How is hydration assessed and managed in acute stroke? A qualitative study of healthcare staff's knowledge, attitudes and experiences.

AIMS AND OBJECTIVES: To explore healthcare staff's experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. BACKGROUND: Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. DESIGN: A descriptive qualitative study reported following the COREQ guidelines. METHODS: Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multidisciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. RESULTS: The themes were mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients' comorbidities and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. CONCLUSION: Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood and addressed. RELEVANCE TO CLINICAL PRACTICE: Multidisciplinary teamwork is important in hydration care after stroke, but clarity is required about the specific contributions of each team member. Without this, hydration care becomes 'everybody's and nobody's job'.

The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review.

BACKGROUND: To successfully reduce the negative impacts of stroke, high-quality health and care practices are needed across the entire stroke care pathway. These practices are not always shared across organisations. Quality improvement collaboratives (QICs) offer a unique opportunity for key stakeholders from different organisations to share, learn and 'take home' best practice examples, to support local improvement efforts. This systematic review assessed the effectiveness of QICs in improving stroke care and explored the facilitators and barriers to implementing this approach. METHODS: Five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, and Cochrane Library) were searched up to June 2020, and reference lists of included studies and relevant reviews were screened. Studies conducted in an adult stroke care setting, which involved multi-professional stroke teams participating in a QIC, were included. Data was extracted by one reviewer and checked by a second. For overall effectiveness, a vote-counting method was used. Data regarding facilitators and barriers was extracted and mapped to the Consolidated Framework for Implementation Research (CFIR). RESULTS: Twenty papers describing twelve QICs used in stroke care were included. QICs varied in their setting, part of the stroke care pathway, and their improvement focus. QIC participation was associated with improvements in clinical processes, but improvements in patient and other outcomes were limited. Key facilitators were inter- and intra-organisational networking, feedback mechanisms, leadership engagement, and access to best practice examples. Key barriers were structural changes during the QIC's active period, lack of organisational support or prioritisation of QIC activities, and insufficient time and resources to participate in QIC activities. Patient and carer involvement, and health inequalities, were rarely considered. CONCLUSIONS: QICs are associated with improving clinical processes in stroke care; however, their short-term nature means uncertainty remains as to whether they benefit patient outcomes. Evidence around using a QIC to achieve system-level change in stroke is equivocal. QIC implementation can be influenced by individual and organisational level factors, and future efforts to improve stroke care using a QIC should be informed by the facilitators and barriers identified. Future research is needed to explore the sustainability of improvements when QIC support is withdrawn. TRIAL REGISTRATION: Protocol registered on PROSPERO ( CRD42020193966 ).

Predictors of recognition of out of hospital cardiac arrest by emergency medical services call handlers in England: a mixed methods diagnostic accuracy study.

BACKGROUND: The aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene. METHODS: Retrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA. RESULTS: A total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term 'Unconscious' plus one or more of symptoms 'Not breathing/Ineffective breathing/Noisy breathing' occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. 'Not breathing' was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms 'Breathing' (OR 0.29), 'Reduced or fluctuating level of consciousness' (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic 'Female patient' (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05). CONCLUSIONS: There is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers' OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity.

Etiologic Workup in Cases of Cryptogenic Stroke: A Systematic Review of International Clinical Practice Guidelines.

Background and Purpose- Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke. Methods- We identified clinical practice guidelines/consensus statements through searches of 4 electronic databases and hand-searching of websites/reference lists. Two reviewers independently assessed reports for eligibility. We extracted data on report characteristics and recommendations relating to etiologic workup in acute ischemic stroke and in cases of cryptogenic stroke. Quality was assessed using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation). Recommendations were synthesized according to a published algorithm for diagnostic evaluation in cryptogenic stroke. Results- We retrieved 16 clinical practice guidelines and 7 consensus statements addressing acute stroke management (n=12), atrial fibrillation (n=5), imaging (n=5), and secondary prevention (n=1). Five reports were of overall high quality. For all patients, guidelines recommended routine brain imaging, noninvasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Additionally, ECG monitoring (>24 hours) was recommended for patients with suspected embolic stroke and echocardiography for patients with suspected cardiac source. Three reports recommended investigations for rarer causes of stroke. None of the reports provided guidance on the extent of investigation needed before classifying a stroke as cryptogenic. Conclusions- While consensus exists surrounding standard etiologic workup, there is little agreement on more advanced investigations for rarer causes of acute ischemic stroke. This gap in guidance, and in the underpinning evidence, demonstrates missed opportunities to better understand and protect against ongoing stroke risk. Registration- URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019127822.

Medication-taking after stroke: a qualitative meta-synthesis of the perspectives of stroke survivors, informal carers and health professionals.

BACKGROUND: Lifelong secondary prevention medication is recommended after stroke or transient ischaemic attack. However, poor medication adherence and persistence, which lead to suboptimal health outcomes, are common, but the reasons for this are not well understood, mainly because there have been few studies reporting adherence barriers in stroke survivors. OBJECTIVE: The aim of this review was to undertake a meta-synthesis of qualitative studies of medication-taking after stroke. Outcomes of interest were: lived experiences, views and beliefs, and strategies and solutions used by community-dwelling stroke and transient ischaemic attack survivors, informal carers and health care professionals in relation to medication-taking. METHOD: The review protocol was registered on PROSPERO (CRD42018086792). A search of online bibliographic databases was performed using key search terms of stroke, persistence, adherence and medication for years 1980-2018. Citation tracking was also carried out. Studies using qualitative or mixed methods were included. Systematic data extraction and synthesis were conducted using a meta-ethnographic approach. RESULTS: Twelve studies were eligible for inclusion, with a total of 412 participants, two-thirds of whom were stroke survivors, ranging from 1 month to over 20 years post-stroke. Third-order themes identified were 'Medicines Work'-Information Work; Health Care Work; Carer Work; Emotional Work; Practical Work and an underpinning theme of Trust. However, many studies had significant methodological weaknesses. CONCLUSIONS: This synthesis suggests that the burden of 'medicines work' after stroke is substantial and multifaceted. Its successful undertaking depends on mutual trust between stroke survivors, carers and health care professionals and trust in the benefits of medicines themselves.

Healthcare practitioners' views and experiences of barriers and facilitators to weight management interventions for adults with intellectual disabilities.

BACKGROUND: Obesity is common in adults with intellectual disabilities, yet little is known about how weight management interventions are provided for this population. METHODS: Semi-structured interviews were held with 14 healthcare practitioners involved in weight management interventions in an English county. A study topic guide was developed to elicit practitioners' views and experiences of barriers and facilitators to weight management for adults with intellectual disabilities. Responses were analysed using thematic analysis. RESULTS: Several barriers are involved in weight management for people with intellectual disabilities including communication challenges, general practitioners' lack of knowledge and awareness of weight management services, inconsistencies in caring support, resource constraints, wider external circumstances surrounding the individuals and motivational issues. Facilitators include reasonable adjustments to existing weight management services. However, there is a need for specialist weight management provision for people with intellectual disabilities. CONCLUSIONS: This study provides suggestions for future research, policy and practice consideration.

The impact of education and training interventions for nurses and other health care staff involved in the delivery of stroke care: An integrative review.

OBJECTIVES: The aim of this review was to explore the impact of stroke education and training of nurses and other health care staff involved in the delivery of stroke care. DESIGN: We performed an integrative review, following PRISMA guidance where possible. DATA SOURCES: We searched MEDLINE, ERIC, PubMed, AMED, EMBASE, HMIC, CINAHL, Google Scholar, IBSS, Web of Knowledge, and the British Nursing Index from 1980 to 2016. REVIEW METHODS: Any intervention studies were included if they focused on the education or training of nurses and other health care staff in relation to stroke care. Articles that appeared to meet the inclusion criteria were read in full. Data were extracted from the articles, and the study quality assessed by two researchers. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance. RESULTS: Our initial search identified 2850 studies of which 21 met the inclusion criteria. Six studies were randomised controlled trials, and one was an interrupted time series. Fourteen studies were quasi-experimental: eight were pretest-posttest; five were non-equivalent groups; one study had a single assessment. Thirteen studies used quality of care outcomes and eight used a patient outcome measure. None of the studies was identified as having a low risk of bias. Only nine studies used a multi-disciplinary approach to education and training and nurses were often taught alone. Interactive education and training delivered to multi-disciplinary stroke teams, and the use of protocols or guidelines tended to be associated with a positive impact on patient and quality of care outcomes. CONCLUSIONS: Practice educators should consider the delivery of interactive education and training delivered to multi-disciplinary groups, and the use of protocols or guidelines, which tend to be associated with a positive impact on both patient and quality of care outcomes. Future research should incorporate a robust design.

An integrative review of multicomponent weight management interventions for adults with intellectual disabilities.

BACKGROUND: Obesity is more prevalent in people with intellectual disabilities and increases the risk of developing serious medical conditions. UK guidance recommends multicomponent weight management interventions (MCIs), tailored for different population groups. METHODS: An integrative review utilizing systematic review methodology was conducted to identify the types of MCIs delivered to adults with intellectual disabilities. FINDINGS: Five studies were identified. All of the studies' MCIs were tailored for adults with intellectual disabilities. Tailoring included measures such as simplified communication tools, individualized sessions, and the presence of carers where appropriate. CONCLUSIONS: Emerging evidence suggests ways in which MCIs can be tailored for adults with intellectual disabilities but, given the few studies identified, it is not possible to recommend how they can be routinely tailored. Further studies are justified for adults with intellectual disabilities at risk of obesity-related conditions.

Integrating acute stroke telemedicine consultations into specialists' usual practice: a qualitative analysis comparing the experience of Australia and the United Kingdom.

BACKGROUND: Stroke telemedicine can reduce healthcare inequities by increasing access to specialists. Successful telemedicine networks require specialists adapting clinical practice to provide remote consultations. Variation in experiences of specialists between different countries is unknown. To support future implementation, we compared perceptions of Australian and United Kingdom specialists providing remote acute stroke consultations. METHODS: Specialist participants were identified using purposive sampling from two new services: Australia's Victorian Stroke Telemedicine Program (n = 6; 2010-13) and the United Kingdom's Cumbria and Lancashire telestroke network (n = 5; 2010-2012). Semi-structured interviews were conducted pre- and post-implementation, recorded and transcribed verbatim. Deductive thematic and content analysis (NVivo) was undertaken by two independent coders using Normalisation Process Theory to explore integration of telemedicine into practice. Agreement between coders was M = 91%, SD = 9 and weighted average κ = 0.70. RESULTS: Cross-cultural similarities and differences were found. In both countries, specialists described old and new consulting practices, the purpose and value of telemedicine systems, and concerns regarding confidence in the assessment and diagnostic skills of unknown colleagues requesting telemedicine support. Australian specialists discussed how remote consultations impacted on usual roles and suggested future improvements, while United Kingdom specialists discussed system governance, policy and procedures. CONCLUSION: Australian and United Kingdom specialists reported telemedicine required changes in work practice and development of new skills. Both groups described potential for improvements in stroke telemedicine systems with Australian specialists more focused on role change and the United Kingdom on system governance issues. Future research should examine if cross-cultural variation reflects different models of care and extends to other networks.

"Can you send an ambulance please?": a comparison of callers' requests for emergency medical dispatch in non-stroke and stroke calls.

BACKGROUND: Identifying 'true stroke' from an emergency medical services (EMS) call is challenging, with over 50% of strokes being misclassified. In a previous study, we examined the relationship between callers' descriptions of stroke symptoms to the emergency medical dispatcher and the subsequent classification and prioritisation of EMS response. The aim of this subsequent study was to explore further the use of keywords by callers when making emergency calls, comparing stroke and non-stroke calls. METHODS: All non-stroke calls to one EMS dispatch centre between 8 March 2010 and 14 March 2010 were analysed. These were compared with the stroke calls made to one EMS dispatch centre between 1 October 2006 and 30 September 2007. Content analysis was used to explore the problems described by the caller, and findings were compared between non-stroke and stroke calls. RESULTS: 277 non-stroke calls were identified. Only eight (3%) callers mentioned stroke, 12 (4%) and 11 (4%) mentioned limb weakness and speech problems, respectively, while no caller mentioned more than one classic stroke symptom. This contrasted with 473 stroke calls, where 188 (40%) callers mentioned stroke, 70 (15%) limb weakness and 72 (15%) speech problems, and 14 (3%) mentioned more than one classic stroke symptom. CONCLUSIONS: People who contact the EMS about non-stroke conditions rarely say stroke, limb weakness, speech problems or facial weakness. These words are more frequently used when people contact the EMS about stroke, although many calls relating to stroke patients do not mention any of these keywords.

The identification of acute stroke: an analysis of emergency calls.

BACKGROUND: Accurate dispatch of emergency medical services at the onset of acute stroke is vital in expediting assessment and treatment. We examined the relationship between callers' description of potential stroke symptoms to the emergency medical dispatcher and the subsequent classification and prioritisation of emergency medical services response. AIM: To identify key 'indicator' words used by people making emergency calls for suspected stroke, comparing these with the subsequent category of response given by the emergency medical dispatcher. METHOD: A retrospective chart review (hospital and emergency medical services) in North West England (October 1, 2006 to September 30, 2007) identified digitally recorded emergency medical services calls, which related to patients who had a diagnosis of suspected stroke at some point on the stroke pathway (from the emergency medical services call taker through to final medical diagnosis). Using content analysis, words used to describe stroke by the caller were recorded. A second researcher independently followed the same procedure in order to produce a list of 'indicator' words. Description of stroke-specific and nonstroke-specific problems reported by the caller was compared with subsequent emergency medical services dispatch coding and demographic features. RESULTS: Six hundred forty-three calls were made to emergency medical services of which 592 (92%) had complete emergency medical services and hospital data. The majority of callers were female (67%) and family members (55%). The most frequently reported problems first said by callers to the emergency medical dispatcher were collapse or fall (26%) and stroke (25%). Callers who identified that the patient was having a stroke were correct in 89% of cases. Calls were dispatched as stroke in 45% of cases, of which 83% had confirmed stroke. Of the first reported problems, Face Arm Speech Test stroke symptoms were mentioned in less than 5% of calls, with speech problems being the most common symptom. No callers mentioned all three Face Arm Speech Test symptoms. CONCLUSION: Callers who contacted emergency medical services for suspected stroke and said stroke as the first reported problem were often correct. Calls categorised as stroke by the emergency medical dispatcher were commonly confirmed as stroke in the hospital. Speech problems were the most commonly reported element of the Face Arm Speech Test test to be reported by callers. Recognition of possible stroke diagnosis in fall and other presentations should be considered by emergency medical dispatchers. Further development and training are needed in the community to improve prehospital stroke recognition in order to expedite hyperacute stroke care.

'Is he awake?': dialogues between callers and call handlers about consciousness during emergency calls for suspected acute stroke.

BACKGROUND: Altered consciousness is an important symptom of acute stroke but assessment may be challenging when cognitive or language deficits are present. Callers are routinely questioned about conscious level by emergency medical services (EMS) call handlers for any presenting problem. OBJECTIVE: This study aimed to identify and compare how patients' conscious level was questioned, described and interpreted by callers and call handlers during acute stroke calls. METHOD: Audio recordings of 643 EMS calls for patients with suspected or confirmed acute stroke, admitted to one hospital in North West England over a 12-month period were retrieved from EMS recordings. Calls from primary care physicians were excluded. The caller's response to two standard questions was coded: 'Is the patient conscious?' and 'Is he/she completely awake?', and other relevant dialogue. Responses which suggested misinterpretation of terms relating to conscious level, or where the call handler used additional clarifying questions, were analysed in detail. RESULTS: 109/643 (17%) of the calls had an altered level of consciousness recorded on the ambulance report form. Calls often contained unscripted, protracted dialogue about conscious level. Conscious level was difficult for the caller to determine, miscommunicated, or conflated with breathing difficulties. CONCLUSION: Ambiguities and contradictions in dialogue about conscious level arise during ambulance calls for suspected and confirmed stroke. Further study is needed to identify whether these issues also arise in non-stroke calls, and which terms are best understood by the public in describing conscious level.

The use of formal and informal knowledge sources in patients' treatment decisions in secondary stroke prevention: qualitative study.

BACKGROUND: There is robust empirical evidence to support clinical decision making in secondary stroke prevention after transient ischaemic attack (TIA) or recovered stroke. However, little attention has been paid to patients' utilization of this evidence in coming to decisions about their treatment choices. OBJECTIVE: To examine the use of formal and informal knowledge by patients in making decisions about carotid endarterectomy (CEA) and medical treatment after TIA/recovered stroke. SETTING AND PARTICIPANTS: Twenty participants were recruited from an outpatient vascular surgical assessment clinic in England. Ten were receiving medical treatment alone, and 10 were undergoing CEA after TIA or recovered stroke. METHOD: Twenty-eight in-depth qualitative interviews were conducted. An iterative approach was used whereby emergent themes were further explored in later interviews. Interviews were audiotaped, transcribed and coded. RESULTS: Participants gathered and utilized several types of knowledge in the process of making treatment decisions: Empirical knowledge (e.g. clinical trial findings); Pathophysiologic findings (e.g., results of clinical investigations); Experiential knowledge (e.g., personal experience of stroke); Goals and values (e.g., potential impact on family); System features (e.g., apparent urgency of treatment). CONCLUSIONS: In addition to formal evidence, patients use other sources of informal or 'non-evidentiary' knowledge to support their decisions about treatment after TIA or recovered stroke. To enable evidence-based patient choice, health professionals need to appreciate the diverse types of evidence which patients use, to help them to access relevant and high-quality evidence, to balance evidence from different sources and to make choices which are congruent with their values and expectations.

Callers' experiences of making emergency calls at the onset of acute stroke: a qualitative study.

BACKGROUND: Rapid access to emergency medical services (EMS) is essential at the onset of acute stroke, but significant delays in contacting EMS often occur. OBJECTIVE: To explore factors that influence the caller's decision to contact EMS at the onset of stroke, and the caller's experiences of the call. METHODS: Participants were identified through a purposive sample of admissions to two hospitals via ambulance with suspected stroke. Participants were interviewed using open-ended questions and content analysis was undertaken. RESULTS: 50 participants were recruited (median age 62 years, 68% female). Only one of the callers (2%) was the patient. Two themes were identified that influenced the initial decision to contact EMS at the onset of stroke: perceived seriousness, and receipt of lay or professional advice. Two themes were identified in relation to the communication between the caller and the call handler: symptom description by the caller, and emotional response to onset of stroke symptoms. CONCLUSIONS: Many callers seek lay or professional advice prior to contacting EMS and some believe that the onset of acute stroke symptoms does not warrant an immediate 999 call. More public education is needed to improve awareness of stroke and the need for an urgent response.