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Parry-Jones AR, Järhult SJ, Kreitzer N, Morotti A, Toni D, Seiffge D, Mendelow AD, Patel H, Brouwers HB, Klijn CJ, Steiner T, Gibler WB, Goldstein JN. Acute care bundles should be used for patients with intracerebral haemorrhage: An expert consensus statement. Eur Stroke J 2024; 9:295-302. [PMID: 38149323 DOI: 10.1177/23969873231220235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
PURPOSE Intracerebral haemorrhage (ICH) is the most devastating form of stroke and a major cause of disability. Clinical trials of individual therapies have failed to definitively establish a specific beneficial treatment. However, clinical trials of introducing care bundles, with multiple therapies provided in parallel, appear to clearly reduce morbidity and mortality. Currently, not enough patients receive these interventions in the acute phase. METHODS We convened an expert group to discuss best practices in ICH and to develop recommendations for bundled care that can be delivered in all settings that treat acute ICH, with a focus on European healthcare systems. FINDINGS In this consensus paper, we argue for widespread implementation of formalised care bundles in ICH, including specific metrics for time to treatment and criteria for the consideration of neurosurgical therapy. DISCUSSION There is an extraordinary opportunity to improve clinical care and clinical outcomes in this devastating disease. Substantial evidence already exists for a range of therapies that can and should be implemented now.
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Affiliation(s)
- Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Susann J Järhult
- Department of Medical Sciences, Uppsala University, Emergency Department, Uppsala University Hospital, Uppsala, Sweden
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Policlinico Umberto I, University La Sapienza Rome, Italy
| | - David Seiffge
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Hiren Patel
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
| | - Hens Bart Brouwers
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Catharina Jm Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst, Frankfurt and Heidelberg University Hospital, Heidelberg, Germany
| | - Walter Brian Gibler
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Teede H, Cadilhac DA, Purvis T, Kilkenny MF, Campbell BCV, English C, Johnson A, Callander E, Grimley RS, Levi C, Middleton S, Hill K, Enticott J. Learning together for better health using an evidence-based Learning Health System framework: a case study in stroke. BMC Med 2024; 22:198. [PMID: 38750449 PMCID: PMC11094907 DOI: 10.1186/s12916-024-03416-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 04/30/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit. MAIN TEXT Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement. CONCLUSIONS The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.
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Affiliation(s)
- Helena Teede
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia.
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia.
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia.
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia.
| | - Tara Purvis
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Level 2 Monash University Research, Victorian Heart Hospital, 631 Blackburn Rd, Clayton, VIC, Australia
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
| | - Bruce C V Campbell
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Heidelberg, VIC, Australia
- Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Coralie English
- School of Health Sciences, Heart and Stroke Program, University of Newcastle, Hunter Medical Research Institute, University Drive, Callaghan, NSW, Australia
| | - Alison Johnson
- Monash Partners Academic Health Science Centre, 43-51 Kanooka Grove, Clayton, VIC, Australia
| | - Emily Callander
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia
| | - Rohan S Grimley
- School of Medicine and Dentistry, Griffith University, Birtinya, QLD, Australia
- Clinical Excellence Division, Queensland Health, Brisbane, Australia
| | - Christopher Levi
- John Hunter Hospital, Hunter New England Local Health District and University of Newcastle, Sydney, NSW, Australia
| | - Sandy Middleton
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
- Nursing Research Institute, St Vincent's Health Network Sydney and and Australian Catholic University, Sydney, NSW, Australia
| | - Kelvin Hill
- Stroke Foundation, Level 7, 461 Bourke St, Melbourne, VIC, Australia
| | - Joanne Enticott
- Monash Centre for Health Research and Implementation, 43-51 Kanooka Grove, Clayton, VIC, Australia
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024:S0140-6736(24)00642-1. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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Eddelien HS, Grøntved S, Hedegaard JN, Thomsen T, Kruuse C, Johnsen SP. Quality of early stroke care and long-term mortality in patients with acute stroke: A nationwide follow-up study. Eur Stroke J 2024:23969873241249580. [PMID: 38706256 DOI: 10.1177/23969873241249580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
INTRODUCTION High quality of early stroke care is essential for optimizing the chance of a good patient outcome. The quality of care may be monitored by process performance measures (PPMs) and previous studies have found an association between fulfilment of PPMs and short-term mortality. However, the association with long-term mortality remains to be determined. We aimed to evaluate the association between fulfilment of PPMs and long-term mortality for patients with acute stroke in Denmark. PATIENTS AND METHODS We used data from Danish health care registers between 2008 and 2020 to identify all patients admitted with incident stroke (haemorrhagic (ICH) or ischaemic stroke). The quality of early stroke care was assessed using 10 PPMs. Mortality was compared using Cox proportional hazard ratios, risk ratios computed using Poisson regression, and standardized relative survival. RESULTS We included 102,742 patients; 9804 cases of ICH, 88,591 cases of ischaemic stroke, and 4347 cases of unspecified strokes. The cumulative 10-year mortality risk was 56.8%. Fulfilment of the individual PPMs was associated with adjusted hazard rate ratios of death between 0.76 and 0.96. Patients with 100% fulfilment of all PPMs had a lower 10-year post-stroke mortality (adjusted risk ratio 0.90) compared to the patients with 0%-49% fulfilment and a standardized relative survival of 81.3%, compared to the general population. CONCLUSION High quality of early stroke care was associated with lower long-term mortality following both ICH and ischaemic stroke, which emphasizes the importance of continued attention on the ability of stroke care providers to deliver high quality of early care.
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Affiliation(s)
- Heidi Shil Eddelien
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Neuroscience, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital Rigshospitalet, Herlev, Denmark
| | - Simon Grøntved
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital Rigshospitalet, Herlev, Denmark
- Region North Psychiatry, Aalborg, Denmark
| | - Jakob Nebeling Hedegaard
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thordis Thomsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Neuroscience, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Neuroscience, University of Copenhagen, Copenhagen, Denmark
- Department of Brain and Spinal Cord Injury, Neuroscience Center, Copenhagen University Hospital Rigshospitalet, Herlev, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Ryan D, Ikramuddin S, Alexander S, Buckley C, Feng W. Three Pillars of Recovery After Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Transl Stroke Res 2024:10.1007/s12975-024-01249-6. [PMID: 38602660 DOI: 10.1007/s12975-024-01249-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurologic disease with high mortality and disability. There have been global improvements in survival, which has contributed to the prevalence of patients living with long-term sequelae related to this disease. The focus of active research has traditionally centered on acute treatment to reduce mortality, but now there is a great need to study the course of short- and long-term recovery in these patients. In this narrative review, we aim to describe the core pillars in the preservation of cerebral function, prevention of complications, the recent literature studying neuroplasticity, and future directions for research to enhance recovery outcomes following aSAH.
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Affiliation(s)
- Dylan Ryan
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27704, USA
| | - Salman Ikramuddin
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | | | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27704, USA.
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Prust ML, Forman R, Ovbiagele B. Addressing disparities in the global epidemiology of stroke. Nat Rev Neurol 2024; 20:207-221. [PMID: 38228908 DOI: 10.1038/s41582-023-00921-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/18/2024]
Abstract
Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.
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Affiliation(s)
- Morgan L Prust
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bruce Ovbiagele
- Department of Neurology, University of California-San Francisco School of Medicine, San Francisco, CA, USA
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Ding R, Betihavas V, McElduff B, Dale S, Coughlan K, McInnes E, Middleton S, Fasugba O. Fever, Hyperglycemia, and Swallowing Management in Stroke Unit and Non-Stroke-Unit European Hospitals: A Quality in Acute Stroke Care (QASC) Europe Substudy. J Neurosci Nurs 2024; 56:42-48. [PMID: 38064588 DOI: 10.1097/jnn.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
ABSTRACT BACKGROUND: Stroke unit care reduces patient morbidity and mortality. The Quality in Acute Stroke Care Europe Study achieved significant large-scale translation of nurse-initiated protocols to manage Fever, hyperglycemia (Sugar), and Swallowing (FeSS) in 64 hospitals across 17 European countries. However, not all hospitals had stroke units. Our study aimed to compare FeSS protocol adherence in stroke unit versus non-stroke-unit hospitals. METHODS: An observational study using Quality in Acute Stroke Care Europe Study postimplementation data was undertaken. Hospitals were categorized using 4 evidence-based characteristics for defining a stroke unit, collected from an organizational survey of participating hospitals. Differences in FeSS Protocol adherence between stroke unit and non-stroke-unit hospitals were investigated using mixed-effects logistic regression, adjusting for age, sex, and National Institutes of Health Stroke Scale. RESULTS: Of the 56 hospitals from 16 countries providing organizational data, 34 (61%) met all 4 stroke unit characteristics, contributing data for 1825 of 2871 patients (64%) (stroke unit hospitals). Of the remaining 22 hospitals (39%), 17 (77%) met 3 of the 4 stroke unit characteristics (non-stroke-unit hospitals). There were no differences between hospitals with a stroke unit and those without for postimplementation adherence to fever (49% stroke unit vs 57% non-stroke unit; odds ratio [OR], 0.400; 95% confidence interval [CI], 0.087-1.844; P = .240), hyperglycemia (50% stroke unit vs 57% non-stroke unit; OR, 0.403; 95% CI, 0.087-1.856; P = .243), swallowing (75% stroke unit vs 60% non-stroke unit; OR, 1.702; 95% CI, 0.643-4.502; P = .284), or overall FeSS Protocol adherence (36% stroke unit vs 36% non-stroke unit; OR, 0.466; 95% CI, 0.106-2.043; P = .311). CONCLUSION: Our results demonstrate that the nurse-initiated FeSS Protocols can be implemented by hospitals regardless of stroke unit status. This is noteworthy because hospitals without stroke unit resources that care for acute stroke patients can potentially implement these protocols. Further effort is needed to ensure better adherence to the FeSS Protocols.
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Flomin Y, Dubenko A, Dubenko O, Sokolova L, Slobodin T, Shepotinnyk Y, Guliaieva M, Pezzella FR. Neurological Practice in the Time of War: Perspectives and Experiences from Ukraine. Semin Neurol 2024; 44:225-232. [PMID: 38485123 DOI: 10.1055/s-0044-1782515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The full-scale Russian invasion of Ukraine has significantly impacted the country's healthcare system. Insufficient infrastructure, destruction of medical facilities, and barriers to prevention and treatment efforts hinder the provision of timely, high-quality care to our patients. We aim to describe the impact of the war on neurological care across Ukraine. In this article, leading national experts in stroke, epilepsy, multiple sclerosis, and movement disorders describe their personal experience and efforts in organizing and providing care since the war started in February 2022. A neurologist who cared for patients in Mariupol recounts the first weeks of the war when the city was under constant attacks. An international stroke expert describes the role of Task Force for Ukraine, a European Stroke Organization initiative to support the Ukrainian stroke community. We discuss a series of critical challenges facing Ukraine's neurologists, patients, and healthcare delivery system, including shortages of personnel and medical supplies, disrupted logistics, and lack of funding. In addition, we highlight various interventions and strategies aimed at counteracting these challenges, including international support, collaborations within Ukraine, and initiatives enhancing the resilience of the Ukrainian neurology community. As the war is ongoing, this article emphasizes the pressing need for continuous support and investment in the Ukrainian healthcare system to preserve guaranteed access to high-quality healthcare for the Ukrainian people during the war and in its aftermath. Insights from the essays can inform the development and implementation of effective strategies and interventions tailored to such extraordinary circumstances.
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Affiliation(s)
- Yuriy Flomin
- Stroke Center, Medical Center 'Universal Clinic 'Oberig' and Bogomolets National Medical University, Kyiv, Ukraine
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Andriy Dubenko
- Department of Child Neurology and Paroxismal States, Institute of Neurology, Psychiatry and Narcology, National Academy of Medical Science of Ukraine, Kharkiv, Ukraine
| | - Olga Dubenko
- Department of Neurology and Child Neurology, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Larysa Sokolova
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | - Tatyana Slobodin
- Department of Neurology, Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine
| | - Yevhen Shepotinnyk
- Stroke Unit, Matsuk Mariupol Municipal Hospital No. 4, Mariupol, Ukraine
| | - Maryna Guliaieva
- Stroke Center, Medical Center 'Universal Clinic 'Oberig' and Bogomolets National Medical University, Kyiv, Ukraine
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
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Zhao JL, Holste KG, Pandey AS, Hu J, Wu G. Intracranial Pressure Monitoring: an Effective Technique to Balance Cerebral Perfusion and Blood Pressure Reduction in ICH Patients. Transl Stroke Res 2024; 15:409-410. [PMID: 36729279 DOI: 10.1007/s12975-023-01129-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 02/03/2023]
Affiliation(s)
- Jian-Lan Zhao
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, China
| | - Katherine G Holste
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, 48105, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, 48105, USA
| | - Jin Hu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, China
| | - Gang Wu
- Department of Neurosurgery, National Center for Neurological Disorders, Neurosurgical Institute of Fudan University, Shanghai Clinical Medical Center of Neurosurgery, Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, 200040, China.
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10
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Zhao Y, Xu Y, Ma D, Fang S, Zhi S, He M, Zhu X, Dong Y, Song D, Yiming A, Sun J. The impact of education/training on nurses caring for patients with stroke: a scoping review. BMC Nurs 2024; 23:90. [PMID: 38308293 PMCID: PMC10835862 DOI: 10.1186/s12912-024-01754-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/22/2024] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND Stroke survivors have complex needs that necessitate the expertise and skill of well-trained healthcare professionals to provide effective rehabilitation and long-term support. Limited knowledge exists regarding the availability of specialized education and training programs specifically designed for nurses caring for stroke patients. AIM This review aims to assess the content and methods of training for nurses caring for stroke patients, examine its impact on both nurses and patients, and identify key facilitators and barriers to its implementation. METHODS We conducted a comprehensive scoping review by reviewing multiple databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, Web of Science, Scopus, ProQuest Dissertations and Theses, Google Scholar, and Cochrane databases. Data extraction and narrative synthesis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. RESULTS Seventeen articles were included in this review. We found that education/training not only enhanced patients' self-care abilities, nursing outcomes, and satisfaction, but also had a positive impact on the knowledge, skills, and practices of nurses. The obstacles to education/training included feasibility and cost-effectiveness, while the driving factors were management support and participation, professional education/training, and controlled environment creation. CONCLUSIONS This review highlights the crucial role of education/training in enhancing stroke care provided by nurses. Effective education/training integrates various educational methods and management support to overcome implementation barriers and optimize clinical practice benefits. These findings indicate the necessity of universal and consistent stroke education/training for nurses to further improve patient outcomes in stroke care.
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Affiliation(s)
- Yanjie Zhao
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
- School of Nursing, Xinjiang Medical University, No.567 Shangde North Road, Urumqi, 830000, Xinjiang, People's Republic of China
| | - Yuezhen Xu
- School of Nursing, Xinjiang Medical University, No.567 Shangde North Road, Urumqi, 830000, Xinjiang, People's Republic of China
| | - Dongfei Ma
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Shuyan Fang
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Shengze Zhi
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Meng He
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Xiangning Zhu
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Yueyang Dong
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - DongPo Song
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Atigu Yiming
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China
| | - Jiao Sun
- School of Nursing, Jilin University, No.965 Xinjiang Street, Changchun, 130021, Jilin, People's Republic of China.
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Wilson S, Dowlatshahi D, Perry JJ. The third intensive care bundle with blood pressure reduction in acute cerebral haemorrhage trial (INTERACT3): an interactional, stepped wedge, cluster randomized controlled trial. CAN J EMERG MED 2024; 26:88-89. [PMID: 38300421 DOI: 10.1007/s43678-023-00638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/20/2023] [Indexed: 02/02/2024]
Affiliation(s)
- Samuel Wilson
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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McInnes E, Dale S, Bagot K, Coughlan K, Grimshaw J, Pfeilschifter W, Cadilhac DA, Fischer T, van der Merwe J, Middleton S. The Quality in Acute Stroke Care (QASC) global scale-up using a cascading facilitation framework: a qualitative process evaluation. BMC Health Serv Res 2024; 24:144. [PMID: 38287332 PMCID: PMC10823736 DOI: 10.1186/s12913-024-10617-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 01/18/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres. .We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework. METHODS The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. RESULTS Individual (n = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework). CONCLUSION A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.
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Affiliation(s)
- Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia.
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
| | - Kathleen Bagot
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
| | - Kelly Coughlan
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Jeremy Grimshaw
- Centre for Practice-Changing Research (CPCR), Ottawa Health Research Institute, Ottawa Hospital - General Campus; and University of Ottawa, Ottawa, ON, Canada
| | - Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany
- Department of Neurology, Germany Centre of Neurology and Neurosurgery, Goethe University, Frankfurt am Main, University Hospital Frankfurt, Frankfurt, Germany
| | - Dominique A Cadilhac
- Translational Public Health Division, Stroke and Ageing Research, School of Clinical Sciences, Monash University, Melbourne, Australia
- Public Health, Stroke Division, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | | | | | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne; and Australian Catholic University, Sydney, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
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Fanning JP, Campbell BCV, Bulbulia R, Gottesman RF, Ko SB, Floyd TF, Messé SR. Perioperative stroke. Nat Rev Dis Primers 2024; 10:3. [PMID: 38238382 DOI: 10.1038/s41572-023-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 01/23/2024]
Abstract
Ischaemic or haemorrhagic perioperative stroke (that is, stroke occurring during or within 30 days following surgery) can be a devastating complication following surgery. Incidence is reported in the 0.1-0.7% range in adults undergoing non-cardiac and non-neurological surgery, in the 1-5% range in patients undergoing cardiac surgery and in the 1-10% range following neurological surgery. However, higher rates have been reported when patients are actively assessed and in high-risk populations. Prognosis is significantly worse than stroke occurring in the community, with double the 30-day mortality, greater disability and diminished quality of life among survivors. Considering the annual volume of surgeries performed worldwide, perioperative stroke represents a substantial burden. Despite notable differences in aetiology, patient populations and clinical settings, existing clinical recommendations for perioperative stroke are extrapolated mainly from stroke in the community. Perioperative in-hospital stroke is unique with respect to the stroke occurring in other settings, and it is essential to apply evidence from other settings with caution and to identify existing knowledge gaps in order to effectively guide patient care and future research.
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Affiliation(s)
- Jonathon P Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Anaesthesia & Perfusion Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
- The George Institute for Global Health, Sydney, New South Wales, Australia.
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Bruce C V Campbell
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Sang-Bae Ko
- Department of Neurology and Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Thomas F Floyd
- Department of Anaesthesiology & Pain Management, Department of Cardiovascular and Thoracic Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven R Messé
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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14
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Rigual R, Fuentes B, Díez-Tejedor E. Management of acute ischemic stroke. Med Clin (Barc) 2023; 161:485-492. [PMID: 37532617 DOI: 10.1016/j.medcli.2023.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 08/04/2023]
Abstract
Ischemic stroke is a serious neurological condition that requires urgent attention. As a time-dependent disease, acute stroke management must be coordinated and effective to provide the best treatment as early as possible. The treatment of the acute phase of ischemic stroke includes general measures to ensure patient hemodynamic stability, the use of reperfusion therapies (intravenous thrombolytics and mechanical thrombectomy), improving cerebral protection by monitoring the homeostasis of certain variables as blood pressure, glycemia, temperature, or oxygenation, as well as preventing cerebral and systemic complications. Also, it is necessary an early planning of comprehensive rehabilitation. To prevent early recurrences, control of vascular risk factors and antithrombotic treatment is recommended. The management of patients with acute ischemic stroke aims to reverse initial symptoms, to prevent further brain damage, improve functional outcomes and avoid ischemic recurrences.
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Affiliation(s)
- Ricardo Rigual
- Servicio de Neurología y Centro de Ictus, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ (Hospital Universitario La Paz - Universidad Autónoma de Madrid), Madrid, España.
| | - Blanca Fuentes
- Servicio de Neurología y Centro de Ictus, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ (Hospital Universitario La Paz - Universidad Autónoma de Madrid), Madrid, España
| | - Exuperio Díez-Tejedor
- Servicio de Neurología y Centro de Ictus, Instituto de Investigación Sanitaria del Hospital Universitario La Paz - IdiPAZ (Hospital Universitario La Paz - Universidad Autónoma de Madrid), Madrid, España.
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15
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Bladin CF, Wah Cheung N, Dewey HM, Churilov L, Middleton S, Thijs V, Ekinci E, Levi CR, Lindley R, Donnan GA, Parsons MW, Meretoja A, Tiainen M, Choi PM, Cordato D, Brown H, Campbell BC, Davis SM, Cloud G, Grimley R, Lee-Archer M, Ghia D, Sanders L, Markus R, Muller C, Salvaris P, Wu T, Fink J. Management of Poststroke Hyperglycemia: Results of the TEXAIS Randomized Clinical Trial. Stroke 2023; 54:2962-2971. [PMID: 38011235 PMCID: PMC10664794 DOI: 10.1161/strokeaha.123.044568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Hyperglycemia in acute ischemic stroke reduces the efficacy of stroke thrombolysis and thrombectomy, with worse clinical outcomes. Insulin-based therapies are difficult to implement and may cause hypoglycemia. We investigated whether exenatide, a GLP-1 (glucagon-like peptide-1) receptor agonist, would improve stroke outcomes, and control poststroke hyperglycemia with minimal hypoglycemia. METHODS The TEXAIS trial (Treatment With Exenatide in Acute Ischemic Stroke) was an international, multicenter, phase 2 prospective randomized clinical trial (PROBE [Prospective Randomized Open Blinded End-Point] design) enrolling adult patients with acute ischemic stroke ≤9 hours of stroke onset to receive exenatide (5 µg BID subcutaneous injection) or standard care for 5 days, or until hospital discharge (whichever sooner). The primary outcome (intention to treat) was the proportion of patients with ≥8-point improvement in National Institutes of Health Stroke Scale score (or National Institutes of Health Stroke Scale scores 0-1) at 7 days poststroke. Safety outcomes included death, episodes of hyperglycemia, hypoglycemia, and adverse event. RESULTS From April 2016 to June 2021, 350 patients were randomized (exenatide, n=177, standard care, n=173). Median age, 71 years (interquartile range, 62-79), median National Institutes of Health Stroke Scale score, 4 (interquartile range, 2-8). Planned recruitment (n=528) was stopped early due to COVID-19 disruptions and funding constraints. The primary outcome was achieved in 97 of 171 (56.7%) in the standard care group versus 104 of 170 (61.2%) in the exenatide group (adjusted odds ratio, 1.22 [95% CI, 0.79-1.88]; P=0.38). No differences in secondary outcomes were observed. The per-patient mean daily frequency of hyperglycemia was significantly less in the exenatide group across all quartiles. No episodes of hypoglycemia were recorded over the treatment period. Adverse events of mild nausea and vomiting occurred in 6 (3.5%) exenatide patients versus 0 (0%) standard care with no withdrawal. CONCLUSIONS Treatment with exenatide did not reduce neurological impairment at 7 days in patients with acute ischemic stroke. Exenatide did significantly reduce the frequency of hyperglycemic events, without hypoglycemia, and was safe to use. Larger acute stroke trials using GLP-1 agonists such as exenatide should be considered. REGISTRATION URL: www.australianclinicaltrials.gov.au; Unique identifier: ACTRN12617000409370. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03287076.
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Affiliation(s)
- Christopher F. Bladin
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Ngai Wah Cheung
- Faculty of Medicine and Health, Westmead Hospital (N.W.C.), University of Sydney, New South Wales, Australia
| | - Helen M. Dewey
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
| | - Leonid Churilov
- Department of Medicine (L.C.), University of Melbourne, Parkville, Australia
- Australian Centre for Accelerating Diabetes Innovations (L.C., E.E.), University of Melbourne, Parkville, Australia
- Austin Health, Australia (L.C., E.E.)
| | - Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia (S.M.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
| | - Elif Ekinci
- Australian Centre for Accelerating Diabetes Innovations (L.C., E.E.), University of Melbourne, Parkville, Australia
- Austin Health, Australia (L.C., E.E.)
| | - Christopher R. Levi
- Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, Australia (C.R.L.)
| | - Richard Lindley
- Faculty of Medicine and Health, Sydney Medical School (R.L.), University of Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, Australia (R.L.)
| | - Geoffrey A. Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
| | - Mark W. Parsons
- Department of Neurology, Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, Australia (M.W.P., D.C.)
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Finland (A.M., M.T.)
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, Finland (A.M., M.T.)
| | - Philip M.C. Choi
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
| | - Dennis Cordato
- Department of Neurology, Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, Australia (M.W.P., D.C.)
| | - Helen Brown
- Princess Alexandra Hospital, Brisbane, Queensland, Australia (H.B.)
| | - Bruce C.V. Campbell
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
| | - Geoffrey Cloud
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Department of Neurology, Monash University, Clayton, Victoria, Australia (C.F.B., H.M.D., P.M.C.C.)
- Department of Medicine (L.C.), University of Melbourne, Parkville, Australia
- The Florey Institute of Neuroscience and Mental Health (C.F.B., V.T., B.C.V.C.), University of Melbourne, Parkville, Australia
- Australian Centre for Accelerating Diabetes Innovations (L.C., E.E.), University of Melbourne, Parkville, Australia
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital (G.A.D., B.C.V.C., S.M.D), University of Melbourne, Parkville, Australia
- Faculty of Medicine and Health, Westmead Hospital (N.W.C.), University of Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School (R.L.), University of Sydney, New South Wales, Australia
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne and School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia (S.M.)
- Austin Health, Australia (L.C., E.E.)
- Department of Neurology, Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, Australia (C.R.L.)
- George Institute for Global Health, Sydney, Australia (R.L.)
- Department of Neurology, Ingham Institute for Applied Medical Research, Liverpool Hospital, University of New South Wales, Sydney, Australia (M.W.P., D.C.)
- Department of Neurology, Helsinki University Hospital, Finland (A.M., M.T.)
- Princess Alexandra Hospital, Brisbane, Queensland, Australia (H.B.)
- Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia, Australia (D.G.)
- Department of Medicine, St John of God Midland Public and Private Hospitals, Perth, Western Australia (P.S.)
- Department of Neurology, Launceston General Hospital, Tasmania, Australia (M.L.-A.)
- Department of Neurology, Christchurch Hospital, New Zealand (T.W., J.F.)
- Department of Neurosciences, St Vincent’s Hospital, Melbourne, Australia (L.S.)
- Department of Neurology, St Vincent’s Hospital, Sydney, Australia (R.M.)
- School of Medicine and Dentistry, Griffith University, Birtinya, Queensland, Australia (R.G.)
- Department of Neurology, Royal Brisbane and Women’s Hospital, University of Queensland, Brisbane, Australia (C.M.)
| | - Rohan Grimley
- School of Medicine and Dentistry, Griffith University, Birtinya, Queensland, Australia (R.G.)
| | - Matthew Lee-Archer
- Department of Neurology, Launceston General Hospital, Tasmania, Australia (M.L.-A.)
| | - Darshan Ghia
- Department of Neurology, Fiona Stanley Hospital, Perth, Western Australia, Australia (D.G.)
| | - Lauren Sanders
- Department of Neurosciences, St Vincent’s Hospital, Melbourne, Australia (L.S.)
| | - Romesh Markus
- Department of Neurology, St Vincent’s Hospital, Sydney, Australia (R.M.)
| | - Claire Muller
- Department of Neurology, Royal Brisbane and Women’s Hospital, University of Queensland, Brisbane, Australia (C.M.)
| | - Patrick Salvaris
- Department of Medicine, St John of God Midland Public and Private Hospitals, Perth, Western Australia (P.S.)
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.W., J.F.)
| | - John Fink
- Department of Neurology, Christchurch Hospital, New Zealand (T.W., J.F.)
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Murray J, Gunasekaran S, Doeltgen S, George S, Harvey G. Implementing a Screen-Clean-Hydrate bundle of care for improving swallow screening, oral health, and hydration in acute stroke: Protocol for a Type 2 hybrid-effectiveness pre-post study. Res Nurs Health 2023; 46:566-575. [PMID: 37837417 DOI: 10.1002/nur.22346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/13/2023] [Accepted: 09/29/2023] [Indexed: 10/16/2023]
Abstract
Stroke clinical guidelines recommend care processes that optimize patient outcomes and minimize hospital-acquired complications. However, audits and surveys illustrate that recommended care is not always consistently or thoroughly implemented. This paper outlines the methods for implementing and evaluating a new bundle of care. Screen-Clean-Hydrate bundles together recommendations from the Australian Clinical Guidelines for Stroke Management and supplements these with evidence-informed best practice from the literature for: swallow screening within 4 h of presentation to hospital (Screen); oral health assessment and delivery of oral care (Clean); and hydration assessment and management (Hydrate). The study is a pre-post Type 2 hybrid effectiveness/implementation design with an embedded process evaluation, which will be conducted in two acute stroke units in a capital city of Australia. The integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework will be used to guide study design, conduct, and evaluation. Clinical effectiveness will be measured by rates of hospital-acquired complications and proxy measures of cost (length of stay, procedure costs) for 60 patient participants pre- and postimplementation. Implementation outcomes will focus on acceptability, feasibility, uptake and fidelity, and identification of barriers and enablers to implementation through staff interviews, medical record audits, and researcher field notes. Due to its design as a hybrid effectiveness/implementation study, once completed, the study will provide information on both intervention and implementation effectiveness, including details of successful and unsuccessful multidisciplinary implementation strategies. This will inform a larger multisite effectiveness/implementation trial for future upscale, leading to improved compliance with stroke guidelines and therefore stroke outcomes.
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Affiliation(s)
- Joanne Murray
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Caring Futures Institute, Flinders University, Adelaide, Australia
- Swallowing Neurorehabilitation Research Laboratory, Flinders University, Adelaide, Australia
| | - Sulekha Gunasekaran
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Sebastian Doeltgen
- Speech Pathology, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
- Caring Futures Institute, Flinders University, Adelaide, Australia
- Swallowing Neurorehabilitation Research Laboratory, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Gillian Harvey
- Caring Futures Institute, Flinders University, Adelaide, Australia
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Caso V, Martins S, Mikulik R, Middleton S, Groppa S, Pandian JD, Thang NH, Danays T, van der Merwe J, Fischer T, Hacke W. Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide. Int J Stroke 2023; 18:898-907. [PMID: 37226325 PMCID: PMC10507995 DOI: 10.1177/17474930231180067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 05/26/2023]
Abstract
The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential.Established in 2016, the Angels Initiative is an international, not-for-profit, public-private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold/platinum/diamond) for all stroke-ready hospitals across the world.The Angels Initiative has supported over 1700 hospitals (>1000 in LMICs) that did not previously treat stroke patients to become "stroke ready." Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced "door to treatment time" (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially.The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of >10,000 stroke-ready hospitals by 2030, and >7500 of these in LMICs.
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Affiliation(s)
| | - Sheila Martins
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Robert Mikulik
- International Clinical Research Center, St. Anne’s University Hospital, Brno, Czech Republic
| | - Sandy Middleton
- Australian Catholic University and St. Vincent’s Health Network Sydney, Sydney, NSW, Australia
| | - Stanislav Groppa
- State University of Medicine and Pharmacy ‘Nicolae Testemitanu,’ Chisinau, Moldova
| | | | | | | | - Jan van der Merwe
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Werner Hacke
- Ruprecht-Karl-University Heidelberg, Heidelberg, Germany
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18
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Foy R, Ivers NM, Grimshaw JM, Wilson PM. What is the role of randomised trials in implementation science? Trials 2023; 24:537. [PMID: 37587521 PMCID: PMC10428627 DOI: 10.1186/s13063-023-07578-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/04/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND There is a consistent demand for implementation science to inform global efforts to close the gap between evidence and practice. Key evaluation questions for any given implementation strategy concern the assessment and understanding of effects. Randomised trials are generally accepted as offering the most trustworthy design for establishing effectiveness but may be underused in implementation science. MAIN BODY There is a continuing debate about the primacy of the place of randomised trials in evaluating implementation strategies, especially given the evolution of more rigorous quasi-experimental designs. Further critiques of trials for implementation science highlight that they cannot provide 'real world' evidence, address urgent and important questions, explain complex interventions nor understand contextual influences. We respond to these critiques of trials and highlight opportunities to enhance their timeliness and relevance through innovative designs, embedding within large-scale improvement programmes and harnessing routine data. Our suggestions for optimising the conditions for randomised trials of implementation strategies include strengthening partnerships with policy-makers and clinical leaders to realise the long-term value of rigorous evaluation and accelerating ethical approvals and decluttering governance procedures for lower risk studies. CONCLUSION Policy-makers and researchers should avoid prematurely discarding trial designs when evaluating implementation strategies and work to enhance the conditions for their conduct.
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Affiliation(s)
- Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Noah M Ivers
- Women's College Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | - Paul M Wilson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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19
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Lynch EA, Bulto LN, Cheng H, Craig L, Luker JA, Bagot KL, Thayabaranathan T, Janssen H, McInnes E, Middleton S, Cadilhac DA. Interventions for the uptake of evidence-based recommendations in acute stroke settings. Cochrane Database Syst Rev 2023; 8:CD012520. [PMID: 37565934 PMCID: PMC10416310 DOI: 10.1002/14651858.cd012520.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
BACKGROUND There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care. OBJECTIVES To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date. SELECTION CRITERIA We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations. MAIN RESULTS We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes. AUTHORS' CONCLUSIONS We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.
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Affiliation(s)
| | - Lemma N Bulto
- Caring Futures Institute, Flinders University, Adelaide, Australia
| | - Heilok Cheng
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Julie A Luker
- Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Kathleen L Bagot
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
| | | | - Heidi Janssen
- School of Health Sciences, The University of Newcastle, Callaghan, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia, Sydney, Australia
- NSW School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Dominique A Cadilhac
- Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- Stroke and Ageing Research, School of Clinical Sciences, Monash University, Clayton, Australia
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Ziai WC, Bower M, Hanley DF. Acute spontaneous intracerebral haemorrhage: does a care bundle approach work? Lancet 2023; 402:2-3. [PMID: 37245518 DOI: 10.1016/s0140-6736(23)00911-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 05/30/2023]
Affiliation(s)
- Wendy C Ziai
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD 21287, USA; Department of Neurology, Division of Neurocritical Care, Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Matthew Bower
- Department of Neurology, Division of Neurocritical Care, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Daniel F Hanley
- Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD 21287, USA
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21
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
AIM The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage. METHODS A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Ma L, Hu X, Song L, Chen X, Ouyang M, Billot L, Li Q, Malavera A, Li X, Muñoz-Venturelli P, de Silva A, Thang NH, Wahab KW, Pandian JD, Wasay M, Pontes-Neto OM, Abanto C, Arauz A, Shi H, Tang G, Zhu S, She X, Liu L, Sakamoto Y, You S, Han Q, Crutzen B, Cheung E, Li Y, Wang X, Chen C, Liu F, Zhao Y, Li H, Liu Y, Jiang Y, Chen L, Wu B, Liu M, Xu J, You C, Anderson CS. The third Intensive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3): an international, stepped wedge cluster randomised controlled trial. Lancet 2023; 402:27-40. [PMID: 37245517 PMCID: PMC10401723 DOI: 10.1016/s0140-6736(23)00806-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/03/2023] [Accepted: 04/17/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Early control of elevated blood pressure is the most promising treatment for acute intracerebral haemorrhage. We aimed to establish whether implementing a goal-directed care bundle incorporating protocols for early intensive blood pressure lowering and management algorithms for hyperglycaemia, pyrexia, and abnormal anticoagulation, implemented in a hospital setting, could improve outcomes for patients with acute spontaneous intracerebral haemorrhage. METHODS We performed a pragmatic, international, multicentre, blinded endpoint, stepped wedge cluster randomised controlled trial at hospitals in nine low-income and middle-income countries (Brazil, China, India, Mexico, Nigeria, Pakistan, Peru, Sri Lanka, and Viet Nam) and one high-income country (Chile). Hospitals were eligible if they had no or inconsistent relevant, disease-specific protocols, and were willing to implement the care bundle to consecutive patients (aged ≥18 years) with imaging-confirmed spontaneous intracerebral haemorrhage presenting within 6 h of the onset of symptoms, had a local champion, and could provide the required study data. Hospitals were centrally randomly allocated using permuted blocks to three sequences of implementation, stratified by country and the projected number of patients to be recruited over the 12 months of the study period. These sequences had four periods that dictated the order in which the hospitals were to switch from the control usual care procedure to the intervention implementation of the care bundle procedure to different clusters of patients in a stepped manner. To avoid contamination, details of the intervention, sequence, and allocation periods were concealed from sites until they had completed the usual care control periods. The care bundle protocol included the early intensive lowering of systolic blood pressure (target <140 mm Hg), strict glucose control (target 6·1-7·8 mmol/L in those without diabetes and 7·8-10·0 mmol/L in those with diabetes), antipyrexia treatment (target body temperature ≤37·5°C), and rapid reversal of warfarin-related anticoagulation (target international normalised ratio <1·5) within 1 h of treatment, in patients where these variables were abnormal. Analyses were performed according to a modified intention-to-treat population with available outcome data (ie, excluding sites that withdrew during the study). The primary outcome was functional recovery, measured with the modified Rankin scale (mRS; range 0 [no symptoms] to 6 [death]) at 6 months by masked research staff, analysed using proportional ordinal logistic regression to assess the distribution in scores on the mRS, with adjustments for cluster (hospital site), group assignment of cluster per period, and time (6-month periods from Dec 12, 2017). This trial is registered at Clinicaltrials.gov (NCT03209258) and the Chinese Clinical Trial Registry (ChiCTR-IOC-17011787) and is completed. FINDINGS Between May 27, 2017, and July 8, 2021, 206 hospitals were assessed for eligibility, of which 144 hospitals in ten countries agreed to join and were randomly assigned in the trial, but 22 hospitals withdrew before starting to enrol patients and another hospital was withdrawn and their data on enrolled patients was deleted because regulatory approval was not obtained. Between Dec 12, 2017, and Dec 31, 2021, 10 857 patients were screened but 3821 were excluded. Overall, the modified intention-to-treat population included 7036 patients enrolled at 121 hospitals, with 3221 assigned to the care bundle group and 3815 to the usual care group, with primary outcome data available in 2892 patients in the care bundle group and 3363 patients in the usual care group. The likelihood of a poor functional outcome was lower in the care bundle group (common odds ratio 0·86; 95% CI 0·76-0·97; p=0·015). The favourable shift in mRS scores in the care bundle group was generally consistent across a range of sensitivity analyses that included additional adjustments for country and patient variables (0·84; 0·73-0·97; p=0·017), and with different approaches to the use of multiple imputations for missing data. Patients in the care bundle group had fewer serious adverse events than those in the usual care group (16·0% vs 20·1%; p=0·0098). INTERPRETATION Implementation of a care bundle protocol for intensive blood pressure lowering and other management algorithms for physiological control within several hours of the onset of symptoms resulted in improved functional outcome for patients with acute intracerebral haemorrhage. Hospitals should incorporate this approach into clinical practice as part of active management for this serious condition. FUNDING Joint Global Health Trials scheme from the Department of Health and Social Care, the Foreign, Commonwealth & Development Office, and the Medical Research Council and Wellcome Trust; West China Hospital; the National Health and Medical Research Council of Australia; Sichuan Credit Pharmaceutic and Takeda China.
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Affiliation(s)
- Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lili Song
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Menglu Ouyang
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xi Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Clinical Research Center, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | - Kolawole W Wahab
- Department of Medicine, University of Ilorin & University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Jeyaraj D Pandian
- Neurology Department, Christian Medical College and Hospital, Ludhiana, India
| | - Mohammad Wasay
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Octavio M Pontes-Neto
- Department of Neurology, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Carlos Abanto
- The Cerebrovascular Disease Research Center, National Institute of Neurological Sciences, Lima, Peru
| | - Antonio Arauz
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Haiping Shi
- Department of Neurosurgery, Suining Central Hospital, Suining, China
| | - Guanghai Tang
- Department of Neurology, Liaoning Thrombus Treatment Centre of Integrated Chinese and Western Medicine, Shenyang, China
| | - Sheng Zhu
- Department of Neurosurgery, Dazhu County People's Hospital, Dazhou, China
| | - Xiaochun She
- Department of Neurosurgery, Jiangsu Rudong County People's Hospital, Nantong, China
| | - Leibo Liu
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Yuki Sakamoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Shoujiang You
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Qiao Han
- Department of Neurology, Suzhou Hospital of Traditional Chinese Medicine, Suzhou, China
| | - Bernard Crutzen
- Department of Radiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Radiology, Grand Hôpital de Charleroi, Charleroi, Belgium
| | - Emily Cheung
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yunke Li
- The George Institute for Global Health China, Beijing, China
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Chen Chen
- The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Feifeng Liu
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yang Zhao
- The George Institute for Global Health China, Beijing, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Jiang
- Department of Nursing and Evidence-based Nursing Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ming Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Craig S Anderson
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China; The George Institute for Global Health China, Beijing, China; The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Clinical Research Center, Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile; Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia; Heart Health Research Center, Beijing, China.
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23
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Tishkovskaya SV, Sutton CJ, Thomas LH, Watkins CL. Determining the sample size for a cluster-randomised trial using knowledge elicitation: Bayesian hierarchical modelling of the intracluster correlation coefficient. Clin Trials 2023; 20:293-306. [PMID: 37036110 PMCID: PMC10262340 DOI: 10.1177/17407745231164569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
BACKGROUND The intracluster correlation coefficient is a key input parameter for sample size determination in cluster-randomised trials. Sample size is very sensitive to small differences in the intracluster correlation coefficient, so it is vital to have a robust intracluster correlation coefficient estimate. This is often problematic because either a relevant intracluster correlation coefficient estimate is not available or the available estimate is imprecise due to being based on small-scale studies with low numbers of clusters. Misspecification may lead to an underpowered or inefficiently large and potentially unethical trial. METHODS We apply a Bayesian approach to produce an intracluster correlation coefficient estimate and hence propose sample size for a planned cluster-randomised trial of the effectiveness of a systematic voiding programme for post-stroke incontinence. A Bayesian hierarchical model is used to combine intracluster correlation coefficient estimates from other relevant trials making use of the wealth of intracluster correlation coefficient information available in published research. We employ knowledge elicitation process to assess the relevance of each intracluster correlation coefficient estimate to the planned trial setting. The team of expert reviewers assigned relevance weights to each study, and each outcome within the study, hence informing parameters of Bayesian modelling. To measure the performance of experts, agreement and reliability methods were applied. RESULTS The 34 intracluster correlation coefficient estimates extracted from 16 previously published trials were combined in the Bayesian hierarchical model using aggregated relevance weights elicited from the experts. The intracluster correlation coefficients available from external sources were used to construct a posterior distribution of the targeted intracluster correlation coefficient which was summarised as a posterior median with a 95% credible interval informing researchers about the range of plausible sample size values. The estimated intracluster correlation coefficient determined a sample size of between 450 (25 clusters) and 480 (20 clusters), compared to 500-600 from a classical approach. The use of quantiles, and other parameters, from the estimated posterior distribution is illustrated and the impact on sample size described. CONCLUSION Accounting for uncertainty in an unknown intracluster correlation coefficient, trials can be designed with a more robust sample size. The approach presented provides the possibility of incorporating intracluster correlation coefficients from various cluster-randomised trial settings which can differ from the planned study, with the difference being accounted for in the modelling. By using expert knowledge to elicit relevance weights and synthesising the externally available intracluster correlation coefficient estimates, information is used more efficiently than in a classical approach, where the intracluster correlation coefficient estimates tend to be less robust and overly conservative. The intracluster correlation coefficient estimate constructed is likely to produce a smaller sample size on average than the conventional strategy of choosing a conservative intracluster correlation coefficient estimate. This may therefore result in substantial time and resources savings.
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Affiliation(s)
- Svetlana V Tishkovskaya
- Lancashire Clinical Trials Unit, Faculty of Health and Care, University of Central Lancashire, Preston, UK
| | - Chris J Sutton
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Lois H Thomas
- Faculty of Allied Health and Wellbeing, University of Central Lancashire, Preston, UK
| | - Caroline L Watkins
- Lancashire Clinical Trials Unit, Faculty of Health and Care, University of Central Lancashire, Preston, UK
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24
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Sanjuan E, Pancorbo O, Santana K, Miñarro O, Sala V, Muchada M, Boned S, Juega JM, Pagola J, García-Tornel Á, Requena M, Rodríguez-Villatoro N, Rodríguez-Luna D, Deck M, Ribo M, Molina CA, Meler P, Romero V, Dalmases G, Rodríguez-Samaniego MT, Calleja L, Gutierrez T, Peña L, Gallego JC, Lorenzo E, Gonzalez Y, Moreno R, Rubiera M. Management of acute stroke. Specific nursing care and treatments in the stroke unit. Neurologia 2023:S2173-5808(23)00022-6. [PMID: 37120108 DOI: 10.1016/j.nrleng.2020.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/29/2020] [Indexed: 05/01/2023] Open
Abstract
OBJECTIVE This study provides a series of updated, evidence-based recommendations for the management of acute stroke. We aim to lay a foundation for the development of individual centres' internal protocols, serving as a reference for nursing care. METHODS We review the available evidence on acute stroke care. The most recent national and international guidelines were consulted. Levels of evidence and degrees of recommendation are based on the Oxford Centre for Evidence-Based Medicine classification. RESULTS The study describes prehospital acute stroke care, the operation of the code stroke protocol, care provided by the stroke team upon the patient's arrival at hospital, reperfusion treatments and their limitations, admission to the stroke unit, nursing care in the stroke unit, and discharge from hospital. CONCLUSIONS These guidelines provide general, evidence-based recommendations to guide professionals who care for patients with acute stroke. However, limited data are available on some aspects, showing the need for continued research on acute stroke management.
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Affiliation(s)
- E Sanjuan
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain.
| | - O Pancorbo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - K Santana
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - O Miñarro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Sala
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Muchada
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - S Boned
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J M Juega
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J Pagola
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Á García-Tornel
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Requena
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - N Rodríguez-Villatoro
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - D Rodríguez-Luna
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Deck
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Ribo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - C A Molina
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - P Meler
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - V Romero
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - G Dalmases
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M T Rodríguez-Samaniego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Calleja
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - T Gutierrez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - L Peña
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - J C Gallego
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - E Lorenzo
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Y Gonzalez
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - R Moreno
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - M Rubiera
- Unidad de Ictus, Servicio de Neurología, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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Lip GYH, Lenarczyk R, Pastori D, Ntaios G, Doehner W, Schnabel R. Post-stroke cardiovascular management: Current concepts, integrated care and future developments. Curr Probl Cardiol 2023; 48:101738. [PMID: 37040854 DOI: 10.1016/j.cpcardiol.2023.101738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023]
Abstract
After an ischaemic stroke patients often have cardiovascular complications known as stroke-heart syndrome. The cardiovascular management after stroke has a significant impact on life expectancy as well as the quality of life. The development and implementation of management pathways to improve outcomes for patients with stroke-heart syndrome requires a multidisciplinary involvement from health care professionals from primary, secondary and tertiary prevention levels. A holistic, integrated care approach could follow the ABC pathway: A) Appropriate antithrombotic therapy in all stroke/TIA patients in the acute phase as well as recommendations for the longer term treatment regimen are required to avoid recurrent stroke. B) For better functional and psychological status the assessment of post-stroke cognitive and physical impairment, depression, and anxiety as part of routine post-stroke work-up in every patient is necessary. C) Cardiovascular risk factors and comorbidities management further includes cardiovascular work-up, adapted drug therapy, but often also lifestyle changes that are central to the success of integrated care for stroke-heart syndrome. Greater patient and family/caregiver involvement in planning actions and the input and feedback on optimizing stroke care pathways is needed. Achieving integrated care is challenging and highly context dependent on different healthcare levels. A tailored approach will utilize a variety of enabling factors. In this narrative review, we summarize the current evidence and outline potential factors that will contribute to the successful implementation of integrated cardiovascular care for stroke-heart syndrome management.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Radosław Lenarczyk
- The Medical University of Silesia, Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Daniele Pastori
- Emergency Medicine Unit - Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Renate Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Miller C, Gibson JME, Jones S, Timoroska AM, Maley A, Romagnoli E, Chesworth BM, Watkins CL. How is hydration assessed and managed in acute stroke? A qualitative study of healthcare staff's knowledge, attitudes and experiences. J Clin Nurs 2023; 32:1089-1102. [PMID: 35437838 DOI: 10.1111/jocn.16332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/29/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To explore healthcare staff's experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. BACKGROUND Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. DESIGN A descriptive qualitative study reported following the COREQ guidelines. METHODS Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multidisciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. RESULTS The themes were mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients' comorbidities and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. CONCLUSION Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood and addressed. RELEVANCE TO CLINICAL PRACTICE Multidisciplinary teamwork is important in hydration care after stroke, but clarity is required about the specific contributions of each team member. Without this, hydration care becomes 'everybody's and nobody's job'.
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Affiliation(s)
- Colette Miller
- Stroke Research Team, University of Central Lancashire, Preston, UK
| | | | - Stephanie Jones
- Stroke Research Team, University of Central Lancashire, Preston, UK
| | - Anne-Marie Timoroska
- Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Preston, UK
| | - Alex Maley
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool Victoria Hospital, Blackpool, UK
| | - Elisa Romagnoli
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool Victoria Hospital, Blackpool, UK
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Lian Z, Xu Y, Wang C, Chen Y, Yuan L, Liu Z, Liu Y, He P, Cai Z, Zhao J. Gut microbiota-derived melatonin from Puerariae Lobatae Radix-resistant starch supplementation attenuates ischemic stroke injury via a positive microbial co-occurrence pattern. Pharmacol Res 2023; 190:106714. [PMID: 36863429 DOI: 10.1016/j.phrs.2023.106714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/17/2023] [Accepted: 02/27/2023] [Indexed: 03/04/2023]
Abstract
Ischemic stroke is closely associated with gut microbiota dysbiosis and intestinal barrier dysfunction. Prebiotic intervention could modulate the intestinal microbiota, thus considered a practical strategy for neurological disorders. Puerariae Lobatae Radix-resistant starch (PLR-RS) is a potential novel prebiotic; however, its role in ischemic stroke remains unknown. This study aimed to clarify the effects and underlying mechanisms of PLR-RS in ischemic stroke. Middle cerebral artery occlusion surgery was performed to establish a model of ischemic stroke in rats. After gavage for 14 days, PLR-RS attenuated ischemic stroke-induced brain impairment and gut barrier dysfunction. Moreover, PLR-RS rescued gut microbiota dysbiosis and enriched Akkermansia and Bifidobacterium. We transplanted the fecal microbiota from PLR-RS-treated rats into rats with ischemic stroke and found that the brain and colon damage were also ameliorated. Notably, we found that PLR-RS promoted the gut microbiota to produce a higher level of melatonin. Intriguingly, exogenous gavage of melatonin attenuated ischemic stroke injury. In particular, melatonin attenuated brain impairment via a positive co-occurrence pattern in the intestinal microecology. Specific beneficial bacteria served as leaders or keystone species to promoted gut homeostasis, such as Enterobacter, Bacteroidales_S24-7_group, Prevotella_9, Ruminococcaceae and Lachnospiraceae. Thus, this new underlying mechanism could explain that the therapeutic efficacy of PLR-RS on ischemic stroke at least partly attributed to gut microbiota-derived melatonin. In summary, improving intestinal microecology by prebiotic intervention and melatonin supplementation in the gut were found to be effective therapies for ischemic stroke.
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Affiliation(s)
- Zhuoshi Lian
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Ying Xu
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Chan Wang
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Ye Chen
- Department of Gastroenterology, Integrative Clinical Microecology Center, Shenzhen Hospital, Southern Medical University, Shenzhen 518100, China
| | - Li Yuan
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Zhongyu Liu
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Yarui Liu
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Peishi He
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China
| | - Zheng Cai
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China; Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou 510315, China.
| | - Jie Zhao
- NMPA Key Laboratory for Research and Evaluation of Drug Metabolism, Guangdong Provincial Key Laboratory of New Drug Screening, School of Pharmaceutical Sciences, Southern Medical University, Guangzhou 510515, China; Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, Guangzhou 510315, China; Microbiome Medicine Center, Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China.
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Landman TRJ, Schoon Y, Warlé MC, Meijer FJA, Leeuw FED, Thijssen DHJ. The effect of repeated remote ischemic postconditioning after an ischemic stroke (REPOST): A randomized controlled trial. Int J Stroke 2023; 18:296-303. [PMID: 35593677 PMCID: PMC9941800 DOI: 10.1177/17474930221104710] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS A potential strategy to treat ischemic stroke may be the application of repeated remote ischemic postconditioning (rIPostC). This consists of several cycles of brief periods of limb ischemia followed by reperfusion, which can be applied by inflating a simple blood pressure cuff and subsequently could result in neuroprotection after stroke. METHODS Adult patients admitted with an ischemic stroke in the past 24 h were randomized 1:1 to repeated rIPostC or sham-conditioning. Repeated rIPostC was performed by inflating a blood pressure cuff around the upper arm (4 × 5 min at 200 mm Hg), which was repeated twice daily during hospitalization with a maximum of 4 days. Primary outcome was infarct size after 4 days or at discharge. Secondary outcomes included the modified Rankin Scale (mRS)-score after 12 weeks and the National Institutes of Health Stroke Scale (NIHSS) at discharge. RESULTS The trial was preliminarily stopped after we included 88 of the scheduled 180 patients (average age: 70 years, 68% male) into rIPostC (n = 40) and sham-conditioning (n = 48). Median infarct volume was 2.19 mL in rIPostC group and 5.90 mL in sham-conditioning, which was not significantly different between the two groups (median difference: 3.71; 95% CI: -0.56 to 6.09; p = 0.31). We found no significant shift in the mRS score distribution between groups. The adjusted common odds ratio was 2.09 (95% CI: 0.88-5.00). We found no significant difference in the NIHSS score between groups (median difference: 1.00; 95% CI: -0.99 to 1.40; p = 0.51). CONCLUSION This study found no significant improvement in infarct size or clinical outcome in patients with an acute ischemic stroke who were treated with repeated remote ischemic postconditioning. However, due to a lower-than-expected inclusion rate, no definitive conclusions about the effectiveness of rIPostC can be drawn.
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Affiliation(s)
- Thijs RJ Landman
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands,Thijs RJ Landman, Department of Physiology,
Radboud Institute for Health Sciences, Radboud University Medical Center, Geert
Grooteplein Zuid 10, 6525 GA Nijmegen, Gelderland, The Netherlands.
| | - Yvonne Schoon
- Department of Geriatric Medicine,
Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frederick JA Meijer
- Department of Medical Imaging, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - Frank-Erik De Leeuw
- Donders Center for Medical
Neuroscience, Department of Neurology, Radboud University Medical Center, Nijmegen,
The Netherlands
| | - Dick HJ Thijssen
- Department of Physiology, Radboud
Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The
Netherlands
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Paul N, Ribet Buse E, Knauthe AC, Nothacker M, Weiss B, Spies CD. Effect of ICU care bundles on long-term patient-relevant outcomes: a scoping review. BMJ Open 2023; 13:e070962. [PMID: 36806060 PMCID: PMC9944310 DOI: 10.1136/bmjopen-2022-070962] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE Care bundles are considered a key tool to improve bedside quality of care in the intensive care unit (ICU). We explored their effect on long-term patient-relevant outcomes. DESIGN Systematic literature search and scoping review. DATA SOURCES We searched PubMed, Embase, CINAHL, APA PsycInfo, Web of Science, CDSR and CENTRAL for keywords of intensive care, care bundles, patient-relevant outcomes, and follow-up studies. ELIGIBILITY CRITERIA Original articles with patients admitted to adult ICUs assessing bundle implementations and measuring long-term (ie, ICU discharge or later) patient-relevant outcomes (ie, mortality, health-related quality of life (HrQoL), post-intensive care syndrome (PICS), care-related outcomes, adverse events, and social health). DATA EXTRACTION AND SYNTHESIS After dual, independent, two-stage selection and charting, eligible records were critically appraised and assessed for bundle type, implementation strategies, and effects on long-term patient-relevant outcomes. RESULTS Of 2012 records, 38 met inclusion criteria; 55% (n=21) were before-after studies, 21% (n=8) observational cohort studies, 13% (n=5) randomised controlled trials, and 11% (n=4) had other designs. Bundles pertained to sepsis (n=11), neurocognition (n=6), communication (n=4), early rehabilitation (n=3), pharmacological discontinuation (n=3), ventilation (n=2) or combined bundles (n=9). Almost two-thirds of the studies reported on survival (n=24), 45% (n=17) on care-related outcomes (eg, discharge disposition), and 13% (n=5) of studies on HrQoL. Regarding PICS, 24% (n=9) assessed cognition, 13% (n=5) physical health, and 11% (n=4) mental health, up to 1 year after discharge. The effects of bundles on long-term patient-relevant outcomes was inconclusive, except for a positive effect of sepsis bundles on survival. The inconclusive effects may have been due to the high risk of bias in included studies and the variability in implementation strategies, instruments, and follow-up times. CONCLUSIONS There is a need to explore the long-term effects of ICU bundles on HrQoL and PICS. Closing this knowledge gap appears vital to determine if there is long-term patient value of ICU bundles.
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Affiliation(s)
- Nicolas Paul
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Elena Ribet Buse
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anna-Christina Knauthe
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies in Germany (AWMF), Philipps-Universität Marburg, Marburg, Germany
| | - Björn Weiss
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Shpakov AO, Zorina II, Derkach KV. Hot Spots for the Use of Intranasal Insulin: Cerebral Ischemia, Brain Injury, Diabetes Mellitus, Endocrine Disorders and Postoperative Delirium. Int J Mol Sci 2023; 24:3278. [PMID: 36834685 PMCID: PMC9962062 DOI: 10.3390/ijms24043278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
A decrease in the activity of the insulin signaling system of the brain, due to both central insulin resistance and insulin deficiency, leads to neurodegeneration and impaired regulation of appetite, metabolism, endocrine functions. This is due to the neuroprotective properties of brain insulin and its leading role in maintaining glucose homeostasis in the brain, as well as in the regulation of the brain signaling network responsible for the functioning of the nervous, endocrine, and other systems. One of the approaches to restore the activity of the insulin system of the brain is the use of intranasally administered insulin (INI). Currently, INI is being considered as a promising drug to treat Alzheimer's disease and mild cognitive impairment. The clinical application of INI is being developed for the treatment of other neurodegenerative diseases and improve cognitive abilities in stress, overwork, and depression. At the same time, much attention has recently been paid to the prospects of using INI for the treatment of cerebral ischemia, traumatic brain injuries, and postoperative delirium (after anesthesia), as well as diabetes mellitus and its complications, including dysfunctions in the gonadal and thyroid axes. This review is devoted to the prospects and current trends in the use of INI for the treatment of these diseases, which, although differing in etiology and pathogenesis, are characterized by impaired insulin signaling in the brain.
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Affiliation(s)
- Alexander O. Shpakov
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, 194223 St. Petersburg, Russia
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Fasugba O, Dale S, McInnes E, Cadilhac DA, Noetel M, Coughlan K, McElduff B, Kim J, Langley T, Cheung NW, Hill K, Pollnow V, Page K, Sanjuan Menendez E, Neal E, Griffith S, Christie LJ, Slark J, Ranta A, Levi C, Grimshaw JM, Middleton S. Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial. Implement Sci 2023; 18:2. [PMID: 36703172 PMCID: PMC9879239 DOI: 10.1186/s13012-023-01260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/06/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals. METHODS A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes. DISCUSSION We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas. TRIAL REGISTRATION ACTRN12622000028707. Registered 14 January, 2022.
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Affiliation(s)
- O Fasugba
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - S Dale
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - E McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - D A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - M Noetel
- School of Psychology, University of Queensland, Brisbane, Australia
| | - K Coughlan
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - B McElduff
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - J Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - T Langley
- St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | - N W Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - K Hill
- Stroke Foundation, Sydney, New South Wales, Australia
| | - V Pollnow
- St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | - K Page
- St Vincent's Health Network Sydney, Sydney, New South Wales, Australia
| | | | - E Neal
- Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - S Griffith
- School of Psychology, University of Queensland, Brisbane, Australia
| | - L J Christie
- Allied Health Research Unit, St Vincent's Health Network, Sydney, Australia
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
| | - J Slark
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - A Ranta
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - C Levi
- John Hunter Health and Innovation Precinct, New Lambton Heights, New South Wales, Australia
- Department of Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - J M Grimshaw
- University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - S Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney & St Vincent's Hospital Melbourne & Australian Catholic University, Level 5, deLacy Building, St. Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia.
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia.
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Cadilhac DA, Marion V, Andrew NE, Breen SJ, Grabsch B, Purvis T, Morrison JL, Lannin NA, Grimley RS, Middleton S, Kilkenny MF. A Stepped-Wedge Cluster-Randomized Trial to Improve Adherence to Evidence-Based Practices for Acute Stroke Management. Jt Comm J Qual Patient Saf 2022; 48:653-664. [PMID: 36307360 DOI: 10.1016/j.jcjq.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data. METHODS STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change champions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and individual indicators (secondary outcome). Patient survival and disability 90-180 days after stroke were also compared. RESULTS Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years; 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years; 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals' action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05-1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50-2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05-1.53). Patient outcomes were unchanged. CONCLUSION External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care.
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Guo F, Fan Q, Liu X, Sun D. Patient's care bundle benefits to prevent stroke associated pneumonia: A meta-analysis with trial sequential analysis. Front Neurol 2022; 13:950662. [DOI: 10.3389/fneur.2022.950662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatient's care bundle has been found to have a beneficial effect on refractory diseases, but the preventive effect of this strategy on stroke-associated pneumonia (SAP) remains unclear. The purpose of this meta-analysis was to determine the role of the patient's care bundle in the prevention of SAP.MethodsA systematic search was conducted in five electronic databases to identify randomized controlled trials (RCTs) published before January 31, 2022. The incidence of SAP and aspiration and the length of hospital stay were assessed. Random pair-wise meta-analysis was conducted using Review Manager 5.4, and trial sequential analysis (TSA) was also performed.ResultsTwenty eligible RCTs involving 1916 patients were included for data analysis. Pooled results suggested that patient's care bundle was associated with significantly lower incidence of SAP (risk ratio [RR], 0.37; 95% CI, 0.29–0.46; p < 0.001; I2 = 0%) and aspiration (RR, 0.23; 95% CI, 0.15–0.35; p < 0.001; I2 = 0%). Meanwhile, patient's care bundle also significantly shortened the length of hospital stay for general patients (mean difference [MD], −3.10; 95% CI, −3.83 to −2.37; p < 0.001; I2 = 16%) and the length of intensive care unit (ICU) stay for patients with severe stoke (MD, −4.85; 95% CI, −5.86−3.84; p < 0.001; I2 = 0%). Results of TSA confirmed that none of the findings could be significantly reversed by future studies.ConclusionsThe patient's care bundle effectively prevents the occurrence of SAP and aspiration and shortens the hospital stay of stroke patients. However, it is necessary to design more high-quality studies to further validate our findings and investigate their applicability in other geographical regions.
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Middleton S, Dale S, McElduff B, Coughlan K, McInnes E, Mikulik R, Fischer T, Van der Merwe J, Cadilhac D, D’Este C, Levi C, Grimshaw JM, Grecu A, Quinn C, Cheung NW, Koláčná T, Medukhanova S, Sanjuan Menendez E, Salselas S, Messchendorp G, Cassier-Woidasky AK, Skrzypek-Czerko M, Slavat-Plana M, Antonella U, Pfeilschifter W. Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study. Eur Stroke J 2022; 8:132-147. [PMID: 37021183 PMCID: PMC10069193 DOI: 10.1177/23969873221126027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Poor adoption of stroke guidelines is a problem internationally. The Quality in Acute Stroke Care (QASC) trial demonstrated significant reduction in death and disability with facilitated implementation of nurse-initiated Methods: This was a multi-country, multi-centre, pre-test/post-test study (2017–2021) comparing post implementation data with historically collected pre-implementation data. Hospital clinical champions, supported by the Angels Initiative conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support co-ordinated remotely from Australia. Prospective audits were conducted 3-month after FeSS Protocol introduction. Pre-to-post analysis and country income classification comparisons were adjusted for clustering by hospital and country controlling for age/sex/stroke severity. Results: Data from 64 hospitals in 17 countries (3464 patients pre-implementation and 3257 patients post-implementation) showed improvement pre-to-post implementation in measurement recording of all three FeSS components, all p < 0.0001: fever elements (pre: 17%, post: 51%; absolute difference 33%, 95% CI 30%, 37%); hyperglycaemia elements (pre: 18%, post: 52%; absolute difference 34%; 95% CI 31%, 36%); swallowing elements (pre: 39%, post: 67%; absolute difference 29%, 95% CI 26%, 31%) and thus in overall FeSS Protocol adherence (pre: 3.4%, post: 35%; absolute difference 33%, 95% CI 24%, 42%). In exploratory analysis of FeSS adherence by countries’ economic status, high-income versus middle-income countries improved to a comparable extent. Discussion and conclusion: Our collaboration resulted in successful rapid implementation and scale-up of FeSS Protocols into countries with vastly different healthcare systems.
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Affiliation(s)
- Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Kelly Coughlan
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Robert Mikulik
- International Clinical Research Centre, Neurology Department, St. Ann’s University Hospital and Masaryk University, Brno, Czech Republic
| | - Thomas Fischer
- Angels Initiative, Boehringer Ingelheim International GmbH, Hamburg, Germany
| | - Jan Van der Merwe
- Angels Initiative, Boehringer Ingelheim International GmbH, Hamburg, Germany
| | - Dominique Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Catherine D’Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australia
- Sax Institute, Sydney, Australia
| | - Christopher Levi
- John Hunter Health and Innovation Precinct, HNE LHD, New Lambton, NSW, Australia
- Department of Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Jeremy M Grimshaw
- University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andreea Grecu
- International Clinical Research Centre, Neurology Department, St. Ann’s University Hospital and Masaryk University, Brno, Czech Republic
| | - Clare Quinn
- Prince of Wales Hospital, Randwick, Australia
| | - Ngai Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
| | | | | | | | | | | | | | | | - Merce Slavat-Plana
- Health Department, Agency for Health Quality and Assessment (AQuAS), CIBER Epidemiología y Salud Pública, CIBERESP, Stroke Programme, Barcelona, Spain
| | - Urso Antonella
- Hospital Network Area-Regional Health Department, Regione Lazio, Rome, Italy
| | - Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
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Lens C, Coeckelberghs E, Seys D, Demeestere J, Weltens C, Vanhaecht K, Lemmens R. Variation in stroke care at the hospital level: A cross-sectional multicenter study. Front Neurol 2022; 13:1004901. [PMID: 36313511 PMCID: PMC9606690 DOI: 10.3389/fneur.2022.1004901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionStroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.Materials and methodsAn observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum – maximum) were calculated.ResultsWe analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7–100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0–100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0–100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0–93.3%)], depression screening [20.2 ± 35.8% (0.0–100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0–60%)].ConclusionWe identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.
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Affiliation(s)
- Charlotte Lens
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
| | - Ellen Coeckelberghs
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
| | - Deborah Seys
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
| | - Jelle Demeestere
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven—University of Leuven, Leuven, Belgium
- VIB, Laboratory of Neurobiology, Center for Brain & Disease Research, Leuven, Belgium
| | - Caroline Weltens
- Department of Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven—University of Leuven, Leuven, Belgium
- Department of Quality, University Hospitals Leuven, Leuven, Belgium
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology, KU Leuven—University of Leuven, Leuven, Belgium
- VIB, Laboratory of Neurobiology, Center for Brain & Disease Research, Leuven, Belgium
- *Correspondence: Robin Lemmens
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Reducing the incidence of stroke-associated pneumonia: an evidence-based practice. BMC Neurol 2022; 22:297. [PMID: 35953801 PMCID: PMC9367053 DOI: 10.1186/s12883-022-02826-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/02/2022] [Indexed: 12/27/2022] Open
Abstract
Background Pulmonary infection is a frequent complication among stroke patients and adversely affects clinical outcomes, increases the length of hospitalization stay and costs, and aggravates the financial burden of the national medical health system. Early identification and management of high-risk patients are necessary and imperative to reduce the incidence of stroke-associated pneumonia (SAP). Aim The evidence-based practice project evaluated the effectiveness of a standard care bundle intervention in preventing the occurrence of SAP. Methods The project was conducted in a neurology department of a teaching hospital. Given the variation in assessment and management standards, evidence-based practice (EBP) methodology was used to establish a process for quality improvement. A thorough literature search was conducted to identify evidence-based interventions to manage and prevent SAP. Thorough critiques of the literature and synthesis of the evidence were completed. A systematic management flow and care bundle interventions were established. The care bundle included interventions, such as the utilization of tools for SAP risk screening; dysphagia screening and rehabilitation; feeding modification, oral care, airway management, position management, and the nursing techniques of traditional Chinese medicine. Results A significant improvement was observed in preventing SAP in patients in the postimplementation group compared with those in the preimplementation group (14.0% vs. 37.2%, p = 0.025). In addition, significantly lower duration of hospitalization, lower rate of aspiration, and improvements in albumin and oral hygiene were found after the implementation of the care bundle. Conclusions Evidence-based care bundles successfully empower nurses to reduce the incidence of SAP. The management flow of SAP prevention could be promoted to other units of the neurology department in the future. The results of the project reflect positively on the capacity to implement EBP in an acute care setting for stroke. The EBP methodology can be utilized to solve other clinical problems. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02826-8.
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Effectiveness of Multidisciplinary Nursing Based on Fever, Blood Sugar, and Swallowing Function Management in Patients with Acute Stroke. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5949760. [PMID: 35774752 PMCID: PMC9239784 DOI: 10.1155/2022/5949760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/09/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022]
Abstract
Purpose The aim of this study was to assess the effectiveness of multidisciplinary nursing based on fever, blood sugar, and swallowing function management in patients with acute stroke (AS). Methods A total of 200 AS patients who were treated in our hospital from January 2016 to January 2020 were recruited and randomized at a ratio of 1 : 1 into a control group and a study group. The control group received standardized early rehabilitation nursing, and the study group received multidisciplinary nursing based on fever, blood sugar, and swallowing function management plus standardized early rehabilitation nursing. The patients were also assigned different blood glucose levels upon admission to a high blood glucose group or a normal blood glucose group. The clinical endpoint is clinical efficacy. Results Multidisciplinary nursing resulted in better clinical outcomes and treatment efficiency in the patients in the study group versus standardized early rehabilitation nursing. When compared with the control group, the patients in the study group showed lower National Institute of Health Stroke Scale (NIHSS) scores, higher Barthel Index (BI) scores, lower fasting blood glucose levels and body temperature 24 hours after admission, a lower incidence of swallowing dysfunction and aspiration pneumonia 30 days after nursing, and lower C-reactive Protein (CRP) levels 7 days after nursing. The NIHSS scores of the high blood glucose group were significantly higher than those of the normal blood glucose group. Conclusion Multidisciplinary nursing based on fever, blood sugar, and swallowing function management for patients with AS improves the clinical outcome and treatment efficiency, restores the swallowing function and blood glucose level, and ameliorates the long-term prognosis of patients.
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Deng S, Mao X, Meng X, Yu L, Xie F, Huang G, Duan Z. A comparison of Knowledge, attitude and practice (KAP) of nurses on nursing Post-stroke dysphagia patients between iii-A and ii-A hospitals in China: a propensity score-matched analysis. BMC Nurs 2022; 21:171. [PMID: 35768870 PMCID: PMC9241219 DOI: 10.1186/s12912-022-00950-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background Whether knowledge, attitude and practice of nurses on nursing post-stroke dysphagia patients varies between different ranking hospitals is still unknown. This study aimed to compare the knowledge, attitude and practice level of nurses on nursing post-stroke dysphagia patients between iii-A and ii-A hospitals in China. Design A cross-sectional study design was used. Methods Data were collected from eighteen hospitals in Wuhan, Hubei in May–July 2020, and a total of 824 nurses were recruited by convenient sampling. After propensity score matching, 205 participants in iii-A hospitals were matched with 205 participants in ii-A hospitals. Results There were no statistically differences in the socio-demographic characteristics between two groups after propensity score matching. Before matching, the regression coefficients between hospital ranking and knowledge, attitude, practice were -0.415, -0.718 and -1.855, respectively. After matching, the coefficients changed to -0.394, -0.824 and -1.278. Nurses from iii-A hospitals had higher knowledge and attitude scores than nurses from ii-A hospitals, but no significant practice scores difference was observed between various rankings of hospitals. Conclusions The KAP of nurses on nursing post-stroke dysphagia patients were different in iii-A and ii-A hospitals. Administrators should strengthen management, provide more learning resources and trainings to meet nurses’ needs about methods to deal with and recognize dysphagia, so as to further improve the quality of post-stroke dysphagia management.
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Affiliation(s)
- Shumin Deng
- Department of Clinical Data Center, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, People's Republic of China
| | - Xiaolan Mao
- Neurology department, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xianmei Meng
- Wuhan University School of Nursing, Wuhan University, Wuhan, China
| | - Liping Yu
- Wuhan University School of Nursing, Wuhan University, Wuhan, China
| | - Fei Xie
- Neurology department, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Guiling Huang
- Neurology department, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhizhou Duan
- Preventive Health Service, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China.
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Minelli C, Bazan R, Pedatella MTA, Neves LDO, Cacho RDO, Magalhães SCSA, Luvizutto GJ, Moro CHC, Lange MC, Modolo GP, Lopes BC, Pinheiro EL, de Souza JT, Rodrigues GR, Fabio SRC, do Prado GF, Carlos K, Teixeira JJM, Barreira CMA, Castro RDS, Quinan TDL, Damasceno E, Almeida KJ, Pontes-Neto OM, Dalio MTRP, Camilo MR, Tosin MHDS, Oliveira BC, de Oliveira BGRB, de Carvalho JJF, Martins SCO. Brazilian Academy of Neurology practice guidelines for stroke rehabilitation: part I. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:634-652. [PMID: 35946713 PMCID: PMC9387194 DOI: 10.1590/0004-282x-anp-2021-0354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/21/2021] [Accepted: 01/18/2022] [Indexed: 06/15/2023]
Abstract
The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke.
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Affiliation(s)
- Cesar Minelli
- Hospital Carlos Fernando Malzoni, Matão SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Rodrigo Bazan
- Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Botucatu SP, Brazil
| | - Marco Túlio Araújo Pedatella
- Hospital Israelita Albert Einstein, Unidade Goiânia, Goiânia GO, Brazil
- Hospital Santa Helena, Goiânia GO, Brazil
- Hospital Encore, Goiânia GO, Brazil
- Hospital Geral de Goiânia, Goiania GO, Brazil
- Hospital de Urgência de Goiânia, Goiânia GO, Brazil
| | | | - Roberta de Oliveira Cacho
- Universidade Federal do Rio Grande do Norte, Faculdade de Ciências da Saúde do Trairi, Santa Cruz RN, Brazil
| | | | - Gustavo José Luvizutto
- Universidade Federal do Triângulo Mineiro, Departamento de Fisioterapia Aplicada, Uberaba MG, Brazil
| | - Carla Heloísa Cabral Moro
- Neurológica Joinville, Joinville SC, Brazil
- Hospital Municipal de Joinville, Joinville SC, Brazil
- Associação Brasil AVC, Joinville SC, Brazil
| | | | | | | | | | - Juli Thomaz de Souza
- Universidade Estadual Paulista, Faculdade de Medicina de Botucatu, Botucatu SP, Brazil
| | - Guilherme Riccioppo Rodrigues
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | | | | | - Karla Carlos
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo SP, Brazil
| | | | | | - Rodrigo de Souza Castro
- Hospital Israelita Albert Einstein, Unidade Goiânia, Goiânia GO, Brazil
- Hospital Encore, Goiânia GO, Brazil
| | | | - Eduardo Damasceno
- Hospital Santa Helena, Goiânia GO, Brazil
- Hospital Encore, Goiânia GO, Brazil
- Hospital Geral de Goiânia, Goiania GO, Brazil
- Hospital Orion, Goiania GO, Brazil
| | | | - Octávio Marques Pontes-Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Marina Teixeira Ramalho Pereira Dalio
- Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Centro de Cirurgia de Epilepsia de Ribeirão Preto, Ribeirão Preto SP, Brazil
| | - Millene Rodrigues Camilo
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | | | | | | | | | - Sheila Cristina Ouriques Martins
- Rede Brasil AVC, Porto Alegre RS, Brazil
- Hospital Moinhos de Vento, Departamento de Neurologia, Porto Alegre RS, Brazil
- Hospital de Clínicas de Porto Alegre, Departamento de Neurologia, Porto Alegre RS, Brazil
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Wu MR, Chen YT, Li ZX, Gu HQ, Yang KX, Xiong YY, Wang YJ, Wang CJ. Dysphagia screening and pneumonia after subarachnoid hemorrhage: Findings from the Chinese stroke center alliance. CNS Neurosci Ther 2022; 28:913-921. [PMID: 35233938 PMCID: PMC9062548 DOI: 10.1111/cns.13822] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 12/15/2021] [Accepted: 02/09/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND PURPOSE Dysphagia is common and is associated with aspiration pneumonia. However, little is known about the prevalence of and factors influencing dysphagia screening (DS) and pneumonia after subarachnoid hemorrhage (SAH). METHODS We used data on SAH patients admitted to 1476 hospitals from the China Stroke Center Alliance (CSCA) from August 2015 to July 2019 to analyze the rates of DS and pneumonia. We then conducted univariate and multivariable analyses to examine the relationship between DS and pneumonia. RESULTS Among 4877 SAH patients who were eligible for DS and had complete data on pneumonia status, 3527 (72.3%) underwent DS, and 1006 (20.6%) developed pneumonia. Compared with patients without pneumonia, patients with pneumonia were older (mean: 63.4 vs. 57.8 years of age), had lower Glasgow Coma Scale (GCS) scores at admission (mean: 13.5 vs. 14.3), were more likely to have dysphagia (15.2% vs. 3.3%), and were more likely to have undergone aneurysm isolation (19.1% vs. 10.0%). In multivariable analyses, factors independently associated with a higher risk of pneumonia were dysphagia [odds ratio (OR), 3.77; 95% confidence interval (CI), 2.85-4.98], age (OR, 1.50 per 10-year increase; 95% CI, 1.40-1.60), male sex (OR, 1.23; 95% CI, 1.02-1.49), arrival at the hospital by emergency medical services (OR, 1.36; 95% CI, 1.16-1.58), nimodipine treatment (OR, 1.42; 95% CI, 1.11-1.81), endovascular embolization of aneurysms (OR, 1.23; 95% CI, 1.03-1.47), cerebral ventricular shunt placement (OR, 2.24; 95% CI, 1.41-3.54), and treatment at a higher grade hospital (OR, 1.44; 95% CI, 1.21-1.71). CONCLUSION More than a quarter of patients with SAH did not have documented DS, while one-fifth developed pneumonia. DS performance was associated with a lower risk of pneumonia. Randomized controlled trials may be needed to determine the effectiveness of DS.
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Affiliation(s)
- Mei-Ru Wu
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Tong Chen
- Nursing Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zi-Xiao Li
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kai-Xuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yun-Yun Xiong
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong-Jun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Chun-Juan Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Zhang X, Zhao J, Zheng L, Li X, Hao Y. Implementation strategies to improve evidence-based practice for post-stroke dysphagia identification and management: A before-and-after study. Int J Nurs Sci 2022; 9:295-302. [PMID: 35891917 PMCID: PMC9305012 DOI: 10.1016/j.ijnss.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/26/2022] [Accepted: 06/11/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Xiaoyan Zhang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Junqiang Zhao
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ontario, Canada
| | - Liping Zheng
- Department of Neurosurgery, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xuejing Li
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yufang Hao
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
- Corresponding author.
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 305] [Impact Index Per Article: 152.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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Kawamura K, Murayama K, Takamura J, Minegishi S. Effect of a weekly functional independence measure scale on the recovery of patient with acute stroke: A retrospective study. Medicine (Baltimore) 2022; 101:e28974. [PMID: 35356904 PMCID: PMC10684118 DOI: 10.1097/md.0000000000028974] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/11/2022] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Excessive assistance may decrease stroke patients' physical activity and make them more dependent on assistance. We have structured a system that provides an ADL (activities of daily living) educational program that focuses on stroke patients' toileting in our daily clinical practice. Here, we investigated the effect of a functional independence measure (FIM) scale on the recovery of patients with acute stroke.We retrospectively collected the data of 407 stroke patients from the medical record system of our emergency hospital in Tsukuba, Japan. The enrolled stroke patients (n = 373) were divided into FIM and control groups. Both groups received the standard treatment, but for the FIM group, ward and rehabilitation staff calculated the toilet FIM score for patients 1 ×/wk. The FIM scale measures the amount of assistance a patient needs to perform activities of daily living and is often used in rehabilitation settings. The rehabilitation staff then instructed the ward staff about better assistance methods based on each patient's physical function and executive dysfunction. We evaluated the usefulness of the FIM scale was based on the patients' FIM scores at discharge and improvements in their scores.The recoveries of the total, motor, and cognitive FIM scores recovery at discharge were significantly greater in the FIM group compared with the control group (68.0 vs 45.0, P = .004; 41.0 vs 24.0, P = .005; and 24.0 vs 20.0, P = .007, respectively). The use of the FIM scale contributes to the patients' recovery of physical function and cognitive function.The FIM scale can contribute to stroke patients' recovery of activities of daily living.
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Affiliation(s)
- Kenta Kawamura
- Correspondence: Kenta Kawamura, Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami, Ami-machi, Inashiki-gun, Ibaraki 300-0394, Japan (e-mail: ).
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Açma A, Carrat F, Hejblum G. Comparing SF-36 Scores Collected Through Web-Based Questionnaire Self-completions and Telephone Interviews: An Ancillary Study of the SENTIPAT Multicenter Randomized Controlled Trial. J Med Internet Res 2022; 24:e29009. [PMID: 35266869 PMCID: PMC8949688 DOI: 10.2196/29009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 10/21/2021] [Accepted: 12/21/2021] [Indexed: 01/22/2023] Open
Abstract
Background The 36-Item Short Form Health Survey (SF-36) is a popular questionnaire for measuring the self-perception of quality of life in a given population of interest. Processing the answers of a participant comprises the calculation of 10 scores corresponding to 8 scales measuring several aspects of perceived health and 2 summary components (physical and mental). Surprisingly, no study has compared score values issued from a telephone interview versus those from an internet-based questionnaire self-completion. Objective This study aims to compare the SF-36 score values issued from a telephone interview versus those from an internet-based questionnaire self-completion. Methods Patients with an internet connection and returning home after hospital discharge were enrolled in the SENTIPAT multicenter randomized trial on the day of discharge. They were randomized to either self-completing a set of questionnaires using a dedicated website (internet group) or providing answers to the same questionnaires administered during a telephone interview (telephone group). This ancillary study of the trial compared SF-36 data related to the posthospitalization period in these 2 groups. To anticipate the potential unbalanced characteristics of the responders in the 2 groups, the impact of the mode of administration of the questionnaire on score differences was investigated using a matched sample of individuals originating from the internet and telephone groups (1:1 ratio), in which the matching procedure was based on a propensity score approach. SF-36 scores observed in the internet and telephone groups were compared using the Wilcoxon-Mann-Whitney test, and the score differences between the 2 groups were also examined according to Cohen effect size. Results Overall, 29.2% (245/840) and 75% (630/840) of SF-36 questionnaires were completed in the internet and telephone groups, respectively (P<.001). Globally, the score differences between groups before matching were similar to those observed in the matched sample. Mean scores observed in the telephone group were all above the corresponding values observed in the internet group. After matching, score differences in 6 out of the 8 SF-36 scales were statistically significant, with a mean difference greater than 5 for 4 scales and an associated mild effect size ranging from 0.22 to 0.29, and with a mean difference near this threshold for 2 other scales (4.57 and 4.56) and a low corresponding effect size (0.18 and 0.16, respectively). Conclusions The telephone mode of administration of SF-36 involved an interviewer effect, increasing SF-36 scores. Questionnaire self-completion via the internet should be preferred, and surveys combining various administration methods should be avoided. Trial Registration ClinicalTrials.gov NCT01769261; https://www.clinicaltrials.gov/ct2/show/record/NCT01769261
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Affiliation(s)
- Ayşe Açma
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Fabrice Carrat
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Unité de Santé Publique, Paris, France
| | - Gilles Hejblum
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
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45
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Zhang G, Li Z, Gu H, Zhang R, Meng X, Li H, Wang Y, Zhao X, Wang Y, Liu G. Dysphagia Management and Outcomes in Elderly Stroke Patients with Malnutrition Risk: Results from Chinese Stroke Center Alliance. Clin Interv Aging 2022; 17:295-308. [PMID: 35321149 PMCID: PMC8937314 DOI: 10.2147/cia.s346824] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/28/2022] [Indexed: 01/02/2023] Open
Abstract
Purpose To investigate the effectiveness of dysphagia screening and subsequent swallowing rehabilitation in elderly stroke patients with malnutrition risk. Patients and Methods Based on the Chinese Stroke Center Alliance (CSCA) from August 1, 2015 to July 21, 2019, we compared the in-hospital adverse outcomes among stroke patients (including ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage) over 70 years old with and without dysphagia screening. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were the composite endpoint of discharge against medical advice (DAMA) or in-hospital death. Results Among 365,530 stroke patients ≥ 70 years old with malnutrition risk in the CSCA, documented dysphagia screening was performed for 288,764 (79.0%) participants. Of these, 41,482 (14.37%) patients had dysphagia, and 33,548 (80.87%) patients received swallowing rehabilitation. A total of 1,694 (0.46%) patients experienced in-hospital death. After adjustment for traditional risk factors, dysphagia screening was associated with a low risk of all-cause mortality in stroke patients [adjusted odds ratio (aOR): 0.75, 95% confidence interval (CI):0.65–0.87]. Compared to patients with dysphagia who did not receive swallowing rehabilitation, patients reveiving swallowing rehabilitation had a reduced risk of in-hospital death (aOR:0.39, 95% CI: 0.33–0.46). Additionally, dysphagia screening had a lower risk for the composite endpoint of DAMA or in-hospital death (aOR:0.83,95% CI: 0.80–0.87), as did subsequent swallowing rehabilitation (aOR:0.43,95% CI: 0.40–0.47). Similar results were observed in the sensitivity analysis through inverse probability of treatment weighting, propensity score matching, and excluding patients without National Institutes of Health Stroke Scale scores. A similar association was observed between dysphagia management and adverse clinical outcomes in ischemic stroke and intracranial hemorrhage patients. Conclusion Dysphagia screening and swallowing rehabilitation were associated with a reduced risk of in-hospital death and composite outcome of DAMA or in-hospital death for stroke patients with malnutrition risk. Future research should concentrate on improving the quality of medical care for dysphagia management to improve patients’ outcomes.
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Affiliation(s)
- Guitao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hongqiu Gu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Runhua Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, People’s Republic of China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, 2019RU018, People’s Republic of China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, People’s Republic of China
- Correspondence: Yongjun Wang; Gaifen Liu, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People’s Republic of China, Tel +86 10-59978350; +86 10-59976746, Email ;
| | - Gaifen Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
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46
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Rosário M, Fonseca AC. Incorporating Quality Improvement Projects Into Stroke Care and Research. Stroke 2022; 53:e118-e121. [PMID: 35135324 DOI: 10.1161/strokeaha.121.038204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Madalena Rosário
- Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal (M.R., A.C.F.)
| | - Ana Catarina Fonseca
- Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal (M.R., A.C.F.).,Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal (A.C.F.)
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47
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Lockwood I, Walker RM, Latimer S, Chaboyer W, Cooke M, Gillespie BM. Process evaluations undertaken alongside randomised controlled trials in the hospital setting: A scoping review. Contemp Clin Trials Commun 2022; 26:100894. [PMID: 36684693 PMCID: PMC9846456 DOI: 10.1016/j.conctc.2022.100894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 11/09/2021] [Accepted: 01/17/2022] [Indexed: 01/25/2023] Open
Abstract
Background There is increasing recognition of the importance of undertaking process evaluations alongside implementation of health interventions by examining mechanisms of impact and contextual factors. However, a comprehensive synthesis of process evaluations undertaken alongside clinical trials in hospital settings is lacking. We undertook a scoping review to address this gap. Methods This review was guided by the methodological framework for scoping studies. Studies were identified using four databases; Ovid Medline, EBSCO CINAHL, EMBASE and Scopus. Two authors independently screened all titles and available abstracts, with a third author available to adjudicate. Studies were eligible for inclusion if they described a process evaluation undertaken alongside a randomised controlled trial in the hospital setting. Data were abstracted by one author and checked by two others and analysed both descriptively and using inductive content analysis. Results Data were extracted from 30 articles reporting on 15 trials, most of which were cluster randomised trials (c-RTs) (n = 12). The most common data collection methods used in process evaluations were interviews, questionnaires or surveys, and records or logs. Data analysis revealed three themes relative to how authors: use process data to interpret, understand and explain trial outcomes; evaluate responses to the intervention; and consider the implementation context. Conclusions Findings from this review demonstrate the complex nature of intervention implementation in the hospital setting. Overall, there is need for standardised reporting of process evaluations and more explicit descriptions of how authors use frameworks to guide their evaluation.
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Affiliation(s)
- Ishtar Lockwood
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia
| | - Rachel M. Walker
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia,Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Sharon Latimer
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia,Gold Coast University Hospital, Southport, Queensland, Australia,Corresponding author. Building L05, Room 3.44, Griffith University, Logan, Queensland, 4131, Australia.
| | - Wendy Chaboyer
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia
| | - Marie Cooke
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia
| | - Brigid M. Gillespie
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia,Gold Coast University Hospital, Southport, Queensland, Australia
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48
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Auditing integrated stroke care to support quality improvement activities: development of a peer-to-peer audit framework. JOURNAL OF INTEGRATED CARE 2022. [DOI: 10.1108/jica-06-2021-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeTo organize stroke care, multiple stakeholders work closely together in integrated stroke care services (ISCS). However, even a well-developed integrated care program needs a continuous quality improvement (CQI) cycle. The current paper aims to describe the development of a unique peer-to-peer audit framework, the development model for integrated care (DMIC), the Dutch stroke care standard and benchmark indicators for stroke.Design/methodology/approachA group of experts was brought together in 2016 to discuss the aims and principles of a national audit framework. The steering group quality assurance (SGQA) consisted of representatives of a diversity of professions in the field of stroke care in the Netherlands, including managers, nurses, medical specialists and paramedics.FindingsAuditors, coordinators and professionals evaluated the framework, agreed on that the framework was easy to use and valued the interesting and enjoyable audits, the compliments, feedback and fruitful insights. Participants consider that a quality label may help to overcome necessity issues and have health care insurers on board. Finally, a structured improvement plan after the audit is needed.Originality/valueAn audit offers fruitful insights into the functioning of an ISCS and the collaboration therein. Best practices and points of improvement are revealed and can fuel collaboration and the development of partnerships. Innovative cure and care may lead to an increasing area of support among professionals in the ISCS and consequently lead to improved quality of delivered stroke care.
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Lip GYH, Lane DA, Lenarczyk R, Boriani G, Doehner W, Benjamin LA, Fisher M, Lowe D, Sacco RL, Schnabel R, Watkins C, Ntaios G, Potpara T. OUP accepted manuscript. Eur Heart J 2022; 43:2442-2460. [PMID: 35552401 PMCID: PMC9259378 DOI: 10.1093/eurheartj/ehac245] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:
A: Appropriate Antithrombotic therapy. B: Better functional and psychological status. C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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Affiliation(s)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, The Medical University of Silesia, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Laura A Benjamin
- Laboratory of Molecular and Cell Biology, University College London National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deborah Lowe
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral CH49 5PE, UK
| | - Ralph L Sacco
- UM Clinical & Translational Science Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Renate Schnabel
- University Heart & Vascular Center Hamburg Eppendorf, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston PR1 2HE, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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50
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Song L, Hu X, Ma L, Chen X, Ouyang M, Billot L, Li Q, Muñoz-Venturelli P, Abanto C, Pontes-Neto OM, Antonio A, Wasay M, Silva AD, Thang NH, Pandian JD, Wahab KW, You C, Anderson CS. INTEnsive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3): study protocol for a pragmatic stepped-wedge cluster-randomized controlled trial. Trials 2021; 22:943. [PMID: 34930428 PMCID: PMC8686093 DOI: 10.1186/s13063-021-05881-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/08/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH. METHODS INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 phases/3 steps), cluster-randomized controlled trial to determine the effectiveness of a multifaceted care package in adult (age ≥ 18 years) patients (target 8360) with acute ICH (< 6 h of onset) recruited from 110 hospitals (average of 19 consecutive patients per phase) in low- and middle-income countries. After a control phase, each hospital implements the intervention (intensive BP lowering, target systolic < 140 mmHg; glucose control, target 6.1-7.8 mmol/L and 7.8-10.0 mmol/L in those without and with diabetes mellitus, respectively; anti-pyrexia treatment to target body temperature ≤ 37.5 °C; and reversal of anticoagulation, target international normalized ratio < 1.5 within 1 h). Information will be obtained on demographic and baseline clinical characteristics, in-hospital management, and 7-day outcomes. Central trained blinded assessors will conduct telephone interviews to assess physical function and health-related quality of life at 6 months. The primary outcome is the modified Rankin scale (mRS) at 6 months analyzed using ordinal logistic regression. The sample size of 8360 subjects provides 90% power (α = 0.05) to detect a 5.6% absolute improvement (shift) in the primary outcome of the intervention versus control standard care, with various assumptions. DISCUSSION As the largest clinical trial in acute ICH, INTERACT3 is on schedule to provide an assessment of the effectiveness of a widely applicable goal-directed care bundle for a serious condition in which a clearly proven treatment has yet to be established. TRIAL REGISTRATION ClinicalTrials.gov NCT03209258. Registered on 1 July 2017. Chinese Trial Registry ChiCTR-IOC-17011787. Registered on 28 June 2017.
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Affiliation(s)
- Lili Song
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China
| | - Xiaoying Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Menglu Ouyang
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Laurent Billot
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Qiang Li
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
| | - Paula Muñoz-Venturelli
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia
- Clinical Research Center, Faculty of Medicine, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Carlos Abanto
- The Cerebrovascular Disease Research Center, National Institute of Neurological Sciences, Cercado de Lima, Peru
| | | | - Arauz Antonio
- Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico City, Mexico
| | - Mohammad Wasay
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Asita de Silva
- Clinical Trials Unit, Faculty of Medicine, University of Kelaniya, Colombo, Sri Lanka
| | | | | | - Kolawole Wasiu Wahab
- Department of Medicine, University of Ilorin & University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China.
| | - Craig S Anderson
- The George Institute China, Peking University Health Science Center, Room 011, Unit 2, Tayuan Diplomatic Office Building, No. 14 Liangmahe Nan Lu, Chaoyang District, Beijing, China.
- The George Institute for Global Health, Faculty of Medicine, UNSW, Level 5, King Street, Newtown, NSW, 2042, Australia.
- Department of Neurosurgery, West China Hospital, Sichuan University, NO.43, St. Guoxuexiang, Chengdu, China.
- Sydney Medical School, University of Sydney, Sydney, Australia.
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia.
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