Early Supported Discharge Team Research Articles

Do Early Supported Discharge Teams Increase the Proportion of Stroke Patients Discharged Directly Home from Acute Hospitals in Ireland?

Abstract Background Early Supported Discharge teams for stroke are associated with improved patient, rehabilitative outcomes, quality of life and potentially reduced mortality. Over the last 5 years the number of ESD teams and the proportion of patients discharge under their care has increased. What is unclear is to what extent has the growth in discharges with ESD support from acute hospitals represent additional discharges or patients who would have been discharged anyway but now receive rehabilitation and support post discharge. Methods Data on patients discharged directly home from the Irish National Stroke Audit (INAS) between January 2018 and December 2022 were analysed along with ESD data. This is the five-year period for which comprehensive data on ESD has been collected by INAS. Data used were available on public platforms and ethics approval was not necessary. Chi Square Statistics were performed, using proprietary software to compare proportions. Results Data on 23183 inpatient episodes were analysed, 57% of patients were male. INAS cases increased 34% from 3730 in 2018 to 4999 in 2022. Proportion of patients with unknown discharge destination (2.5%-2.9%) and who died (11.0%-10.8%) remained stable across the period. Proportion discharged home increased from 55.6% in 2018 to 59.5% in 2022 (Chi Sq 13.0, p=0.0003), (4.9% absolute, 7.0% relative). Proportion of ESD discharges increased from 3.7% to 9.8% of all patients (Chi Sq 117.3, p<0.0001) and from 6.7% to 16.5% of direct discharges home (Chi Sq 106.6, p<0.0001). However, direct discharges home without ESD support declined from 51.9% to 49.7% of the total population (Chi Sq 4.16, p=0.04). This suggests that, compared to 2018, 64% of ESD discharges in 2022 were additional and contingent on ESD availability. Conclusion ESD is an effective way of increasing direct discharges of people with stroke home from hospital. The proportion of patients with access to ESD remains low.

Transitioning to home and beyond following stroke: a prospective cohort study of outcomes and needs

IntroductionUnderstanding of the needs of people with stroke at hospital discharge and in the first six-months is limited. This study aim was to profile and document the needs of people with stroke at hospital discharge to home and thereafter.MethodsA prospective cohort study recruiting individuals with stroke, from three hospitals, who transitioned home, either directly, through rehabilitation, or with early supported discharge teams. Their outcomes (global-health, cognition, function, quality of life, needs) were described using validated questionnaires and a needs survey, at 7–10 days, and at 3-, and 6-months, post-discharge.Results72 patients were available at hospital discharge; mean age 70 (SD 13); 61% female; median NIHSS score of 4 (IQR 0–20). 62 (86%), 54 (75%), and 45 (63%) individuals were available respectively at each data collection time-point. Perceived disability was considerable at hospital discharge (51% with mRS ≥ 3), and while it improved at 3-months, it increased thereafter (35% with mRS ≥ 3 at 6-months). Mean physical health and social functioning were “fair” at hospital discharge and ongoing; while HR-QOL, although improved over time, remained impaired at 6-months (0.69+/-0.28). At 6-months cognitive impairment was present in 40%. Unmet needs included involvement in transition planning and care decisions, with ongoing rehabilitation, information, and support needs. The median number of unmet needs at discharge to home was four (range:1–9), and three (range:1–7) at 6-months.ConclusionStroke community reintegration is challenging for people with stroke and their families, with high levels of unmet need. Profiling outcomes and unmet needs for people with stroke at hospital-to-home transition and onwards are crucial for shaping the development of effective support interventions to be delivered at this juncture.ISRCTN registration02/08/2022; ISRCTN44633579.

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England.

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives. Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners. Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward. Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

Adapting stroke rehabilitation during the COVID-19 pandemic: Exploring the experiences of patients and families of an Early Supported Discharge telerehabilitation programme

Purpose: To describes stroke survivors (SS) and carer’s experiences of an Early Supported Discharge (ESD) programme delivered via telerehabilitation during the COVID-19 pandemic. Methods: Purposive sampling was conducted to recruit stroke survivors and carers who participated in telerehabilitation with a regional ESD team. Semi-structured interviews were conducted online. Interviews were transcribed and coded. Qualitative data analysis was conducted. Results: Eleven people were recruited including individual stroke survivors (n=4), carers (n=1) and family dyads (n=3). Four major themes were identified: (1) Channels of communication and enabling relationships (2) The importance of the daily rehabilitation routine, (3) Hands-off training and technology, (4) Virtual and non-tactile reality. Open channels of telecommunication were central to ensuring continuity of care and imparting information and education. Conclusion: Despite the implications of the COVID-19 pandemic, most participants described positive experiences of ‘virtual and non-tactile’ video enabled rehabilitation. Telerehabilitation enabled stroke survivors and therapists to build relationships which fostered engagement and supported rehabilitation. Further work is required to examine upscaling telerehabilitation use beyond the pandemic and to better understand key factors regarding patient selection.

53 Development of Early Supported Frailty Discharge Team

Abstract Introduction The aim of the audit is to find out whether Rockall clinical frailty score (CFS) has an effect on hospital admissions, such as length of hospital stay, readmission within 30 days after discharge. By knowing the association, we can provide early supported frailty discharge team’s service to patients with specific frailty scores to reduce 30-day readmission rate. Method 58 patients from Geriatric wards of Southend Hospital including age, reason of admission, and Proactive Elderly Advanced Care Plan (PEACE) status were collected as a baseline. Admission status, length of hospital stay, readmission and mortality were recollected on a weekly basis in the month of October and November 2019, together with clinical frailty score documented on discharge. Results The analysed data was left with 37 patients, after excluding 22 patients whose clinical frailty scores not documented on discharge. Clinical frailty score was independent of age. 85% of the patients were CFS 6 and above, 15% were CFS 4 and 5. The mean length of stay was 15 days. The severity of frailty was directly proportionate to the average number of days spent in hospital. Patients with CFS 9 had the highest mean hospital stay of 18 compared to 22 days in the group of CFS 4. Significant 30-day readmission rate (33%) was seen in patients with clinical frailty score of 5 and 6. Patients with upper extreme end of frailty scores were associated with mortality, 83% in CFS 9. In 5 out of 20 patients with CFS of 7 and above, PEACE was put in place. It might explain the reason why there were relatively lower readmission rates in such groups. Conclusion From analysis of our data collection, CFS is a good predictor of duration of hospital stay which is in line with previous studies. Severity of frailty may help indicate the likely risks and frailty-related outcomes and help to plan treatments and interventions which may decrease length of stay. As a part of quality improvement project, we are introducing community early supported discharge team to CFS 5 and above patients.

Effectiveness of Stroke Early Supported Discharge: Analysis From a National Stroke Registry.

Implementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.

An extended stroke rehabilitation service for people who have had a stroke: the EXTRAS RCT.

There is limited evidence about the effectiveness of rehabilitation in meeting the longer-term needs of stroke patients and their carers. To determine the clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS). A pragmatic, observer-blind, parallel-group, multicentre randomised controlled trial with embedded health economic and process evaluations. Participants were randomised (1 : 1) to receive EXTRAS or usual care. Nineteen NHS study centres. Patients with a new stroke who received early supported discharge and their informal carers. Five EXTRAS reviews provided by an early supported discharge team member between 1 and 18 months post early supported discharge, usually over the telephone. Reviewers assessed rehabilitation needs, with goal-setting and action-planning. Control treatment was usual care post early supported discharge. The primary outcome was performance in extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post randomisation. Secondary outcomes at 12 and 24 months included patient mood (Hospital Anxiety and Depression Scale), health status (Oxford Handicap Scale), experience of services and adverse events. For carers, secondary outcomes included carers' strain (Caregiver Strain Index) and experience of services. Cost-effectiveness was estimated using resource utilisation costs (adaptation of the Client Service Receipt Inventory) and quality-adjusted life-years. A total of 573 patients (EXTRAS, n = 285; usual care, n = 288) with 194 carers (EXTRAS, n = 103; usual care, n = 91) were randomised. Mean 24-month Nottingham Extended Activities of Daily Living Scale scores were 40.0 (standard deviation 18.1) for EXTRAS (n = 219) and 37.2 (standard deviation 18.5) for usual care (n = 231), giving an adjusted mean difference of 1.8 (95% confidence interval -0.7 to 4.2). The mean intervention group Hospital Anxiety and Depression Scale scores were not significantly different at 12 and 24 months. The intervention did not improve patient health status or carer strain. EXTRAS patients and carers reported greater satisfaction with some aspects of care. The mean cost of resource utilisation was lower in the intervention group: -£311 (95% confidence interval -£3292 to £2787), with a 68% chance of EXTRAS being cost-saving. EXTRAS was associated with 0.07 (95% confidence interval 0.01 to 0.12) additional quality-adjusted life-years. At current conventional thresholds of willingness to pay for a quality-adjusted life-year, there is a 90% chance that EXTRAS is cost-effective. EXTRAS did not improve stroke survivors' performance in extended activities of daily living but did improve their overall satisfaction with services. Given the impact on costs and quality-adjusted life-years, there is a high chance that EXTRAS could be considered cost-effective. Further research is required to identify whether or not community-based interventions can improve performance of extended activities of daily living, and to understand the improvements in health-related quality of life and costs seen by provision of intermittent longer-term specialist review. Current Controlled Trials ISRCTN45203373. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 24. See the NIHR Journals Library website for further project information.

Introducing a clinically effective allied health rapid discharge team within a complex aged subacute in-patient cohort on a cost recovery basis: the Supported Patient centred Early Discharge (SPeED) initiative.

This case study reports the outcomes of an early supported discharge program. This model of care was trialled after Victoria introduced subacute weighted inlier equivalent separations funding to subacute in-patients in 2016. An allied health team (Supported Patient centred Early Discharge (SPeED)) managed patients suitable for assessment, intervention and early supported discharge (ESD). The SPeED cohort was compared to a matched historical control. Data included no advantage financially (NAF) days, length of stay (LOS), functional independence measure (FIM) scores and 30-day readmission rates. Staff and patient experiences were collected through surveys and call-back data. Regression analysis compared quantitative data, whereas a broad thematic approach compared qualitative data. There were no differences between the study cohort and historical control in age or sex (P>0.05). The SPeED cohort had lower median NAF days (F=-21.38; 95% confidence interval (CI) -37.70, -15.00; P<0.001), shorter LOS (F)=4.65; 95% CI -0.41, -0.02; P=0.034), fewer readmissions within 30 days (odds ratio 0.14; 95% CI -0.03, 0.68; P=0.014) and greater change in FIM scores during admission (F=4.20; 95% CI 0.16, 10.74; P=0.044). Staff morale was high in recognition of improved patient care. Patient satisfaction remained positive across the SPeED cohort and historical control group. The introduction of a dedicated allied health ESD team within a geriatric evaluation and management population is effective and enhances patient outcomes.

Evaluation of an Extended Stroke Rehabilitation Service (EXTRAS)

Background and Purpose- There is limited evidence to guide rehabilitation to meet the longer term needs of stroke survivors. The clinical effectiveness and cost-effectiveness of an extended stroke rehabilitation service (EXTRAS) provided following early supported discharge were determined. Methods- EXTRAS was a pragmatic parallel-group observer-blind randomized controlled trial involving 19 UK centers. Patients with stroke were individually randomized to receive EXTRAS or usual care at discharge from early supported discharge. Five EXTRAS reviews were provided by an early supported discharge team member between one and 18 months, usually by telephone. Reviews consisted of a semi-structured interview assessing progress, rehabilitation needs, and service provision, with goal setting and action planning. The primary outcome was performance in extended activities of daily living (Nottingham EADL Scale) at 24 months post-randomization. The Nottingham EADL Scale is scored 0 to 66, with higher scores indicating better performance in these activities. Cost-effectiveness was estimated using resource utilization costs and Quality Adjusted Life Years. Analyses were intention to treat. Results- Between January 9, 2013 and October 26, 2015, 573 participants were randomized (EXTRAS, n=285; usual care, n=288). Mean 24 month Nottingham EADL Scale scores were EXTRAS (n=219) 40.0 (SD 18.1) and usual care (n=231) 37.2 (SD 18.5) giving an adjusted mean difference of 1.8 (95% CI, -0.7 to 4.2). 1155/1338 (86%) of expected EXTRAS reviews were undertaken. Over 24 months, the mean cost of resource utilization was lower in the intervention group: -£311 (-$450 [95% CI, -£3292 to £2787; -$4764 to $4033]). EXTRAS provided more Quality Adjusted Life Years (0.07 [95% CI, 0.01 to 0.12]). At current conventional thresholds of willingness to pay (£20 000 [$28 940] per Quality Adjusted Life Years), there was a 90% chance that EXTRAS could be considered cost-effective. Conclusions- EXTRAS did not significantly improve stroke survivors' performance in extended activities of daily living. However, given the impact on costs and Quality Adjusted Life Years, EXTRAS may be an affordable addition to improve stroke care. Clinical Trial Registration- URL: www.isrctn.com. Unique identifier: ISRCTN45203373.

Home rehabilitation in France. The model of stroke

Ambulatory care is the most frequent type of rehabilitation for chronic diseases. French guidelines recommend after a stroke assessment and rehabilitation by a multidisciplinary team for all the patients with a persistent deficiency. According to the needs of each patient, different ways to provide home rehabilitation can be used in France. For simple needs targeting specific deficiency, rehabilitation can be provided by a professional alone in ambulatory care. Only Physiotherapy (PT) and speech therapy (ST) are refunded by the national health insurance. For complex needs a PRM multidisciplinary team, can be ordered either in day hospital (the patient living home and receiving rehabilitation during repeated stays) which is the main organization, or mobile rehabilitation team, the team coming each day at home like an early supported discharge team (not very developed in France). We report here the global activity base on the analysis of the national registry on the 80,000 annual new strokes (excluding transient attacks and deceased) After the acute care, 37% of stroke patients received a multidisciplinary rehabilitation during a mean of 3 months (33% in an inpatient center and 4% in an outpatient center). For the patient discharge at home 30% (directly discharge from an acute center) to 50% (discharge from a rehabilitation center) receive PT and 9 to 15% ST. At the chronic phase 35% of the patients receive PT at home. Ambulatory occupational therapy and ST are less developed and less available. Effort is needed to improve multidisciplinary rehabilitation at home in France. Home hospital could be interesting to develop for dependent and fragile patients, mobile rehabilitation team for the rehabilitation of the instrumental activities of daily livings, and day hospital for rehabilitation requiring technical platform of a rehabilitation center.

Stroke unit care, inpatient rehabilitation and early supported discharge

Stroke units reduce death and disability through the provision of specialist multidisciplinary care for diagnosis, emergency treatments, normalisation of homeostasis, prevention of complications, rehabilitation and secondary prevention. All stroke patients can benefit from provision of high-quality basic medical care and some need high impact specific treatments, such as thrombolysis, that are often time dependent. A standard patient pathway should include assessment of neurological impairment, vascular risk factors, swallowing, fluid balance and nutrition, cognitive function, communication, mood disorders, continence, activities of daily living and rehabilitation goals. Good communication and shared decision making with patients and their families are key to high-quality stroke care. Patients with mild or moderate disability, who are medically stable, can continue rehabilitation at home with early supported discharge teams rather than needing a prolonged stay in hospital. National clinical guidelines and prospective audits are integral to monitoring and developing stroke services in the UK.

Delivering psychological care in an early supported discharge team for stroke survivors

A description of a service model and consideration of the mechanisms which allow effective implementation of psychological care.

Hyper acute stroke unit patient suitability for early supported discharge: Coordination and data analysis project

Research has shown the benefits of early supported discharge (ESD) from stroke units on patient outcomes as well as reducing bed days in hospital. This 6-month project identified that there are higher numbers of patients (12%) who could go home earlier from the hyper acute stroke unit via ESD services when there was an ESD coordinator role in place. In order for this to occur, however, there needs to be a closer interprofessional working relationship with social services with regards to ensuring that both patient health and social needs are met. This role could potentially increase the amount of appropriate patients being discharged to ESD teams, thus allowing access to evidence-based care. This short report describes how appropriate coordination can meet patient needs while saving the local stroke health economy over £230 000 in a 6-month period.

Evaluating an extended rehabilitation service for stroke patients (EXTRAS): study protocol for a randomised controlled trial.

BackgroundDevelopment of longer term stroke rehabilitation services is limited by lack of evidence of effectiveness for specific interventions and service models. We describe the protocol for a multicentre randomised controlled trial which is evaluating an extended stroke rehabilitation service. The extended service commences when routine ‘organised stroke care’ (stroke unit and early supported discharge (ESD)) ends.Methods/designThis study is a multicentre randomised controlled trial with health economic and process evaluations. It is set within NHS stroke services which provide ESD. Participants are adults who have experienced a new stroke (and carer if appropriate), discharged from hospital under the care of an ESD team.The intervention group receives an extended stroke rehabilitation service provided for 18 months following completion of ESD. The extended rehabilitation service involves regular contact with a senior ESD team member who leads and coordinates further rehabilitation. Contact is usually by telephone. The control group receives usual stroke care post-ESD. Usual care may involve referral of patients to a range of rehabilitation services upon completion of ESD in accordance with local clinical practice. Randomisation is via a central independent web-based service.The primary outcome is extended activities of daily living (Nottingham Extended Activities of Daily Living Scale) at 24 months post-randomisation. Secondary outcomes (at 12 and 24 months post-randomisation) are health status, quality of life, mood and experience of services for patients, and quality of life, experience of services and carer stress for carers. Resource use and adverse events are also collected. Outcomes are undertaken by a blinded assessor.Implementation and delivery of the extended stroke rehabilitation service will also be described. Semi-structured interviews will be conducted with a subsample of participants and staff to gain insight into perceptions and experiences of rehabilitation services delivered or received.Allowing for 25% attrition, 510 participants are needed to provide 90% power to detect a difference in mean Nottingham Extended Activities of Daily Living Scale score of 6 with a 5% significance level.DiscussionThe provision of longer term support for stroke survivors is currently limited. The results from this trial will inform future stroke service planning and configuration.Trial registrationThis trial was registered with ISRCTN (identifier: ISRCTN45203373) on 9 August 2012.

Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials.

BackgroundAcquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI.MethodsWe conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers.ResultsA total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation.ConclusionsThe review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6963-14-397) contains supplementary material, which is available to authorized users.

P282 An Integrated IT System For COPD Between Primary, Secondary and Community Care Using SystmOne

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Understanding the role of the stroke physician in early supported discharge services. Collaborative Leadership in Applied Health rRsearch and Care (CLAHRC), Nottinghamshire, Derbyshire and Lincolnshire, UK

Our recent research, using expert consensus with trialists who had contributed to the Cochrane systematic review, has helped to establish key components of effective Stroke Early Supported Discharge (ESD) services. One essential element is that the ESD multidisciplinary team should have access to specialist stroke knowledge. However, how this is organised and put into working practice is less well-defined. The current qualitative phase of our study investigates such questions about ESD team composition and roles. The stroke physician’s (SP) involvement may start with commissioning and strategic representation of the service. The SP can then be pivotal to the early identification of eligible patients, and ensuring their medical stability prior to transfer. Within the ESD multidisciplinary team, the SP role includes goal review, goal setting, and giving specialist medical guidance. By providing reassurance to the team on their choice of actions, the SP may also help avoid hospital readmission. Another key component of the SP role has been informal and formal education for the ESD team, on such issues as secondary prevention, and common medical problems post stroke. Finally, SP liaison with the acute stroke team, other hospital specialists and primary care physicians facilitates successful cross-boundary working and can aid patient adherence to secondary prevention measures. These preliminary findings and experiences suggest that the SP role is critical to effective ESD functioning, and may also offer some useful insights into how to cultivate an integrated and co-ordinated care system for stroke patients.

A Consensus on Stroke

Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review. We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success. Consensus of opinion (>75% agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited. We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.

Support after stroke.

There is strong evidence for early supported discharge after a stroke. This service development project used an interdisciplinary journal club to promote communication and identify the role of the nurse in an early supported discharge team. The team members were able to evaluate journal findings against the practice of their own team, which had been established after the closure of a stroke rehabilitation ward.

The role of the community stroke rehabilitation nurse

There is strong evidence for early supported discharge (ESD) following stroke, but there is no evidence on how these services should be organized or the best models of care. ESD teams rarely include a community stroke rehabilitation nurse. A service development project was undertaken in Portsmouth Hospitals NHS Trust's community stroke rehabilitation team to identify and explore the unique contributions of community stroke rehabilitation nurses in an established ESD team. When the team was set up, the nurses had inpatient stroke rehabilitation skills, but no community experience. This novel approach, which involved taking specialist hospital nurses into the community, meant there was a steep learning curve and, unfortunately, there were no role models to support their development. During these early days, it became apparent that intensive stroke rehabilitation within an interdisciplinary ESD team required effective and timely nursing intervention, the development of skills to support interdisciplinary working and a greater understanding of the roles of all team members. Locally and nationally, questions were being asked pertaining to the nurses' role, which precipitated this project. Through a series of journal club sessions, the interdisciplinary team reviewed the evidence base of the nurse role in stroke rehabilitation. The team were able to evaluate findings against current practice. The project confirmed that the community stroke rehabilitation nurse provides a unique and fundamental role to the team that strengthens the model of interdisciplinary teamworking.