Implementation of evidence-based stroke care: enablers, barriers, and the role of facilitators

Needs Assessment Survey for Stroke Care Core Competency-Based Training for Neuroscience Nurses

BACKGROUND

Assessment of stroke care core competency for neuroscience nurses is crucial for developing training programs to improve the quality of care for patients who have a stroke. The goal of this study was to determine the priorities for competency-based training using an importance-performance analysis of stroke care core competency among neuroscience nurses.

METHOD

A cross-sectional descriptive survey was conducted using a convenience sample of 154 neuroscience nurses. Differences in importance and performance scores were analyzed with paired t tests. The training priority was determined using the importance-performance matrix.

RESULTS

The overall performance score was significantly lower than the importance score. The highest priority areas of training were (a) principles of stroke care and (b) cardiovascular and respiratory effects.

CONCLUSION

Competency-based continuing education is needed in implementing stroke best practices for neuroscience nurses to achieve optimal competency. [J Contin Educ Nurs. 2024;55(2):63-68.].

Cognitive screening and rehabilitation after cardiac arrest: only a few hurdles to take

Dutch and European guidelines recommend systematic screening for cognitive and emotional impairments in cardiac arrest survivors. We aimed to clarify opinions on cognitive screening and rehabilitation, identify barriers and facilitators for implementation in the Netherlands, and arrive at recommendations in this field. We conducted 22 semi-structured interviews with various stakeholders using the Tailored Implementation in Chronic Diseases checklist. There is broad-based acknowledgement of the relevance of cognitive impairment and a positive attitude regarding early cognitive screening among health professionals and patients. Barriers to implementation include a lack of practical recommendations on how, where and when to screen, insufficient knowledge of cognitive consequences of cardiac arrest, insufficient collaboration and knowledge sharing among different specialties within hospitals, insufficient resources, and insufficient evidence of the effectiveness of screening and therapy to justify financial compensation. Most of the identified barriers to implementation are solvable: national guidelines need practical recommendations and knowledge gaps among healthcare workers can be bridged by in-hospital collaboration. Fulfilling these requirements should be sufficient for the implementation of simple screening and tailored advice. More extensive cognitive rehabilitation therapy needs stronger evidence of efficacy in order to warrant stronger guideline recommendations and financial reimbursement.

The Implementation Process of Two Evidence-Based Protocols: A Spatial Neglect Network Initiative

Introduction

Spatial neglect, a neurocognitive disorder of lateralized spatial attention, is prevalent among stroke survivors especially in inpatient rehabilitation facilities (IRFs). The ultimate goal of the project was to improve spatial neglect care in inpatient rehabilitation and trained as many OTs as possible using both tools in their regular practices as the means to achieve our overall objective. Therefore, we conducted a project aimed at implementing two evidence-based protocols, one for assessment (KF-NAP®) and the other for treatment (KF-PAT®), and share the implementation process, which included barriers and facilitators identified during and after the process, and implementation outcomes.

Methods

Sixteen IRFs were involved. The Knowledge-To-Action Cycle was used to describe the process of knowledge inquiry (training), translating knowledge (implementation) and evaluating the use of knowledge in clinical practice (outcomes). Barriers and strategies were reported using the Consolidated Framework for Implementation Research and identified through a survey, after the study concluded.

Results

Thirty-two therapists at the participating sites were trained to some level of the KF-NAP and KF-PAT. Throughout the project and also once after it finished, different barriers were identified by researchers and clinicians, who then determined together actions to eliminate or minimize the barriers. For example, multiple sites reported: "not having time to train other staff at their hospital due to high patient volume and other responsibilities."

Discussion

The project shared our implementation process which demonstrated the importance of using implementation methods and incorporating a researcher-clinician partnership, not only for knowledge generation but also knowledge translation. Frequent communications and exchanging information with stakeholders at different levels, may be determinant to the success of each implementation phase. Further research is needed.

Improving stroke care in Nova Scotia, Canada: a population-based project spanning 14 years

Stroke is a complex disorder that challenges healthcare systems. An audit of in-hospital stroke care in the province of Nova Scotia, Canada, in 2004-2005 indicated that many aspects of care delivery fell short of national best practice recommendations. Stroke care in Nova Scotia was reorganised using a combination of interventions to facilitate systems change and quality improvement. The focus was mainly on implementing evidence-based stroke unit care, augmenting thrombolytic therapy and enhancing dysphagia assessment. Key were the development of a provincial network to facilitate ongoing collaboration and structured information exchange, the creation of the stroke coordinator and stroke physician champion roles, and the implementation of a registry to capture information about adults hospitalised because of stroke or transient ischaemic attack. To evaluate the interventions, a longitudinal analysis compared the audit results with registry data for 2012, 2015 and 2019. The proportion of patients receiving multidisciplinary stroke unit care rose from 22.4% in 2005 to 74.0% in 2019. The proportion of patients who received alteplase increased steadily from 3.2% to 18.5%, and the median delay between hospital arrival and alteplase administration decreased from 102 min to 56 min, without an increase in intracranial haemorrhage. Dysphagia screening increased from 41.4% to 77.4%. More patients were transferred from acute care to a dedicated in-patient rehabilitation unit, and fewer were discharged to residential or long-term care. These enhancements did not prolong length-of-stay in acute care. The network was a critical success factor; competing priorities in the healthcare system were the main challenge to implementing change. A multidimensional, multiyear, improvement intervention yielded substantial and sustained improvements in the process and structure of stroke care in Nova Scotia.

Barriers and Facilitators to Rehabilitation Care of Individuals With Spatial Neglect: A Qualitative Study of Professional Views

Objective

To identify barriers and facilitators to achieving optimal inpatient rehabilitation outcome among individuals with spatial neglect (SN).

Design

Cross-sectional, semistructured focus group discussions.

Setting

Rehabilitation hospitals.

Participants

A total of 15 occupational therapists and 14 physical therapists treating patients with SN on 3 campuses of a rehabilitation hospital system (N=29). Six focus group sessions were conducted and audio-recorded for transcription.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Participants identified several patient-related characteristics that posed barriers to treatment, including the symptoms of SN itself, cognitive issues, physical weakness, comorbidities, and reduced therapy engagement. Supportive family members were considered a key facilitator, but lack of preparedness to assume caregiving roles, poor understanding of SN and rehabilitation goals, and inadequate levels of involvement were family-related barriers to successful treatment. Participants expressed that having resources and technologies available at their center to support SN treatment facilitated positive outcomes and perceived limited staff knowledge and skills and poor interclinician communication as barriers to treatment. At the health care system level, barriers included a lack of responsive measures of SN progress and insurer-related issues. Strong continuity of care between transitions was considered an important factor for enabling effective treatment.

Conclusions

Barriers and facilitators to the current practice of SN care were identified from occupational and physical therapists’ point of view. Opportunities exist to promote identified facilitators and minimize barriers to improve SN rehabilitation. The present study makes a unique contribution in identifying specific needs for innovative interventions that involve family support and training, promotion of interdisciplinary collaboration, development of interprofessional vocabulary, and continuous treatment and follow-up assessment for SN through care transitions.

Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives

BACKGROUND AND OBJECTIVE

Efforts to improve the adoption of evidence-based interventions for optimal patient outcomes in low-/middle-income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals' views on strategies to improve quality stroke care for people who had a stroke in a LMIC.

METHODS

A qualitative interview study design was adopted. A semi-structured interview guide was used to conduct in-depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data.

RESULTS

A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers.

CONCLUSION

Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context-specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.

STEPS-T Program Improves Endovascular Treatment Outcomes of Acute Ischemic Stroke; A 6-Year Study

Background: Early endovascular recanalization of occluded vessels in acute ischemic stroke (AIS) is a major contributor to good clinical outcome. We report the analysis of all AIS patients throughout a 6-year experience following the deployment of a quality initiative aiming at improving care, speed and maintaining quality for AIS treatment.

Methods: Using a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2017, workflow/outcomes were recorded. There were no exclusion criteria. During the first year, a quality program employing “digital-object” technology, staff education, and workflow improvement was implemented to reduce time-to-treatment. Using electronic recording, workflow times were collected for onset (T_O), CT (T_CT), door (T_D), angiography-suite (T_A), groin puncture (T_G), DSA (T_DSA), and recanalization (T_R). Recanalization time (T_G-T_R) and workflow intervals were compared at Year 1 and 6.

Results: Analysis of 382 patients (aged 71.3 ± 12.9) undergoing mechanical thrombectomy for AIS (206 male and 176 female) was performed. Recanalization time was significantly reduced from 82 min in 2012 to 34 min by 2017 (IQR 52–117 min and 23–49 min), a 59% reduction (P < 0.001). Further, consistent year-over-year reductions in setup time (T_A-T_G) (44% improvement) and T_CT to T_A times were observed. During the same period, clinical outcome significantly improved year-over-year as measured with the modified Rankin Scale 0–2 (33, 37, 38, 41, 53, and 58%).

Conclusions: Significant improvements were observed following the deployment of a quality initiative enabling iterative evidence-based process improvements, thereby sustaining significant reductions in time-to-treat and improved clinical outcomes for AIS patients.

Perceived barriers and enablers for implementing water protocols in acute stroke care: A qualitative study using the Theoretical Domains Framework

Purpose: To identify perceived enablers and barriers that may influence the implementation of water protocols (WPs) as an intervention for dysphagia in acute stroke settings. Method: Semi-structured interviews were conducted with nine nurses, eight speech-language pathologists (SLPs), five doctors and four dietitians working in acute stroke units in a major city in Australia. Data were thematically analysed and themes were mapped to the Theoretical Domains Framework. Result: Ten barriers and nine enablers were identified. Key barriers were: nurses lack oral care skills and agency nurses lack stroke-specific skills; only SLPs are perceived to be involved with WPs; WP rules will not get followed and may lead to adverse patient outcomes; WPs increase nursing workload; transient workforce impacts efficiency of implementation; and established culture of using thickened fluids. Key enablers were: patients would benefit from WPs; communication and education systems are already in place; acute hospital brings unique benefits; and peer support and modelling support implementation. Conclusion: The perceptions of barriers and enablers to implementation of WPs can be used to inform future studies designed to evaluate the safety and efficacy of WPs and subsequently facilitate their uptake in acute stroke as an alternate dysphagia management strategy.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Endovascular treatment outcomes using the Stroke Triage Education, Procedure Standardization, and Technology (STEPS-T) program

Background "Door to treatment" time affects outcomes of acute ischemic stroke (AIS) patients undergoing endovascular treatment (EVT). However, the correlation between staff education and accessible technology with stroke outcomes has not been demonstrated. Objective The objective of this paper is to demonstrate the five-year impact of the Stroke Triage Education, Procedure Standardization, and Technology (STEPS-T) program on time-to-treat and clinical outcomes. Methods The study analyzed a prospectively maintained database of AIS patients who benefited from EVT through implementation of STEPS-T. Demographics, clinical characteristics, and modified Rankin Score at three months were analyzed. Thrombolysis in Cerebral Infarction (TICI) scale was used to grade pre- and post-procedure angiographic recanalization. Using electronic hemodynamic recording, stepwise workflow times were collected for door time (T_D), entering angiography suite (T_A), groin puncture (T_G), first DSA (T_DSA), microcatheter placement (T_M), and final recanalization (T_R). Median intervention time (T_A to T_R) and recanalization time (T_G to T_R) were compared through Year 1 to Year 5. Results A total of 230 individuals (age 74 ± 12, between 30 to 95) were enrolled. Median intervention and recanalization times were significantly reduced, from 121 minutes to 52 minutes and from 83 minutes to 36 minutes respectively from Year 1 to Year 5, ( p < 0.001). Across the study period, annual recruitment went up from 12 to 66 patients, and modified Rankin Score between 0 and 2 increased from 36% to 59% ( p = 0.024). Conclusions STEPS-T improved time-to-treat in patients undergoing mechanical thrombectomy for AIS. During the observation period, clinical outcomes significantly improved.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review

BACKGROUND

Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings.

METHODOLOGY

A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used.

RESULTS

Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers.

CONCLUSIONS

Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings.

TRIAL REGISTRATION

The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).

Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

OBJECTIVE

Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.

DESIGN

A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.

SETTING

A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.

PARTICIPANTS

A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.

RESULTS

Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.

CONCLUSION

Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

Socioeconomic differences in one-year survival after ischemic stroke: the effect of acute and post-acute care-pathways in a cohort study

Background

The reasons for socioeconomic inequity in stroke mortality are not well understood. The aim of this study was to explore the role of ischemic stroke care-pathways on the association between education level and one-year survival after hospital admission.

Methods

Hospitalizations for ischemic stroke during 2011/12 were selected from Lazio health data. Patients’ clinical history was defined by retrieving previous hospitalizations and drugs prescriptions. The association between education level and mortality after stroke was studied for acute and post-acute phases using multilevel logistic models (Odds Ratio (OR)). Different scenarios of quality care-pathways were identified considering hospital performance, access to rehabilitation and drug treatment post-discharge. The probability to survive to acute and post-acute phases according to education level and care-pathway scenarios was estimated for a “mean-severity” patient. One-year survival probability was calculated as the product of two probabilities. For each scenario, the 1-year survival probability ratio, university versus elementary education, and its Bootstrap Confidence Intervals (95 % BCI) were calculated.

Results

We identified 9,958 patients with ischemic stroke, 53.3 % with elementary education level and 3.2 % with university. The mortality was 14.9 % in acute phase and 14.3 % in post-acute phase among survived to the acute phase. The adjusted mortality in acute and post-acute phases decreased with an increase in educational level (OR = 0.90 p-trend < 0.001; OR = 0.85 p-trend < 0.001). For the best care-pathway, the one-year survival probability ratio was 1.06 (95 % BCI = 1.03–1.10), while it was 1.17 (95 % BCI = 1.09–1.25) for the worst.

Conclusions

Education level was inversely associated with mortality both in acute and post-acute phases. The care-pathway reduces but does not eliminate 1-year survival inequity.