Evidence Tables and References 6.4 Discharge Planning Canadian Best Practice Recommendations for Stroke Care 2011-2013 Update Last Updated: June 21, 2013
Table of Contents Search Strategy... 2 What existing clinical practice guidelines include Discharge Planning?... 3 Discharge Planning... 5 References... 11 June 8 th, 2013 1
Search Strategy Identification Cochrane, Medline, and CINAHL, Clinicaltrials.gov, and National Guideline Clearing House were searched Screening Titles and Abstracts of each study were reviewed. Bibliographies of major reviews or meta-analyses were searched for additional relevant articles Eligibility Excluded articles: Non-English, Commentaries, Case- Studies, Narratives, Book Chapters, Editorials, Nonsystematic Reviews (scoping reviews), and conference abstracts. Included Articles: English language articles, RCTs, observational studies and systematic reviews/meta-analysis. Relevant guidelines addressing the topic were also included. Included A total of 6 Articles and 3 Guidelines Cochrane, Medline, and CINAHL, Clinicaltrials.gov, and National Guideline Clearing House were search using medical subject. Titles and abstract of each article were reviewed for relevance. Bibliographies were reviewed to find additional relevant articles. Articles were excluded if they were: non-english, commentaries, case-studies, narrative, book chapters, editorials, non-systematic review, or conference abstracts. Additional searches for relevant best practice guidelines were completed and included in a separate section of the review. A total of 6 articles and 3 guidelines were included and were separated into separate categories designed to answer specific questions. June 8 th, 2013 2
Guidelines What existing clinical practice guidelines include Discharge Planning? Guideline Clinical Guidelines for Stroke Rehabilitation and Recovery National Stroke Foundation, Clinical Guidelines for Stroke Management, 2010 Australia VA/DoD Clinical Practice Guideling: Management of Stroke Rehabilitation Recommendations Safe transfer of care from hospital to community: a) Prior to hospital discharge, all patients should be assessed to determine the need for a home visit, which may be carried out to ensure safety and provision of appropriate aids, support and community services [Grade C]. b) To ensure a safe discharge occurs, hospital services should ensure the following are completed prior to discharge: Patients and families/carers have the opportunity to identify and discuss their post-discharge needs (e.g. physical, emotional, social, recreational, financial, and community support) with relevant members of the multidisciplinary team [Grade GPP]. General practitioners, primary healthcare teams, and community services are informed before or at the time of discharge [Grade GPP]. All medications, equipment and support services necessary for a safe discharge are organized [Grade GPP]. Any continuing specialist treatment required is organized [Grade GPP]. A documented post-discharge plan is developed in collaboration with the patients and family and a copy provided to them. This may include relevant community services, self-management strategies (e.g. information on medications and compliance advice, goals and therapy to continue at home), stroke support services, any further rehabilitation or outpatient appointments, and an appropriate contact number for any queries [Grade GPP]. c) A locally developed protocol may assist in implementation of a safe discharge process [Grade GPP]. d) A discharge planner may be used to coordinate a comprehensive discharge program for stroke survivors [Grade D]. Carer Training: Relevant members of the multidisciplinary team should provide specific and tailored training for carers/family before the stroke survivor is discharged home. This should include training, as necessary, in personal care techniques, communication strategies, physical handling techniques, ongoing prevention and other specific stroke-related problems, safe swallowing and appropriate dietary modifications, and management of behaviours and psychosocial issues. [Grade B]. Transfer to Community Living: 1. Recommend that all patients planning to return to independent community living should be assessed for mobility, ADL and IADL prior to discharge (including a community skills evaluation and home assessment). 2. Recommend that the patient, family, and caregivers are fully informed about, prepared for, and involved in all aspects of healthcare and safety needs. [I] 3. Recommend that case management be put in place for complex patient and family situations. [I] June 8 th, 2013 3
The Management of Stroke Rehabilitation Working Group 2010 Stroke Council of American Heart Association; Veteran s Health Administration, DoD Duncan et al., 2005 4. Recommend that acute care hospitals and rehabilitation facilities maintain up-to-date inventories of community resources, provide this information to stroke patients and their families and caregivers, and offer assistance in obtaining needed services. Patients should be given information about, and offered contact with, appropriate local statutory and voluntary agencies. [I] Discharge from Rehabilitation: 1. Recommend that the rehabilitation team ensure that a discharge plan is complete for the patient s continued medical and functional needs prior to discharge from rehabilitation services. 2. Recommend that every patient participate in a secondary prevention program (see Annotation D). [A] 3. Recommend post-acute stroke patients be followed by a primary care provider to address stroke risk factors and continue treatment of co-morbidities. 4. Recommend patient and family are educated regarding pertinent risk factors for stroke. 5. Recommend that the family and caregivers receive all necessary equipment and training prior to discharge from rehabilitation services. [I] 6. Family counseling focusing on psychosocial and emotional issues and role adjustment should be encouraged and made available to patients and their family members upon discharge. 1. Recommend that every patient participate in a secondary prevention program (see Section III-D, Initiation of Secondary Prevention of Stroke and Atherosclerotic Vascular Disease ). 2. Recommend that post acute stroke patients be followed up by a primary care provider to address stroke risk factors and continue treatment of comorbidities. 3. Recommend that patient and family be educated about pertinent risk factors for stroke. June 8 th, 2013 4
Evidence Summary Discharge Planning Study/Type Sheppard et al. 2013 Systematic Review and Meta-Analysis (Cochrane Review) Quality Rating N/A Sample Description 24 studies met inclusion criteria consisting of 8039 participants. Exclusion criteria: any RCT in which discharge planning is mentioned but is not the primary focus of the study. Method Outcomes Key Findings 14 trials were included in a meta-analysis (3 new trials identified in 2013 update). All other trials were discussed qualitatively. Outcomes of interest were divided into three sections: 1. Use of acute care: length of stay in hospital, readmission rates and discharge destination. 2. Patient and caregiver outcomes: patient mortality, a variety of outcomes including (functional, psychosocial, quality of life and health status) and patient and caregiver satisfaction. 3. Health care costs: hospital, community, medication, and overall costs. 1. Use of acute care: a. A selection of ten trials with older patient populations, found a statistically significant decrease in length of hospital stay for patients receiving discharge planning compared to controls (MD -0.91; 95% CI - 1.55 to -0.27). Other subgroup analyses found no statistically significant differences. b. A selection of 12 trials consisting of older patients with a medical condition, found a statistically significant decrease in readmission to hospital at 3 months post discharge (RR 0.82; 95% CI 0.73 to 0.92). Findings on readmission rates were variable depending on assessment time point (e.g. four weeks, nine months, one year etc.) c. Trials reporting on discharge destination were limited. Trials (2 studies) comparing home to residential care found no significant differences between groups (RR 1.03; 95% CI 0.93 to 1.14). One trial consisting of a variety of patients found that patients in the intervention group were more likely to be discharged home compared to a nursing home, deceased or other (Difference 6%; 95% CI 0.4% to 12%). 2. Patient and caregiver outcomes: June 8 th, 2013 5
Study/Type Quality Rating Sample Description Method Outcomes Key Findings a. Mortality: No statistically significant differences in mortality between intervention and control groups. b. Health outcomes: One trial assessing functional outcomes of patients recovering from stroke using the Barthel Index found a statistically significant improvement in the intervention group compared to controls (Median difference of 6 points; P<0.01). In the same study, there were significant differences in quality or life between the groups using the EuroQol (Difference of 9 points; P<0.005), but no differences in Rankin score or anxiety and depression (HADS). 3. Health care costs: There were no comparisons between studies for hospital, community or medication costs. Note: This study found no trials assessing the effectiveness of communication between health care providers associated with discharge planning. Sulch et al., 2000 CA: Blinding: 152 patients within 2 weeks of stroke onset. Participants were randomized to the Integrated Care Pathway Mortality, institutionalization, Length of stay, Barthel Key Points: Some evidence to suggest that discharge planning is effective in reducing patient length of stay in hospital and hospital readmission rates. Only one study was specific to patients recovering from stroke; patient population types were quite variable between studies. No significant between group differences were reported with respect to 6-month mortality (13% vs. 8%), institutionalization (13% vs. 21%), June 8 th, 2013 6
UK Study/Type RCT Shyu et al. 2008 Taiwan Quazi-RCT Quality Rating Patient Therapist Assessor ITT: CA: Blinding: Patient Assessor ITT: Sample Description Patients with mild deficits who did not require rehabilitation and those with severe premorbid physical or cognitive disability were excluded. 201 patient / caregiver dyads. Patients had a primary diagnosis of stroke and were identified as high risk patients requiring discharge planning services. Patients who were less than 65 years of age, terminally ill, or were not discharged home were excluded, as were caregivers who were not primarily responsible for providing direct care / supervision. Method Outcomes Key Findings group (ICP; n=76) or the conventional care group (n=76). Those is the ICP group received interventions, including discharge planning, according to a care pathway. Patient / caregiver dyads were admitted to one of four wards that were randomly assigned to provide either a caregiveroriented discharge planning program (n=97) or routine discharge planning (n=104). The discharge planning program was conducted by trained research nurses who evaluated caregiver needs during hospitalization and used results to guide individualized interventions, which included both health education and referral services. Once discharged, carers were contacted within one Index, Hospital Depression and Anxiety Scale (HADS), Rankin, and EuroQol Quality of Life Scale. Timing of Assessment: Baseline, 1, 4, 12, and 26 weeks (not all measures were assessed at the 1 and 4 week follow-up). Nurse Evaluation of Caregiver Preparation Scale, Preparedness for Caregiving Scale (caregiver selfevaluation), Caregiver Discharge Needs Assessment Scale, Balance Between Competing Needs Scale. And Barthel Index. Timing of Assessment: At admission, discharge, and onemonth following discharge. Note: not all measures were administered at all assessment points. or length of stay (50±19 vs. 45±23). However, those randomized to receive conventional care experienced significantly greater change on the Barthel Index from 4 to 12 weeks (median change = 6 vs. 2, p<0.01) and reported significantly greater scores on the EuroQol at 6- months (72 vs. 63, p<0.01). For dyads in the intervention group, significant improvement in both nurse and caregiver selfevaluation of preparation was reported from admission to discharge (both at p<0.001). Caregivers in the control group were also reported to improve on the nurse s evaluation of preparation (p<0.01) but not on the selfevaluation. Dyads in both groups demonstrated significant improvement in caregiver satisfaction of discharge needs from discharge to the onemonth follow-up (p<0.001). In between group comparisons, those in the intervention group demonstrated significantly greater caregiver preparedness on both nursing and self-reported evaluations at discharge (both at p<0.01). At the one-month follow-up, those in the intervention group demonstrated significantly greater satisfaction with discharge needs than those in the control group (p<0.001). There were no between group differences in terms of balancing competing needs (p>0.05). June 8 th, 2013 7
Study/Type Shyu et al. 2010 Taiwan Quazi-RCT (follow-up of Shyu et al. 2008) Mayo et al. 2008 Canada RCT Quality Rating CA: Blinding: Patient Assessor ITT: CA: Blinding: Patient Assessor ITT: Sample Description 12% of those screened were eligible for inclusion. 158 patient / caregiver dyads. Patients had a primary diagnosis of stroke and were identified as high risk patients requiring discharge planning services. 1-year follow-up of Shyu et al. 2008. 190 stroke patients discharged home from an acute care hospital who were identified as having a specific need for health Method Outcomes Key Findings week by telephone and two home visits were made (one week, one month) to advise and support caregivers in the home environment. Patient / caregiver dyads were admitted to one of four wards that were randomly assigned to provide either a caregiveroriented discharge planning program (n=97) or routine discharge planning (n=104). The discharge planning program was conducted by trained research nurses who evaluated caregiver needs during hospitalization and used results to guide individualized interventions, which included both health education and referral services. Participants were randomized to receive either a case management intervention (n=96) or care as usual (n=94). The intervention involved coordination with the patient s personal physician Health-related quality of life (HRQoL; SF-36), quality of care (Family Caregiving Consequence Inventory), health service utilization (readmission, length of stay, and institutionalization), and self-care ability (Barthel Index). Timing of Assessment: 3, 6 and 12 months after discharge. Primary Outcome: The Physical Component Summary of the Short- Form-36 (SF-36). Secondary Outcome: Health Care Utilization, the Medical Dropouts: Intervention group=25 (26%); Control group=18 (17%). No significant between group differences were reported in terms of HRQoL for patients or carers. Carers in the intervention group reported significantly better quality of care at 6 months (p<0.01) but not at any other assessment point; however, further analysis revealed that overall quality of care was significantly superior in the intervention group over the 1-year follow-up period (p<0.05). No significant group differences were reported with respect to self-care ability or hospital readmissions. However, patients in the intervention group were significantly less likely to be institutionalized between 6 and 12 months post-discharge, as compared to those in the control group (p<0.05). Lost to Follow-up (from 1-month to 1-year follow-up): Intervention group=11(15%); experimental group=11(13%). No significant between group differences were reported in terms of the SF-36 Physical Component Summary score (the primary outcome), health care utilization, or any of the other secondary outcome measures, with the only exception being that those in the control group had significantly fewer specialists visits (on average) from the 6-week to 6-month June 8 th, 2013 8
Study/Type Quality Rating Sample Description care supervision following discharge (e.g., lives alone, medical comorbidity). 65% of those screened for eligibility were randomized. Method Outcomes Key Findings and telephone contact and home visits with the patient. Duration of Intervention: 6- weeks. Component of the SF- 36, the Euroquol EQ- 5D, the Preference- Based Stroke Index, the Reintegration to Normal Living Index, the Barthel Index, the Geriatric Depression Scale, Gait Speed, and the Timed Up and Go Test. follow-up, as compared to those in the intervention group (3.4 vs. 2.2, p<0.01). Lost to Follow-up: Intervention group=15 (16%); Control group=18 (19%). Sackley and Pound, 2002 UK Consensus Panel N/A A panel of 12 individuals, including 4 nurses, 2 medical practitioners, 4 therapists, and 2 involved in other aspects of stroke care. A systematic literature review combined with information provided by stroke unit staff resulted in 22 statements representing priorities for discharge planning for stroke patients entering nursing home care. Three themes were identified: the discharge process, patients physical care needs, and patients care needs. A Nominal Group Technique was used to facilitate group decisionmaking in prioritizing statements. Timing of Assessment: At discharge, following the intervention, and 6-months post-stroke. Prioritized statements in each of 3 themes: 1) Discharge process, 2) Patients physical care needs, and 3) Patients care needs. Agreement improved during the process and was described as being good. The top priorities for discharge in each theme were as follows: Discharge Process: Plans need to be coordinated by one person. Other priority areas included an assessment of needs for aids and the recording of patient information in written format. Physical Care Needs: Clear written information on nutritional needs should be provided. Other priorities included history and risk of pressure sores and falls. Care Needs: Clear written information on medication should be provided. Other priority areas included information on communication June 8 th, 2013 9
Study/Type Quality Rating Sample Description Method Outcomes Key Findings and methods of transfer/mobilization. June 8 th, 2013 10
References 1. 2. 3. 4. 5. 6. Mayo NE, Nadeau L, Ahmed S, White C, Grad R, Huang A, Yaffe MJ, Wood-Dauphinee S. Bridging the gap: the effectiveness of a stroke coordinator with patient s personal physician on the outcome of stroke. Age Ageing 2008;37:32-38. Sackley C, Pound K. Setting priorities for a discharge plan for stroke patients entering nursing home care. Clin Rehabil 2002;16:859-866. Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD000313. DOI:10.10002/14651858.CD000313.pub4. Shyu YIL, Chen MC, Chen ST, Wang HP, Shao JH. A family caregiver-oriented discharge planning program for older stroke patients and their family caregivers. J Clin Nursing 2008;17:2497-2508. Shyu YIL, Kuo LM, Chen MC, Chen ST. A clinical trial of an individualised intervention programme for family caregivers of older stroke victims in Taiwan. J Clin Nuring 2010;19:1675-1685. Sulch D, Perez I, Melbourn A, Kalra L. Randomized controlled trial of integrated (managed) care pathway for stroke rehabilitation. Stroke 2000;31:1929-1934. June 8 th, 2013 11