Types of participants
This review will consider studies that included elderly inpatients, aged 65 years or older, discharged from acute care and post-acute care rehabilitation hospitals (including skilled nursing home facilities) to home.
Types of intervention(s)/phenomena of interest
This review will consider studies that assess the following nursing discharge planning interventions:
- Early geriatric assessment34
- Discharge preparation: education/teaching medication self-management, developing self-care management skills, symptoms management, effective communication and information about discharge plan, effective multidisciplinary communication35
- Patient or caregivers participation/involvement to the discharge planning and decision making related to discharge destination36-38
- Continuity of care (coordination and effective communication between hospital staff, primary care and health care providers, coordination of the patient's discharge/transitional plan, management of patient's transition and post discharge needs39,40
- Day of discharge assessment regarding discharge planning (medication reconciliation, completion and explanation to the patient of the discharge summary)17 and
- Post discharge follow-up (home care follow up/visits, follow-up phone calls).41
This systematic review will focus on discharge planning interventions: i) provided by at least one nurse; and ii) which are incorporated into a multidisciplinary and/or interdisciplinary model of care.
Types of outcomes
This review will consider studies that include the following outcome measures:
- Functional ability/functional limitations
- Symptoms/medical condition management/adverse outcomes
- Unmet needs after hospital discharge
- Coping with disease /coping difficulties
- Health related quality of life
- Satisfaction with care during the discharge planning process
- Health care utilization (eg number of hospital visits).
Types of studies
The review will consider any randomized controlled trials (RCT and quasi-RCT); in the absence of RCTs, other research designs, such as non-randomized controlled trials and pre-post studies, will be considered for inclusion in a narrative summary to enable the identification of current best evidence regarding discharge planning nursing interventions for elderly hospitalized.
This review will not consider studies that include patients discharged from emergency departments or psychiatric hospitals.
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be used in this review. An initial limited search in MEDLINE and CINAHL databases will be first performed, followed by an analysis of the text words contained in the title and abstract, and of index terms used to describe article. A second search using all identified keywords and index terms will then be performed across all included databases. Third, the reference list of all identified reports and articles will be assessed to identify further additional studies.
Studies published in English, from 1 January 2000 to 31 December 2013 will be considered for inclusion in this review. Studies published in other languages will be excluded.
The following databases will be analyzed: PubMed, CINAHL, Embase Health Source, Cochrane Library (DARE, CCTR) and Web of Knowledge.
The search for unpublished studies will include:
ProQuest, Networked Digital Library of Thesis and Dissertations, The Dart, TripDatabase and the Mednar search platform.
Initial keywords to be used will be:
advanced care nurse
health care utilization
continuity of care
Assessment of methodological quality
Prior to inclusion in the review, retrieved papers meeting the inclusion criteria will be assessed by two independent reviewers (CM, SM) for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements arising between the two reviewers will be resolved through discussion and with a third reviewer (AD).
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). Data will be extracted independently by the two reviewers (CM, SM). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Authors of primary studies will be contacted for missing information or to clarify questions about the data.
The primary objective is to pool all quantitative data, where possible, for statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry by the two reviewers (CM, SM). Effect sizes (expressed as an odds ratio for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Statistical heterogeneity will be assessed using the standard Chi-square. In the presence of significant heterogeneity (p < 0.05), a random effects meta-analysis will be used. Causes of heterogeneity will be explored using MAStARI by conducting sensitivity and subgroup analyses based on the different quantitative study designs, geographic locations, as well as patients’ age range and polymorbidity.
The secondary objective is to determine the relative strength of correlations between individual interventions as a means to identify areas requiring further research clarification (ie what is the relative contribution of each intervention in promoting positive outcomes for discharge).42,43
The model-based meta-analysis follows several steps.42,44 First, the reviewer gathers all available information about relationships among the full set of variables included in the model. The process reveals which pathways in the model are frequently examined and which relationships have yet to be studied. When multiple studies have contributed information about a given relationship between interventions, statistical techniques of meta-analysis allow (a) estimation of the strength of the relationship between interventions (on average) and (b) estimation of the amount of intervention across studies in relationship strength, by adopting the random-effects model.45 Generalizations about research findings across different studies are based on this evidence. Model-based meta-analysis then takes the additional step of using the matrix of average correlations to estimate a series of regression equations.46 These equations provide a picture of the relationships among the interventions that takes their covariation into account.42,44 Ideally, one would like to have large, representative studies that include all the interventions of interest that are measured with a high degree of specificity. In reality, the reviewer is typically faced with a group of diverse studies examining different subsets of the interventions in the model. The task is to find patterns that are supported across studies and to discuss potential explanations for any important variability in these patterns across studies.47,48
When statistical pooling will not be possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
The authors have no relevant disclosures to make ant there is no conflict of interest regarding this systematic review.
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Appendix I: MAStARI Appraisal instrument
Appendix II: Data extraction instrument