Rev. Enferm. UFSM - REUFSM

Santa Maria, RS, v. 11, e79, p. 1-22, 2021

DOI: 10.5902/2179769264383

ISSN 2179-7692

 

Submission: 02/22/2021    Acceptance: 05/28/2021    Publication: 12/02/2021

Original Article

 

Transition strategies for hospital discharge used by nurses: integrative review

Estratégias de transição para alta hospitalar utilizadas por enfermeiros: revisão integrativa

Estrategias de transición para el alta hospitalaria utilizadas por los enfermeros: revisión integradora

 

 

Valéria Cristina Lopes GalloI

Daiana Kloh Khalaf^II

Karina Silveira de Almeira Hammerschmidt^III

Mariane Lima Santiago^IV

Carine Vendruscolo^V

                                                                                                                                       

I Nurse, Master's Student in the Postgraduate Program in Health Care Practice at the Federal University of Paraná (PPGENF/UFPR), Curitiba, Paraná, Brazil. E-mail: enf.valeria.gallo77@gmail.com, Orcid: https://orcid.org/0000-0003-1789-4998

II Nurse, Professor of Nursing at the Federal University of Paraná, PhD in Nursing, Curitiba, Paraná, Brazil. E-mail: daianakloh@gmail.com, Orcid: https://orcid.org/0000-0001-5770-7523

III Nurse, Professor of Nursing at the Federal University of Paraná, PhD in Nursing, Curitiba, Paraná, Brazil. E-mail: ksalmeidah@ufpr.br, Orcid: https://orcid.org/0000-0002-7140-3427

IV Student, scientific initiation scholarship holder in the Nursing course at the Federal University of Paraná, Curitiba, Paraná, Brazil. E-mail: marianels2010@outlook.com, Orcid: https://orcid.org/0000-0003-3492-2727

V Nurse, Professor of Nursing at the State University of Santa Catarina, PhD in Nursing, Chapecó, Santa Catarina, Brazil. E-mail: carine.vendruscolo@udesc.br, Orcid: https://orcid.org/0000-0002-5163-4789

 

Abstract: Objective: to identify strategies for the transition of care at hospital discharge, used by nurses to strengthen the continuity of care, available in the scientific literature. Method: integrative review of the literature, which included complete studies, based on the strategies "care transition" OR "Continuity of Patient Care" OR "care continuity" AND nurse for the databases VHL, PubMed, SCOPUS and WoS and "care transition" OR "care continuity" AND nurse for CINAHL , published in English, Spanish or Portuguese, between 2016 and 2020, which answered the review question. Results: 23 articles were selected, and the strategies for transition from care to hospital discharge used by nurses to strengthen care were health education, drug reconciliation, telemonitoring, discharge planning, counter-referral and home visit. Conclusion: nurses are responsible for developing interconnected transition strategies to strengthen care, developing diversified actions that qualify attention.

Descriptors: Nursing; Care Transition; Continuity of Patient; Patient Discharge; Strategies

 

Resumo: Objetivo: identificar estratégias de transição do cuidado na alta hospitalar, utilizadas por enfermeiros para o fortalecimento da continuidade do cuidado, disponíveis na literatura científica. Método: revisão integrativa da literatura, que incluiu estudos completos, tendo como referência as estratégias "care transition" OR "Continuity of Patient Care" OR "care continuity" AND nurse para as bases de dados BVS, PubMed, SCOPUS e WoS   e "care transition" OR "care continuity" AND nurse para CINAHL, publicados em inglês, espanhol ou português, entre 2016 e 2020, que responderam à questão de revisão. Resultados: foram selecionados 23 artigos, e as estratégias de transição do cuidado para a alta hospitalar usadas por enfermeiros para o fortalecimento do cuidado foram educação em saúde, reconciliação medicamentosa, telemonitoramento, planejamento da alta, contrarreferência e visita domiciliar. Conclusão: o enfermeiro é responsável pelo desenvolvimento de estratégias de transição interconectadas para o fortalecimento do cuidado, desenvolvendo ações diversificadas que qualificam a atenção.

Descritores: Enfermagem; Cuidado Transicional; Continuidade da Assistência ao Paciente; Alta do Paciente; Estratégias

 

Resumen: Objetivo: identificar estrategias para la transición de la atención al alta hospitalaria, utilizadas por los enfermeros para fortalecer la continuidad de la atención, disponibles en la literatura científica. Método: revisión integradora de la literatura, que incluyó estudios completos, basados en las estrategias "care transition" OR "Continuity of Patient Care" OR "care continuity" AND “nurse” para las bases de datos BVS, PubMed, SCOPUS y WoS y "care transition" OR "care continuity" AND “nurse” para CINAHL, publicada en inglés, español o portugués, entre 2016 y 2020, que respondió a la pregunta de la revisión. Resultados: se seleccionaron 23 artículos, y las estrategias para la transición de la atención al alta hospitalaria utilizadas por los enfermeros para fortalecer la atención fueron la educación para la salud, la conciliación de medicamentos, la telemonitorización, la planificación del alta, la contrarreferencia y la visita domiciliaria. Conclusión: los enfermeros son responsables de desarrollar estrategias de transición interconectadas para fortalecer el cuidado, desarrollando acciones diversificadas que califiquen la atención.

Descriptores: Enfermería; Cuidado de Transición; Continuidad de la Atención al Paciente; Alta del Paciente; Estrategias

 

Introduction

The continuity of health care is considered essential to comprehensive care to the user of the health system, because it refers to the attribute of Primary Care, which ensures the provision of the necessary care over time, that is, longitudinality.¹ The continuity of care provided by the integration of various dimensions, such as physical, psychological and economic, provides improvements in the user and health services relationship.^1-3

The system user experiences several moments of tension during his/her journey in a health care network, requiring actions aimed at ensuring the coordination and continuity of care,⁴ related to the its transition. However, when poorly sized, it is related to serious adverse effects such as medication errors, delays in care, duplication of treatment, reduced treatment, worsening in quality of life, avoidable readmissions, inadequate use of services and increased cost of health.^4-5 In the post-hospital discharge period, the user may present greater vulnerability and risk of clinical deterioration.⁶

The search for continuity of care, guaranteed by the safe transition of care and quality, is highlighted in several countries, especially in the United States of America (USA) and in European countries, being initially driven to reduce costs with avoidable readmissions,⁵ being commonly associated with improved quality of care and life of users. In this context, nurses have been the professional involved in the processes of transition of care because they have the capacity to identify critical points of the process, plan discharge, involvement in rehabilitation, health education and articulation in the health care network,^4,7 strengthening the continuity of care after hospital discharge.

In Brazil, researchers have been developing studies and testing strategies to strengthen the continuity of care in the hospital setting and transition to primary care, especially in the last decade.^4,7-8 However, greater efforts are still needed to identify, develop and implement transition-strengthening strategies that allow continuity of care, especially in the scenario of hospital discharge in the Unified Health System (SUS in Portuguese).

Thus, the presentation of detailed and updated analysis of care transition strategies, which involve nurses on hospital discharge and return home, may be relevant to increase knowledge about the continuity of care and stimulate its strengthening. This paper may contribute to evidence-based practice and nurses' decision-making. The aim of the study is to identify the strategies for the transition from care to hospital discharge, used by nurses to strengthen the continuity of care, available in the scientific literature.

 

Method

This is a literature integrative review, elaborated and structured from a protocol composed of the following steps: (1) definition of the review question; (2) sampling and selection; (3) representation of the characteristics of the captured material; (4) analysis of the selected sample; (5) interpretation of the results; and (6) final presentation.⁹

In Step 1, the review question was defined: what strategies for the transition from care to hospital discharge are used by nurses to strengthen the continuity of care available in the scientific literature? The strategy PICO, acronym for Patient (P), Intervention (I), Comparison (C) and "Outcome" (O) was used. The PICO strategy can be used for questioning of various natures, arising from the clinic, from the management of human and material resources, from the search for instruments for symptom assessment, among others.⁷ Thus, were defined P - nurses, I - transition strategies, C - do not apply and O - continuity of care were considered.

In step 2, the definition of the search strategy was obtained, initiated with the choice of databases Virtual Health Library (VHL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), U. S. National Library of Medicine (PubMed), SCOPUS and Web of Science (WoS) by two researchers, independently. This definition was followed by the definition of sampling and selection, defined by the collection clipping regarding the search filters in the databases and period.

Controlled descriptors obtained from the Descriptors in Health Science (DeCS) were selected - nurses, transitional care, continuity of patient care; and at The Medical Subject Headings (MeSH), the descriptors nurse, care transition, care continuity and continuity of patient were selected. These descriptors were combined with Boolean connectors and represented the search strategies "care transition" OR "Continuity of Patient Care" OR "care continuity" AND nurse, for the VHL, PubMed, SCOPUS and WoS databases; and "care transition" OR "care continuity" AND nurse for CINAHL. The recovered studies were exported to the Endnote Web^® reference manager, with sorting in folders for each database, with subsequent identification and removal of duplicates. Data collection occurred in August 2020.

Complete inclusion criteria were included, in English, Portuguese or Spanish, published between January 2016 and August 2020, which presented in the title or abstract the strategies used by nurses to strengthen the continuity of care among health services. Exclusion criteria were review articles.

The strategies applied allowed the recovery of 2,246 articles in the databases, with subsequent removal of 489 per duplicate, remaining 1,757 for evaluation of titles and abstracts. The application of the inclusion criteria resulted in the removal of 1,629 articles, leaving 128 that were read in full. For these, the exclusion criteria were applied with the final selection of 23 articles for the corpus of integrative review analysis, as can be verified in the flowchart (Figure 1).

Figure 1- Primary studies selection flow chart, 2020.

 

In the publications of the sample (corpus of analysis), the levels of evidence (NE) of each study were identified. Levels are classified as NE 1, systematic reviews or meta-analysis; NE 2, randomized clinical trials; NE 3, non-randomized controlled trial; NE 4, control cases and cohort; NE 5, systematic reviews of descriptive studies and qualitative studies; NE 6, evidence of a single descriptive or qualitative study; and NE 7, expert opinion reports.¹⁰

In step 3, representation of the characteristics of the captured material, information on the studies selected for the corpus of analysis is presented. The use of Microsoft Office Excel® spreadsheet allowed organizing the data, distributed in the fields reference code, level of evidence, year of publication, title, authors, database, journal, study site, methodological design, objective and strategy of transition of care after hospital discharge.

The 23 articles selected for the review were analyzed in step 4, in three phases (pre-analysis, exploration and interpretation), according to the coding and analysis process. In the pre-analysis phase, the selected material was floating reading. In the exploration phase of the material, the coding operations included the clippings of the units of recording the results of the studies, the aggregation of information into initial categories from the identification of keywords and the thematic aggregation with the formation of initial, intermediate and final categories. In the third phase, the contents were interpreted, highlighting the similar and different aspects of the studies. It was assisted with Microsoft Office Excel® spreadsheets for the process of decoding and coding with grouping by similarities.

The analysis allowed to identify the units of registration, which were grouped into initial thematic categories, involving strategies for the transition of care performed by nurses. In step 5, interpretation of the results, the initial categories were articulated among themselves, forming six intermediate categories.

Step 6 constituted the final presentation of the article, and, at this stage, the contributions of the studies were highlighted at the first appearance in the text, mentioning the reference code.

 

Results

The results will be presented first with brief characterization of the studies. As observed in Chart 1, in this review, 23 articles were selected and analyzed: eight (34.8%) from the SCOPUS database; seven (30.5%) from the VHL; five (21.7%) from CINAHL; two (8.7%), from PubMed; and one (4.3%) from WoS.

 

Table 1 – Characterization of the integrative review sample, 2020.

Reference Code / Year of Publication	Methodological Design / Level of Evidence	Objective	Continuity of care strategy after hospital discharge	Main results
111 2016	Quasi-experimental study NE-4	Evaluate the effect of tele-nursing on the adhering to treatment plans in patients discharged after myocardial revascularization surgery	Control group: routine education and completion of a questionnaire to support the treatment plan before discharge and five weeks after discharge; Intervention group: routine education, six tele-nursing care and questionnaire to support the treatment plan before discharge and in the fifth week.	Tele-nursing can be used as a system for providing continued health care to increase treatment adhering to revascularized patients.
212 2018	Pilot study NE-4	Provide support to patients after discharge until the beginning of primary care follow-up for a smooth transition after discharge.	Discharge meeting, identification of patients, discussion of planned interventions and contact before discharge to explain the intervention.	The transition nurse supported the transition from hospital to primary health care (PHC) with positive results to improve the quality of care for patients at higher risk, such as diabetics and drug addicts.
313 2016	Randomized clinical trial NE-2	To assess the effectiveness of a transition of care intervention using remote patient monitoring in reducing all-cause readmissions within 180 days in an elderly population with heart failure.	Pre-discharge education (primer, orientation of the use of portable play media, scale and blood pressure and heart rate monitor); Nine training phone calls, reinforcing pre-discharge guidelines (between 48 and 72 hours after discharge; second week; between third and fourth week; monthly up to six months) Message-to-call center telemonitoring about weight, blood pressure and heart rate and three symptoms.	The intervention had a significant effect on the improvement of quality of life among respondents in 180 days.
414 2018	Pilot study NE- 4	Create a Care Transition Intervention (CTI) service model.	Structured telephone contact up to 18 hours after hospital discharge, with the use of a script addressing the understanding of the disease, health maintenance and self-care.	Structured telephone consultations to review self-care and maintenance and health promotion guidelines are simple and effective interventions to reduce readmission rates within 30 days of discharge.
515 2019	Study pilot NE- 4	Implement a consistent 48-hour post-discharge phone call process for patients with heart failure (HF).	Conference of lists of patients diagnosed with heart failure who are discharged from the hospital; Telephone call, 48 hours after discharge, using a script developed by the service and recorded in the electronic medical record shared with the primary care provider.	Post-discharge calling programs are a simple and effective way to identify and intervene in patients' issues after discharge. Nurses play a key role in post-discharge monitoring programs for safe care transition.
616 2016	Case control study NE- 4	Reduce post-discharge readmission rates of patients at high risk of readmission.	Application of the LACE scale (predictive assessment of risk of readmission or death within 30 days) for patients admitted to surgical, medical and telemetry units (LACE score between 11 and 15 - referred to the program through electronic medical records); Single home visit, structured between 48 and 72 hours after discharge for medication reconciliation, disease management and education, and referral of ongoing support resources and care plan adjustment.	The 30-day readmission rate for the control group was 23.61% and for the intervention group it was 12.22%. The association of LACE score assessment with structured home visits substantially reduced readmissions within 30 days. The intervention with home visits promoted greater communication with the PHC team.
717 2018	Randomized clinical trial NE- 2	Assess whether a scheduled phone call made by a hospital nurse decreases the rate of return to the emergency room, readmission or death within 30 days	Call from a nurse 1 to 3 days after discharge using a questionnaire (obstacles to elements of successful care transitions: purchasing medications, post-discharge instructions, and getting medical follow-up).	The 30-day readmission rate was 15.5% in the intervention group and 15.2% in the control group. Death within 30 days was unusual. Follow-up of scheduled phone calls by nurses after discharge did not reduce turnaround rates in 30 days
818 2017	Pre- and post-intervention study NE- 4	Assess readmission rates in 30 days after the implementation of a care transition service program.	Multifaceted approach: identification of readmission rates before intervention; identification of patients for the intervention, with risk score (age, diagnosis and previous hospitalization); pre-discharge planning; home visit, followed by three phone calls (30 days), including medication reconciliation; and addressing psychosocial challenges.	Readmission rate before the intervention was 13.7% and after, 11.4%. Nursing involvement in the care transition program is an essential component to identify patients at risk. Readmission rates decreased significantly after the intervention.
919 2019	Pilot study NE- 4	Determine the efficacy and feasibility of the transfer by videoconference of hospital care to the home in pediatrics.	Videoconferences scheduled the day before hospital discharge, with the participation of the case manager, bedside nurse, PHC, patient and family. Use a tablet with secure video conferencing app and checklist. Case discussion addressing health status, safety, interventions, response to treatment, care plan and need for equipment, supplies and visits.	Videoconferences have improved communication, care coordination and staff involvement during the care transition and have the potential to reduce anxiety by improving preparation, as well as increasing comfort with the arrival of a nurse in your home. Videoconferencing can be a viable and effective means of achieving a smooth transition and continuity of care.
1020 2019	Quasi-experimental study NE- 4	Evaluate the effectiveness of the multi-component transition intervention based on the ideal care transition model (ITC), on reducing readmission within 30 and 90 days.	Patient selection, early involvement to anticipate discharge needs; drug reconciliation; patient education; advance guidance and contingency plan; and follow-up with a structured link (assess symptoms and review guidelines).	Patients had lower chances of readmission at 30 and 90 days. Multifactor intervention performed by nurses was effective in reducing readmission at 30 and 90 days and in reducing costs.
1121 2018	Pilot study  NE- 4	Deploy the transition care program called Transitions Across Care Settings - TRACS.	Home visit with assessment of the need for education, environmental assessment, personalized education for self-management of care at home, with medication reconciliation (supply of medication box). Weekly phone call to monitor and reinforce guidelines. Communication from the PHC about the health status and follow-up needs, with the aid of communication forms.	Improved communication between health services, self-management and self-care.
1222 2016	Randomized clinical trial NE- 2	To evaluate the impact of the E-Coach program on readmission rates, or death after discharge in patients with chronic obstructive pulmonary disease (COPD) and HF.	E-Coach is condition-specific tailored intervention and in-hospital and post-discharge support by a care transition nurse, post-discharge interactive voice-response calls, and follow-up nursing versus usual post-discharge care. During hospitalization: assessment and training by the care transition nurse regarding medication self-management, recognition of signs and symptoms, and use of the E-Coach support and monitoring system. Automatic calls daily for seven days and then every three days until 28 calls are completed.	Overall readmission rate for the control group was 16.3% and for the intervention group 15.0%. The system collected patient data, provided personalized education and motivation, and alerted the nurse to alert responses.
1323 2019	Multicenter randomized clinical trial NE- 2	To verify readmission or death within 30 days after intervention of the transition service model of patient-centered care.	Usual care group: education and a home visit Intervention: nurse at discharge assessed needs, provided self-care education with structured discharge summary, arrangements for medical follow-up in PHC, referral for post-discharge home visit by nurses, followed by weekly structured visits or telephone calls for four to six weeks.	Three-month readmission rates were 49.4% for the intervention group and 50.2% for the control group, with no significant difference.
1424 2017	Descriptive study NE- 6	Identify and quantify the activities of the navigator nurse for the coordination of hospital discharge. Identify and quantify the activities of the navigator nurse for the coordination of hospital discharge.	Patient follow-up with help for the patient, with links for guidance or information relay; Management of technical problems, with calls to alert about service problems such as delivery of supplies, malfunctioning equipment; and guidance on service protocols with clarifications.	Nurses' activities involve organizational and managerial coordination, training and qualification for patients and professionals. Possibility of collecting and transmitting patient data to other services.
1525 2016	Pilot study NE- 4	Assess whether a postoperative education checklist reduces readmissions among new ileostomized	Development of a patient-centered knowledge checklist, with skills considered essential for successful discharge with ileostomy (24 hours after surgery, with guidance during hospitalization). Monitoring of patient autonomy.	Significant reduction in readmission assigned to the checklist (P= 0.04). Patient-centered and self-care-oriented checklist, focused on autonomy and independence; significantly improves the readmission rate after making an ileostomy.
1626 2018	Pre- and post-intervention study NE-4	Reduce visits to the emergency department in the population with preexisting chronic conditions and increase PHC follow-up after discharge.	Care transition alert with exchange of health information within 24 hours, by secure electronic message, with patient consent, in an automated way. Use of the ePECAM software to support the clinical decision, filled in by the nurse in the phone call. COMPLEXedex clinical algorithm, with Big Data analysis (data from the electronic medical record stratify the risk of readmission based on comorbidities).	Use of data science can harmonize person-centered care with evidence-based, transitional care practices that qualify nursing care. Incorporate information on social and behavioral determinants of health in the electronic medical record for exchange between services. Risk stratification of patient readmission.
1727 2016	Retrospective descriptive study NE-6	Use the information collected by post-discharge calls to assess the symptoms of patients undergoing pulmonary resection and identify patients at higher risk of unmet needs after discharge.	Telephone contact made by nurses (questions scripted in the first week after hospital discharge to assess health conditions and provide health advice). Registration of care in the electronic medical record and referral to services in case of need.	Of the 523 patients who underwent lung resection, 245 (46.8%) received telephone contact, on average, 4.6 days after discharge, and 81 (33.1%) required counseling during the calls. Patients at risk of having care difficulties after discharge. Attempts to better prepare patients for discharge.
1828 2019	Quantitative descriptive study NE-6	Identify and describe the activities of the liaison nurse for continuity of care after hospital discharge.	Selection of patients by active search or indication of the multidisciplinary team. Hospital discharge planning started at different times of hospitalization (interviews with patients and family members). Liaison nurses transfer information between the hospital and other services with the support of information and communication technologies (ICT) between 48 hours before discharge and 24 hours after discharge.	Liaison nurse acts as coordinator of the discharge process and actively participates in identifying post-discharge care needs. Contribution to the continuity of care with identification of clinical and social conditions, survey of needs and resources in PHC, and reinforcement of discharge guidelines.
1929 2018	Randomized clinical trial NE-2	Determine whether a single nurse-led telephone call after discharge decreases the rate of reuse of the hospital service.	Telephone call between 48 and 96 hours after discharge, supported by a standardized model for the disease, used in home visits. High instruction reinforcement guidelines. Identification of changes, contact with the clinician or the PHC for control and standardized care of education for discharge.	442 (91.5%) received calls within 96 hours. Hospital reuse rate in 30 days in the control group was 13.1% and in the intervention group, 15.9%. A single phone call made by a nurse did not change the health service reuse rate. Intervention was well accepted after discharge, and parents were better able to identify warning signs in the child.
2030 2020	Randomized clinical trial NE-2	Examine the effectiveness of a primary care-based telephone support intervention for veterans after discharge from the emergency department.	Usual nursing care, including recommendation for scheduling appointments with the PHC. Two structured phone calls focused on improving the transition from the emergency department to PHC, self-management of chronic illnesses, and education about the PHC model (additional call option).	The 30-day emergency department return rate was 23.1% and 24.9% for the control and intervention groups, respectively. Nurse-led telephone support program after emergency room care did not reduce repeated hospital visits. Programs must focus sociopsychological factors to meet health needs.
2131 2017	Prospective study NE-6	Reduce readmission rates in 30 days of patients with heart failure (HF).	STOP-HF-Clinic Program: an early visit in the first week of discharge by a nurse; assessment to identify change (potential for decompensation) and request for additional assessments; blood collection for laboratory analysis; personalized health education activities for the patient and caregiver; three new visits for adjustment and orientation (during the 30 days); medication administration; sending an electronic message to the patient (after 30 days) and recording in the electronic medical record	Average time between discharge and first visit was five days; the average number of post-discharge visits was 3.1 days. Rehospitalization rate for any cause within 30 days was reduced by 47.5% with the intervention. Nurses were responsible for medication reconciliation, health education for self-care and participation in the immediate treatment of changes. 518 patients were oriented and followed up.
2232 2018	Intervention research NE-4	Identify the profile of users counter-referenced by the liaison nurse.	Selection of users and their care needs after hospital discharge; Identification of the PHC health unit (reference), make telephone contact with the nurse to discuss needs and schedule a post-discharge consultation; Fill out the counter-reference form and send it along with the discharge summary to APS (by email, and deliver a copy to the user); Guide the user to deliver the form to the health unit nurse	43 users were counter-referred to the APS with a discharge summary. Dialogue between health services and agility in the acquisition of supplies to ensure continuity of care. Liaison nurse proved to be a strategy to improve integration between services and promote continuity of care.
2333 2017	Pilot study NE- 4	Assess the feasibility and usefulness of home visits. for children with medical complexities.	Home visit conducted by a nurse (72 to 96 hours after discharge, lasting between 60-90 minutes). Topics covered during the visit: reinforcement of education about the discharge plan, review of the medication list, inspection and guidance on home care equipment and supplies, assessment of the home environment, identification and resolution of issues arising in the post-discharge period and assessment of social determinants of health.	38 patients were eligible for visits, and 36 (94.7%) received the visit. Visits occurred a median of three days after hospital discharge and lasted an average of 73 minutes. Home visits helped to identify and resolve post-discharge problems that occurred with children with medical complexity, as well as the assessment of social determinants of health, home environment and provided health guidance.

 

Ten (43.5%) articles were published in interprofessional journals; eight (34.8%) of nursing and five (21.7%) of medicine. The publishing languages were English (86.9%), Portuguese (8.7%) and Spanish (4.4%). The research development countries were USA (73.9%), Canada (8.7%), Iran (4.3%), France (4.3%), Spain (4.3%) and Brazil (4.3%).

Regarding the year of publication, six (26.1%) were made available in 2016, four (17.4%) in 2017, seven (30.4%) in 2018, five (21.7%) in 2019 and one (4.4%) in 2020. Regarding the design, it was found that seven (30.4%) were pilot studies; six (26.1%), randomized clinical trials; four (17.4%), descriptive studies; three, pre and post-intervention (13.1%); two (8.7%), almost experimental; and one (4.3%) was control case.

In relation to the emerging categories, the following stand out: I) health education, II) drug reconciliation, III) telemonitoring, IV) discharge planning, V) counter-reference and VI) home visit, which led to a final category, outcome and strategies for transition from care to hospital discharge (Figure 2).

                Figure 2 - Initial, intermediate and final categories (outcome).

 

The first intermediate category, presented in Figure 2, brings health education as a strategy for the transition of care, which consists of processes related to self-care, addressed before and after hospital discharge by 16 (69.5%) Studies. Health education, considered a set of practices that contribute to increase the user's autonomy to achieve health, according to their care needs,³⁴ was associated with other strategies, especially after hospital discharge.

Health education was identified in the pre-discharge period with actions of care guidelines, disease and treatment,^{11,16,20,23,25,28} support and guidance of the use of monitoring equipment¹³ and self-management of medications.²² In the post-hospital discharge period, nurses developed self-care and counseling guidelines through telephone calls^{11,14,17,20-22,27,29} and home visits.^21,31,33

The second intermediate category was drug reconciliation,^{16,18,20-21,33} considered a strategy for comparing the complete and detailed list of drugs used with prescriptions performed in admissions, transfers, outpatient consultations and hospital discharge. This activity allows the use of medications in the transition of care in a safe way, reducing the risk of errors.³⁵

Telemonitoring was the third strategy used by nurses and covered real-time nursing teleconsultation for guidance and risk assessment of discontinuity of care,^{11-12,14-15,17-18,20-21,23,26-27,29-30} automatic telemonitoring from artificial intelligence software with identification of the need for contact in real time^13,22,31 and applications with data capture to support clinical decision-making.²⁶

As the fourth intermediate category, the planning of discharge is characterized as systematization of activities determined from the needs and participation of the user to promote the well-being and resources necessary to ensure safe care and continuity of care.³⁶ For its effectiveness, plans were addressed,^18-19,28 use of a needs checklist,¹⁹ identification of users with higher risks of discontinuity of care and the performance of liaison, transition or navigation nurses.^{12,15-16,18-20,22-26}

The fifth category was formed by the counter-reference, which allowed an effective exchange of information between the different care services and health professionals, ^{15,21-24,26,29} use of videoconference for information exchange¹⁹ and identification of health care network resources necessary for continuity of care.^{16-17,19,24,28,33}

The sixth intermediate category included home visits, which consists of the care, follow-up and guidance of users in their homes.³⁷ This category was present associated with others, such as health education, medication administration and telemonitoring.^16,18,21-23 The six intermediate categories led to the outcome of the analysis, with the identification of the final category: transition strategies from care to hospital discharge.

 

Discussion

The main strategies for the transition of care aimed at strengthening the continuity of care after hospital discharge, identified in the scientific literature, were health education, drug reconciliation, telemonitoring, hospital discharge planning, counter-referral and home visit. There was a constant production of studies on the subject between 2016 and 2019, with a sharp reduction in 2020, which needs to be better understood.

The USA presented significant production of studies developed on the theme of the transition of care, especially aimed at continuity of care, aimed at reducing avoidable hospital readmissions for the consequent reduction of health costs.^{12-22,25-27,29-30,33} This reality is justified by the private health system in force in the country, which seeks strategies to reduce costs and optimize financial resources.⁵

Multidisciplinary journals were also highlighted as the main sources of knowledge dissemination and studies on transition strategies and continuity of care (43.5%), followed by those specialized in nursing.^20-21,23,31 This finding evidenced the multidimensional aspect of the theme as well as the increased interest on the subject in various areas of knowledge.⁵

There was a predominance of studies with NE 4 (56.5%), followed by NE 2 (26%) and NE 6 (17.4%). This reality proves the need to increase methodological rigor to strengthen the practice of the transition of care based on evidence. All the articles included in this review addressed more than one strategy of transition from care to hospital discharge.

It was noticed that 16 studies presented health education actions, described as pre- and post-hospital discharge guidelines, mainly aimed at self-care.^{11,13-14,16-17,20-23,25,27-31,33} Among the topics addressed, the understanding of the disease and its complications stood out,^16,30 adhering to physical activities,¹¹ control of risk factors,^11,14 relief of signs and symptoms^20-21,29 and monitoring of vital signs.¹³

In a review conducted in Canada, researchers identified that health education applied in isolation as a care transition strategy did not show a positive impact on the reduction of hospital readmission, however, when associated with other interventions, it had an impact on improving quality of life and adhering to the proposed treatment. Health education involves the construction of knowledge considering the participation and reflection of reality.⁶

In drug reconciliation, nurses play an active role in preventing discrepancies related to safety and treatment interruptions, with consequent reduction of worsening of comorbidities.³⁸ This is a strategy developed and used in the USA to improve the safety and continuity of therapy after discharge.³⁸ Drug reconciliation was used in association with health education^16,20 and home visits.^16,18,21,23

The telemonitoring used by nurses to facilitate and support continuity of care was present in seventeen studies^{11-15,17-18,20-23,26-27,29-31} involving contacts between nurses and users of health systems in real time or by programmed electronic messages. In recent years, the use of information and communication technologies, especially through calls on mobile devices, has been more present. When associated with strategies such as health education and home visits, it can help the success of continuity of care after hospital discharge^18,21,23,31 by facilitating a transition of safe care.

Researchers have evidenced the use of structured scripts as important to the development of telemonitoring because they standardized the review of self-care guidelines, maintenance and health promotion.^{11-12,15,17,20,23,27,29} The research guidelines and post-discharge guidelines were carried out with guidelines for discharge adopted by the institutions as reference. This action was necessary to facilitate communication between nurses in monitoring centers, which played a fundamental role in post-discharge monitoring programs for a safe care transition.^{17-18,21-22,25}

The planning of discharge was observed as part of the activities of nurses, with identification of users with risks of discontinuity of care,^15-16,18,28 preparation of discharge plans^19,28 and the performance of professionals specialized in care transition.^{12,18-20,22-26,28,32}

The identification of users at risk of discontinuity of care and hospital readmission was important to optimize actions appropriate to their needs. Checklists and risk scores have been developed and used by professionals involved in the care transition.^15-16,18 The development of discharge plans helps the process of education and management of self-care in the processes of transition of care, providing information relevant to disease control, treatment to the therapeutic plan, pain control and use of health equipment and insums.^18-19,28 Nurses specialized in transition processes develop activities aimed at ensuring the coordination and continuity of care among health services.⁴

The counter-reference or exchange of health information between professionals and services is increasingly present. The use of shared electronic medical records,¹⁵ the sending of information from hospitalization to PHC by telephone calls, electronic alerts and discharge forms^21,27-29,31 emerge as efficient strategies for strengthening the transition and continuity of care. Communication during the care transition processes created an opportunity to deliver essential information,⁵ and nurses should pursue it effectively to ensure the user’s safety.³⁹

Furthermore , there was mention of the home visit, used by PHC-related nurses to implement continuity of care, allowing knowledge of family dynamics, adequacy and adjustment of self-care guidelines, direct care and assessment of psychosocial risks involved in discontinuity of care.^{16,18,21,23,31,33} Home visits should occur early, allowing the identification of alterations with potential for clinical decompensation for adequate management and reduction of potential adverse effects in the post-discharge period.³¹

As a limitation of this study, we highlight the use of a sample of scientific articles from the last five years and the use of search filters, which may restrict the results of the research.

          

Conclusion 

The results highlighted as strategies for the transition of care in hospital discharge activities of health education, drug reconciliation, telemonitoring, discharge planning, counter-reference and home visit, carried out in an interconnected way. The outcome presented in the corpus of analysis of the review reinforces the relevance of comprehensive care to the user of the health system, with the provision of the necessary care over time, that is, the longitudinality or continuity of care involving various levels of health care services.

Nurses are the key professionals in the development of connected care transition strategies, demonstrating their essentiality to ensure continuity of care. The integration of various strategies enables the qualification of care developed by nurses, thus being essential the transition of care in the provision of post-discharge care, integrating users, family and service providers.

 

References

1. Mendes FRP, Gemito MLGP, Caldeira EC, Serra IC, Casas-Novas MV. A continuidade de cuidados de saúde na perspectiva dos utentes. Ciênc Saúde Colet. 2017;22(3):841-53. doi: 10.1590/1413-81232017223.26292015

2. Cunha EM, Giovanella L. Longitudinality/continuity of care: identifying dimensions and variables to the evaluation of Primary Health Care in the context of the Brazilian public health system. Ciênc Saúde Colet. 2011;6(Suppl 1):1029-42. doi: 10.1590/S1413-81232011000700036

3. Vargas I, Garcia-Subirats I, Mogollón-Pérez AS, Paepe PD, Silva MRF, Unger JP, et al. Patient perceptions of continuity of health care and associated factors. Cross-sectional study in municipalities of central Colombia and North-eastern Brazil. Health Policy Plan. 2017;32(4):549-62. doi: 10.1093/heapol/czw168

4. Acosta AM, Câmara CE, Weber LAF, Fontenele RM. Nurse´s activities in care transition: realities and challenges. Rev Enferm UFPE On Line. 2018;12(12):3190-7. doi: 10.5205/1981-8963-v12i12a231432p3190-3197-2018

5. Carr DD. High-Quality care transitions promote continuity of care and safer discharges. J N Y State Nurses Assoc [Internet]. 2019 [cited 2021 Feb 05];46(2):4-9. Available from: https://issuu.com/nystatenursesassociation/docs/nysnajournalv46no2/s/10321671

6. Spall HC, Rahman T, Mytton O, Ramasundarahettige C, Ibrahim Q, Kabali M, et al. Comparative effectiveness of transitional care services in patients discharged from the hospital with heart failure: a systematic review and network meta-analysis. Eur J Heart Fail. 2017;19(11):1427-43. doi: 10.1002/ejhf.765

7. Weber LAF, Lima MADS, Acosta AM, Marques GQ. Care transition from hospital to home: integrative review. Cogitare Enferm. 2017;22(3):e47615. doi: 10.5380/ce.v22i3.47615

8. Ribas EDN, Bernardino E, Larocca LM, Poli PP, Aued GK, Silva CPC. Nurse liaison: a strategy for counter-referral. Rev Bras Enferm. 2018;71(Suppl 1):546-53. doi: 10.1590/0034-7167-2017-0490

9. Ganong LH. Integrative reviews of nursing research. Res Nurs Health. 1987;10(1):1-11. doi: 10.1002/nur.4770100103

10. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2011.

11. Bikmoradi A, Masmouei B, Ghomeisi M, Roshnaei G. Impact of Tele-nursing on adherence to treatment plan in discharged patients after coronary artery bypass graft surgery: a quasi-experimental study in Iran. Int J Med Inform. 2016;86:43-8. doi: 10.1016/j.ijmedinf.2015.12.001

12. Moyer A, McGillen B. Transitioning Patients Across the Care Continuum. Nurse Lead. 2018;16(6):389-92. doi: 10.1016 / j.mnl.2018.07.011

13. Ong MK, Romano PS, Edginton S, Aronow HU, Auerbach AD, Black JT, et al. Effectiveness of remote patient monitoring after discharge of hospitalized patients With heart failure: The Better Effectiveness After Transition - Heart Failure (BEAT-HF) randomized clinical trial. JAMA Intern Med. 2016. 176(3):310-8. doi: 10.1001/jamainternmed.2015.7712

14. Phelps P, Sutton K. Structured telephonic consultation to decrease heart failure readmissions. Medsurg Nurs [Internet]. 2018 [cited 2021 Feb 05];27(3):153-72. Available from: https://www.proquest.com/openview/be0aa8f01d43d82fabe75f0db9287b5f/1?pq-origsite=gscholar&cbl=30764

15. Ruggiri JC, Milner KA, Buonocore D. Implementing post-discharge 48-hour scripted call for patients with heart failure: an evidence-based practice quality improvement project. Medsurg Nurs [Internet]. 2019 [cited 2021 Feb 05];28(3):183-7. Available from: https://www.proquest.com/openview/40722d1745ed79b1ea423e02a0115dbe/1?pq-origsite=gscholar&cbl=30764

16. Smith J, Pan DM, Novelli MA. Nurse practitioner-led intervention to reduce hospital readmissions. J Nurse Pract. 2016;12(5):311-6. doi: 10.1016/j.nurpra.2015.11.020

17. Biese KJ, Busby-Whitehead J, Cai J, Stearns SC, Roberts E, Milhas P, et al. Telephone follow-up for older adults discharged to home from the emergency department: a pragmatic randomized controlled trial. J Am Geriatr Soc. 2018;66(3):452-8. doi: 10.1111/jgs.15142

18. Dizon ML, Reinking C. Reducing readmissions: nurse-driven interventions in the transition of care from the hospital. Worldviews Evid Based Nurs. 2017;14(6):432-9. doi: 10.1111/wvn.12260

19. Knight SW, Trinkle J, Tschnnen D. Hospital-to-homecare videoconference handoff: improved communication, coordination of care, and patient/family engagement. Home Healthc Now. 2019;37(4):198-207. doi: 10.1097/NHH.0000000000000755

20. Kripalani S, Chen G, Ciampa P, Theobald C, Cao A, McBride M, et al. A transition care coordinator model reduces hospital readmissions and costs. Contemp Clin Trials. 2019;81:55-61. doi: 10.1016/j.cct.2019.04.014

21. Radhakrishnan K, Jones TL, Weems D, Knight TW, Rice WH. Seamless transitions: achieving patient safety through communication and collaboration. J Patient Saf. 2018;14(1):e3-5. doi: 10.1097/PTS.0000000000000168

22. Ritchie CS, Houston TK, Richman JS, Sobko HJ, Berner ES, Taylor BB, et al. The E-Coach technology-assisted care transition system: a pragmatic randomized trial. Transl Behav Med. 2016;6(3):428-37. doi: 10.1007/s13142-016-0422-8

23. Spall HGC, Lee SF, Xie F, Oz UE, Perez R, Mitoff PR, et al. Effect of patient-centered transitional care services on clinical outcomes in patients hospitalized for heart failure: the PACT-HF randomized clinical trial. JAMA. 2019;321(8):753-61. doi: 10.1001/jama.2019.0710

24. Yatim F, Cristofalo P, Ferrua M, Girault A, Lacaze M, Palma MD, et al. Analysis of nurse navigators’ activities for hospital discharge coordination: a mixed method study for the case of cancer patients. Support Care Cancer. 2017;25(3):863-8. doi: 10.1007/s00520-016-3474-x

25. Hardiman KM, Reames CD, Mcleod MC, Regenbogen SE. Patient autonomy-centered self-care checklist reduces hospital readmissions after ileostomy creation. Surgery. 2016;160(5):1302-8. doi: 10.1016/j.surg.2016.05.007

26. Hewnwe S, Sullivan SS, Yu G. Reducing emergency room visits and in-hospitalizations by implementing best practice for transitional care using innovative technology and big data. Worldviews Evid Based Nurs. 2018;15(3):170-7. doi: 10.1111/wvn.12286

27. Anronoff MB, Ragalie W, Correa AM, Spicer JD, Sepesi B, Roth JA, et al. Results of postdischarge nursing telephone assessments: persistent symptoms common among pulmonary resection patients. Ann Thorac Surg. 2016;102(1):276-81. doi: 10.1016/j.athoracsur.2016.01.062

28. Aued GK, Bernardino E, Lapierre J, Dallaire C. Liaison nurse activities at hospital discherge: a strategy for continuity of care. Rev Latinoam Enferm. 2019;27:e3162. doi: 10.1590/1518-8345.3069-3162

29. Auger KA, Shah SS, Tubbs-Cooley HL, Sucharew HJ, Gold JM, Wade-Murphy S, et al. Effects of a 1-Time nurse-led telephone call after pediatric discharge: the H2O II randomized clinical trial. JAMA Pediatr. 2018;172(9):e181482. doi: doi: 10.1001/jamapediatrics.2018.1482

30. Hastings SN, Stechuchak KM, Coffman CJ, Mahanna EP, Weunberger M, Houtven CHV, et al. Discharge information and support for patients discharged from the emergency department: results from a randomized controlled trial. J Gen Intern Med. 2020;35(1):79-86. doi: 10.1007/s11606-019-05319-6

31. Pacho C, Domingo M, Núñez R, Lupón J, Moliner P, Antonio A, et al. Una consulta específica al alta (STOP-HF-Clinic) reduce los reingresos a 30 días de los pacientes ancianos y frágiles con insuficiencia cardiaca. Rev Esp Cardiol. 2017;70(8):631-8. doi: 10.1016/j.recesp.2016.12.026

32. Ribas EN, Bernardino E, Larocca LM, Poli Neto P,  Aued GK, Silva CPC. Nurse liaison: a strategy for counter-referral. Rev Bras Enferm. 2018;71(Suppl 1):546-53. doi: 10.1590/0034-7167-2017-0490

33. Wells S, O'Neill M, Rogers J, Blaine K, Hoffman A, McBride S, et al. Nursing-led home visits post-hospitalization for children with medical complexity. J Pediatr Nurs. 2017;34:10-6. doi: 10.1016/j.pedn.2017.03.003

34. Ministério da Saúde (BR), Secretaria de Gestão do Trabalho e da Educação na Saúde, Departamento de Gestão e da Regulação do Trabalho em Saúde. Câmara de Regulação do Trabalho em Saúde. Brasília (DF): Ministério da Saúde; 2006.

35. World Health Organization (WHO). Medication without harm: WHO global patient safety challenge [Internet]. Geneva (CH): WHO; 2017 [cited 2021 Feb 05]. Available from: http://apps.who.int/iris/bitstream/10665/255263/1/WHO-HIS-SDS-2017.6- eng.pdf?ua=1

36. Lemos DMP, Saldanha PF, Vieira LF, Azzolin KO. Nursing taxonomies in hospital discharge planning: a quasi-experimental study. Rev Bras Enferm. 2020;73(5):e20180896. doi: 10.1590/0034-7167-2018-0896

37. Cunha LP, Silva FVC, Santos FK, Pires AS, Leone DRR, Silva LCS. The home visit in peritoneal dialysis: relevant aspects to nursing care. Rev Pesq Cuid Fundam. 2017;9(1):128-36. doi: 10.9789/2175-5361.2017.v9i1.128-136

38. Lombardi NF, Mendes AEM, Lucchetta RC, Reis WCT, Fávero MLD, Correr CJ. Analysis of the discrepancies identified during medication reconciliation on patient admission in cardiology units: a descriptive study. Rev Latinoam Enferm. 2016;24:e2760. doi: 10.1590/1518-8345.0820.2760

39. Jackson, ML. Transitional care: methods and processes for transitioning older adults with cancer in a postacute settin. Clin J Oncology Nurs. 2018;22(6):37-41. doi: 10.1188/18.CJON.S2.37-41

 

Chief Scientific Editor: Cristiane Cardoso de Paula

Associate Publisher: Etiane de Oliveira Freitas

 

Corresponding Author

Karina Silveira de Almeida Hammerschmidt

E-mail: ksalmeidah@ufpr.br

Address: Rua 24 de Maio, 980, Apartment 704 – Neighborhood: Rebouças; City: Curitiba; State: Paraná. CEP: 80220-060

 

 

Authoring Contributions

 

1 – Valéria Cristina Lopes Gallo

Conception or design of the study/research; (2) analysis and/or interpretation of data (3) final review with critical and intellectual participation in the manuscript.

 

2 – Daiana Kloh Khalaf

Conception or design of the study/research; (3) final review with critical and intellectual participation in the manuscript).

 

3 – Karina Silveira de Almeira Hammerschmidt

Conception or design of the study/research; (3) final review with critical and intellectual participation in the manuscript.

 

4 – Mariane Lima Santiago

Analysis and/or interpretation of data

 

5 – Carine Vendruscolo

Final review with critical and intellectual participation in the manuscript

 

 

How to cite this article

Gallo VCL, Khalaf DK, Hammerschmidt KSA, Santiago ML, Vendruscolo C. Estratégias de transição para alta hospitalar utilizadas por enfermeiros: revisão integrativa Rev. Enferm. UFSM. 2021 [Acesso em: Anos Mês Dia]; vol.11 e79: 1-22. DOI: https://doi.org/10.5902/2179769264383