Puhr M Irene, Thompson Hilaire J
Questions or comments about this article may be directed to M. Irene Puhr, DNP ARNP, at
J Neurosci Nurs. 2015 Aug;47(4):223-34. doi: 10.1097/JNN.0000000000000143.
Transitional care (TC) models are used to reduce adverse outcomes and hospital readmissions. This article reviews the scholarly literature to identify TC models that have been used successfully in patients with stroke.
Literature in CINAHL, PubMed, and the Cochrane Database of Systematic Reviews from January 2000 to June 2013 was searched using the keywords "transitional care," "discharge planning," "care-coordination," "continuity of care," "follow-up after discharge," and "stroke." Web sites of established TC models were also reviewed to identify additional studies meeting review criteria. To be included in the review, studies must have been written in the English language and focused on adult patients aged 19 years and older with stroke, discharged from the hospital or acute rehabilitation facility to home. TC interventions were defined as those that employed one or more of the National Transitions of Care Coalition intervention categories: medication management, transition planning, patient and family engagement or education, information transfer, follow-up care, healthcare provider engagement, or shared accountability across providers and organizations (National Transitions of Care Coalition, 2011). The author examined the title and abstract of each study for eligibility against stated criteria.
Thirteen articles representing 11 studies were found to meet the inclusion criteria. In the identified studies, TC was compared with usual care; however, what constituted usual care was not consistently elucidated. Fewer than half of the studies reported significantly improved results on selected outcomes. Across all the studies, TC did not result in a reported significant decrease in emergency department visits or hospital readmission rates. There was substantive heterogeneity in (a) intervention providers, (b) interventions used in TC, and (c) measures of outcome identified. Six of the 13 studies were identified as having successful interventions.
Some evidence exists to support positive outcomes using TC in patients with stroke. Standardization of interventions and outcome measures is needed to determine the most effective interventions. Additional large-scale randomized, controlled trials should be undertaken to provide reliable data regarding effective TC interventions for persons after stroke.
过渡性护理（TC）模式用于减少不良后果和医院再入院率。本文回顾学术文献，以确定已成功应用于中风患者的TC模式。
检索2000年1月至2013年6月CINAHL、PubMed和Cochrane系统评价数据库中的文献，使用关键词“过渡性护理”“出院计划”“护理协调”“护理连续性”“出院后随访”和“中风”。还查阅了已建立的TC模式的网站，以确定符合审查标准的其他研究。要纳入本综述，研究必须用英文撰写，且关注19岁及以上中风成年患者，从医院或急性康复机构出院后回家的情况。TC干预被定义为采用国家护理过渡联盟干预类别中的一项或多项的干预措施：药物管理、过渡计划、患者及家属参与或教育、信息传递、随访护理、医疗服务提供者参与，或跨提供者和组织的共同责任（国家护理过渡联盟，2011年）。作者根据既定标准检查每项研究的标题和摘要是否符合资格。
发现13篇文章代表11项研究符合纳入标准。在已确定的研究中，将TC与常规护理进行了比较；然而，常规护理的构成并未得到一致阐明。不到一半的研究报告在选定结局上有显著改善的结果。在所有研究中，TC并未导致急诊就诊或医院再入院率显著降低。在（a）干预提供者、（b）TC中使用的干预措施和（c）确定的结局测量方面存在实质性异质性。13项研究中有6项被确定为具有成功的干预措施。
有一些证据支持在中风患者中使用TC取得积极结果。需要对干预措施和结局测量进行标准化，以确定最有效的干预措施。应开展更多大规模随机对照试验，以提供关于中风后患者有效TC干预措施的可靠数据。
