The organisational context of nursing care in stroke units: A case study approach

Background Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. Design A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Findings Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

What aspects of rehabilitation provision contribute to self-reported met needs for rehabilitation one year after stroke - amount, place, operator or timing?

BACKGROUND AND OBJECTIVE: To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self-reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke. METHODS: The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self-reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home-based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset. RESULTS: Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd-4th quarters of the first year (OR 8.36, CI 1.40-49.88 P = 0.020) were more likely to report met rehabilitation needs. CONCLUSION: For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self-reported met needs for rehabilitation.

Unfulfilled rehabilitation needs and dissatisfaction with care 12 months after a stroke : an explorative observational study

BACKGROUND: People who have suffered a stroke commonly report unfulfilled need for rehabilitation. Using a model of patient satisfaction, we examined characteristics in individuals that at 3 months after stroke predicted, or at 12 months were associated with unmet need for rehabilitation or dissatisfaction with health care services at 12 months after stroke. METHODS: The participants (n = 175) received care at the stroke units at the Karolinska University Hospital, Sweden. The dependent variables "unfulfilled needs for rehabilitation" and "dissatisfaction with care" were collected using a questionnaire. Stroke severity, domains of the Stroke Impact Scale (SIS), the Sense of Coherence scale (SOC) and socio demographic factors were used as independent variables in four logistic regression analyses. RESULTS: Unfulfilled needs for rehabilitation at 12 months were predicted by strength (SIS) (odds ratio (OR) 7.05) at three months, and associated with hand function (SIS) (OR 4.38) and poor self-rated recovery (SIS) (OR 2.46) at 12 months. Dissatisfaction with care was predicted by SOC (OR 4.18) and participation (SIS) (OR 3.78), and associated with SOC (OR 3.63) and strength (SIS) (OR 3.08). CONCLUSIONS: Thirty-three percent of the participants reported unmet needs for rehabilitation and fourteen percent were dissatisfied with the care received. In order to attend to rehabilitation needs when they arise, rehabilitation services may need to be more flexible in terms of when rehabilitation is provided. Long term services with scheduled re-assessments and with more emphasis on understanding the experiences of both the patients and their social networks might better be able to provide services that attend to patients' needs and aid peoples' reorientation; this would apply particularly to those with poor coping capacity.

Comparison of intraarterial and intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign

BACKGROUND AND PURPOSE: It is unclear whether intraarterial (IAT) or intravenous (IVT) thrombolysis is more effective for ischemic stroke with hyperdense middle cerebral artery sign (HMCAS) on computed tomography (CT). The aim of this study was to compare IAT and IVT in stroke patients with HMCAS. METHODS: Comparison of data from 2 stroke units with similar management of stroke associated with HMCAS, except that 1 unit performed IAT with urokinase and the other IVT with plasminogen activator. Time to treatment was up to 6 hours for IAT and up to 3 hours for IVT. Outcome was measured by mortality and the modified Rankin Scale (mRS), dichotomized at 3 months into favorable (mRS 0 to 2) and unfavorable (mRS 3 to 6). RESULTS: One hundred twelve patients exhibited a HMCAS, 55 of 268 patients treated with IAT and 57 of 249 patients who underwent IVT. Stroke severity at baseline and patient age were similar in both groups. Mean time to treatment was longer in the IAT group (244+/-63 minutes) than in the IVT group (156+/-21 minutes; P=0.0001). However, favorable outcome was more frequent after IAT (n=29, 53%) than after IVT (n=13, 23%; P=0.001), and mortality was lower after IAT (n=4, 7%) than after IVT (n=13, 23%; P=0.022). After multiple regression analysis IAT was associated with a more favorable outcome than IVT (P=0.003) but similar mortality (P=0.192). CONCLUSIONS: In this observational study intraarterial thrombolysis was more beneficial than IVT in the specific group of stroke patients presenting with HMCAS on CT, even though IAT was started later. Our results indicate that a randomized trial comparing both thrombolytic treatments in patients with middle cerebral artery occlusion is warranted.

Beneficial Effects of a Semi-Intensive Stroke Unit are Beyond the Monitor.

BACKGROUND AND PURPOSE Precise mechanisms underlying the effectiveness of the stroke unit (SU) are not fully established. Studies that compare monitored stroke units (semi-intensive type, SI-SU) versus an intensive care unit (ICU)-based mobile stroke team (MST-ICU) are lacking. Although inequalities in access to stroke unit care are globally improving, acute stroke patients may be admitted to Intensive Care Units for monitoring and followed by a mobile stroke team in hospital's lacking an SU with continuous cardiovascular monitoring. We aimed at comparing the stroke outcome between SI-SU and MST-ICU and hypothesized that the benefits of SI-SU are driven by additional elements other than cardiovascular monitoring, which is equally offered in both care systems. METHODS In a single-center setting, we compared the unfavorable outcomes (dependency and mortality) at 3 months in consecutive patients with ischemic stroke or spontaneous intracerebral hemorrhage admitted to a stroke unit with semi-intensive monitoring (SI-SU) to a cohort of stroke patients hospitalized in an ICU and followed by a mobile stroke team (MST-ICU) during an equal observation period of 27 months. Secondary objectives included comparing mortality and the proportion of patients with excellent outcomes (modified Rankin Score (mRS) 0-1). Equal cardiovascular monitoring was offered in patients admitted in both SI-SU and MST-ICU. RESULTS 458 patients were treated in the SI-SU and compared to the MST-ICU (n = 370) cohort. The proportion of death and dependency after 3 months was significantly improved for patients in the SI-SU compared to MST-ICU (p < 0.001; aOR = 0.45; 95% CI: 0.31-0.65). The shift analysis of the mRS distribution showed significant shift to the lower mRS in the SI-SU group, p < 0.001. The proportion of mortality in patients after 3 months also differed between the MST-ICU and the SI-SU (p < 0.05), but after adjusting for confounders this association was not significant (aOR = 0.59; 95% CI: 0.31-1.13). The proportion of patients with excellent outcome was higher in the SI-SU (59.4 vs. 44.9%, p < 0.001) but the relationship was no more significant after adjustment (aOR = 1.17; 95% CI: 0.87-1.5). CONCLUSIONS Our study shows that moving from a stroke team in a monitored setting (ICU) to an organized stroke unit leads to a significant reduction in the 3 months unfavorable outcome in patients with an acute ischemic or hemorrhagic stroke. Cardiovascular monitoring is indispensable, but benefits of a semi-intensive Stroke Unit are driven by additional elements beyond intensive cardiovascular monitoring. This observation supports the ongoing development of Stroke Centers for efficient stroke care. © 2015 S. Karger AG, Basel.

Stroke Unit Management and Revascularisation in Acute Ischemic Stroke

Background: Stroke affects one in six people throughout their lifetimes and is the most frequent cause of disability in adults. Several recanalization therapies have emerged and the management of patients in stroke units has improved over the last decades. Summary: This article examines the current treatment options for stroke patients, summarizing the key clinical evidence, as well as listing the complications and practical issues related to each of these main treatment options. Key Messages: Recent advances in the treatment of acute stroke include developments in intravenous thrombolysis (IVT), intra-arterial treatment and bridging therapies. Clinical Implications: Treatment within a stroke unit reduces mortality and disability regardless of age, sex and stroke severity. IVT is widely available and reduces disability when initiated within 4.5 h after the onset of symptoms. The major limitations of IVT are the low recanalization rates and the narrow time frame. Intra-arterial treatment, especially when using newly developed stent-retrievers, achieves very high recanalization rates. It is restricted by its limited availability and by the longer time span required to initiate therapy. Bridging both therapies is a promising approach that combines the advantages of both therapies, but the superiority of this approach remains to be proven. Future strategies to reduce the burden of acute stroke in Europe should focus on immediate access to acute stroke care and dedicated stroke units for all patients.

Effects of care pathways on stroke care practices at regional hospitals

Background: Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals. Methods: The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies. Results: Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti-thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003). Conclusion: Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination.

Resigning: a classic grounded theory of working within constraints when caring for stroke patients in the acute general care setting

This research aims to explore the challenges nurses face, when caring for stroke patients on a general medical/surgical ward, in the acute care setting and identify how nurses resolve or process this challenge. Healthcare environments continue to face the pressures of constraints such as reduced staffing levels, budgets, resources and less time, which influence care provision. Patient safety is central in care provision where nurses face the challenge of delivering best quality care when working within constraints. The incidence of stroke is increasing worldwide and internationally stroke units are the recognised minimum standard of care. In Ireland with few designated stroke units in operation many stroke patients are cared for in the acute general care setting. A classic grounded theory methodology was utilised for this study. Data was collected and analysed simultaneously through coding, constant comparison, theoretical sampling and memoing. Individual unstructured interviews with thirty two nurses were carried out. Twenty hours of non-participant observations in the acute general care setting were undertaken. The main concern that emerged was working within constraints. This concern is processed by nurses through resigning which consists of three phases; idealistic striving, resourcing and care accommodation. Through the process of resigning nurses engage in an energy maintenance process enabling them to continue working within constraints. The generation of the theory of resigning explains how nurses’ resolve or process working within constraints. This theory adds to the body of knowledge on stroke care provision. This theory has the potential to enhance nursing care, minimise burnout and make better use of resources while advocating for best care of stroke patients.

Using an end-of-life care pathway in acute stroke: a mixed methods study of decision-making and care experiences

Background: The evidence base on end-of-life care in acute stroke is limited, particularly with regard to recognising dying and related decision-making. There is also limited evidence to support the use of end-of-life care pathways (standardised care plans) for patients who are dying after stroke. Aim: This study aimed to explore the clinical decision-making involved in placing patients on an end-of-life care pathway, evaluate predictors of care pathway use, and investigate the role of families in decision-making. The study also aimed to examine experiences of end-of-life care pathway use for stroke patients, their relatives and the multi-disciplinary health care team. Methods: A mixed methods design was adopted. Data were collected in four Scottish acute stroke units. Case-notes were identified prospectively from 100 consecutive stroke deaths and reviewed. Multivariate analysis was performed on case-note data. Semi-structured interviews were conducted with 17 relatives of stroke decedents and 23 healthcare professionals, using a modified grounded theory approach to collect and analyse data. The VOICES survey tool was also administered to the bereaved relatives and data were analysed using descriptive statistics and thematic analysis of free-text responses. Results: Relatives often played an important role in influencing aspects of end-of-life care, including decisions to use an end-of-life care pathway. Some relatives experienced enduring distress with their perceived responsibility for care decisions. Relatives felt unprepared for and were distressed by prolonged dying processes, which were often associated with severe dysphagia. Pro-active information-giving by staff was reported as supportive by relatives. Healthcare professionals generally avoided discussing place of care with families. Decisions to use an end-of-life care pathway were not predicted by patients’ demographic characteristics; decisions were generally made in consultation with families and the extended health care team, and were made within regular working hours. Conclusion: Distressing stroke-related issues were more prominent in participants’ accounts than concerns with the end-of-life care pathway used. Relatives sometimes perceived themselves as responsible for important clinical decisions. Witnessing prolonged dying processes was difficult for healthcare professionals and families, particularly in relation to the management of persistent major swallowing difficulties.

Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden

BACKGROUND: With a pending need to identify potential means to improved quality of care, national quality registries (NQRs) are identified as a promising route. Yet, there is limited evidence with regards to what hinders and facilitates the NQR innovation, what signifies the contexts in which NQRs are applied and drive quality improvement. Supposedly, barriers and facilitators to NQR-driven quality improvement may be found in the healthcare context, in the politico-administrative context, as well as with an NQR itself. In this study, we investigated the potential variation with regards to if and how an NQR was applied by decision-makers and users in regions and clinical settings. The aim was to depict the interplay between the clinical and the politico-administrative tiers in the use of NQRs to develop quality of care, examining an established registry on stroke care as a case study. METHODS: We interviewed 44 individuals representing the clinical and the politico-administrative settings of 4 out of 21 regions strategically chosen for including stroke units representing a variety of outcomes in the NQR on stroke (Riksstroke) and a variety of settings. The transcribed interviews were analysed by applying The Consolidated Framework for Implementation Research (CFIR). RESULTS: In two regions, decision-makers and/or administrators had initiated healthcare process projects for stroke, engaging the health professionals in the local stroke units who contributed with, for example, local data from Riksstroke. The Riksstroke data was used for identifying improvement issues, for setting goals, and asserting that the stroke units achieved an equivalent standard of care and a certain level of quality of stroke care. Meanwhile, one region had more recently initiated such a project and the fourth region had no similar collaboration across tiers. Apart from these projects, there was limited joint communication across tiers and none that included all individuals and functions engaged in quality improvement with regards to stroke care. CONCLUSIONS: If NQRs are to provide for quality improvement and learning opportunities, advances must be made in the links between the structures and processes across all organisational tiers, including decision-makers, administrators and health professionals engaged in a particular healthcare process.

Acidente vascular cerebral e desporto : um estudo multicêntrico em Portugal

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Ganhos em independência funcional no doente com AVC

Introdução – O Acidente Vascular Cerebral (AVC) representa a principal causa de dependência funcional da população adulta portuguesa. Conhecer os fatores que possam aumentar os ganhos em independência funcional é crucial para uma melhoria na abordagem destes doentes. Objetivo – Analisar os ganhos em independência funcional no doente que sofreu AVC considerando a diferença no Índice de Barthel entre a admissão e a alta e desde a alta até à primeira consulta. Métodos – Estudo de coorte retrospetivo, utilizando a base de dados hospitalar para doentes admitidos numa unidade de AVC entre 2010 e 2014. O Índice de Barthel (IB) na admissão, alta e primeira consulta após alta foi usado para calcular ganhos em independência funcional por dia entre a admissão e a alta (diferença entre IB na alta e na admissão dividindo pelo número de dias de internamento) e por semana entre a alta e a primeira consulta (diferença entre IB na primeira consulta e na alta dividindo pelo número de semanas entre a alta e a consulta). Com modelos de regressão linear avaliou-se a influência de fatores demográficos, clínicos e o destino após a alta nos ganhos em independência funcional por dia e por semana, obtendo-se coeficientes de regressão e respetivo intervalo de confiança a 95% (IC95%). Resultados – Nos 483 doentes estudados, a idade mediana é 76 anos, 59,0% são homens, 84,3% têm AVC isquémico e 30,6% foram para o domicílio após a alta. A independência funcional por dia aumentou nos anos mais recentes, particularmente em 2013 em que este parâmetro aumentou 1,164 pontos (com IC95%: 0,192 e 2,135; p=0,019) em comparação com 2010. Também o diagnóstico influenciou os ganhos diários em independência funcional, com LACI e PACI apresentando um aumento estatisticamente significativo de 1,372 pontos (IC95%: 0,324 e 2,421; p=0,010) e de 1,275 pontos (IC95%: 0,037 e 2,514; p=0,044), respetivamente, em comparação com POCI. Relativamente à independência funcional por semana, idades mais avançada e score elevado do IB na alta estão associados a menos ganhos por semana (p<0,001 e p=0,002). Também o destino após alta influencia os ganhos por semana, doentes encaminhados para unidades de convalescença apresentam ganhos de 1,289 pontos (IC95%: 0,661 e 1,917; p<0,001) em comparação com os doentes que foram para o domicílio. iv Conclusões – Houve melhoria na evolução funcional entre a admissão e a alta dos doentes em anos mais recentes sugerindo melhorias nas unidades de AVC. Atenção particular deve ser dada a estes doentes após a alta, particularmente nos de idade mais avançada.

Factors facilitating a national quality registry to aid clinical quality improvement : findings of a national survey

Objectives: While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement. Methods: Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression. Results: A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R2=0.76) with ‘Colleagues’ call for local results’ (p=<0.001), ‘Management Request of Registry data’ (p=<0.001), and it was said to be ‘Simple to explain the results to colleagues’ (p=0.02). Using stepwise regression, ‘Colleagues’ call for local results’ was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results. Conclusions: While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.

Advance care planning in stroke: Influence of time on engagement in the process

Purpose Individuals who experience stroke have a higher likelihood of subsequent stroke events, making it imperative to plan for future medical care. In the event of a further serious health event, engaging in the process of advanced care planning (ACP) can help family members and health care professionals (HCPs) make medical decisions for individuals who have lost the capacity to do so. Few studies have explored the views and experiences of patients with stroke about discussing their wishes and preferences for future medical events, and the extent to which stroke HCPs engage in conversations around planning for such events. In this study, we sought to understand how the process of ACP unfolded between HCPs and patients post-stroke. Patients and methods Using grounded theory (GT) methodology, we engaged in direct observation of HCP and patient interactions on an acute stroke unit and two stroke rehabilitation units. Using semi-structured interviews, 14 patients and four HCPs were interviewed directly about the ACP process. Results We found that open and continual ACP conversations were not taking place, patients experienced an apparent lack of urgency to engage in ACP, and HCPs were uncomfortable initiating ACP conversations due to the sensitive nature of the topic. Conclusion In this study, we identified lack of engagement in ACP post-stroke, attributable to patient and HCP factors. This encourages us to look further into the process of ACP in order to develop open communication between the patient with stroke, their families, and stroke HCPs.