Transition of care for stroke patients: an integrative review

Authors

DOI:

https://doi.org/10.15253/2175-6783.20222380560

Keywords:

Stroke; Continuity of Patient Care; Transitional Care; Patient Discharge.

Abstract

Objective: to analyze, based on scientific evidence, how the transition of care for people with stroke occurs after hospital discharge. Methods: integrative literature review, conducted in the databases Scopus, Web of Science, Pubmed/MEDLINE, Latin American and Caribbean Literature on Health Sciences, Nursing Database and The Cumulative Index to Nursing and Allied Health Literature. A total of 21 articles were included in the final sample, which were then descriptively analyzed. Results: factors related to the adequate transition of care included: organizational barriers of the health services involved in the transition of care, the importance of health information, and the adequate coordination of care. Conclusion: the studies express limits experienced by individuals, family members and health professionals in systems that are fragmented and rule out the possibility of integral care in times of transition. Contributions to practice: the study reveals the necessary articulation of those who provide health care to people with this grievance and their families, to recognize points to be improved in their health practices and minimize complications arising from failures in care transitions.

References

Roy-O’reilly M, McCullough LD. Age and sex are critical factors in ischemic stroke pathology. Endocrinology. 2018;159(8):3120-31. doi: https://doi.org/10.1210/en.2018-00465

Lotufo PA, Goulart AC, Passos VMA, Satake FM, Souza MFM, França EB, et al. Cerebrovascular disease in Brazil from 1990 to 2015: Global Burden of Disease 2015. Rev Bras Epidemiol. 2017;20(1):129-41. doi: https://doi.org/10.1590/1980-5497201700050011

Feigin VL, Brainin M, Norrving B, Martins S, Sacco RL, Hacke W, et al. World Stroke Organization (WSO): Global Stroke Fact Sheet 2022. Int J Stroke. 2022;17(1):18-29. doi: https://doi.org/10.1177/17474930211065917

Tsai PC, Yip PK, Tai JJ, Lou MF. Needs of family caregivers of stroke patients: a longitudinal study of caregivers' perspectives. Patient Prefer Adherence. 2015;9:449-57. doi: https://doi.org/10.2147/PPA.S77713

White CL, Brady TL, Saucedo LL, Motz D, Sharp J, Birnbaum LA. Towards a better understanding of readmissions after stroke: partnering with stroke survivors and caregivers. J Clin Nurs. 2015;24(7-8):1091-100. doi: https://doi.org/10.1111/jocn.12739

Janzen S, Mirkowski M, McIntyre A, Mehta S, Iruthayrajah J, Teasell R. Referral patterns of stroke rehabilitation inpatients to a model system of outpatient services in Ontario, Canada: a 7-year retrospective analysis. BMC Health Serv Res. 2019;19:399. doi: https://doi.org/10.1186/s12913-019-4236-5

Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nur. 2005;52(5):543-53. doi: https://doi:10.1111/j.1365-2648.2005.03621.x

The Joanna Briggs Institute. Joanna Briggs Institute Reviewers. Manual: 2014 edition [Internet]. 2014 [cited Mar 14, 2022]. Available from: http://joannabriggs.org/assets/docs/sumari/review-ersmanual-2014.pdf

Melnyk BM, Fineout-Overholt E. Making the case for evidence-based practice. In: Melnyk BM, Fineout-Overholt E. Evidence based practice in nursing & healthcare. A guide to best practice. Philadelphia: Lippincott Williams & Wilkins; 2005. p.3-24.

Rodrigues RAP, Marques S, Kusumota L, Santos EB, Fhon JRS, Fabrício-Wehbe SCC. Transition of care for the elderly after cerebrovascular accidents - from hospital to the home. Rev Latino-Am Enfermagem. 2013;21(Spec):216-24. doi: https://doi.org/10.1590/S0104-11692013000700027

Struwe JH, Baernholdt M, Noerholm V, Lind J. How is nursing care for stroke patients organised? Nurses' views on best practices. J Nurs Manag. 2013;21(1):141-51. doi: https://doi.org/10.1111/jonm.12016

Lutz BJ, Young ME, Cox KJ, Martz C, Creasy KR. The crisis of stroke: experiences of patients and their family caregivers. Top Stroke Rehabil. 2011;18(6):786-97. doi: https://doi.org/10.1310/tsr1806-786

Hill KM, Twiddy M, Hewison J, House AO. Measuring patient-perceived continuity of care for patients with long-term conditions in primary care. BMC Fam Pract. 2014;15:191. doi: https://doi.org/10.1186/s12875-014-0191-8

Chouliara N, Fisher RJ, Kerr M, Walker MF. Implementing evidence-based stroke Early Supported Discharge services: a qualitative study of challenges, facilitators and impact. Clin Rehabil. 2014;28(4):370-7. doi: https://doi.org/10.1177/0269215513502212

Nordin Å, Sunnerhagen KS, Axelsson ÅB. Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study. BMC Neurol. 2015;15:235. doi: https://doi.org/10.1186/s12883-015-0492-0

Cassoudesalle H, Nozères A, Petit H, Cressot V, Muller F, Rouanet F, et al. Post-acute referral of stroke victims in a French urban area: Results of a specific program. Ann Phys Rehabil Med. 2016;59(4):248-54. doi: https://doi.org/10.1016/j.rehab.2016.02.003

Ghazzawi A, Kuziemsky C, O’Sullivan T. Using a complex adaptive system lens to understand family caregiving experiences navigating the stroke rehabilitation system. BMC Health Serv Res. 2016;16(1):538. doi: https://doi.org/10.1186/s12913-016-1795-6

Waring J, Bishop S, Marshall F. A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service. BMC Health Serv Res. 2016;16:297. doi: https://doi.org/10.1186/s12913-016-1568-2

Davoody N, Koch S, Krakau I, Hagglund M. Post-discharge stroke patients’ information needs as input to proposing patient-centred eHealth services. BMC Med Inform Decis Mak. 2016;16:66. doi: https://doi.org/10.1186/s12911-016-0307-2

Rattray NA, Sico JJ, Cox LM, Russ AL, Matthias MS, Frankel RM. Crossing the communication chasm: challenges and opportunities in transitions of care from the hospital to the primary care clinic. Jt Comm J Qual Patient Saf. 2017;43(3):127-37. doi: https://doi.org/10.1016/j.jcjq.2016.11.007

Gilmore-Bykovskyi AL, Kennelty KA, DuGoff E, Kind AJH. Hospital discharge documentation of a designated clinician for follow-up care and 30-day outcomes in hip fracture and stroke patients discharged to sub-acute care. BMC Health Serv Res. 2018;18:103. doi: https://doi.org/10.1186/s12913-018-2907-2

Kable A, Baker A, Pond D, Southgate E, Turner A, Levi C. Health professionals’perspectives on the discharge process and continuity of care for stroke survivors discharged home in regional Australia: A qualitative, descriptive study. Nurs Health Sci. 2019;21(2):253-61. doi: https://doi.org/10.1111/nhs.12590

Bettger JP, Jones SB, Kucharska-Newton AM, Freburger JK, Coleman SWC, Mettam H, et al. Meeting Medicare requirements for transitional care: Do stroke care and policy align? Neurology. 2019;92(9):427-34. doi: https://doi.org/10.1212/WNL.0000000000006921

Yang CP, Cheng HM, Lu MC, Lang HC. Association between continuity of care and long-term mortality in Taiwanese first-ever stroke survivors: an 8-year cohort study. PLoS One. 2019;14(5):e0216495. doi: https://doi.org/10.1371/journal.pone.0216495

Krishnan S, Hay CC, Pappadis MR, Deutsch A, Reistetter TA. Stroke survivors' perspectives on post-acute rehabilitation options, goals, satisfaction, and transition to home. J Neurol Phys Ther. 2019;43(3):160-7. doi: https://doi.org/10.1097/NPT.0000000000000281

Deutschbein J, Grittner U, Schneider A, Schenk L. Community care coordination for stroke survivors: results of a complex intervention study. BMC Health Serv Res. 2020;19;20(1):1143. doi: https://doi.org/10.1186/s12913-020-05993-x

Lindblom S, Ytterberg C, Elf M, Flink M. Perceptive dialogue for linking stakeholders and units during care transitions - a qualitative study of people with stroke, significant others and healthcare professionals in Sweden. Int J Integr Care. 2020;20(1):11. doi: http://doi.org/10.5334/ijic.4689

Bierhals CCBK, Day CB, Mocellin D, Santos NO, Predebon ML, Dal Pizzol FLF, et al. Use of health services by elderly people post-stroke: a randomized controlled trial. Rev Gaúcha Enferm. 2020;41:e20190138. doi: https://doi.org/10.1590/1983-1447.2020.20190138

Sheehan J, Lannin NA, Laver K, Reeder S, Bhopti A. Primary care practitioners' perspectives of discharge communication and continuity of care for stroke survivors in Australia: a qualitative descriptive study. Health Soc Care Community. 2021. doi: https://doi.org/10.1111/hsc.13696

Pedersen RA, Petursson H, Hetlevik I, Thune H. Stroke follow-up in primary care: a discourse study on the discharge summary as a tool for knowledge transfer and collaboration. BMC Health Serv Res. 2021;21(1):41. doi: https://doi.org/10.1186/s12913-020-06021-8

Guzinski C, Lopes ANM, Flor J, Migliavaca J, Tortato C, Dal Pai D. Good practices for effective communication: the experience of the interdisciplinary round in orthopedic surgery. Rev Gaúcha Enferm. 2019;40:e20180353. doi: https://doi.org/10.1590/1983-1447.2019.20180353

Cameron JI, O’Connell C, Foley N, Salter K, Booth R, Boyle R, et al. Heart and Stroke Foundation Canadian Stroke Best Practice Committees. Canadian stroke best practice recommendations: managing transitions of care following Stroke, Guidelines Update 2016. Int J Stroke. 2016;11(7):807-22. doi: https://doi.org/10.1177/1747493016660102

Costa MFBNA, Sichieri K, Poveda VB, Baptista CMC, Aguado PC. Transitional care from hospital to home for older people: implementation of best practices. Rev Bras Enferm. 2020;73(3):e20200187. doi: https://doi.org/10.1590/0034-7167-2020-0187

Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11(4):459-84. doi: https://doi.org/10.1177/1747493016643553

Pindus DM, Mullis R, Lim L, Wellwood I, Rundell AV, Aziz NAA, et al. Stroke survivors’ and informal caregivers’ experiences of primary care and community healthcare services – a systematic review and meta-ethnography. PLoS One. 2018;13(4):e0196185. doi: https://doi.org/10.1371/journal.pone.0192533

Wang Y, Yang F, Shi H, Yang C, Hu H. What type of transitional care effectively reduced mortality and improved ADL of stroke patients? A meta-analysis. Int J Environ Res Public Health. 2017;14(5):510. doi: https://doi.org/10.3390/ijerph14050510

Giovanella L, Mendonça MHM. Atenção Primária à Saúde: seletiva ou coordenadora dos cuidados? [Internet]. 2012 [cited Jan 21, 2022]. Available from: http://cebes.org.br/site/wp-content/uploads/2015/02/9ATEN%C3%87%C3%83O-PRIM%C3%81RIA-%C3%80-SA%C3%9ADE.pdf

Rocha MSG, Almeida ACF, N Abath Neto O, Porto MPR, Brucki SMD. Impact of stroke unit in a public hospital on length of hospitalization and rate of early mortality of ischemic stroke patients. Arq Neuro-Psiquiatr. 2013;71(10):774-79. doi: https://doi.org/10.1590/0004-282X20130120

Feigin V, Norrving B, George MG, Foltz JL, Roth GA, Mensah GA. Prevention of stroke: a strategic global imperative. Nat Rev Neurol. 2016;12(9):501-12. doi: https://doi.org/10.1038/nrneurol.2016.107

Mendes LDS, Almeida PF. Do primary and specialized care physicians know and use coordination mechanisms? Rev Saúde Pública. 2020;54:121. doi: https://doi.org/10.11606/s1518-8787.2020054002475

Coleman OA, Parry C, Chalmers S, Min S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-28. doi: https://doi.org/10.1001/archinte.166.17.1822

Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50:e344–e418. doi: https://doi.org/10.1161/STR.0000000000000211

Naylor M, Keating SA. Transitional care. Am J Nurs. 2008;108(9):58-63. doi: https://doi.org/10.1097/01.NAJ.0000336420.34946.3a

Published

2022-08-16

How to Cite

Magagnin, A. B., Heidemann, I. T. S. B., & Brum, C. N. de. (2022). Transition of care for stroke patients: an integrative review. Rev Rene, 23, e80560. https://doi.org/10.15253/2175-6783.20222380560

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Section

Review Article

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