When to Discharge a Patient with Hemorrhagic Stroke
Patients with hemorrhagic stroke should be discharged when they are medically stable, have completed initial rehabilitation assessment, demonstrate no ongoing neurological deterioration for at least 24 hours, have adequate blood pressure control, and have appropriate discharge destination arrangements with multidisciplinary rehabilitation services in place.
Initial Stabilization Period Required Before Discharge Consideration
Patients must remain in intensive care or dedicated stroke unit for at least the first 24 hours with hourly neurological assessments using validated scales (NIHSS or Glasgow Coma Scale), as over 20% of hemorrhagic stroke patients deteriorate within the first few hours 1, 2, 3.
Blood pressure must be stabilized and maintained at target levels (typically systolic BP 140-160 mmHg) for at least 24 hours without ongoing titration of intravenous antihypertensive medications 1, 3.
Hematoma stability must be confirmed on repeat neuroimaging, typically performed at 24 hours, demonstrating no expansion or new hemorrhage 1, 2.
Medical Stability Criteria That Must Be Met
Neurological examination must show no deterioration for at least 24 hours, with stable or improving scores on validated neurological scales 1, 3.
Coagulopathy must be fully reversed if present, with INR normalized in warfarin-treated patients and platelet counts adequate 1, 2, 3.
Intracranial pressure must be controlled without need for ongoing osmotherapy or other acute interventions 1, 2, 3.
Seizures, if present, must be controlled on oral anticonvulsant regimen without recurrence 1, 2, 3.
Temperature should be normalized (36-37°C) without active fever requiring ongoing intervention 1.
Functional Assessment and Rehabilitation Planning Required
Multidisciplinary rehabilitation assessment must be completed, including evaluation by physical therapy, occupational therapy, and speech-language pathology to determine residual deficits and rehabilitation needs 1.
Formal dysphagia screening must be performed and passed before oral intake, or alternative feeding route established 2, 3.
Determination of appropriate discharge destination (home with services, inpatient rehabilitation facility, skilled nursing facility) based on functional status, cognitive abilities, family support, and caregiver capacity 1.
Discharge Destination and Timing Considerations
For patients with mild to moderate disability (modified Rankin Scale ≤3), early supported discharge to home with intensive home rehabilitation services is beneficial and should occur as soon as medically stable, typically increasing likelihood of independent living at 3 months 1, 4.
Patients requiring intensive rehabilitation should be transferred to inpatient rehabilitation facilities when medically stable, typically after 24-48 hours of stability 1.
Very early mobilization within the first 24 hours is associated with worse outcomes and should be avoided; rehabilitation should begin 24-48 hours after onset once stability is confirmed 1.
Essential Discharge Planning Elements
Secondary stroke prevention measures must be initiated before discharge, including blood pressure management with oral antihypertensive medications achieving target BP, and addressing modifiable risk factors 1.
Comprehensive discharge education must be provided to patients and caregivers covering: stroke warning signs, medication management, blood pressure monitoring, activity restrictions, fall prevention, skin care, nutrition/dysphagia precautions, and emergency contact information 1.
Follow-up appointments must be scheduled with neurology/stroke specialist within 1-2 weeks and primary care within 1 week of discharge 1.
Venous thromboembolism prophylaxis plan must be established, with continuation of pharmacological prophylaxis or intermittent pneumatic compression as appropriate for immobile patients 1, 3.
Critical Contraindications to Discharge
Ongoing neurological deterioration or fluctuating examination mandates continued inpatient monitoring regardless of other factors 1, 2, 3.
Uncontrolled blood pressure requiring intravenous medications or frequent titration 1, 3.
Signs of increased intracranial pressure requiring active management 1, 2, 3.
Inadequate social support or unsafe home environment for patients with functional deficits 1.
Inability to establish safe oral intake or alternative feeding route 2, 3.
Common Pitfalls to Avoid
Do not discharge patients within the first 24 hours even if they appear stable, as early deterioration is common and unpredictable in hemorrhagic stroke 1, 2, 3.
Avoid discharging patients before completing comprehensive rehabilitation assessment and establishing appropriate outpatient or facility-based rehabilitation services 1.
Do not discharge without confirming adequate caregiver education and support for patients with functional deficits 1.
Ensure blood pressure is controlled on oral medications for at least 24 hours before discharge, not just controlled with intravenous agents 1, 3.