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 man....

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 require....

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 .......

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. It.......

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.