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The Effect of Telenursing on Referral Rates of Patients With Head Trauma and Their Family's Satisfaction After Discharge

Shahrokhi, Akram, MSc; Azimian, Jalil, PhD; Amouzegar, Atousa, MSc; Oveisi, Sonia, PhD

doi: 10.1097/JTN.0000000000000382

We aimed to assess the effect of telenursing on referral rates of patients with head trauma and their family's satisfaction after discharge. Seventy-two patients with head trauma were randomly allocated to equal intervention and control groups. The caregivers in both groups were provided with 1-hr face-to-face training on patients' home care and educational booklets, 2 days before discharge. The cell phone numbers of the telenurse was given to the caregivers of the intervention group. Then, the patients in the intervention group were followed up every week through phone calls by the telenurse for 12 weeks and the patient status checklists were completed. Caregivers in the intervention group could call the telenurse any time they desired. The health status of the control group was followed once by a phone call after 12 weeks. Data were analyzed using SPSS software, version 19. Ultimately, 33 patients with a mean ± SD age of 31.12 ± 10.83 years were studied in the control group and 35 patients with a mean ± SD age of 34.11 ± 12.34 years were studied in the intervention group (p = .098). The 2 groups differed significantly with respect to referral rates; 39.4% of the participants in the control group referred to physicians whereas only 25.7% of the patients in the intervention group needed to refer to physicians (p = .017). Also, the mean times of referring to a physician differed significantly in both groups. In general, 53.8% of the caregivers were satisfied with the telenursing program. Follow-up programs using telephone calls were effective and would lead to higher caregiver satisfaction.

Department of Critical Care Nursing (Mss Shahrokhi and Amouzegar), Nursing & Midwifery Faculty (Dr Azimian), and School of Nursing and Midwifery (Dr Oveisi), Qazvin University of Medical Sciences, Qazvin, Iran.

Correspondence: Atousa Amouzegar, MSc, Critical Care Nursing Department, Nursing & Midwifery School, Qazvin University of Medical Sciences, Qazvin, Iran (

The authors declare no conflicts of interest.

Each year, about 1.7 million head traumas occur in the United States, leading to nearly 52,000 deaths and 275,000 hospitalizations (Hinkle & Cheever, 2014), about 1.1 million of whom are treated and discharged from hospital (Brunner, Smeltzer, Bare, Hinkle, & Cheever, 2010), and a considerable number (80,000–90,000) suffer from long-term disability (Hinkle & Cheever, 2014). During 2012–2013, 55,427 individuals were referred to three main trauma centers in Tehran because of head trauma, who were mainly (74%) men and the main causes of trauma included road accidents, falls, and beatings (Aligholi & Safahani, 2015). Head trauma is a major reason of referral to trauma centers in Iran; 18.9% of admissions in three great teaching hospitals in Tehran, capital of Iran, had occurred because of head trauma (Ghodsi, Moez Ardalan, & Daroughehdar, 2002). Incidence rate of head trauma in the central region of Iran was 429 per 100,000 population, so 4,290 patients with head trauma had been admitted to Kashan hospitals during a 2-year period (Fazel et al., 2008).

Head trauma can lead to several complications, ranging from mild concussions to coma and death (Hinkle & Cheever, 2014). Traumatic brain injury is the leading cause of death and disability worldwide and imposes a great burden on the health care system (Langlois, Rutland-Brown, & Wald, 2006 ; Vafaee et al., 2013). The most common complications after head trauma and brain injury include coma, urinary and respiratory tract infections, septicemia, wound injury, meningitis, and brain abscess (Białkowska, Sowa, & Maksymowicz, 2012 ; Hinkle & Cheever, 2014). Many head trauma survivors live with major disabilities, including physical, cognitive, mental, emotional, and behavioral defects (Haffejee, Ntsiea, & Mudzi, 2013 ; Vafaee et al., 2013). Considering the complications mentioned, the possibility of readmission increases in patients with traumatic brain injury. Therefore, follow-up is a major part of health care services to establish a consistent and dynamic health care relationship with patients to increase their knowledge and improve the function of patients and their families (Behzad, Bastani, & Haghani, 2016 ; Zakerimoghadam, Bassampour, Rjab, Faghihzadeh, & Nesari, 2009).

The family, as the main social unit, plays a key role in the patients' sense of well-being and their ability to adapt to different conditions. Moreover, lack of knowledge about the treatment process could create anxiety in families (Imani, Dabirian, Safavibiat, & Payandeh, 2015). Since caring for patients with head trauma could lead to changes in family roles, weak social adaptation, social isolation, anguish and sorrow, anxiety, depression, and financial problems in the family, such families experience lower quality of life and need to be supported (Arango-Lasprilla et al., 2011 ; Brunner et al., 2010 ; Chiou, Chang, Chen, & Wang, 2009 ; Hinkle & Cheever, 2014). Considering that one of the main reasons for treatment program failure and undesirable reaction to the prescribed treatment is the weak or partial adherence to the treatment program, and that follow-up after discharge could prevent lack of adherence, telenursing could be an effective method for communicating with patients and their caregivers (Kamrani et al., 2016).

Telenursing can be an effective method for communication with patients and their care providers for information exchange, education, and health-related knowledge by health care personnel (or nurses, etc....; Kamrani et al., 2016). Telenursing is also applicable for home care providers (Maserat, Samadi, Mehrnush, Mohamad, & Zali, 2011). Among the technologies used in telenursing, the telephone is frequently used, as it is more accessible (Rahnavard, Bastani, & Rajabi, 2013). By phone, families can find the answers to many of their questions (Imani et al., 2015).

Considering that phone follow-ups and distant training to patients by nurses have not been investigated in Iran, the present study aimed to assess the effect of telenursing on the referral rate of patients with head trauma and their family's satisfaction after discharge. The results of this study could be used to improve health care programs in the country.

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This randomized controlled trial investigated 72 patients with head trauma, who were admitted to eight hospitals in Tehran, Iran. The Ethics Committee of Ghazvin University of Medical Sciences approved the study (Code: D/20/9376), and the trial was registered at the Iranian registry of Clinical Trials (IRCT1N2014110919868). The study population consisted of patients with head trauma and the person or people taking care of them at home. Written informed consent was obtained from the participants after informing them about the aims and methods of the study. The sample size was calculated to be 56 patients considering a power of 80%. Therefore, considering a dropout rate of 20%, 72 patients were recruited (36 in each group).

Sampling was based on the convenient sampling method, according to the inclusion and exclusion criteria and the recruited participants were randomly allocated to intervention and control groups, 36 patients in each group, using block randomization. Patients or caregivers who used services provided by nursing consultation centers at home or did not answer the phone calls of the telenurse for three consecutive weeks were excluded from the study (n = 4, three in the control group and one in intervention group; Figure 1).

Figure 1

Figure 1

The inclusion criteria consisted of patients who were 18–60 years of age, with a Glasgow Coma Scale score of 11–15, admitted to the hospital for the first time after trauma, without known urinary or respiratory infections, infected or had Grade 3 and 4 pressure ulcers and diabetes mellitus, and had undergone thoracostomy and percutaneous endoscopic gastrostomy. The inclusion criteria for caregivers consisted of being literate, spending at least 12 hr caring for the patients, having access to phone (cell phone or telephone), no auditory or speech disorders, not working in the health sector, and willingness to participate in the study.

Data were collected through a patient status checklist, including demographic characteristics of the patients and the caregivers, the patient's condition upon discharge, during and at the end of intervention, and the outcome of care (readmission, occurrence of pressure ulcer, duration of pressure ulcer healing in case of having pressure ulcer at discharge, and the time of readmission after discharge). The content validity of the checklist was approved by the expert opinion of 10 faculty members of the Department of Nursing of Ghazvin University of Medical Sciences, and internal consistency was confirmed by a Cronbach α of 0.82. Norton's scale was used to determine the risk of pressure ulcer formation.

The content validity of the caregivers' satisfaction measurement tool was also approved by the expert opinion of 10 faculty members of the Department of Nursing of Ghazvin University of Medical Sciences.

Phone calls were made using cell phones or landlines. For both groups, 2 days before discharge, the patients' caregivers (one or two of the closest people who cared for the patients) were trained face-to-face (60-min session) on how to care for the patients at home during one session and then they received a booklet with the same content. The cell phone number of the telenurse was given to the caregivers of the intervention group. During a period of 12 weeks after discharge, the telenurse contacted the caregivers of intervention group weekly by phone calls and the patient status checklists (Figure 2) were completed. Moreover, caregivers in the intervention group could call the telenurse any time they desired (Table 1). For the control group, necessary instructions were given before discharge (similar to the intervention group) and one phone call was made to ask the patients' status after 12 weeks and they did not get any contact from telenurse before 12th week of intervention for study group.

Figure 2

Figure 2



None of the patients in both groups had Foley and external catheters at discharge and they were not used by any patient during the 12 weeks of study.

Data were analyzed using SPSS software, version 19. Chi-square, Mann–Whitney, and independent t tests were used as appropriate. A p value of less than .05 was considered as statistically significant.

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Thirty-three patients with a mean ±SD age of 31.12 ± 10.83 years were studied in the control group, and 35 patients with a mean ±SD age of 34.11 ± 12.34 years were studied in the intervention group (p = .098). Of the 68 studied patients, 50 were men and 18 were women.

With respect to referral rates, 39.4% of the participants in the control group referred to physicians whereas only 25.7% of the patients in the intervention group needed to refer to physicians (p = .017, χ2 test). The mean ±SD number of referrals were 1.33 ± 2.07 and 0.28 ± 0.51 in the control and intervention groups (p = .005, independent t test).

The most common reason for referral to physicians in both groups was headache and vertigo and no significant difference was found between the two groups in this regard (p = .392). The most frequent order was readmission (38.4%) in the control group and magnetic resonance imaging (22.2%) in the intervention group (p = .222, χ2 test). In control group, 38.47% of those who had referred to a physician had readmitted, but despite no readmission in study group, there was no statistically significant difference between two groups (p = .139). But clinically, 6.1% readmissions in the control group are notable in the present study, which shows high rate of readmission after head injury. The main causes of readmission in the present study included hydrocephaly, headache, nausea, and rhinorrhea, which were unpreventable, as they are common complications associated with head trauma.

Moreover, in 25.7% of cases, the caregivers contacted the nurse, and the most frequent reason for calling the nurse was headache and vertigo, comprising 33.3% of the phone calls.

With respect to satisfaction with the telenursing program, we found that 46.1% of the caregivers emphasized on the necessity of follow-up by the hospital, and 57.7% of the caregivers emphasized on the existence of a reference source for calling to ask patient-related questions and existence of a follow-up program for the patient.

In general, 53.8% of the caregivers were satisfied with the telenursing program. The positive characteristics of this program, as stated by the caregivers, were as follows: follow-up using phone calls, providing psychological support for the patients and their family, positive mental effect, providing required information, accessibility of an expert, and receiving needed information (42.3%; Figure 3).

Figure 3

Figure 3

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We found that our telenursing program effectively reduced referral to physicians as well as the number of referrals. Moreover, it increased the satisfaction of caregivers after discharge. Previous studies on patients with chronic obstructive pulmonary disease (Caress, Luker, Chalmers, & Salmon, 2009) and those who had underwent radical prostatectomy (Inman, Maxson, Johnson, Myers, & Holland, 2011) have also shown the positive effects of telenursing in reducing referral rates to emergency wards, contact with the caregiving team, and even treatment costs. However, in our study, we did not assess treatment costs, which is one of the limitations of the study, but it is obvious that when referrals decrease, some of the expenses are saved. Another previous study also showed that telenursing reduced referral rates to medical centers (Maserat et al., 2011).

We found that the caregivers were satisfied with the telenursing program. This finding is consistent with two previous related studies regarding the use of distant medical programs for supporting family members of patients with traumatic brain injury and chronic obstructive pulmonary disease. The researchers found that the participants evaluated distant learning positively and were satisfied with the program and believed that the nurses have a protective effect in preventing and reducing readmission and in turn the duration of admission (Rietdijk, Togher, & Power, 2012 ; Sorknæs Madsen, Hallas, Jest, & Hansen-Nord, 2011).

One other limitation of this study was the short duration of the follow-up period. We suggest that further studies be done using longer follow-up periods (at least 6–12 months).

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Considering the nature of head trauma and its possible complications, setting up a follow-up system in all trauma centers and hospitals in Iran is necessary. Establishing a comprehensive follow-up program using telephone calls would be beneficial and affordable to reduce referral rates and patient readmission, as well as to improve caregivers' support and their higher satisfaction.

Treatment costs were not measured in this study, but because telenursing had a statistically significant difference between the two groups on referral rate to the doctor and the frequency of referral to the doctor, it can be concluded that it has probably been effective in reducing treatment costs. As in some studies, the effect of telenursing on cost reduction has been evaluated and its effect has been statistically significant.

Patient education and their caregivers have made them more satisfied with telenursing services, and effective communication with them, as well as the needs assessment and follow-up program for the patients and their caregivers improved accordingly the process. It seems that establishing contact with the patients and their caregivers and assuring them of the availability of nurses can improve their satisfaction. Nurse's availability and communication are two important aspects for patients and caregivers that can increase their satisfaction.

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  • According to the results of this study, telenursing education had an effective role in reducing the referral rates of patients to health centers and physicians.
  • The reduction of referral rates will reduce the treatment costs such as doctor's visit cost, transportation expenses, and so on in return.
  • Following patient's status by their caregivers through telenursing will not only improve the quality of care but also have a positive effect on patients and caregivers emotionally and spiritually because of the emotional support.
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This thesis is extracted from the master's thesis conducted in Ghazvin University of Medical Sciences. The authors thank the patients and their families for their cooperation during this study. They also thank the personnel of the studied hospitals as well as the Faculty of Nursing of Ghazvin University of Medical Sciences for their support.

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Caregivers; Head trauma; Outcome assessment; Patient care; Telenursing

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