Abstract P864: Use of the American Stroke Association Patient Time Tracker Tool to Reduce DTN Times in Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jo-Ann M Sarafin ◽  
Melissa Harmon
Keyword(s):  
Patient Outcomes ◽  
Professional Staff ◽  
Point Of View ◽  
Phase Iii ◽  
Treatment Team ◽  
Stroke Patients ◽  
Timely Manner ◽  
Internal Review ◽  
Bodies Of Evidence ◽  
Therapy Treatment

Introduction: More expedient door-to-needle (DTN) times with IV Alteplase in stroke have proven to result in better patient outcomes. Despite multiple bodies of evidence that support this conclusion, there remains challenges in accomplishing rapid times to treatment. The American Stroke Association (ASA) has developed in Target Stroke Phase III, criteria that requires DTN times within 45 minutes for at least 75% of applicable patients and DTN times within 30 minutes for at least 50 % of applicable patients. Despite various quality improvement projects many hospitals still struggle to shorten DTN times. Objective: An internal review of data from January 2019 to December 2019 revealed that despite more experience in acute stroke thrombolytic therapy, treatment times were prolonged. In order to shorten DTN times, a method to highlight time targets in evaluation and treatment was instituted. The ASA Time Tracker Tool was utilized to provide feedback on all stroke patients receiving IV Alteplase with the goal of better exploring reasons for delay in a timely manner that included input from the treatment team. Methods: In March 2020 the utilization of the ASA Time Tracker Tool was introduced. The tool was completed for every stroke patient receiving IV t-PA within 48-72 hours of thrombolytic administration. Each case included reasons for delay that was documented in the EMR. Professional staff including nursing and medicine were provided each case and asked for input regarding perceived delays to treatment to better discern obstacles to care. Results: Prior to institution of the ASA Time Tracker Tool the median DTN time was 41.7 minutes for 2019. After the tool was instituted the DTN times fell in Quarter 2 2020 to 38 minutes. Residents and nurses alike verbalized positively about receiving the tool as a mechanism for valuable feedback as well as an opportunity to provide their own input on potentially correctable areas to reduce DTN times. Conclusion: The use of the ASA Time Tracker Tool to share crucial time sensitive targets in the acute treatment of ischemic stroke is one method to reduce DTN times. Further study is needed to determine frequently occurring obstacles from the treatment team’s point of view with attention to correcting those barriers that prolong DTN times.

In silico modeling of cellular probabilistic nanoparticle radiosensitization in head and neck cancers

Nanomedicine ◽  
2020 ◽  
Vol 15 (29) ◽  
pp. 2837-2850
Author(s):  
Myxuan Huynh ◽  
Ivan Kempson ◽  
Eva Bezak ◽  
Wendy Phillips
Keyword(s):  
Head And Neck ◽  
Patient Outcomes ◽  
Head And Neck Cancers ◽  
New Approach ◽  
Treatment Regimens ◽  
Therapeutic Benefits ◽  
In Silico Modeling ◽  
The Individual ◽  
Dose Deposition ◽  
Therapy Treatment

Background: The use of gold nanoparticles (AuNPs) as radiosensitizers may offer a new approach in the treatment of head and neck cancers; minimizing treatment-associated toxicities and improving patient outcomes. AuNPs promote localized dose deposition; permitting improved local control and/or dose reduction. Aim: This work aimed to address the theoretical optimization of radiation doses, fractionation and nanoparticle injection schedules to maximize therapeutic benefits. Materials & methods: Probabilistic nanoparticle sensitization factors were incorporated into the individual cell-based HYP-RT computer model of tumor growth and radiotherapy. Results: Total dose outcomes across all radiation therapy treatment regimens were found to be significantly reduced with the presence of AuNPs, with bi-weekly injections showing the most decrease. Conclusion: Outcomes suggest the need for regular AuNP administration to permit effective radiosensitization.

558 Programmed death (PD)-1 and PD-ligand-1 inhibitors in the treatment of non-small cell lung cancer: a systematic review of their efficacy and safety

2020 ◽  
Vol 8 (Suppl 3) ◽  
pp. A592-A592
Author(s):  
Melissa Lingohr-Smith ◽  
Chelsea Deitelzweig ◽  
Grace Lin ◽  
Jay Lin
Keyword(s):  
Clinical Trials ◽  
Adverse Events ◽  
Patient Outcomes ◽  
Nsclc Patient ◽  
Response Rates ◽  
Phase Iii ◽  
Combination Therapies ◽  
Phase Iii Clinical Trials ◽  
Programmed Death ◽  
Grade 3

BackgroundTreatment advances have been made in non-small cell lung cancer (NSCLC) with the development and approval of programmed death (PD)-1 and PD-ligand 1 (PD-L1) inhibitors. PD-1 and PD-L1 inhibitors may be used as monotherapies or in combination with other agents and have been shown to improve NSCLC patient outcomes in clinical trials. We conducted a systematic search to compare the efficacy and safety of PD-1/PD-L1 inhibitors in the treatment of NSCLC.MethodsA systematic literature search of PubMed was conducted to identify phase III clinical trials in which the efficacy of PD-1/PD-L1 inhibitors in the treatment of NSCLC was evaluated. PD-1 inhibitors included nivolumab and pembrolizumab; PD-L1 inhibitors included atezolizumab, avelumab, and durvalumab. Patient characteristics and efficacy data were extracted.ResultsSixteen phase III clinical trials were identified (nivolumab=4; pembrolizumab=5; atezolizumab=5; avelumab=1; durvalumab=1). Across the 3 nivolumab monotherapy trials (n=638; median ages: 61–63 years), median progression-free survival (PFS) ranged 2.3–4.2 months; response rates ranged 19%-26%; grade 3/4 adverse events occurred in 7%-18% of patients. Nivolumab in combination with iplimumab (n=583; median age: 64 years) had a median PFS of 5.1 months and response rate of 33%; grade 3/4 adverse events occurred in 33% of patients. Across the 3 pembrolizumab monotherapy trials (n=1,481; median ages: 63–64 years), median PFS ranged 3.9–10.3 months; response rates ranged 18%-45%; grade ≥3 adverse events occurred in 13%-27% of patients. In the 2 pembrolizumab combination therapy trials (n=688; median ages: 65 years), median PFS ranged 6.4–8.8 months; response rates ranged 48%-58%; grade ≥3 adverse events occurred in 67%-70% of patients. In the 4 atezolizumab combination therapy trials (n=1,486; median ages: 63–64 years), median PFS ranged 6.3–8.3 months; response rates ranged 47%-63.5%; grade 3/4 adverse events occurred in 54%-73% of patients. In the 3 monotherapy trials of atezolizumab (n=613; median age: 63 years), avelumab (n=396; median age: 64 years), and durvalumab (n=476; median age: 64 years), the median months of PFS were 2.7, 2.8, and 17.2, respectively; response rates were 14%, 15%, and 30%, respectively; grade ≥3 adverse events occurred in 15%, 10%, and 30.5% of patients, respectively.ConclusionsAlthough treatment responses varied, most of the evaluated PD-1/PD-L1 inhibitors were associated with a clinical benefit for NSCLC trial patients. Generally, treatment efficacy was greater with combination therapies, but adverse events occurred more frequently. Innovations in the targeting/personalization of PD-1/PD-L1 combination therapies will likely lead to improved NSCLC patient outcomes and further research is needed in this regard.

Abstract 3418: Acute Care Nurse Practicioner Led Critical Care Transport Team Leads to Improved Door to Imaging Time in Acute Ischemic Stroke Patients

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Michelle M Winfield ◽  
Julie A McNeil ◽  
Stephanie L Steiner ◽  
Christopher F Manacci ◽  
Damon Kralovic ◽  
...  
Keyword(s):  
Critical Care ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Care Transitions ◽  
Cleveland Clinic ◽  
Stroke Patients ◽  
Time Intervals ◽  
Care Nurse ◽  
Transport Team

Background: In evaluating the acute ischemic stroke (AIS) patient, targeting time intervals for imaging and treatment times are paramount in optimizing outcomes. Initial evaluation by skilled providers who can facilitate the extension of a tertiary care facility can positively influence patient outcomes. A collaborative approach with a hospital based Critical Care Transport (CCT) Team can extend primary stroke program care out to a referring facility’s bedside. In the Cleveland Clinic Health System, the suspicion of a large vessel occlusion causing AIS in patients at an outside hospital triggers an “Auto Launch” process, bypassing typical transfer processes to expedite care transitions for patients with time sensitive emergencies. Referring facilities contact a CCT Coordinator, with immediate launching of the transport team that consists of an Acute Care Nurse Practitioner (ACNP) who evaluates the patient at outside facility, performs NIHSS and transitions the patient directly to CT/MRI upon return to Cleveland Clinic facility. Patient is met by the Stroke Neurology Team at CT scanner for definitive care. A CCT Team with an ACNP on board can augment not only door to CT and MRI times, but also time to evaluation by a stroke neurologist and time to intervention, bypassing the Emergency Department upon their arrival and proceeding directly to studies and/or time sensitive intervention as appropriate. Objective: To describe a stroke program with a coordinated approach with a CCT Team to facilitate rapid care transitions as well as decreased time to imaging in patients with AIS by having an ACNP on board during transport and throughout the continuum of care. Methods: A retrospective audit of a database of patients undergoing hyperacute evaluation of acute ischemic stroke symptoms from April 30, 2010 to July 31, 2011 was performed. Demographic information, types of imaging performed, hyperacute therapies administered and time intervals to imaging modalities and treatment were collected and analyzed. Results: 107 patients total, 28 males, and 36 females with a mean age of 70 were included in the analysis. 60% [64] of patients transferred via the CCT Team over 26.42 average nautical miles. The mean time of call to arrival was 1 hr and 19 min. The CCT Team monitored tPA infusion in 27 patients and initiated tPA infusion in 2 patients. 64 patients had CT imaging performed and 64 had MRI performed following the CT. [The average door to CT completion was 22 min, the average door to MRI completion was 1 hr and 29 min, compared to 1 hr and 8 min and 2 hr and 36 min, respectively, in patients not arriving by CCT Team], p<0.05. Conclusion: Collaboration between the Stroke Neurology Team and CCT Team has allowed acute ischemic stroke patients to be taken directly to CT/MRI scanner, allowing for rapid evaluation, definitive treatment decisions, and the potential for improved patient outcomes by decreasing the door to imaging time.

Abstract WP178: Acute Stroke Ischemic Symptom Onset-to-Arrival Time in Michigan Hospitals

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Muhammad U Farooq ◽  
Kathie Thomas
Keyword(s):  
African American ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Patient Outcomes ◽  
Symptom Onset ◽  
Arrival Time ◽  
Heart Association ◽  
The United States ◽  
Stroke Patients ◽  
White Patients

Objectives: Stroke is the fifth-leading cause of death and the leading cause of disability in the United States. One of the primary goals of the American Heart Association/American Stroke Association is to increase the number of acute stroke patients arriving at emergency departments (EDs) within 1-hour of symptom onset. Earlier treatment with thrombolysis in patients with acute ischemic stroke translates into improved patient outcomes. The objective of this abstract is to examine the association between the use of emergency medical services (EMS) and symptom onset-to-arrival time in patients with ischemic stroke. Methods: A retrospective review of ischemic stroke patients (n = 8873) from 25 Michigan hospitals from January 2012-December 2014 using Get With the Guidelines databases was conducted. Symptom onset-to-ED arrival time and arrival mode were examined. Results: It was found that 17.4% of ischemic stroke patients arrived at the hospitals within 1-hour of symptom onset. EMS transported 69.1% of patients who arrived within 1-hour of symptom onset. During this 1-hour period African American patients (22%) were less likely to use EMS transportation as compared to White patients (72%). The majority of patients, 41.8%, arrived after 6-hours of symptom onset. EMS transported only 40% of patients who arrived after 6-hours of symptom onset. As before, during this 6-hour period African American patients (20%) were also less likely to use EMS transportation as compared to White patients (75%). Symptom onset-to-ED arrival time was shorter for those patients who used EMS. The median pre-hospital delay time was 2.6 hours for those who used EMS versus 6.2 hours for those who did not use EMS. Conclusions: The use of EMS is associated with a decreased pre-hospital delay, early treatment with thrombolysis and improved patient outcomes in ischemic stroke patients. Community interventions should focus on creating awareness especially in minority populations about stroke as a neurological emergency and encourage EMS use amongst stroke patients.

Abstract P119: Factors Influencing Door to Needle Administration for Acute Stroke Patients in the Emergency Department

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nicolle W Davis ◽  
Meghan Bailey ◽  
Natalie Buchwald ◽  
Amreen Farooqui ◽  
Anna Khanna
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Patient Outcomes ◽  
Time Of Day ◽  
Stroke Patients ◽  
Acute Stroke Care ◽  
The Impact ◽  
Iv Tpa

Background/Objective: There is growing importance on discovering factors that delay time to intervention for acute ischemic stroke (AIS) patients, as rapid intervention remains essential for better patient outcomes. The management of these patients involves a multidisciplinary effort and quality improvement initiatives to safely increase treatment with intravenous thrombolytic (IV tPa). The objective of this pilot is to evaluate factors of acute stroke care in the emergency department (ED) and the impact they have on IV tPa administration. Methods: A sample of 89 acute ischemic stroke patients that received IV tPa from a single academic medical institution was selected for retrospective analysis. System characteristics (presence of a stroke nurse and time of day) and patient characteristics (mode of arrival and National Institutes of Health Stroke Scale score (NIHSS) on arrival) were analyzed using descriptive statistics and multiple regression to address the study question. Results: The mean door to needle time is 53.74 minutes ( + 38.06) with 74.2% of patients arriving to the ED via emergency medical services (EMS) and 25.8% having a stroke nurse present during IV tPa administration. Mode of arrival ( p = .001) and having a stroke nurse present ( p = .022) are significant predictors of door to needle time in the emergency department (ED). Conclusion: While many factors can influence door to needle times in the ED, we did not find NIHSS on arrival or time of day to be significant factors. Patients arriving to the ED by personal vehicle will have a significant delay in IV tPa administration, therefore emphasizing the importance of using EMS. Perhaps more importantly, collaborative efforts including the addition of a specialized stroke nurse significantly decreased time to IV tPa administration for AIS patients. With this dedicated role, accelerated triage and more effective management of AIS patients is accomplished, leading to decreased intervention times and potentially improving patient outcomes.

Abstract 1122‐000099: Establishing “Code NI” in Addition to “Code Stroke” is Warranted When Mechanical Thrombectomy is Needed

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Kiana Moussavi ◽  
Mohammad Moussavi
Keyword(s):  
Patient Outcomes ◽  
Mechanical Thrombectomy ◽  
Medical Emergency ◽  
Number Needed To Treat ◽  
Insurance Company ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Essential Information ◽  
Bed Management ◽  
Comprehensive Stroke Center

Introduction : Hospital medical emergencies are prone to inefficiencies related to delayed dissemination of information, communication error, role confusion, and delayed decision making. The use of medical codes is intended to convey emergent and essential information quickly while preventing stress and mismanagement. The more complex, critical, and time sensitive an event is, the greater the need to establish a Code. Major mechanical thrombectomy (MT) trials published in 2015 and 2016 proved emergent MT to be more effective compared to IV tPA in stroke patients with large vessel occlusion (LVO). It has been proven that time to reperfusion with MT is directly proportional to severity of patient outcomes, coining the phrase, “save a minute, save a week”. When compared to the use of percutaneous intervention (PCI) in the treatment of STEMI, the number needed to treat for MT is estimated at 5 compared to 16 for PCI. Despite this fact, most hospitals have yet to adopt a code specific to MT. Our Purpose is to emphasize the importance of establishing a dedicated Code NI (Neuro‐Intervention) for stroke patients who require MT by sharing our Methods : After defining the problems, measuring the need, and analyzing the process, we identified the urgency for improvements in our facility. The administration was persuaded to support us in implementation of improvements after realizing the success of MT trials in patient outcomes, length of stay, hospital rankings, Comprehensive Stroke Center Certification, and insurance company compensation. Results : In early 2018, after many presentations and meetings, it was decided to implement “Code NI” for acute stroke patients who met MT criteria. Many teams and individuals including Neurointervention, Neuroradiology, Angio Suite, Anesthesia, ICU, Bed management, and transport were alerted. Following these implementations, from 2018 to 2021, our Door to Puncture Time and Puncture to Recanalization Time has been trending down from 219 to 120; and 261 to 147 minutes respectively. Conclusions : Approximately 70% of stroke patients with LVO have the potential of a meaningful recovery if treated efficiently and effectively. Establishing a “Code NI” for this time sensitive medical emergency helps the patients, their families, hospitals, and society.

scholarly journals The Role of Continuous Theta Burst TMS in the Neurorehabilitation of Subacute Stroke Patients: A Placebo-Controlled Study

2021 ◽  
Vol 12 ◽  
Author(s):  
Ana Dionísio ◽  
Rita Gouveia ◽  
João Castelhano ◽  
Isabel Catarina Duarte ◽  
Gustavo C. Santo ◽  
...  
Keyword(s):  
Motor Function ◽  
Primary Motor Cortex ◽  
Phase Iii ◽  
Repeated Measure ◽  
Controlled Study ◽  
Stroke Patients ◽  
Post Stroke ◽  
Subacute Stroke ◽  
Theta Burst

Objectives: Transcranial magnetic stimulation, in particular continuous theta burst (cTBS), has been proposed for stroke rehabilitation, based on the concept that inhibition of the healthy hemisphere helps promote the recovery of the lesioned one. We aimed to study its effects on cortical excitability, oscillatory patterns, and motor function, the main aim being to identify potentially beneficial neurophysiological effects.Materials and Methods: We applied randomized real or placebo stimulation over the unaffected primary motor cortex of 10 subacute (7 ± 3 days) post-stroke patients. Neurophysiological measurements were performed using electroencephalography and electromyography. Motor function was assessed with the Wolf Motor Function Test. We performed a repeated measure study with the recordings taken pre-, post-cTBS, and at 3 months' follow-up.Results: We investigated changes in motor rhythms during arm elevation and thumb opposition tasks and found significant changes in beta power of the affected thumb's opposition, specifically after real cTBS. Our results are consistent with an excitatory response (increase in event-related desynchronization) in the sensorimotor cortical areas of the affected hemisphere, after stimulation. Neither peak-to-peak amplitude of motor-evoked potentials nor motor performance were significantly altered.Conclusions: Consistently with the theoretical prediction, this contralateral inhibitory stimulation paradigm changes neurophysiology, leading to a significant excitatory impact on the cortical oscillatory patterns of the contralateral hemisphere. These proof-of-concept results provide evidence for the potential role of continuous TBS in the neurorehabilitation of post-stroke patients. We suggest that these changes in ERS/ERD patterns should be further explored in future phase IIb/phase III clinical trials, in larger samples of poststroke patients.

Abstract 183: Time to Alteplase and Symptomatic Intracranial Hemorrhage Complication Rates

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Muhammad U Farooq ◽  
Kathie Thomas
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
American Heart ◽  
Phase Iii ◽  
P Value ◽  
Complication Rates ◽  
Stroke Patients ◽  
Number Of Patients ◽  
Symptomatic Intracranial Hemorrhage ◽  
Get With The Guidelines

Background/Objective: The American Heart Association’s Target Stroke initiative focuses on reducing door-to-needle time for faster treatment with Alteplase and improved patient outcomes. The concern for reducing door-to-needle time is that there will be an increase in complication rates, specifically the rate of symptomatic intracranial hemorrhage (ICH). This study sought to review whether reduced door-to-needle times were associated with increased rates of complications in Midwest hospitals. Methods: A retrospective review of acute ischemic stroke patients treated with Alteplase was conducted from 2010-2018 in 13 Midwestern states (IN, IL, KS, KY, MI, MN, NO, ND, OH, SD, and WI) using the American Stroke Association’s Get With The Guidelines (GWTG) Stroke database. Percentage of eligible patients treated with Alteplase, treatment times, and complication rates were reviewed. Results: From 2010-2018 the rate of ischemic stroke patients treated with Alteplase in the approved 3-hour window increased from 68.9% to 88.5%. The number of patients treated with Alteplase in 60 minutes increased from 24.1% in 2010 to 74.9% in 2018. The median time to treatment for Alteplase was reduced from 80 minutes in 2010 to 46 minutes in 2018. The rate of complications associated with thrombolytics was 6.5% in 2010 and dropped to 4.5% in 2018. This is statistically significant at a p-value of .05. Conclusions: In the Midwest Region, a reduction in door-to-needle times was not associated with increased complication rates. Interestingly, a reduction in door-to-needle times was associated with a reduction in complication rates. This supports the American Heart Association’s new Target Stroke Phase III initiative which seeks to further reduce door-to-needle times.

Primary to comprehensive stroke center transfers: Appropriateness, not futility

2018 ◽  
Vol 13 (6) ◽  
pp. 550-553 ◽  
Author(s):  
Mayank Goyal ◽  
Bijoy K Menon ◽  
Alexis T Wilson ◽  
Mohammed A Almekhlafi ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Decision Making ◽  
Endovascular Treatment ◽  
Patient Outcomes ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
Nuanced Understanding ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Post Hoc ◽  
Transfer Decisions

Background and purpose Ischemic stroke patients must be transferred to comprehensive stroke centers for endovascular treatment, but this transfer can be interpreted post hoc as “futile” if patients do not ultimately undergo the procedure or have a poor outcome. We posit that transfer decisions must instead be evaluated in terms of appropriateness at the time of decision-making. Methods We propose a classification schema for Appropriateness of Transfer for Endovascular Thrombectomy based on patient, logistic, and center characteristics. Results The classification outline characteristics of patients that are 1. Appropriate for transfer for endovascular treatment; 2. Inappropriate for transfer; and 3. Appropriate for transfer for higher level of care. Conclusions Appropriate transfer decisions for endovascular treatment are significant for patient outcomes. A more nuanced understanding of transfer decision-making and a classification for such transfers can help minimize inappropriate transfers in acute stroke.

Using MRI art, poetry, photography and patient narratives to bridge clinical and human experiences of stroke recovery

2019 ◽  
Vol 46 (3) ◽  
pp. 243-249 ◽  
Author(s):  
Gabrielle Brand ◽  
Ashlee Osborne ◽  
Steve Wise ◽  
Collette Isaac ◽  
Christopher Etherton-Beer
Keyword(s):  
Health Professional ◽  
Professional Staff ◽  
Workforce Education ◽  
Reflective Learning ◽  
Stroke Recovery ◽  
Depth Of Field ◽  
Stroke Patients ◽  
Staff Perceptions ◽  
Improvement Project ◽  
Patient Narratives

Integrating co-produced humanities-based pedagogy into patient and workforce education is of growing interest. The aim of our Depth of Field: Exploring Stroke Recovery project grew from a strong commitment to use patients' lived experiences as a voice to educate new stroke patients and the health professional staff who will care for them. The aim of the initial Quality Improvement project at a West Australian Stroke Rehabilitation Unit (SRU) was to co-produce a reflective learning resource with stroke patients and their families to help navigate the stroke recovery journey. A series of artefacts (documentary-style photographs, audio-narrated vignettes, MRI images and poetry) were collected from four stroke patients and their families at differing stages of recovery over 12 months as they recounted the honest and raw reality of what life is really like following a stroke. These artefacts were used in a pilot qualitative project to explore new stroke patients, their families and SRU health professional staff perceptions towards the artefacts in order to inform the final educational resource. These findings enhance our understandings of how we can use art and patient (healthcare consumers) voice to widen the lens of stroke recovery and provides a valuable template to co-produce peer-to-peer and health professions education reflective learning resources to promote more human- centred approaches to care.

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