Ethical consideration
Our study has been certified and approved by the medical ethics committee of the affiliated Suzhou science & technology town hospital of Nanjing medical university (200824), and all the included patients agreed to participant and signed the written informed consents.
Patients
Tracheostomy patients with severe TBI from January 2018 to December 2019 treated in our hospital were identified. The patients recruited from January 2018 to December 2018 underwent the traditional nursing care, while the patients recruited from January 2019 to December 2019 underwent HCH nursing care. The inclusion criteria for patients were: ① The diagnosis meet the clinical diagnostic criteria[17, 18] for severe TBI upon admission; ② Patients accepted the tracheostomy treatment during hospitalization, and the tracheotomy ostomy was not closed when discharge;③ Patients were willing to participate in this study and signed the informed consent. The exclusion criteria for patients were: ①The patients did not have primary caregivers (the relatives of the patient or their spouses who were responsible for taking care of the patient's food, clothing, living and medical-related issues); ②Patients weren’t willing to participate in this study and did not sign the informed consent.
Nursing care
For control group, we conducted the routine discharge follow-up process. We conducted telephone return visits within 1 week to ask patients about the diet, urine, sputum, consciousness, and physical activity after discharge from the hospital. In response to the problems encountered by patients in care, the nurses conducted home visits within 2 weeks to provide guidance on on-site care issues. During the follow-up in the outpatient clinic two months after discharge, the nurse evaluated the patient's current situation and guided the nursing care accordingly.
For HCH group, the nursing care were:
The establishment of the medical consortium Under the support of the hospital medical consortium, a group of 5 hospital nurses and 5 community nurses was established, and the team leader was the head nurse of neurosurgery department of our hospital. The community nursing staff trained in the department of neurosurgery for one month to master the knowledge and nursing skills of severe TBI, and understood the family visit content, and passed the assessment of the head nurse. And we used software WeChat to facilitate the understanding of the situations of patients and their families and to strengthen the information exchange between nurses.
Preparation before discharge Community nurses went to ward before patient’s discharge to meet with patient and related family members, and the hospital nurses, and leave WeChat with each other to enhance the relationship between community nurses, patients and their families to build a sense of trust. On the day before discharge, the hospital records on the patient's characteristics such as age, diagnosis, self-care ability, contact information et al. And the records were transferred to the community health service institution. And we instructed the caregiver to record the relevant information such as sputum, urine etc. every day.
Follow-up The community nurse conducted home visits to the patient’s place of residence in the first week after the patient’s discharge from the hospital, the nurse guided the nursing care hand-in-hand, and the nurses recorded the identified problem. And we conducted group discussions on the results of the visit. Hospital nurses and community nurses will conduct the second home visit two weeks after discharge. According to the home record, more attentions were payed to the problems found by previous home visit, and we conducted on-site education and guidance. The community nurse visited the patient's home 4 and 6 weeks after the patient was discharged. And the patient followed up in the outpatient clinic of our hospital 2 months after discharge.
Outcome assessment
All the patients underwent Glasgow coma score (GCS), Karnofsky, Self-Anxiety Scale (SAS) and Barthel assessment at the discharge and two months after discharge. The GCS[19] included three aspects: open eye response, language response and limb movement. We used Karnofsky to assess the functional status of patients[20], with 100 being normal and o being death. The higher the score, the better the health. In addition, we use the SAS to evaluate the negative emotions of the primary caregivers of the patients[21]. The higher the score of SAS, the more serious the anxiety. Furthermore, we used Barthel Index to evaluate the self-care ability of patients[22]. The content of the Barthel Index included eating, bathing, grooming, dressing, et al ten items, each item scored 0-15 points, and the total score were 100 points. The higher of the score, the better of self-care ability.
Furthermore, the tracheostomy related complications including subcutaneous emphysema, pulmonary infection, incision infection, block of artificial tracheal cannula were diagnosed by two experienced doctors. And the incidence of readmission was also recorded.
Statistical analysis
SPSS 23.0 software was used for relevant data analysis in this study. The continuous data was expressed as mean ± standard deviation, the comparison between groups was conducted by t test. And the binary data was expressed by rate (%), and the chi-square test was used for groups comparisons. The comparative test level of this study was α=0.05, and P<0.05 was considered statistically significant.