The levels of evidence supporting the recommendations (I-IV) and clinical practice points (CPP) are defined at the end of the "Major Recommendations" field.
Family and Team Meetings
The stroke team should meet regularly with the person with stroke and the family to involve them in management, goal setting and planning for discharge. (CPP)
Pre-discharge Needs Assessment
Before discharge, people with stroke and their carers should have the opportunity to identify and discuss their post-discharge needs (e.g., physical, emotional, social and financial) with the interdisciplinary team. (CPP)
Before discharge (or home trial) from inpatient care and, where appropriate, a home assessment should be carried out to ensure safety and community access. Optimal independence will be facilitated through home modification and adaptive equipment, as required. (CPP)
Care Plans
People with stroke, their carers, the general practitioner and community care providers should be involved with the interdisciplinary team in the development of a care plan that outlines care in the community after discharge, including the development of self-management strategies, provision of equipment and support services, and outpatient appointments. (CPP)
Carer Training
Relevant members of the interdisciplinary team should provide specific training for carers before the person's discharge home. This should include training, as necessary, in:
- Personal care techniques, communication strategies, physical handling techniques, ongoing prevention and other specific stroke-related problems (Level II, [Kalra, et al., 2004])
- Safe swallowing and modified diet (CPP)
Liaison with Community Providers
The stroke survivor's general practitioner, other primary health professionals and community service providers should be involved in, and informed about, the discharge plans and agreed post-discharge management, as early as possible prior to discharge. (CPP)
Post-discharge Follow-up
Contact with a family support/liaison worker may be considered for carers and stroke survivors in the community to assist with their knowledge and/or satisfaction. (Level II, [Dennis et al., 1997; Mant et al., 2000; Lincoln et al., 2003])
Stroke survivors and their families should be followed up by a relevant member of the team after their discharge from a formal rehabilitation program. (CPP)
People with stroke and carers should be provided with a contact person (in the hospital or community) for any post-discharge queries. (CPP)
General Information and Education
All stroke survivors and their families should be provided with timely, up-to-date information in conjunction with opportunities to learn via education from members of the interdisciplinary team and other appropriate community service providers. Simple information provision alone is not effective. (Level I, [Bhogal et al., 2003; Forster et al., 2001]; Level II, [Kalra et al., 2004; Clark, Rubenach, & Winsor, 2003])
Definitions:
Levels of Evidence
| I |
Evidence obtained from a systematic review of all relevant randomised controlled trials. |
| II |
Evidence obtained from at least one properly designed randomised controlled trial. |
| III-1 |
Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method). |
| III-2 |
Evidence obtained from comparative studies with concurrent controls and allocation randomised (cohort studies), case-control studies, or interrupted time-series with group. |
| III-3 |
Evidence obtained from comparative studies with historical control, two or more studies, or interrupted time series without a parallel control group. |
| IV |
Evidence obtained from case series, either post-test or pre-test and post-test. |
Clinical Practice Points
| CPP |
Recommended best practise based on clinical experience and expert opinion. |
