J Korean Clin Nurs Res.  2017 Dec;23(3):376-387. 10.22650/JKCNR.2017.23.3.376.

A Systematic Review on Nurse-Led Transitional Care Programs for Discharged Patients from Hospital to Home

• Lee HJ
• Kim Y
• Oh EG

• KMID: 2405627
• DOI: http://doi.org/10.22650/JKCNR.2017.23.3.376

Abstract

PURPOSE
This study was to systematically review the contents and effects of nurse-led transitional care programs for discharged patients from hospital to home.
METHODS
Randomized controlled trials published between 2005 and 2015 were searched in Pubmed, Embase, Cochrane(Central Register of Controlled Trials) and CINAHL. Data were analyzed using Cochrane Review Manager(Revman) software 5.3.
RESULTS
Nine studies were selected and analyzed. Patient assessment, education and discharge planning were included in pre-discharge phase. Referring, communication and care planning were performed by nurses in transition phase. Home and phone visits, monitoring and multidisciplinary advices were included in post-discharge phase. Various outcome measures such as hospital utilization(30 days readmission and emergency department visit), quality of life, and cost were used to identify effectiveness of nurse-led transitional care programs. 30 days readmission(OR=.73, 95% CI 0.54, 0.98; p=.03) and emergency department visit(OR=.67, 95% CI 0.50, 0.88; p=.005) were statistically significant in meta-analysis. However, participant blinding was not done in seven studies which put at the risk of performance bias.
CONCLUSION
The results indicated that nurse-led transitional care program is effective in reducing unnecessary hospital utilization. Nevertheless, small sample size and risk at performance bias are the limitation of this study. Thus, we suggest that well-designed randomized controlled trials need to be conducted.

Keyword

Patient Discharge; Transitional Care; Continuity of Patient Care

MeSH Terms

Bias (Epidemiology)
Continuity of Patient Care
Education
Emergency Service, Hospital
Humans
Outcome Assessment (Health Care)
Patient Discharge
Quality of Life
Sample Size
Transitional Care*