Transition of care in stroke patients discharged home: a single-center prospective cohort study

Abstract

Introduction Approximately two-thirds of the patients admitted to the hospital with an ischemic stroke are discharged directly home. Discontinuity of care may result in avoidable patient harm, re-admissions and even death. We hypothesized that the transfer of information is most essential in this patient group since any future care for these patients relies solely on the information that is available to the care provider responsible at that time. Aim The objective of this study was to evaluate the continuity of transmural care in ischemic stroke patients by assessing 1) the transfer of clinical information through discharge letters to general practitioners (GPs), 2) subsequent documentation of this information and early follow-up by GPs and 3) the documentation of medication-related information in discharge letters, at GPs and community pharmacies (CPs). Methods This prospective cohort study was conducted from September 2019 through March 2020 in OLVG, Amsterdam, the Netherlands, in patients with a first stroke discharged directly home. Outcome measures were derived from national guidelines and regional agreements. Results were analyzed using descriptive analysis. Results A total of 33 patients were included. Discharge letters (n = 33) and outpatient clinic letters (n = 24) to GPs contained most of the essential items, but 16% (n = 9) of the letters were sent in time. GPs (n = 31) infrequently adhered to guidelines since 10% (n = 3) of the diagnoses were registered using the correct code and 55% (n = 17) of the patients received follow-up shortly after discharge. Medication overviews were inaccurately communicated to GPs since 62% (n = 150) of all prescriptions (n = 243) were correctly noted in the discharge letter. Further loss of information was seen as only 39% (n = 95) of all prescriptions were documented correctly in GP overviews. We found that 59% (n = 144) of the prescriptions were documented correctly in CP overviews. Conclusion In this study, we found that discontinuity of care occurred to a varying extent throughout transmural care in patients with a first stroke who were discharged home.

Evaluating the Hospital Standardized Home-Transition Ratios for Cerebral Infarction in Japan: A Retrospective Observational Study from 2016 through 2020

“…Second, other risk factors of cerebral infarction, such as blood pressure level, medical history, social economic status, and hospital function were not considered in this study [ 36 , 37 ]. Third, we could not examine patients whose condition worsened after discharge in this study, but previous studies indicated that care after discharge is important [ 38 , 39 , 40 ].…”

Development of Discharge Planning for Stroke Patients

“…It is necessary to optimize the standard discharge plans that have been commonly used in recent times. This is because, according to a study, there is a significant prevalence of care discontinuity following the discharge of patients who have experienced a first-ever stroke (de Mooij et al 2021). Studies have found that the implementation of discharge planning is frequently limited to the moment when patients leave the healthcare facility.…”