A Nursing-Centered Standardized Operating Procedure for Transitional Neurorehabilitation After Stroke and Traumatic Brain Injury

Summary

This protocol describes a nursing-centered standardized operating procedure for transitional neurorehabilitation in adults recovering from stroke or traumatic brain injury. The workflow integrates pre-discharge risk stratification, caregiver teach-back training, individualized home rehabilitation planning, tier-linked follow-up, adherence monitoring, and escalation-based safety management.

Abstract

The goal of this protocol is to provide a reproducible nursing-centered standardized operating procedure (SOP) for transitional neurorehabilitation in adult patients recovering from stroke or traumatic brain injury. Post-discharge neurorehabilitation is often fragmented, and patients may experience reduced rehabilitation intensity, inconsistent home supervision, delayed recognition of safety risks, and increased caregiver pressure. This protocol organizes the discharge-to-home transition into a structured nursing workflow that includes pre-discharge risk stratification, caregiver skill training with teach-back verification, individualized home rehabilitation planning, tier-linked follow-up, adherence documentation, safety surveillance, and predefined escalation rules. The procedure is designed to help nurses translate broad rehabilitation principles into repeatable actions that can be documented, audited, and adapted to different patient risk levels. A prospective clinical application involving 121 patient-caregiver dyads was used to demonstrate how the SOP can be implemented, monitored, and evaluated over a 6-month home rehabilitation period. Representative outcomes include completion of baseline risk tiering, caregiver competency verification, follow-up delivery, adherence recording for home rehabilitation, safety event documentation, and closed-loop escalation management. This protocol provides a practical framework for strengthening continuity of nursing care after discharge and for standardizing key rehabilitation support tasks across the hospital-to-home transition.

Introduction

Neurological injuries, particularly stroke and traumatic brain injury (TBI), remain major contributors to long-term adult disability worldwide^1,2. Population aging further increases the number of patients living with neurofunctional impairment, placing sustained pressure on families, rehabilitation services, and health systems³. Recovery after neurological injury is usually prolonged and multidimensional, involving motor impairment, cognitive changes, dysphagia, communication difficulty, emotional adjustment, and dependence in activities of daily living⁴. For many patients, the discharge period is a vulnerable transition point because structured inpatient rehabilitation gives way to a home environment where supervision, training intensity, and safety monitoring may become less consistent.

Nursing has a central role in this transition because nurses remain closely involved in assessment, discharge preparation, patient education, caregiver guidance, symptom monitoring, and coordination with rehabilitation professionals. Within neurorehabilitation, nursing practice is no longer limited to basic daily care; it increasingly includes structured risk screening, early recognition of complications, adherence support, caregiver coaching, and timely referral for emerging problems^5,6. Nursing-led assessment is especially important for risks such as dysphagia, aspiration, pressure injury, falls, infection signals, and deep vein thrombosis, which may develop or worsen after discharge if warning signs are not recognized early^7,8. Because home-based recovery depends heavily on family participation, caregiver training and competency verification are also essential components of a safe and sustainable rehabilitation pathway⁹.

Despite these needs, post-discharge neurorehabilitation is still frequently delivered through fragmented and experience-dependent practices. In many clinical settings, discharge education, rehabilitation guidance, follow-up contact, and safety escalation are performed without a unified operating procedure. This can lead to variation in assessment content, timing of follow-up, caregiver instruction, documentation quality, and response to safety signals¹⁰. Existing guidance often describes general principles of transitional care or rehabilitation support, but frontline nurses may still lack a stepwise method that specifies what to assess, when to intervene, how to verify caregiver competency, how to adjust follow-up intensity, and when to escalate care¹¹.

Compared with conventional discharge education or unstructured telephone follow-up, the nursing-centered SOP presented here has several method-specific advantages. First, it links baseline nursing risk assessment to a Red/Yellow/Green stratification system, allowing follow-up intensity to be matched to patient and caregiver risk. Second, it uses teach-back verification rather than passive education, requiring caregivers to demonstrate understanding of key home-care and safety tasks before discharge. Third, it records home rehabilitation dose, adherence, barriers, and safety signals in standardized fields, making post-discharge support traceable rather than dependent on informal communication. Finally, it uses predefined escalation rules to convert warning signs into timely nursing, rehabilitation, or medical responses.

This article presents a reproducible nursing-centered standardized operating procedure for transitional neurorehabilitation in adult patients recovering from stroke or TBI. The protocol covers patient-caregiver dyad screening, baseline nursing assessment, risk stratification, caregiver teach-back training, individualized home rehabilitation planning, tier-linked follow-up, adherence monitoring, safety surveillance, escalation management, and implementation fidelity audit. A prospective clinical application is included as representative evidence to show how the procedure can be delivered and monitored over a 6-month home rehabilitation period, rather than as the primary focus of the article¹².

Protocol

Approval was obtained from the institutional ethics committee before protocol initiation. Written informed consent was obtained from each patient and primary caregiver before screening, baseline assessment, caregiver training, follow-up contact, and collection of clinical application data.

1. Prepare the nursing-centered transitional neurorehabilitation SOP

1. Assemble a nursing-led neurorehabilitation team before implementation. Include nurses responsible for discharge preparation, post-discharge follow-up, caregiver training, safety monitoring, and documentation review.
2. Prepare the SOP documents required for implementation. These include the patient-caregiver screening form, baseline assessment form, Red/Yellow/Green risk stratification form, caregiver teach-back checklist, home rehabilitation prescription form, follow-up contact form, adverse-event screening form, escalation log, and fidelity audit checklist.
3. Use one active version of each SOP document throughout the implementation period. Record the document version, date of use, and responsible staff member in the SOP master file.
4. Train all participating nurses on the SOP workflow before patient enrollment. Confirm that each nurse can complete baseline risk assessment, caregiver teach-back verification, follow-up documentation, and escalation reporting using the standardized forms.
5. Assign outcome assessment to staff members who are not involved in SOP delivery whenever clinical application data are collected. Outcome assessment includes administration and scoring of scheduled patient-reported, caregiver-reported, functional, safety, and implementation-related measures at the predefined assessment time points. Record staff roles in the delegation log to reduce assessment bias.

2. Screen patient-caregiver dyads before discharge

1. Screen adult patients who are preparing for discharge or transition to the rehabilitation phase after stroke, traumatic brain injury, or another neurological condition requiring post-discharge rehabilitation support. Perform screening by reviewing the discharge plan, neurological diagnosis, rehabilitation consultation notes, nursing records, and caregiver availability, and then confirm eligibility with the responsible nurse or clinician before approaching the patient-caregiver dyad.
2. Confirm that the patient is clinically stable for discharge or rehabilitation transition. Confirm clinical stability by checking that the responsible clinician has approved discharge or rehabilitation transfer, that vital signs are stable, that no acute deterioration or untreated emergency condition is present, and that the patient can participate in basic nursing assessment or caregiver-supported home rehabilitation planning.
3. Verify functional limitations using bedside nursing assessment, rehabilitation consultation notes, and functional screening findings. Relevant limitations may include impaired mobility or transfer ability, reduced independence in activities of daily living, dysphagia or feeding-related risk, cognitive or communication difficulty affecting home-care safety, fall risk, pressure injury risk, pressure injury risk, or dependence on caregiver assistance for daily care.
4. Enroll patients only if they are between 18 and 75 years old, are in the recovery or rehabilitation phase after neurological disease or injury, require rehabilitation support because of functional limitations, are clinically stable for discharge or rehabilitation transition, are available for follow-up, have at least one participating primary caregiver, and have provided written informed consent.
5. Exclude patients if they have an expected survival of less than 6 months, end-stage disease, persistent coma without a stable caregiver, a severe unstable medical condition, an acute severe infection that prevents training participation, a severe psychiatric or behavioral condition that interferes with safe participation, planned relocation outside the follow-up area, unreliable contact information, or concurrent participation in another interventional study likely to affect SOP outcomes.
6. Enroll a caregiver only when the caregiver is at least 18 years old, is the designated primary caregiver after discharge, is expected to remain involved during follow-up, can receive nursing skills guidance, can provide follow-up information, and has provided written informed consent.
7. Exclude a caregiver if cognitive impairment, abnormal mental status, planned prolonged absence, refusal of follow-up, or inability to complete basic caregiving tasks prevent safe participation.
8. Assign a unique protocol ID to each patient-caregiver dyad before baseline assessment. Verify at least two reliable contact routes, such as a telephone number, a messaging account, or a caregiver backup contact.
9. Record all eligibility decisions, consent completion, and reasons for exclusion in the screening log before any SOP-specific training or follow-up planning is performed.

3. Define the clinical application group and usual-care comparator

1. Conduct the representative clinical application as a prospective controlled, non-randomized evaluation of the nursing-centered SOP. Enroll eligible patient-caregiver dyads consecutively during the implementation period and assign them to the SOP group or the usual-care comparator group according to the approved clinical application arrangement.
2. Do not describe the allocation as randomized because no random sequence generation or allocation concealment procedure was implemented. Record the allocation date, allocator, group assignment, and actual allocation basis in the allocation log.
3. Record baseline characteristics in both groups before delivery of SOP-specific components. These characteristics include patient demographic information, neurological diagnosis, major comorbidities, rehabilitation needs, functional independence status, nursing safety risks, caregiver availability, and contact information. Use these data to assess baseline comparability and to support adjusted analyses in the representative clinical application.
4. Assign outcome assessment to staff members who are not involved in SOP delivery whenever feasible. Outcome assessment includes administration and scoring of scheduled functional, caregiver-burden, quality-of-life, safety-event, adherence, and implementation-related indicators at the predefined assessment time points. Record assessor identity and role separation in the delegation log to reduce detection bias.
5. Provide the usual-care comparator group with routine in-hospital nursing care, standard discharge education, medication instructions, and routine outpatient or rehabilitation referral according to institutional practice.
   NOTE: SOP-specific components, including risk-tiered follow-up, caregiver teach-back verification, standardized rehabilitation dose logging, structured follow-up scripts, and escalation algorithms, were applied only in the SOP group and were not delivered to the usual-care comparator group.
6. Collect representative outcome and implementation data at the same scheduled time points in both groups when comparative results are reported. Apply the same assessment windows and instruments to both groups.

4. Conduct the baseline nursing assessment before discharge

1. Complete the baseline assessment within 48–72 h before discharge or before transition into the rehabilitation phase. Use the standardized baseline assessment form.
2. Record demographic and clinical information using fixed fields. Include age, sex, neurological diagnosis, discharge destination, major comorbidities, rehabilitation needs, caregiver availability, and contact information.
3. Assess patient functional independence using the Barthel Index, a standardized scale for evaluating independence in basic activities of daily living. Record the raw score before assigning any severity band¹³.
4. Assess caregiver burden using the Zarit Burden Interview when caregiver burden is included in the SOP assessment battery. The Zarit Burden Interview is a validated caregiver-reported measure of perceived caregiving burden. Record the raw score before assigning any burden category¹⁴.
5. Screen key nursing safety risks before discharge. Include pressure injury risk, fall risk, swallowing or aspiration risk, infection warning signs, and any condition requiring closer post-discharge monitoring.
6. Use Table 1 as the single reference for assessment instruments, score ranges, interpretation direction, threshold bands, and scheduled time points. Record raw values first, then derive interpretation bands according to Table 1.
7. Perform a completeness check before risk tiering. Do not assign the final tier until required fields are complete or a permitted missing-data code with reason has been entered.

5. Assign the Red/Yellow/Green baseline risk tier

1. Assign each patient-caregiver dyad to one baseline risk tier: Red, Yellow, or Green. Use the trigger-based algorithm in Table 1 and record both the final tier and the triggering criteria.
2. Assign the Red tier when any high-risk trigger is present. High-risk triggers include severe functional dependence, high caregiver burden, high pressure injury risk, high fall risk, failed swallowing or aspiration screening, or any safety red flag requiring close monitoring after discharge.
3. Assign the Yellow tier when no Red-tier trigger is present but at least one moderate-risk trigger is identified. Moderate-risk triggers include moderate functional dependence, moderate caregiver burden, moderate pressure injury or fall risk, psychosocial concern, or documented caregiving difficulty requiring structured monitoring.
4. Assign the Green tier only when Red- and Yellow-tier triggers are absent. Green-tier dyads should have lower nursing risk, lower caregiver burden, no failed swallowing or aspiration screen, and no active safety red flag at baseline.
5. Record the tier decision in the risk stratification form. Include the date, responsible nurse, raw scores used for tiering, trigger category, and planned follow-up intensity.
6. Review unclear cases with the clinical lead before discharge. Record the final decision and rationale in the risk stratification form.

6. Link the risk tier to the discharge SOP bundle

1. Generate a discharge SOP bundle for each dyad in the SOP group. Include the risk tier, individualized home rehabilitation prescription, caregiver training checklist, follow-up schedule, safety warning list, and escalation contact pathway.
2. Set follow-up intensity according to the baseline tier. Red-tier dyads require the highest intensity, Yellow-tier dyads require structured intermediate monitoring, and Green-tier dyads require routine scheduled follow-up.
3. Specify the follow-up modality for each planned contact. Use telephone, video call, outpatient review, or in-person review according to clinical need, patient access, and institutional capacity.
4. Give the patient and caregiver a written or electronic discharge instruction sheet. Include rehabilitation goals, daily training frequency, session duration, safety precautions, warning symptoms, and contact instructions.
5. Confirm that the caregiver understands when to continue home training, when to pause training, and when to contact the nursing team or seek urgent medical review.

7. Train the caregiver using teach-back verification

1. Deliver caregiver training before discharge. Cover safe positioning, transfer assistance, basic mobility support, swallowing or feeding precautions when relevant, skin inspection, fall prevention, medication-related reminders, rehabilitation dose recording, and warning-signal recognition.
2. Demonstrate each required caregiving skill using the standardized checklist. Ask the caregiver to repeat the explanation or demonstrate the skill back to the nurse.
3. Score caregiver competency using the teach-back checklist. Define passing as a total score of at least 80% with all critical safety items passed.
4. If the caregiver does not meet the pass criteria, repeat training on the failed items. Re-test the caregiver within 24–48 h when discharge timing allows.
   NOTE: Caregiver training was not considered complete until all critical safety items were passed. The first attempt, retraining content, re-test result, and final competency status were recorded in the teach-back checklist.
5. If the caregiver cannot pass critical safety items before discharge, notify the clinical lead. Adjust the discharge plan, increase follow-up intensity, arrange additional support, or delay discharge-related training completion according to institutional practice.

8. Issue the individualized home rehabilitation prescription

1. Prepare an individualized home rehabilitation prescription before discharge for each SOP-group dyad. Write the prescription in practical terms that the patient and caregiver can follow safely at home.
2. Select rehabilitation activities according to the patient’s main functional limitations, baseline mobility, swallowing or communication status, cognitive capacity, caregiver availability, and home environment. Activities may include bed mobility, sitting balance, transfer practice, assisted standing or walking, upper-limb task practice, activities of daily living training, breathing or endurance exercises, and swallowing-related precautions when indicated.
3. Specify the rehabilitation goal, activity type, daily or weekly frequency, minutes per session, repetitions or task attempts, progression rule, stopping rule, and safety precautions. Match the prescription to the patient’s baseline function and risk tier, and avoid unsupervised activities that exceed the patient’s safe mobility, swallowing, cardiopulmonary, cognitive, or communication capacity.
4. Adjust progression according to patient tolerance and observed performance. Increase duration, repetitions, task complexity, or walking distance only when the patient completes the current activity without unsafe fatigue, dizziness, pain aggravation, choking, falls, marked shortness of breath, or new neurological symptoms. Reduce or pause activity when warning signs occur.
5. Explain the caregiver’s role in supporting safe home rehabilitation. The caregiver should prepare a safe practice space, provide guarding or transfer assistance when needed, remind the patient to rest, observe warning symptoms, and stop the activity when the stopping rule is met. The caregiver should not force completion of prescribed activities when the patient is medically unwell or visibly unsafe.
6. Explain how completed rehabilitation activities should be recorded using simple dose units, such as minutes per session, number of sessions, repetitions, walking distance, or task completion count. Record the final prescription in the rehabilitation prescription form, provide one copy to the patient-caregiver dyad, and keep one copy in the SOP file.

9. Conduct post-discharge follow-up using the tier-linked schedule

1. Initiate the first post-discharge follow-up contact within 7 days after discharge. Use telephone, video call, outpatient review, or in-person review according to the dyad’s risk tier, access conditions, and clinical need.
2. During each follow-up contact, review the patient’s current functional status, completion of the home rehabilitation prescription, caregiver-reported performance, adherence barriers, safety signals, caregiver concerns, and need for plan adjustment.
3. Ask the caregiver how the prescribed activities were performed at home, including the level of assistance required, patient tolerance, rest breaks, symptoms during practice, and whether the activity became easier, unchanged, or more difficult.
4. Review the completed rehabilitation dose using the most appropriate unit for the prescribed activity, such as minutes, sessions, repetitions, walking distance, or task completion count. Identify missed or reduced sessions and clarify whether the cause was fatigue, pain, medical symptoms, caregiver unavailability, environmental barriers, poor understanding, or fear of injury.
5. Provide rehabilitation-focused coaching when minor barriers are identified. Clarify activity instructions, correct unsafe practice, adjust session timing, divide activities into shorter bouts, reinforce rest breaks, or remind the caregiver how to provide safe guarding and supervision within the nurse’s scope of practice.
   NOTE: Nurses did not independently modify medical treatment or advanced rehabilitation intensity beyond the SOP rules. When progression, deterioration, or safety concerns exceeded the nursing scope of practice, the dyad was referred to a rehabilitation therapist or the responsible clinician.
6. Refer the dyad to a rehabilitation therapist or responsible clinician when the patient shows functional deterioration, repeated inability to complete prescribed activities, unsafe transfer or walking practice, suspected aspiration, repeated falls, new neurological symptoms, uncontrolled pain, marked fatigue, or when further progression requires professional rehabilitation assessment.
7. Record each completed and missed contact briefly in the follow-up log. Include the contact date, modality, rehabilitation activities reviewed, adherence estimate, barriers identified, safety screening result, coaching or referral provided, and next planned contact.

10. Monitor safety signals and apply the escalation algorithm

1. Screen for safety signals during every follow-up contact. Ask about falls, aspiration or choking episodes, fever or infection signs, pressure injury, new or worsening neurological symptoms, seizure warning signs, severe headache, respiratory difficulty, medication-related problems, and emergency visits.
2. Classify each safety signal using the adverse-event and escalation definitions in Table 2. Record the event type, onset date, severity level, verification source, and current status.
3. Apply the escalation algorithm immediately when a trigger threshold is met. Assign one action level: nursing advice and monitoring, rapid clinic review within 48 h, same-day urgent referral or emergency evaluation, or interdisciplinary consultation.
4. Document the escalation episode in the escalation log. Include the trigger, action level, time of identification, time of action, receiving service, responsible staff member, and follow-up plan.
5. Close the loop after each escalation episode. Record whether the issue resolved, remained under monitoring, required a tier upgrade, required prescription modification, or led to medical referral.
6. Require clinical-lead review for any high-risk trigger without documented action. Complete the review within 72 h and record corrective action in the quality assurance log.

11. Re-tier the dyad during follow-up

1. Reassess the risk tier at each scheduled assessment point and whenever an interim safety trigger occurs. Use the same Red/Yellow/Green criteria used at baseline.
2. Upgrade the tier immediately when a Red-tier trigger appears during follow-up. Record the new trigger, date of change, revised follow-up intensity, and staff member responsible for the decision.
3. Maintain the current tier when risk status is unclear or when safety information is incomplete. Arrange reassessment before downgrading.
4. Downgrade the tier only when higher-tier triggers are absent and reassessment findings meet the lower-tier criteria. Record the evidence supporting the downgrade.
5. Update the follow-up schedule, rehabilitation prescription, and caregiver guidance after any tier change.

12. Coordinate interdisciplinary support when indicated

1. Refer the dyad to a rehabilitation therapist when exercise progression, movement correction, mobility training, or assistive-device adjustment exceeds nursing instruction.
2. Refer the patient to the responsible clinician when new neurological symptoms, suspected infection, uncontrolled pain, suspected aspiration, repeated falls, seizure warning signs, or medication-related concerns are reported.
3. Refer the caregiver for additional support when severe burden, emotional distress, inability to perform essential care tasks, or repeated failure of teach-back items is identified.
4. Record all interdisciplinary coordination in the follow-up form. Include the reason for referral, receiving discipline, date of referral, feedback received, and resulting SOP adjustment.

13. Conduct scheduled outcome and implementation assessments

1. Conduct scheduled assessments at T0, T1, T2, and T3 when the SOP is used in a prospective clinical application. Define T0 as 48–72 h before discharge or transition; T1 as 2 weeks post-discharge with a ±3-day window; T2 as 3 months post-discharge with a ±14-day window; and T3 as 6 months post-discharge with a ±14-day window.
2. Use the same assessment windows for the SOP and usual-care groups when a comparator group is included. Record the assessment date, modality, assessor identity, and completion status.
3. Record raw scores before deriving interpretation bands. Store raw values and derived categories under the same dyad ID and time point.
4. Use Table 1 as the single reference for scheduled instruments and score interpretation. Use Table 2 as the single reference for implementation fidelity, escalation documentation, and quality indicators.
5. Record missing assessment data using predefined reason categories. Use categories such as unable to contact, patient hospitalized, caregiver unavailable, refused assessment, death, transfer out of follow-up area, or other documented reason.
6. Keep SOP implementation indicators separate from clinical outcome indicators. Implementation indicators should include follow-up completion, teach-back pass status, dose documentation completeness, adherence recording, escalation documentation, and closed-loop resolution.
   NOTE: SOP records were periodically reviewed for documentation completeness, implementation fidelity, follow-up adherence, safety-event recording, and escalation tracking. Incomplete records and protocol deviations were corrected and documented according to institutional quality-control procedures. Finalized SOP records, follow-up forms, safety-event logs, and assessment forms were retained for the representative clinical analysis.

14. Maintain essential safety, rehabilitation-dose, and assessment records

1. Capture safety events throughout the post-discharge follow-up period using the adverse-event checklist and escalation definitions in Table 2.
2. For each safety signal, record the event type, onset date, severity level, action taken, verification source when available, current outcome, and next follow-up plan.
3. Review home rehabilitation exposure during follow-up. Record the prescribed and completed rehabilitation dose using the most appropriate unit, such as minutes per session, number of sessions, repetitions, walking distance, or task completion count.
4. Identify missed or incomplete rehabilitation sessions and document the main reason, such as fatigue, pain, medical symptoms, caregiver unavailability, poor understanding, environmental barriers, refusal, or hospitalization.
5. Use the same assessment instruments and time-point windows for the SOP and usual-care groups when representative clinical application data are collected. Assessors should follow the standardized scoring instructions listed in Table 1.
6. Record incomplete assessments using predefined reason categories, such as unable to contact, patient hospitalized, caregiver unavailable, refused assessment, death, transfer out of the follow-up area, or other documented reason.
   NOTE: Missing values were not replaced during data entry. The original missing-data code and reason were preserved for later representative analysis.

15. Summarize representative clinical application data

1. Summarize the representative clinical application after the follow-up forms, safety-event records, rehabilitation-dose records, and assessment forms have been reviewed.
2. Report participant flow, baseline comparability, follow-up completion, home rehabilitation adherence, safety-event recognition, and referral or escalation when needed.
3. Present clinical outcomes as representative results of SOP application rather than as definitive evidence of universal effectiveness. Include functional recovery, caregiver burden, safety signals, and rehabilitation-support indicators when available.
4. When comparing SOP and usual-care groups, report effect estimates with confidence intervals. Clearly state that the clinical application was prospective, controlled, and non-randomized.
5. Acknowledge that the non-randomized allocation, single-center setting, and higher follow-up intensity in the SOP group may introduce selection bias, limited generalizability, and performance bias.
6. Interpret the representative results in relation to rehabilitation continuity, caregiver-supported home training, adherence to prescribed rehabilitation activities, safety-event recognition, and timely referral when needed.

Results

Participant flow and baseline feasibility
A total of 121 patient-caregiver dyads were included in the representative clinical application, including 60 dyads in the nursing-centered SOP group and 61 dyads in the usual-care comparator group. Figure 1 summarizes eligibility assessment, exclusions, enrollment, baseline Red/Yellow/Green risk stratification, group assignment, follow-up completion, and analysis-set construction.

Baseline assessment was completed for all enrolled dyads before discharge or transition into the rehabilitation phase. Patient and caregiver baseline characteristics were broadly comparable between groups (Table 3 and Table 4). Baseline Barthel Index scores were 44.8 ± 17.6 in the SOP group and 45.6 ± 16.9 in the usual-care group. Baseline caregiver burden scores were 34.7 ± 12.6 and 35.4 ± 12.1, respectively. Because this was a prospective controlled but non-randomized clinical application, baseline comparability should be interpreted descriptively and does not eliminate the possibility of selection bias.

Follow-up completion and functional trajectory
Follow-up assessments were conducted at T1, T2, and T3 using the same assessment windows in both groups. Barthel Index completion in the SOP and usual-care groups was 57/60 and 58/61 at T1, 55/60 and 56/61 at T2, and 52/60 and 53/61 at T3, respectively. These completion rates indicate that the follow-up schedule was feasible over the 6-month post-discharge period.

Functional recovery is shown in Figure 3. Figure 3A displays individual Barthel Index trajectories, Figure 3B shows group-level mean trajectories, and Figure 3C shows the distribution of change from baseline to 6 months. Mean Barthel Index increased from 44.8 ± 17.6 to 81.6 ± 16.2 in the SOP group and from 45.6 ± 16.9 to 74.2 ± 16.8 in the usual-care group. These findings illustrate how functional recovery can be monitored after SOP implementation, rather than serving as stand-alone proof of treatment efficacy.

Multidomain outcome monitoring
Figure 4 summarizes patient, caregiver, safety, and implementation domains. Figure 4A provides a standardized radar display, Figure 4B presents standardized effect estimates by domain, and Figure 4C shows standardized change magnitudes by domain group. At T3, EQ-5D-5L utility index was 0.74 ± 0.16 in the SOP group and 0.68 ± 0.17 in the usual-care group. Caregiver burden measured by the ZBI-22 was 27.8 ± 12.0 and 31.9 ± 12.6, respectively.

These findings show that the SOP can capture both patient recovery and caregiver burden within the same transitional-care pathway. A favorable result pattern is suggested when multidomain improvement occurs together with completed risk tiering, caregiver teach-back verification, timely follow-up, adequate dose documentation, and closed-loop escalation records. A suboptimal pattern is suggested when outcome improvement is limited and accompanied by missed contacts, incomplete dose records, unresolved safety triggers, or delayed escalation.

SOP implementation fidelity and dose documentation
Implementation exposure was summarized in the SOP group (Table 8 and Figure 5). Figure 5A shows total coaching dose by participant, Figure 5B summarizes implementation fidelity components, and Figure 5C displays the exploratory relationship between coaching dose and functional gain.

The median number of delivered follow-up contacts was 9, compared with a median of 10 planned contacts. Tier-specific follow-up intensity met the predefined fidelity threshold in 49/60 dyads, and dose documentation completeness met the threshold in 50/60 dyads. Median home rehabilitation adherence was 82%. Structured follow-up script fidelity was 456/525 contacts, and documentation timeliness was 472/525 contacts.

Successful SOP implementation is indicated by first contact within 7 days, documented teach-back pass status, dose-documentation completeness of at least 80%, timely contact-note entry, and closed-loop escalation documentation. Repeated missed contacts, missing teach-back results, incomplete dose records, or delayed escalation documentation indicate suboptimal implementation.

Safety-event capture and escalation performance
Safety-event capture and escalation performance are shown in Figure 6 and Table 9. Figure 6A summarizes safety-event categories, Figure 6B shows escalation dispositions, and Figure 6C displays the cumulative incidence of first safety or escalation event over 0–180 days.

At least one adverse event was recorded in 28/60 participants in the SOP group and 35/61 participants in the usual-care group. Falls were recorded in 12/60 versus 17/61 participants, suspected aspiration episodes in 7/60 versus 10/61, and new or worsened pressure injury in 5/60 versus 8/61. Any emergency department visit occurred in 9/60 versus 15/61 participants.

Among 38 trigger events identified through SOP safety screening, 35/38 had a documented action category and timing record. For the remaining three trigger events, clinical-lead review within 72 h was documented. This finding supports closed-loop escalation documentation as a practical quality indicator for the SOP.

Exploratory subgroup display
Figure 7 provides an exploratory display of whether SOP-related functional gain varied across prespecified baseline strata. Figure 7A shows subgroup-specific estimates for change in Barthel Index from baseline to 6 months, and Figure 7B summarizes standardized benefit patterns across outcome domains. These subgroup findings are descriptive and should not be interpreted as confirmatory effect-modification evidence because the clinical application was single-center and non-randomized.

Figure 1: Participant flow for the representative clinical application. Flow diagram showing screening, eligibility assessment, enrollment of 121 patient-caregiver dyads, baseline Red/Yellow/Green nursing risk stratification, non-randomized group assignment, scheduled follow-up at T1, T2, and T3, and representative analysis-set construction. Please click here to view a larger version of this figure.

Figure 2: Nursing-centered transitional neurorehabilitation SOP pathway. Workflow showing baseline nursing assessment, Red/Yellow/Green risk stratification, discharge SOP bundle preparation, caregiver teach-back training, tier-linked post-discharge follow-up, safety surveillance, escalation management, dynamic re-tiering, interdisciplinary coordination, and fidelity audit. Please click here to view a larger version of this figure.

Figure 3: Representative functional recovery trajectories. (A) Individual Barthel Index trajectories across T0–T3. (B) Group mean Barthel Index trajectories with uncertainty estimates. (C) Distribution of Barthel Index change from baseline to 6 months. Please click here to view a larger version of this figure.

Figure 4: Multidomain representative outcome summary. (A) Standardized domain profile for patient, caregiver, safety, and implementation outcomes. (B) Standardized effect estimates by outcome domain. (C) Standardized change magnitude by domain group with visible x-axis scale. Please click here to view a larger version of this figure.

Figure 5: SOP implementation fidelity and dose documentation. (A) Total coaching dose by participant in the SOP group. (B) Fidelity indicators across core SOP components. (C) Exploratory association between total coaching dose and Barthel Index change from baseline to 6 months. Please click here to view a larger version of this figure.

Figure 6: Safety-event capture and escalation pathway performance. (A) Safety-event categories by group. (B) Escalation dispositions by group. (C) Cumulative incidence of first safety or escalation event over the 0–180 day follow-up period. Please click here to view a larger version of this figure.

Figure 7: Exploratory subgroup display. (A) Subgroup-specific estimates for Barthel Index change from baseline to 6 months. (B) Standardized benefit patterns across outcome domains and subgroup levels. Findings are descriptive and not confirmatory. Please click here to view a larger version of this figure.

TABLE 1: Standardized assessment battery and scoring rules for the nursing-centered SOP. This table lists the patient and caregiver assessment instruments used in the SOP, including score ranges, interpretation direction, threshold bands, scheduled time points, and clinically indicated repeat assessments. Please click here to download this Table.

TABLE 2: SOP implementation fidelity and quality indicators. This table defines the operational indicators used to monitor SOP delivery, including fidelity definitions, thresholds, data sources, measurement windows, audit rules, and escalation documentation requirements. Please click here to download this Table.

TABLE 3: Baseline demographic and clinical characteristics of patients. Patient demographics, index neurological condition, comorbidities, functional status, cognition, psychological symptoms, nursing risk screening results, discharge destination, and medication structure are summarized by group. Values are reported as mean (SD), median (IQR), or n (%) as appropriate. Please click here to download this Table.

TABLE 4: Baseline caregiver and care-context characteristics. Caregiver demographics, relationship to the patient, living context, caregiving intensity, digital access, health status, psychological symptoms, caregiver burden, perceived support, and household context are summarized by group. Values are reported as mean (SD), median (IQR), or n (%) as appropriate. Please click here to download this Table.

TABLE 5: Representative patient, caregiver, safety, and implementation outcomes used to monitor SOP application. This table lists the outcomes used to monitor the representative clinical application of the SOP, including assessment target, measurement tool, interpretation direction, data source, and scheduled assessment time points. Please click here to download this Table.

TABLE 6: Barthel Index trajectory and change from baseline. Barthel Index values at T0, T1, T2, and T3 and change from baseline to 6 months are summarized by group. Values are reported as mean (SD), with follow-up completion counts provided for each scheduled assessment point. Please click here to download this Table.

TABLE 7: Representative secondary outcomes during follow-up. Patient quality of life, psychological symptoms, cognition, caregiver burden, caregiver psychological symptoms, and selected nursing risk indicators are summarized at scheduled follow-up time points. Continuous outcomes are reported as mean (SD) with between-group estimates where applicable; binary outcomes are reported as n/N (%). Please click here to download this Table.

TABLE 8: SOP implementation exposure and fidelity indicators. Implementation exposure and fidelity indicators are summarized for the SOP group using predefined operational definitions and thresholds. Indicators include delivered follow-up contacts, follow-up intensity fidelity, dose documentation completeness, adherence recording, structured script completion, documentation timeliness, and escalation documentation. Please click here to download this Table.

TABLE 9: Safety events and escalation actions during 6-month follow-up. Safety events, safety signals, health service use, escalation dispositions, serious adverse events, and hospitalization days are summarized by group over the 6-month follow-up period using predefined event categories and verification rules. Please click here to download this Table.

Discussion

This article presents a nursing-centered standardized operating procedure for transitional neurorehabilitation after discharge in adult patients recovering from stroke or traumatic brain injury. Similar transitional rehabilitation programs have emphasized the need to maintain functional support after discharge¹⁵, but the present protocol focuses on translating this need into a stepwise nursing workflow that can be delivered, documented, audited, and modified according to patient-caregiver risk. Its core components are pre-discharge nursing assessment, Red/Yellow/Green risk stratification, caregiver teach-back verification, individualized home rehabilitation planning, tier-linked follow-up, safety-event screening, escalation management, and implementation fidelity review. The representative clinical application shows how these components can be organized across a 6-month discharge-to-home period, but the main value of the article lies in the reproducible SOP rather than in presenting definitive treatment-effect evidence.

Several steps are critical for successful implementation. The first is completion of the baseline nursing assessment before discharge, because later risk-tier assignment and follow-up intensity depend on the accuracy of this assessment. Functional status, caregiver burden, pressure injury risk, fall risk, swallowing or aspiration risk, and contact feasibility should be recorded before the patient leaves the hospital. The second critical step is caregiver teach-back verification, since caregiver-focused interventions after acquired brain injury have shown that family members need structured support rather than passive instruction alone¹⁶. In this SOP, a caregiver should not be considered trained until critical safety items have been demonstrated correctly.

The third critical step is the first post-discharge contact. This contact should occur within 7 days after discharge because early home barriers often emerge before the first scheduled outpatient review. During this contact, the nurse should confirm the patient’s current status, review home rehabilitation completion, identify barriers, screen for safety signals, and update the follow-up plan within the scope of the SOP. The fourth critical step is closed-loop escalation. Discharge planning studies in stroke care suggest that post-discharge safety depends not only on education but also on timely identification and response to risks such as swallowing-related complications¹⁷. For this reason, each trigger in the SOP should be linked to an action level, responsible staff member, time of action, follow-up plan, and resolution status.

Common implementation problems should be anticipated. If a caregiver fails the teach-back checklist, the nurse should repeat only the failed components, re-test within 24–48 h when discharge timing allows, and notify the clinical lead if critical safety items remain incomplete. If follow-up contact is missed, the team should use the backup contact route, document the attempt, and reschedule within the allowed window. Evidence from caregiver intervention trials after acquired brain injury indicates that continuity and structured support are central to maintaining care quality over time¹⁸; therefore, incomplete rehabilitation-dose records should prompt the nurse to clarify the recording method, simplify the dose unit when appropriate, and determine whether the problem reflects poor understanding, patient fatigue, caregiver time constraints, or medical deterioration. If a safety trigger is identified without documented action, clinical-lead review should be completed within 72 h and the escalation log should be corrected through the audit trail.

The protocol can be modified for different clinical settings while preserving its core structure. In resource-limited hospitals, the number of follow-up contacts may be reduced, but baseline risk stratification, caregiver teach-back verification, safety-trigger definitions, and closed-loop escalation should be retained. Blended-care models for caregivers of patients with acquired brain injury show that support can be adapted across delivery modes while maintaining structured follow-up logic¹⁹. In settings where video follow-up is unavailable, telephone follow-up may therefore be used, provided that caregiver reports, dose records, and warning-signal screening are documented consistently. In community-based settings, rehabilitation therapists or primary care nurses may assume part of the follow-up role, but role boundaries and escalation pathways should be defined before implementation.

Compared with conventional discharge education, this SOP provides a more structured and auditable approach. Standard discharge education often depends on one-time verbal instruction and may not verify caregiver competence. Nurse-led telerehabilitation models have highlighted the practical value of structured remote contact after discharge²⁰, but unstructured telephone follow-up may still fail to document rehabilitation dose, barriers, safety triggers, or escalation closure. By contrast, the present SOP links baseline risk to follow-up intensity, requires teach-back verification, records home rehabilitation adherence, and uses predefined escalation rules. These elements make the pathway more reproducible for nursing teams and more transparent for quality review.

The representative clinical application suggested that the SOP could be delivered with acceptable follow-up completion, dose documentation, safety-event capture, and escalation closure. However, these findings should be interpreted cautiously. The clinical application was prospective and controlled but non-randomized, so selection bias cannot be excluded. The study was conducted in a single center, which limits generalizability to other hospitals, regions, staffing models, and patient populations. The SOP group also received more structured contact and documentation than the usual-care comparator, which may introduce performance bias. For this reason, the observed clinical outcome patterns should be understood as representative application findings rather than confirmatory evidence of universal effectiveness.

Resource requirements also need consideration before broader adoption. Nurse-led bundle-care studies in stroke show that standardized nursing processes require coordination, staff training, and sustained implementation capacity²¹. In the present SOP, this means nurse training, standardized forms, follow-up time, caregiver teaching space, documentation review, and a defined escalation pathway with access to clinicians or rehabilitation therapists. These requirements may be manageable in hospitals with established rehabilitation nursing teams but may be more difficult in settings with limited staffing or weak post-discharge infrastructure. Future work should evaluate workload, cost-effectiveness, staff acceptability, patient and caregiver usability, and multicenter adaptability. Further studies using randomized or cluster-randomized designs would help clarify the clinical effectiveness of the SOP beyond feasibility and representative implementation.

In summary, this nursing-centered SOP provides a reproducible workflow for transitional neurorehabilitation after discharge. Its most important methodological features are risk-tiered follow-up, caregiver teach-back verification, standardized dose and safety documentation, dynamic re-tiering, and closed-loop escalation. When implemented carefully, the protocol can help nursing teams convert fragmented post-discharge rehabilitation support into a structured, traceable, and adaptable care pathway.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Adverse-event checklist	Study team / institution-developed SOP document	Local SOP checklist	Used to capture falls, suspected aspiration, pressure injury, infection signs, neurological warning signs, emergency visits, readmissions, and other safety signals.
Assessor training and calibration log	Study team / institution-developed SOP document	Local training log	Used to record assessor training completion, paired scoring checks, discrepancy resolution, retraining actions, and assessor authorization status.
Automatic upper-arm blood pressure monitor	OMRON Healthcare or equivalent validated supplier	HEM-7120 / HEM-7121	Used to measure blood pressure and pulse during in-person assessment or home-monitoring review when vital-sign monitoring is clinically required.
Barthel Index assessment form	Institution-approved clinical assessment form / official scale source	Local approved form	Used to assess activities of daily living and functional independence at T0, T1, T2, and T3. Record the raw score before deriving severity bands.
Caregiver teach-back checklist	Study team / institution-developed SOP document	Local SOP checklist	Used before discharge to verify caregiver competency. Include required skills, critical safety items, pass/fail status, retraining items, and final competency decision.
Case report form / clinical application CRF	Study team / institution-developed SOP document	Local CRF	Used to capture baseline variables, scheduled assessment scores, follow-up completion, missing-data reasons, safety events, and implementation indicators.
Disposable examination gloves	Kimberly-Clark / Halyard or equivalent hospital-approved supplier	Kimtech Purple Nitrile 55082	Used during hands-on caregiver training, transfer demonstration, skin inspection demonstration, and infection-control procedures.
Electronic clinical thermometer	Welch Allyn / Hillrom or equivalent medical supplier	SureTemp Plus 690	Used to screen body temperature when fever, infection signs, or clinical deterioration are reported.
Electronic data capture database or password-protected spreadsheet	Institution-approved data-management system	Local EDC or password-protected database	Used to store de-identified protocol data, follow-up completion records, fidelity indicators, safety-event records, and missing-data codes.
Electronic medical record system	Hospital information system	Local EMR system	Used to verify diagnosis, discharge information, comorbidities, medication instructions, safety events, emergency visits, readmissions, and escalation outcomes.
Emergency contact card	Study team / institution-developed SOP document	Local contact card	Given at discharge. Include routine contact route, urgent escalation route, responsible department, and emergency service instructions according to local practice.
EQ-5D-5L questionnaire	EuroQol Research Foundation / institution-approved version	EQ-5D-5L licensed version	Used to assess health-related quality of life. Use the approved language version and follow permission requirements.
Escalation log	Study team / institution-developed SOP document	Local SOP log	Used to document trigger condition, action level, action time, receiving service, responsible staff member, outcome, follow-up plan, and closed-loop resolution status.
Fingertip pulse oximeter	Nonin Medical or equivalent validated supplier	Onyx Vantage 9590	Used to assess oxygen saturation and pulse rate when dyspnea, suspected aspiration, fatigue, or respiratory warning signs are reported during follow-up.
Gait belt	Dynarex or equivalent medical supplier	4352	Used for caregiver teach-back training in assisted standing, transfer support, and short-distance mobility practice. Use according to institutional fall-prevention and manual-handling policy.
Home rehabilitation prescription form	Study team / institution-developed SOP document	Local SOP form	Used to record rehabilitation goals, activity type, frequency, minutes per session, progression rules, stopping rules, safety precautions, and caregiver recording method.
Hospital Anxiety and Depression Scale	Authorized scale source / institution-approved version	HADS	Used to assess anxiety and depression symptoms in patients and caregivers when included in the assessment battery.
Medical penlight	Institution-approved medical supplier	Institution-approved reusable or disposable penlight	Used during caregiver education for visual inspection of skin redness, pressure areas, and other visible warning signs.
Montreal Cognitive Assessment	MoCA Cognition / institution-approved version	Official MoCA version	Used to assess cognitive status when included in the assessment battery. Follow official administration and scoring requirements.
Patient/caregiver rehabilitation diary	Study team / institution-developed SOP document	Local diary template	Used by the caregiver to record home rehabilitation completion, missed sessions, symptoms, safety concerns, and questions for follow-up.
Printed patient and caregiver instruction sheet	Study team / institution-developed SOP document	Local discharge instruction sheet	Given at discharge. Include home rehabilitation schedule, safety precautions, warning symptoms, contact pathway, and instructions for urgent medical review.
Rehabilitation dose and adherence log	Study team / institution-developed SOP document	Local SOP log	Used to record prescribed dose, completed dose, missed sessions, reasons for missed sessions, adherence percentage, and date of nurse review.
Secure telephone or hospital call system	Hospital or institution-approved communication system	Local approved system	Used for scheduled and unscheduled follow-up contacts. Record call date, duration, respondent, staff member, and follow-up script completion.
Secure video-call platform	Hospital or institution-approved telehealth platform	Local approved platform	Used when visual demonstration, movement correction, caregiver return demonstration, or skin inspection review is needed. Use only platforms approved by the institution for patient communication.
Signature, Date, and Planned Follow-up Intensity	Study team / institution-developed SOP document	Local form	To record signature, date, and planned follow-up intensity.
SOP fidelity audit checklist	Study team / institution-developed SOP document	Local SOP checklist	Used to audit baseline tiering, teach-back completion, follow-up completion, dose documentation, documentation timeliness, protocol deviations, and escalation closure.
Statistical software	R Foundation for Statistical Computing	R version 4.3.2	Used for representative clinical application summaries, figures, and reproducibility documentation. Archive scripts and session information with the final dataset.
Structured follow-up script	Study team / institution-developed SOP document	Local SOP script	Used for scheduled and unscheduled post-discharge follow-up. Include patient status, adherence, barriers, safety signals, caregiver concerns, coaching action, and next contact plan.
Surface disinfectant wipes	Metrex or equivalent hospital-approved disinfectant supplier	CaviWipes / CaviWipes1	Used to clean reusable training equipment and non-porous surfaces between patient or caregiver demonstrations according to institutional infection-control policy.
Transfer board / slide board	Drive Medical or equivalent medical supplier	RTL6045	Used when bed-to-chair or wheelchair transfer demonstration is clinically indicated. Include only for patients whose home rehabilitation prescription requires transfer assistance training.
Zarit Burden Interview, 22-item version	Authorized scale source / institution-approved version	ZBI-22	Used to assess caregiver burden at scheduled assessment points. Use an authorized version according to applicable permission requirements.