A study to assess the effect of nursing interventions at the weekend for people with stroke

Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review

QUESTION

Are additional weekend allied health services effective and cost-effective for acute general medical and surgical wards, and subacute rehabilitation hospital wards?

DESIGN

Systematic review and meta-analysis of studies published between January 2000 and May 2017. Two reviewers independently screened studies for inclusion, extracted data, and assessed methodological quality. Meta-analyses were conducted for relative measures of effect estimates.

PARTICIPANTS

Patients admitted to acute general medical and surgical wards, and subacute rehabilitation wards.

INTERVENTION

All services delivered by allied health professionals during weekends (Saturday and/or Sunday). This study limited allied health professions to: occupational therapy, physiotherapy, social work, speech pathology, dietetics, art therapy, chiropractic, exercise physiology, music therapy, oral health (not dentistry), osteopathy, podiatry, psychology, and allied health assistants.

OUTCOME MEASURES

Hospital length of stay, hospital re-admission, adverse events, discharge destination, functional independence, health-related quality of life, and cost of hospital care.

RESULTS

Nineteen articles (20 studies) were identified, comprising 10 randomised and 10 non-randomised trials. Physiotherapy was the most commonly investigated profession. A meta-analysis of randomised, controlled trials showed that providing additional weekend allied health services in subacute rehabilitation wards reduced hospital length of stay by 2.35days (95% CI 0.45 to 4.24, I²=0%), and may be a cost-effective way to improve function (SMD 0.09, 95% CI -0.01 to 0.19, I²=0%), and health-related quality of life (SMD 0.10, 95% CI -0.01 to 0.20, I²=0%). For acute general medical and surgical hospital wards, it was unclear whether the weekend allied health service model provided in the two identified randomised trials led to significant changes in measured outcomes.

CONCLUSION

The benefit of providing additional allied health services is clearer in subacute rehabilitation settings than for acute general medical and surgical wards in hospitals.

REGISTRATION

PROSPERO CRD76771. [Sarkies MN, White J, Henderson K, Haas R, Bowles J, Evidence Translation in Allied Health (EviTAH) Group (2018) Additional weekend allied health services reduce length of stay in subacute rehabilitation wards but their effectiveness and cost-effectiveness are unclear in acute general medical and surgical hospital wards: a systematic review. Journal of Physiotherapy 64: 142-158].

Challenges, uncertainties and perceived benefits of providing weekend allied health services-a managers' perspective

Background

Health services that operate 7 days per week are under pressure to show the increased cost of providing weekend services can be measured in improved patient outcomes. The evidence for weekend allied health services in acute medical and surgical wards is weak and there is wide variation between the services offered at different hospitals.

Methods

This qualitative study was undertaken during a multi-site stepped wedge randomised controlled trial involving twelve acute medical and surgical wards from two Australian hospitals, in which weekend allied health services were removed before being reinstated with a stakeholder driven model. In-depth interviews were conducted with twenty-two staff responsible for managing weekend services at the involved hospitals. Participants were asked about their perceptions of the advantages and disadvantages of providing a weekend allied health service.

Results

Managers perceive the services improve patient flow and quality of care and reduce adverse incidents, such as falls and intensive care admissions. They also highlighted the challenges involved in planning, staffing and managing these services and the uncertainties about how to provide it most effectively.

Conclusions

Rising healthcare costs provide opportunity for public and professional debate about the most effective way of providing weekend allied health care services, particularly when health services provide limited other weekend services. Some managers perceived weekend allied health services to improve patient quality of care, but without studies which show these services on acute medical and surgical wards clearly change patient outcomes or provide health economic gains, these resources may need to be redirected. The resources may be better spent in areas with clear evidence to show the addition of weekend allied health services improves patient outcomes, such as on acute assess units and rehabilitation wards.

Feasibility of a Nurse-Led Weekend Group Exercise Program for People after Stroke

Background. Additional physical activity including repetitive task practice can improve outcomes after stroke. The additional practice can be facilitated by therapists and family members or could also be delivered by nursing staff. Objective. To investigate the feasibility of a nurse-led weekend exercise program after stroke. Participants. Individuals after stroke, who participated in a weekend exercise program during their hospital admission. Methods. A retrospective audit of the number of referrals to and amount of exercise repetitions achieved in a nurse-led weekend exercise program was undertaken. The weekend exercise program occurs on each Saturday and Sunday for one hour. The repetitions of exercise completed during each class were documented by staff. An audit was conducted to ascertain the amount and type of exercise completed within the class. Results. During the study period 284 people were referred to the exercise program. The mean number of exercise repetitions completed per participant in each class was 180.7 (SD 205.4). The number of exercise repetitions completed by participants was highly variable ranging from 0 to 1190 per class. Conclusion. The amount of average exercise repetitions completed in the Weekend Warrior program was large but with significant variability. A nurse-led exercise class is a feasible method of delivering exercise opportunities to individuals in hospital after stroke.

After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review

QUESTION

In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation decrease length of stay and improve functional outcome, activities of daily living performance and physical activity?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults participating in an inpatient rehabilitation program.

INTERVENTION

Additional rehabilitation provided after hours (evening or weekend).

OUTCOME MEASURES

Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores.

RESULTS

Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after-hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD -1.8 days, 95% CI -5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10).

CONCLUSION

Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay.

REVIEW REGISTRATION

PROSPERO CRD42014007648. [Scrivener K, Jones T, Schurr K, Graham PL, Dean CM (2015) After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review.Journal of Physiotherapy61: 61-67].

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.

Effects of a nurse-led acupressure programme for stroke patients in China

AIM AND OBJECTIVE

To examine the effects of a nurse-led acupressure programme on the recovery of motor function and daily activities of stroke patients.

BACKGROUND

Stroke is one of the main causes of death and permanent physical disability in the world. The traditional Chinese medicine (TCM) is widely used for the treatment and rehabilitation of people with stroke in China. Physiotherapy or occupational therapy cannot be performed several times a day. Therefore, researchers and healthcare providers have been seeking effective and efficient alternative strategies for the rehabilitation of stroke patients. Acupressure, non-invasive and widely accessible to any healthcare professionals, is one of the promising alternatives.

METHODS

Seventy-eight stroke patients were recruited and randomly assigned into an intervention or control group, with 39 patients in each. The intervention group received acupressure plus routine care, while the control group received only routine care only. The acupressure treatment was carried out by nurses. Patient's activities of daily living (ADL) and motor function from both groups were evaluated at the point of recruitment, and at the end of the first and third month after stroke.

RESULTS

The ADL and the Fugl-Meyer motor scores in the intervention group were significantly higher than those in the control group at the end of the third month (p<0.05).

CONCLUSION

Nurse-led acupressure programme had positive effects on the recovery of motor function and daily activities of stroke patients. Our study suggests that nurse-led acupressure programmes play an important role in the recovery of stroke patients.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers need to think about alternative care methods including acupressure for the rehabilitation of stroke patients. Acupressure is one of the promising alternatives nursing intervention for stroke patients in practice.

The Mauk Model for Poststroke Recovery: assessing the phases

Despite the estimated 795,000 strokes occurring in America annually (American Heart Association, 2009), few practical models guide nurses when they provide quality care to stroke survivors. The Mauk Model for Poststroke Recovery is a theoretical framework concerning six phases of poststroke recovery. The purpose of this article is to discuss a pilot study detailing the ways in which nursing students used the Mauk model to identify these phases of stroke recovery via patient case examples. A sample of 30 volunteer nursing students read five case studies and determined the phase of stroke recovery. Descriptive statistics about sample characteristics and frequencies were calculated using SPSS 14 for Windows. Nearly 57% (n = 17) of the students rated all of the case studies to the correct phase. Ways in which the model might be clarified and used as a valuable tool when assessing the phase of stroke recovery are described.

The role of nursing in the rehabilitation of stroke survivors: an extended theoretical account

This article provides a critique and theoretical extension of a work that sought to describe the contribution of nurses to stroke rehabilitation. At the time, the role of nursing was considered important but therapeutically nonspecific. Stroke nursing research has increased significantly and so has research focusing on the patient experiences of the adjustment and rehabilitation processes following a stroke. These developments provide significant new insights that may refine and extend the original understanding of the role of nursing in stroke rehabilitation. This article proposes an extended theoretical framework of the role of nursing in stroke recovery and rehabilitation.

Effectiveness of two rehabilitation strategies provided by nurses for stroke patients in Mexico

OBJECTIVE

Rehabilitation strategies have been developed to improve functional state in stroke patients. The main objective of this study was to evaluate the effectiveness of the early rehabilitation at hospital and its continuity at home provided by nurses, on the functional recovery of basic and social activities in stroke patients compared with conventional care.

DESIGN

A randomised clinical trial was carried out in three general hospitals of the Mexican Institute of Social Security (IMSS) in Mexico City between April 2003-May 2004.

PARTICIPANTS

Stroke patients.

METHODS

Two rehabilitation strategies provided by nurses for stroke patients were compared: physiotherapy plus caregiver education in rehabilitation (strategy 1, S1) vs. education alone (strategy 2, S2). The main outcome variables were the basic (Barthel index) and social (Frenchay activities index) activities of daily living, of each patient. Age, sex, morbidity, stroke symptoms, complications, neurological damage (Canadian Scale), cognitive state (mini-mental state examination questionnaire) and duration of hospitalisation were defined as the control variables. Patients were evaluated at baseline and months one, three and six thereafter.

RESULTS

One hundred and ten patients with ischaemic stroke were enrolled and randomised; 59 were assigned to S1 and 51 to S2. Comparison of the outcome variables showed that patients improved significantly over time, but no differences were observed between groups. We observed no significant difference in strategy performance with regard to the basic and instrumental activities of daily living.

RELEVANCE TO CLINICAL PRACTICE

Participants who received physiotherapy with additional caregiver education benefit no more than those whose caregivers received education alone. Those countries that do not have integral rehabilitation programmes for stroke patients should understand their importance and budget resources for them. Meanwhile, both caregiver education and nurses trained in specific care and physiotherapy are alternatives that benefit these patients.

Impact of intensity of practice after stroke: Issues for consideration

PURPOSE

The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the paper raises the question of what it is that patients actually learn when they improve their functional skills. Search strategy. For this purpose articles from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE and PiCarta and references presented in relevant publications were examined.

DISCUSSION AND CONCLUSION

Although, there is strong evidence that early augmented exercise therapy time (expressed as time dedicated to practice) may enhance functional recovery, there is a discrepancy between the evidence for the benefits of intensive practice, on the one hand, and, the implementation of intensive rehabilitation treatment programmes in the current healthcare system on the other. Further emphasis should be given on a better understanding of the time-dependency of prognostic factors that determine the effectiveness of intensive practice in patients with stroke. In addition, a better understanding is needed of the neurophysiological and biomechanical mechanisms that underlie compensation-related learning of functional tasks after stroke.