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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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2
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Liu M, Whittam S, Thornton A, Goncharov L, Slade D, McElduff B, Kelly P, Law CK, Walsh S, Pollnow V, Cuffe J, McMahon J, Aggar C, Bilo J, Bowen K, Chow JSF, Duffy K, Everett B, Ferguson C, Frost SA, Gleeson N, Hackett K, Komusanac I, Marshall S, May S, McErlean G, Melbourne G, Murphy J, Newbury J, Newman D, Rihari-Thomas J, Sciuriaga H, Sturgess L, Taylor J, Tuqiri K, McInnes E, Middleton S. The ACCELERATE Plus (assessment and communication excellence for safe patient outcomes) Trial Protocol: a stepped-wedge cluster randomised trial, cost-benefit analysis, and process evaluation. BMC Nurs 2023; 22:275. [PMID: 37605224 PMCID: PMC10440862 DOI: 10.1186/s12912-023-01439-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: 06/08/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Nurses play an essential role in patient safety. Inadequate nursing physical assessment and communication in handover practices are associated with increased patient deterioration, falls and pressure injuries. Despite internationally implemented rapid response systems, falls and pressure injury reduction strategies, and recommendations to conduct clinical handovers at patients' bedside, adverse events persist. This trial aims to evaluate the effectiveness, implementation, and cost-benefit of an externally facilitated, nurse-led intervention delivered at the ward level for core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication. We hypothesise the trial will reduce medical emergency team calls, unplanned intensive care unit admissions, falls and pressure injuries. METHODS A stepped-wedge cluster randomised trial will be conducted over 52 weeks. The intervention consists of a nursing core physical assessment, structured patient-centred bedside handover and improved multidisciplinary communication and will be implemented in 24 wards across eight hospitals. The intervention will use theoretically informed implementation strategies for changing clinician behaviour, consisting of: nursing executive site engagement; a train-the-trainer model for cascading facilitation; embedded site leads; nursing unit manager leadership training; nursing and medical ward-level clinical champions; ward nurses' education workshops; intervention tailoring; and reminders. The primary outcome will be a composite measure of medical emergency team calls (rapid response calls and 'Code Blue' calls), unplanned intensive care unit admissions, in-hospital falls and hospital-acquired pressure injuries; these measures individually will also form secondary outcomes. Other secondary outcomes are: i) patient-reported experience measures of receiving safe and patient-centred care, ii) nurses' perceptions of barriers to physical assessment, readiness to change, and staff engagement, and iii) nurses' and medical officers' perceptions of safety culture and interprofessional collaboration. Primary outcome data will be collected for the trial duration, and secondary outcome surveys will be collected prior to each step and at trial conclusion. A cost-benefit analysis and post-trial process evaluation will also be undertaken. DISCUSSION If effective, this intervention has the potential to improve nursing care, reduce patient harm and improve patient outcomes. The evidence-based implementation strategy has been designed to be embedded within existing hospital workforces; if cost-effective, it will be readily translatable to other hospitals nationally. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ID: ACTRN12622000155796. Date registered: 31/01/2022.
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Grants
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- Big Ideas Grant Maridulu Budyari Gumal Sydney Partnership for Health, Education, Research and Enterprise (SPHERE)
- 1196352 National Health and Medical Research Council Investigator Leadership Grant
- New South Wales Nursing and Midwifery Strategy Reserve Fund
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Affiliation(s)
- Mark Liu
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia
| | - Susan Whittam
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Anna Thornton
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Liza Goncharov
- Institute for Communication in Healthcare, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Acton, ACT, 2601, Australia
| | - Diana Slade
- Institute for Communication in Healthcare, Australian National University, Baldessin Precinct Building, 110 Ellery Crescent, Acton, ACT, 2601, Australia
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia
| | - Patrick Kelly
- School of Public Health, University of Sydney, Edward Ford Building, A27 Fisher Road, Camperdown, NSW, 2006, Australia
| | - Chi Kin Law
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Medical Foundation Building, 92-94 Parramatta Road, Camperdown, NSW, 2050, Australia
| | - Sarah Walsh
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Vivien Pollnow
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Jayde Cuffe
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jake McMahon
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Christina Aggar
- Southern Cross University, Military Road, East Lismore, NSW, 2480, Australia
- Northern NSW Local Health District, Crawford House, Hunter Street, Lismore, NSW, 2480, Australia
| | - Jacqueline Bilo
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Karen Bowen
- Northern NSW Local Health District, Crawford House, Hunter Street, Lismore, NSW, 2480, Australia
| | - Josephine S F Chow
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW, 2170, Australia
| | - Katharine Duffy
- Northern NSW Local Health District, Crawford House, Hunter Street, Lismore, NSW, 2480, Australia
| | - Bronwyn Everett
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Caleb Ferguson
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Steven A Frost
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Narelle Gleeson
- Lismore Base Hospital, 60 Uralba Street, Lismore, NSW, 2480, Australia
| | - Kate Hackett
- South Eastern Sydney Local Health District, The Sutherland Hospital and Community Health Service, Corner The Kingsway and Kareena Road, Caringbah, NSW, 2229, Australia
| | - Ivanka Komusanac
- Sydney Local Health District, King George V Building, Missenden Road, Camperdown, NSW, 2050, Australia
| | - Sonia Marshall
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
| | - Sharon May
- Fairfield Hospital, Polding Street and Prairie Vale Road, Prairiewood, NSW, 2176, Australia
| | - Gemma McErlean
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Gregory Melbourne
- South Western Sydney Local Health District, Liverpool Hospital Eastern Campus, Corner of Lachlan and Hart Streets, Liverpool, NSW, 2170, Australia
| | - Jade Murphy
- St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Joanne Newbury
- The Sutherland Hospital, Corner The Kingsway and Kareena Road, Caringbah, NSW, 2229, Australia
| | - Deb Newman
- Lismore Base Hospital, 60 Uralba Street, Lismore, NSW, 2480, Australia
| | - John Rihari-Thomas
- University of Wollongong, Northfields Avenue, Wollongong, NSW, 2522, Australia
| | - Hayley Sciuriaga
- Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Lauren Sturgess
- St George Hospital, Gray Street, Kogarah, NSW, 2217, Australia
| | - Joanne Taylor
- St Vincent's Health Network Sydney, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
| | - Karen Tuqiri
- Prince of Wales Hospital, 320-346 Barker Street, Randwick, NSW, 2031, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, Australian Catholic University, De Lacy Building, 390 Victoria Street, Darlinghurst, NSW, 2010, Australia.
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia.
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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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4
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Kõrv J, Antsov K, Gross-Paju K, Kalju I, Kreis A, Liigant A, Vibo R. Developments in quality of stroke care in Estonia. Eur Stroke J 2023; 8:35-43. [PMID: 36793745 PMCID: PMC9923126 DOI: 10.1177/23969873221110745] [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: 04/26/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background Monitoring and measuring different aspects of stroke care pathway is the cornerstone for improvement of quality. We aim to analyze and give an overview of improvements of stroke care quality in Estonia. Patients and methods National stroke care quality indicators are collected and reported using reimbursement data and include all adult stroke cases. In Estonia, five stroke-ready hospitals are participating in Registry of Stroke Care Quality (RES-Q), providing data on all stroke patients 1 month every year. Data from the national quality indicators and RES-Q from 2015 to 2021 are presented. Results The proportion of intravenous thrombolysis for all Estonian hospitalized ischemic stroke cases increased from 16% (95% Confidence Interval, CI 15%-18%) in 2015 to 28% (95% CI 27%-30%) in 2021. Mechanical thrombectomy was provided to 9% (95% CI 8%-10%) in 2021. The 30-day mortality rate has decreased from 21% (95% CI 20%-23%) to 19% (95% CI 18%-20%). More than 90% of patients with cardioembolic stroke are prescribed anticoagulants at discharge, but only 50% are on anticoagulant treatment 1 year after stroke. Also, the availability of inpatient rehabilitation needs improvement, being 21% (95% CI 20%-23%) in 2021. A total of 848 patients are included in the RES-Q. The proportion of patients receiving recanalization therapies was comparable to the national stroke care quality indicators. All stroke-ready hospitals show good onset-to-door times. Conclusion The overall stroke care quality in Estonia is good, especially the availability of recanalization treatments. However, secondary prevention and the availability of rehabilitation services need improvement in the future.
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Affiliation(s)
- Janika Kõrv
- Department of Neurology and Neurosurgery,
University of Tartu, Tartu, Estonia,Janika Kõrv, Department of Neurology and
Neurosurgery, University of Tartu, L. Puusepa 8, Tartu 50406, Estonia.
| | - Katrin Antsov
- II Department of Internal Diseases, Pärnu
Hospital, Pärnu, Estonia
| | | | - Inga Kalju
- Centre of Neurology, East-Tallinn Central
Hospital, Tallinn, Estonia
| | - Andrus Kreis
- Neurology Centre, North Estonia Medical
Centre, Tallinn, Estonia
| | - Aive Liigant
- Department of Neurology and Neurosurgery,
University of Tartu, Tartu, Estonia,Department of Neurology, Tartu University
Hospital, Tartu, Estonia
| | - Riina Vibo
- Department of Neurology and Neurosurgery,
University of Tartu, Tartu, Estonia
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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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A nurse-led multicomponent intervention supported by advanced electronic health records to improve the acute management of stroke patients: A pre- and post-intervention study. INTERNATIONAL JOURNAL OF NURSING STUDIES ADVANCES 2021. [DOI: 10.1016/j.ijnsa.2021.100023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Cost Burden and Cost-Effective Analysis of the Nationwide Implementation of the Quality in Acute Stroke Care Protocol in Australia. J Stroke Cerebrovasc Dis 2021; 30:105931. [PMID: 34157669 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The Quality in Acute Stroke Care (QASC) protocol is a multidisciplinary approach to implement evidence-based treatment after acute stroke that reduces death and disability. This study sought to evaluate the cost-effectiveness of implementing the QASC protocol across Australia, from a healthcare and a societal perspective. MATERIALS AND METHODS A decision-analytic model was constructed to reflect one-year outcomes post-stroke, aligned with the stroke severity categories of the modified Rankin scale (mRS). Decision analysis compared outcomes following implementation of the QASC protocol versus no implementation. Population data were extracted from Australian databases and data inputs regarding stroke incidence, costs, and utilities were drawn from published sources. The analysis assumed a progressive uptake and efficacy of the QASC protocol over five years. Health benefits and costs were discounted by 5% annually. The cost of each year lived by an Australian, from a societal perspective, was based on the Australian Government's 'value of statistical life year' (AUD 213,000). RESULTS Over five years, the model predicted 263,722 strokes among the Australian population. The implementation of the QASC protocol was predicted to prevent 1,154 deaths and yield a gain of 876 years of life (0.003 per stroke), and 3,180 quality-adjusted life years (QALYs) (0.012 per stroke). There was an estimated net saving of AUD 65.2 million in healthcare costs (AUD 247 per stroke) and AUD 251.7 million in societal costs (AUD 955 per stroke). CONCLUSIONS Implementation of the QASC protocol in Australia represents both a dominant (cost-saving) strategy, from a healthcare and a societal perspective.
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