders would increase understanding of priorities for stroke survivors, and inform the key components of an intervention at transition from hospital-to-home.

Trial registration

CRD42021237397 - https://www.crd.york.ac.uk/prospero

Perspectives and Experiences of Cardiac Rehabilitation after Stroke—A Qualitative Study

Cardiac rehabilitation (CR) after stroke has been proven to be a safe and feasible secondary prevention intervention. Limited qualitative data capture people’s experiences and perceptions of attending CR following stroke, but with none addressing translational aspects when CR is delivered as routine clinical care. Using a phenomenological, qualitative approach, four semi-structured focus groups were conducted with 15 individuals (60% male) who had completed CR during their stroke care pathway. Our inductive thematic analysis identified five themes. The first centred on recognising stroke as a cardiovascular disease and the applicability of CR post-stroke. The second addressed how peer understanding, camaraderie, and medical supervision created a safe and supportive environment. The third identified how the programme-built confidence supported longer-term healthy lifestyle choices in physical activity, diet, and smoking. The penultimate theme addressed the period from hospital discharge to attending CR as a time of uncertainty where many participants experienced cognitive difficulties, mood disturbances, and mental fatigue without adequate support. Lastly, participants identified unmet needs in their care pathway that included a lack of information about their referral to CR, the programme content, and accessing local supports ahead of CR. Ongoing and unmet needs both during and after CR related to self-management of secondary prevention medications, neurological issues, post-stroke fatigue, and the lack of structured support following CR completion.

Development of a patient decision aid for discharge planning of hospitalized patients with stroke

Background

Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke.

Methods

A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria.

Results

In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of:

1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient;

2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated “patients-like-me” model with outcome information about discharge destinations;

3) a summary sheet to support actual decision-making during consultation, containing the patient’s values and preferences concerning discharge planning.

In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information.

Conclusions

The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.

Co-creating Digital Stories With UK-Based Stroke Survivors With the Aim of Synthesizing Collective Lessons From Individual Experiences of Interacting With Healthcare Professionals

Background

Stroke survivor narratives can provide valuable insight into experiences of healthcare and beyond. There is need to further understand collective lessons from stroke survivor narratives, yet prior studies utilizing digital storytelling tend to not synthesize lessons from individual experiences. This study aims to develop a novel method to co-create digital stories with stroke survivors that will aim to synthesize and portray important collective lessons from individual stroke survivors' experiences of interacting with healthcare professionals.

Methods

This study follows-up a qualitative study conducted with 30 stroke survivors exploring factors that help or hinder survivors to positively reconfigure their identity post-stroke. Five co-creation workshops were conducted with a subset of UK-based stroke survivors from this previous study. Participants were invited to join through: online workshops, an online bulletin board, and as an advisor. A four-stage workshop framework was developed through the integration of UK Design Council's Double Diamond method, digital storytelling strategies and the Behavior Change Wheel (BCW) framework for developing behavioral change interventions.

Findings

Six online workshop participants (three male, three female; aged 33–63; time since stroke 2–16 years) co-created digital stories that share six collective lessons aimed at increasing empathy and encouraging behavior change in healthcare professionals (HCPs) working with stroke survivors. Online bulletin board participants (n = 1) and advisors (n = 5) supported the co-creation process. Collective lessons identified were: (1) Stroke has a variety of symptoms that must all be considered; (2) Stroke can affect anyone of any age and not just the elderly; (3) Assumptions should not be made about a survivor's lifestyle or habits; (4) It is important to acknowledge the person behind the stroke and ensure that they are communicated with and listened to; (5) Stroke survivors can often feel unprepared for the reality of life after stroke; (6) Adapting to life after stroke is a long-term process requiring long-term support.

Conclusion

Stroke survivor stories highlighted preconceptions, attitudes and behaviors embedded within healthcare that negatively impacted their experiences and recovery. The novel methodology employed in this study enabled these stories to be synthesized into collective lessons to bring about improvements in these behaviors in future.

Transitional care for patients with acute stroke-A priority-setting project

Background

The scope of this priority‐setting process is communication and collaboration in transitional care for patients with acute stroke. Actively involving persons with stroke and their family caregivers is important both in transitional care and when setting priorities for research. Established priority‐setting methods are time‐consuming and require extensive resources. They are therefore not feasible in small‐scale research. This article describes a pragmatic priority‐setting process to identify a prioritized top 10 list of research needs regarding transitional care for patients with acute stroke.

Methods

A pragmatic priority‐setting approach inspired by the James Lind Alliance was developed. It involves establishing a user group, identifying the research needs through an online survey, analysing and checking the research needs against systematic reviews, culminating in an online prioritization of the top 10 list.

Results

The process was completed in 7 months. A total of 122 patients, family caregivers, health personnel and caseworkers submitted 484 research needs, and 19 users prioritized the top 10 list. The list includes the categories ‘patients and caregivers’ needs and health literacy’, ‘health personnel's common understanding’, ‘information flow between health personnel and patients and caregivers’, ‘available interventions and follow‐up of patients and caregivers’, ‘interaction and collaboration between health personnel and caseworkers across hospital and primary healthcare’ and ‘disabilities after stroke’.

Conclusion

This paper outlines a pragmatic approach to identifying and prioritizing users' research needs that was completed in 7 months. The top 10 list resulting from this priority setting process can guide future research relating to communication and collaboration during the transition from hospital to the community for patients with stroke.

Patient and Public Contribution

Members of three stroke organizations participated in the advisory group. They gave feedback on the scope and the process, distributed the surveys and prioritized the top 10 list. Persons with stroke and their caregivers submitted research needs in the survey.

Early supported discharge for older adults admitted to hospital with medical complaints: a systematic review and meta-analysis

INTRODUCTION

Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home and continue to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. The concept has shown reduced length of stay and improved functional outcomes in stroke patients. This systematic review aims to explore the totality of evidence for the use of early supported discharge in older adults hospitalised with medical complaints.

METHODS

A literature search of CINAHL in EBSCO, Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE and MEDLINE in EBSCO was carried out. Randomised controlled trials or quasi-randomised controlled trials were included. The Cochrane Risk of Bias Tool 2.0 was used for quality assessment. The primary outcome measure was hospital length of stay. Secondary outcomes included mortality, function, health related quality of life, hospital readmissions, long-term care admissions and cognition. A pooled meta-analysis was conducted using RevMan software 5.4.1.

RESULTS

Five studies met the inclusion criteria. All studies were of some concern in terms of their risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (REM, MD = -6.04, 95% CI -9.76 to -2.32, I² = 90%, P = 0.001). No statistically significant effects favouring ESD interventions were established in secondary outcomes.

CONCLUSION

ESD interventions can have a statistically significant impact on the length of stay of older adults admitted to hospital for medical reasons. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.

Effectiveness of interventions to support the transition home after acute stroke: a protocol for a systematic review

Background

Despite advances in the quality of acute stroke management, there are gaps in knowledge about effective support interventions to better manage the transition of care to home for patients with this complex condition.  The goal of this systematic review is to explore the literature around support interventions available for patients as they navigate from acute hospital, rehabilitation or early supported discharge (ESD) services to independent living at home; and to establish if, in comparison with usual care or other comparative active interventions, support services offered to patients as they transition from acute hospital, inpatient rehabilitation/ESD to home, can achieve better patient and / or process outcomes.

Protocol 

In June 2021, we will carry out, on electronic peer-reviewed databases, a comprehensive literature search based on a pre-defined search strategy, developed and conducted in collaboration with an Information Specialist.   In an effort to identify all published trials we will perform citation tracking of included studies, check reference lists of relevant articles, review grey literature, and extend our search to google scholar.

We will include randomised controlled trials (including cluster and quasi-randomisation) recruiting stroke patients transitioning to home, to receive either usual care or any support intervention designed to improve outcomes after stroke.

The primary clinical outcome will be functional status.  Two review authors will scrutinise trials, categorise them on their eligibility, and extract data. We will analyse the results for all trials and perform meta-analyses where possible.  We will assess risk of bias for the included trials and use GRADE to assess the quality of the body of evidence.

Patient and public involvement (PPI) engaged in the development of the research questions, and will participate in co-design of a strategy for dissemination of findings.

Conclusions: The findings from this review will be used to identify knowledge gaps to direct future research.

Nursing's Role in Successful Stroke Care Transitions Across the Continuum: From Acute Care Into the Community

Facilitating successful care transitions across settings is a key nursing competency. Although we have achieved improvements in acute stroke care, similar advances in stroke care transitions in the postacute and return to community phases have lagged far behind. In the current delivery system, care transitions are often ineffective and inefficient resulting in unmet needs and high rates of unnecessary complications and avoidable hospital readmissions. Nurses must use evidence-based approaches to prepare stroke survivors and their family caregivers for postdischarge self-management, rehabilitation, and recovery. The purpose of this article is to provide evidence on the important nursing roles in stroke care and transition management across the care continuum, discuss cross-setting issues in stroke care, and provide recommendations to leverage nursing's impact in optimizing outcomes for stroke survivors and their family unit across the continuum. To optimize nursing's influence in facilitating safe, effective, and efficient care transitions for stroke survivors and their family caregivers across the continuum we have the following recommendations (1) establish a system of coordinated and seamless comprehensive stroke care across the continuum and into the community; (2) implement a stroke nurse liaison role that provides consultant case management for the episode of care across all settings/services for improved consistency, communication and follow-up care; (3) implement a validated caregiver assessment tool to systematically assess gaps in caregiver preparedness and develop a tailored caregiver/family care plan that can be implemented to improve caregiver preparedness; (4) use evidence-based teaching and communication methods to optimize stroke survivor/caregiver learning; and (5) use technology to advance stroke nursing care. Nurses must leverage their substantial influence over the health care delivery system to achieve these improvements in stroke care delivery to improve the health and lives of stroke survivors and their families.

Effectiveness of interventions to support the transition home after acute stroke: a protocol for a systematic review

Background Despite advances in the quality of acute stroke management, there are gaps in knowledge about effective support interventions to better manage the transition of care to home for patients with this complex condition.  The goal of this systematic review is to explore the literature around support interventions available for patients as they navigate from acute hospital, rehabilitation or early supported discharge (ESD) services to independent living at home; and to establish if, in comparison with usual care or other comparative active interventions, support services offered to patients as they transition from acute hospital, inpatient rehabilitation/ESD to home, can achieve better patient and / or process outcomes. Protocol  In September 2021, we will carry out, on electronic peer-reviewed databases, a comprehensive literature search based on a pre-defined search strategy, developed and conducted in collaboration with an Information Specialist.   In an effort to identify all published trials we will perform citation tracking of included studies, check reference lists of relevant articles, review grey literature, and extend our search to google scholar. We will include randomised controlled trials (including cluster and quasi-randomisation) recruiting stroke patients transitioning to home, to receive either usual care or any support intervention designed to improve outcomes after stroke. The primary clinical outcome will be functional status.  Two review authors will scrutinise trials, categorise them on their eligibility, and extract data. We will analyse the results for all trials and perform meta-analyses where possible.  We will assess risk of bias for the included trials and use GRADE to assess the quality of the body of evidence. Patient and public involvement (PPI) engaged in the development of the research questions, and will participate in co-design of a strategy for dissemination of findings. Conclusions: The findings from this review will be used to identify knowledge gaps to direct future research.

Preventability of 7-Day Versus 30-Day Readmissions at an Academic Children's Hospital

BACKGROUND AND OBJECTIVES

The 30-day readmission rate is a common quality metric used by Medicare for adult patients. However, studies in pediatrics have shown lower readmission rates and potentially less preventability. Therefore, some question the utility of the 30-day readmission time frame in pediatrics. Our objective was to describe the characteristics of patients readmitted within 30 days of discharge over a 1-year period and determine the preventability of readmissions occurring 0 to 7 vs 8 to 30 days after discharge from a pediatric hospitalist service at an academic children's hospital.

METHODS

Retrospective chart review and hospital administrative data were used to gather medical characteristics, demographics, and process-level metrics for readmitted patients between July 1, 2015, and June 30, 2016. All readmissions were reviewed by 2 senior authors and assigned a preventability category. Subgroup analysis comparing preventability in 0-to-7- and 8-to-30-day readmissions groups was performed. Qualitative thematic analysis was performed on readmissions deemed preventable.

RESULTS

Of 1523 discharges that occurred during the study period, 49 patients, with 65 distinct readmission encounters, were readmitted for an overall 30-day readmission rate of 4.3% (65 of 1523). Twenty-eight percent (9 of 32) of readmissions within 7 days of discharge and 12.1% (4 of 33) occurring 8 to 30 days after discharge were deemed potentially preventable (P = .13). Combined, the 30-day preventable readmission rate was 20% (13 of 65).

CONCLUSIONS

We identified a possible association between preventability and time to readmission. If confirmed by larger studies, the 7-day, rather than 30-day, time frame may represent a better quality metric for readmitted pediatric patients.

Users' experience of community-based power assisted exercise: a transition from NHS to third sector services

PURPOSE

Seated Power Assisted Exercise (PAE) equipment is an accessible exercise mode for people with limited mobility following stroke and is available at a small number of community-based venues. The purpose of this qualitative study was to understand the lived experience of using PAE amongst PwS in a community venue and identify recommendations for the development and advancement of PAE equipment.

METHOD

Semi-structured interviews were conducted with 8 participants (PwS) attending a community stroke venue where PAE equipment was available. Transcribed data were analysed using interpretative phenomenological analysis.

RESULTS

Three overarching themes emerged from the analysis; 1) Don't tell me I've plateaued; 2) PAE facilitates the transition into long-term recovery; 3) Reframing the experience of stroke. Participants associated the uptake of PAE alongside venue membership as a turning point in their adjustment to life following stroke. In addition, recommendations for future development of the equipment were identified.

CONCLUSION

These findings indicate that membership of a stroke venue alongside engagement with PAE facilitated transition from early stroke rehabilitation into longer term recovery. The results of this study have informed the need for future product design and highlighted PAE is an effective mode for continued rehabilitation in third-sector services.

Enablers and barriers in hospital-to-home transitional care for stroke survivors and caregivers: A systematic review

AIMS AND OBJECTIVES

To synthesise qualitative research evidence on the experience of stroke survivors and informal caregivers in hospital-to-home transitional care.

BACKGROUND

Due to a shortened hospital stay, stroke survivors/caregivers must take over complex care on discharge from hospital to home. Gaps in the literature warrant a meta-synthesis of qualitative studies on perceived enablers and barriers during this crucial period.

DESIGN

A systematic review and meta-synthesis.

METHODS

A review was guided by Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist where six databases were searched from April to June 2020 including CINAHL Plus, MEDLINE, PsycINFO, Scopus, Web of Science and ProQuest and ProQuest Dissertations and Theses. There was no date limit to the search. Selected studies were critically appraised. A thematic synthesis approach was applied.

RESULTS

The synthesis of 29 studies identified three major findings. First, partnerships with stroke survivors/caregivers empower discharge preparation, foster competence to navigate health and social care systems and activate self-management capabilities. Second, gaps in discharge planning and the lack of timely postdischarge support contribute to unmet care needs for stroke survivors/caregivers and affect their ability to cope with poststroke changes. Third, stroke survivors/caregivers expect integrated transitional care that promotes shared decision-making and enables long-term self-management at home.

CONCLUSIONS

Hospital-to-home transition is a challenging period in the trajectory of poststroke rehabilitation and recovery. Further research is required to deepen understandings of all stakeholders' views and address unmet needs during transitional care.

RELEVANCE TO CLINICAL PRACTICE

Protocols and clinical guidelines relating to discharge planning and transitional care need to be reviewed to ensure partnership approach with survivors/caregivers in the design and delivery of individualised transitional care. Stroke nurses are in a unique position to lead timely support for survivors/caregivers and to bridge service gaps in hospital-to-home transitional care.

Association Between Use of Rehabilitation in the Acute Care Hospital and Hospital Readmission or Mortality in Patients With Stroke

OBJECTIVE

To examine the association between the number of physical and occupational therapist visits received in the acute care hospital and the risk of hospital readmission or death.

DESIGN

Retrospective cohort study of electronic health records and administrative claims data collected for 2.25 years (January 1, 2016-March 30, 2018).

SETTING

Twelve acute care hospitals in a large health care system in western Pennsylvania.

PARTICIPANTS

Adults (N=8279) discharged with a primary stroke diagnosis.

INTERVENTIONS

The exposure was number of physical and occupational therapist visits during the acute care stay.

MAIN OUTCOME MEASURES

Generalized linear mixed models were estimated to examine the relationship between therapy use and 30- and 7-day hospital readmission or death (outcome), controlling for patient demographic and clinical characteristics.

RESULTS

The 30- and 7-day readmission or death rates were 16.0% and 5.7%, respectively. The number of therapist visits was inversely related to the risk of 30-day readmission or death. Relative to no therapist visits, the odds of readmission or death were 0.70 (95% confidence interval [CI], 0.54-0.90) for individuals who received 1-2 visits, 0.59 (95% CI, 0.43-0.81) for 3-5 visits, and 0.57 (95% CI, 0.39-0.81) for >5 visits. A similar pattern was seen for the 7-day outcome, with slightly larger effect sizes. Effects were also greater in individuals with more mobility limitations on admission and for those discharged to a postacute care facility vs home.

CONCLUSIONS

There was an inverse relationship between the number of therapist visits and risk for readmission or death for patients with stroke discharged from an acute care hospital. Effects differed by time to the event (30d vs 7d), discharge location, and mobility limitations on admission.

Methods and Effectiveness of Communication Between Hospital Allied Health and Primary Care Practitioners: A Systematic Narrative Review

Background

There is a compelling rationale that effective communication between hospital allied health and primary care practitioners may improve the quality and continuity of patient care. It is not known which methods of communication to use, nor how effectively they facilitate the transition of care when a patient is discharged home from hospital. Our systematic review aims to investigate the methods and effectiveness of communication between hospital allied health and primary care practitioners.

Methods

Systematic review of quantitative and qualitative studies with narrative synthesis. Medline, CINAHL, EMBASE, PsycInfo and Proquest Nursing and Allied Health Sources were searched from January 2003 until January 2020 for studies that examined hospital-based allied health professionals communicating with community-based primary care practitioners. Risk of bias in the different study designs was appraised using recognized tools and a content analysis conducted of the methodologies used.

Results

From the located 12,281 papers (duplicates removed), 24 studies met the inclusion criteria with hospital allied health communicating in some form with primary care practitioners. While none of the included studies specifically investigated the methods or effectiveness of communication between hospital allied health and primary care practitioners, 12 of the 24 studies described processes that addressed components of their discharge communication. Four enablers to effective communication between hospital allied health and primary care practitioners were identified: multidisciplinary care plans, patient and caregiver involvement, health information technology and a designated person for follow up/care management.

Conclusion

There is currently no “gold standard” method or measure of communication between hospital allied health and primary care practitioners. There is an urgent need to develop and evaluate multidisciplinary communication with enhanced information technologies to improve collaboration across care settings and facilitate the continuity of integrated people-centered care.

Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review

INTRODUCTION

Stroke is the second most common cause of death after HIV/AIDS and a significant health burden in South Africa. The extent to which universal health coverage (UHC) is achieved for people with stroke in South Africa is unknown. Therefore, a scoping review to explore the opportunities and challenges within the South African health system to facilitate the achievement of UHC for people with stroke is warranted.

METHODS AND ANALYSIS

The scoping review will follow the approach recommended by Levac, Colquhoun and O'Brien, which includes five steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising and reporting the results. Health Systems Dynamics Framework and WHO Framework on integrated people-centred health services will be used to map, synthesise and analyse data thematically.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review, as it will only include published and publicly available data. The findings of this review will be published in an open-access, peer-reviewed journal and we will develop an accessible summary of the results for website posting and stakeholder meetings.

Clinical outcomes for moderate and severe stroke survivors receiving early supported discharge: A quasi-experimental cohort study

Introduction

The aim of this study was to compare outcomes for functional independence, activities of daily living participation and balance achieved by moderate and severe stroke survivors receiving an early supported discharge model of care with those receiving standard treatment.

Method

A quasi-experimental cohort method was utilised, with a control group of convenience. Forty-one patients ( n = 28 early supported discharge group, n = 13 control group) who were medically stable post stroke, safe for discharge home, able to be treated in the home environment and requiring intensive rehabilitation from at least two disciplines participated.

Results

There was no significant difference in outcomes between early supported discharge and control groups for functional independence, activities of daily living participation or balance from baseline to 4 weeks, or 4 weeks to 8 weeks. However, patients receiving early supported discharge made further improvements across the study period, while those receiving standard care made limited improvement between 4 weeks and 8 weeks. All minimal clinically important differences on outcome measures were identified between baseline and 4 weeks.

Conclusions

Moderate and severe stroke survivors can achieve comparable outcomes when receiving early supported discharge or standard treatment. Early supported discharge models of care may also enhance ongoing improvement during the early phases of stroke recovery.

Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke

OBJECTIVES

To explore the perceived quality of care transitions from hospital to the home with referral to subsequent rehabilitation in the home, and factors associated with low perceived quality, in people with stroke.

DESIGN

Observational study.

SETTING AND PARTICIPANTS

Eligible were patients with a suspected acute stroke admitted to 1 of 4 inpatient hospital units in the Stockholm region and discharged home with referral to a neurorehabilitation team in primary care.

METHODS

Data on perceived quality of care transition was collected with the Care Transition Measure (CTM-15) 1 week after discharge. Additional data were mainly retrieved from medical records. To analyze difference in mean total score of the CTM-15 between participants' characteristics, length of hospital stay, disease-related data, and functioning, the Mann-Whitney U test and independent sample t test were used for dichotomized variables and 1-way analysis of variance and the Tukey post hoc test for variables with more than 2 groups. To analyze differences between participants with low and high perceived quality per item, univariable regression analyses were performed. Thereafter, multivariable regression models were created to explore associations between low perceived quality and the independent variables.

RESULTS

Mean age of the 189 participants was 75 years and 91% had a mild or very mild stroke. The majority perceived most areas of the care transition to be of high quality. Nevertheless, several areas for improvement were identified. People with a more severe stroke perceived the quality of the care transition to be lower in comparison with those with a mild stroke. The association was weak between patient or clinical characteristics and the perceived quality.

CONCLUSION AND IMPLICATIONS

Our findings suggest that preparation for discharge and information and support for self-management postdischarge should be enhanced in the referral-based care transition after stroke. Special attention should be given to people with severe stroke.

Evaluating the implementation of an early supported discharge (ESD) program for stroke survivors: A mixed methods longitudinal case study

BACKGROUND

Early supported discharge (ESD) models of care for stroke survivors coordinate inpatient and community services, with the aim of reducing length of stay. While there is an established evidence base around the clinical outcomes of ESD), less is known about the implementation of this approach into existing stroke care service. The aim of this case study was to describe staff perceptions of the implementation of an ESD model of care for stroke survivors at a large metropolitan public hospital in Australia.

METHODS

This case study utilised a mixed methods design, which was designed in explicit alignment with the Consolidated Framework for Implementation Research (CFIR). Participants included staff that referred patients for ESD, and staff involved in the planning, implementation or delivery of ESD. Survey data was collected at three time points (ESD commencement, 3 months and 6 months), and focus groups were undertaken at the conclusion of the study. All quantitative data was analysed descriptive, while qualitative data was evaluated using thematic analysis.

RESULTS

Results from both sources of data identified changes in staff perceptions of ESD implementation over time. While very few changes were statistically significant, they were diverse patterns of change across the CFIR constructs over time. The characteristics of individuals and ESD characteristics attracted consistently positive perceptions, while patient needs and resources was the most prevalent theme within the data. While perceptions of factors related to the inner setting were mixed, there was a steady improvement in perceptions about the process across the later stages of implementation.

CONCLUSIONS

The sophistication of knowledge translation and implementation in modern complex healthcare environments is highlighted by the multiple interactions between the CFIR domains and constructs. While the implementation process described was generally positive and effective, using the CFIR as a framework confirmed that it also entailed some challenges and unanticipated outcomes.

Factors Associated With 90-Day Readmission After Stroke or Transient Ischemic Attack

Background and Purpose—

Readmissions after stroke are common and appear to be associated with comorbidities or disability-related characteristics. In this study, we aimed to determine the patient and health-system level factors associated with all-cause and unplanned hospital readmission within 90 days after acute stroke or transient ischemic attack (TIA) in Australia.

Methods—

We used person-level linkages between data from the Australian Stroke Clinical Registry (2009–2013), hospital admissions data and national death registrations from 4 Australian states. Time to first readmission (all-cause or unplanned) for discharged patients was examined within 30, 90, and 365 days, using competing risks regression to account for deaths postdischarge. Covariates included age, stroke severity (ability to walk on admission), stroke type, admissions before stroke/TIA and the Charlson Comorbidity Index (derived from International Statistical Classification of Diseases and Related Health Problems, Tenth Revision , [Australian modified] coded hospital data in the preceding 5 years).

Results—

Among the 13 594 patients discharged following stroke/TIA (45% female; 65% ischemic stroke; 11% intracerebral hemorrhage; 4% undetermined stroke; and 20% TIA), 25% had an all-cause readmission and 15% had an unplanned readmission within 90 days. In multivariable analyses, the factors independently associated with a greater risk of unplanned readmission within 90 days were being female (subhazard ratio, 1.13 [95% CI, 1.03–1.24]), greater Charlson Comorbidity Index scores (subhazard ratio, 1.11 [95% CI, 1.09–1.12]) and having an admission ≤90 days before the index event (subhazard ratio, 1.85 [95% CI, 1.59–2.15]). Compared with being discharged to rehabilitation or aged care, those who were discharged directly home were more likely to have an unplanned readmission within 90 days (subhazard ratio, 1.44 [95% CI, 1.33–1.55]). These factors were similar for readmissions within 30 and 365 days.

Conclusions—

Apart from comorbidities and patient-level characteristics, readmissions after stroke/TIA were associated with discharge destination. Greater support for transition to home after stroke/TIA may be needed to reduce unplanned readmissions.

Patient engagement in the development of best practices for transitions from hospital to home: a scoping review

OBJECTIVES

To explore the extent of patient engagement in the development of best practice reports related to transitions from hospital to home.

DESIGN

Scoping review.

DATA SOURCES

Electronic databases (MEDLINE, EMBASE, CINAHL, Scopus, Trip Database, DynaMed Plus and Public Health Plus) and multiple provincial regulatory agency and healthcare organisation websites.

ELIGIBILITY CRITERIA

We included best practice reports related to the transition from hospital to a long-term care facility, community dwelling or rehabilitation centre. We included documents disseminated in English between 1947 and 2019.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened for eligibility and one extracted and analysed data using a data extraction tool we developed based on established patient engagement frameworks. Only records actively engaging patients were analysed (n=11). The methodological quality of actively engaging patients was assessed using domain 2 (item 5) of stakeholder involvement from the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

RESULTS

The search yielded 1921 citations of which 23 met the inclusion criteria and were included for narrative synthesis. These were disseminated between 1995 and 2019, with 18 (78%) published after 2010. Most were conducted in North America (USA 43%, Canada 22%), Europe (UK 30%) and Australia (4%). Eleven (48%) actively involved patients, of which only two involved patients across all stages of development. Most involved patients through direct or indirect consultation. The mean AGREE II domain 2 item 5 score (of those that actively engaged patients) was 5.9 out of 7.

CONCLUSIONS

Only half of existing best practice reports related to the transition from hospital to home actively involved patients in report development. However, the extent of patient engagement has been increasing over time. More organisations should strive to engage patients throughout the best practice development process and provide patients with opportunities for shared leadership.