To Enhance the Discharge Planning for the Stroke Patients in Acute Stroke Unit – ASU Discharge Nursing Round

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Authors (including presenting author) :
Lam KM(1), Cheng SY(1), Chan PK(1), Wong CL(1), Tam YM(1), Yu CTM(2), Ng YB(1)
Affiliation :
(1)Department of Medicine and Geriatrics, United Christian Hospital (2)Nursing Services Division, United Christian Hospital
Introduction :
Stroke is a well-known global health problem and causing a great burden to the family and the society. Appropriate post stroke community care support can reduce the readmission rate and partially relieved the burden in healthcare setting. Early discharge planning with good community support for stroke patients can enhance their rehabilitation outcomes and relieved the carer stress. Medical Social Collaboration (MSC) Team collaborates with stroke nurses to implement a routine discharge nursing round to determine the appropriate community transitional service to elderly stroke patients.
Objectives :
1.To facilitate the discharge planning and reducing the unplanned readmission rate for stroke patients in acute stroke unit. 2.To support the stroke patients to continue aging-in-place in a familiar community.
Methodology :
The early discharge planning team for stroke patients was established in June 2018. The team members include Nurse Consultant (Stroke), Stroke nurses and Medical Social Collaboration (MSC) coordinator. Routine discharge nursing round was held once per week in ASU. The comprehensive discharge planning was formulated. The member will integrate the patient’s medical and social conditions and liaise with MSC coordinator to tailor make the appropriate community support to the stroke survivors and the carer. The clients would be referred to the Transitional Residential Care Service (TRC), Integrated Care and Discharge Support for Elderly Patient (ICDS), Home Support Team (HST), Community Nursing Service (CNS) and Non-Government Organizations (NGO). The team also liaise with GDH to offer early appointment for the particular cases. After the round, early discharge plan and the patient’s will be identified by the Team.
Result & Outcome :
The program was implemented from June to December 2018. Total 25 nursing rounds completed and 213 patients were recruited. Total 21 patients were referred to the community support services.76% of the target patients (n=16) were prioritized to the transitional service after rapid assessment. Meanwhile 24% (n=5) were referred to home base physiotherapy and occupation therapy for rehabilitation training. 86% of target patient (n=18) could be avoided unplanned readmission after discharge from hospital. In conclusion, the nursing round could facilitate the discharge planning for stroke patients and reduce the unplanned readmission rate.

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