Neurosurgical Transitional Care Programme (TCP)

April 29, 2025 updated by: Barts & The London NHS Trust

Transitional Care Services: A Quality and Safety Process Improvement Programme in Neurosurgery

Readmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. Recently, a readmission reduction program in the United States was associated with significantly shorter length of stay, earlier discharge, and reduced 30-day readmission after elective neurosurgery. These results underscore the importance of patient education and surveillance after hospital discharge, and it would be beneficial to test whether the same approach yields beneficial results in a different health system, the NHS. In this study, the investigators will replicate the Transitional Care Program (TCP) with the goal of decreasing length of stay, improving discharge efficiency, and reducing readmissions in neurosurgical patients by optimizing patient education and post-discharge surveillance.

Study Overview

Status

Terminated

Conditions

Intervention / Treatment

Detailed Description

Discharge Program Process Abbreviations: AA: administrative assistant; MRN: medical record number; OT: occupational therapy; PT: physical therapy; and TCT = Transitional Care Team.

CLINIC (pre-enrolment)

  • Patient has clinic visit with surgeon and is identified for surgery
  • Surgeon identifies that the patient is eligible to participate in the program and consents the patient for enrolment.
  • Patients will be given a written information sheet on the program, and will have the opportunity to receive the information via email as well.
  • Their consent will be obtained in clinic; the use of interpreters will be used for individuals with special communication needs.

AFTER CLINIC

  • Once individuals consent to be randomised into the study, their MRN will be given to the TCP nurse, who will randomise the patient into the control or intervention group using a random number generator.
  • Patients randomised to the TCP will be given a pre-determined discharge date when they are called to schedule their operation. The anticipated discharge date will be determined by each surgeon's expected length of stay per procedure.
  • AA provides brief intro to patient about the discharge pilot, including need for family member to be present to take patient home after appointment is complete. The surgery and discharge appointments are then booked.
  • AA sends surgical letter (with anticipated length of stay and discharge appointment date/time) and discharge pilot postcard to patient via email or mail
  • AA enters case and discharge information into NSU Discharge Calendar
  • Transitional Care Team (TCT) checks NSU Discharge Calendar daily for scheduled cases and discharge appointments

ADMISSION (TCT)

  • TCT monitors operating theatre regularly for post-op pilot patients and visits daily
  • TCT updates Safety Round white boards with all discharge appointment information
  • TCT sends daily dept. email, including PT/OT, with following day's discharge appointment details

ADMISSION (INPATIENT/OUTPATIENT TEAMS)

  • Patient is deemed appropriate for impending discharge by neurosurgery team
  • TCT updates Safety Rounds white board and discusses discharge checklist with care team.
  • Inpatient team completes discharge summary
  • Inpatient team completes take-away medication list by 4pm one day prior to discharge appointment
  • Inpatient team rationalises the need for further blood tests (as part of standard medical treatment, not for study purposes).
  • Inpatient team confirms PT/OT is complete
  • Inpatient team completes discharge checklist and puts in letter tray in TCP Nurse office for collection

POST-DISCHARGE APPOINTMENT

  • Staff nurse or ward sister discharges patient
  • TCT pulls discharge medications from pharmacy for appointments
  • Healthcare assistant or staff nurse transports patient to discharge appointment
  • Discharge appointment checklist completed by TCT for appointment
  • Volunteer transports patient to hospital exit or Discharge Lounge

AFTER POST-DISCHARGE APPOINTMENT

  • TCT/volunteer scans signed discharge appointment checklist into medical record
  • TCT/volunteer records data in the spreadsheet
  • TCT/volunteer shreds checklists
  • TCT communicates any outstanding issues to primary teams
  • Patient is asked to complete a patient satisfaction survey which will be sent via post and email. A second request will be sent at one week and two weeks post discharge.

FOLLOW-UP PHONE CALLS

  • After completion of post-discharge appointments, TCT makes follow-up phone calls
  • Call template is completed
  • Call template is scanned into medical record
  • All outstanding issues will be signed out to the primary teams by the TCT

Outcome measures will be collected through:

Intake forms Longitudinal data collection from hospital medical records and patient satisfaction surveys.

Data collected will be 30-day unplanned hospital re-admissions (to the same institution as the index operation) and length of hospital stay, the latter of which will be evaluated continuously by the number of hours of the initial hospitalisation. Time of discharge (with an early discharge defined as before 12:00 PM) will also be recorded.

Study Type

Interventional

Enrollment (Actual)

242

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Patients are eligible for the TCP if scheduled for elective neurological surgery (including spinal surgery performed by an orthopedic surgeon) and were expected to have a discharge disposition to home.

Exclusion Criteria:

  • Patients with an anticipated discharge to a facility other than home
  • Patients with an anticipated discharge to home who are then discharged to a facility other than home will be excluded from the statistical analysis

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Transitional Care Programme
The primary intervention of the Transitional Care Programme (TCP) will be additional patient education, framing of expectations for the hospital course and length of stay, coordinated team preparation for discharge, a dedicated discharge appointment, and a follow up phone call.
Other: Transitional Care Programme
These patients will receive a pre-admission overview of their surgery, an anticipated discharge date, and a pre-scheduled discharge appointment to set patient expectations for a shorter hospitalization. On the day of discharge, the patient and his or her caregiver will attend an extended discharge appointment with a TCP-trained nurse. Finally, patients will receive a surveillance phone call 48 hours after discharge.
Other Names:
  • Discharge Planning
No Intervention: Standard of Care
Patients are admitted without a pre-determined discharge date. They do not receive a dedicated discharge appointment, and will not receive a follow up phone call 48 hours after discharge.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Length of Hospital Stay
Time Frame: From time of hospital admission until the time of first hospital discharge or time of death from any cause, whichever came first. Assessed up to 4 months post-admission.
Time from admission until discharge (reported in hours)
From time of hospital admission until the time of first hospital discharge or time of death from any cause, whichever came first. Assessed up to 4 months post-admission.

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Hospital Readmission
Time Frame: From the time of hospital discharge from the original admission until 30 days after hospital discharge
Unplanned Readmission
From the time of hospital discharge from the original admission until 30 days after hospital discharge
Discharge before 12:00pm
Time Frame: This is assessed on the date of discharge from time 00:00 to time 23:59. The actual time of discharge or time of death from any cause, whichever came first, will be noted. Assessed up to 4 months post-admission.
Early morning discharge (between 00:00 and 11:59)
This is assessed on the date of discharge from time 00:00 to time 23:59. The actual time of discharge or time of death from any cause, whichever came first, will be noted. Assessed up to 4 months post-admission.
Cost
Time Frame: The cost of the hospital admission will be calculated for the time frame from the initial hospital admission until 30 days after hospital discharge, or time of death from any cause.
Total cost of hospital admission, transitional care programme, and readmission
The cost of the hospital admission will be calculated for the time frame from the initial hospital admission until 30 days after hospital discharge, or time of death from any cause.
Patient Satisfaction scores based on a single survey provided to the patient at the time of discharge.
Time Frame: From the time of hospital discharge from the original admission up until 2 weeks after discharge
5-point Likert-scale scores will be analyzed from a single patient satisfaction survey that is provided to the patient at the time of discharge. This survey was reported previously by Robertson et al. (Journal of Neurosurgery, 2017). The patient will have 2 weeks to complete the survey. Scores will assess patient satisfaction with 1 being the least satisfied and 5 being the most satisfied. Scores will be averaged for analysis and reporting.
From the time of hospital discharge from the original admission up until 2 weeks after discharge

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Barts & The London NHS Trust

Collaborators

Harvard Medical School (HMS and HSDM)
Brigham and Women's Hospital

Investigators

  • Principal Investigator: Edward McKintosh, FRCS(SN) PhD, Barts Health

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

May 30, 2019

Primary Completion (Actual)

August 18, 2019

Study Completion (Actual)

August 30, 2019

Study Registration Dates

First Submitted

June 5, 2018

First Submitted That Met QC Criteria

July 10, 2018

First Posted (Actual)

July 20, 2018

Study Record Updates

Last Update Posted (Actual)

May 2, 2025

Last Update Submitted That Met QC Criteria

April 29, 2025

Last Verified

April 1, 2025

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • IRAS238850
  • ReDA No: 012315 (Other Identifier: Joint Research Management Office)

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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