1) Explore perspectives and experiences of medical providers, rehabilitation providers, patients and caregivers concerning TBI discharge planning; 2) Examine the completion rate of TBI discharge planning steps; and 3) Synthesise themes from interviews and discharge planning step completion rates from surveys.
A convergent parallel mixed-methods study utilised one-on-one semi-structured interviews and a cross-sectional survey. Purposive convenience sampling was conducted for interviews and surveys of medical and rehabilitation providers, patients, caregivers, and medical charts with equal distribution from the Mulago National Referral Hospital (MNRH) and Mbarara Regional Referral Hospital (MRRH). Qualitative interviews were informed by the Care Transition Framework. Consultation of Ugandan and international neurological experts informed a survey of 12-14 discharge planning steps in local practice. Providers repeated surveys across multiple discharges (“provider discharges”). Patients with 15/15 Glasgow Coma Scale (GCS) were recruited. For patients with 15/15 GCS, caregivers were recruited. Patients and caregivers completed a single survey at time of interview. Codebook thematic analysis identified themes of translated, verbatim transcripts. Descriptive statistics analysed discharge planning step completion rates.
10 medical providers (MNRH: 6), 10 rehabilitation providers (MNRH: 4), 10 patients (MNRH: 5), and 10 caregivers (MNRH: 5) were interviewed. Key themes from medical and rehabilitation provider interviews were: 1) Discharge planning for TBI is challenged by variability of patient presentation; 2) Limited opportunity exists for rehabilitation provider involvement in discharge planning; and 3) Communication challenges between services impedes teamwork for discharge planning. Key themes from patient and caregiver interviews were: 1) Limited understanding of the purpose of rehabilitation services in discharge practice; 2) Challenged involvement of caregivers in discharge planning due to perceived limited opportunity and communication from providers; and 3) An expressed desire for more rehabilitation education at discharge. Survey responses included 44 medical provider discharges, 21 rehabilitation provider discharges, 10 patients, 10 caregivers, and 70 medical charts. Percent completion of all steps varied, with Medical Providers averaging 84% and Rehab Providers averaging 75%. Caregivers recalled 58% and patients recalled 45% of the discharge planning steps. Only 33% of steps were documented in medical files. Completion of multidisciplinary care meetings was the least utilised step across all subgroups. Reported completion of patient and caregiver education at discharge varied between healthcare providers (Medical Providers = 98%; Rehabilitation Providers = 91%) and Patients (60%) and Caregivers (40%).
Meta themes from interviews revealed multidisciplinary care coordination was perceived as challenging by healthcare providers, while the survey of medical files revealed limited documentation of multidisciplinary care. Patients and Caregivers perceived limited education during discharge, and survey findings revealed patients and caregivers reported their questions were less often answered at discharge.
These data demonstrate the need for developing care transition interventions that increase multidisciplinary care, patient and caregiver rehabilitation services education; and inform policymakers of the need to increase capacity for multidisciplinary care inclusive of rehabilitation providers across Uganda’s healthcare system.
Discharge Planning
Traumatic Brain Injury
