scholarly journals Effectiveness of Stroke Early Supported Discharge

2020 ◽  
Vol 13 (8) ◽  
Author(s):  
Rebecca J. Fisher ◽  
Adrian Byrne ◽  
Niki Chouliara ◽  
Sarah Lewis ◽  
Lizz Paley ◽  
...  
Keyword(s):  
Stroke Survivor ◽  
Evidence Based ◽  
Modified Rankin Scale ◽  
National Audit ◽  
Item Score ◽  
Unique Identifier ◽  
Early Supported Discharge ◽  
Consensus Score ◽  
Service Models ◽  
Core Components

Background: Implementation of stroke early supported discharge (ESD) services has been recommended in many countries’ clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Methods and Results: Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016–December 31, 2016), measures of ESD effectiveness were “days to ESD” (number of days from hospital discharge to first ESD contact; n=6222), “rehabilitation intensity” (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%–49%] and increased treatment intensity by 2% [95% CI, 0.3%–4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. Conclusions: This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/ ; Unique identifier: ISRCTN15568163.

scholarly journals Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

2021 ◽  
Vol 9 (22) ◽  
pp. 1-150
Author(s):  
Rebecca J Fisher ◽  
Niki Chouliara ◽  
Adrian Byrne ◽  
Trudi Cameron ◽  
Sarah Lewis ◽  
...  
Keyword(s):  
Patient Outcomes ◽  
Care Pathway ◽  
Stroke Care ◽  
Realist Evaluation ◽  
Mixed Methods Study ◽  
Evidence Based ◽  
Work Package ◽  
Early Supported Discharge ◽  
Consensus Score ◽  
Core Components

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration Current Controlled Trials ISRCTN15568163. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

Using population-based routinely collected data from the Sentinel Stroke National Audit Programme to investigate factors associated with discharge to care home after rehabilitation

2017 ◽  
Vol 32 (8) ◽  
pp. 1108-1118 ◽  
Author(s):  
Dipankar Dutta ◽  
Daniel Thornton ◽  
Emily Bowen
Keyword(s):  
Care Home ◽  
Univariate Analysis ◽  
Population Based ◽  
National Institutes Of Health ◽  
National Audit ◽  
Factors Associated ◽  
Routinely Collected Data ◽  
Early Supported Discharge ◽  
Research Findings ◽  
First Time

Objectives: We investigated factors associated with Care Home (CH) discharge following stroke using routinely collected data in unselected patients and assessed the relevance of previous research findings to such patients seen in routine clinical practice. Design: Retrospective analysis of data from the Sentinel Stroke National Audit Programme using univariate analysis and logistic regression. Setting: A large acute and rehabilitation UK stroke unit with access to early supported discharge. Subjects: All patients with stroke treated from 1 January 2014 to 1 January 2017. Main measures: National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). Results: Of 2584 patients (median age 78 years, interquartile range (IQR) 69–86; 50.6% male; 86.7% infarcts; median admission NIHSS 4, IQR 2–9), 401 (15.5%) died in hospital and 203 patients (7.9%) were permanently discharged to CH for the first time. Most had pre-discharge mRS scores of 4/5. Factors (odds ratios; 95% confidence intervals) associated with CH discharge included age (1.07; 1.05–1.10), incontinence (11.5; 7.13–19.25), dysphagia (2.13; 1.39–3.29), severe weakness (1.93; 1.28–2.92), pneumonia (1.68; 1.13–2.50), urinary tract infection (UTI) (1.70; 1.04–2.75) and depression (1.65; 1.00–2.72). In a subgroup of all patients with a pre-discharge mRS of 4/5, age (1.04; 1.02–1.06), incontinence (4.87; 2.39–11.02), UTI (2.0; 1.09–3.71) and pneumonia (1.59; 1.02–2.50) were the only factors associated with CH discharge. Conclusion: Potentially modifiable variables like incontinence, UTI and pneumonia were associated with CH discharge, particularly in the severely disabled.

Less is more: Implementing the ‘Minimal Intervention Needed for Change (MINC)’ approach to increase contextual fit of speech-language interventions

2021 ◽  
Author(s):  
Maura Curran ◽  
Rouzana Komesidou ◽  
Tiffany P. Hogan
Keyword(s):  
Clinical Settings ◽  
Evidence Based ◽  
Evidence Based Practices ◽  
Minimal Intervention ◽  
Less Is More ◽  
Resource Limitations ◽  
Practice Method ◽  
Core Components ◽  
Contextual Fit ◽  
Clinically Significant

AbstractPurpose: Speech-Language Pathologists (SLPs) and researchers face difficulties in moving evidence-based practices from clinical research into widespread practice, in part due to a mismatch between the design of typical intervention research studies and the realities of clinical settings. SLPs must adapt interventions from the literature or established programs to fit the needs of specific clients and settings. Researchers must design studies that better reflect clinical practice. Method: Here, we provide an overview of the Minimal Intervention Needed for Change (MINC) approach; a systematic approach to developing and adapting interventions that focuses on achieving meaningful outcomes within specific contexts. We outline the principles of MINC, and illustrate this process through use of a case study.Results: MINC can support systematic development and adaptation of interventions in clinical and research settings, particularly settings with resource limitations. Conclusions: Researchers should work to align research intervention work with typical clinical settings. This involves both targeting outcomes that are functional and clinically significant and acknowledging resource limitations. SLPs should adapt evidence-based interventions systematically and carefully to meet the needs of clients and settings while retaining the core components of intervention that result in meaningful change for clients.

scholarly journals Redefining Pain and Addiction: Creation of a Statewide Curriculum

2020 ◽  
Vol 135 (6) ◽  
pp. 756-762
Author(s):  
Lisa Villarroel ◽  
Aram S. Mardian ◽  
Cara Christ ◽  
Shakaib Rehman
Keyword(s):  
Public Health ◽  
Health Services ◽  
Professional Education ◽  
Evidence Based ◽  
Health Issues ◽  
Department Of Health ◽  
Core Components ◽  
Philosophical Framework ◽  
Single Standard ◽  
Implementation Progress

Objectives In response to a declared statewide public health emergency due to opioid-related overdose deaths, the Arizona Department of Health Services guided the creation of a modern, statewide, evidence-based curriculum on pain and addiction that would be relevant for all health care provider types. Methods The Arizona Department of Health Services convened and facilitated 4 meetings during 4 months with a workgroup comprising the deans and curriculum representatives of all 18 medical, osteopathic, physician assistant, nurse practitioner, dental, podiatry, and naturopathic programs in Arizona. During this collaborative and iterative process, the workgroup reviewed existing curricula, established a philosophical framework, and developed a flexible and practical structure for a curriculum that would suit the needs of all program types. Results The Arizona Pain and Addiction Curriculum was finalized in June 2018. The curriculum aims to redefine pain and addiction as multidimensional public health issues and is structured as 10 core components, each supported by a detailed set of evidence-based objectives. The curriculum includes a set of annual metrics to collect from both programs (focused on implementation progress and barriers) and learners (focused on knowledge, attitudes, and practice plans). Conclusions To our knowledge, this is the first example of a statewide collaboration among diverse health professional education programs to create a single, standard curriculum. This collaborative process and the nonproprietary Arizona Pain and Addiction Curriculum may serve as a useful template for other states to enhance pain and addiction education.

scholarly journals Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage

Stroke ◽  
2019 ◽  
Vol 50 (11) ◽  
pp. 3064-3071 ◽  
Author(s):  
Philip M. Bath ◽  
Lisa J. Woodhouse ◽  
Kailash Krishnan ◽  
Jason P. Appleton ◽  
Craig S. Anderson ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Glyceryl Trinitrate ◽  
Global Analysis ◽  
Mass Effect ◽  
Modified Rankin Scale ◽  
Unique Identifier ◽  
Serious Adverse Events ◽  
Clinical Trial Registration ◽  
Prehospital Treatment ◽  
Acute Intracerebral Hemorrhage

Background and Purpose— Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset. Methods— We undertook a multicentre, paramedic-delivered, ambulance-based, prospective randomized, sham-controlled, blinded-end point trial in adults with presumed stroke within 4 hours of ictus. Participants received transdermal GTN (5 mg) or a sham dressing (1:1) in the ambulance and then daily for three days in hospital. The primary outcome was the 7-level modified Rankin Scale at 90 days assessed by central telephone treatment-blinded follow-up. This prespecified subgroup analysis focuses on participants with an intracerebral hemorrhage as their index event. Analyses are intention-to-treat. Results— Of 1149 participants with presumed stroke, 145 (13%; GTN, 74; sham, 71) had an intracerebral hemorrhage: time from onset to randomization median, 74 minutes (interquartile range, 45–110). By admission to hospital, blood pressure tended to be lower with GTN as compared with sham: mean, 4.4/3.5 mm Hg. The modified Rankin Scale score at 90 days was nonsignificantly higher in the GTN group: adjusted common odds ratio for poor outcome, 1.87 (95% CI, 0.98–3.57). A prespecified global analysis of 5 clinical outcomes (dependency, disability, cognition, quality of life, and mood) was worse with GTN; Mann-Whitney difference, 0.18 (95% CI, 0.01–0.35; Wei-Lachin test). GTN was associated with larger hematoma and growth, and more mass effect and midline shift on neuroimaging, and altered use of hospital resources. Death in hospital but not at day 90 was increased with GTN. There were no significant between-group differences in serious adverse events. Conclusions— Prehospital treatment with GTN worsened outcomes in patients with intracerebral hemorrhage. Since these results could relate to the play of chance, confounding, or a true effect of GTN, further randomized evidence on the use of vasodilators in ultra-acute intracerebral hemorrhage is needed. Clinical Trial Registration— URL: http://www.controlled-trials.com . Unique identifier: ISRCTN26986053.

scholarly journals First Steps towards Evidence-Based Preventive Home Visits: Experiences Gathered in a Swedish Municipality

2012 ◽  
Vol 2012 ◽  
pp. 1-11 ◽  
Author(s):  
Charlotte Löfqvist ◽  
Staffan Eriksson ◽  
Torbjörn Svensson ◽  
Susanne Iwarsson
Keyword(s):  
Home Visits ◽  
Evidence Base ◽  
Evidence Based ◽  
Social Psychological ◽  
Environmental Aspects ◽  
Broad Perspective ◽  
Preventive Home Visits ◽  
Health And Wellbeing ◽  
Core Components ◽  
Practical Experiences

The purpose of preventive home visits is to promote overall health and wellbeing in old age. The aim of this paper was to describe the process of the development of evidence-based preventive home visits, targeting independent community-living older persons. The evidence base was generated from published studies and practical experiences. The results demonstrate that preventive home visits should be directed to persons 80 years old and older and involve various professional competences. The visits should be personalized, lead to concrete interventions, and be followed up. The health areas assessed should derive from a broad perspective and include social, psychological, and medical aspects. Core components in the protocol developed in this study captured physical, medical, psychosocial, and environmental aspects. Results of a pilot study showed that the protocol validly identified health risks among older people with different levels of ADL dependence.

scholarly journals Implementation strategies and outcomes for occupational therapy in adult stroke rehabilitation: a scoping review

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
J. Edward Murrell ◽  
Janell L. Pisegna ◽  
Lisa A. Juckett
Keyword(s):  
Occupational Therapy ◽  
Scoping Review ◽  
Stroke Rehabilitation ◽  
Implementation Strategy ◽  
Implementation Strategies ◽  
Stroke Care ◽  
Stroke Survivor ◽  
Educational Outreach ◽  
Evidence Based ◽  
Implementation Outcomes

Abstract Background Stroke survivors often encounter occupational therapy practitioners in rehabilitation practice settings. Occupational therapy researchers have recently begun to examine the implementation strategies that promote the use of evidence-based occupational therapy practices in stroke rehabilitation; however, the heterogeneity in how occupational therapy research is reported has led to confusion about the types of implementation strategies used in occupational therapy and their association with implementation outcomes. This review presents these strategies and corresponding outcomes using uniform language and identifies the extent to which strategy selection has been guided by theories, models, and frameworks (TMFs). Methods A scoping review protocol was developed to assess the breadth and depth of occupational therapy literature examining implementation strategies, outcomes, and TMFs in the stroke rehabilitation field. Five electronic databases and two peer-reviewed implementation science journals were searched to identify studies meeting the inclusion criteria. Two reviewers applied the inclusion parameters and consulted with a third reviewer to achieve consensus. The 73-item Expert Recommendations for Implementing Change (ERIC) implementation strategy taxonomy guided the synthesis of implementation strategies. The Implementation Outcomes Framework guided the analysis of measured outcomes. Results The initial search yielded 1219 studies, and 26 were included in the final review. A total of 48 out of 73 discrete implementation strategies were described in the included studies. The most used implementation strategies were “distribute educational materials” (n = 11), “assess for readiness and identify barriers and facilitators” (n = 11), and “conduct educational outreach visits” (n = 10). “Adoption” was the most frequently measured implementation outcome, while “cost” was not measured in any included studies. Eleven studies reported findings supporting the effectiveness of their implementation strategy or strategies; eleven reported inconclusive findings, and four found that their strategies did not lead to improved implementation outcomes. In twelve studies, at least partially beneficial outcomes were reported, corresponding with researchers using TMFs to guide implementation strategies. Conclusions This scoping review synthesized implementation strategies and outcomes that have been examined in occupational therapy and stroke rehabilitation. With the growth of the stroke survivor population, the occupational therapy profession must identify effective strategies that promote the use of evidence-based practices in routine stroke care and describe those strategies, as well as associated outcomes, using uniform nomenclature. Doing so could advance the occupational therapy field’s ability to draw conclusions about effective implementation strategies across diverse practice settings.

Ensuring High-Quality Implementation and Sustainability of Evidence-Based Interventions and Coalitions

2018 ◽  
Author(s):  
Abigail A. Fagan ◽  
J. David Hawkins ◽  
Richard F. Catalano ◽  
David P. Farrington
Keyword(s):  
United States ◽  
The United States ◽  
Technical Support ◽  
Evidence Based ◽  
Community Based ◽  
High Quality ◽  
Core Components ◽  
Over Time ◽  
Coalition Functioning

This chapter reviews the importance of delivering community-based systems and EBIs with fidelity (i.e., in accordance with their implementation requirements) and sustaining these interventions over time. The chapter describes the training and technical support provided in CTC to ensure that coalitions take necessary actions to maintain their functioning in the long term and deliver EBIs in adherence to their core components and to their intended recipients. It is especially important that coalitions collect data on coalition functioning and EBI delivery and use these data when problems are identified. Examples of how CTC coalitions in the United States and other countries have engaged in these efforts are highlighted.

Trauma-Focused Family Therapy With Children and Their Families

2019 ◽  
Vol 27 (2) ◽  
pp. 175-182
Author(s):  
Wanda Boyer
Keyword(s):  
Family Therapy ◽  
Family Support ◽  
Behavioral Therapy ◽  
Behavioral Responses ◽  
Behavioral Functioning ◽  
Evidence Based ◽  
Family Experiences ◽  
Traumatized Children ◽  
Core Components ◽  
Emotional And Behavioral Functioning

Family life is considered to be a context in which children can safely learn life skills such as managing and directing their cognitive, physical, emotional, and behavioral responses to events as a way to achieve a sense of purpose and mastery in life. Traumatic events such as natural disasters, serious accidents, and violence in our homes, schools, or communities may alter an individual’s ability to manage cognitive, physical, emotional, and behavioral functioning. Trauma can significantly affect children and their families, impacting relationships, interactions, and their context. There is evidence to support the use of family therapy with children who have experienced trauma. Family support can improve interactions and relationships and can assist children in resolving trauma symptomology. Trauma-focused cognitive behavioral therapy (TF-CBT) is professionally recognized as an evidence-based intervention. There are also TF-CBT intervention derivations that have been developed to support children experiencing trauma. TF-CBT and TF-CBT intervention derivations are explored in this article including core components of evidence-based trauma-focused family therapy necessary to support traumatized children and their families. Discussion also includes the importance and evidence-based support for honoring cultural diversity and including optimism and hope into family experiences as both a preventative and interventive measure to manage trauma symptomology.

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