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Carlsson GE, Törnbom K, Nordin Å, Stibrant-Sunnerhagen K. Coming home in the context of Very Early Supported Discharge after stroke - an interview study of patients´ experiences. J Stroke Cerebrovasc Dis 2024:107869. [PMID: 39032718 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107869] [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: 12/07/2023] [Revised: 06/24/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024] Open
Abstract
OBJECTIVES To explore patients' experiences of coming home and managing everyday life within the context of very early supported discharge after stroke (VESD). STUDY DESIGN An explorative qualitative study using semi structured interviews. METHOD This study was nested within a randomised controlled trial,; Gothenburg Very Early Supported Discharge (GOTVED), comparing a home rehabilitation intervention given by a coordinated team (VESD) with conventional care. Eleven participants with a median age 70.0 years (range 63-95) of which nine scoring 0-4 on the NIHSS indicating no symptoms or minor stroke were interviewed on average 12 days after discharge. Data was analysed using thematic analysis. RESULTS The diversity of patients´ experiences was reflected in the overarching main theme Very Early Supported Discharge after stroke - a multifaceted experience, built upon five themes: "Conditions surrounding the discharge", "Concerns about the condition", "Confronting a new everyday life", "Experiences of the intervention" and the "Role of next of kin". CONCLUSIONS The respondents were largely satisfied with the very early supported discharge which might be expected, given that it was well planned regarding timing, individualisation and content. The patients need to be aware of the purpose of the VESD intervention. Due to the unpredictability of the stroke and its consequences, interventions need to be flexible. Goal setting is important but must be comprehensible. The role and burden of next of kin should be addressed and negotiated, and the ending of the intervention must be planned, with seamless transition to further rehabilitation and social support including the issue of participation in everyday life.
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Affiliation(s)
- Gunnel E Carlsson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience/Rehabilitation Medicine, Sahlgrenska Academy University of Gothenburg, Sweden.
| | - Karin Törnbom
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience/Rehabilitation Medicine, Sahlgrenska Academy University of Gothenburg, Sweden; Faculty of Social Sciences, Department of Social Work, University of Gothenburg, Sweden.
| | - Åsa Nordin
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience/Rehabilitation Medicine, Sahlgrenska Academy University of Gothenburg, Sweden; Department of Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Katharina Stibrant-Sunnerhagen
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience/Rehabilitation Medicine, Sahlgrenska Academy University of Gothenburg, Sweden; Neurocare, Sahlgrenska University Hospital, Gothenburg Sweden.
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2
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Eliassen M, Arntzen C, Nikolaisen M, Gramstad A. Rehabilitation models that support transitions from hospital to home for people with acquired brain injury (ABI): a scoping review. BMC Health Serv Res 2023; 23:814. [PMID: 37525270 PMCID: PMC10388520 DOI: 10.1186/s12913-023-09793-x] [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: 11/08/2022] [Accepted: 07/07/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Research shows a lack of continuity in service provision during the transition from hospital to home for people with acquired brain injuries (ABI). There is a need to gather and synthesize knowledge about services that can support strategies for more standardized referral and services supporting this critical transition phase for patients with ABI. We aimed to identify how rehabilitation models that support the transition phase from hospital to home for these patients are described in the research literature and to discuss the content of these models. METHODS We based our review on the "Arksey and O`Malley framework" for scoping reviews. The review considered all study designs, including qualitative and quantitative methodologies. We extracted data of service model descriptions and presented the results in a narrative summary. RESULTS A total of 3975 studies were reviewed, and 73 were included. Five categories were identified: (1) multidisciplinary home-based teams, (2) key coordinators, (3) trained family caregivers or lay health workers, (4) predischarge planning, and (5) self-management programs. In general, the studies lack in-depth professional and contextual descriptions. CONCLUSIONS There is a wide variety of rehabilitation models that support the transition phase from hospital to home for people with ABI. The variety may indicate a lack of consensus of best practices. However, it may also reflect contextual adaptations. This study indicates that health care service research lacks robust and thorough descriptions of contextual features, which may limit the feasibility and transferability to diverse contexts.
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Affiliation(s)
- Marianne Eliassen
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway.
| | - Cathrine Arntzen
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
- Center for Care Sciences, North, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
| | - Morten Nikolaisen
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
- Center for Care Sciences, North, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
| | - Astrid Gramstad
- Department of Health and Care Sciences, University of Tromsø, The Artic University of Norway, Tromsø, 9037, Norway
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Fisher RJ, Chouliara N, Byrne A, Cameron T, Lewis S, Langhorne P, Robinson T, Waring J, Geue C, Paley L, Rudd A, Walker MF. Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway.
Objectives
To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness.
Design
A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes.
Setting and interventions
Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England.
Participants
Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services.
Data and main outcome
Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness.
Results
A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway.
Limitations
Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory.
Conclusions
The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness.
Trial registration
Current Controlled Trials ISRCTN15568163.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca J Fisher
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Adrian Byrne
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Trudi Cameron
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Justin Waring
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Claudia Geue
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Anthony Rudd
- Sentinel Stroke National Audit Programme, King’s College London, London, UK
| | - Marion F Walker
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
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Keetley R, Bennett E, Williams J, Stewart I, Whitehouse WP, Pilling P, Manning JC. Outcomes for children with acquired brain injury (ABI) admitted to acute neurorehabilitation. Dev Med Child Neurol 2021; 63:824-830. [PMID: 33694160 DOI: 10.1111/dmcn.14846] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 01/28/2023]
Abstract
AIM To evaluate an innovative paediatric neurorehabilitation model in relation to improving quality of neurorehabilitation and reducing length of stay (LOS) for children with acquired brain injury. METHOD A process evaluation approach was conducted in line with Medical Research Council evaluation of complex interventions guidance. Analysis was conducted on routinely collected patient data from 2017 to 2018, including LOS and family feedback. Descriptive and inferential statistics were used for quantitative analysis and qualitative data was analysed thematically. RESULTS Outcomes for 70 children (0-16y, median age 5y, IQR 1-11y, 46 males, 24 females) referred to the service indicated improved function and reduced complexity of need. The mean LOS was 10.6 days compared to baseline mean LOS of 41 days (2011-2012). High satisfaction from the families was recorded; however, ongoing needs and service gaps regarding long-term support were identified. INTERPRETATION This service model is effective in delivering quality paediatric neurorehabilitation, demonstrating a sustained impact on LOS, and positive patient outcome data and family feedback for this group of patients. What this paper adds Investment in early intensive neurorehabilitation and supported discharge impacts length of stay (LOS) for children with acquired brain injury. Early intensive neurorehabilitation and supported discharge is effective. This is demonstrated by a sustained reduction in LOS, positive patient outcomes, and family feedback.
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Affiliation(s)
- Rachel Keetley
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Emily Bennett
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jane Williams
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iain Stewart
- NIHR Biomedical Research Centre, University of Nottingham, Nottingham, UK.,School of Medicine, University of Nottingham, Nottingham, UK
| | - William P Whitehouse
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Medicine, University of Nottingham, Nottingham, UK
| | - Pauline Pilling
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joseph C Manning
- Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Children and Young People's Health Research, School of Health Sciences, University of Nottingham, Nottingham, UK
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Fisher RJ, Byrne A, Chouliara N, Lewis S, Paley L, Hoffman A, Rudd A, Robinson T, Langhorne P, Walker M. Effect of stroke early supported discharge on length of hospital stay: analysis from a national stroke registry. BMJ Open 2021; 11:e043480. [PMID: 33472788 PMCID: PMC7818805 DOI: 10.1136/bmjopen-2020-043480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The first observational study to investigate the impact of early supported discharge (ESD) on length of hospital stay in real-world conditions. DESIGN Using historical prospective Sentinel Stroke National Audit Programme (SSNAP) data (1 January 2013-31 December 2016) and multilevel modelling, cross-sectional (2015-2016; 30 791 patients nested within 55 hospitals) and repeated cross-sectional (2013-2014 vs 2015-2016; 49 266 patients nested within 41 hospitals) analyses were undertaken. SETTING Hospitals were sampled across a large geographical area of England covering the West and East Midlands, the East of England and the North of England. PARTICIPANTS Stroke patients whose data were entered into the SSNAP database by hospital teams. INTERVENTIONS Receiving ESD along the patient care pathway. PRIMARY AND SECONDARY OUTCOME MEASURES Length of hospital stay. RESULTS When adjusted for important case-mix variables, patients who received ESD on their stroke care pathway spent longer in hospital, compared with those who did not receive ESD. The percentage increase was 15.8% (95% CI 12.3% to 19.4%) for the 2015-2016 cross-sectional analysis and 18.8% (95% CI 13.9% to 24.0%) for the 2013-2014 versus 2015-2016 repeated cross-sectional analysis. On average, the increased length of hospital stay was approximately 1 day. CONCLUSIONS This study has shown that by comparing ESD and non-ESD patient groups matched for important patient characteristics, receiving ESD resulted in a 1-day increase in length of hospital stay. The large reduction in length of hospital stay overall, since original trials were conducted, may explain why a reduction was not observed. The longer term benefits of accessing ESD need to be investigated further. TRIAL REGISTRATION NUMBER http://www.isrctn.com/ISRCTN15568163.
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Affiliation(s)
- Rebecca J Fisher
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Adrian Byrne
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Niki Chouliara
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Lizz Paley
- Department of Population Health Sciences, King's College London, London, UK
| | - Alex Hoffman
- Department of Population Health Sciences, King's College London, London, UK
| | - Anthony Rudd
- Department of Population Health Sciences, King's College London, London, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Peter Langhorne
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Marion Walker
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
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6
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Hough P, Gleeson S, Shkuratova N, Coker F, Williams C. Introducing a clinically effective allied health rapid discharge team within a complex aged subacute in-patient cohort on a cost recovery basis: the Supported Patient c entred Early Discharge (SPeED) initiative. AUST HEALTH REV 2020; 44:931-934. [PMID: 33264590 DOI: 10.1071/ah19137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 12/15/2019] [Indexed: 11/23/2022]
Abstract
This case study reports the outcomes of an early supported discharge program. This model of care was trialled after Victoria introduced subacute weighted inlier equivalent separations funding to subacute in-patients in 2016. An allied health team (Supported Patient centred Early Discharge (SPeED)) managed patients suitable for assessment, intervention and early supported discharge (ESD). The SPeED cohort was compared to a matched historical control. Data included no advantage financially (NAF) days, length of stay (LOS), functional independence measure (FIM) scores and 30-day readmission rates. Staff and patient experiences were collected through surveys and call-back data. Regression analysis compared quantitative data, whereas a broad thematic approach compared qualitative data. There were no differences between the study cohort and historical control in age or sex (P>0.05). The SPeED cohort had lower median NAF days (F=-21.38; 95% confidence interval (CI) -37.70, -15.00; P<0.001), shorter LOS (F)=4.65; 95% CI -0.41, -0.02; P=0.034), fewer readmissions within 30 days (odds ratio 0.14; 95% CI -0.03, 0.68; P=0.014) and greater change in FIM scores during admission (F=4.20; 95% CI 0.16, 10.74; P=0.044). Staff morale was high in recognition of improved patient care. Patient satisfaction remained positive across the SPeED cohort and historical control group. The introduction of a dedicated allied health ESD team within a geriatric evaluation and management population is effective and enhances patient outcomes.
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Affiliation(s)
- Peter Hough
- Peninsula Health, Subacute Allied Health, The Mornington Centre, corner Tyalla Grove and Separation Street, Mornington, Vic. 3931, Australia. ; ;
| | - Stephanie Gleeson
- Peninsula Health, Subacute Allied Health, The Mornington Centre, corner Tyalla Grove and Separation Street, Mornington, Vic. 3931, Australia. ; ;
| | - Nataliya Shkuratova
- Peninsula Health, Subacute Allied Health, The Mornington Centre, corner Tyalla Grove and Separation Street, Mornington, Vic. 3931, Australia. ; ;
| | - Freya Coker
- Peninsula Health, Allied Health, Frankston Hospital, 2 Hastings Road, Frankston, Vic. 3199, Australia. ; and Monash University, School of Primary and Allied Health Care, McMahons Road, Frankston, Vic. 3199, Australia
| | - Cylie Williams
- Peninsula Health, Allied Health, Frankston Hospital, 2 Hastings Road, Frankston, Vic. 3199, Australia. ; and Monash University, School of Primary and Allied Health Care, McMahons Road, Frankston, Vic. 3199, Australia; and Corresponding author.
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7
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Radford K, Nilsen D. BJOT special issue: Stroke rehabilitation. Br J Occup Ther 2020. [DOI: 10.1177/0308022620972248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kathryn Radford
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Dawn Nilsen
- Programs in Occupational Therapy, Columbia University, New York, USA
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8
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Leach K, Neale S, Steinfort S, Hitch D. Clinical outcomes for moderate and severe stroke survivors receiving early supported discharge: A quasi-experimental cohort study. Br J Occup Ther 2020. [DOI: 10.1177/0308022620939860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The aim of this study was to compare outcomes for functional independence, activities of daily living participation and balance achieved by moderate and severe stroke survivors receiving an early supported discharge model of care with those receiving standard treatment. Method A quasi-experimental cohort method was utilised, with a control group of convenience. Forty-one patients ( n = 28 early supported discharge group, n = 13 control group) who were medically stable post stroke, safe for discharge home, able to be treated in the home environment and requiring intensive rehabilitation from at least two disciplines participated. Results There was no significant difference in outcomes between early supported discharge and control groups for functional independence, activities of daily living participation or balance from baseline to 4 weeks, or 4 weeks to 8 weeks. However, patients receiving early supported discharge made further improvements across the study period, while those receiving standard care made limited improvement between 4 weeks and 8 weeks. All minimal clinically important differences on outcome measures were identified between baseline and 4 weeks. Conclusions Moderate and severe stroke survivors can achieve comparable outcomes when receiving early supported discharge or standard treatment. Early supported discharge models of care may also enhance ongoing improvement during the early phases of stroke recovery.
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Affiliation(s)
- Kathleen Leach
- Allied Health, Western Health, Sunshine Hospital, St. Albans, Victoria, Australia
| | - Sharon Neale
- Allied Health, Western Health, Sunshine Hospital, St. Albans, Victoria, Australia
| | - Sarah Steinfort
- Allied Health, Western Health, Sunshine Hospital, St. Albans, Victoria, Australia
| | - Danielle Hitch
- Allied Health, Western Health, Sunshine Hospital, St. Albans, Victoria, Australia
- Occupational Therapy, Deakin University, Waterfront Campus, Geelong, Victoria, Australia
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9
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Fisher RJ, Byrne A, Chouliara N, Lewis S, Paley L, Hoffman A, Rudd A, Robinson T, Langhorne P, Walker MF. Effectiveness of Stroke Early Supported Discharge: Analysis From a National Stroke Registry. Circ Cardiovasc Qual Outcomes 2020; 13:e006395. [PMID: 32674640 PMCID: PMC7439934 DOI: 10.1161/circoutcomes.119.006395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Implementation of stroke early supported discharge (ESD) services has been recommended in many countries’ clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Methods and Results: Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016–December 31, 2016), measures of ESD effectiveness were “days to ESD” (number of days from hospital discharge to first ESD contact; n=6222), “rehabilitation intensity” (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%–49%] and increased treatment intensity by 2% [95% CI, 0.3%–4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. Conclusions: This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.
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Affiliation(s)
- Rebecca J Fisher
- University of Nottingham, United Kingdom (R.J.F., A.B., N.C., S.L., M.F.W.)
| | - Adrian Byrne
- University of Nottingham, United Kingdom (R.J.F., A.B., N.C., S.L., M.F.W.)
| | - Niki Chouliara
- University of Nottingham, United Kingdom (R.J.F., A.B., N.C., S.L., M.F.W.)
| | - Sarah Lewis
- University of Nottingham, United Kingdom (R.J.F., A.B., N.C., S.L., M.F.W.)
| | - Lizz Paley
- King's College London, United Kingdom (L.P., A.H., A.R.)
| | - Alex Hoffman
- King's College London, United Kingdom (L.P., A.H., A.R.)
| | - Anthony Rudd
- King's College London, United Kingdom (L.P., A.H., A.R.)
| | | | | | - Marion F Walker
- University of Nottingham, United Kingdom (R.J.F., A.B., N.C., S.L., M.F.W.)
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10
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Gittins M, Lugo-Palacios D, Vail A, Bowen A, Paley L, Bray B, Gannon B, Tyson SF. Delivery, dose, outcomes and resource use of stroke therapy: the SSNAPIEST observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Therapy is key to effective stroke care, but many patients receive little.
Objectives
To understand how stroke therapy is delivered in England, Wales and Northern Ireland, and which factors are associated with dose, outcome and resource use.
Design
Secondary analysis of the Sentinel Stroke National Audit Programme, using standard descriptive statistics and multilevel mixed-effects regression models, while adjusting for all known and measured confounders.
Setting
Stroke services in England, Wales and Northern Ireland.
Participants
A total of 94,905 adults admitted with stroke, who remained an inpatient for > 72 hours.
Results
Routes through stroke services were highly varied (> 800), but four common stroke pathways emerged. Seven distinct impairment-based patient subgroups were characterised. The average amount of therapy was very low. Modifiable factors associated with the average amount of inpatient therapy were type of stroke team, timely therapy assessments, staffing levels and model of therapy provision. More (of any type of) therapy was associated with shorter length of stay, less resource use and lower mortality. More occupational therapy, speech therapy and psychology were also associated with less disability and institutionalisation. Large amounts of physiotherapy were associated with greater disability and institutionalisation.
Limitations
Use of observational data does not infer causation. All efforts were made to adjust for all known and measured confounding factors but some may remain. We categorised participants using the National Institutes of Health Stroke Scale, which measures a limited number of impairments relatively crudely, so mild or rare impairments may have been missed.
Conclusions
Stroke patients receive very little therapy. Modifiable organisational factors associated with greater amounts of therapy were identified, and positive associations between amount of therapy and outcome were confirmed. The reason for the unexpected associations between large amounts of physiotherapy, disability and institutionalisation is unknown. Prospective work is urgently needed to investigate further. Future work needs to investigate (1) prospectively, the association between physiotherapy and outcome; (2) the optimal amount of therapy to provide for different patient groups; (3) the most effective way of organising stroke therapy/rehabilitation services, including service configuration, staffing levels and working hours; and (4) how to reduce unexplained variation in resource use.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - David Lugo-Palacios
- Centre for Health Economics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andy Vail
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Audrey Bowen
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Lizz Paley
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Benjamin Bray
- Sentinel Stroke National Audit Programme, Department of Population Health Sciences, King’s College London, London, UK
| | - Brenda Gannon
- School of Economics, The University of Queensland, Brisbane, QLD, Australia
| | - Sarah F Tyson
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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11
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Rafsten L, Danielsson A, Nordin A, Björkdahl A, Lundgren-Nilsson A, Larsson MEH, Sunnerhagen KS. Gothenburg Very Early Supported Discharge study (GOTVED): a randomised controlled trial investigating anxiety and overall disability in the first year after stroke. BMC Neurol 2019; 19:277. [PMID: 31706292 PMCID: PMC6878692 DOI: 10.1186/s12883-019-1503-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 10/20/2019] [Indexed: 12/13/2022] Open
Abstract
Background and purpose Early supported discharge (ESD) has been shown to be efficient and safe as part of the stroke care pathway. The best results have been seen with a multidisciplinary team and after mild to moderate stroke. However, how very early supported discharge (VESD) works has not been studied. The aim of this study was to investigate whether VESD for stroke patients in need of ongoing individualized rehabilitation affects the level of anxiety and overall disability for the patient compared with ordinary discharge routine. Methods A randomized controlled trial was performed with intention to treat analyses comparing VESD and ordinary discharge from hospital. All patients admitted at the stroke care unit at Sahlgrenska University Hospital of Gothenburg between August 2011 and April 2016 were screened. Inclusion occurred on day 4 using a block randomization of 20 and with a blinded assessor. Assessments were made 5 days post-stroke and 3 and 12 months post-stroke. Patients in the VESD group underwent continued rehabilitation in their homes with a multidisciplinary team from the stroke care unit for a maximum of 1 month. The patients in the control group had support as usual after discharge when needed such as home care service and outpatient rehabilitation. The primary outcome was anxiety as assessed by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A). The secondary outcome was the patients’ degree of overall disability, measured by the modified Rankin Scale (mRS). Results No significant differences were found between the groups regarding anxiety at three or 12 months post-stroke (p = 0.811). The overall disability was significantly lower in the VESD group 3 months post-stroke (p = 0.004), compared to the control group. However, there was no significant difference between the groups 1 year post-stroke. Conclusions The VESD does not affects the level of anxiety compared to ordinary rehabilitation. The VESD leads to a faster improvement of overall disability compared to ordinary rehabilitation. We suggest considering coordinated VESD for patients with mild to moderate stroke in addition to ordinary rehabilitation as part of the service from a stroke unit. Trial registration Clinical Trials.gov: NCT01622205. Registered 19 June 2012 (retrospectively registered).
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Affiliation(s)
- Lena Rafsten
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden. .,Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden. .,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden.
| | - Anna Danielsson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Asa Nordin
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Ann Björkdahl
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Institute of Social Science, Campus Bräcke, Ersta Sköndal Bräcke University College, Gothenburg, Sweden
| | - Asa Lundgren-Nilsson
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Maria E H Larsson
- Institute of Neuroscience and Physiology, Department of Health and Rehabilitation, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Närhälsan, Research and Development Primary Health Care, Gothenburg, Region Västra Götaland, Sweden
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Per Dubbsgatan 14, fl. 3, 413 45, Gothenburg, Sweden.,Gothenburg Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
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12
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Broussy S, Rouanet F, Lesaine E, Domecq S, Kret M, Maugeais M, Aly F, Dehail P, Bénard A, Wittwer J, Salamon R, Sibon I, Saillour-Glenisson F. Post-stroke pathway analysis and link with one year sequelae in a French cohort of stroke patients: the PAPASePA protocol study. BMC Health Serv Res 2019; 19:770. [PMID: 31665006 PMCID: PMC6820977 DOI: 10.1186/s12913-019-4522-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Stroke is a health problem with serious consequences, both in terms of mortality, and after-effects affecting patient quality of life. Stroke requires both urgent and chronic management involving the entire health care system. Although large variability in the management of stroke patients have been noticed, knowledge of the diversity and the scalability of post-stroke pathways, whether it is the care pathway or the life pathway, is currently not sufficient. Moreover the link between post-stroke pathways and patients sequelae have not been yet clearly defined. All this information would be useful to better target the needs to improve stroke patient management. The purposes are to identify the post-stroke life pathways components associated with sequelae (activity limitations – main purpose, cognitive disorders, anxio-depressive disorders, fatigue, participation restrictions) at 3 months and 1 year post-stroke, to define a typology of life pathways of patients during the post-stroke year and to analyze the social and geographical inequalities in the management of stroke. Methods Design: a prospective multicenter comparative cohort study with a follow up to 1 year after the acute episode. Participant centers: 13 hospitals in the Aquitaine region (France). Study population: patients diagnosed with a confirmed ischemic or hemorrhagic stroke included in the Aquitaine Observatory of Stroke (ObA2) cohort and voluntary to participate. Data sources are existing databases (ObA2 database and the French National Health Data System - SNDS) to collect information about care pathways, patient characteristics and stroke characteristics and Ad hoc surveys to collect information about life pathways and post-stroke sequelae. The endpoints of the study are post-stroke activity limitations evaluated by the modified Rankin score, other post-stroke sequelae (Cognitive disorders, anxio-depressive disorders, fatigue, restriction of participation) assessed by standardized and validated scales and Clusters of patients responding to pathways with common or similar characteristics.; Discussion By integrating a longitudinal dimension and relying on a large cohort, the project will make it possible to identify the sources of disturbances and the factors favorable to the outcome of the life pathways, important for the planning of the offer and the management of the public policies concerning stroke pathways. Trial registration ClinicalTrials.gov ID: NCT03865173, March 6th, 2019.
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Affiliation(s)
- S Broussy
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France. .,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.
| | - F Rouanet
- Pôle des Neurosciences Cliniques (I.S., F.R.) CHU Bordeaux, Bordeaux, France
| | - E Lesaine
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France
| | - S Domecq
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France
| | - M Kret
- CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
| | - M Maugeais
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France
| | - F Aly
- Physical and Rehabilitation Medicine Unit, EA4136, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - P Dehail
- Physical and Rehabilitation Medicine Unit, EA4136, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - A Bénard
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.,CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
| | - J Wittwer
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France
| | - R Salamon
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France
| | - I Sibon
- Pôle des Neurosciences Cliniques (I.S., F.R.) CHU Bordeaux, Bordeaux, France.,Neurology, Stroke Unit, INCIA CNRS UMR 5287, Bordeaux University Hospital, University of Bordeaux, Bordeaux, France
| | - F Saillour-Glenisson
- Université de Bordeaux, Institut de Santé Publique d'Epidémiologie et de Développement, Centre INSERM U1219 Bordeaux Population Health center, 146 rue Léo Saignat, 33076, Bordeaux Cedex, France.,INSERM, ISPED, Centre INSERM U1219-Bordeaux Population Health, F-33000, Bordeaux, France.,CHU de Bordeaux, Pôle de santé publique, Service d'Information Médicale, F-33000, Bordeaux, France
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13
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Fisher R, Chouliara N, Byrne A, Lewis S, Langhorne P, Robinson T, Waring J, Geue C, Hoffman A, Paley L, Rudd A, Walker M. What is the impact of large-scale implementation of stroke Early Supported Discharge? A mixed methods realist evaluation study protocol. Implement Sci 2019; 14:61. [PMID: 31196123 PMCID: PMC6567399 DOI: 10.1186/s13012-019-0908-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 05/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke Early Supported Discharge (ESD) is a service innovation that facilitates discharge from hospital and delivery of specialist rehabilitation in patients' homes. There is currently widespread implementation of ESD services in many countries, driven by robust clinical trial evidence. In England, the type of ESD service patients receive on the ground is variable, and in some regions, ESD is still not offered at all. This protocol presents a study designed to investigate the mechanisms and outcomes of implementing ESD at scale in real-world conditions. This will help to establish which models of ESD are most effective and in what context. METHODS A realist evaluation approach composed of two interlinking work packages will be adopted to investigate how and why ESD works, for whom and in what circumstances. Work package 1 (WP1) will begin with a rapid evidence synthesis to formulate preliminary realist hypotheses. Quantitative analyses of historical prospective Sentinel Stroke National Audit Programme (SSNAP) data will be performed to evaluate service outcomes based on the degree to which evidence-based ESD has been implemented. Work package 2 (WP2) will involve the qualitative investigation of purposively selected case study sites featuring in WP1 and covering different regions in England. The perspectives of clinicians, managers, commissioners, and service users will be explored qualitatively. Cost implications of ESD models will be examined using a cost-consequence analysis. Cross-case comparisons and triangulation of the data sources from both work packages will be performed to test, revise, and refine initial programme theories and address research aims. DISCUSSION This study will investigate whether and how current large-scale implementation of ESD is achieving the outcomes suggested by the evidence base. The theory-driven evaluation approach will highlight key mechanisms and contextual conditions necessary to optimise outcomes and allow us to draw transferable lessons to inform the effective implementation and sustainability of ESD in clinical practice. In addition, the methodological framework will progress the theoretical understanding of implementation and evaluation of complex rehabilitation interventions in stroke care. TRIAL REGISTRATION ISRCTN: 15568163, registration date: 26 October 2018.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Anthony Rudd
- King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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14
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Morris JH, Bernhardsson S, Bird ML, Connell L, Lynch E, Jarvis K, Kayes NM, Miller K, Mudge S, Fisher R. Implementation in rehabilitation: a roadmap for practitioners and researchers. Disabil Rehabil 2019; 42:3265-3274. [PMID: 30978129 DOI: 10.1080/09638288.2019.1587013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners.Methods: Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings.Results and Conclusions: Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation.Implications for rehabilitationEffective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them.Understanding context for implementation is critically important and using theory can facilitate development of understanding.Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change.Sustainability requires regular revisiting of the interconnected steps.
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Affiliation(s)
- Jacqui H Morris
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Susanne Bernhardsson
- Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden.,The Sahlgrenska Academy Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Marie-Louise Bird
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Louise Connell
- School of Health Sciences, University of Central Lancashire, Preston, UK
| | - Elizabeth Lynch
- Adelaide Nursing School, University of Adelaide, Adelaide, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia.,NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Victoria, Australia
| | - Kathryn Jarvis
- School of Health Sciences, University of Central Lancashire, Preston, UK
| | - Nicola M Kayes
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| | - Kim Miller
- Evidence Centre, Sunny Hill Health Centre for Children, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Suzie Mudge
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| | - Rebecca Fisher
- School of Medicine, University of Nottingham, Nottingham, UK
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15
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Bråndal A, Eriksson M, Glader EL, Wester P. Effect of early supported discharge after stroke on patient reported outcome based on the Swedish Riksstroke registry. BMC Neurol 2019; 19:40. [PMID: 30866844 PMCID: PMC6417172 DOI: 10.1186/s12883-019-1268-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 03/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The efficacy of early supported discharge (ESD) has not been tested in current stroke care setting, which provide relatively short hospital stays, access to hyper-acute therapies and early carotid stenosis interventions. This study aimed to compare patient-reported outcome measures (PROM) among patients with stroke that received modern stroke unit care with or without ESD. METHODS Observational study of 30,232 patients with first-ever stroke registered in the Riksstroke registry in Sweden, between 1 January 2010 and 31 December 2013. Patient characteristics were collected from the Riksstroke and Statistics Sweden databases. The primary outcome was satisfaction with the rehabilitation at 3 months after discharge. Secondary outcome were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toileting and dressing) at 3 months after the stroke. We used separate multivariable logistic regression models for each PROM variable to analyze associations between PROMs and ESD/no ESD. RESULTS The ESD group comprised 1495 participants: the control group comprised 28,737 participants. Multivariable logistic regression models of PROMs showed that, compared to controls, the ESD group was more satisfied with rehabilitation after discharge (OR: 1.78, 95% CI: 1.17-2.49), experienced less dysthymia/depression (OR: 0.68, 95% 0.55-0.84) and showed more independence in mobility (OR: 1.50, 95% CI: 1.17-1.92), toileting (OR: 1.30, 95%CI: 1.05-1.61), and dressing (OR: 1.23, 95%CI: 1.02-1.48). CONCLUSION In the setting of modern stroke unit care, ESD appeared to have positive effects on stroke rehabilitation, in the subacute phase.
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Affiliation(s)
- Anna Bråndal
- Department of Public Health and Clinical Medicine, Umeå University, S-901 87, Umeå, Sweden. .,Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, S-901 87, Umeå, Sweden.
| | - Marie Eriksson
- Department of Statistics, Umeå School of Business and Economics Umeå University, S-901 87, Umeå, Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University, S-901 87, Umeå, Sweden
| | - Per Wester
- Department of Public Health and Clinical Medicine, Umeå University, S-901 87, Umeå, Sweden.,Department of Clinical Sciences, Karolinska Institute, Danderyd hospital, S-182 88, Stockholm, Sweden
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16
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Miller KK, Lin SH, Neville M. From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke. Arch Phys Med Rehabil 2018; 100:1162-1175. [PMID: 30465739 DOI: 10.1016/j.apmr.2018.10.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 10/18/2018] [Accepted: 10/27/2018] [Indexed: 12/25/2022]
Abstract
Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group's Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.
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Affiliation(s)
- Kristine K Miller
- Department of Physical Therapy, Indiana University, Indianapolis, IN.
| | - Susan H Lin
- Department of Occupational Therapy, Massachusetts General Hospital Institute of Health Professions, Boston, MA
| | - Marsha Neville
- School of Occupational Therapy, Texas Woman's University, Dallas, TX
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17
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Lloyd A, Bannigan K, Sugavanam T, Freeman J. Experiences of stroke survivors, their families and unpaid carers in goal setting within stroke rehabilitation. ACTA ACUST UNITED AC 2018; 16:1418-1453. [DOI: 10.11124/jbisrir-2017-003499] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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18
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Lynch EA, Chesworth BM, Connell LA. Implementation—The Missing Link in the Research Translation Pipeline: Is It Any Wonder No One Ever Implements Evidence-Based Practice? Neurorehabil Neural Repair 2018; 32:751-761. [DOI: 10.1177/1545968318777844] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the exponential growth in the evidence base for stroke rehabilitation, there is still a paucity of knowledge about how to consistently and sustainably deliver evidence-based stroke rehabilitation therapies in clinical practice. This means that people with stroke will not consistently benefit from research breakthroughs, simply because clinicians do not always have the skills, authority, knowledge or resources to be able to translate the findings from a research trial and apply these in clinical practice. This “point of view” article by an interdisciplinary, international team illustrates the lack of available evidence to guide the translation of evidence to practice in rehabilitation, by presenting a comprehensive and systematic content analysis of articles that were published in 2016 in leading clinical stroke rehabilitation journals commonly read by clinicians. Our review confirms that only a small fraction (2.5%) of published stroke rehabilitation research in these journals evaluate the implementation of evidence-based interventions into health care practice. We argue that in order for stroke rehabilitation research to contribute to enhanced health and well-being of people with stroke, journals, funders, policy makers, researchers, clinicians, and professional associations alike need to actively support and promote (through funding, conducting, or disseminating) implementation and evaluation research.
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Affiliation(s)
- Elizabeth A. Lynch
- University of Adelaide, Adelaide, South Australia, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
- NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery, Parkville, Victoria, Australia
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19
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Affiliation(s)
- Katie Gallacher
- From the Institute of Health and Well Being (K.G.) and Institute of Cardiovascular and Medical Sciences (T.J.Q.), University of Glasgow, United Kingdom
| | - Terence J. Quinn
- From the Institute of Health and Well Being (K.G.) and Institute of Cardiovascular and Medical Sciences (T.J.Q.), University of Glasgow, United Kingdom
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20
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Cadilhac DA, Fisher R, Bernhardt J. How to do health services research in stroke: A focus on performance measurement and quality improvement. Int J Stroke 2018; 13:166-174. [PMID: 29299958 DOI: 10.1177/1747493017750924] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Dominique A Cadilhac
- 1 Stroke and Ageing Research Centre, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,2 Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Rebecca Fisher
- 3 Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Julie Bernhardt
- 2 Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
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21
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Kraut J, Singer BJ, Singe KP. Clinician and client views of utilising early supported discharge services. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2016. [DOI: 10.12968/ijtr.2016.23.10.464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background/Aims: To explore the beliefs and attitudes of potential referrers and referrees regarding the possible utilisation of early supported discharge (ESD) prior to hospital discharge. Methods: Semi-standardised one-to-one interviews were conducted with nine consultants and ten dyads, comprising inpatients and corresponding treating staff members involved in referral of these patients to ESD. Content analysis was completed to identify key themes and to group the data into categories. Results: Rehabilitation consultants reported safety and the ability to manage at home were the primary considerations in ESD referral decision making. Most patients were extremely likely to agree to referral to ESD. Four main categories were identified in the responses from the patient/staff dyads, which were summarised as: positive and negative aspects of ESD, and barriers and enablers to early discharge. Patients were only willing to return home with ESD once they were ambulant in some capacity. Staff identified considerably more potential disadvantages, and fewer benefits than patients with regard to early discharge. However, there was no indication that staff beliefs had a negative influence on patient views regarding their participation in ESD. Conclusions: Patients and staff generally approved of ESD services; however, staff may need to place greater consideration on advantages, such as the potential emotional and mental benefits that some patients associate with returning home sooner with ESD.
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Affiliation(s)
- Jacey Kraut
- The Centre for Musculoskeletal Studies, School of Surgery, TheUniversity of Western Australia, Perth, Western Australia, Australia, Rehabilitation in the Home, SMHS, Perth, Western Australia, Australia
| | - Barbara J Singer
- The Centre for Musculoskeletal Studies, School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - Kevin P Singe
- The Centre for Musculoskeletal Studies, School of Surgery, The University of Western Australia, Perth, Western Australia, Australia
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22
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Nordin Å, Sunnerhagen KS, Axelsson ÅB. Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study. BMC Neurol 2015; 15:235. [PMID: 26572860 PMCID: PMC4647613 DOI: 10.1186/s12883-015-0492-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An Early Supported Discharge (ESD) and rehabilitation from a coordinated team in the home environment is recommended in several high-income countries for patients with mild to moderate symptoms after stroke. Returning home from the hospital takes place very early in Sweden today (12 days post stroke), thus the term Very Early Supported Discharge (VESD) is used in the current study. The aim of this study was to describe patients' expectations of coming home very early after stroke with support and rehabilitations at home. METHOD This is an interview study nested within a randomized controlled trial; Gothenburg Very Early Supported Discharge (GOTVED), comparing VESD containing a home rehabilitation intervention from a coordinated team to conventional care after stroke. Ten participants (median age 69) with mild to moderate stroke symptoms (NHISS 0 to 8 points) were recruited from the intervention group in GOTVED. Interviews were conducted 0-5 days before discharge and the material was analyzed with qualitative content analysis. RESULTS Four main categories containing 11 subcategories were found. The VESD team was expected to provide "Support towards independency", by helping the participants to manage and feel safe at home as well as to regain earlier abilities. The very early discharge gave rise to expectations of coming home to "A new and unknown situation", causing worries not to manage at home and to leave the safe environment at the ward. A fear to suffer a recurrent stroke when being out of reach of immediate professional help was also pronounced. In contrast to these feelings of insecurity and fear, "Returning to one's own setting" described the participants longing home, where they would become autonomous and capable people again. They expected this to facilitate recovery and rehabilitation. "A new everyday life" waited for the participants at home and this was expected to be challenging. Different strategies to deal with these challenges were described. CONCLUSIONS The participants described mixed expectations such as insecurity and fear, and on the other hand, longing to come home. Moreover, they had a high degree of confidence in the expected support of the VESD team. The health professionals at the hospital may build on this trust to reduce the patients' insecurity for coming home. In addition, it may be beneficial to explore the patients' expectations thoroughly in front of discharge, as certain feelings and thoughts could complicate or support the home coming process. Thus, a greater attention on such expectations may facilitate the patient's transition from hospital to home after stroke.
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Affiliation(s)
- Åsa Nordin
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Katharina S Sunnerhagen
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- University of Gothenburg Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Sunnaas Rehabilitation Hospital, Nesodden, Oslo, Norway.
| | - Åsa B Axelsson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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