Tableaux de données probantes et liste de reference (en anglais)
In a recent Cochrane review investigating discharge planning for patients discharged from hospital, 24 RCTs, representing 8,039 patients were identified (Shepperd et al. 2013). In most cases, trials evaluated a discharge plan either as a stand-alone intervention, or as a component of a broader intervention vs. usual care in most cases (n=19). In a single trial (Sulch et al. 2000) the sample was restricted to discharge from hospital following a stroke. In all other studies, patients with other medical conditions were included. The use of discharge plans was associated with a significantly reduced LOS (MD -0.91; 95% CI -1.55 to -0.27) and a significant reduction in readmissions at 3 months (RR= 0.82; 95% CI 0.73 to 0.92). No significant between group differences were reported in terms of discharge destination (RR 1.03, 95% CI 0.93 to 1.14) and mortality (RR 0.99, 95% CI 0.78 to 1.25).
Within 48 hours of admission to acute care, Shyu et al. (2008) randomized 208 patient/caregiver dyads to one of 4 wards where they received a caregiver-oriented discharge planning program or routine discharge planning. 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 week by telephone and two home visits were made (one week, one month) to advise and support caregivers in the home environment. Caregivers in the intervention group demonstrated significantly greater caregiver preparedness on both nursing and self-reported evaluations at discharge. At the one-month follow-up, those in the intervention group demonstrated significantly greater satisfaction with discharge needs than those in the control group. In a follow-up study (Shyu et al. 2010), the overall quality of care was reported to be significantly superior in the intervention group over the 1-year follow-up period. 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, compared to those in the control group (p<0.05).
In the only RCT identified that specifically recruited stroke patients, 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 days).
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). A stroke survivor 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 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.