How do stroke early supported discharge services achieve intensive and responsive service provision? Findings from a realist evaluation study (WISE)

Investigating the Implementation of Community-Based Stroke Telerehabilitation in England; A Realist Synthesis Study Protocol

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high-quality, equitable community-based stroke rehabilitation, and under what conditions. Using a realist approach, we will synthesise information from (1) an evidence review, (2) qualitative interviews with clinicians (n ≤ 30), and patient-family carer dyads (n ≤ 60) from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service-users and policy-makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice, and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of a realist methodology and co-production to inform evidence-based recommendations that consider the needs and priorities of clinicians and people affected by stroke.

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England

BACKGROUND

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives.

METHODS

Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners.

RESULTS

Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward.

CONCLUSIONS

Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

Healthcare professionals' experiences of delivering a stroke Early Supported Discharge service - An example from Ireland

OBJECTIVE

To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic.

DESIGN

Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis.

SETTING

Nine Early Supported Discharge service sites in Ireland.

PARTICIPANTS

Purposive sampling identified 16 healthcare professionals.

RESULTS

Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families.

CONCLUSIONS

Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

Inpatient Rehabilitation Outcomes after Primary Severe Haemorrhagic Stroke: A Retrospective Study Comparing Surgical versus Non-Surgical Management

BACKGROUND

Haemorrhagic stroke, accounting for 10-20% of all strokes, often requires decompressive surgery as a life-saving measure for cases with massive oedema and raised intracranial pressure. This study was conducted to compare the demographics, characteristics and rehabilitation profiles of patients with severe haemorrhagic stroke who were managed surgically versus those who were managed non-surgically.

METHODS

A single-centre retrospective study of electronic medical records was conducted over a 3-year period from 1 January 2018 to 31 December 2020. The inclusion criteria were first haemorrhagic stroke, age of >18 years and an admission Functional Independence Measure (FIM™) score of 18-40 upon admission to the rehabilitation centre. The primary outcome measure was discharge FIM™. Secondary outcome measures included modified Rankin Scale (mRS), rehabilitation length of stay (RLOS) and complication rates.

RESULTS

A total of 107 patients' records were analysed; 45 (42.1%) received surgical intervention and 62 (57.9%) patients underwent non-surgical management. Surgically managed patients were significantly younger than non-surgical patients, with a mean age of [surgical 53.1 (SD 12) vs. non-surgical 61.6 (SD 12.3), p = 0.001]. Admission FIM was significantly lower in the surgical vs. non-surgical group [23.7 (SD6.7) vs. 26.71 (SD 7.4), p = 0.031). However, discharge FIM was similar between both groups [surgical 53.91 (SD23.0) vs. non-surgical 57.0 (SD23.6), p = 0.625). Similarly, FIM gain (surgical 30.1 (SD 21.1) vs. non-surgical 30.3 (SD 21.1), p = 0.094) and RLOS [surgical 56.2 days (SD 21.5) vs. non-surgical 52.0 days (SD 23.4), p = 0.134) were not significantly different between groups. The majority of patients were discharged home (surgical 73.3% vs. non-surgical 74.2%, p = 0.920) despite a high level of dependency.

CONCLUSIONS

Our findings suggest that patients with surgically managed haemorrhagic stroke, while older and more dependent on admission to rehabilitation, achieved comparable FIM gains, discharge FIM and discharge home rates after ~8 weeks of rehabilitation. This highlights the importance of rehabilitation, especially for surgically managed haemorrhagic stroke patients.