Tableaux de données probantes et liste de reference (en anglais)
Discharge planning should begin as soon as possible during each phase of care and should involve the patient, family/caregivers, and all members of the interprofessional team. The goal of discharge planning is to ensure a safe and efficient transition between care settings while maintaining a continuity of care and coordination of services that optimize recovery and secondary prevention, as appropriate. Discharge planning activities should include a pre-discharge needs assessment, home visits, meetings between the care team, patient, and family/caregivers, a post-discharge follow-up plan, and communication with team members at the next phase of care. In a recent Cochrane review Gonçalves-Bradley et al. (2016) identified 30 RCTs including patients admitted to any type of hospital (acute, rehabilitation or community) with any medical or surgical condition (one trial [Sulch et al. 2010]) included patients with a diagnosis of stroke). Trials evaluated discharge plans from hospital that included assessment, planning, implementation and monitoring components, initiated at some point prior to discharge. Hospital length of stay (MD -0.73, 95% CI -1.33 to -0.12) and unscheduled three-month readmission rates (RR=0.87, 95% CI 0.79 to 0.97) were both found to be significantly reduced for elderly patients with a medical condition who received discharge planning, compared to care as usual. No significant between group differences were reported in terms of discharge destination or mortality. In the only RCT identified in the Cochrane review, Sulch et al. (2000) randomized 152 patients within two-weeks of stroke onset to receive discharge planning according to an integrated care pathway or care as usual. No significant between group differences were reported with respect to six-month mortality (13% vs. 8%), institutionalization (13% vs. 21%), 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 six-months (72 vs. 63, p<0.01).
Navigating through the post-stroke continuum has been highlighted as a frequent source of dissatisfaction, for patients and informal caregivers, particularly during the transition from hospital to community. Several studies have been conducted to evaluate the benefit of individuals who coordinate access to appropriate services for patients recovering from stroke, who go by many names including stroke navigator, case manager, care coordinator, or system navigator). Manderson et al. (2011) conducted a systematic review including 15 publications, representing 9 RCTs examining system navigation models for older adults living with multiple chronic diseases making transitions across healthcare settings. The services provided included care planning, coordination of care, phone support, home visits, liaison with medical and community services, and patient and caregiver education. In most of the studies, economic, psychosocial and functional benefits were associated with system navigation. While the services of a registered occupational therapist, who functioned as a community stroke navigator, resulted in significant improvements in the mean daily functioning subscale of the Reintegration to Normal Living Index RNLI among 51 patients at the end of four months, (54.1 to 59.3, p=0.02), there were no significant improvements in other outcomes (2-minute walk test, depression outcomes), or any caregiver outcomes (Egan et al. 2010).
Transitions between and within health care settings pose a safety and quality of care concern for patients recovering from stroke. A consensus policy statement by the American College of Physicians in 2009 highlighted concerns of patient safety at transition points, particularly between inpatient and outpatient care (Snow et al. 2009). Following stroke, a person is vulnerable to many of these transition points as they progress through the acute, sub-acute and chronic stages of recovery, interacting with a range of physicians in several different health-care settings. Communication between these physicians and care settings is critical for ensuring patient safety and quality of care. In a systematic review (Kattel et al 2018), included 19 studies which described hospital discharge communication between hospital-based providers and primary care physicians (PCPs). While a median of 55.1% of hospital discharge communications were transferred to the PCP within 48 hours, 8.5% of discharge summaries never reached the PCP. Information that was absent from discharge summaries included diagnostic test results (61%), pending tests at discharge (25%), and follow-up plans (41%). PCP received notification of discharge in only 23% of cases. In a controlled study of 3,248 hospitals, Mitchell (2015) explored the association between physician/nurse communication with the patient regarding discharge instructions and readmission. An average of 84% of patients reported receiving discharge instructions. Hospitals that had smaller bed numbers, were non-profit and located in non-urban areas were more likely to provide discharge instructions. Patients reported that, on average, nurses and doctors communicated well with them 78% and 82% of the time. Controlling for other factors, increasing frequency of communication surrounding discharge instructions was associated with significantly lower number of 30-day hospital re-admissions.
Areas of communication deficits were reported in a systematic review by Kripalani et al. (2007), which included the results of 73 studies examining communication deficits between hospitals and primary care providers, and interventions to improve communication during this transition. While a median of 53% of discharge letters had arrived at the physician’s office within one week of discharge, only 14.5% of discharge summaries were received the same timeframe. However, 11% of discharge letters and 25% of discharge summaries never reached the primary care physician. Discharge letters were missing a main diagnosis in 7%-48% of cases, hospital treatment details in 22%-45% of cases, medications at discharge for 7%-48% of cases, plans for follow-up in 23%-48% of cases, and notes on patient or family counselling in 92%-97% of cases. In terms of effectiveness of interventions, a significantly higher percentage of discharge summaries that were hand delivered (compared with mailing) were received by week 4 following discharge (80% vs. 57%, p<0.001). The overall quality of the summaries was perceived to be higher and the summaries were longer when computer generated, using a standard template, and were received by the primary care physician sooner.
Halasyamani et al. (2006) described the development of a discharge checklist, based on a literature review, expert committee and peer review, designed to identify the critical components in the process when discharging elderly patients from hospital. The final checklist includes 3 types of discharge documents: the discharge summary, patient instruction and communication on the day of discharge to the receiving care provider. Data elements included on the final checklist were: problem that precipitated hospitalization, key findings and test results, final primary and secondary diagnoses, condition at discharge (functional and cognitive), discharge destination, discharge medications, follow-up appointments, list of pending lab results and person to whom results will be sent, recommendations of sub-specialty consultants, documentation of patient education and understanding, identification of atypical problems and suggested interventions, 24/7 call-back number, identification of referring and receiving providers, resuscitation status.