Benefits of clinical facilitators on improving stroke care in acute hospitals: a new programme for Australia

Finding the right dose: a scoping review examining facilitation as an implementation strategy for evidence-based stroke care

BACKGROUND

Despite evidence supporting interventions that improve outcomes for patients with stroke, their implementation remains suboptimal. Facilitation can support implementation of research into clinical practice by helping people develop the strategies to implement change. However, variability in the amount (dose) and type of facilitation activities/facilitator roles that make up the facilitation strategies (content), may affect the effectiveness of facilitation. This review aimed to determine if, and how, facilitation dose is measured or reported and the type of facilitation strategies used to support adoption of stroke interventions in hospitals and subacute settings. We also assessed whether the included studies had reporting checklists or guidelines.

METHODS

The scoping review was based on Arksey and O'Malley's framework. Cochrane, CINAHL and MEDLINE databases were searched to identify randomised trials and quasi-experimental studies of stroke interventions published between January 2017 and July 2023. Accompanying publications (quantitative, qualitative, mixed methods or process evaluation papers) from eligible studies were also included. Narrative data synthesis was undertaken.

RESULTS

Ten studies (23 papers) from 649 full-text papers met the inclusion criteria. Only two studies reported the total facilitation dose, measured as the frequency and duration of facilitation encounters. Authors of the remaining eight studies reported only the frequency and/or duration of varying facilitation activities but not the total dose. The facilitation activities included remote external facilitator support via ongoing telecommunication (phone calls, emails, teleconferences), continuous engagement from on-site internal facilitators, face-to-face workshops and/or education sessions from external or internal facilitators. Facilitator roles were broad: site-specific briefing, action planning and/or goal setting; identifying enablers and barriers to change; coaching, training, education or feedback; and network support. Only two studies included reporting checklists/guidelines to support researchers to describe interventions and implementation studies in sufficient detail to enable replication.

CONCLUSIONS

There is a paucity of information on the measurement of facilitation dose and reporting on specific details of facilitation activities in stroke implementation studies. Detailed reporting of dose and content is needed to improve the scientific basis of facilitation as strategic support to enable improvements to stroke care. Development of a standardised measurement approach for facilitation dose would inform future research and translation of findings.

Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial

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.

Understanding Coordinator Roles in Acute Stroke Care: A National Survey

OBJECTIVES

Coordinators contribute to stroke care quality. Evidence on the scope of practice of coordinator roles for stroke is lacking. We aimed to survey Australian stroke coordinators and describe their responsibilities and characteristics, and compare these based on perceived competency.

MATERIALS AND METHODS

Online survey of non-physician coordinators with a clinical leadership position for acute stroke in Australian hospitals. Participants were identified from the Stroke Foundation National Audit, and advertising via national associations/networks. Quantitative data were analysed descriptively; characteristics and responsibilities assessed by Benner's self-perceived competency (novice/advanced beginner/competent, proficient or expert). Inductive thematic analysis was used for open-ended responses.

RESULTS

Results from 105/141 coordinators (103 hospitals, 90% female, 90% registered nurses). Two-thirds developed the role/were self-taught, with 36% using the 'stroke coordinator' title. Perceived competency varied; 22% expert, 40% proficient, and 33% competent. A variety of important clinical tasks, along with leadership/management, education and research responsibilities were described. Most frequently reported clinical responsibility was discharge planning (77%), with patient and staff education (85% and 88%), and data collection (94%) common. Compared to those reporting lesser competency, 'experts' had greater involvement in outpatient clinics (50% vs 14%) and leadership/management responsibilities (e.g. local hospital committees 77% vs 46%). 'Knowledge of evidence' and 'empowering others' were important characteristics to 'expert' coordinators.

CONCLUSIONS

A contemporary understanding of important responsibilities and characteristics of acute stroke coordinators are provided. Perceived competency affected scope of practice. Structured education, training and role delineation is warranted to improve competency. Career development of stroke coordinators is urgently needed to support optimal role performance.

Rationale and design of individualized quality improvement based on the Computer Analysing system to improve Stroke management quality Evaluation (CASE): a multicenter historically controlled study

Background

Guideline-based medical care has been identified to improve outcomes in stroke. However, data acquisition and medical quality management during hospital stay still need to be improved in China. We have developed a computer-based medical data collecting system, together with automated calculation of key performance indicators (KPIs) and regular individualized education, and thus aim to explore whether it can improve the medical care quality of acute ischemic stroke (AIS) during hospital stay in stroke centers.

Methods

The individualized quality improvement based on the Computer Analysing system to improve Stroke management quality Evaluation (CASE) trial is a prospective, multicenter, historical control study among 30 stroke centers in China. In this trial, the data is directly extracted from the saved original medical record of each AIS patient during hospital stay, regardless of different Electronic Medical Record System (EMRS) in each center. Then, the automated calculation of KPIs and the regular education via teleconference per month allow the clinicians to examine the causes of non-compliance of guideline-based care and develop programs to decrease their frequency.

Discussion

We compare KPIs between pre-intervention stage and post-intervention stage (without or with education) among stroke centers. If proved effective, this approach might be generalized around China and even worldwide, where a unified EMRS is difficult to be applied and in-patient care needs to be improved.

Trial registration

ClinicalTrials.gov NCT03684629. Registered on 9 December 2018. Retrospectively registered.

A systematic review and meta-synthesis of policy intervention characteristics that influence the implementation of government-directed policy in the hospital setting: implications for infection prevention and control

Background

Government-directed policy plays an important role in the regulation and supervision of healthcare quality. Effective implementation of these policies has the potential to significantly improve clinical practice and patient outcomes, including the prevention of healthcare-associated infections. A systematic review of research describing the implementation of government-directed policy in the hospital setting was performed with the aim to identify policy intervention characteristics that influence implementation.

Methods

A systematic search of four electronic databases was undertaken to identify eligible articles published between 2007 and 2017. Studies were included if published in the English language and described the implementation of government-directed policy in a high-income country hospital setting. Data on policy and implementation were extracted for each article and interpretive syntheses performed.

Results

A total of 925 articles were retrieved and titles and abstracts reviewed, with 69 articles included after review of abstract and full text. Qualitative synthesis of implementation data showed three overarching themes related to intervention characteristics associated with implementation: clarity; infrastructure; and alignment.

Conclusion

Better understanding and consideration of policy intervention characteristics during development and planning will facilitate more effective implementation although research describing implementation of government-directed policy in the hospital setting is limited and of variable quality. The findings of this study provide guidance to staff tasked with the development or implementation of government-directed policy in the hospital setting, infection prevention and control professionals seeking to maximise the impact of policy on practice and improve patient outcomes.

Changes in acute hospital costs after employing clinical facilitators to improve stroke care in Victoria, Australia

Background

Hospital costs for stroke are increasing and variability in care quality creates inefficiencies. In 2007, the Victorian Government (Australia) employed clinical facilitators for three years in eight public hospitals to improve stroke care. Literature on the cost implications of such roles is rare. We report changes in the costs of acute stroke care following implementation of this program.

Methods

Observational controlled before-and-after cohort design. Standardised hospital costing data were compared pre-program (financial year 2006–07) and post-program (2010–11) for all admitted episodes of stroke or transient ischaemic attack (TIA) using ICD-10 discharge codes. Costs in Australian dollars (AUD) were adjusted to a common year 2010. Generalised linear regression models were used for adjusted comparisons.

Results

A 20% increase in stroke and TIA episodes was observed: 2624 pre-program (age > 75 years: 53%) and 3142 post-program (age > 75 years: 51%); largely explained by more TIA admissions (up from 785 to 1072). Average length of stay reduced by 22% (pre-program 7.3 days to post-program 5.7 days, p < 0.001). Six hospitals provided cost data. Average per-episode costs decreased by 10% (pre-program AUD7888 to post-program AUD7115). After adjusting for age, sex, stroke type, and hospital, average per-episode costs decreased by 6.1% from pre to post program (p = 0.025). When length of stay was additionally adjusted for, these costs increased by 10.8%, indicating a greater mean cost per day (p < 0.001).

Conclusion

Cost containment of acute inpatient episodes was observed after the implementation of stroke clinical facilitators, likely associated with the shorter lengths of stay.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3836-9) contains supplementary material, which is available to authorized users.

Is length of time in a stroke unit associated with better outcomes for patients with stroke in Australia? An observational study

OBJECTIVE

Spending at least 90% of hospital admission in a stroke unit (SU) is a recommended indicator of receiving high-quality stroke care. However, whether this makes a difference to patient outcomes is unknown. We aimed to investigate outcomes and factors associated with patients with acute stroke spending at least 90% of their admission in an SU, compared with those having less time in the SU.

DESIGN

Observational study using cross-sectional data.

SETTING

Data from hospitals which participated in the 2015 Stroke Foundation National Audit: Acute Services (Australia) and had an SU. This audit includes an organisational survey and retrospective medical record audit of approximately 40 admissions from each hospital.

PARTICIPANTS

Patients admitted to an SU during their acute admission were included.

OUTCOME MEASURES

Hospital-based patient outcomes included length of stay, independence on discharge, severe complications and discharge destination. Patient, organisational and process indicators were included in multilevel logistic modelling to determine factors associated with spending at least 90% of their admission in an SU.

RESULTS

Eighty-eight hospitals with an SU audited 2655 cases (median age 76 years, 55% male). Patients who spent at least 90% of their admission in an SU experienced: a length of stay that was 2 days shorter (coefficient -2.77, 95% CI -3.45 to -2.10), fewer severe complications (adjusted OR (aOR) 0.60, 95% CI 0.43 to 0.84) and were less often discharged to residential aged care (aOR 0.59, 95% CI 0.38 to 0.94) than those who had less time in the SU. Patients admitted to an SU within 3 hours of hospital arrival were three times more likely to spend at least 90% of their admission in an SU.

CONCLUSION

Spending at least 90% of time in an SU is a valid measure of stroke care quality as it results in improved patient outcomes. Direct admission to SUs is warranted.

How to do health services research in stroke: A focus on performance measurement and quality improvement

The objective of this "How to" research series article is to provide guidance on getting started in Health Services Research. The purpose of health services research is to contribute knowledge that can be used to help improve health systems and clinical services through influencing policy and practice. The methods used are broad, have varying levels of rigor, and may require different specialist skills. This paper sets out practical steps for undertaking health services research. Importantly, use of the highlighted techniques can identify solutions to address inadequate knowledge translation or promote greater access to evidence-based stroke care to optimize patient outcomes.