ORCID Profile
0000-0002-7201-4394
Current Organisations
Nursing Research Institute, St Vincent's Health Australia (Syd) and Australian Catholic University
,
Australian Catholic University - North Sydney Campus
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Research Topics
In Research Link Australia (RLA), "Research Topics" refer to ANZSRC FOR and SEO codes. These topics are either sourced from ANZSRC FOR and SEO codes listed in researchers' related grants or generated by a large language model (LLM) based on their publications.
Top 5 Research Topics
ANZSRC Field of Research (FoR)
Nursing | Health and Community Services | Aged Care Nursing | Public Health and Health Services | Human Bioethics | Public Health And Health Services Not Elsewhere Classified | Public Policy | Nursing Not Elsewhere Classified | Sociology | Social Change | Clinical Nursing: Secondary (Acute Care) | Nursing not elsewhere classified | Organisational Planning and Management | Organisation and Management Theory
ANZSRC Socio-Economic Objective (SEO)
Health and support services not elsewhere classified | Public services management | The professions and professionalisation | Changing work patterns | Nursing | Nursing | Health not elsewhere classified | Evaluation of health outcomes | Health policy evaluation |
Related Links
Publications
Low blood pressure and adverse outcomes in acute stroke: HeadPoST study explanations.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-09-2021
Weekend hospital discharge is associated with suboptimal care and outcomes: An observational Australian Stroke Clinical Registry study
Publisher: SAGE Publications
Date: 22-10-2018
Abstract: The quality of stroke care may diminish on weekends. We aimed to compare the quality of care and outcomes for patients with stroke/transient ischemic attack discharged on weekdays compared with those discharged on weekends. Data from the Australian Stroke Clinical Registry from January 2010 to December 2015 ( n = 45 hospitals) were analyzed. Differences in processes of care by the timing of discharge are described. Multilevel regression and survival analyses (up to 180 days postevent) were undertaken. Among 30,649 registrants, 2621 (8.6%) were discharged on weekends (55% male median age 74 years). Compared to those discharged on weekdays, patients discharged on weekends were more often patients with a transient ischemic attack (weekend 35% vs. 19% p 0.001) but were less often treated in a stroke unit (69% vs. 81% p 0.001), prescribed antihypertensive medication at discharge (65% vs. 71% p 0.001) or received a care plan if discharged to the community (47% vs. 53% p 0.001). After accounting for patient characteristics and clustering by hospital, patients discharged on weekends had a 1 day shorter length of stay (coefficient = −1.31, 95% confidence interval [CI] = −1.52, −1.10), were less often discharged to inpatient rehabilitation (aOR = 0.39, 95% CI = 0.34, 0.44) and had a greater hazard of death within 180 days (hazard ratio = 1.22, 95% CI = 1.04, 1.42) than those discharged on weekdays. Patients with stroke/transient ischemic attack discharged on weekends were more likely to receive suboptimal care and have higher long-term mortality. High quality of stroke care should be consistent irrespective of the timing of hospital discharge.
Cluster‐Randomized Trial of Thrombolysis Implementation Support in Metropolitan and Regional Australian Stroke Centers: Lessons for Individual and Systems Behavior Change
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-02-2020
Abstract: Intravenous thrombolytic therapy ( IVT ) with tissue plasminogen activator for acute ischemic stroke is underutilized in many parts of the world. Randomized trials to test the effectiveness of thrombolysis implementation strategies are limited. This study aimed to test the effectiveness of a multicomponent, multidisciplinary tissue plasminogen activator implementation package in increasing the proportion of thrombolyzed cases while maintaining accepted benchmarks for low rates of intracranial hemorrhage and high rates of functional outcomes at 3 months. A cluster randomized controlled trial of 20 hospitals in the early stages of thrombolysis implementation across 3 Australian states was undertaken. Monitoring of IVT rates during the baseline period allowed hospitals (the unit of randomization) to be grouped into 3 baseline IVT strata—very low rates (0% to ≤4.0%) low rates ( .0% to ≤10.0%) and moderate rates ( .0%). Hospitals were randomized to an implementation package (experimental group) or usual care (control group) using a 1:1 ratio. The 16‐month intervention was based on behavioral theory and analysis of the steps, roles, and barriers to rapid assessment for thrombolysis eligibility and involved comprehensive strategies addressing in idual and system‐level change. The primary outcome was the difference in tissue plasminogen activator proportions between the 2 groups postintervention. The absolute difference in postintervention IVT rates between intervention and control hospitals adjusted for baseline IVT rate and stratum was not significant (primary outcome rate difference=1.1% (95% CI −1.5% to 3.7% P =0.38). Rates of intracranial hemorrhage remained below international benchmarks. The implementation package resulted in no significant change in tissue plasminogen activator implementation, suggesting that ongoing support is needed to sustain initial modifications in behavior. URL : www.anzctr.org.au Unique identifiers: ACTRN 12613000939796 and U1111‐1145‐6762
Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation
Publisher: Wiley
Date: 17-01-2023
DOI: 10.1111/JEP.13803
Abstract: Mobile stroke units (MSUs) are increasingly being implemented to provide acute stroke care in the prehospital environment, but a comprehensive implementation evaluation has not been undertaken. To identify successes and challenges in the pre‐ and initial operations of the first Australian MSU service from an interdisciplinary perspective. Process evaluation of the Melbourne MSU with a mixed‐methods design. Purposive s ling targeted key stakeholder groups. Online surveys (administered June–September 2019) and semistructured interviews (October–November 2019) explored experiences. Directed content analysis (raters' agreement 85%) and thematic analysis results are presented using the Interactive Sociotechnical Analysis framework. Participants representing executive rogram operations, MSU clinicians and hospital‐based clinicians completed 135 surveys and 38 interviews. Results converged, with major themes addressing successes and challenges: stakeholders, vehicle, knowledge, training/education, communication, work processes and working relationships. Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.
Peri-operative nurses' knowledge and reported practice of pressure injury risk assessment and prevention: A before-after intervention study
Publisher: Springer Science and Business Media LLC
Date: 24-11-2012
Abstract: Patients are at risk of developing pressure injuries in the peri-operative setting. Studies evaluating the impact of educational interventions on peri-operative nurses’ knowledge and reported practice are scarce. The purpose of this study was to evaluate the effect of a multifaceted intervention on peri-operative nurses’ (a) knowledge of pressure injury risks, risk assessment and prevention strategies for patients in the operating suite and (b) reported practice relating to risk assessment practices and implementation of prevention strategies for patients in the operating suite. A before-after research design was used. A convenience s le of all registered and enrolled nurses employed in two hospitals’ operating suites was recruited. A multifaceted intervention was delivered which comprised a short presentation, educational materials and reminder posters. A 48-item survey tool was completed pre-and post-intervention to measure self-reported knowledge and practice. 70 eligible peri-operative nurses completed both surveys. Post-intervention, statistically significant improvements were seen in knowledge of correct descriptions of pressure injury stages (p=0.001) appropriate reassessment for patients with a new pressure injury (p=0.05) appropriate actions for patients with an existing stage 1 (p=0.02) and stage 2 pressure injury (p=0.04). Statistical improvements were also seen in reported practice relating to an increase in the use of a risk assessment tool in conjunction with clinical judgement (p=0.0008) verbal handover of patients’ pressure injury risk status from the operating room nurse to the recovery room (p=0.023) and from the recovery room nurse to the postoperative ward nurse (p=0.045). The number of participants reporting use of non-recommended and recommended pressure-relieving strategies was unchanged. A multi-faceted educational intervention can improve some aspects of perioperative nurses’ knowledge and reported practice such as risk assessment practices but not others such as use of recommended pressure-relieving devices. Further research is required to ascertain effective interventions which improve all areas of practice and knowledge, particularly in the use of appropriate pressure-relieving devices in order to prevent pressure injuries in surgical patients.
Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial
Publisher: Springer Science and Business Media LLC
Date: 26-01-2023
DOI: 10.1186/S13012-023-01260-9
Abstract: Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals. A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms—high- or low-intensity external remote facilitation or a no facilitation control group—in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation – Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical ch ions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever ( n =5) (ii) hyperglycaemia ( n =6) and (iii) swallowing protocols ( n =7) adherence to the in idual elements that make up each of these protocols comparison for composite outcomes between (i) metropolitan and rural/remote hospitals and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes. We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas. ACTRN12622000028707. Registered 14 January, 2022.
14th International Symposium on Thrombolysis, Thrombectomy and Acute Stroke Therapy: Proceedings and summary of discussions
Publisher: SAGE Publications
Date: 28-03-2019
Abstract: The 14th International Symposium on Thrombolysis, Thrombectomy and Acute Stroke Therapy (TTST) took place in Houston, Texas on 21–22 October 2018. Attended by 150+ invited global experts, the objectives of TTST 2018 were to explore the changing landscape of acute ischemic stroke therapy and to address current controversies in thrombolysis and thrombectomy, including expanding access and systems of care with global relevance. This article summarizes the proceedings of TTST 2018. The key points of each session are listed below, the full text of presentations and discussion are available in the online supplement, and the full list of contributing authors appear in the Appendix at the end of this article.
Statistical analysis plan (SAP) for the Very Early Rehabilitation in Speech (VERSE) after stroke trial: an international 3-arm clinical trial to determine the effectiveness of early, intensive, prescribed, direct aphasia therapy
Publisher: SAGE Publications
Date: 10-2018
Abstract: Limited evidence exists to support very early intensive aphasia rehabilitation after stroke. VERSE is a PROBE trial designed to determine whether two types of intensive aphasia therapy, beginning within 14 days of acute stroke, provide greater therapeutic and cost-effectiveness than usual care. To publish the detailed statistical analysis plan for the VERSE trial prior to unblinding. This statistical analysis plan was based on the published and registered VERSE trial protocol and was developed by the blinded steering committee and management team, led by the trial statistician. This plan was developed using outcome measures and trial data collection forms. The VERSE statistical analysis plan is consistent with reporting standards for clinical trials and provides for clear and open reporting. Publication of a statistical analysis plan serves to reduce potential trial reporting bias and outlines transparent pre-specified analyses. Australian New Zealand Clinical Trials Registry (ANZCTR) Registration number: ACTRN12613000776707 Universal Trial Number (UTN) is U1111-1145-4130.
Arrival Time to Stroke Unit as Crucial a Measure as Arrival Time to Emergency Department
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2008
Mortality Reduction for Fever, Hyperglycemia, and Swallowing Nurse-Initiated Stroke Intervention
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2017
DOI: 10.1161/STROKEAHA.116.016038
Abstract: Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005–2010). We now examine long-term all-cause mortality. Mortality was ascertained using Australia’s National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber–White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates. One thousand and seventy-six participants (intervention n=600 control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival ( %), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79 95% confidence interval [CI], 0.58–1.07 P =0.13 adjusted HR, 0.77 95% CI, 0.59–0.99 P =0.045). Older age (75–84 years HR, 4.9 95% CI, 2.8–8.7 P .001) and increasing stroke severity (HR, 1.5 95% CI, 1.3–1.9 P .001) were associated with increased mortality, while being married (HR, 0.70 95% CI, 0.49–0.99 P =0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths. Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care. URL: www.anzctr.org.au . Unique identifier: ACTRN12608000563369.
Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical
Publisher: Springer Science and Business Media LLC
Date: 28-11-2016
Barriers and enablers to adherence to anticoagulation in heart failure with atrial fibrillation: patient and provider perspectives
Publisher: Wiley
Date: 31-03-2017
DOI: 10.1111/JOCN.13759
Abstract: The purpose of this study was to elucidate the barriers and enablers to adherence to anticoagulation in in iduals with chronic heart failure (CHF) with concomitant atrial fibrillation (AF) from the perspective of patients and providers. CHF and AF commonly coexist and are associated with increased stroke risk and mortality. Oral anticoagulation significantly reduces stroke risk and improves outcomes. Yet, in approximately 30% of cases, anticoagulation is not commenced for a variety of reasons. Qualitative study using narrative inquiry. Data from face-to-face in idual interviews with patients and information retrieved from healthcare file note review documented the clinician perspective. This study is a synthesis of the two data sources, obtained during patient clinical assessments as part of the Atrial Fibrillation And Stroke Thromboprophylaxis in hEart failuRe (AFASTER) Study. Patient choice and preference were important factors in anticoagulation decisions, including treatment burden, unfavourable or intolerable side effects and patient refusal. Financial barriers included cost of travel, medication cost and reimbursement. Psychological factors included psychiatric illness, cognitive impairment and depression. Social barriers included homelessness and the absence of a caregiver or lack of caregiver assistance. Clinician reticence included fear of falls, frailty, age, fear of bleeding and the challenges of multimorbidity. Facilitators to successful prescription and adherence were caregiver support, reminders and routine, self-testing and the use of technology. Many barriers remain to high-risk in iduals being prescribed anticoagulation for stroke prevention. There are a number of enabling factors that facilitate prescription and optimise treatment adherence. Nurses should challenge these treatment barriers and seek enabling factors to optimise therapy. Nurses can help patients and caregivers to understand complex anticoagulant risk-benefit information, and act as a patient advocate when making complex stroke prevention decisions.
Better outcomes for hospitalized patients with TIA when in stroke units: an observational study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-05-2016
Organisational survey for acute stroke care in Vietnam: Regional Collaboration Programme
Publisher: Elsevier BV
Date: 11-2022
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2022.106792
Abstract: Low-middle income countries, such as Vietnam have a greater burden from stroke than high-income countries. Few health professionals have stroke specialist training, and the quality of care may vary between hospitals. To support improvements to stroke care, we aimed to gain a better understanding of the resources available in hospitals in Vietnam to manage acute stroke. The survey questions were adapted from the Australian Organisational Survey of Stroke Services (Stroke Foundation). The final 65 questions covered the topics: hospital size and admissions for stroke use of clinical protocols and assessments conducted team structure and coordination communication and team roles. The survey was distributed electronically or via paper form in Vietnamese to clinical leaders of 91 eligible hospitals (November-December 2020). Data were summarised descriptively. Sixty-six (73%) hospitals responded, and doctors predominately completed the survey (98%). Approximately 70% of hospitals had a stroke unit median 630 acute strokes/year (IQR: 250-1200) and >90% used stroke clinical protocols. The daytime nurse-patient ratio was 1:4. There was a perceived lack of access to allied health staff, including psychologists/neuropsychologists, occupational therapists, and speech pathologists. Only 50% reported having a standardised rehabilitation assessment process. This is the first large-scale cross-sectional, national overview of stroke services in Vietnam. Future research should include a systematic clinical audit of stroke care to confirm aspects of the data from these hospitals. Repeating the survey in future years will enable the tracking of progress and may influence capacity building for stroke care in Vietnam.
Fatal and non-fatal events within 14 days after early, intensive mobilization post stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 23-02-2020
DOI: 10.1212/WNL.0000000000011106
Abstract: This tertiary analysis from A Very Early Rehabilitation Trial (AVERT) examined fatal and nonfatal serious adverse events (SAEs) at 14 days. AVERT was a prospective, parallel group, assessor blinded, randomized international clinical trial comparing mobility training commenced hours poststroke, termed very early mobilization (VEM), to usual care (UC). Primary outcome was assessed at 3 months. Patients with ischemic or hemorrhagic stroke within 24 hours of onset were included. Treatment with thrombolytics was allowed. Patients with severe premorbid disability or comorbidities were excluded. Interventions continued for 14 days or hospital discharge if less. The primary early safety outcome was fatal SAEs within 14 days. Secondary outcomes were nonfatal SAEs classified as neurologic, immobility-related, and other. Mortality influences were assessed using binary logistic regression adjusted for baseline stroke severity (NIH Stroke Scale [NIHSS] score) and age. A total of 2,104 participants were randomized to VEM (n = 1,054) or UC (n = 1,050) with a median age of 72 years (interquartile range [IQR] 63–80) and NIHSS 7 (IQR 4–12). By 14 days, 48 had died in VEM, 32 in UC, age and stroke severity adjusted odds ratio of 1.76 (95% confidence interval 1.06–2.92, p = 0.029). Stroke progression was more common in VEM. Exploratory subgroup analyses showed higher odds of death in intracerebral hemorrhage and years subgroups, but there was no significant treatment by subgroup interaction. No difference in nonfatal SAEs was found. While the overall case fatality at 14 days poststroke was only 3.8%, mortality adjusted for age and stroke severity was increased with high dose and intensive training compared to usual care. Stroke progression was more common in VEM. Australian New Zealand Clinical Trials Registry, ACTRN12606000185561. This study provides Class I evidence that very early mobilization increases mortality at 14 days poststroke.
A behavior change program to increase outings delivered during therapy to stroke survivors by community rehabilitation teams: The Out-and-About trial
Publisher: SAGE Publications
Date: 23-02-2016
Abstract: Australian guidelines recommend that outdoor mobility be addressed to increase participation after stroke. To investigate the efficacy of the Out-and-About program at increasing outings delivered during therapy by community teams, and outings taken by stroke survivors in real life. Cluster-randomized trial involving 22 community teams providing stroke rehabilitation. Experimental teams received the Out-and-About program (a behavior change program comprising a training workshop with barrier identification and booster session, printed educational materials, audit, and feedback). Control teams received printed clinical guidelines only. The primary outcome was the percentage of stroke survivors receiving four or more outings during therapy. Secondary outcomes included the number of outings received by stroke survivors during therapy and undertaken in real life. At 12 months after implementation of the behavior change program, 9% of audited experimental group stroke survivors received four or more outings during therapy compared with 5% in the control group (adjusted risk difference 4%, 95% CI − 9 to 17, p = 0.54). They received 1.1 (SD 0.9) outings during therapy compared with 0.6 (SD 1.0) in the control group (adjusted mean difference 0.5, 95% CI − 0.4 to 1.4 p = 0.26). After six months of rehabilitation, observed experimental group stroke survivors took 9.0 (SD 3.0) outings per week in real life compared with 7.4 (SD 4.0) in the control group (adjusted mean difference 0.5, 95% CI − 1.8 to 2.8 p = 0.63). The Out-and-About program did not change team or stroke survivor behavior.
COVID-19 pandemic impact on care for stroke in Australia: emerging evidence from the Australian stroke clinical registry
Publisher: Frontiers Media SA
Date: 26-02-2021
DOI: 10.3389/FNEUR.2021.621495
Abstract: We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years 56% male ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p & 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.
Outcomes of carotid endarterectomy: How does the Australian state of New South Wales compare with international benchmarks?
Publisher: Elsevier BV
Date: 07-2002
Abstract: The objective of this study was to determine the outcomes of carotid endarterectomy (CEA) in New South Wales, Australia. This state-wide prospective audit of all public and private hospitals during a 6-month period had main outcome measures of 30-day mortality, 30-day fatal stroke, 30-day nonfatal stroke, and 30-day combined stroke and mortality. Fifty-three of 54 eligible surgeons participated (response rate, 98%). The audit obtained inpatient data for 689 internal CEA procedures performed on 666 patients. Of 666 first or only procedures, 462 (69.4%) were performed on patients who were symptomatic and 204 (30.6%) on patients who were asymptomatic. After adjustment for cluster by surgeon, we determined a state-wide 30-day death rate of 1.2% (95% CI, 0.3% to 2.1%), a 30-day fatal or nonfatal stroke rate of 3.0% (95% CI, 1.6% to 4.4% ipsilateral stroke, 2.6%), a 30-day nonfatal stroke rate of 2.3% (95% CI, 1.1% to 3.4% ipsilateral stroke, 2.0%), and a 30-day combined stroke and death rate of 3.5% (95% CI, 2.1% to 4.9%). A significant linear relationship was found between patient preoperative hypertensive status and the combined 30-day stroke and death rate (trend odds ratio, 3.5 95% CI, 1.6 to 7.7). No association was seen between any main outcome measures and hospital volume ( or = 10 CEAs). Four patients underwent surgery outside guideline recommendations (CEA performed for either < or = 30% stenosis or occluded carotid artery). This first comprehensive state-wide audit confirms that Australian surgeons achieve 30-day outcomes comparable with international benchmarks.
Effective discharge policy: are we getting there?
Publisher: CSIRO Publishing
Date: 2004
DOI: 10.1071/AH040255
Abstract: Purpose: To determine patients? knowledge before admission about how many days they were likely to be hospitalised and, after discharge, to determine patients? perceptions of their ?readiness? to leave hospital following carotid endarterectomy. Usefulness of discharge communications to patients? GPs also was ascertained. Methods: Pre- and post-operative self-administered questionnaires to 133 patients and a followup telephone survey of GPs providing primary care to 118 of these patients. Results: Pre-operatively, the majority (84.2%) of patients recalled being told how many days they were likely to be hospitalised. Univariate analysis did not demonstrate any factors predicting positive recall. The majority (87.0%) of patients perceived themselves ?ready to go home? at discharge. Twenty-eight GPs (23.7%) had received both a discharge summary from the hospital and a personalised letter from the patient?s surgeon. GP?s rated the surgeons? letters as significantly more useful than discharge summaries (P = 0.01). Conclusions: Although hospitals are required by NSW Health?s Effective Discharge Policy to inform patients about their likely length of stay in hospital, not all patients recalled whether they were so informed pre-operatively. Barriers impeding realisation of the NSW Health policy remain.
Patients with heart failure with and without a history of stroke in the Netherlands: a secondary analysis of psychosocial, behavioural and clinical outcomes up to three years from the COACH trial
Publisher: BMJ
Date: 08-2019
DOI: 10.1136/BMJOPEN-2018-025525
Abstract: To identify differences in psychosocial, behavioural and clinical outcomes between patients with heart failure (HF) with and without stroke. A secondary analysis of 1023 patients with heart failure enrolled in the Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure. Seventeen hospitals located across the Netherlands. Depressive symptoms (Centre for Epidemiological Studies Depression Scale), quality of life (Minnesota Living with Heart Failure Questionnaire, Ladder of Life Scale), self-care (European Heart Failure Self-Care Behaviour Scale), adherence to HF management (modified version of the Heart Failure Compliance Questionnaire) and readmission for HF, cardiovascular-cause and all-cause hospitalisations at 18 months, and all-cause mortality at 18 months and 3 years. Compared with those without stroke, patients with HF with a stroke (10.3% n=105) had twice the likelihood of severe depressive symptoms (OR 2.83, 95% CI 1.27 to 6.28, p=0.011 OR 2.24, 95% CI 1.03 to 4.88, p=0.043) at 12 and 18 months, poorer disease-specific and generic quality of life (OR 2.80, 95% CI 1.61 to 4.84, p .001 OR 2.00, 95% CI 1.09 to 3.50, p=0.019) at 12 months, poorer self-care (OR 1.80, 95% CI 1.05 to 3.11, p=0.034 OR 2.87, 95% CI 1.61 to 5.11, p .0011) and HF management adherence (OR 0.39, 95% CI 0.18 to 0.81, p=0.012 OR 0.35, 95% CI 0.17 to 0.72, p=0.004) at 12 and 18 months, higher rates of hospitalisations and mortality at 18 months and higher all-cause mortality (HR 1.43, 95% CI 1.07 to 1.91, p=0.016) at 3 years. Patients with HF and stroke have worse psychosocial, behavioural and clinical outcomes, notably from 12 months, than those without stroke. To ameliorate these poor outcomes long-term, integrated disease management pathways are warranted.
International translation of Fever, Sugar, Swallow Protocols: The Quality in Acute Stroke Care Europe Project
Publisher: SAGE Publications
Date: 16-04-2020
Abstract: The Quality in Acute Stroke (QASC) trial demonstrated a significant reduction in death and disability when clinicians were assisted to introduce protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS) following stroke. We describe a unique international collaboration between the Nursing Research Institute at Australian Catholic University the European Stroke Organisation and the Angels Initiative, working collaboratively to support implementation of the nurse-led FeSS Protocols in 20 European countries. We currently have 71 hospitals from 16 countries participating (hospitals from four countries are in the preparation phase) with 49 hospitals currently entering data (n=2819 patients to-date). Baseline data have been received from 39 hospitals, with FeSS Protocol implementation commenced at 16 hospitals. Five hospitals have completed the Project. 'Upscale and spread' of these evidence-based, nursing protocols into countries with vastly different healthcare systems, many of whom also have no access to the latest stroke therapies, is likely to make a significant impact in reducing death and disability after stroke.
A cluster randomised controlled trial of nurse and GP partnership for care of chronic obstructive pulmonary disease
Publisher: Springer Science and Business Media LLC
Date: 03-06-2008
A Randomised Controlled Trial of Intensive Aphasia Therapy after Acute Stroke: The Very Early Rehabilitation for Speech (Verse) Study
Publisher: Elsevier BV
Date: 2018
DOI: 10.2139/SSRN.3251502
Knowledge, attitudes, beliefs and behaviour intentions for three bowel management practices in intensive care: Effects of a targeted protocol implementation for nursing and medical staff
Publisher: Springer Science and Business Media LLC
Date: 31-01-2015
Triage, Treatment, and Transfer
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2015
Vital sign monitoring following stroke associated with 90-day independence: A secondary analysis of the QASC cluster randomized trial
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.IJNURSTU.2018.09.014
Abstract: The Quality in Acute Stroke Care Trial implemented nurse-initiated protocols to manage fever, hyperglycaemia and swallowing (Fever, Sugar, Swallow clinical protocols) achieving a 16% absolute improvement in death and dependency 90-day post-stroke. To examine associations between 90-day death and dependency, and monitoring and treatment processes of in-hospital nursing stroke care targeted in the trial. Secondary data analysis from a single-blind cluster randomised control trial. 19 acute stroke units in New South Wales, Australia. English-speakers ≥18 years with ischaemic stroke or intracerebral haemorrhage arriving at participating stroke units <48 h of stroke onset, excluding those for palliation and without a telephone. Data from patients in the 10 intervention hospitals and the nine control hospitals in the QASC trial post-intervention cohort, who had both hospital process of care data and 90-day outcome data were included. Associations between independence at 90-day (modified Rankin Score ≤1) and processes of care for fever, hyperglycaemia, and dysphagia screening were examined using multiple logistic regression adjusting for treatment group, sex, age group, premorbid modified Rankin scale, marital status, education, stroke severity and correlation within hospitals. Of 1126 patients in the post-intervention cohort (intervention or control), 970 had both in-hospital processes of care data and 90-day outcome data. Patients had significantly lower odds of 90-day independence if, within the first 72 h of stroke unit admission, they had one or more: febrile event (≥37.5 °C) (OR 0.47 95%CI:0.35-0.61 P < 0.0001), higher mean temperature (OR:0.25 95%CI:0.14-0.45 P < 0.0001), finger-prick blood glucose reading ≥11 mmol/L (OR:0.61 95%CI:0.47-0.79 P = 0.0002), higher mean blood glucose (OR 0.89 95%CI:0.84-0.95 P = 0.0006), or failed the swallowing screen (OR 0.35 95%CI:0.22-0.56 P < 0.0001). Patients had greater odds of independence when: venous blood glucose was taken on admission to hospital or within 2 h of stroke unit admission (OR 1.4 95%CI:1.01-1.83 P = 0.04) finger-prick blood glucose was measured within 72 h of stroke unit admission (OR 1.3 95%CI:1.02-1.55 P = 0.03) or when swallowing screening or assessment was performed within 24 h of stroke unit admission (OR 1.8 95%CI:1.29-2.55 P = 0.0006). We have provided robust evidence of the importance of monitoring patients' temperature, blood glucose and swallowing status to improve 90-day stroke outcomes. Routine nursing care can result in significant reduction in death and dependency post-stroke.
Delivering an evidence-based outdoor journey intervention to people with stroke: Barriers and enablers experienced by community rehabilitation teams
Publisher: Springer Science and Business Media LLC
Date: 19-01-2010
The caregiver role in thromboprophylaxis management in atrial fibrillation: A literature review
Publisher: Oxford University Press (OUP)
Date: 14-08-2015
Abstract: Atrial fibrillation is a common arrhythmia and a risk factor for adverse events including stroke. People living with atrial fibrillation are commonly elderly and have multiple comorbidities. The role of a caregiver in supporting the in idual to manage a chronic and complex condition has received limited attention. This review aims to summarize available information on the caregiver role in atrial fibrillation, specifically in promoting adherence to thromboprophylaxis and evidence for strategies to support and enable the caregiver. A review of electronic databases and search engines was undertaken including Medline, Scopus and CINAHL. The search terms 'atrial fibrillation', 'anticoagulation', 'carer', 'caregiver', 'family support' were used. Dates searched were from January 1990 to November 2012. The review found limited original clinical research studies. The majority of the literature identified in the initial search included review papers and work which recommends the inclusion of the caregiver in the care of patients with atrial fibrillation but limited empirical evidence. Caregivers have an essential role to play in advocacy, family centred care and shared decision-making. This may influence thromboprophylaxis treatment choices and potentially adherence. Assessment of caregiver needs and support should be central to patient assessment and care planning. There is a need for clinical intervention studies which more target and address the caregiver role.
Hospital organizational context and delivery of evidence-based stroke care: a cross-sectional study
Publisher: Springer Science and Business Media LLC
Date: 18-01-2019
ASSESSING SURGEONS’ DISCLOSURE OF RISK INFORMATION BEFORE CAROTID ENDARTERECTOMY
Publisher: Wiley
Date: 26-06-2006
DOI: 10.1111/J.1445-2197.2006.03788.X
Abstract: To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and 'non-treatment' options. A survey was conducted to determine patients' recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA). A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA. A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001). Patients recalled discussions with their surgeon about short-term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.
Treatment fidelity monitoring, reporting and findings in a complex aphasia intervention trial: a substudy of the Very Early Rehabilitation in SpEech (VERSE) trial
Publisher: Springer Science and Business Media LLC
Date: 16-06-2022
DOI: 10.1186/S13063-022-06433-3
Abstract: Treatment fidelity is inconsistently reported in aphasia research, contributing to uncertainty about the effectiveness of types of aphasia therapy following stroke. We outline the processes and outcomes of treatment fidelity monitoring in a pre-specified secondary analysis of the VERSE trial. VERSE was a 3-arm, single-blinded RCT with a 12-week primary endpoint comparing Usual Care (UC) to two higher intensity treatments: Usual Care-Plus (UC-Plus) and VERSE, a prescribed intervention. Primary outcome results were previously reported. This secondary analysis focused on treatment fidelity. Video-recorded treatment sessions in the higher intensity study arms were evaluated for treatment adherence and treatment differentiation. Treatment components were evaluated using a pre-determined fidelity checklist. Primary outcome: prescribed amount of therapy time (minutes) secondary outcomes: (i) adherence to therapy protocol (%) and (ii) treatment differentiation between control and high intensity groups. Two hundred forty-six participants were randomised to Usual Care ( n =81), Usual Care-Plus ( n =82), and VERSE ( n =83). One hundred thirty-five (82%) participants in higher intensity intervention arms received the minimum prescribed therapy minutes. From 10,805 (UC 7787 UC-Plus 1450 VERSE 1568) service events, 431 treatment protocol deviations were noted in 114 participants. Four hundred thirty-seven videos were evaluated. The VERSE therapists achieved over 84% adherence to key protocol elements. Higher stroke and aphasia severity, older age, and being in the UC-Plus group predicted more treatment deviations. We found high levels of treatment adherence and differentiation between the intervention arms, providing greater confidence interpreting our results. The comprehensive systems for intervention fidelity monitoring and reporting in this trial make an important contribution to aphasia research and, we argue, should set a new standard for future aphasia studies. ACTRN 12613000776707
Continence management in acute stroke: a survey of current practices in Australia
Publisher: Wiley
Date: 24-10-2010
DOI: 10.1111/J.1365-2648.2010.05480.X
Abstract: The aim of the study was to determine current national urinary incontinence management practices in Australian acute stroke units and their concordance with the National Stroke Foundation guidelines. Urinary incontinence is a common consequence after stroke and a statistically significant indicator of poor outcome, including disability and admission to institutional care. The National Stroke Foundation has produced guidelines for the acute and post-acute phase of care, offering Australian nurses evidence-based recommendations regarding stroke management including the management of urinary incontinence. In 2007-2008, dedicated acute stroke units in Australia were identified and a senior nurse from each unit was invited to participate in a 10-minute telephone survey to ascertain their current urinary continence management practices. Representatives from 41 acute stroke units participated in the survey (response rate 98%). Participants from less than half of the units reported that they had a formal plan for urinary incontinence management (n=19, 46%), and the majority of those who did not would find a formal plan useful (n=15, 79%). Two-thirds of respondents stated that they would manage urinary incontinence with indwelling catheterization (n=25, 61%). Only 30% (n=12) were 'satisfied' or 'very satisfied' with urinary continence management in their acute stroke unit. A large proportion of acute stroke units were yet to establish formal urinary incontinence management plans. The implementation of evidence-based urinary incontinence management plans after stroke is integral to improving patient outcomes. An increase in resources for professional development in the assessment, treatment and management of urinary incontinence is essential to improve and maintain skills in after-stroke care.
A study of 90-day outcomes for a cohort of patients admitted to an Australian metropolitan acute stroke unit
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.JVN.2010.11.004
Abstract: This study investigated patients' 90-day outcomes poststroke following an admission to one Australian metropolitan Acute Stroke Unit (ASU) and examined premorbid risk factors associated with these outcomes. Data from patients consecutively admitted from January 2006 to July 2007 (n = 54) to an acute stroke unit within 48 hours of onset of symptoms were linked with the Quality in Acute Stroke Care research project data and were analyzed to identify associations between premorbid risk factors (atrial fibrillation, hypertension, high cholesterol, smoking and diabetes) demographic, clinical and stroke characteristics and death, disability (modified Rankin Score ≥ 2), dependency (Barthel Index score ≥ 95) and health status (SF-36) poststroke. Within 90 days, 4 participants had died and 45.5% were classified as dependent. Of the total participants, 56.8% were classified as disabled. The SF-36 mean scores indicated that the cohort had less than optimal physical health (46.7, SD = 9.8) and mental health (46.4, SD = 13.1). Analysis of baseline variables showed that participants with atrial fibrillation were more likely to have a severe stroke (p = 0.037). Patients presenting with intracerebral haemorrhage (p = 0.017) and those with subsequent strokes (p = 0.000) had significantly lower Barthel Index scores. A lower SF-36 physical component score at 90 days was significantly associated with intracerebral haemorrhages (p = 0.018) and subsequent strokes (p = 0.026). Although most patients were alive at 90 days poststroke, there were variable levels of morbidity-associated stroke type, subsequent strokes and premorbid risk factors, particularly atrial fibrillation. The findings provide insight into the 90-day outcomes of patients discharged from an ASU, which may be of use to plan appropriate postdischarge support for this group. In particular, aggressive management of stroke risk factors to prevent recurrent stroke is warranted.
Quality in Acute Stroke Care (QASC): Process Evaluation of an Intervention to Improve the Management of Fever, Hyperglycemia, and Swallowing Dysfunction following Acute Stroke
Publisher: SAGE Publications
Date: 12-2013
DOI: 10.1111/IJS.12202
Abstract: Our randomized controlled trial of a multifaceted evidence-based intervention for improving the inpatient management of fever, hyperglycemia, and swallowing dysfunction in the first three-days following stroke improved outcomes at 90 days by 15%. We designed a quantitative process evaluation to further explain and illuminate this finding. Blinded retrospective medical record audits were undertaken for patients from 19 stroke units prior to and following the implementation of three multidisciplinary evidence-based protocols (supported by team-building workshops, and site-based education and support) for the management of fever (temperature ≥37·5°C), hyperglycemia (glucose mmol/l), and swallowing dysfunction in intervention stroke units. Data from 1804 patients (718 preintervention 1086 postintervention) showed that significantly more patients admitted to hospitals allocated to the intervention group received care according to the fever ( n = 186 of 603, 31% vs. n = 74 of 483, 15%, P 0·001), hyperglycemia ( n = 22 of 603, 3·7% vs. n = 3 of 483,0·6%, P = 0·01), and swallowing dysfunction protocols ( n = 241 of 603, 40% vs. n = 19 of 483, 4·0%, P ≤ 0·001). Significantly more patients in these intervention stroke units received four-hourly temperature monitoring ( n = 222 of 603, 37% vs. n = 90 of 483, 19%, P 0·001) and six-hourly glucose monitoring (194 of 603, 32% vs. 46 of 483, 9·5%, P 0·001) within 72 hours of admission to a stroke unit, and a swallowing screen (242 of 522, 46% vs. 24 of 350, 6·8%, P ≤ 0·0001) within the first 24 hours of admission to hospital. There was no difference between the groups in the treatment of patients with fever with paracetamol (22 of 105, 21% vs. 38 of 131, 29%, P = 0·78) or their hyperglycemia with insulin (40 of 100, 40% vs. 17 of 57, 30%, P = 0·49). Our intervention resulted in better protocol adherence in intervention stroke units, which explains our main trial findings of improved patient 90-day outcomes. Although monitoring practices significantly improved, there was no difference between the groups in the treatment of fever and hyperglycemia following acute stroke. A significant link between improved treatment practices and improved outcomes would have explained further the success of our intervention, and we are still unable to explain definitively the large improvements in death and dependency found in the main trial results. One potential explanation is that improved monitoring may have led to better overall surveillance of deteriorating patients and faster initiation of treatments not measured as part of the main trial.
Nurse- and midwife-led trials in Australia and New Zealand: scoping review protocol
Publisher: Elsevier BV
Date: 10-2022
Evaluation of the implementation of a bowel management protocol in intensive care: Effect on clinician practices and patient outcomes
Publisher: Wiley
Date: 20-12-2014
DOI: 10.1111/JOCN.12448
Abstract: To evaluate the effect of a multifaceted implementation of a bowel management protocol on outcomes for intensive care patients, in particular the incidence of constipation and diarrhoea, and on clinicians' bowel management practices. Complications associated with poor bowel management for critically ill patients result in adverse outcomes. Implementation of protocols requires strategies proven to change clinician behaviour. Before and after study. Our bowel management protocol was implemented using three evidence-based elements: education sessions, printed educational materials in the form of a fact sheet and reminders. We retrospectively collected data from patients' medical records admitted at two time points within three Sydney metropolitan intensive care units (preimplementation, n = 101 postimplementation, n = 107). No significant difference was found in the incidence of constipation and diarrhoea pre and postimplementation of the protocol. Seventy-two per cent (n = 73) of patients preimplementation and 70% (n = 75) of patients postimplementation experienced one or more episodes of constipation (bowels not open for 72 hours or greater), and 16% (n = 16) of patients preimplementation and 20% (n = 21) of patients postimplementation experienced one or more episodes of diarrhoea. There was a slight nonsignificant increase in bowel assessment on admission by medical officers postimplementation (pre, 47%, n = 48 post, 60%, n = 64). Targeted multifaceted implementation of a bowel management protocol did not have an impact on the incidence of constipation or diarrhoea for intensive care patients or on clinician practices. The lack of impact on patient outcomes may be due to clinicians' nonadherence to our bowel management protocol. Reasons clinicians' practices did not change may include the influences of clinical decision-making on behaviour. This study highlights difficulties inherent in changing clinician behaviour and practices to improve patient outcomes despite using an evidence-based multifaceted implementation strategy. Further research is required to ascertain the most effective implementation strategies.
Review article: A primer for clinical researchers in the emergency department: Part VIII. Implementation science: An introduction
Publisher: Wiley
Date: 24-04-2019
Abstract: New research findings may not lead to change in practice, or a change at the front line may be delayed by years. A number of terms have been used to describe efforts and strategies to speed a change in evidence-based practice, such as: implementation science, knowledge translation, research translation and others. In contrast to traditional clinical research, implementation science generally aims to understand and change health professional behaviour to promote evidence uptake as opposed to attempting to change patient behaviour. There are now theoretical frameworks and evolving evidence providing guidance how to change clinician behaviour and, specifically, emerging evidence on how to achieve this in the emergency setting. This review will provide an introduction to implementation science and illustrate how to target evidence practice gaps using ED ex les.
Early intervention for chronic obstructive pulmonary disease by practice nurse and GP teams: A cluster randomized trial
Publisher: Oxford University Press (OUP)
Date: 17-08-2016
Abstract: Early detection and intervention for chronic obstructive pulmonary disease (COPD) could potentially slow disease progress and minimize harm. To assess the effectiveness of early intervention by a practice nurse-GP team on quality of life (QoL) and process of care in patients with newly diagnosed COPD, compared with usual care. Nurses and GPs in intervention practices were educated to develop and implement disease management plans for COPD. A 12-month, multicentre, pragmatic randomized controlled trial with blinded outcome assessment was conducted. Participants were current and former smokers aged 40 to 85 years newly identified as having COPD on post-bronchodilator spirometry. The primary outcome was health-related QoL, assessed with the St George's Respiratory Questionnaire (SGRQ). Secondary outcome measures were other QoL measures, lung function, disease knowledge, smoking and immunization status, inhaler technique and health service use. Of the 10 234 patients from 36 practices in Sydney invited to a case-finding appointment, 1641 (16%) attended and 287 (18%) were diagnosed with COPD. Nineteen practices (144 patients) were randomized to the intervention group and 17 practices (110 patients) to the control group. Only 15.3% (n = 22) patients in the intervention group saw the nurse for COPD care following case finding. There was no between-group difference in SGRQ score at follow-up (mean difference -0.21 P = 0.86). Influenza vaccination was higher in the intervention group (OR 2.31: P = 0.035), but there were no other significant between-group differences in outcomes. Intervention uptake was low and had no additional beneficial effect, over usual care, on participants' health-related QoL.
Predicting functional outcomes after stroke: an observational study of acute single-channel EEG
Publisher: Informa UK Limited
Date: 09-11-2020
Reviewing recommendations of root cause analyses
Publisher: CSIRO Publishing
Date: 2007
DOI: 10.1071/AH070288
Abstract: Objective: To determine the opinion of medical and nursing clinicians of recommendations arising from root cause analyses (RCAs) conducted between 1 April 2003 and 30 September 2004 in one Sydney Area Health Service. Methods: Twelve doctors (response rate 86%) and 17 nurses (response rate 100%) reviewed 328 recommendations arising from 59 RCAs and completed a self-administered survey. Results: Nurses were significantly more likely than doctors to rate recommendations made by the original RCA team as ?relevant to the causal statement?, ?understandable?, ?measurable? and ?achievable?. Doctors and nurses involved in the original RCA were significantly more likely to state that recommendations would ?eliminate? or ?control? the risk of a similar event occurring in the future. Conclusions: This is one of the first studies to analyse RCA data at the area health service level. That nurses reviewed recommendations more favourably may have implications for successful adoption of recommendations at the clinical level. We recommend further detailed analyses of recommendations arising from RCAs in order to determine their usefulness to inform strategies for improved patient safety.
Understanding Coordinator Roles in Acute Stroke Care: A National Survey
Publisher: Elsevier BV
Date: 12-2021
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2021.106111
Abstract: Coordinators contribute to stroke care quality. Evidence on the scope of practice of coordinator roles for stroke is lacking. We aimed to survey Australian stroke coordinators and describe their responsibilities and characteristics, and compare these based on perceived competency. Online survey of non-physician coordinators with a clinical leadership position for acute stroke in Australian hospitals. Participants were identified from the Stroke Foundation National Audit, and advertising via national associations/networks. Quantitative data were analysed descriptively characteristics and responsibilities assessed by Benner's self-perceived competency (novice/advanced beginner/competent, proficient or expert). Inductive thematic analysis was used for open-ended responses. Results from 105/141 coordinators (103 hospitals, 90% female, 90% registered nurses). Two-thirds developed the role/were self-taught, with 36% using the 'stroke coordinator' title. Perceived competency varied 22% expert, 40% proficient, and 33% competent. A variety of important clinical tasks, along with leadership/management, education and research responsibilities were described. Most frequently reported clinical responsibility was discharge planning (77%), with patient and staff education (85% and 88%), and data collection (94%) common. Compared to those reporting lesser competency, 'experts' had greater involvement in outpatient clinics (50% vs 14%) and leadership/management responsibilities (e.g. local hospital committees 77% vs 46%). 'Knowledge of evidence' and 'empowering others' were important characteristics to 'expert' coordinators. A contemporary understanding of important responsibilities and characteristics of acute stroke coordinators are provided. Perceived competency affected scope of practice. Structured education, training and role delineation is warranted to improve competency. Career development of stroke coordinators is urgently needed to support optimal role performance.
Outcome evaluation in nursing in Australia, 1960-1980
Publisher: CSIRO Publishing
Date: 1998
DOI: 10.1071/AH980072
Abstract: While empirical evaluation of the outcome of patient care has come to the fore inrecent years due to political initiatives, there has always been a professional interestby nurses in the end result of their care. A review of the literature shows that outcomeevaluation was advocated for nursing as early as the 1860s by Florence Nightingale.This article explores the evolvement of outcome evaluation within nursing inAustralia, discussing its origins during the 1960s and 1970s. The measurement ofpatient outcomes is more relevant than ever before, with the recent drive for anevidence-based approach to nursing care.
A mixed-methods study to explore opinions of research translation held by researchers working in a Centre of Research Excellence in Australia
Publisher: BMJ
Date: 09-2018
DOI: 10.1136/BMJOPEN-2018-022357
Abstract: There is a growing need for researchers to demonstrate impact, which is reliant on successful research translation. The Australian National Health and Medical Research Council funded a Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke) to enhance collaborations between researchers conducting different types of stroke rehabilitation research. The purpose of this study was to explore opinions about research translation held by CRE-Stroke researchers conducting preclinical and clinical research, in terms of scope, importance, responsibility and perceived skills and knowledge. Mixed-methods study, comprising a paper-based survey and semistructured interviews. Interview data were inductively coded and thematically analysed. Survey and interview data were compared and synthesised. 55 (7 preclinical, 48 clinical) researchers attending a CRE-Stroke research forum completed a paper-based survey. Semistructured interviews with 22 CRE-Stroke (5 preclinical, 17 clinical) researchers were conducted. Research translation was described as translating to other research and translating to clinical practice and policy. Most researchers (n=54, 98%) reported that research translation was important, particularly in terms of generating research impact, but the most common sign of project completion reported by researchers (n=7, 100% preclinical n=37, 77% clinical) was publication. Most researchers (preclinical n=4, 57% clinical n=37, 77%) reported having responsibility for translating research, but less than half reported having the necessary skills (n=1, 14% preclinical n=17, 35% clinical) and knowledge (n=3, 43% preclinical n=19, 40% clinical). Differing opinions about who should be responsible for translating findings to clinical practice were expressed. Stroke rehabilitation researchers appear confident to translate their research via the traditional mechanism of publications. To optimise impact, clarity is needed regarding who is best placed to translate research findings to clinical practice and policy. Education and skills development to apply broader translation processes are needed to maximise the use of research at all stages.
Economic evaluation of the Very Early Rehabilitation in SpEech (VERSE) intervention
Publisher: Informa UK Limited
Date: 06-07-2023
Barriers to using warfarin in non-valvular atrial fibrillation [5]
Publisher: BMJ
Date: 02-02-2006
Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice – protocol for a cluster randomised controlled trial in acut
Publisher: Springer Science and Business Media LLC
Date: 25-03-2014
Risk-Adjusted hospital mortality rates for stroke: Evidence from the Australian Stroke Clinical Registry (AuSCR)
Publisher: AMPCo
Date: 05-2017
DOI: 10.5694/MJA16.00525
Abstract: Hospital data used to assess regional variability in disease management and outcomes, including mortality, lack information on disease severity. We describe variance between hospitals in 30-day risk-adjusted mortality rates (RAMRs) for stroke, comparing models that include or exclude stroke severity as a covariate. Cohort design linking Australian Stroke Clinical Registry data with national death registrations. Multivariable models using recommended statistical methods for calculating 30-day RAMRs for hospitals, adjusted for demographic factors, ability to walk on admission, stroke type, and stroke recurrence. Australian hospitals providing at least 200 episodes of acute stroke care, 2009-2014. Hospital RAMRs estimated by different models. Changes in hospital rank order and funnel plots were used to explore variation in hospital-specific 30-day RAMRs that is, RAMRs more than three standard deviations from the mean. In the 28 hospitals reporting at least 200 episodes of care, there were 16 218 episodes (15 951 patients median age, 77 years women, 46% ischaemic strokes, 79%). RAMRs from models not including stroke severity as a variable ranged between 8% and 20% RAMRs from models with the best fit, which included ability to walk and stroke recurrence as variables, ranged between 9% and 21%. The rank order of hospitals changed according to the covariates included in the models, particularly for those hospitals with the highest RAMRs. Funnel plots identified significant deviation from the mean overall RAMR for two hospitals, including one with borderline excess mortality. Hospital stroke mortality rates and hospital performance ranking may vary widely according to the covariates included in the statistical analysis.
Prognostic significance of early urinary catheterization after acute stroke: Secondary analyses of the international HeadPoST trial
Publisher: SAGE Publications
Date: 19-02-2021
Abstract: An indwelling urinary catheter (IUC) is often inserted to manage bladder dysfunction, but its impact on prognosis is uncertain. We aimed to determine the association of IUC use on clinical outcomes after acute stroke in the international, multi-center, cluster crossover, Head Positioning in Acute Stroke Trial (HeadPoST). Data were analyzed on HeadPoST participants (n = 11,093) randomly allocated to the lying-flat or sitting-up head position. Binomial, logistic regression, hierarchical mixed models were used to determine associations of early insertion of IUC within seven days post-randomization and outcomes of death or disability (defined as “poor outcome,” scores 3–6 on the modified Rankin scale) and any urinary tract infection at 90 days with adjustment of baseline and post-randomization management covariates. Overall, 1167 (12%) patients had an IUC, but the frequency and duration of use varied widely across patients in different regions. IUC use was more frequent in older patients, and those with vascular comorbidity, greater initial neurological impairment (on the National Institutes of Health Stroke Scale), and intracerebral hemorrhage as the underlying stroke type. IUC use was independently associated with poor outcome (adjusted odds ratio (aOR): 1.40, 95% confidence interval (CI): 1.13–1.74), but not with urinary tract infection after adjustment for antibiotic treatment and stroke severity at hospital separation (aOR: 1.13, 95% CI: 0.59–2.18). The number exposed to IUC for poor outcome was 13. IUC use is associated with a poor outcome after acute stroke. Further studies are required to inform appropriate use of IUC.
QASC trial: swallow surveillance rates comparable with international data
Publisher: Elsevier BV
Date: 04-2012
Influence of stroke coordinators on delivery of acute stroke care and hospital outcomes: An observational study
Publisher: SAGE Publications
Date: 14-11-2018
Abstract: Stroke coordinators have been inconsistently used in various countries to support stroke care in hospital. To investigate the association between stroke coordinators and the provision of evidence-based care and patient outcomes in hospitals with acute stroke units. Observational study using cross-sectional data from the 2015 National Acute Services Audit Program (Australia): including a retrospective medical record audit (40 records from each hospital) and a self-reported survey of organizational resources for stroke. Multilevel random effects logistic regression for patient outcomes including complications, independence on discharge, and death. Median regression for length of stay comparisons. A total of 109 hospitals submitted 4060 cases 59 (54%) had a stroke coordinator. Compared with patients from stroke unit hospitals with no stroke coordinator ( N = 33, 1333 cases), patients in stroke unit hospitals with a stroke coordinator ( N = 53, 2072 cases) were more likely to receive clinical practices including rehabilitation therapy within 48 hours of initial assessment (88 vs. 82%, p 0.001), risk factor modification advice (62 vs. 55%, p = 0.003) and receive a discharge care plan (65 vs. 48%, p 0.001). No differences in complications, independence on discharge, or deaths were evident. Patients from hospitals with a stroke coordinator were more likely to access inpatient rehabilitation (adjusted odds ratio 1.8, 95% confidence interval 1.1–2.8) and have a reduced length of acute stay if discharged (median 14 h, p = 0.03). Presence of stroke coordinators was associated with reduced length of stay and improved delivery of evidence-based care in hospitals with a stroke unit.
Acute EEG Patterns Associated With Transient Ischemic Attack
Publisher: SAGE Publications
Date: 25-07-2018
Abstract: Background. Transient ischemic attack (TIA) is characterized by stroke-like neurologic signs and symptoms in the absence of demonstrable structural neuropathology. There is no test for TIA, with classification often reliant on subjective, retrospective report. Functional brain measures such as the electroencephalogram (EEG) may be helpful in objectively detecting and describing the pathophysiology of TIA, but this has not been adequately examined. Methods. EEG was obtained from a single electrode over the left frontal lobe during 3-minute resting-state and auditory oddball conditions administered to consecutive patients within 72 hours of admission to the acute stroke ward of a tertiary hospital. Separately, patients were classified by their treating team as having suffered either an ischemic stroke (n = 10) or a TIA (n = 10). Relative power of delta, theta, alpha, and beta EEG frequency bands were extracted for comparison between the 2 clinical groups and an existing normative s le of 10 healthy, age-, gender-, and education-matched older adults. Results. Analysis of variance with post hoc testing identified pronounced delta activity in stroke patients, while alpha and beta power were elevated in TIA patients. Both patient groups exhibited attenuated theta activity compared with healthy controls. Receiver operating characteristic curve analysis identified thresholds for each EEG frequency capable of distinguishing the 3 participant groups. Conclusions. TIA, ischemic stroke, and healthy aging are each associated with distinct electrophysiological profiles. These preliminary findings suggest that acute EEG may be helpful in elucidating the pathophysiology and reversibility of TIA symptoms, and further exploration of the value of this unique functional brain data is encouraged.
Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes
Publisher: Elsevier BV
Date: 09-2022
DOI: 10.1016/J.INJURY.2022.04.024
Abstract: Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury. ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes. There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites. Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery. ANZCTR: ACTRN12618001548224, approved 17/09/2018.
Stroke clinicians' priorities for stroke research
Publisher: Nova Southeastern University
Date: 2012
DOI: 10.46743/1540-580X/2012.1419
Abstract: Purpose: The purpose of this study was to identify research questions perceived as important by clinicians who treat stroke survivors in New South Wales (NSW), Australia. Methods: A cross-sectional, 3-round Delphi survey method was used. Participants invited to respond in Round I included stroke researchers (n=26) Rounds II and III included stroke clinicians (n=470) identified from NSW Health Stroke Services and/or NSW Rural Stroke Service databases. Participants in Round I were asked to identify stroke research questions of the highest priority participants in Rounds II and III then rated these research questions on both importance and feasibility using a 5-point Likert scale. Results: Responses were received from 14 expert stroke researchers during Round I (54%), 38 stroke clinicians (8%) in Round II, and 56 stroke clinicians (12%) in Round III. Research topics rated as “very important” were interventions that target life-long rehabilitation, best methods for providing post-discharge rehabilitation, and delivery of physical rehabilitation.Conclusions: Clinicians who provide day-to-day stroke care perceive that the effectiveness of rehabilitation interventions and delivery require investigation as a key priority.
Midwifery-led care: finding evidence for an antenatal model
Publisher: Elsevier BV
Date: 06-2004
From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design
Publisher: BMJ
Date: 05-2016
No benefit of flat head positioning in early moderate-severe acute ischaemic stroke: A HeadPoST study subgroup analysis
Publisher: BMJ
Date: 25-06-2020
Abstract: Although the Head Positioning in acute Stroke Trial (HeadPoST) showed no effect of the flat head position (FP vs sitting up head position (SUP)) on functional outcome, we hypothesised that it could still offer benefits if commenced early in those with acute ischaemic stroke (AIS) of at least moderate severity. Subgroup analysis of HeadPoST in participants with National Institutes of Health Stroke Scale (NIHSS) scores ≥7, ≥10 and ≥14, randomised to FP or SUP .5 hours of AIS onset on functional outcomes defined by a shift in scores on the modified Rankin scale (mRS) and death/disability (mRS scores 3–6), and any cardiovascular serious adverse event. Logistic regression analyses were undertaken adjusted for study design and baseline risk factors. There was no significant differential treatment effect in patient subgroups defined by increasing baseline NIHSS scores: adjusted OR and 95% CI for ordinal shift and binary (3–6) mRS scores: for NIHSS ≥7 (n=867) 0.92 (0.67 to 1.25) and 0.74 (0.52 to 1.04) NIHSS ≥ 10 (n=606) 0.80 (0.58 to 1.10) and 0.77 (0.49 to 1.19) NIHSS ≥14 (n=378) 0.82 (0.54 to 1.24) and 1.22 (0.69 to 2.14). Early FP had no significant effect in patients with moderate–severe AIS. NCT02162017 .
Correction
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2015
How has the profile of Australian nurse practitioners changed over time?
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.COLEGN.2014.10.004
Abstract: To examine longitudinal changes in the profile of Australian nurse practitioners surveyed in both 2007 and 2009 ('resurveyed respondents') and to determine differences between nurse practitioners who completed the census only in 2009 ('new respondents') and resurveyed respondents. The nurse practitioner role is integral to the development and sustainability of advanced practice roles in healthcare systems. However, its success depends upon support from policy makers, health services and nursing. A census of Australian nurse practitioners previously was conducted in 2007 to obtain national data on the role and scope of practice of nurse practitioners in Australia. A quantitative self-administered survey. Questionnaires were sent to all authorised Australian nurse practitioners in 2009. A total of 408 surveys were administered with 293 questionnaires completed (response rate 76.3%). Of these, 49% of participants also had completed the 2007 survey. There were no differences in the limitations and enablers identified in 2007 compared to 2009, indicating that perceived barriers had not been addressed over time, nor had there been substantial improvements. New respondents were more likely to have worked as a nurse practitioner in the previous week (p < 0.004). There was a significant increase in the number of nurse practitioners waiting on approval for some or all clinical protocols (p = 0.024). Conditions enabling work to full scope of practice continue to be perceived as suboptimal by Australian nurse practitioners. Supportive strategies are needed to enable the role to be effectively utilised.
Treatment and Outcomes of Working Aged Adults with Stroke: Results from a National Prospective Registry
Publisher: S. Karger AG
Date: 2017
DOI: 10.1159/000484141
Abstract: b i Background: /i /b Given the potential differences in etiology and impact, the treatment and outcome of younger patients (aged 18–64 years) require examination separately to older adults (aged ≥65 years) who experience acute stroke. b i Methods: /i /b i /i Data from the Australian Stroke Clinical Registry (2010–2015) including demographic and clinical characteristics, provision of evidence-based therapies and health-related quality of life (HRQoL) post-stroke was used. Descriptive statistics and multilevel regression models were used for group comparisons. b i Results: /i /b Compared to older patients (age ≥65 years) among 26,220 registrants, 6,526 (25%) younger patients (age 18–64 years) were more often male (63 vs. 51% i /i & #x3c 0.001), born in Australia (70 vs. 63% i /i & #x3c 0.001), more often discharged home from acute care (56 vs. 38% i /i & #x3c 0.001), and less likely to receive antihypertensive medication (61 vs. 73% i /i & #x3c 0.001). Younger patients had a 74% greater odds of having lower HRQoL compared to an equivalent aged-matched general population (adjusted OR 1.74, 95% CI 1.56–1.93, i /i & #x3c 0.001). b i Conclusions: /i /b i /i Younger stroke patients exhibited distinct differences from their older counterparts with respect to demographic and clinical characteristics, prescription of antihypertensive medications and residual health status.
Addressing the stroke evidence-treatment gap
Publisher: Informa UK Limited
Date: 06-05-2016
Protocol of a randomized controlled trial investigating the effectiveness of Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS)
Publisher: SAGE Publications
Date: 14-06-2021
DOI: 10.1177/17474930211022678
Abstract: To address unmet needs, electronic messages to support person-centered goal attainment and secondary prevention may avoid hospital presentations/readmissions after stroke, but evidence is limited. Compared to control participants, there will be a 10% lower proportion of intervention participants who represent to hospital (emergency/admission) within 90 days of randomization. Multicenter, double-blind, randomized controlled trial with intention-to-treat analysis. The intervention group receives 12 weeks of personalized, goal-centered, and administrative electronic messages, while the control group only receive administrative messages. The trial includes a process evaluation, assessment of treatment fidelity, and an economic evaluation. Participants: Confirmed stroke (modified Rankin Score: 0-4), aged ≥18 years with internet/mobile phone access, discharged directly home from hospital. Randomization: 1:1 computer-generated, stratified by age and baseline disability. Outcomes assessments: Collected at 90 days and 12 months following randomization. Primary outcomes include hospital emergency presentations/admissions within 90 days of randomization. Secondary outcomes include goal attainment, self-efficacy, mood, unmet needs, disability, quality-of-life, recurrent stroke/cardiovascular events/deaths at 90 days and 12 months, and death and cost-effectiveness at 12 months. S le size: To test our primary hypothesis, we estimated a s le size of 890 participants (445 per group) with 80% power and two-tailed significance threshold of α = 0.05. Given uncertainty for the effect size of this novel intervention, the s le size will be adaptively re-estimated when outcomes for n = 668 are obtained, with maximum s le capped at 1100. We will provide new evidence on the potential effectiveness, implementation, and cost-effectiveness of a tailored eHealth intervention for survivors of stroke.
Care of patients with a diagnosis of chronic obstructive pulmonary disease
Publisher: AMPCo
Date: 10-2012
DOI: 10.5694/MJA12.10813
Abstract: To evaluate a partnership model of care for patients with a diagnosis of chronic obstructive pulmonary disease (COPD). Cluster randomised controlled trial with blinded outcome assessment of 44 general practices in south-western Sydney comprising 451 people with a diagnosis of COPD, conducted between 2006 and 2009. Participants from intervention group practices were visited at their home by a registered nurse with specific training in COPD care who worked with the general practitioner, the patient and other health professionals to develop and implement an in idualised care plan based on best-practice guidelines. Participants from control group practices received usual care. The primary outcome was disease-related quality of life measured using the St George's Respiratory Questionnaire (SGRQ) at 12-month follow-up. Other outcomes were overall quality of life, lung function, smoking status, immunisation status, patient knowledge of COPD, and health service use. Of the 451 participants, 257 (57.8%) were confirmed as having COPD on post-bronchodilator spirometry. Follow-up was completed for 330 patients (73.2%). At 12 months, there was no statistically significant difference in the mean SGRQ scores between intervention and control groups (38.7 v 37.6 difference, 1.1 95% CI, - 1.53-3.74 P = 0.41) or in measures of quality of life, lung function and smoking status. Compared with the control group, in the intervention group, attendance at pulmonary rehabilitation was more frequent (31.1% v 9.6% OR, 5.16 95% CI, 2.40-11.10 P = 0.002) and the mean COPD knowledge score was higher (10.5 v 9.8 difference, 0.70 CI, 0.10-1.21 P = 0.02). The nurse-GP partnership intervention did not have an impact on disease-related quality of life at 12-month follow-up. However, there was evidence of improved quality of care, in particular, in attendance at pulmonary rehabilitation and patient knowledge of COPD. Australian Clinical Trials Registry ACTRN012606000304538.
Back to Basics: Adherence With Guidelines for Glucose and Temperature Control in an American Comprehensive Stroke Center Sample
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2018
DOI: 10.1097/JNN.0000000000000358
Abstract: Background: Variance from guideline-directed care for glucose and temperature control remains unknown in the United States at a time when priorities have shifted to ensure rapid diagnosis and treatment of acute stroke patients. However, protocol-driven nursing surveillance for control of hyperglycemia and hyperthermia has been shown to improve patient outcomes. Methods: We conducted an observational pilot study to assess compliance with American guidelines for glucose and temperature control and association with discharge outcomes in consecutive acute stroke patients admitted to 5 US comprehensive stroke centers. Data for the first 5 days of stroke admission were collected from electronic medical records and entered and analyzed in SPSS using descriptive statistics, Mann-Whitney U test, Student t tests, and logistic regression. Results: A total of 1669 consecutive glucose and 3782 consecutive temperature measurements were taken from a s le of 235 acute stroke patients the s le was 87% ischemic and 13% intracerebral hemorrhage. Poor glucose control was found in 33% of patients, and the most frequent control method ordered (35%) was regular insulin sliding scale without basal dosing. Poor temperature control was noted in 10%, and 39% did not have temperature recorded in the emergency department. Lower admission National Institutes of Health Stroke Scale score and well-controlled glucose were independent predictors of favorable outcome (discharge modified Rankin Scale score, 0–2) in reperfusion patients. Conclusion: Glucose and temperature control may be overlooked in this era of rapid stroke diagnosis and treatment. Acute stroke nurses are well positioned to assume leadership of glucose and temperature monitoring and treatment.
Benefit of linking hospital resource information and patient-level stroke registry data
Publisher: Oxford University Press (OUP)
Date: 2023
Abstract: Variation in the delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient, and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. The 2017 National Audit organizational survey (Australia) was linked to patient-level data from the Australian Stroke Clinical Registry (2016–2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90–180-day readmissions and health-related quality of life. Models were adjusted for patient factors, including the severity of stroke. Fifty-two out of 127 hospitals with organizational survey data were merged with 22 832 Australian Stroke Clinical Registry patients with an admission for a first-ever stroke or transient ischaemic attack (median age 75 years, 55% male, and 66% ischaemic). In metropolitan hospitals (n = 42, 20 977 patients, 1701 thrombolyzed, and 2395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with ≥500 annual stroke admissions [−15.9 minutes, 95% confidence interval (CI) −27.2, −4.7], annual thrombolysis & patients (−20.2 minutes, 95% CI −32.0, −8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator −12.7 minutes, 95% CI −25.0, −0.4). A reduced likelihood of all-cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (odds ratio 0.82, 95% CI 0.67–0.99). In regional/rural hospitals (n = 10, 1855 patients), being discharged with a care plan was also associated with the use of stroke clinical pathways (odds ratio 3.58, 95% CI 1.45–8.82). No specific hospital resources influenced 90–180-day health-related quality of life. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.
Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke
Publisher: Massachusetts Medical Society
Date: 22-06-2017
Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department
Publisher: Wiley
Date: 09-06-2021
DOI: 10.1111/JOCN.15883
Abstract: To compare the effectiveness and safety of ultrasound‐guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors. The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors. A prospective cohort study. The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013–December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies. Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors ( n = 207, 64.3%) with 22.4% ( n = 72) by nurses and in 13.3% ( n = 43) of patients the clinician was not documented. There were no differences between the nurse‐inserted and doctor‐inserted groups for mean pain scores 1 hr post‐FIB insertion clinically significant reduction (≥30%) in pain score 1 hr post‐FIB insertion pain score 4 hr post‐FIB insertion delirium incidence opioid use post‐FIB insertion or time to FIB insertion. No adverse events were identified in either group. Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture. Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.
What are the reasons for clinical network success? A qualitative study
Publisher: Springer Science and Business Media LLC
Date: 06-2015
Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study
Publisher: Springer Science and Business Media LLC
Date: 15-05-2019
Six years of the Angels Initiative: Aims, achievements, and future directions to improve stroke care worldwide
Publisher: SAGE Publications
Date: 02-08-2023
DOI: 10.1177/17474930231180067
Abstract: The rate of stroke-related death and disability is four times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), yet stroke units exist in only 18% of LMICs, compared with 91% of HICs. In order to ensure universal and equitable access to timely, guideline-recommended stroke care, multidisciplinary stroke-ready hospitals with coordinated teams of healthcare professionals and appropriate facilities are essential. Established in 2016, the Angels Initiative is an international, not-for-profit, public–private partnership. It is run in collaboration with the World Stroke Organization, European Stroke Organisation, and regional and national stroke societies in over 50 countries. The Angels Initiative aims to increase the global number of stroke-ready hospitals and to optimize the quality of existing stroke units. It does this through the work of dedicated consultants, who help to standardize care procedures and build coordinated, informed communities of stroke professionals. Angels consultants also establish quality monitoring frameworks using online audit platforms such as the Registry of Stroke Care Quality (RES-Q), which forms the basis of the Angels award system (gold latinum/diamond) for all stroke-ready hospitals across the world. The Angels Initiative has supported over 1700 hospitals ( in LMICs) that did not previously treat stroke patients to become “stroke ready.” Since its inception in 2016, the Angels Initiative has impacted the health outcomes of an estimated 7.46 million stroke patients globally (including an estimated 4.68 million patients in LMICs). The Angels Initiative has increased the number of stroke-ready hospitals in many countries (e.g. in South Africa: 5 stroke-ready hospitals in 2015 vs 185 in 2021), reduced “door to treatment time” (e.g. in Egypt: 50% reduction vs baseline), and increased quality monitoring substantially. The focus of the work of the Angels Initiative has now expanded from the hyperacute phase of stroke treatment to the pre-hospital setting, as well as to the early post-acute setting. A continued and coordinated global effort is needed to achieve the target of the Angels Initiative of ,000 stroke-ready hospitals by 2030, and of these in LMICs.
Scoping review: Scope of practice of nurse‐led services and access to care for people experiencing homelessness
Publisher: Wiley
Date: 27-07-2022
DOI: 10.1111/JAN.15387
Abstract: To investigate the scope of practice of nurse‐led services for people experiencing homelessness, and the influence on access to healthcare. A scoping review. On 20 November 2020, the following databases were searched: CINAHL, Embase, MEDLINE, PubMed and Scopus. Included studies focused on people experiencing homelessness aged 18 years and over, nurse‐led services in any setting and described the nursing scope of practice. Studies were peer‐reviewed primary research, published in English from the year 2000. Three authors performed quality appraisals using the mixed methods assessment tool. Results were synthesized and discussed narratively and reported according to the PRISMA‐ScR 2020 Statement. Nineteen studies were included from the United States ( n = 9), Australia ( n = 4), United Kingdom ( n = 4) and Canada ( n = 2). The total participant s le size was n = 6303. Studies focused on registered nurses ( n = 10), nurse practitioners ( n = 5) or both ( n = 4), in outpatient or community settings. The nursing scope of practice was broad and covered a range of skills, knowledge and attributes. Key skills identified include assessment and procedural skills, client support and health education. Key attributes were a trauma‐informed approach and building trust through communication. Important knowledge included understanding the impact of homelessness, knowledge of available services and the capacity to undertake holistic assessments. Findings suggest that nurse‐led care facilitated access to healthcare through building trust and supporting clients to access services. Optimized nursing scope of practice can facilitate access to healthcare for people experiencing homelessness. Key factors in enabling this include autonomy in nursing practice, organizational support and education. The broad range of skills, knowledge and attributes reported provide a foundation from which to design an educational framework to optimize the nursing scope of practice, thereby increasing access to healthcare for people experiencing homelessness.
Living clinical guidelines for stroke: updates, challenges and opportunities
Publisher: Wiley
Date: 15-05-2022
DOI: 10.5694/MJA2.51520
Stroke care in Australia: Why is it still the poor cousin of health care?
Publisher: AMPCo
Date: 08-2013
DOI: 10.5694/MJA13.10476
Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial
Publisher: Wiley
Date: 13-03-2020
DOI: 10.5694/MJA2.50549
Implementation of a patient blood management program in an Australian private hospital orthopedic unit
Publisher: Informa UK Limited
Date: 06-2018
DOI: 10.2147/JBM.S157571
Management of Fever, Hyperglycemia, and Swallowing Dysfunction following Hospital Admission for Acute Stroke in New South Wales, Australia
Publisher: SAGE Publications
Date: 10-11-2013
DOI: 10.1111/IJS.12194
Abstract: Fever, hyperglycemia, and swallow dysfunction poststroke are associated with significantly worse outcomes. We report treatment and monitoring practices for these three items from a cohort of acute stroke patients prior to randomization in the Quality in Acute Stroke Care trial. Retrospective medical record audits were undertaken for prospective patients from 19 stroke units. For the first three-days following stroke, we recorded all temperature readings and administration of paracetamol for fever (≥37.5°C) and all glucose readings and administration of insulin for hyperglycemia ( mmol/L). We also recorded swallow screening and assessment during the first 24 h of admission. Data for 718 (98%) patients were available 138 (19%) had four hourly or more temperature readings and 204 patients (29%) had a fever, with 44 (22%) receiving paracetamol. A quarter of patients ( n = 102/412, 25%) had six hourly or more glucose readings and 23% (95/412) had hyperglycemia, with 31% (29/95) of these treated with insulin. The majority of patients received a swallow assessment ( n = 562, 78%) by a speech pathologist in the first instance rather than a swallow screen by a nonspeech pathologist ( n = 156, 22%). Of those who passed a screen ( n = 108 of 156, 69%), 68% ( n = 73) were reassessed by a speech pathologist and 97% ( n = 71) were reconfirmed to be able to swallow safely. Our results showed that acute stroke patients were: undermonitored and undertreated for fever and hyperglycemia and underscreened for swallowing dysfunction and unnecessarily reassessed by a speech pathologist, indicating the need for urgent behavior change.
Altering the rehabilitation environment to improve stroke survivor activity : A Phase II trial
Publisher: SAGE Publications
Date: 13-04-2021
DOI: 10.1177/17474930211006999
Abstract: Environmental enrichment involves organization of the environment and provision of equipment to facilitate engagement in physical, cognitive, and social activities. In animals with stroke, it promotes brain plasticity and recovery. To assess the feasibility and safety of a patient-driven model of environmental enrichment incorporating access to communal and in idual environmental enrichment. A nonrandomized cluster trial with blinded measurement involving people with stroke ( n = 193) in four rehabilitation units was carried out. Feasibility was operationalized as activity 10 days after admission to rehabilitation and availability of environmental enrichment. Safety was measured as falls and serious adverse events. Benefit was measured as clinical outcomes at three months, by an assessor blinded to group. The experimental group ( n = 91) spent 7% (95% CI −14 to 0) less time inactive, 9% (95% CI 0–19) more time physically, and 6% (95% CI 2–10) more time socially active than the control group ( n = 102). Communal environmental enrichment was available 100% of the time, but in idual environmental enrichment was rarely within reach (24%) or sight (39%). There were no between-group differences in serious adverse events or falls at discharge or three months or in clinical outcomes at three months. This patient-driven model of environmental enrichment was feasible and safe. However, the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes three months after stroke do not provide justification for an efficacy trial.
A systems change intervention for nurse-led smoking cessation care in hospitals
Publisher: Elsevier BV
Date: 04-2019
Outcomes for Patients With In-Hospital Stroke: A Multicenter Study From the Australian Stroke Clinical Registry (AuSCR)
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.JSTROKECEREBROVASDIS.2019.01.026
Abstract: The quality of care and outcomes for people who experience stroke whilst in hospital for another condition has not been previously studied in Australia. To explore differences in long-term outcomes among patients with in-hospital events treated in stroke units (SUs) compared to those managed in other hospital wards. Forty-five hospitals participating in the Australian Stroke Clinical Registry between January 2010 and December 2014 contributed data. Survival of all patients with in-hospital stroke to 180 days after stroke and health-related quality of life, using EQ-5D-3L among 73% eligible, were compared using multilevel, multivariable regression models. Models were adjusted for age, sex, index of relative socioeconomic disadvantage, ability to walk, stroke type, transfer from another hospital, and history of stroke. Among 20,786 stroke events, 1182 (5.1%) occurred in-hospital (median age 77 years, 49% male). Patients with in-hospital stroke treated in SUs died less often within 30 days (Hazard Ratio 0.56 95% CI 0.39-0.81) than those not admitted to SUs. Survivors reported similar health-related quality of life between 90 and 180 days compared to those treated in other wards (coefficient = 0.01, 95% CI -0.06-0.09, P = .78). Patients managed in SUs more often received recommended management (e.g. swallowing screening). The benefits of SU care may extend to patients experiencing in-hospital stroke. Validation, including accounting for potential residual confounding factors, is required.
Multicenter, Prospective, Controlled, Before-and-After, Quality Improvement Study (Stroke123) of Acute Stroke Care
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2019
DOI: 10.1161/STROKEAHA.118.023075
Abstract: Hospital uptake of evidence-based stroke care is variable. We aimed to determine the impact of a multicomponent program involving financial incentives and quality improvement interventions, on stroke care processes. A prospective study of interventions to improve clinical care quality indicators at 19 hospitals in Queensland, Australia, during 2010 to 2015, compared with historical controls and 23 other Australian hospitals. After baseline routine audit and feedback (control phase, 30 months), interventions involving financial incentives (21 months) and then addition of externally facilitated quality improvement workshops with action plan development (9 months) were implemented. Postintervention phase was 13 months. Data were obtained for the analysis from a previous continuous audit in Queensland and subsequently the Australian Stroke Clinical Registry. Primary outcome: change in median composite score for adherence to ≤8 indicators. Secondary outcomes: change in adherence to self-selected indicators addressed in action plans and 4 national indicators compared with other Australian hospitals. Multivariable analyses with adjustment for clustered data. There were 17 502 patients from the intervention sites (median age, 74 years 46% women) and 20 484 patients from other Australian hospitals. Patient characteristics were similar between groups. There was an 18% improvement in the primary outcome across the study periods (95% CI, 12%–24%). The largest improvement was following introduction of financial incentives (14% 95% CI, 8%–20%), while indicators addressed in action plans provided an 8% improvement (95% CI, 1%–17%). The national score (4 indicators) improved by 17% (95% CI, 13%–20%) versus 0% change in other Australian hospitals (95% CI, −0.03 to 0.03). Access to stroke units improved more in Queensland than in other Australian hospitals ( P .001). The quality improvement interventions significantly improved clinical practice. The findings were primarily driven by financial incentives, but were also contributed to by the externally facilitated, quality improvement workshops. Assessment in other regions is warranted.
Review article: A primer for clinical researchers in the emergency department: Part XII. Sustainability of improvements in care: An introduction
Publisher: Wiley
Date: 02-08-2022
Abstract: Despite an increased focus on ways to improve implementation of evidence and de‐implementation of practices with no known benefit, there is limited guidance on how to sustain these improvements. This review provides an introduction to sustainability of improvements in care and sustainability research, discussing how to support sustainability in practice and detailing a sustainability research agenda for the emergency medicine setting.
Sustainability of evidence-based practices in the management of infants with bronchiolitis in hospital settings - a PREDICT study protocol
Publisher: Springer Science and Business Media LLC
Date: 29-08-2022
DOI: 10.1186/S12913-022-08450-Z
Abstract: Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals improvements one-and-two years at control hospitals and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals. A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian ( n = 20) and New Zealand ( n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome composite score) and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework. This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care. Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.
Editorial: Keeping it simple: the power of three clinical protocols
Publisher: Wiley
Date: 22-10-2012
DOI: 10.1111/JOCN.12002
A pragmatic cluster randomized controlled trial of early intervention for chronic obstructive pulmonary disease by practice nurse-general practitioner teams
Publisher: Springer Science and Business Media LLC
Date: 07-09-2012
Abstract: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of disability, hospitalization, and premature mortality. General practice is well placed to diagnose and manage COPD, but there is a significant gap between evidence and current practice, with a low level of awareness and implementation of clinical practice guidelines. Under-diagnosis of COPD is a world-wide problem, limiting the benefit that could potentially be achieved through early intervention strategies such as smoking cessation, dietary advice, and exercise. General practice is moving towards more structured chronic disease management, and the increasing involvement of practice nurses in delivering chronic care. A pragmatic cluster randomised trial will test the hypothesis that intervention by a practice nurse-general practitioner (GP) team leads to improved health-related quality of life and greater adherence with clinical practice guidelines for patients with newly-diagnosed COPD, compared with usual care. Forty general practices in greater metropolitan Sydney Australia will be recruited to identify patients at risk of COPD and invite them to attend a case finding appointment. Practices will be randomised to deliver either practice nurse-GP partnership care, or usual care, to patients newly-diagnosed with COPD. The active intervention will involve the practice nurse and GP working in partnership with the patient in developing and implementing a care plan involving (as appropriate), smoking cessation, immunisation, pulmonary rehabilitation, medication review, assessment and correction of inhaler technique, nutritional advice, management of psycho-social issues, patient education, and management of co-morbidities. The primary outcome measure is health-related quality of life, assessed with the St George’s Respiratory Questionnaire 12 months after diagnosis. Secondary outcome measures include validated disease-specific and general health related quality of life measures, smoking and immunisation status, medications, inhaler technique, and lung function. Outcomes will be assessed by project officers blinded to patients’ randomization groups. This study will use proven case-finding methods to identify patients with undiagnosed COPD in general practice, where improved care has the potential for substantial benefit in health and healthcare utilization. The study provides the capacity to trial a new model of team-based assessment and management of newly diagnosed COPD in Australian primary care. ACTRN12610000592044\\
Team-building intervention to improve acute stroke care – Authors' reply
Publisher: Elsevier BV
Date: 04-2012
Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: A cluster randomised controlled trial of knowledge transfer
Publisher: Springer Science and Business Media LLC
Date: 16-03-2009
Which strategies support the effective use of clinical practice guidelines and clinical quality registry data to inform health service delivery? A systematic review
Publisher: Springer Science and Business Media LLC
Date: 09-11-2022
DOI: 10.1186/S13643-022-02104-1
Abstract: Empirical evidence suggests data and insights from the clinical practice guidelines and clinical quality registries are not being fully utilised, leaving health service managers, clinicians and providers without clear guidance on how best to improve healthcare delivery. This lack of uptake of existing research knowledge represents low value to the healthcare system and needs to change. Five electronic databases (MEDLINE, Embase, CINAHL, Cochrane Central and Cochrane Database of Systematic Reviews) were systematically searched. Included studies were published between 2000 and 2020 reporting on the attributes, evidence usage and impact of clinical practice guidelines and clinical quality registries on health service delivery. Twenty-six articles including one randomised controlled trial, eight before-and-after studies, eight case studies/reviews, five surveys and four interview studies, covering a wide range of medical conditions and conducted in the USA, Australia and Europe, were identified. Five complementary strategies were derived to maximise the likelihood of best practice health service delivery: (1) feedback and transparency, (2) intervention sustainability, (3) clinical practice guideline adherence, (4) productive partnerships and (5) whole-of-team approach. These five strategies, used in context-relevant combinations, are most likely to support the application of existing high-quality data, adding value to health service delivery. The review highlighted the limitations of study design in opportunistic registry studies that do not produce clear, usable evidence to guide changes to health service implementation practices. Recommendations include exploration of innovative methodologies, improved coordination of national registries and the use of incentives to encourage guideline adherence and wider dissemination of strategies used by successful registries.
Self-care research: How to grow the evidence base?
Publisher: Elsevier BV
Date: 05-2020
Case Scenarios to Assess Australian General Practitioners’ Understanding of Stroke Diagnosis, Management, and Prevention
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2003
DOI: 10.1161/01.STR.0000096209.04460.BB
Abstract: Background and Purpose— Stroke represents the third-leading cause of death in Western society. Prompt and appropriate intervention for those with stroke or at risk of stroke is highly dependent on general practitioners’ (GPs’) knowledge and referral practices. Methods— We randomly selected 490 eligible GPs from New South Wales, Australia, to complete our self-administered questionnaire. Case scenarios were used to assess GPs’ knowledge of transient ischemic attack/ stroke risk factors, stroke prevention strategies, and management of asymptomatic and symptomatic patients. Results— We received 296 completed questionnaires (60% response rate). Nearly all GPs (286, 96.6%) strongly agreed or agreed that stroke is a medical emergency. Most were aware that management by multidisciplinary teams improves outcomes (strongly agree or agree, 279 94.3%). GPs endorsed the effectiveness of aspirin and warfarin in reducing stroke morbidity. GPs also were aware of the benefit of carotid endarterectomy (CEA) for symptomatic patients with % carotid stenosis but were less aware of the value of CEA for symptomatic patients with moderate stenosis. Vascular surgeon was the specialist of choice for referral of patients with high-grade carotid stenosis. Few GPs reported having seen the Cochrane Collaboration reviews of CEA for symptomatic (3.0%) and asymptomatic (1.7%) patients. Conclusions— GPs were well apprised of the evidence to support CEA for symptomatic patients with high-grade carotid stenosis. Our findings, however, invite more purposeful and effective education of GPs about stroke prevention, diagnosis, and management if optimal outcomes are to be realized.
Midwife led randomised controlled trials in Australia and New Zealand: a scoping review
Publisher: Elsevier BV
Date: 09-2023
Barriers and Enablers to Implementing Clinical Treatment Protocols for Fever, Hyperglycaemia, and Swallowing Dysfunction in the Quality in Acute Stroke Care (QASC) Project—A Mixed Methods Study
Publisher: Wiley
Date: 20-01-2015
DOI: 10.1111/WVN.12078
Abstract: The Quality in Acute Stroke Care (QASC) trial evaluated systematic implementation of clinical treatment protocols to manage fever, sugar, and swallow (FeSS protocols) in acute stroke care. This cluster-randomised controlled trial was conducted in 19 stroke units in Australia. To describe perceived barriers and enablers preimplementation to the introduction of the FeSS protocols and, postimplementation, to determine which of these barriers eventuated as actual barriers. Preimplementation: Workshops were held at the intervention stroke units (n = 10). The first workshop involved senior clinicians who identified perceived barriers and enablers to implementation of the protocols, the second workshop involved bedside clinicians. Postimplementation, an online survey with stroke ch ions from intervention sites was conducted. A total of 111 clinicians attended the preimplementation workshops, identifying 22 barriers covering four main themes: (a) need for new policies, (b) limited workforce (capacity), (c) lack of equipment, and (d) education and logistics of training staff. Preimplementation enablers identified were: support by clinical ch ions, medical staff, nursing management and allied health staff easy adaptation of current protocols, care-plans, and local policies and presence of specialist stroke unit staff. Postimplementation, only five of the 22 barriers identified preimplementation were reported as actual barriers to adoption of the FeSS protocols, namely, no previous use of insulin infusions hyperglycaemic protocols could not be commenced without written orders medical staff reluctance to use the ASSIST swallowing screening tool poor level of engagement of medical staff and doctors' unawareness of the trial. The process of identifying barriers and enablers preimplementation allowed staff to take ownership and to address barriers and plan for change. As only five of the 22 barriers identified preimplementation were reported to be actual barriers at completion of the trial, this suggests that barriers are often overcome whilst some are only ever perceived rather than actual barriers.
Are service and patient indicators different in the presence or absence of nurse practitioners? The EDPRAC cohort study of Australian emergency departments
Publisher: BMJ
Date: 07-2019
DOI: 10.1136/BMJOPEN-2018-024529
Abstract: To evaluate the impact of nurse practitioner (NP) service in Australian public hospital emergency departments (EDs) on service and patient safety and quality indicators. Cohort study comprising ED presentations (July 2013–June 2014) for a random s le of hospitals, stratified by state/territory and metropolitan versus non-metropolitan location and a retrospective medical record audit of ED re-presentations. Service indicator data (patient waiting times for Australasian Triage Scale categories 2, 3, 4 and 5 number of patients who did not-wait length of ED stay for non-admitted patients) were compared between EDs with and without NPs using logistic regression and Cox proportional hazards regression, adjusting for hospital and patient characteristics and correlation of outcomes within hospitals. Safety and quality indicator data (rates of ED unplanned re-presentations) for a random subset of re-presentations were compared using Poisson regression. Of 66 EDs, 55 (83%) provided service indicator data on 2 463 543 ED patient episodes while 58 (88%) provided safety and quality indicator data on 2853 ED re-presentations. EDs with NPs had significantly (p .001) higher rates of waiting times compared with EDs without NPs. Patients presenting to EDs with NPs spent 13 min (8%) longer in ED compared with EDs without NPs (median, (first quartile–third quartile): 156 (93–233) and 143 (84–217) for EDs with and without NPs, respectively). EDs with NPs had 1.8% more patients who did not wait, but similar re-presentations rates as EDs with NPs. EDs with NPs had statistically significantly lower performance for service indicators. However, these findings should be treated with caution. NPs are relatively new in the ED workforce and low NP numbers, staffing patterns and still-evolving roles may limit their impact on service indicators. Further research is needed to explain the dichotomy between the benefits of NPs demonstrated in in idual clinical outcomes research and these macro system-wide observations.
Education and practice gaps on atrial fibrillation and anticoagulation: a survey of cardiovascular nurses.
Publisher: Springer Science and Business Media LLC
Date: 12-01-2016
Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study
Publisher: Elsevier BV
Date: 12-2020
Barriers to the use of anticoagulation for nonvalvular atrial fibrillation
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2008
DOI: 10.1161/STROKEAHA.107.495036
Abstract: Background and Purpose— Anticoagulation reduces the risk of stroke in nonvalvular atrial fibrillation yet remains underused. We explored barriers to the use of anticoagulants among Australian family physicians. Methods— The authors conducted a representative, national survey. Results— Of the 596 (64.4%) eligible family physicians who participated, 15.8% reported having a patient with nonvalvular atrial fibrillation experience an intracranial hemorrhage with anticoagulation and 45.8% had a patient with known nonvalvular atrial fibrillation experience a stroke without anticoagulation. When presented with a patient at “very high risk” of stroke, only 45.6% of family physicians selected warfarin in the presence of a minor falls risk and 17.1% would anticoagulate if the patient had a treated peptic ulcer. Family physicians with less decisional conflict and longer-standing practices were more likely to endorse anticoagulation. Conclusion— Strategies to optimize the management of nonvalvular atrial fibrillation should address psychological barriers to using anticoagulation.
Self-care research: How to grow the evidence base? (reprint)
Publisher: Elsevier BV
Date: 02-2021
A scoping review of nurse-led randomised controlled trials
Publisher: Wiley
Date: 03-02-2023
DOI: 10.1111/JOCN.16632
Abstract: Nurses comprise the largest portion of the healthcare workforce worldwide. However, nurse representation in the leadership of clinical research and research funding is largely unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established to provide a coordinated network, focussed on building research capacity in nursing and midwifery. To support this work, this scoping review of nurse‐led randomised controlled trials was conducted to summarise research activity, as well as highlight future research directions, gaps and resources. Midwife‐led trials will be reported elsewhere. To quantify number, type and quality of nurse‐led randomised controlled trials registered between 2000–2021. A scoping review of RCTs. Medline, Emcare and Scopus were searched from 2000 to August 2021. ANZCTR, NHMRC, MRFF and HRC (NZ) registries were searched from inception to July 2021. This review was informed by the JBI scoping review framework using the PRISMA‐ScR. Our search yielded 188 nurse‐led publications and 279 registered randomised controlled trials. Multiple trials had the same nurse leaders. There were more registrations than publications. Publications were predominantly of high methodological quality however, there was a reliance on active controls and blinding was low. Trial registrations indicate that universities and hospital/healthcare organisations were the major sources of funding, while publications indicate that Governments and the National Health and Medical Research Council were the main funding bodies. A small number of high‐quality, large‐scale, nationally funded randomised controlled trials were identified, with a larger number of locally funded small trials. There was a disparity between the number of registered trials and those published. Additional infrastructure, funding and career frameworks are needed to enable nurses to design, conduct and publish clinical trials that inform the health system and improve health outcomes. Research initiated and led by nurses has the potential to improve the health and well‐being of in iduals and communities, and current nurse‐led research is of high methodological quality however, there were very few nurse‐led RCTs, conducted by a small pool of nurse researchers. This gap highlights the need for support in the design, conduct and publishing of nurse‐led RCTs. This is a scoping review therefore, patient or public contribution is not applicable.
Nurse-Initiated Acute Stroke Care in Emergency Departments
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2019
DOI: 10.1161/STROKEAHA.118.020701
Abstract: We aimed to evaluate the effectiveness of an intervention to improve triage, treatment, and transfer for patients with acute stroke admitted to the emergency department (ED). A pragmatic, blinded, multicenter, parallel group, cluster randomized controlled trial was conducted between July 2013 and September 2016 in 26 Australian EDs with stroke units and tPA (tissue-type plasminogen activator) protocols. Hospitals, stratified by state and tPA volume, were randomized 1:1 to intervention or usual care by an independent statistician. Eligible ED patients had acute stroke hours from symptom onset and were admitted to the stroke unit via ED. Our nurse-initiated T 3 intervention targeted (1) Triage to Australasian Triage Scale category 1 or 2 (2) Treatment: tPA eligibility screening and appropriate administration clinical protocols for managing fever, hyperglycemia, and swallowing (3) prompt ( hours) stroke unit Transfer. It was implemented using (1) workshops to identify barriers and solutions (2) face-to-face, online, and written education (3) national and local clinical opinion leaders and (4) email, telephone, and site visit follow-up. Outcomes were assessed at the patient level. Primary outcome: 90-day death or dependency (modified Rankin Scale score of ≥2) secondary outcomes: functional dependency (Barthel Index ≥95), health status (Short Form [36] Health Survey), and ED quality of care (Australasian Triage Scale monitoring and management of tPA, fever, hyperglycemia, swallowing prompt transfer). Intention-to-treat analysis adjusted for preintervention outcomes and ED clustering. Patients, outcome assessors, and statisticians were masked to group allocation. Twenty-six EDs (13 intervention and 13 control) recruited 2242 patients (645 preintervention and 1597 postintervention). There were no statistically significant differences at follow-up for 90-day modified Rankin Scale (intervention: n=400 [53.5%] control n=266 [48.7%] P =0.24) or secondary outcomes. This evidence-based, theory-informed implementation trial, previously effective in stroke units, did not change patient outcomes or clinician behavior in the complex ED environment. Implementation trials are warranted to evaluate alternative approaches for improving ED stroke care. URL: www.anzctr.org.au . Unique identifier: ACTRN12614000939695.
Interventions for the uptake of evidence-based recommendations in acute stroke settings
Publisher: Wiley
Date: 22-01-2017
A qualitative study of senior hospital managers' views on current and innovative strategies to improve hand hygiene
Publisher: Springer Science and Business Media LLC
Date: 18-11-2014
Regional variation in acute stroke care organisation
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.JNS.2016.10.026
Abstract: Few studies have assessed regional variation in the organisation of stroke services, particularly health care resourcing, presence of protocols and discharge planning. Our aim was to compare stroke care organisation within middle- (MIC) and high-income country (HIC) hospitals participating in the Head Position in Stroke Trial (HeadPoST). HeadPoST is an on-going international multicenter crossover cluster-randomized trial of 'sitting-up' versus 'lying-flat' head positioning in acute stroke. As part of the start-up phase, one stroke care organisation questionnaire was completed at each hospital. The World Bank gross national income per capita criteria were used for classification. 94 hospitals from 9 countries completed the questionnaire, 51 corresponding to MIC and 43 to HIC. Most participating hospitals had a dedicated stroke care unit/ward, with access to diagnostic services and expert stroke physicians, and offering intravenous thrombolysis. There was no difference for the presence of a dedicated multidisciplinary stroke team, although greater access to a broad spectrum of rehabilitation therapists in HIC compared to MIC hospitals was observed. Significantly more patients arrived within a 4-h window of symptoms onset in HIC hospitals (41 vs. 13% P<0.001), and a significantly higher proportion of acute ischemic stroke patients received intravenous thrombolysis (10 vs. 5% P=0.002) compared to MIC hospitals. Although all hospitals provided advanced care for people with stroke, differences were found in stroke care organisation and treatment. Future multilevel analyses aims to determine the influence of specific organisational factors on patient outcomes.
Setting stroke research priorities: The consumer perspective
Publisher: Elsevier BV
Date: 12-2010
DOI: 10.1016/J.JVN.2010.09.001
Abstract: To test a method of engaging consumers in research priority-setting using a quantitative approach and to determine consumer views on stroke research priorities for clinical practice recommendations with lower levels of evidence (Level III and Level IV) and expert consensus opinion as published in the Australian stroke clinical practice guidelines. Survey Urban community Eighteen stroke survivors (n = 12) and carers (n = 6) who were members of the "Working Aged Group - Stroke" (WAGS) consumer support group. Phase I: Participants were asked whether recommendations were "worth" researching ("yes" or "no") and, if researched, what potential impact they likely would have on patient outcomes. Phase II: Participants were asked to rank recommendations rated by more than 75% of participants in Phase I as "worth" researching and "highly likely" or "likely" to generate research with a significant effect on patient outcomes (n = 13) in order of priority for future stroke research. All recommendations were rated by at least half (n = 9, 50%) of participants as "worth" researching. The majority (67% to 100%) rated all recommendations as "highly likely" or "likely" that research would have a significant effect on patient outcomes. Thirteen out of 20 recommendations were ranked for their research priorities. Recommendations under the topic heading Getting to hospital were ranked highest and Organization of care and Living with stroke were ranked as a lower priority for research. This study provided an ex le of how to involve consumers in research priority setting successfully using a quantitative approach. Stroke research priorities from the consumer perspective were different from those of health professionals, as published in the literature thus, consumer opinion should be considered when setting research priorities.
Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study
Publisher: BMJ
Date: 23-02-2017
Clinical guidelines for acute stroke management: Which recommendations should remain consensus-based?
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.JVN.2012.10.001
Abstract: Although guideline recommendations should be based on the highest levels of evidence available, it may be appropriate for some recommendations to remain consensus-based. This study investigated stroke clinicians' and academics' opinions about which consensus-based recommendations from the Australian National Stroke Foundation Clinical Guidelines for Acute Stroke Management (2007) should remain as such, using a self-administered questionnaire. In the study, 43 people participated (62% response rate). Of the 50 recommendations presented, at least half the participants believed that 35 (70%) of these should remain consensus-based. In an adjusted multivariable analysis, recommendations perceived to be "highly likely" or "likely" to have an impact on patient outcomes were less likely to be perceived by respondents as appropriate to remain consensus-based (OR = 0.16 [95% CI 0.13-0.19], P < .001). Further, although females were less likely to state that recommendations should remain consensus-based (OR = 0.26 for female gender, [95% CI 0.08-0.88], P = .031), those with higher level of educational qualifications (OR = 1.45 per an incremental unit increase in education level [95% CI 1.04-2.03], P = .028) and those from nursing and medicine disciplines in comparison with allied health (OR = 25.2 for medical, nursing, and "other" disciplines in comparison with allied health [95% CI 1.54-413.1], P = .024) were more likely to state that a recommendations should remain consensus-based. The results indicated there was agreement that it may be appropriate that a proportion of recommendations in clinical guidelines remain consensus-based. Assessing the views of what areas require more robust research evidence according to academic and clinical experts may allow for prioritization and optimal allocation of scarce research resources.
Nursing practice environment: How does one Australian hospital compare with magnet hospitals?
Publisher: Wiley
Date: 19-09-2008
Are there commonalities among audit tools used to measure carotid endarterectomy outcomes in New South Wales?
Publisher: Wiley
Date: 2002
DOI: 10.1046/J.1445-2197.2002.02292.X
Abstract: To prepare for a state-wide audit of carotid endarterectomy (CEA), we sought to ascertain pre-existing practices and identify common process and outcome measures among audits tools used by NSW vascular surgeons. Telephone survey comprising five questions about CEA audit practices. Of 37 known vascular surgeons in NSW, all performed CEA and agreed to participate in our telephone survey (response rate 100%). All but one reported collecting CEA data (97%). Two thirds of these collected data prospectively. From those 19 surgeons (51%) who stated that they used standard tools for audit, we received five CEA-specific tools. Process measures common to all five were: side of CEA, date of operation, sex, past history of hypertension, history of diabetes, use of shunt, use of patch. There were only three outcome measures common to all five CEA-specific tools: postoperative transient ischaemic attack (TIA), postoperative stroke, and postoperative death. Data about outcomes beyond discharge were inconsistently collected. While most vascular surgeons in NSW report collecting information about CEA outcomes, not all do so prospectively. Only three outcomes (postoperative TIA, postoperative stroke and death) were common to all tools, inviting the development and use of a comprehensive and standard tool.
Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice
Publisher: AMPCo
Date: 08-2011
DOI: 10.5694/J.1326-5377.2011.TB03271.X
Abstract: To compare the clinical diagnosis of chronic obstructive pulmonary disease (COPD) with results of post-bronchodilator spirometry in general practice, and examine practitioner, practice and patient characteristics associated with agreement between clinical and spirometric diagnoses. General practitioners from practices in Sydney identified eligible patients aged 40-80 years seen in the past year and prescribed respiratory medications whom they regarded as having COPD. Between November 2006 and April 2008, we collected information on the GPs and their practices, and demographic information, smoking status, comorbidities, respiratory medicines use, vaccination status, quality of life and spirometry results for participating patients. Frequency of COPD diagnosis on spirometry odds ratios for characteristics associated with agreement between clinical and spirometric diagnoses. 56 GPs from 44 practices participated in the study. Of 1144 eligible patients, 445 were recruited (mean age, 65 years 49% male). Of these, 257 (57.8%) had post-bronchodilator spirometry consistent with COPD ± asthma, 16 (3.6%) had asthma only, 82 (18.4%) had normal spirometry, and 90 (20.2%) had other spirometric diagnoses. Having a spirometer in the practice was not predictive of agreement between clinical and spirometric diagnoses. Older patient age was significantly associated with correct diagnosis, while higher numbers of comorbidities were associated with misdiagnosis. A substantial proportion of patients clinically identified as having COPD in general practice do not have the condition according to spirometric criteria, with inaccurate diagnosis more common in patients with comorbidities. Policy and practice change is needed to support the use of spirometry in primary care.
Dysphagia screening and risks of pneumonia and adverse outcomes after acute stroke: An international multicenter study
Publisher: SAGE Publications
Date: 21-06-2020
Abstract: Dysphagia is associated with aspiration pneumonia after stroke. Data are limited on the influences of dysphagia screen and assessment in clinical practice. To determine associations between a “brief” screen and “detailed” assessment of dysphagia on clinical outcomes in acute stroke patients. A prospective cohort study analyzed retrospectively using data from a multicenter, cluster cross-over, randomized controlled trial (Head Positioning in Acute Stroke Trial [HeadPoST]) from 114 hospitals in nine countries. HeadPoST included 11,093 acute stroke patients randomized to lying-flat or sitting-up head positioning. Herein, we report predefined secondary analyses of the association of dysphagia screening and assessment and clinical outcomes of pneumonia and death or disability (modified Rankin scale 3–6) at 90 days. Overall, 8784 (79.2%) and 3917 (35.3%) patients were screened and assessed for dysphagia, respectively, but the frequency and timing for each varied widely across regions. Neither use of a screen nor an assessment for dysphagia was associated with the outcomes, but their results were compared to “screen-pass” patients, those who failed had higher risks of pneumonia (adjusted odds ratio [aOR] = 3.00, 95% confidence interval [CI] = 2.18–4.10) and death or disability (aOR = 1.66, 95% CI = 1.41–1.95). Similar results were evidence for the results of an assessment for dysphagia. Subsequent feeding restrictions were related to higher risk of pneumonia in patients failed dysphagia screen or assessment (aOR = 4.06, 95% CI = 1.72–9.54). Failing a dysphagia screen is associated with increased risks of pneumonia and poor clinical outcome after acute stroke. Further studies concentrate on determining the effective subsequent feeding actions are needed to improve patient outcomes.
Evaluation of a Housing Support Program for People Who Are at Risk of Homelessness: Perspective of People Who Refer Clients
Publisher: Informa UK Limited
Date: 12-2010
Comprehensive Stroke Units: A Review of Comparative Evidence and Experience
Publisher: SAGE Publications
Date: 19-07-2012
DOI: 10.1111/J.1747-4949.2012.00850.X
Abstract: Stroke unit care offers significant benefits in survival and dependency when compared to general medical ward. Most stroke units are either acute or rehabilitation, but comprehensive (combined acute and rehabilitation) model (comprehensive stroke unit) is less common. To examine different levels of evidence of comprehensive stroke unit compared to other organized inpatient stroke care and share local experience of comprehensive stroke units. Cochrane Library and Medline (1980 to December 2010) review of English language articles comparing stroke units to alternative forms of stroke care delivery, different types of stroke unit models, and differences in processes of care within different stroke unit models. Different levels of comparative evidence of comprehensive stroke units to other models of stroke units are collected. There are no randomized controlled trials directly comparing comprehensive stroke units to other stroke unit models (either acute or rehabilitation). Comprehensive stroke units are associated with reduced length of stay and greatest reduction in combined death and dependency in a meta-analysis study when compared to other stroke unit models. Comprehensive stroke units also have better length of stay and functional outcome when compared to acute or rehabilitation stroke unit models in a cross-sectional study, and better length of stay in a ‘before-and-after’ comparative study. Components of stroke unit care that improve outcome are multifactorial and most probably include early mobilization. A comprehensive stroke unit model has been successfully implemented in metropolitan and rural hospital settings. Comprehensive stroke units are associated with reductions in length of stay and combined death and dependency and improved functional outcomes compared to other stroke unit models. A comprehensive stroke unit model is worth considering as the preferred model of stroke unit care in the planning and delivery of metropolitan and rural stroke services.
The management of non-valvular atrial fibrillation (NVAF) in Australian general practice: Bridging the evidence-practice gap. A national, representative postal survey
Publisher: Springer Science and Business Media LLC
Date: 13-11-2008
Treatment with exenatide in acute ischemic stroke trial protocol: A prospective, randomized, open label, blinded end-point study of exenatide vs. standard care in post stroke hyperglycemia
Publisher: SAGE Publications
Date: 18-07-2018
Abstract: Post-stroke hyperglycemia occurs in up to 50% of patients presenting with acute ischemic stroke. It reduces the efficacy of thrombolysis, increases infarct size, and worsens clinical outcomes. Insulin-based therapies have generally not been beneficial in treating post-stroke hyperglycemia as they are difficult to implement, may cause hypoglycaemia, possibly increase mortality and worsen clinical outcomes. Exenatide may be a safer, simpler, and more effective alternative to insulin in acute ischemic stroke. TEXAIS is a three year, Phase 2, multi-center, prospective, randomized, open label, blinded end-point trial comparing exenatide to standard of care. It aims to recruit 528 patients with a primary end point of major neurological improvement at 7 days defined as a ≥8-point improvement in NIHSS score, or NIHSS 0–1. Secondary outcomes of hyper- and hypoglycaemia at 5 days and NIHSS and mRS at 90 days will be measured. The treatment arm will receive exenatide 5 µg subcutaneously twice daily. The control arm will receive standard stroke unit care. Continuous glucose monitors will track the dynamic variability of glucose. TEXAIS aims to show that exenatide is safe and effective in the treatment of post-stroke hyperglycemia. It has been designed to be highly generalizable with an ability to enroll a large percentage of patients with acute ischemic stroke, regardless of admission blood glucose level, diabetes status, or stroke severity, with very low risk of hypoglycemia. Trial registration: ClinicalTrials.gov/ANZCTR NTA1127
Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread
Publisher: Springer Science and Business Media LLC
Date: 02-09-2019
Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial
Publisher: Elsevier BV
Date: 11-2011
Improving stroke Emergency Department nursing care: The Code Stroke 2.0 pre-test/post-test feasibility study
Publisher: Elsevier BV
Date: 10-2023
The role of stroke nurses in thrombolysis administration in Australia and the United Kingdom: A cross‐sectional survey of current practice
Publisher: Wiley
Date: 06-2021
DOI: 10.1111/JOCN.15892
Abstract: The role of stroke nurses in patient selection and administration of recombinant tissue plasminogen activator (rt‐PA) for acute ischaemic stroke is evolving. To compare differences in stroke nurses' practices related to rt‐PA administration in Australia and the United Kingdom (UK) and to examine whether these differences influence rt‐PA treatment rates. A cross‐sectional, self‐administered questionnaire administered to a lead stroke clinician from hospitals known to provide rt‐PA for acute ischaemic stroke. Chi‐square tests were used to analyse between‐country differences in ten pre‐specified rt‐PA practices. Non‐parametric equality of medians test was used to assess within‐country differences for likelihood of undertaking practices and association with rt‐PA treatment rates. Reporting followed STROBE checklist. Response rate 68% (Australia: 74% [ n = 63/85] UK: 65% [ n = 93/144]). There were significant differences between countries for 7/10 practices. UK nurses were more likely to: request CT scan screen patient for rt‐PA suitability gain informed consent use telemedicine to assess, diagnose or treat assist in the decision for rt‐PA with Emergency Department physician or neurologist and undergo training in rt‐PA administration. Reported median hospital rt‐PA treatment rates were 12% in the UK and 7.8% in Australia: (7.8%). In Australia, there was an association between higher treatment rates and nurses involvement in 5/10 practices read and interpret CT scans screen patient for rt‐PA suitability gain informed consent assess suitability for rt‐PA with neurologist/stroke physician undergo training in rt‐PA administration. There was no relationship between UK treatment rates and likelihood of a stroke nurse to undertake any of the ten rt‐PA practices. Stroke nurses' active role in rt‐PA administration can improve rt‐PA treatment rates. Models of care that broaden stroke nurses' scope of practice to maximise rt‐PA treatment rates for ischaemic stroke patients are needed. This study demonstrates that UK and Australian nurses play an important role in thrombolysis practices however, they are underused. Formalising and extending the role of stroke nurses in rt‐PA administration could potentially increase thrombolysis rates with clinical benefits for patients.
Stroke management: Updated recommendations for treatment along the care continuum
Publisher: Wiley
Date: 05-2012
DOI: 10.1111/J.1445-5994.2012.02774.X
Abstract: The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5 h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management.
Exploring the precursors of outcome evaluation in Australia: Linking structure, process and outcome by peer review
Publisher: Wiley
Date: 09-1998
DOI: 10.1046/J.1440-172X.1998.00086.X
Abstract: Reviews of the structure of the health system and the processes that contributed to them were the main forms of evaluation within nursing in Australia during the 1970s and 1980s. The documentation of the end result of care, or outcome evaluation, was rarely undertaken until more recent times. The development and implementation of formal assessment tools such as Qualpacs, the Phaneuf Nursing Audit, the Rush Medicus Nursing Process Methodology, Monitor, and Senior Monitor indicated the focus on structure and process evaluation. This paper examines how nursing care delivered to patients during the l970s and 1980s was evaluated, and explores why structure and process review were necessary precursors to outcome evaluation in the nineties. The necessity of linking structure and process analysis is discussed, in order to perform effective outcome evaluation to close the feedback loop between quality assessment and quality improvement. Peer review is one mechanism that can be used to achieve this. How this may also be a form of evidence-based practice which results in health gains for patients is also explored.
Protocol and Pilot Data for Establishing the Australian Stroke Clinical Registry
Publisher: SAGE Publications
Date: 06-2010
DOI: 10.1111/J.1747-4949.2010.00430.X
Abstract: Disease registries assist with clinical practice improvement. The Australian Stroke Clinical Registry aims to provide national, prospective, systematic data on processes and outcomes for stroke. We describe the methods of establishment and initial experience of operation. Australian Stroke Clinical Registry conforms to new national operating principles and technical standards for clinical quality registers. Features include: online data capture from acute public and private hospital sites opt-out consent expert consensus agreed core minimum dataset with standard definitions outcomes assessed at 3 months post-stroke formal governance oversight and formative evaluations for improvements. Qualitative feedback from sites indicates that the web-tool is simple to use and the user manuals, data dictionary, and training are appropriate. However, sites desire automated data-entry methods for routine demography variables and the opt-out consent protocol has sometimes been problematic. Data from 204 patients (median age 71 years, 54% males, 60% Australian) were collected from four pilot hospitals from June to October 2009 (mean, 50 cases per month) including ischaemic stroke (in 72%), intracerebral haemorrhage (16%), transient ischaemic attack (9%), and undetermined (3%), with only one case opting out. Australian Stroke Clinical Registry has been well established, but further refinements and broad roll-out are required before realising its potential of improving patient care through clinician feedback and allowance of local, national, and international comparative data.
Improving quality and outcomes of stroke care in hospitals: Protocol and statistical analysis plan for the Stroke123 implementation study
Publisher: SAGE Publications
Date: 15-09-2018
Abstract: The effectiveness of clinician-focused interventions to improve stroke care is uncertain. To determine whether an organizational intervention can improve the quality of stroke care over usual care. To detect an absolute 10% difference in overall performance (composite outcome), a minimum of 21 hospitals and 843 patients per group was determined. Before and after controlled design in hospitals in Queensland, Australia. Externally facilitated program (StrokeLink) using outreach workshops incorporating clinical performance feedback, patient outcomes (survival, quality of life at 90–180 days), local barrier assessments to best practice care, action planning, and ongoing support. Descriptive and multivariable analyses adjusted for patient correlations by hospital (intention-to-treat method). Concurrent implementation of financial incentives to increase stroke unit access and use of the Australian Stroke Clinical Registry for performance monitoring. Primary outcome: net change in composite score (i.e. total number of process indicators achieved ided by the sum of eligible indicators for each cohort). Secondary outcomes: change in in idual indicators, change in composite score comparing hospitals that did or did not develop action plans (per-protocol analysis), impact on 90–180-day health outcomes. Sensitivity analyses: hospital self-rated status, alternate cross-sectional audit data (Stroke Foundation). To account for temporal effects, comparison of Queensland hospital performance relative to other Australian hospitals will also be undertaken. Twenty-one hospitals were recruited however, one was unable to participate within the study time frame. Workshops were held between 11 March 2014 and 7 November 2014. Data are ready for analysis.
Exploring barriers to stroke coordinator roles in Australia: A national survey
Publisher: Elsevier BV
Date: 08-2022
Is length of time in a stroke unit associated with better outcomes for patients with stroke in Australia? An observational study
Publisher: BMJ
Date: 11-2018
DOI: 10.1136/BMJOPEN-2018-022536
Abstract: Spending at least 90% of hospital admission in a stroke unit (SU) is a recommended indicator of receiving high-quality stroke care. However, whether this makes a difference to patient outcomes is unknown. We aimed to investigate outcomes and factors associated with patients with acute stroke spending at least 90% of their admission in an SU, compared with those having less time in the SU. Observational study using cross-sectional data. Data from hospitals which participated in the 2015 Stroke Foundation National Audit: Acute Services (Australia) and had an SU. This audit includes an organisational survey and retrospective medical record audit of approximately 40 admissions from each hospital. Patients admitted to an SU during their acute admission were included. Hospital-based patient outcomes included length of stay, independence on discharge, severe complications and discharge destination. Patient, organisational and process indicators were included in multilevel logistic modelling to determine factors associated with spending at least 90% of their admission in an SU. Eighty-eight hospitals with an SU audited 2655 cases (median age 76 years, 55% male). Patients who spent at least 90% of their admission in an SU experienced: a length of stay that was 2 days shorter (coefficient −2.77, 95% CI −3.45 to –2.10), fewer severe complications (adjusted OR (aOR) 0.60, 95% CI 0.43 to 0.84) and were less often discharged to residential aged care (aOR 0.59, 95% CI 0.38 to 0.94) than those who had less time in the SU. Patients admitted to an SU within 3 hours of hospital arrival were three times more likely to spend at least 90% of their admission in an SU. Spending at least 90% of time in an SU is a valid measure of stroke care quality as it results in improved patient outcomes. Direct admission to SUs is warranted.
Influence of Including Patients with Premorbid Disability in Acute Stroke Trials: The HeadPoST Experience
Publisher: S. Karger AG
Date: 2021
DOI: 10.1159/000512608
Abstract: b i Background: /i /b Patients with premorbid functional impairment are generally excluded from acute stroke trials. We aimed to determine the impact of including such patients in the Head Positioning in acute Stroke Trial (HeadPoST) and early additional impairment on outcomes. b i Methods: /i /b Post hoc analyses of HeadPoST, an international, cluster-randomized crossover trial of lying-flat versus sitting-up head positioning in acute stroke. Associations of early additional impairment, defined as change in modified Rankin scale (mRS) scores from premorbid levels (estimated at baseline) to Day 7 (“early ΔmRS”), and poor outcome (mRS score 3–6) at Day 90 were determined with generalized linear mixed model. Heterogeneity of the trial treatment effect was tested according to premorbid mRS scores 0–1 versus 2–5. b i Results: /i /b Of 8,285 patients (38.9% female, mean age 68 ± 13 years) with complete data, there were 1,984 (23.9%) with premorbid functional impairment (mRS 2–5). A significant linear association was evident for early ∆mRS and poor outcome (per 1-point increase in ΔmRS, adjusted odds ratio 1.20, 95% confidence interval 1.14–1.27 i /i & #x3c 0.0001). Patients with greater premorbid functional impairment were less likely to develop additional impairment, but their risk of poor 90-day outcome significantly increased with increasing (worse) premorbid mRS scores (linear trend i /i & #x3c 0.0001). There was no heterogeneity of the trial treatment effect by level of premorbid function. b i Conclusions: /i /b Early poststroke functional impairment that exceeded premorbid levels was associated with worse 90-day outcome, and this association increased with greater premorbid functional impairment. Yet, including premorbid impaired patients in the HeadPoST did not materially affect the subsequent treatment effect. b i Clinical Trial Registration: /i /b HeadPoST is registered at www.ClinicalTrials.gov (NCT02162017).
Vascular disease risk factor management 4 years after carotid endarterectomy: are opportunities missed?
Publisher: Wiley
Date: 04-2003
DOI: 10.1046/J.1445-1433.2002.02570.X
Abstract: Because a large percentage of patients surviving carotid endarterectomy (CEA) subsequently die from a vascular cause, the aim of the present paper was to determine risk factor management for a cohort of patients 4 years after their CEA. Surviving patients who had a CEA within the region administered by the Central Sydney Area Health Service in 1995 were asked to complete a self-administered questionnaire to determine vascular risk factors. Of the 181 patients eligible to participate, 162 returned questionnaires (response rate: 90%). While 106 (65.4%) patients recalled that they had been diagnosed with high blood pressure either before or after their CEA, only 79.2% recalled that their latest blood pressure reading was 'about right for my age'. Nearly one in five (16.7%) who had had their cholesterol level checked in the last 12 months (n = 120) indicated that the reading was 'too high'. Only 76.5% reported taking medications to 'thin the blood'. Almost one-fifth of patients (17.3%) were current smokers. Only 35.2% of patients participated in a level of physical activity sufficient to confer a health benefit. Further, 30.2% of patients were overweight and 14.8% were obese. The majority of patients (98.1%) reported having a regular general practitioner (GP). Of these, 98.7% had visited their GP at least once within the previous 6 months. Vascular risk factor management following CEA is suboptimal, inviting the implementation and evaluation of strategies to improve outcomes.
Measuring outcomes from the patients’ perspective
Publisher: Wiley
Date: 09-1999
DOI: 10.1046/J.1440-172X.1999.00165.X
Abstract: This descriptive study examines the outcomes of care from the perspective of patients following a recent orthopaedic admission at a teaching hospital in Sydney. Results were extracted and analysed from transcripts of audio-taped focus groups. Participants identified five nursing activities that made a positive difference to patient outcomes. These activities were: (i) patient-controlled analgesia (ii) water-filled gloves placed under patients' heels (iii) cream rubbed into patients' heels (iv) an explanation, at pre-admission clinic, of the impending operation and (v) being informed about the details of their treatment while in hospital. Three activities that participants felt made a negative difference to their outcome were also identified, as were seven activities not performed by nursing staff that participants felt would have made a positive difference to their outcome. The results from this study reinforce the importance of basic nursing care, and the value of measuring outcomes, not only from the professional perspective, but also from the patients' viewpoint.
Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation
Publisher: Public Library of Science (PLoS)
Date: 07-10-2021
DOI: 10.1371/JOURNAL.PONE.0256027
Abstract: Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period. The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. ANZCTR: ACTRN12618001548224 , approved 17/09/2018
Quality of life is poorer for patients with stroke who require an interpreter an observational australian registry study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2018
DOI: 10.1161/STROKEAHA.117.019771
Abstract: In multicultural Australia, some patients with stroke cannot fully understand, or speak, English. Language barriers may reduce quality of care and consequent outcomes after stroke, yet little has been reported empirically. An observational study of patients with stroke or transient ischemic attack (2010–2015) captured from 45 hospitals participating in the Australian Stroke Clinical Registry. The use of interpreters in hospitals, which is routinely documented, was used as a proxy for severe language barriers. Health-Related Quality of Life was assessed using the EuroQoL-5 dimension-3 level measured 90 to 180 days after stroke. Logistic regression was undertaken to assess the association between domains of EuroQoL-5 dimension and interpreter status. Among 34 562 registrants, 1461 (4.2%) required an interpreter. Compared with patients without interpreters, patients requiring an interpreter were more often women (53% versus 46% P .001), aged ≥75 years (68% versus 51% P .001), and had greater access to stroke unit care (85% versus 78% P .001). After accounting for patient characteristics and stroke severity, patients requiring interpreters had comparable discharge outcomes (eg, mortality, discharged to rehabilitation) to patients not needing interpreters. However, these patients reported poorer Health-Related Quality of Life (visual analogue scale coefficient, −9 95% CI, −12.38, −5.62), including more problems with self-care (odds ratio: 2.22 95% CI, 1.82, 2.72), pain (odds ratio: 1.84 95% CI, 1.52, 2.34), anxiety or depression (odds ratio: 1.60 95% CI, 1.33, 1.93), and usual activities (odds ratio: 1.62 95% CI, 1.32, 2.00). Patients requiring interpreters reported poorer Health Related Quality of Life after stroke/transient ischemic attack despite greater access to stroke units. These findings should be interpreted with caution because we are unable to account for prestroke Health Related Quality of Life. Further research is needed.
Increased fluid intake for the prevention of urinary tract infection in adults and children in all settings: A systematic review
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.JHIN.2019.08.016
Abstract: Non-antibiotic interventions for urinary tract infection (UTI) prevention have been investigated as a strategy to reduce antibiotic prescribing for UTI and subsequent antibiotic resistance. Increased hydration is widely advocated for preventing UTI however, evidence for its effectiveness is unknown. To systematically review the published literature on the effectiveness of increased fluid intake as a preventive intervention for UTI in adults and children in any setting. Five electronic databases were searched from inception to February 2019 to identify published randomized controlled trials (RCTs) and quasi-experimental studies evaluating the effectiveness of high (≥1.5 L/24 h) versus normal/low (<1.5 L/24 h) fluid intake for UTI prevention. The outcome was UTI incidence. Risk of bias was assessed using the Cochrane Collaboration's tool. Due to the small number of studies identified, meta-analysis was not possible. Hence a narrative synthesis was undertaken. Of the 2822 potentially relevant papers, two were eligible for inclusion: an RCT (in idual randomization) and a cluster-RCT. Both studies differed regarding participants, setting, s le size, UTI definition, and intervention. The RCT was assessed as having a low risk of bias whereas the cluster-RCT had a high risk of bias. Only the RCT, which included healthy premenopausal women visiting primary care clinics, demonstrated statistical significance for the effect of high fluid intake for UTI prevention. The lack of enough adequately powered and robust RCTs highlights the need for further research on the effectiveness of this intervention for UTI prevention.
Pain & Cognitive Status in the Institutionalized Elderly
Publisher: SLACK, Inc.
Date: 08-1998
DOI: 10.3928/0098-9134-19980801-07
Abstract: ABSTRACT The purposes of this study were t examine the relationship between: (1) nurses' ratings of pain and corresponding administration of pain medication to elderly long-term care residents, and (2) cognitive status the elderly and pain medication orders/administration. Participants were 83 residents, 60 years of age and older, in two groups: cognitiveIy impaired (n = 64), and cognitively intact (n = 19). For comparison purposes, 19 of the cognitively impaire subjects were matched on age an diagnosis to provide control fi potentially painful conditions. A retrospective medication review of the residents' charts was conducted to compare medication orders and administration on analgesics that were scheduled and p.r.n. (given needed). The pain ratings of 25 RN using a visual analogue scaie wen correlated with pain medication given to the resident on the day o the rating. Results indicated that RNs' ratings of resident pain and the administration of pain medications were not significantly correlated. In addition, cognitively impaired residents were prescribed significantly less scheduled medication and received significantly less pain medication (either p.r.n. or scheduled) than the cognitively intact elderly. Implications for practice and research are discussed.
Atrial fibrillation: Stroke prevention in focus
Publisher: Elsevier BV
Date: 05-2014
DOI: 10.1016/J.AUCC.2013.08.002
Abstract: Atrial fibrillation (AF) is a common arrhythmia and a risk factor for stroke and other, adverse events. Internationally there have been recent advancements in the therapies available for, stroke prevention in AF. Nurses will care for in iduals with AF across a variety of primary and acute, care settings and should be familiar with evidence based therapies. This paper provides a review of the epidemiology of AF and stroke, stroke and bleeding risk, assessment tools and evidence based treatments for the prevention of stroke in AF including the use of, novel anti-thrombin agents. A review of key databases was conducted from 2002 to 2012 using the key search terms 'atrial, fibrillation' 'anticoagulation' 'risk assessment' and 'clinical management'. The following electronic, databases were searched: CINAHL, Medline, Scopus, the Cochrane Library and Google Scholar., Reference lists were manually hand searched. Key clinical guidelines from National Institute for, Clinical Excellence (NICE, UK), American Heart Association (AHA, USA), American College of Cardiology, (ACC, USA) and the European Society of Cardiology (ESC) and key government policy documents were, also included. Articles were included in the review if they addressed nursing management with a focus, on Australia. Many treatment options exist for AF. Best practice guidelines make a variety of, recommendations which include cardioversion, ablation, pulmonary vein isolation, pharmacological, agents for rate or rhythm control approaches, and antithrombotic therapy (including anticoagulation, and antiplatelet therapy). Treatment should be patient centred and in idualised based upon, persistency of the rhythm, causal nature, risk and co-morbid conditions. AF is a common and burdensome condition where treatment is complex and not without, risk. Nurses will encounter in iduals with AF across a variety of primary and acute care areas, understanding the risk of AF and appropriate therapies is important across all care settings. Treatment, must be in idually tailored to the needs of the patient and balanced with the best available evidence.
How registry data are used to inform activities for stroke care quality improvement across 55 countries: A cross‐sectional survey of Registry of Stroke Care Quality (RES‐Q) hospitals
Publisher: Wiley
Date: 21-08-2023
DOI: 10.1111/ENE.16024
Abstract: The Registry of Stroke Care Quality (RES‐Q) is a worldwide quality improvement data platform that captures performance and quality measures, enabling standardized comparisons of hospital care. The aim of this study was to determine if, and how, RES‐Q data are used to influence stroke quality improvement and identify the support and educational needs of clinicians using RES‐Q data to improve stroke care. A cross‐sectional self‐administered online survey was administered (October 2021–February 2022). Participants were RES‐Q hospital local coordinators responsible for stroke data collection. Descriptive statistics are presented. Surveys were sent to 1463 hospitals in 74 countries responses were received from 358 hospitals in 55 countries (response rate 25%). RES‐Q data were used “always” or “often” to: develop quality improvement initiatives ( n = 213, 60%) track stroke care quality over time ( n = 207, 58%) improve local practice ( n = 191, 53%) and benchmark against evidence‐based policies, procedures and/or guidelines to identify practice gaps ( n = 179, 50%). Formal training in the use of RES‐Q tools and data were the most frequent support needs identified by respondents ( n = 165, 46%). Over half “strongly agreed” or “agreed” that to support clinical practice change, education is needed on: (i) using data to identify evidence–practice gaps ( n = 259, 72%) and change clinical practice ( n = 263, 74%), and (ii) quality improvement science and methods ( n = 255, 71%). RES‐Q data are used for monitoring stroke care performance. However, to facilitate their optimal use, effective quality improvement methods are needed. Educating staff in quality improvement science may develop competency and improve use of data in practice.
Maximising data value and avoiding data waste
Publisher: AMPCo
Date: 10-12-2019
DOI: 10.5694/MJA2.12029
Abstract: To determine the feasibility of linking data from the Australian Stroke Clinical Registry (AuSCR), the National Death Index (NDI), and state-managed databases for hospital admissions and emergency presentations to evaluate data completeness and concordance between datasets for common variables. Cohort design probabilistic/deterministic data linkage of merged records for patients treated in hospital for stroke or transient ischaemic attack from New South Wales, Queensland, Victoria, and Western Australia. Descriptive statistics for data matching success concordance of demographic variables common to linked databases sensitivity and specificity of AuSCR in-hospital death data for predicting NDI registrations. Data for 16 214 patients registered in the AuSCR during 2009-2013 were linked with one or more state datasets: 15 482 matches (95%) with hospital admissions data, and 12 902 matches (80%) with emergency department presentations data were made. Concordance of AuSCR and hospital admissions data exceeded 99% for sex, age, in-hospital death (each κ = 0.99), and Indigenous status (κ = 0.83). Of 1498 registrants identified in the AuSCR as dying in hospital, 1440 (96%) were also recorded by the NDI as dying in hospital. In-hospital death in AuSCR data had 98.7% sensitivity and 99.6% specificity for predicting in-hospital death in the NDI. We report the first linkage of data from an Australian national clinical quality disease registry with routinely collected data from several national and state government health datasets. Data linkage enriches the clinical registry dataset and provides additional information beyond that for the acute care setting and quality of life at follow-up, allowing clinical outcomes for people with stroke (mortality and hospital contacts) to be more comprehensively assessed.
Stroke care equity in rural and remote areas - novel strategies
Publisher: OAE Publishing Inc.
Date: 2021
Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes
Publisher: Elsevier BV
Date: 2021
Patient care guidelines: a telephone survey of intensive care practices in New South Wales.
Publisher: Elsevier BV
Date: 02-2009
DOI: 10.1016/J.AUCC.2009.10.001
Abstract: There are a number of practice areas highlighted in the literature as important for the care of critically ill patients. However, the current implementation of evidence into clinical practice for these areas is largely unknown. The development of clinical practice guidelines can translate the current evidence into useful tools to guide clinicians in providing evidence based care. To identify existence of current guidelines and informal routine procedures and clinicians' views of same within New South Wales (NSW) Intensive Care Units (ICUs) and High Dependency Units (HDUs) for 11 practice areas, namely, bowel management, endotracheal tube (ETT) stabilisation, tracheostomy tube stabilisation, feeding, analgesia, sedation, thromboembolic prevention, head of bed elevation, ulcer prophylaxis and glucose control. A telephone survey conducted with a representative from NSW ICUs and HDUs. There was variation in the number of guidelines and informal routine procedures reported for the 11 practice areas within the study units. Larger ICUs (Joint Faculty of Intensive Care Medicine Level II and Level III) and those who employed an onsite CNC were significantly more likely to have formal guidelines in place. Overall, there were very few audits reportedly conducted for the 11 practice areas. Bowel management was the area of practice most respondents reported as a neglected area of critical care nursing practice and the one they were least satisfied with. This survey provides a baseline of current practice and guideline use within NSW ICUs and HDUs. It also highlights areas for consideration to further develop clinical practice guidelines that could benefit critically ill patients.
Barriers and outcomes of an evidence-based approach to diagnosis and management of chronic obstructive pulmonary disease (COPD) in Australia: A qualitative study
Publisher: Oxford University Press (OUP)
Date: 30-09-2017
Abstract: Chronic obstructive pulmonary disease (COPD) is commonly managed in primary care but there is poor awareness of evidence-based guidelines and the quality and interpretation of spirometry is suboptimal. The aims of this qualitative study were to explore how an intervention involving case finding and management of COPD was implemented, and the extent to which the GPs and practice nurses (PNs) worked in partnership to diagnose and manage COPD. Semi-structured interviews with PNs (n = 7), GPs (n = 4) and patients (n = 26) who had participated in the Primary care EarLy Intervention for Copd mANagement (PELICAN) study. The Theoretical Domains Framework was used to guide the coding and analysis of the interviews with PN and GPs. The patient interviews were analysed thematically. PNs developed technical skills and understood the requirements for good-quality spirometry. However, many lacked confidence in its interpretation and felt this was not part of their professional role. This was reflected in responses from the GPs. Once COPD was diagnosed, the GPs tended to manage the patients with the PNs less involved. This was in contrast with PNs' active role in managing patients with other chronic diseases such as diabetes. The extent to which the GPs and PNs worked in partnership to manage COPD varied. PNs improved their skills and confidence in performing spirometry. Beliefs about their professional role, identity and confidence influenced the extent to which PNs were involved in interpretation of the spirometry results and managing the patient in partnership with the GP.
Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study
Publisher: SAGE Publications
Date: 24-10-2022
DOI: 10.1177/23969873221126027
Abstract: Poor adoption of stroke guidelines is a problem internationally. The Quality in Acute Stroke Care (QASC) trial demonstrated significant reduction in death and disability with facilitated implementation of nurse-initiated This was a multi-country, multi-centre, pre-test ost-test study (2017–2021) comparing post implementation data with historically collected pre-implementation data. Hospital clinical ch ions, supported by the Angels Initiative conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support co-ordinated remotely from Australia. Prospective audits were conducted 3-month after FeSS Protocol introduction. Pre-to-post analysis and country income classification comparisons were adjusted for clustering by hospital and country controlling for age/sex/stroke severity. Data from 64 hospitals in 17 countries (3464 patients pre-implementation and 3257 patients post-implementation) showed improvement pre-to-post implementation in measurement recording of all three FeSS components, all p 0.0001: fever elements (pre: 17%, post: 51% absolute difference 33%, 95% CI 30%, 37%) hyperglycaemia elements (pre: 18%, post: 52% absolute difference 34% 95% CI 31%, 36%) swallowing elements (pre: 39%, post: 67% absolute difference 29%, 95% CI 26%, 31%) and thus in overall FeSS Protocol adherence (pre: 3.4%, post: 35% absolute difference 33%, 95% CI 24%, 42%). In exploratory analysis of FeSS adherence by countries’ economic status, high-income versus middle-income countries improved to a comparable extent. Our collaboration resulted in successful rapid implementation and scale-up of FeSS Protocols into countries with vastly different healthcare systems.
Testing a systematic approach to identify and prioritise barriers to successful implementation of a complex healthcare intervention
Publisher: Springer Science and Business Media LLC
Date: 07-02-2017
Improving the quality of healthcare: a cross-sectional study of the features of successful clinical networks.
Publisher: The Sax Institute
Date: 2018
Abstract: Networks of clinical experts are being established internationally to help embed evidence based care in health systems. There is emerging evidence that these clinical networks can drive quality improvement programs, but the features that distinguish successful networks are largely unknown. We examined the factors that make clinical networks effective at improving quality of care and facilitating system-wide changes. We conducted a retrospective cross-sectional study of 19 state-wide clinical networks that reflected a range of medical and surgical specialty care and were in operation from 2006 to 2008 in New South Wales, Australia. We conducted qualitative interviews with network leaders to characterise potential impacts, and conducted internet surveys of network members to evaluate external support and the organisational and program characteristics of their respective networks. The main outcome measures were median ratings of in idual network impacts on quality of care and system-wide changes, determined through independent assessment of documented evidence by an expert panel. We interviewed 19 network managers and 32 network co-chairs 592 network members completed internet surveys. Three networks were rated as having had high impact on quality of care, and seven as having had high impact on system-wide change. Better-perceived strategic and operational network management was significantly associated with higher ratings of impact on quality of care (coefficient estimate 0.86 95% confidence interval [CI] 0.02, 1.69). Better-perceived leadership of the network manager (coefficient estimate 0.47 95% CI 0.10, 0.85) and strategic and operational network management (coefficient estimate 0.23 95% CI 0.06, 0.41) were associated with higher ratings of impact on system-wide change. This study represents the largest study of clinical networks undertaken to date. The results suggest that clinical networks that span the health system can improve quality of care and facilitate system-wide change. Network management and leadership, encompassing both strategic and operational elements at the organisational level, appear to be the primary influences on network success. These findings can guide future organisational and system-wide change programs and the development or strengthening of clinical networks to help implement evidence based care to improve service delivery and outcomes.
Statistical analysis plan for the Head Position in Stroke Trial (HeadPoST): An international cluster cross-over randomized trial.
Publisher: SAGE Publications
Date: 24-03-2017
Abstract: There is evidence to indicate that the lying flat head position increases cerebral blood flow and oxygenation in patients with acute ischemic stroke, but how these physiological effects translate into clinical outcomes is uncertain. The Head Position in Stroke Trial aims to determine the comparative effectiveness of lying flat (0°) compared to sitting up (≥30°) head positioning, initiated within 24 h of hospital admission for patients with acute stroke. An international, pragmatic, cluster-randomized, crossover, open, blinded outcome assessed clinical trial. Each hospital with an established acute stroke unit (cluster) site was required to recruit up to 140 consecutive cases of acute stroke (one phase of head positioning before immediately crossing over to the other phase of head positioning), including both acute ischemic stroke and intracerebral hemorrhage, in each randomized head position as a ‘business as usual’ policy. To outline in detail the predetermined statistical analysis plan for the study. All accumulated data will be reviewed and formally assessed. Information regarding baseline characteristics of patients, their process of care and management will be outlined, and for each item, statistically relevant descriptive elements will be described. For the trial outcomes, the most appropriate statistical comparisons are described. A statistical analysis plan was developed that is transparent, verifiable, and predetermined before completion of data collection. We developed a predetermined statistical analysis plan for Head Position in Stroke Trial to avoid analysis bias arising from prior knowledge of the findings, in order to reliably quantify the benefits and harms of lying flat versus sitting up early after the onset of acute stroke. ClinicalTrials.gov identifier NCT02162017 ANZCTR identifier ACTRN12614000483651
Improving discharge care: the potential of a new organisational intervention to improve discharge after hospitalisation for acute stroke, a controlled before–after pilot study
Publisher: BMJ
Date: 08-2017
DOI: 10.1136/BMJOPEN-2017-016010
Abstract: Provision of a discharge care plan and prevention therapies is often suboptimal. Our objective was to design and pilot test an interdisciplinary, organisational intervention to improve discharge care using stroke as the case study using a mixed-methods, controlled before–after observational study design. Acute care public hospitals in Queensland, Australia (n=15). The 15 hospitals were ranked against a benchmark based on a composite outcome of three discharge care processes. Clinicians from a ‘top-ranked’ hospital participated in a focus group to elicit their success factors. Two pilot hospitals then participated in the organisational intervention that was designed with experts and consumers. Hospital clinicians involved in discharge care for stroke and patients admitted with acute stroke or transient ischaemic attack. A four-stage, multifaceted organisational intervention that included data reviews, education and facilitated action planning. Three discharge processes collected in Queensland hospitals within the Australian Stroke Clinical Registry were used to select study hospitals: (1) discharge care plan (2) antihypertensive medication prescription and (3) antiplatelet medication prescription (ischaemic events only). Primary measure: composite outcome. Secondary measures: in idual adherence changes for each discharge process sensitivity analyses. The performance outcomes were compared 3 months before the intervention (preintervention), 3 months postintervention and at 12 months (sustainability). Data from 1289 episodes of care from the two pilot hospitals were analysed. Improvements from preintervention adherence were: antiplatelet therapy (88%vs96%, p=0.02) antihypertensive prescription (61%vs79%, p .001) discharge planning (72%vs94%, p .001) composite outcome (73%vs89%, p .001). There was an insignificant decay effect over the 12-month sustainability period (composite outcome: 89% postintervention vs 85% sustainability period, p=0.08). Discharge care in hospitals may be effectively improved and sustained through a staged and peer-informed, organisational intervention. The intervention warrants further application and trialling on a larger scale.
Nursing intervention after carotid endarterectomy: a randomized trial of Co‐ordinated Care Post‐Discharge (CCPD)
Publisher: Wiley
Date: 29-09-2005
DOI: 10.1111/J.1365-2648.2005.03587.X
Abstract: This paper reports a study evaluating the short-term impact of nursing-led, co-ordinated care after discharge following carotid endarterectomy. Patient education about stroke risk factors, combined systematically with carotid endarterectomy, holds unrealized potential to improve patient outcomes. Nurses are well-placed in the healthcare system to co-ordinate this type of education. A randomized controlled trial was conducted between October 2001 and October 2002. Patients having carotid endarterectomy (n = 133) were randomized to either the intervention (n = 66) or control group (n = 67). The intervention consisted of telephone liaison with the patient by a Registered Nurse at 2, 6 and 12 weeks following carotid endarterectomy, combined with education about stroke risk factor management and structured liaison with the patient's surgeon and referring general practitioner. While patients allocated to the control group did not receive any postoperative telephone contact directly from the Registered Nurse during the study, their general practitioners received structured postoperative liaison. The co-ordinated care postdischarge intervention had a statistically significant positive effect on patient knowledge of stroke warning signs (P = 0.002), patient self-reported changes to improve lifestyle (P = 0.006) and diet modification (P < 0.001). Statistically significant improvements from baseline to follow-up were detected in both groups for other outcomes. While nursing-led, co-ordinated care after discharge achieves important improvements for short-term outcomes, carotid endarterectomy itself may have been a catalyst for improved patient outcomes. Further research of nursing-led co-ordinated care initiatives for vascular surgery patients is needed.
An exploratory study of pain in the institutionalized elderly
Publisher: SAGE Publications
Date: 07-1997
DOI: 10.1177/153331759701200403
Abstract: There is a paucity of research concerning pain in the elderly, and consequently, health care professionals' understanding of this phenomenon in the elderly is limited For the elderly subgroup who have a reduced ability to communicate due to cognitive impairment or severe physical disabilities, the experience of pain may go unreported In addition, staff perceptions of pain may differ depending upon the person's cognitive status. 1-6
Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study
Publisher: Springer Science and Business Media LLC
Date: 04-11-2020
DOI: 10.1186/S13012-020-01057-0
Abstract: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T 3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators ( n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action (ii) Fidelity to the protocols : reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence) and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. Despite initial high ‘buy-in’ from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).
Quality of Acute Care and Long-Term Quality of Life and Survival
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2017
DOI: 10.1161/STROKEAHA.116.015714
Abstract: Uncertainty exists over whether quality improvement strategies translate into better health-related quality of life (HRQoL) and survival after acute stroke. We aimed to determine the association of best practice recommended interventions and outcomes after stroke. Data are from the Australian Stroke Clinical Registry during 2010 to 2014. Multivariable regression was used to determine associations between 3 interventions: received acute stroke unit (ASU) care and in various combinations with prescribed antihypertensive medication at discharge, provision of a discharge care plan, and outcomes of survival and HRQoL (EuroQoL 5-dimensional questionnaire visual analogue scale) at 180 days, by stroke type. An assessment was also made of outcomes related to the number of processes patients received. There were 17 585 stroke admissions (median age 77 years, 47% female 81% managed in ASUs 80% ischemic stroke) from 42 hospitals (77% metropolitan) assessed. Cumulative benefits on outcomes related to the number of care processes received by patients. ASU care was associated with a reduced likelihood of death (hazard ratio, 0.49 95% confidence interval, 0.43–0.56) and better HRQoL (coefficient, 21.34 95% confidence interval, 15.50–27.18) within 180 days. For those discharged from hospital, receiving ASU+antihypertensive medication provided greater 180-day survival (hazard ratio, 0.45 95% confidence interval, 0.38–0.52) compared with ASU care alone (hazard ratio, 0.64 95% confidence interval, 0.54–0.76). HRQoL gains were greatest for patients with intracerebral hemorrhage who received care bundles involving discharge processes (range of increase, 11%–19%). Patients with stroke who receive best practice recommended hospital care have improved long-term survival and HRQoL.
Does the Addition of Non-Approved Inclusion and Exclusion Criteria for rtPA Impact Treatment Rates? Findings in Australia, the UK, and the USA
Publisher: S. Karger AG
Date: 25-09-2018
DOI: 10.1159/000493020
Abstract: b i Background: /i /b Strict criteria for recombinant tissue plasminogen activator (rtPA) eligibility are stipulated on licences for use in ischaemic stroke however, practitioners may also add non-standard rtPA criteria. We examined eligibility criteria variation in 3 English-speaking countries including use of non-standard criteria, in relation to rtPA treatment rates. b i Methods: /i /b Surveys were mailed to 566 eligible hospitals in Australia (AUS), the UK, and the USA. Criteria were pre-classified as standard (approved indication and contraindications) or non-standard (approved warning or researcher “decoy”). Percentage for criterion selection was calculated/compared linear regression was used to assess the association between use of non-standard criteria and rtPA treatment rates, and to identify factors associated with addition of non-standard criteria. b i Results: /i /b Response rates were 74% AUS, 65% UK, and 68% USA mean rtPA treatment rates were 8.7% AUS, 12.7% UK, and 8.7% USA. Median percentage of non-standard inclusions was 33% (all 3 countries) and included National Institutes of Health Stroke Scale (NIHSS) scores & #x3e 4, computed tomography (CT) angiography documented occlusion, and favourable CT perfusion. Median percentage of non-standard exclusions was 25% AUS, 28% UK, and 60% USA, and included depressed consciousness, NIHSS & #x3e 25, and use of antihypertensive infusions. No AUS or UK sites selected 100% of standard exclusions. b i Conclusions: /i /b Non-standard criteria for rtPA eligibility were evident in all three countries and could, in part, explain comparably low use of rtPA. Differences in the use of standard criteria may signify practitioner intolerance for those derived from original efficacy studies that are no longer relevant.
A survey of acute care clinicians' views on factors influencing hand hygiene practice and actions to improve hand hygiene compliance
Publisher: Elsevier BV
Date: 05-2016
A mixed-methods feasibility study of a new digital health support package for people after stroke: the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (
Publisher: Springer Science and Business Media LLC
Date: 19-11-2022
DOI: 10.1186/S40814-022-01197-8
Abstract: Evidence for digital health programmes to support people living with stroke is growing. We assessed the feasibility of a protocol and procedures for the Re covery-focused C ommunity support to A void readmissions and improve P articipation after S troke (ReCAPS) trial. We conducted a mixed-method feasibility study. Participants with acute stroke were recruited from three hospitals (Melbourne, Australia). Eligibility: Adults with stroke discharged from hospital to home within 10 days, modified Rankin Score 0–4 and prior use of Short Message System (SMS)/email. While in hospital, recruited participants contributed to structured person-centred goal setting and completed baseline surveys including self-management skills and health-related quality of life. Participants were randomised 7–14 days after discharge via REDCap® (1:1 allocation). Following randomisation, the intervention group received a 12-week programme of personalised electronic support messages (average 66 messages sent by SMS or email) aligned with their goals. The control group received six electronic administrative messages. Feasibility outcomes included the following: number of patients screened and recruited, study retainment, completion of outcome measures and acceptability of the ReCAPS intervention and trial procedures (e.g. participant satisfaction survey, clinician interviews). Protocol fidelity outcomes included number of goals developed (and quality), electronic messages delivered, stop messages received and engagement with messages. We undertook inductive thematic analysis of interview/open-text survey data and descriptive analysis of closed survey questions. Between November 2018 and October 2019, 312 patients were screened 37/105 (35%) eligible patients provided consent (mean age 61 years 32% female) 33 were randomised (17 to intervention). Overall, 29 (88%) participants completed the12-week outcome assessments with 12 (41%) completed assessments in the allocated timeframe and 16 also completing the satisfaction survey (intervention=10). Overall, trial participants felt that the study was worthwhile and most would recommend it to others. Six clinicians participated in one of three focus group interviews while they reported that the trial and the process of goal setting were acceptable, they raised concerns regarding the additional time required to personalise goals. The study protocol and procedures were feasible with acceptable retention of participants. Consent and goal personalisation procedures should be centralised for the phase III trial to reduce the burden on hospital clinicians. Australian New Zealand Clinical Trials Registry, ACTRN12618001468213 (date 31/08/2018) Universal Trial Number: U1111-1206-7237
Doing the simple things well
Publisher: Elsevier BV
Date: 06-2012
A randomized control trial of intensive aphasia therapy after acute stroke: The Very Early Rehabilitation for SpEech (VERSE) study
Publisher: SAGE Publications
Date: 06-10-2020
Abstract: Effectiveness of early intensive aphasia rehabilitation after stroke is unknown. The Very Early Rehabilitation for SpEech trial (VERSE) aimed to determine whether intensive aphasia therapy, beginning within 14 days after stroke, improved communication recovery compared to usual care. Prospective, randomized, single-blinded trial conducted at 17 acute-care hospitals across Australia/New Zealand from 2014 to 2018. Participants with aphasia following acute stroke were randomized to receive usual care (direct usual care aphasia therapy), or one of two higher intensity regimens (20 sessions of either non-prescribed (usual care-plus or prescribed (VERSE) direct aphasia therapy). The primary outcome was improvement of communication on the Western Aphasia Battery-Revised Aphasia Quotient (AQ) at 12 weeks after stroke. Our pre-planned intention to treat analysis combined high intensity groups for the primary outcome. Among 13,654 acute stroke patients screened, 25% (3477) had aphasia, of whom 25% (866) were eligible and 246 randomized to usual care ( n = 81 33%), usual care-plus ( n = 82 33%) or VERSE ( n = 83 34%). At 12 weeks after stroke, the primary outcome was assessed in 217 participants (88%) 14 had died, 9 had withdrawn, and 6 were too unwell for assessment. Communication recovery was 50.3% (95% CI 45.7–54.8) in the high intensity group ( n = 147) and 52.1% (95% CI 46.1–58.1) in the usual care group ( n = 70 difference −1.8, 95% CI −8.7–5.0). There was no difference between groups in non-fatal or fatal adverse events ( p = 0.72). Early, intensive aphasia therapy did not improve communication recovery within 12 weeks post stroke compared to usual care.
Determinants of successful clinical networks: The conceptual framework and study protocol
Publisher: Springer Science and Business Media LLC
Date: 13-03-2012
Stroke unit Nurse Managers' views of individual and organizational factors liable to influence evidence-based practice: A survey
Publisher: Wiley
Date: 05-05-2016
DOI: 10.1111/IJN.12396
Abstract: The uptake of evidence into practice may be impeded or facilitated by in idual and organizational factors within the local context. This study investigated Nurse Managers of New South Wales, Australia, stroke units (n = 19) in their views on: leadership ability (measured by the Leadership Practices Inventory), organizational learning (measured by the Organizational Learning Survey), attitudes and beliefs towards evidence-based practice (EBP) and readiness for change. Overall Nurse Managers reported high-level leadership skills and a culture of learning. Nurse Managers' attitude towards EBP was positive, although nursing colleague's attitudes were perceived as less positive. Nurse Managers agreed that implementing evidence in practice places additional demands on staff and almost half (n = 9, 47%) reported that resources were not available for evidence implementation. The findings indicate that key persons responsible for evidence implementation are not allocated sufficient time to coordinate and implement guidelines into practice. The findings suggest that barriers to evidence uptake, including insufficient resources and time constraints, identified by Nurse Managers in this study are not likely to be unique to stroke units. Furthermore, Nurse Managers may be unable to address these organizational barriers (i.e. lack of resources) and thus provide all the components necessary to implement EBP.
A Stepped-Wedge Cluster-Randomized Trial to Improve Adherence to Evidence-Based Practices for Acute Stroke Management
Publisher: Elsevier BV
Date: 12-2022
DOI: 10.1016/J.JCJQ.2022.09.003
Abstract: There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data. STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change ch ions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and in idual indicators (secondary outcome). Patient survival and disability 90-180 days after stroke were also compared. Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals' action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05-1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50-2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05-1.53). Patient outcomes were unchanged. External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care.
Identifying Safety Practices Perceived as Low Value: An Exploratory Survey of Healthcare Staff in the United Kingdom and Australia
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 16-12-2022
The prevalence and impact of unprofessional behaviour among hospital workers
Publisher: AMPCo
Date: 10-11-2021
DOI: 10.5694/MJA2.50849
A phase III, multi-arm multi-stage covariate-adjusted response-adaptive randomized trial to determine optimal early mobility training after stroke (AVERT DOSE)
Publisher: SAGE Publications
Date: 06-01-2023
DOI: 10.1177/17474930221142207
Abstract: The evidence base for acute post-stroke rehabilitation is inadequate and global guideline recommendations vary. To define optimal early mobility intervention regimens for ischemic stroke patients of mild and moderate severity. Compared with a prespecified reference arm, the optimal dose regimen(s) will result in more participants experiencing little or no disability (mRS 0–2) at 3 months post-stroke (primary), fewer deaths at 3 months, fewer and less severe complications during the intervention period, faster recovery of unassisted walking, and better quality of life at 3 months (secondary). We also hypothesize that these regimens will be more cost-effective. For the primary outcome, recruitment of 1300 mild and 1400 moderate participants will yield 80% power to detect a 10% risk difference. Multi-arm multi-stage covariate-adjusted response-adaptive randomized trial of mobility training commenced within 48 h of stroke in mild (NIHSS 7) and moderate (NIHSS 8–16) stroke patient strata, with analysis of blinded outcomes at 3 (primary) and 6 months. Eligibility criteria are broad, while excluding those with severe premorbid disability (mRS 2) and hemorrhagic stroke. With four arms per stratum (reference arm retained throughout), only the single treatment arm demonstrating the highest proportion of favorable outcomes at the first stage will proceed to the second stage in each stratum, resulting in a final comparison with the reference arm. Three prognostic covariates of age, geographic region and reperfusion interventions, as well as previously observed mRS 0–2 responses inform the adaptive randomization procedure. Participants randomized receive prespecified mobility training regimens (functional task-specific), provided by physiotherapists/nurses until discharge or 14 days. Interventions replace usual mobility training. Fifty hospitals in seven countries (Australia, Malaysia, United Kingdom, Ireland, India, Brazil, Singapore) are expected to participate. Our novel adaptive trial design will evaluate a wider variety of mobility regimes than a traditional two-arm design. The data-driven adaptions during the trial will enable a more efficient evaluation to determine the optimal early mobility intervention for patients with mild and moderate ischemic stroke.
Oral care practices in stroke: findings from the UK and Australia
Publisher: Springer Science and Business Media LLC
Date: 15-09-2021
DOI: 10.1186/S12912-021-00642-Y
Abstract: To examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia. Poor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries. A cross-sectional survey. Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times. Completed questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents. Unacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing in idual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.
Letter to the Editor regarding: Critical Considerations for Stroke Management During COVID-19 Pandemic in response to Inglis et al., Heart Lung Circ. 2020;29(9): 1263–1267.
Publisher: Elsevier BV
Date: 12-2020
Development and validation of a survey to measure features of clinical networks.
Publisher: Springer Science and Business Media LLC
Date: 30-09-2016
Effect of the Coronavirus Disease 2019 Pandemic on the Quality of Stroke Care in Stroke Units and Alternative Wards: A National Comparative Analysis
Publisher: Korean Stroke Society
Date: 31-01-2022
Abstract: Background and Purpose Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients’ treatment setting (stroke unit or alternate ward).Methods We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients’ treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses.Results In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. Overall, 75% were treated in stroke units. Before the pandemic, treatment in a stroke unit was superior to alternate wards for the provision of all evidence-based therapies assessed. During the pandemic period, the proportion of patients receiving a swallow screen or assessment, being discharged to rehabilitation, and being prescribed secondary prevention medications decreased by 0.58% to 1.08% per week in patients treated in other ward settings relative to patients treated in stroke units. This change represented a 9% to 17% increase in the care gap between these treatment settings during the period of the pandemic that was evaluated (16 weeks).Conclusions During the first 6 months of the pandemic, widening care disparities between stroke units and alternate wards have occurred.
Identifying measures for evaluating new models of nursing care: A survey of NSW nurse practitioners
Publisher: Wiley
Date: 15-11-2007
Self-care research: Where are we now? Where are we going?
Publisher: Elsevier BV
Date: 04-2021
Triage, treatment and transfer of patients with stroke in emergency department trial (the T3 Trial): a cluster randomised trial protocol
Publisher: Springer Science and Business Media LLC
Date: 18-10-2016
International Uptake of a Proven Intervention to Reduce Death and Dependency in Acute Stroke: A Cross‐Sectional Survey Following the QASC Trial
Publisher: Wiley
Date: 14-08-2017
DOI: 10.1111/WVN.12253
Abstract: Uptake of proven interventions requires dedicated resources that may only result in local implementation, thus precluding international practice change. We explored international uptake through online dissemination of the fever, sugar, and swallow (FeSS) protocols from the Quality in Acute Stroke Care (QASC) trial, which showed decreased death and dependency by 15.7% 90-day poststroke. To identify: (a) the clinical discipline of healthcare professionals who downloaded the QASC resources (b) the purpose for downloading (c) successful implementation of any or all the FeSS protocols (d) barriers to implementation and (e) associations with self-reported successful implementation. A cross-sectional, online survey of those who downloaded the QASC resources between October 2011 and August 2013. Associations between implementation and participant characteristics were determined. One-hundred and fifty-nine people from 21 countries participated. Nurses were the largest group to download the resources (n = 54, 38%), with the primary purpose to inform clinical practice (n = 97, 64%). Less than half (n = 77, 48%) downloaded, and less than a quarter (n = 38, 24%) attempted to implement all three protocols. Of those personally involved in implementation (n = 50) half reported doing so successfully for one or more protocols (n = 27, 54%) with 10 (20%) reporting successful implementation of all three protocols. Only about half (n = 13, 48%) used the proven implementation strategy with about one-third (n = 10, 29%) confirming successful uptake via audit. Implementation barriers were potential increase in nursing workload (n = 28, 56%) and lack of medical staff engagement (n = 27, 53%). Higher autonomy was associated with greater likelihood of implementation of all three protocols (p = .038). The QASC intervention required use of all three protocols. However, less than half downloaded them all and implementation was not guided by the proven implementation strategy. While encouraging that these resources were being used to drive practice change, piecemeal implementation of a proven intervention is unlikely to improve patient outcomes.
Improving Quality of Life by Increasing Outings after Stroke: Study Protocol for the Out-and-About Trial
Publisher: SAGE Publications
Date: 24-12-2012
DOI: 10.1111/J.1747-4949.2012.00966.X
Abstract: Almost one-third of Australians need help to travel outdoors after a stroke. Ambulation training and escorted outings are recommended as best practice in Australian clinical guidelines for stroke. Yet fewer than 20% of people with stroke receive enough of these sessions in their local community to change outcomes. The Out-and-About trial aims to determine the efficacy and cost effectiveness of an implementation program to change team behavior and increase outings by people with stroke. A two-group cluster-randomized trial will be conducted using concealed allocation, blinded assessors, and intention-to-treat analysis. Twenty community teams and their stroke clients ( n = 300) will be recruited. Teams will be randomized to receive either the Out-and-About program or written guidelines only. The primary outcome is the proportion of people with stroke receiving multiple escorted outings during therapy sessions, measured at baseline and 13 months postintervention. Secondary outcomes include number of outings and distance traveled, measured using a self-report diary at baseline and six months postbaseline, and a global positioning system after six months. Cost effectiveness will measure quality-adjusted life years and health service use, measured at baseline and six months postbaseline. A potential outcome of this study will be evidence for a costed, transferable implementation program. If successful, the program will have international relevance and transferability. Another potential outcome will be validation of a novel and objective method of measuring outdoor travel (global positioning system) to supplement self-report methods.
Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the Theoretical Domains Framework (TDF): The T3Trial
Publisher: Springer Science and Business Media LLC
Date: 17-07-2017
Barriers and enablers to implementinghospital-acquired urinary tract infection prevention strategies: a qualitative study using the Theoretical Domains Framework
Publisher: Elsevier BV
Date: 07-2021
Compliance with Australian stroke guideline recommendations for outdoor mobility and transport training by post-inpatient rehabilitation services: An observational cohort study
Publisher: Springer Science and Business Media LLC
Date: 29-07-2015
Factors associated with arrival by ambulance for patients with stroke: a multicentre, national data linkage study
Publisher: Elsevier BV
Date: 09-2021
Validating the Alberta Context Tool in a multi-site Australian Emergency Department nurse population
Publisher: Public Library of Science (PLoS)
Date: 09-04-2019
Blood pressure variability and outcome in acute ischemic and hemorrhagic stroke: a post hoc analysis of the HeadPoST study
Publisher: Springer Science and Business Media LLC
Date: 20-03-2019
Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial
Publisher: AMPCo
Date: 11-2019
DOI: 10.5694/MJA2.50394
Abstract: To determine whether routine blood glucose assessment of patients admitted to hospital from emergency departments (EDs) results in higher rates of new diagnoses of diabetes and documentation of follow-up plans. Cluster randomised trial in 18 New South Wales public district and tertiary hospitals, 31 May 2011 - 31 December 2012 outcomes follow-up to 31 March 2016. Patients aged 18 years or more admitted to hospital from EDs. Routine blood glucose assessment at control and intervention hospitals automatic requests for glycated haemoglobin (HbA New diagnoses of diabetes and documented follow-up plans for patients with admission blood glucose levels of 14 mmol/L or more. Blood glucose was measured in 133 837 patients admitted to hospital from an ED. The numbers of new diabetes diagnoses with documented follow-up plans for patients with blood glucose levels of 14 mmol/L or more were similar in intervention (83/506 patients, 16%) and control hospitals (73/278, 26% adjusted odds ratio [aOR], 0.83 95% CI 0.42-1.7 P = 0.61), as were new diabetes diagnoses with or without plans (intervention, 157/506, 31% control, 86/278, 31% aOR, 1.51 95% CI, 0.83-2.80 P = 0.18). 30-day re-admission (31% v 22% aOR, 1.34 95% CI, 0.86-2.09 P = 0.21) and post-hospital mortality rates (24% v 22% aOR, 1.07 95% CI, 0.74-1.55 P = 0.72) were also similar for patients in intervention and control hospitals. Glucose and HbA Australian New Zealand Clinical Trials Registry, ACTRN12611001007921.
The Mobile Stroke Unit Nurse: An International Exploration of Their Scope of Practice, Education, and Training
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2022
DOI: 10.1097/JNN.0000000000000632
Abstract: BACKGROUND: Mobile stroke units (MSUs) are ambulance-based prehospital stroke care services. Through immediate roadside assessment and onboard brain imaging, MSUs provide faster stroke management with improved patient outcomes. Mobile stroke units have enabled the development of expanded scope of practice for stroke nurses however, there is limited published evidence about these evolving prehospital acute nursing roles. AIMS: The aim of this study was to explore the expanded scope of practice of nurses working on MSUs by identifying MSUs with onboard nurses describing the roles and responsibilities, training, and experience of MSU nurses, through a search of the literature and describing 2 international MSU services incorporating nurses from Memphis, Tennessee, and Melbourne, Australia. METHODS: We searched PubMed, CINAHL, and the Joanna Briggs Institute Evidence-Based Practice database using the terms “mobile stroke unit” and “nurse.” Existing MSUs were identified through the PRE-hospital Stroke Treatment Organization to determine models that involved nurses. We describe 2 MSUs involving nurses: one in Memphis and one in Melbourne, led by 2 of our authors. RESULTS: Ninety articles were found describing 15 MSUs however, staffing details were lacking, and it is unknown how many employ nurses. Nine articles described the role of the nurse, but role specifics, training, and expertise were largely undocumented. The MSU in Memphis, the only unit to be staffed exclusively by onboard nurse practitioners, is supported by a neurologist who consults via telephone. The Melbourne MSU plans to trial a nurse-led telemedicine model in the near future. CONCLUSION: We lack information on how many MSUs employ nurses, and the nurses' scope of practice, training, and expertise. Expert stroke nurse practitioners can safely perform many of the tasks undertaken by the onboard neurologist, making a nurse-led telemedicine model an effective and potentially cost-effective model that should be considered for all MSUs.
Comments on Selected Recent Dysphagia Literature
Publisher: Springer Science and Business Media LLC
Date: 25-02-2012
Mapping workforce configuration and operational models in australian emergency departments : A national survey
Publisher: CSIRO Publishing
Date: 2017
DOI: 10.1071/AH16231
Abstract: Objective Hospital emergency departments (ED) in Australia and internationally have been experiencing increased demand, resulting in reduced hospital quality, impaired access and adverse health outcomes. Effective evaluation of new ED service models and their effect on outcomes is reliant on baseline measures of the staffing configuration and organisational characteristics of the EDs being studied. The aim of the present study was to comprehensively measure these variables in Australian EDs. Methods Australian hospital EDs with 24-h medical and nursing cover were identified and invited to participate in the study. Telephone interviews were conducted with nursing or medical department managers to collect data related to hospital characteristics, ED workforce and training and ED service and operational models. Results Surveys were completed in 87% of the population s le (n = 135). Metropolitan EDs were significantly more likely to retain higher full-time equivalents (FTEs) in several medical (staff specialist, registrar, resident and intern) and nursing (nurse practitioner (NP), nurse educator, nurse unit manager and registered nurse) positions. NPs were employed by 52% of Australian EDs overall, but this ranged from 40% to 75% depending on jurisdiction. The most commonly used operational models were FastTrack teams (72% of EDs), short-stay/observational unit (59%) and patient liaison models for aged care (84%) and mental health (61%). EDs that employed NPs were significantly more likely to use FastTrack (P = 0.002). Allied health services most frequently available within these EDs were radiology (60%), social work (69%), physiotherapy (70%) and pharmacy (65%). Conclusions The present study has established a baseline measure of the staffing configuration and organisational characteristics of Australian EDs. What is known about the topic? EDs are overcrowded due, in part, to the combined effect of increased service demand and access block. Innovative service and workforce models have been implemented by health departments aiming to improve service and performance. National uptake of these service and workforce innovations is unknown. What does this paper add? The present study is the most comprehensive to date profiling Australian EDs covering hospital characteristics, workforce configuration, operational models and NP service patterns and practice. What are the implications for practitioners? Information from the present study will assist health service planners to evaluate workforce and service reform models, and to monitor trends in emergency service development.
Increasing delivery of an outdoor journey intervention to people with stroke: A feasibility study involving five community rehabilitation teams
Publisher: Springer Science and Business Media LLC
Date: 29-07-2010
Prescription of antihypertensive medication at discharge influences survival following stroke
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 31-01-2018
DOI: 10.1212/WNL.0000000000005023
Abstract: To investigate the risk of death from cardiovascular disease between patients who were and were not prescribed antihypertensive medication following stroke or TIA. This was a large cohort study using routinely collected prospective data from the Australian Stroke Clinical Registry. Patients registered between 2009 and 2013 who were discharged to the community or rehabilitation were included. Cases were linked to the National Death Index to determine the date and cause of death. Propensity score matching with stratification was utilized to compare between similar subgroups of patients. Multivariable competing risks regression, with noncardiovascular death as a competing risk, was conducted to investigate the association between the prescription of antihypertensive medications and cardiovascular death at 180 days after admission. Among 12,198 patients from 40 hospitals, 70% were prescribed antihypertensive medications. Patients who were older, were treated in a stroke unit, and had better socioeconomic position were more often discharged from hospital with an antihypertensive medication. Including only patients within propensity score quintiles with acceptable levels of balance in covariates between groups (n = 8,786), prescription of antihypertensive medications was associated with a 23% greater reduction in the subhazard of cardiovascular death compared to those who were not prescribed these agents (subhazard ratio 0.77 95% confidence interval 0.61 to 0.97). People who are prescribed antihypertensive medications at discharge from hospital after a stroke or TIA demonstrate better cardiovascular and all-cause survival outcomes than those not prescribed these agents.
An investigation of family carers' needs following stroke survivors' discharge from acute hospital care in Australia
Publisher: Informa UK Limited
Date: 2011
DOI: 10.3109/09638288.2011.553702
Abstract: To expand understanding of informal stroke care-giving, validated tools previously used in Hong Kong and in the U.K. were used with Australian stroke carers to assess their stroke-related knowledge, perceived needs, satisfaction with services received and sense of burden after stroke patients' discharge home from acute hospital care. Record audit and telephone interviews with two cohorts of 32 carers recruited in Sydney and Brisbane 1 and 3 months post-hospital discharge, using validated scales and open questions in May-July 2006. Female carers, those with prior care-giving responsibility, and those interviewed at three compared to one month post-discharge reported greatest needs and burden from the care-giving role needs alone significantly predicted burden. Getting information and being prepared for life after discharge were central concerns. Some felt this was accomplished, but inadequate information giving and communication mismatches were apparent. Service providers need to develop partnership working with stroke families and provide a network of services and inputs that cut across conventional boundaries between health and social care, public, private and voluntary organisations, with care plans that deliver what they delineate. Stroke care-givers have common issues across countries and healthcare systems collaborative research-based service development is advocated.
Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Hear
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2021
DOI: 10.1161/STR.0000000000000357
Abstract: In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.
Implementing root cause analysis in an area health service: views of the participants
Publisher: CSIRO Publishing
Date: 2005
DOI: 10.1071/AH050422
Abstract: Purpose: This study identifies the attitudes of participants in the root cause analysis (RCA) process and barriers to it?s implementation within one New South Wales area health service. Method: Employees and consumer representatives of the former South Western Sydney Area Health Service who participated in an RCA as either a team member or a team leader between December 2002 and October 2003 completed a self-administered survey. Results: Thirty seven of 39 eligible participants completed the survey (response rate 95%). The respondents identified formulation of causal statements, ensuring the causal statements met the ?rules of causality? outlined by New South Wales Health, and arranging times for interviews as most difficult. Team leader respondents (n = 7) ranked keeping the team focused, organising the first meeting within 7 days of the incident, and completing the RCA in three 2-hour meetings as barriers to the process. Conclusions: Training was valued by participants, however greater emphasis on the development of causal statements could be beneficial. Team leaders expressed difficulty in keeping the team focused and meeting the stipulated RCA timeframes, suggesting that additional support for RCA participants may be warranted.
A randomized controlled trial of very early rehabilitation in speech after stroke
Publisher: SAGE Publications
Date: 05-05-2016
Abstract: The efficacy of rehabilitation therapy for aphasia caused by stroke is uncertain. The Very Early Rehabilitation of Speech (VERSE) trial aims to determine if intensive prescribed aphasia therapy (VERSE) is more effective and cost saving than non-prescribed, intensive (usual care-plus) and non-intensive usual care (UC) therapy when started within 15 days of stroke onset and continued daily over four weeks. We hypothesize that aphasia therapy when started very early after stroke and delivered daily could enhance recovery of communication compared with UC. A total of 246 participants (82 per arm) will provide 80% power to detect a 4.4% improvement on aphasia quotient between VERSE and UC plus at a significance level of α = 0.05. Acute-care hospitals and accompanying rehabilitation services throughout Australia, 2014–2017. Three-arm, prospective, randomized, parallel group, open-label, blinded endpoint assessment (PROBE) trial. Acute stroke in previous 14 days and aphasia diagnosed by aphasia quotient (AQ) of the Western Aphasia Battery (WAB). Computer-generated blocked randomization procedure stratified by aphasia severity according to Western Aphasia Battery, to one of three arms. All participants receive UC—usual ward-based aphasia therapy. Arm 1: UC—no additional therapy Arm 2: UC-plus usual ward-based therapy Arm 3: VERSE therapy—a prescribed and structured aphasia therapy program. Arms 2 and 3 receive a total of 20 additional sessions (45–60 min, provided daily) of aphasia therapy. The additional intervention must be provided before day 50 post stroke. The aphasia quotient of Western Aphasia Battery at 12 weeks post stroke. Secondary outcomes include discourse measures, the Stroke and Aphasia Quality of Life Scale-39 and the Aphasia Depression Rating Scale at 12 and 26 weeks. Incremental cost-effectiveness ratios at 26 weeks will be reported. This trial is designed to test whether the intensive and prescribed VERSE intervention is effective in promoting maximum recovery and preventing costly health complications in a vulnerable population of survivors of stroke. It will also provide novel, prospective, aphasia specific cost-effectiveness data to guide future policy development for this population.
Improving stroke outcomes in NSW: A study of GP perspectives
Publisher: CSIRO Publishing
Date: 2004
DOI: 10.1071/PY04022
Abstract: Stroke is the third leading cause of death in western society, imposing a heavy economic burden on communities worldwide. This study investigated NSW general practitioners? (GPs) views on stroke services. A postal survey was conducted of 296 randomly-selected GPs in NSW (60% response fraction). The main outcome measures were: satisfaction with access to specialists and services GPs? views on the usefulness of quality indicators when referring patients for carotid endarterectomy GPs? views about services to enhance stroke outcomes. GPs were satisfied with their access to private vascular laboratories (n=199, 67.2%), casualty/ emergency rooms for stroke patients (n=156, 52.7%), and medical beds for acute stroke in their local hospital (n=157, 53.0%). However, rural and remote GPs were significantly less likely than urban GPs to be satisfied with access to neurologists (?2=12.44, P .001), vascular surgeons (?2=8.57, P=0.003), public vascular laboratories (?2=9.46, P=0.002), private vascular laboratories (?2=5.19, P=0.02), and multidisciplinary stroke services (?2=6.09, P=0.014). GPs rated discharge planning most highly as a strategy to improve stroke outcomes (n=260, 87.8%). Our results invite particular attention to rural access to diagnostic, preventive and treatment stroke services. Discharge planning to ensure seamless transfer of care from hospital to general practice is also important.
Correction to: Hospital organizational context and delivery of evidence-based stroke care: a cross-sectional study
Publisher: Springer Science and Business Media LLC
Date: 08-02-2019
Multi-morbidity, frailty and self-care: important considerations in treatment with anticoagulation drugs. Outcomes of the AFASTER study.
Publisher: Oxford University Press (OUP)
Date: 07-07-2017
Abstract: Chronic heart failure (CHF) and atrial fibrillation (AF) are complex cardiogeriatric syndromes mediated by physical, psychological and social factors. Thromboprophylaxis is an important part of avoiding adverse events in these syndromes, particularly stroke. This study sought to describe the clinical characteristics of a cohort of patients admitted to hospital with CHF and concomitant AF and to document the rate and type of thromboprophylaxis. We examined the practice patterns of the prescription of treatment and determined the predictors of adverse events. Prospective consecutive participants with CHF and concomitant AF were enrolled during the period April to October 2013. Outcomes were assessed at 12 months, including all-cause readmission to hospital and mortality, stroke or transient ischaemic attack, and bleeding. All-cause readmission to hospital was frequent (68%) and the 12-month all-cause mortality was high (29%). The prescription of anticoagulant drugs at discharge was statistically significantly associated with a lower mortality at 12 months (23 vs. 40% p=0.037 hazards ratio 0.506 95% confidence interval 0.267-0.956), but was not associated with lower rates of readmission to hospital among patients with CHF and AF. Sixty-six per cent of participants were prescribed anticoagulant drugs on discharge from hospital. Self-reported self-care behaviour and 'not for cardiopulmonary resuscitation' were associated with not receiving anticoagulant drugs at discharge. Although statistical significance was not achieved, those patients who were assessed as frail or having greater comorbidity were less likely to receive anticoagulant drugs at discharge. This study highlights multi-morbidity, frailty and self-care to be important considerations in thromboprophylaxis. Shared decision-making with patients and caregivers offers the potential to improve treatment knowledge, adherence and outcomes in this group of patients with complex care needs.
Changing clinician behaviour in stroke care
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2006
Assessment and communication excellence for safe patient outcomes (ACCELERATE)
Publisher: Elsevier BV
Date: 10-2022
Implementing a protocol for a research impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery
Publisher: Springer Science and Business Media LLC
Date: 08-2018
Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1016/J.AUCC.2021.04.003
Abstract: Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. S le medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-s le z-test. Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min there was no difference in time to activation between business hours and after-hours time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]). High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.
Health Service Management Study for Stroke: A Randomized Controlled Trial to Evaluate Two Models of Stroke Care
Publisher: SAGE Publications
Date: 03-01-2014
DOI: 10.1111/IJS.12240
Abstract: The most effective and efficient model for providing organized stroke care remains uncertain. This study aimed to compare the effect of two models in a randomized controlled trial. Patients with acute stroke were randomized on day one of admission to combined, co-located acute/rehabilitation stroke care or traditionally separated acute/rehabilitation stroke care. Outcomes measured at baseline and 90 days post-discharge included functional independence measure, length of hospital stay, and functional independence measure efficiency (change in functional independence measure score ÷ total length of hospital stay). Among 41 patients randomized, 20 were allocated co-located acute/rehabilitation stroke care and 21 traditionally separated acute/rehabilitation stroke care. Baseline measurements showed no significant difference. There was no significant difference in functional independence measure scores between the two groups at discharge and again at 90 days postdischarge (co-located acute/rehabilitation stroke care: 103·6 ± 22·2 vs. traditionally separated acute/rehabilitation stroke care: 99·5 ± 27·7 P = 0·77 at discharge co-located acute/rehabilitation stroke care: 109·5 ± 21·7 vs. traditionally separated acute/rehabilitation stroke care: 104·4 ± 27·9 P= 0·8875 at 90 days post-discharge). Total length of hospital stay was 5·28 days less in co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (24·15 ± 3·18 vs. 29·42 ± 4·5, P = 0·35). There was significant improvement in functional independence measure efficiency score among participants assigned to co-located acute/rehabilitation stroke care compared with traditionally separated acute/rehabilitation stroke care (co-located acute/rehabilitation stroke care: median 1·60, interquartile range: 0·87–2·81 traditionally separated acute/rehabilitation stroke care: median 0·82, interquartile range: 0·27–1·57, P = 0·0393). Linear regression analysis revealed a high inverse correlation ( R 2 = 0·89) between functional independence measure efficiency and time spent in the acute stroke unit. This proof-of-concept study has shown that co-located acute/rehabilitation stroke care was just as effective as traditionally separated acute/rehabilitation stroke care as reflected in functional independence measure scores, but significantly more efficient as shown in greater functional independence measure efficiency. Co-located acute/rehabilitation stroke care has potential for significantly improved hospital bed utilization with no patient disadvantage.
Atrial fibrillation and thromboprophylaxis in heart failure: the need for patient-centered approaches to address adherence
Publisher: Informa UK Limited
Date: 2013
DOI: 10.2147/VHRM.S39571
Oxygen desaturation and adverse outcomes in acute stroke: Secondary analysis of the HeadPoST study
Publisher: Elsevier BV
Date: 08-2021
DOI: 10.1016/J.CLINEURO.2021.106796
Abstract: Uncertainty exists over the prognostic significance of low arterial oxygen saturation (SaO Post-hoc analyzes of HeadPoST, a pragmatic cluster-crossover randomized trial of lying flat versus sitting up head positioning in 11,093 patients (age ≥18 years) with acute stroke at 114 hospitals in 9 countries during 2015-2016. Associations of the lowest recorded SaO There was an inverse J-shaped association between SaO Any change in SaO HeadPoST is registered at ClinicalTrials.gov (NCT02162017).
An Outcomes Approach to Stroke Care: The Importance of Teamwork and Evidence-Based Nursing Care
Publisher: SAGE Publications
Date: 09-03-2012
DOI: 10.1111/J.1747-4949.2012.00774.X
Abstract: The Quality in Acute Stroke Care (QASC) was a cluster randomised control trial (CRCT) which evaluated the effectiveness of evidence-based clinical treatment protocols for the management of fever, hyperglycaemia and swallowing, in conjunction with multidisciplinary team building workshops, and a standardised interactive staff education program (collectively known as the Fever, Sugar, Swallowing (FeSS) intervention) to improve patient outcomes 90-days. We found that patients cared for in stroke units who received our intervention were 15.7% more likely to be alive and independent 90 days following their stroke. They also had significantly: fewer episodes of fever, lower mean temperatures, lower mean blood glucose levels, and better screening for swallowing difficulties.
Impact of Evidence‐Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-07-2019
Abstract: The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence‐based processes of care for acute ischemic stroke ( AIS ) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke. Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients acute stroke unit care antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation dysphagia assessment and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0–2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect‐free” care, was associated with improved outcome (odds ratio, 1.40 95% CI, 1.18–1.65) and better survival (odds ratio, 2.23 95% CI , 1.62–3.09). Defect‐free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0–1) (odds ratio, 1.22 95% CI , 1.04–1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and in idual rates. Use of evidence‐based care is associated with improved clinical outcome in AIS . Strategies are required to address regional variation in the use of proven AIS treatments. URL : www.clinicaltrials.gov . Unique Identifier: NCT 02162017.
Understanding the Role of External Facilitation to Drive Quality Improvement for Stroke Care in Hospitals
Publisher: MDPI AG
Date: 25-08-2021
DOI: 10.3390/HEALTHCARE9091095
Abstract: The use of external facilitation within the context of multicomponent quality improvement interventions (mQI) is growing. We aimed to evaluate the influence of external facilitation for improving the quality of acute stroke care. Clinicians from hospitals participating in mQI (Queensland, Australia) as part of the Stroke123 study were supported by external facilitators in a single, on-site workshop to review hospital performance against eight clinical processes of care (PoCs) collected in the Australian Stroke Clinical Registry (AuSCR) and develop an action plan. Remote support (i.e., telephone/email) after the workshop was provided. As part of a process evaluation for Stroke123, we recorded the number and mode of contacts between clinicians and facilitators type of support provided and frequency of self-directed, hospital-level stroke registry data reviews. Analysis: We measured the association between amount/type of external facilitation, (i) development of action plans, and (ii) adherence to PoCs before and after the intervention using AuSCR data from 2010 to 2015. In total, 14/19 hospitals developed an action plan. There was no significant difference in amount or type of external facilitator support provided between hospitals that did, and did not, develop an action plan. There was no relationship between the amount of external facilitation and change in adherence to PoCs. Most (95%) hospitals accessed stroke registry performance data. In the Stroke123 study, the amount or type of external facilitation did not influence action plan development, and the amount of support did not influence the changes achieved in adherence to PoCs. Remote support may not add value for mQI.
What people say about travelling outdoors after their stroke: A qualitative study
Publisher: Wiley
Date: 03-06-2011
DOI: 10.1111/J.1440-1630.2011.00935.X
Abstract: Reduced walking ability and loss of confidence are common after stroke. Many people cannot drive or use public transport, which can restrict participation. This qualitative study aimed to explore the experiences and attitudes of people following stroke to travelling outdoors early after hospital discharge. Two semi-structured interviews were conducted with 19 people post-stroke, all of whom were receiving rehabilitation to increase outdoor travel. Mean age was 68.6 years (SD 11.7years). Eight significant others also participated. Interviews were conducted at home (median 21 days post-discharge), with a second interview three months later. Questions focussed on common destinations, modes of travel including driving when relevant and factors that influenced outdoor travel. Qualitative data were analysed using constant comparative (grounded theory) methods, resulting in themes and categories. People with stroke were categorised as either a hesitant or confident explorer, in relation to walking, catching public transport and driving. Factors influencing outdoor travel included their emotional disposition, having meaningful destinations, expectations of recovery and the sphere of influence, including family and therapists. These factors could have an enabling or restricting effect. A pre-stroke walking habit also positively contributed to outdoor travel. Gate-keeping by therapists, general practitioners and family members seemed to adversely affect travel. This emerging theory offers insights into the experiences and attitudes to outdoor travel of people who were ambulant and participating in community rehabilitation following a stroke. Future research could explore the experiences of people with more severe mobility, cognitive and communication problems.
Australian Clinical Guidelines for Acute Stroke Management 2007
Publisher: SAGE Publications
Date: 05-2008
Death, dependency and health status 90 days following hospital admission for acute stroke in NSW
Publisher: Wiley
Date: 10-2011
DOI: 10.1111/J.1445-5994.2010.02330.X
Abstract: Stroke is an Australian health priority area causing considerable levels of disability. We report 90-day outcomes for a cohort of acute stroke patients in New South Wales (NSW), Australia prior to randomization to a large cluster randomized controlled trial (CRCT), the Quality in Acute Stroke Care (QASC) trial. This paper describes prospectively collected, 90-day outcome data for a cohort of NSW stroke patients, providing pre-intervention data for the QASC trial. A consecutive s le of patients from acute stroke units in NSW was recruited. We measured patient death, disability (modified Rankin Score (mRS)), dependency (Barthel Index (BI)) and Health Status (Medical Outcomes Short-Form Health Survey (SF-36)) 90 days post-hospital admission. We also collected self-reported healthcare utilization and patient satisfaction with health professionals' advice and management to reduce risk of subsequent stroke. Ninety-day outcome data were obtained for 687 patients, of which, 335 (49%) had an mRS ≥2 44 patients (6.4%) had died. For the 643 surviving patients, the mean BI was 87.2 (SD 21.9) and the mean scores for SF-36 Physical Component Summary score and Mental Component Summary score were 46.2 (SD 10.1) and 46.3 (SD 12.6) respectively. In this pre-intervention cohort of selected acute stroke inpatients, stroke severity was mild to moderate and subsequent clinical outcomes were favourable in the majority. The findings from this study provide a comprehensive description of 90-day health outcomes of patients who have experienced a mild-moderate stroke managed in stroke care units across metropolitan NSW and provide valuable data to inform the subsequent cluster trial.
Related Organisations
Nursing Research Institute, St Vincent's Health Australia (Syd) And Australian Catholic University
Location: Australia
Australian Catholic University - North Sydney Campus
Location: Australia
Related Funding Activities
Linkage Projects - Grant ID: LP110200389
Start Date: 03-2012
End Date: 12-2015
Amount: $507,178.00
Funder: Australian Research Council
View Funded ActivityLinkage Projects - Grant ID: LP0668886
Start Date: 02-2007
End Date: 12-2009
Amount: $575,000.00
Funder: Australian Research Council
View Funded ActivityLinkage Projects - Grant ID: LP100100300
Start Date: 2010
End Date: 12-2015
Amount: $292,000.00
Funder: Australian Research Council
View Funded ActivitySpecial Research Initiatives - Grant ID: SR0354508
Start Date: 02-2004
End Date: 03-2005
Amount: $10,000.00
Funder: Australian Research Council
View Funded Activity