The clinical practice guidelines for discharge planning of patients with stroke_Chinese Journal of Evidence-Based Medicine

Authors：

 Neurosurgery Branch of the Chinese Medical Association , Evidence-based Nursing Center, West China Hospital, Sichuan University , Sichuan Provincial Engineering Research Center of Medical Nursing Equipment and Materials

Corresponding?author：

Neurosurgery Branch of the Chinese Medical Association, Email: hxhljy2018@163.com

Keywords：

Stroke; Discharge planning; Clinical practice guidelines

DOI：

10.7507/1672-2531.202603065

Video：

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Abstract Full text Figures/Tables Video References Cited by

Patients with stroke are often in the early stage of recovery at the time of discharge, with many experiencing functional or cognitive impairments. Additionally, patients and their caregivers generally lack the knowledge and skills for disease management, leading to recurrent episodes and a high risk of readmission. This severely impacts patients' quality of life and increases the burden on families and society. A scientific and standardized discharge plan is crucial for ensuring continuity of care and improving the prognosis. Therefore, this guideline was developed by a multidisciplinary team, initiated by the Evidence-based Nursing Center with support from the Neurosurgery Branch of the Chinese Medical Association and West China Hospital, Sichuan University. Clinical questions were formulated through systematic reviews and stakeholder interviews, and key issues were identified through expert consultations. Evidence summaries and evidence quality grading were conducted based on domestic and international evidence. Finally, 21 recommendations were formed through expert consensus, covering the entire process of discharge planning for stroke patients, including assessment, preparation, implementation, and follow-up. This guideline aims to provide scientific, standardized, and actionable guidance for clinical practice, promote the standardized implementation of discharge planning, enhance continuity of care, reduce readmission rates, and improve patient prognosis and quality of life.

Citation： Neurosurgery Branch of the Chinese Medical Association, Evidence-based Nursing Center, West China Hospital, Sichuan University, Sichuan Provincial Engineering Research Center of Medical Nursing Equipment and Materials. The clinical practice guidelines for discharge planning of patients with stroke. Chinese Journal of Evidence-Based Medicine, 2026, 26(8): 890-902. doi: 10.7507/1672-2531.202603065 Copy

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2.	國家衛生健康委加強腦卒中防治工作減少百萬新發殘疾工程專家委員會, 吉訓明. 《2024年中國腦卒中防治報告》概要[J]. 首都醫科大學學報, 2025, 46(6): 947-960.
3.	Yin Z, Deng Y, Li Z, et al. Assessment of rehabilitation following acute ischaemic stroke in China: a registry-based retrospective observational study[J]. BMJ Open, 2024, 14(3): e082279.
4.	Lo JW, Crawford JD, Desmond DW, et al. Profile of and risk factors for poststroke cognitive impairment in diverse ethnoregional groups[J]. Neurology, 2019, 93(24): 2257-2271.
5.	Liu C, Luo L, Liu Q, et al. Predictors, timing, causes and cost of 30-day readmission after acute ischemic stroke: insights from a Chinese cohort 2015-2018[J]. Neurol Res, 2022, 44(11): 1011-1023.
6.	Feng H, Zhang J, Qin Z, et al. Analysis of readmission and hospitalization expenditures of patients with ischemic stroke suffering from different comorbidities[J]. Heliyon, 2024, 10(17): e36462.
7.	Gon?alves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital[J]. Cochrane Database Syst Rev, 2022, (2): CD000313.
8.	Tang E, Moran N, Cadman M, et al. Stroke rehabilitation in adults: summary of updated NICE guidance[J]. BMJ, 2024, 384: q498.
9.	Sinclair AJ, Dashora U, George S, et al. Joint British Diabetes Societies for Inpatient Care (JBDS-IP) clinical guideline inpatient care of the frail older adult with diabetes: an executive summary[J]. Diabet Med, 2020, 37(12): 1981-1991.
10.	Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines[J]. Circulation, 2022, 145(18): e895-e1032.
11.	Department of Health. Discharge from hospital: pathway, process and practice[Z]. 2003.
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35.	Moncion K, Rodrigues L, Wiley E, et al. Aerobic exercise interventions for promoting cardiovascular health and mobility after stroke: a systematic review with Bayesian network meta-analysis[J]. Br J Sports Med, 2024, 58(7): 392-400.
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1. Feigin VL, Brainin M, Norrving B, et al. World Stroke Organization: global stroke fact sheet 2025[J]. Int J Stroke, 2025, 20(2): 132-144.
2. 國家衛生健康委加強腦卒中防治工作減少百萬新發殘疾工程專家委員會, 吉訓明. 《2024年中國腦卒中防治報告》概要[J]. 首都醫科大學學報, 2025, 46(6): 947-960.
3. Yin Z, Deng Y, Li Z, et al. Assessment of rehabilitation following acute ischaemic stroke in China: a registry-based retrospective observational study[J]. BMJ Open, 2024, 14(3): e082279.
4. Lo JW, Crawford JD, Desmond DW, et al. Profile of and risk factors for poststroke cognitive impairment in diverse ethnoregional groups[J]. Neurology, 2019, 93(24): 2257-2271.
5. Liu C, Luo L, Liu Q, et al. Predictors, timing, causes and cost of 30-day readmission after acute ischemic stroke: insights from a Chinese cohort 2015-2018[J]. Neurol Res, 2022, 44(11): 1011-1023.
6. Feng H, Zhang J, Qin Z, et al. Analysis of readmission and hospitalization expenditures of patients with ischemic stroke suffering from different comorbidities[J]. Heliyon, 2024, 10(17): e36462.
7. Gon?alves-Bradley DC, Lannin NA, Clemson L, et al. Discharge planning from hospital[J]. Cochrane Database Syst Rev, 2022, (2): CD000313.
8. Tang E, Moran N, Cadman M, et al. Stroke rehabilitation in adults: summary of updated NICE guidance[J]. BMJ, 2024, 384: q498.
9. Sinclair AJ, Dashora U, George S, et al. Joint British Diabetes Societies for Inpatient Care (JBDS-IP) clinical guideline inpatient care of the frail older adult with diabetes: an executive summary[J]. Diabet Med, 2020, 37(12): 1981-1991.
10. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines[J]. Circulation, 2022, 145(18): e895-e1032.
11. Department of Health. Discharge from hospital: pathway, process and practice[Z]. 2003.
12. 倪小佳, 林浩, 羅旭飛, 等. 腦卒中中西醫結合防治指南(2023版)[J]. 中國全科醫學, 2025, 28(5): 521-533.
13. 潘鈺, 謝欲曉, 張皓, 等. 腦卒中重癥康復指南[J]. 康復學報, 2025, 35(5): 453-462.
14. Green TL, McNair ND, Hinkle JL, et al. Care of the patient with acute ischemic stroke (posthyperacute and prehospital discharge): update to 2009 comprehensive nursing care scientific statement: a scientific statement from the American Heart Association[J]. Stroke, 2021, 52(5): e179-e197.
15. Schünemann HJ, Wiercioch W, Etxeandia I, 等. 指南2. 0: 為成功制定指南而系統研發的全面清單[J]. 中國循證醫學雜志, 2014, 14(9): 1135-1149.
16. Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables[J]. J Clin Epidemiol, 2011, 64(4): 383-394.
17. 陳耀龍. 衛生保健實踐指南的報告規范研究[D]. 蘭州: 蘭州大學, 2015.
18. Wang C, Yu T, Luo X, et al. Protocol for the development of a clinical practice guideline for discharge planning of stroke patients[J]. Ann Transl Med, 2022, 10(17): 937.
19. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both[J]. BMJ, 2017, 358: j4008.
20. Sterne JC, Savovi? J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials[J]. BMJ, 2019, 366: l4898.
21. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses[J]. Eur J Epidemiol, 2010, 25(9): 603-605.
22. Balshem H, Helfand M, Schünemann HJ, et al. GRADE guidelines: 3. Rating the quality of evidence[J]. J Clin Epidemiol, 2011, 64(4): 401-406.
23. Guyatt GH, Alonso-Coello P, Schünemann HJ, et al. Guideline panels should seldom make good practice statements: guidance from the GRADE working group[J]. J Clin Epidemiol, 2016, 80: 3-7.
24. Guyatt GH, Oxman AD, Kunz R, et al. Going from evidence to recommendations[J]. BMJ, 2008, 336(7652): 1049-1051.
25. Larsen T, Olsen TS, Sorensen J. Early home-supported discharge of stroke patients: a health technology assessment[J]. Int J Technol Assess Health Care, 2006, 22(3): 313-320.
26. 范彩英, 洪翠芹, 宋斌, 等. 介護師參與下多學科延續護理對腦卒中肢體功能障礙患者康復的影響[J]. 護理學雜志, 2023, 38(6): 116-120.
27. UTMB Health. Patient discharge[Z]. 2020.
28. 中國老年護理聯盟. 老年患者出院準備服務專家共識(2019版)[J]. 中華護理雜志, 2020, 55(2): 220-227.
29. 柯鍵, 汪暉, 王穎, 等. 住院患者出院計劃實踐工具的范圍綜述[J]. 中華護理雜志, 2020, 55(12): 1876-1883.
30. 鄭靜, 胡歡歡, 葉夢穎, 等. 腦卒中患者出院計劃的構建[J]. 上海護理, 2024, 24(9): 14-18.
31. 汪暉, 王穎, 劉于, 等. 住院患者出院計劃關鍵任務的證據總結[J]. 中華護理雜志, 2020, 55(9): 1412-1419.
32. 劉華華, 蔣紅, 戈娜, 等. 急性腦梗死患者出院計劃需求調查問卷的可行性研究[J]. 護士進修雜志, 2015, 30(23): 2179-2180.
33. Pereira TA, De Oliveira MPB, Serr?o P, et al. Effect of lower limb resistance training on ICF components in chronic stroke: a systematic review and meta-analysis of RCTs[J]. Ann Phys Rehabil Med, 2023, 66(7): 101766.
34. Veldema J, Jansen P. Resistance training in stroke rehabilitation: systematic review and meta-analysis[J]. Clin Rehabil, 2020, 34(9): 1173-1197.
35. Moncion K, Rodrigues L, Wiley E, et al. Aerobic exercise interventions for promoting cardiovascular health and mobility after stroke: a systematic review with Bayesian network meta-analysis[J]. Br J Sports Med, 2024, 58(7): 392-400.
36. Ferrarello F, Baccini M, Rinaldi LA, et al. Efficacy of physiotherapy interventions late after stroke: a meta-analysis[J]. J Neurol Neurosurg Psychiatry, 2011, 82(2): 136-143.
37. Huang J, Ji JR, Liang C, et al. Effects of physical therapy-based rehabilitation on recovery of upper limb motor function after stroke in adults: a systematic review and meta-analysis of randomized controlled trials[J]. Ann Palliat Med, 2022, 11(2): 521-531.
38. Legg LA, Lewis SR, Schofield-Robinson OJ, et al. Occupational therapy for adults with problems in activities of daily living after stroke[J]. Cochrane Database Syst Rev, 2017, (7): CD003585.
39. Legg L, Drummond A, Leonardi-Bee J, et al. Occupational therapy for patients with problems in personal activities of daily living after stroke: systematic review of randomised trials[J]. BMJ, 2007, 335(7626): 922.
40. Pozuelo-Carrascosa DP, Carmona-Torres JM, Laredo-Aguilera JA, et al. Effectiveness of respiratory muscle training for pulmonary function and walking ability in patients with stroke: a systematic review with meta-analysis[J]. Int J Environ Res Public Health, 2020, 17(15): 1-13.
41. Wu F, Liu Y, Ye G, et al. Respiratory muscle training improves strength and decreases the risk of respiratory complications in stroke survivors: a systematic review and meta-analysis[J]. Arch Phys Med Rehabil, 2020, 101(11): 1991-2001.
42. Cacciante L, Kiper P, Garzon M, et al. Telerehabilitation for people with aphasia: a systematic review and meta-analysis[J]. J Commun Disord, 2021, 92: 106111.
43. Brady MC, Kelly H, Godwin J, et al. Speech and language therapy for aphasia following stroke[J]. Cochrane Database Syst Rev, 2016, (6): CD000425.
44. Ge L, Zheng QX, Liao YT, et al. Effects of traditional Chinese exercises on the rehabilitation of limb function among stroke patients: a systematic review and meta-analysis[J]. Complement Ther Clin Pract, 2017, 29: 35-47.
45. Lin S, Guo J, Chen X, et al. Effect of acupuncture on unilateral spatial neglect after stroke: a systematic review and meta-analysis of randomized controlled trials[J]. Geriatr Nurs, 2022, 46: 13-20.
46. Wang SB, Wang YY, Zhang QE, et al. Cognitive behavioral therapy for post-stroke depression: a meta-analysis[J]. J Affect Disord, 2018, 235: 589-596.
47. Minshall C, Pascoe MC, Thompson DR, et al. Psychosocial interventions for stroke survivors, carers and survivor-carer dyads: a systematic review and meta-analysis[J]. Top Stroke Rehabil, 2019, 26(7): 554-564.
48. Cheng HY, Chair SY, Chau JP. The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors: a systematic review and meta-analysis[J]. Patient Educ Couns, 2014, 95(1): 30-44.
49. Dayuan Z, Lan L, Hui C, et al. The effect of music as an intervention for post-stroke depression: a systematic review and meta-analysis[J]. Complement Ther Med, 2022, 71: 102901.
50. Liu Q, Li W, Yin Y, et al. The effect of music therapy on language recovery in patients with aphasia after stroke: a systematic review and meta-analysis[J]. Neurol Sci, 2022, 43(2): 863-872.
51. Al Alshaikh S, Quinn T, Dunn W, et al. Multimodal interventions to enhance adherence to secondary preventive medication after stroke: a systematic review and meta-analyses[J]. Cardiovasc Ther, 2016, 34(2): 85-93.
52. Zeng Z, Wu T, Lv M, et al. Impact of mobile health and telehealth technology on medication adherence of stroke patients: a systematic review and meta-analysis of randomized controlled trials[J]. Int J Clin Pharm, 2022, 44(1): 4-14.
53. Liu J, Dong J, Guo J. The effects of nutrition supplement on rehabilitation for patients with stroke: analysis based on 16 randomized controlled trials[J]. Medicine (Baltimore), 2022, 101(37): e29651.
54. 華小倩, 黎巧玲, 胡宏美, 等. 基于德爾菲法構建腦卒中患者家屬對卒中復發應急能力評估量表[J]. 現代醫學, 2022, 50(9): 1150-1156.
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Chinese Journal of Evidence-Based Medicine

The clinical practice guidelines for discharge planning of patients with stroke

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