A Nursing-Centered Standardized Operating Procedure for Transitional Neurorehabilitation After Stroke and Traumatic...

Area of Science:

• Neuroscience
• Nursing Science
• Rehabilitation Medicine

Background:

• Post-discharge neurorehabilitation is often fragmented, leading to reduced intensity and inconsistent home support.
• Patients recovering from stroke or traumatic brain injury face challenges like delayed safety risk recognition and increased caregiver burden.
• Current transitional care lacks standardized nursing workflows, impacting rehabilitation continuity.

Purpose of the Study:

• To develop a reproducible, nursing-centered standardized operating procedure (SOP) for transitional neurorehabilitation.
• To structure the discharge-to-home transition into a manageable nursing workflow.
• To enhance continuity of nursing care and standardize rehabilitation support tasks.

Main Methods:

• Developed a structured nursing workflow including risk stratification, caregiver training, and individualized home rehabilitation planning.
• Implemented a tier-linked follow-up system with adherence documentation and safety surveillance.
• Utilized a prospective clinical application with 121 patient-caregiver dyads over 6 months.

Main Results:

• Demonstrated successful implementation of risk tiering and caregiver competency verification.
• Tracked follow-up delivery, home rehabilitation adherence, and safety event documentation.
• Showcased closed-loop escalation management for patient safety.

Conclusions:

• The SOP provides a practical framework for nurses to manage transitional neurorehabilitation.
• Standardized nursing workflows improve continuity of care and support across the hospital-to-home transition.
• The protocol is adaptable to different patient risk levels and facilitates auditing and evaluation.