Transitional care from hospital to home for older people: implementation of best practices

Costa, Maria Fernanda Baeta Neves Alonso da; Sichieri, Karina; Poveda, Vanessa de Brito; Baptista, Cleide Maria Caetano; Aguado, Priscila Cantoni

doi:10.1590/0034-7167-2020-0187

Cited by 22 publications

(32 citation statements)

References 15 publications

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“…To adopt the best evidence from the TC of people with HF, it is necessary to promote the adoption, by health professionals, of teaching-learning strategies to foster the development of knowledge, attitudes and skills of patients and caregivers to monitor, recognize and manage symptoms of HF appropriately (7)(8)(9)(12)(13)(14) . In addition, it is necessary to contribute to the use by nurses of the best scientific evidence applied to clinical practice (10,14) .…”

Section: Discussionmentioning

confidence: 99%

“…It is noteworthy that, during hospitalization, transitional care should be started as soon as possible (if possible, upon admission) and intensified during the preparation for hospital discharge (6) . Along with the educational processes, the other care needs of patients with HF must be continuously identified, met, and shared among health professionals, based on structured and individualized discharge planning (13)(14) . This sharing characterizes the transition of care by the different health care devices (6,13) , mainly in the referral and counter-referral system provided for in the Unified Health System's Health Care Network.…”

Section: Discussionmentioning

confidence: 99%

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Transitional care from the hospital to the home in heart failure: implementation of best practices

Melo

Conceição

Cruz³

et al. 2022

Rev. Bras. Enferm.

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Objectives: Assess the compliance of the implementation of better evidence in the transitional care of the person with heart failure from the hospital to the home. Methods: Evidence implementation project according to the JBI methodology in a cardiology hospital in São Paulo. Six criteria were audited before and after implementing strategies to increase compliance with best practices. 14 nurses and 22 patients participated in the audits. Results: In the baseline audit, compliance was null with five of the six criteria. Strategies: training of nurses; reformulation of the hospital discharge form and guidance on self-care in care contexts; and making telephone contact on the 7th, 14th and 21st days after discharge. In the follow-up audit, there was 100% compliance with five of the six criteria. Conclusion: The project made it possible to increase the compliance of transitional care practices in people with heart failure with the recommendations based on the best evidence.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Transitional care from the hospital to the home in heart failure: implementation of best practices

Melo

Conceição

Cruz³

et al. 2022

Rev. Bras. Enferm.

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“…According to guidelines and evidence review, women should be oriented about perineal hygiene, frequent pads exchange, and hand hygiene. Nurses' work is essential in implementing evidence-based practices through educational activities, actions to improve treatment adherence, and care and discharge plans based on patients' needs (24) .…”

Section: Follow-up Auditmentioning

confidence: 99%

Implementation of evidence-based practices in the perineal pain management in the postpartum period

Tomaz

Brito²,

Riesco³

2022

Rev. Bras. Enferm.

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Objectives: To implement strategies for managing perineal pain in puerperal women admitted to a public maternity hospital in São Paulo state and to evaluate their compliance with evidence-based practices. Methods: Implementation study using the JBI model conducted with nursing professionals and puerperal women between September and December 2019. Interviews with puerperal women and medical record data were used to audit seven evidence-based criteria. The interventions adopted included a care protocol, professional training, and folder elaboration for puerperal women. Results: Prior to the intervention, deficits in audited practices and obstacles to pain management were identified, which were overcome by the strategies employed. The follow-up audit demonstrated improvements in compliance with best care practices. Conclusion: There was an increase in the criteria compliance evaluated after the implemented strategies, contributing to improving the nursing care results in the perineal pain management based on the best scientific evidence.

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“…With the need to provide holistic and coordinated care, nursing teams have evolved from a traditional flattened structure of nurses to multi-skilled and multi-professional teams [ 10 ]. The elderly often require coordination of care among multiple healthcare and social-care providers [ 11 ] and transitional care from the hospital to home [ 12 ]. This has also accentuated the role of nurses in care coordination and management [ 13 14 ].…”

Section: Introductionmentioning

confidence: 99%

“…These registered nurses (RN) were based in acute care hospitals and promote the safe and timely transfer of patients between care settings by taking on activities at hospital discharge and post-discharge care. This decreases preventable adverse events during care transition, such as medication errors and falls [ 12 ].…”

Section: Introductionmentioning

confidence: 99%

The Evolving Roles of Nurses Providing Care at Home: A Qualitative Case Study Research of a Transitional Care Team

Chen

Chow

2022

International Journal of Integrated Care

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Purpose: To examine the roles of transitional care nurses in an integrated healthcare system and how the integrated healthcare system influences their evolving roles. Background: Transitional care teams have been introduced to enable the seamless transfer of patients from acute-care to the home settings. A qualitative case study of the transitional care team was conducted to understand the changing roles of these nurses in an integrated Regional Health System (RHS) in Singapore. Methods: A hospital transitional team of an integrated RHS was studied. Purposive sampling was used. Non-participant observations and follow-up interviews were conducted with four nurses. Data were triangulated with the interviews of two managers and three healthcare professionals, and the analysis of documents. Within-case thematic analysis was carried out. Results: Three themes were identified: ‘Coming together to meet the needs of all’; ‘Standing strong amidst the stormy waves’; and ‘Searching for the right formula in handling complexity’. These themes have explained on the atypical roles taken on by nurses in their attempts to close the gaps and meet the patients’ needs. Various factors influencing the evolving roles were revealed. Conclusion: The roles of nurses have ‘emerged differently’ from their traditional counterparts. Various nursing roles have been undertaken to facilitate care integration. The findings emphasised the important balance between formal structural practices and informal processes in facilitating and supporting the nurses in their role development.

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Transitional care from hospital to home for older people: implementation of best practices

Cited by 22 publications

References 15 publications

Transitional care from the hospital to the home in heart failure: implementation of best practices

Transitional care from the hospital to the home in heart failure: implementation of best practices

Implementation of evidence-based practices in the perineal pain management in the postpartum period

The Evolving Roles of Nurses Providing Care at Home: A Qualitative Case Study Research of a Transitional Care Team

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