Optimal Evidence Summary for Discharge Preparation in Elderly Chemotherapy Patients

Introduction

Discharge planning, an integral component of hospital services, encompasses developing a comprehensive post-discharge care strategy or facilitating the transfer to subsequent care services for patients and their caregivers.¹ This process is crucial for ensuring treatment continuity and enhancing patient adherence and adjustment to care protocols post-discharge. With the world’s fastest-growing and largest elderly population, China faces a direct upsurge in the number of individuals predisposed to malignancies, resulting in a rapid increase in cancer incidence and related mortality rates.² Specifically, the incidence of cancer among the elderly Chinese demographic constitutes 55.8% of the nation’s total cancer cases.³ Given the prevalence of comorbid conditions and the manifestation of geriatric syndromes, chemotherapy emerges as a prevalent modality for treating cancer in the elderly. However, this patient group encounters heightened challenges due to the pronounced limitations and adverse reactions associated with chemotherapy treatments.⁴

The limited duration of in-hospital treatment necessitates discharging patients to continue their recovery at home, underlining the pivotal role of effective discharge management. This management is essential for maintaining the continuum of oncological care and improving the life quality for elderly oncology patients. Current research, both within China and internationally, provides a vast body of literature on discharge planning for the elderly.⁵ However, the information is often fragmented and overwhelming, lacking the targeted, thematic distillation required to offer succinct, actionable guidance for nursing professionals and patients.

To address this gap, the present study concentrates on discharge preparation for the elderly chemotherapy patients, aiming to systematically collate and summarize evidence through evidence-based methodologies. The objective is to arm nursing professionals with a robust theoretical foundation for implementing discharge planning tailored to this demographic. This synthesis is focused on elderly patients undergoing chemotherapy within conventional medical facilities. The findings are intended to serve as a reliable, condensed guide for clinical application, facilitating the translation of evidence-based practices into bedside nursing. This initiative is a part of the Evidence Translation and Clinical Application Project led by the Evidence-Based Nursing Center at Fudan University (Fudanebn202335).

Materials and Methods

Study Design and Setting

This study employs the PIPOST framework to construct evidence-based questions,⁶ defining the inclusion criteria based on specific issues as follows: a) The target population for the evidence application is elderly oncology patients undergoing chemotherapy during hospitalization. b) The intervention method is discharge planning services, which encompass admission assessment, treatment plan evaluation, discharge service planning, implementation, and post-discharge evaluation. c) Professionals applying the evidence include oncology nurses and physicians. d) Outcome indicators are the readiness for discharge, adherence (patient outcomes); knowledge related to discharge planning services and rate of process implementation (implementer outcomes); discharge preparation process for elderly chemotherapy patients, and quality of discharge preparation (system outcomes). e) The evidence application settings are hospital oncology departments and related caregiving institutions. f) The types of evidence selected are thematic evidence syntheses, clinical practice guidelines, expert consensus, and systematic reviews. Exclusion Criteria: Given the focus of this evidence summary on the discharge preparation of elderly chemotherapy patients, evidence unrelated to this theme is excluded.

Evidence Search Strategy

For the retrieval of relevant literature, the search strategy was aligned with the “6S” hierarchy of evidence resources and a top-down search principle.⁷ Systematic electronic searches were performed across websites such as BMJ Best Clinical Practice, UpToDate Clinical Advisor Library, and the Cochrane Library. Further searches were extended to include the Campbell Collaboration, Global Initiative for Nursing (GIN), Medlive Clinical Guidelines, the Registered Nurses’ Association of Ontario (RNAO), the UK’s National Institute for Health and Care Excellence (NICE), and the Scottish Intercollegiate Guidelines Network (SIGN) to access evidence-based resource databases. Supplementary searches were carried out in comprehensive databases including PubMed, EMBASE, National Comprehensive Cancer Network(NCCN), and American Society Of Clinical Oncology(ASCO).

We also searched the following Chinese databases: CNKI (China National Knowledge Infrastructure), VIP (Chinese Science and Technology Periodical Database), Wanfang Database, China Medical Journal Full-text Database, and China Biology Medicine disc, as well as specialised oncology websites such as China Anti-cancer website. China Medical Journal Full-text Database, and China Biology Medicine disc, as well as specialty oncology websites such as China Anti-cancer Association (CACA).

The types of evidence included were thematic evidence syntheses, clinical practice guidelines, expert consensus, and systematic reviews. When searching clinical decision-making platforms, recommended practices, evidence syntheses, clinical practice guidelines, and professional society websites, search terms were utilized as follows. Chinese search terms included: “elderly aging/old age”,‘chemotherapy/chemotherapeutic treatment’, “discharge plan/discharge preparation plan/dis-charge guidance/discharge services/inpatient comprehensive management/discharge health education/discharge management/hospital management/continuing care”.

English search terms included: “older populations/older people/old*”, “chemotherapy”, “discharge planning/Discharge plan/Discharge preparation plan/discharge guidance/discharge services/full h-ospitalization management/discharge health education/discharge management/hospitalization m-anagement/continuing care”.

The Chinese search strategy was: (Keywords = elderly + aging + old age + chemotherapy + chemotherapeutic treatment) AND (Keywords = discharge plan + discharge preparation plan + discharge guidance + discharge services + inpatient comprehensive management + discharge health education + discharge management + hospital management) AND (guidelines + expert consensu-s + systematic review + meta-analysis + evidence summary).

The English search strategy was:

(((odder populations [Title/Abstract] OR (older people [Title/Abstract]) OR (chemotherapy [Title/Abstract])) AND (((discharge planning [Title/Abstract]) OR (Discharge plan [Title/Abstract])) OR (Discharge readiness [Title/Abstract])). The search covered literature from the inception of each database up to January 2024.The flowchart of literature screening is shown in Figure 1.

Figure 1 The flowchart of literature screening.

Evidence Quality Appraisal

The study team rigorously appraised the quality of the evidence, selecting appraisal tools congruent with the specific evidence formats. Guideline documents were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework, renowned for its methodological rigor.⁸ For systematic reviews and consensus statements, the Joanna Briggs Institute’s (JBI) critical appraisal instruments were utilized, acknowledged for their comprehensive assessment criteria.⁹ This appraisal was meticulously conducted by two evaluators, proficient in evidence-based methodology, ensuring an unbiased and thorough evaluation. Discrepancies between assessors were resolved through deliberative consultation with a third, experienced team member to establish a unanimous conclusion, thereby reinforcing the validity of the quality assessment process.

Process and Methods for Reviewing Evidence

A total of 10 healthcare professionals were invited to join the expert group, comprising one associate chief nurse, two chief physicians, and seven supervisor nurses. These individuals were selected based on their extensive clinical experience and familiarity with the process of discharging geriatric chemotherapy patients. The expert meeting was conducted in March 2024. Based on an evaluation of the FAME scale (feasibility, appropriateness, meaningfulness, and effectiveness of the evidence), as well as the evidence transformation sites, medical resources, and staffing ratios, we conducted a comprehensive review of the evidence article by article. This process ultimately led to the inclusion of 29 pieces of evidence. The FAME scale form in Supplementary Material 1. The experts invited to participate in the meeting met the following criteria: a)They were clinical medicine, nursing, pharmacy experts, and nutritional specialists working in oncology chemotherapy. b)They held intermediate or higher titles, a bachelor’s degree or higher, and 10 or more years of work experience in related fields. c)They were familiar with the treatment, nursing care, and rehabilitation of oncology chemotherapy patients.

Analytical Framework

The team meticulously reviewed the literature included post-screening, performing evidence extraction and synthesis. When encountering discrepancies in evidence conclusions or content from different sources, precedence was given to evidence of higher quality and more recent publication. For evidence lacking a grading system, the “2014 JBI Evidence Hierarchy and Recommendation Levels” was employed.¹⁰ Details of the 2014 JBI Evidence Hierarchy and Recommendation Levels are provided in Supplementary Material 2. Clinical practice guidelines, recommended practices, and evidence syntheses retained their inherent grading systems. This process was informed by the original literature types that contributed to the generation of the best evidence, allowing for a stratified approach to grading diverse evidence sources. Subsequent to evidence extraction, two researchers from our team independently assigned grades to the evidence. Where opinions diverged, a third researcher joined the discussion to reach a consensus. All personnel involved in the production and writing of this evidence synthesis were systematically trained in evidence-based nursing methodology and possess extensive practical experience within this domain.

Results

Evidence Retrieval Results

A total of 224 articles were retrieved from both domestic and international databases. After screening using NoteExpress literature management software, 112 duplicate articles were removed. By reviewing the title and abstract sections, 94 articles that did not match the research content and type were removed. Subsequently, 3 articles that did not match the research topic were removed based on the full-text content, and finally, 15 articles were included. The evidence screening process is shown in Figure 1.

General Characteristics of the Included Literature

This study included one clinical decision,¹¹ two expert consensus,^1,12 six systematic reviews,^13–18 two meta-analyses,^19,20 and four clinical guidelines.^21–24 The general characteristics of the included literature is shown in Table 1.

Table 1 Characteristics of the Included Studies

Quality Evaluation Results of the Included Studies

This study included two expert consensus papers,^1,12 respectively from China National Knowledge Infrastructure and PubMed. The evaluation results for item 6 of the expert consensus on whether there are any inconsistencies between the viewpoints proposed and previous literature are all “no”, while the other items are all “yes”. The overall quality is high and it is allowed to be included. Six systematic reviews and two meta-analyses,^13–20 and four clinical guidelines were published within 10 years.^21–24 The study design is relatively complete, and after quality evaluation of the methodology, the overall quality is high, and it is allowed to be included. See Tables 2–5.

Table 2 Methodological Quality Evaluation of the Expert Consensus (n=2)

Table 3 Methodological Quality Evaluation of the Systematic Review and Meta-Analysis (n=8)

Table 4 Methodological Quality Evaluation of the Guidelines

Table 5 Literature Quality Evaluation Form

Summary of Evidence

A total number of 29 pieces evidence was extracted, summarized and condensed into four themes: evaluation, planning, implementation, and evaluation, as shown in Table 6.

Table 6 The Best Evidence Content and Rating for Discharge Preparation of Elderly Chemotherapy Patients

Discussion

Assessment for Discharge Preparation

The discharge of elderly chemotherapy patients from hospital is often associated with the implementation of complex healthcare plans, presenting a challenging period for both the patients and their carers.²⁵ The accurate and systematic assessment of patients’ readiness for discharge plays a crucial role in preventing premature discharges and facilitating the transition from hospital care to home care or community rehabilitation. This approach has been shown to reduce the incidence of adverse post-discharge outcomes. The evidence presented in references highlights the importance of assessment and specifies the timing, content, and methods of assessment.^{1,11–13,16,19,22–24} The evidence further suggests that discharge readiness in elderly chemotherapy patients is an ongoing and dynamic process. In addition to the initial screening and assessment of patients within 24 hours of admission, team members must reassess patients when their condition changes, when they are transferred to a new department, or when patients or families have new needs.

The most pertinent predictive instrument for the discharge preparation in elderly chemotherapy patients is the Comprehensive Geriatric Assessment (CGA), which is regarded by the International Society for Geriatric Oncology as a pivotal screening tool for elderly patients.²⁶ The most widely used assessment tool is the Blaylock Risk Assessment and Scoring Scale (BRASS), which is employed primarily to quantify significant factors influencing patient care requirements.²⁷ The scale can guide the modification of discharge preparation plans in accordance with the scores obtained. However, the extensive scope of this scale presents a challenge in terms of understanding the individualized needs of elderly chemotherapy patients. To comprehend the personalized requirements of elderly chemotherapists in accordance with the scale’s content, it can be employed in accordance with the recommendations of Panlan et al and Yang et al, who proposed the utilization of the Blaylock Risk Assessment and Screening Score as a tool for evaluating patients’ care needs.^28,29 Consequently, the Patient Discharge Needs Scale, revised by Yang et al, in conjunction with the recommendations of Pan Lan et al, can be employed to provide discharge preparation services for elderly chemotherapy patients. This approach allows for the dynamic adjustment of services during the implementation process, ensuring that both the individual needs of patients and their families are understood at the assessment stage and that sufficient preparations are made for the development and implementation of discharge preparation plans for elderly patients. These assessments should cover physical function, fall risk, comorbidities, polypharmacy, nutrition, symptoms, depression, and cognitive function. Additionally, evaluations of medical and care needs, home environment, caregiving capacity, economic support, and patient abilities at home (self-care, mobility, and environmental hazards) are essential before discharge. A comprehensive geriatric assessment conducted prior to treatment is recommended for elderly patients in order to reduce the risk of adverse effects during treatment.^30,31

Planning and Implementation of Discharge Preparation

A number of sources have highlighted the necessity of a multidisciplinary team and a professional coordinator to oversee the discharge preparation process.^{1,11,12,14,16,18,19} The discharge preparation service for elderly chemotherapy patients is a continuous process comprising four steps: assessment, planning, implementation, and evaluation. In addition, it encompasses two phases: in-hospital service and out-of-hospital service. As each of these tasks is onerous and encompasses all aspects of the patient’s and family’s needs, it necessitates the input of a multidisciplinary team comprising professionals such as doctors, nurses, nurse managers, rehabilitators, dietitians, pharmacists, social workers, and other specialists.

Discharge preparation services involve a variety of professionals, with different indicators and standards being used by each according to their area of expertise. Rehabilitation personnel, for instance, focus on the patient’s functional rehabilitation ability,³² while dietitians concentrate on the patient’s nutritional risk, and nursing staff are primarily concerned with the the patient’s ability to care for themselves after discharge. This is a crucial aspect that must be considered.⁵ However, the process of receiving discharge preparation services often results in a lack of coherent guidance and information, which can be challenging for patients and their families to navigate. This highlights the importance of appointing a professional coordinator to facilitate the transition and ensure a smooth integration into the community. The charge nurse, being the professional who has has the most contact with the patient during their hospitalization, is in a position to gain a deeper insight into the changes in the patient’s condition and psychological characteristics. This enables the charge nurse to play a pivotal role in the discharge preparation service, acting as a coordinator to ensure the integration of information provided by different professionals and enhance the effectiveness of the discharge preparation service.³³

Evaluation of Discharge Preparation

The assessment of discharge preparation services for elderly chemotherapy patients is primarily relies on the perspectives of patients, caregivers, and healthcare institutions at all levels, utilizing research methods such as questionnaires, interviews, observations, and measurements.³⁴ The Group Standard for Follow-up Services for Discharged Patients presents a standardized follow-up process and procedure, including the content, assessment, and guidance for follow-up visits, with the objective of ensuring the quality of patients’ home care or community rehabilitation after discharge.³⁵ The timing of evaluation varies across healthcare institutions. Expert consensus recommends the initial evaluation occur between 3 and 7 days after discharge, followed by a second evaluation conducted between 2 and 4 weeks after discharge.¹ Subsequent adjustments may be made according to the needs of the patient and carer, hospital manpower allocation, home environment, and community readiness.

In order to evaluate the quality of discharge instruction for patients by medical workers, Wang Binghua et al³⁶ conducted a localized revision and a reliability and validity test of the Quality of Discharge Teaching Scale (QDTS) compiled by Weiss et al in 2007 in 2016.³⁷ This specifically included the subjective perception of patients. Shepperd et al showed that implementing a systematic and comprehensive discharge plan, combined with continuous community care and home management, can reduce hospital stays, improve patient satisfaction, and optimize health outcomes. This approach promotes a safer, smoother transition to home and community care. (Shepperd et al demonstrated that the implementation of a systematic and comprehensive discharge plan for patients, coupled with the assurance of uninterrupted community care and home management, can reduce the length of hospitalization, enhance patient satisfaction and optimize disease outcomes).³⁸ This, in turn, facilitates a safer and more seamless transition to home and the community.³⁹

The evidence includes 29 pieces of key information for the care of older patients with tumors (oncology patients) requiring chemotherapy. It encompasses the assessment and screening that should be conducted upon admission, the management and information support of patients during their hospitalization, as well as the post-charge considerations and follow-up. A cross-sectional survey conducted in Spain revealed that 86% of colorectal cancer survivors had at least one unmet care need during clinical treatment.⁴⁰ Similarly, a survey of colorectal cancer survivors in Singapore demonstrated that approximately 52% of patients had at least one unmet care need during treatment in the hospital.⁴¹ These findings indicate gaps in the current care processes. This study aims to equip clinical nurses with the necessary information to better address the nursing needs of elderly oncology patients.

Limitations

This study included 15 documents, which may limit the comprehensiveness of the evidence. The limited variety of document types might affect the applicability of the summarized evidence.

Conclusion

This study obtained high-quality, scientific, rigorous, and reliable evidence through strict evidence screening processes and the use of scientific literature quality evaluation tools. The 29 pieces of evidence were synthesized, summarizing that discharge preparation services for elderly chemotherapy patients should involve four steps: assessment, planning, implementation, and evaluation.

For elderly chemotherapy patients, pre-chemotherapy assessment is crucial. It involves not only evaluating the discharge risks and general conditions of the elderly patients—encompassing physiological, psychological, familial, and communal resources—but also conducting a comprehensive geriatric evaluation and calculating the risk of chemotherapy toxicity. During the planning phase, a discharge plan must be crafted based on the multidisciplinary team’s insights and assessments, while also considering the patients’ preferences. The discharge plan should cover health education, medication management, referrals, and follow-up appointments. The success of discharge preparation services hinges on a dedicated “coordinator” overseeing the discharge process. Additionally, daily monitoring of discharge service execution is crucial to ensure the integrity of the entire process. Lastly, after discharge, it is essential to continually offer informational support and perform telephone follow-ups, providing patients with tools and platforms to evaluate the services they received. The evidence summary provides a reliable basis for implementing evidence-based discharge preparation services for elderly chemotherapy patients, laying a foundation for future clinical practice applications.