Promoting Optimal Physical Exercise for Life (PROPEL): aerobic exercise and self-management early after stroke to increase daily physical activity-study protocol for a stepped-wedge randomised trial.

INTRODUCTION: Physical exercise after stroke is essential for improving recovery and general health, and reducing future stroke risk. However, people with stroke are not sufficiently active on return to the community after rehabilitation. We developed the Promoting Optimal Physical Exercise for Life (PROPEL) programme, which combines exercise with self-management strategies within rehabilitation to promote ongoing physical activity in the community after rehabilitation. This study aims to evaluate the effect of PROPEL on long-term participation in exercise after discharge from stroke rehabilitation. We hypothesise that individuals who complete PROPEL will be more likely to meet recommended frequency, duration and intensity of exercise compared with individuals who do not complete the programme up to 6 months post discharge from stroke rehabilitation. METHODS AND ANALYSIS: Individuals undergoing outpatient stroke rehabilitation at one of six hospitals will be recruited (target n=192 total). A stepped-wedge design will be employed; that is, the PROPEL intervention (group exercise plus self-management) will be 'rolled out' to each site at a random time within the study period. Prior to roll-out of the PROPEL intervention, sites will complete the control intervention (group aerobic exercise only). Participation in physical activity for 6 months post discharge will be measured via activity and heart rate monitors, and standardised physical activity questionnaire. Adherence to exercise guidelines will be evaluated by (1) number of 'active minutes' per week (from the activity monitor), (2) amount of time per week when heart rate is within a target range (ie, 55%-80% of age-predicted maximum) and (3) amount of time per week completing 'moderate' or 'strenuous' physical activities (from the questionnaire). We will compare the proportion of active and inactive individuals at 6 months post intervention using mixed-model logistic regression, with fixed effects of time and phase and random effect of cluster (site). ETHICS AND DISSEMINATION: To date, research ethics approval has been received from five of the six sites, with conditional approval granted by the sixth site. Results will be disseminated directly to study participants at the end of the trial, and to other stake holders via publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02951338; Pre-results.

Using a quality improvement process to create measurable improvement in care delivery for acute stroke.

The introduction of thrombolytic therapy has revolutionized the management of acute ischemic stroke, and it has now been conclusively established that tissue plasminogen activator (t-PA) given within 4.5 hours of stroke onset both limits irreversible ischemic neuronal damage by establishing reperfusion of the penumbra and improves outcomes for patients who have undergone stroke. As a regional stroke centre, Hamilton Health Services (HHS) seeks to ensure it meets guidelines and readiness criteria in acute stroke care. This article discusses how HHS developed and used a quality improvement process to ensure all patients receive thrombosis therapy within 60 minutes of arrival at hospital.

Detecting cognitive impairment in clients with mild stroke or transient ischemic attack attending a stroke prevention clinic.

Twenty clients diagnosed with probable transient ischemic attack (TIA) or stroke attending a stroke prevention clinic (SPC) were screened for cognitive function, as one inclusion criteria for a pilot study examining medication adherence and hypertension management. The Mini Mental State Examination (MMSE) was administered at study admission followed by a second screening within two weeks using the Montreal Cognitive Assessment (MoCA) tool. Individual scores for the MMSE and MoCA were compared. Results demonstrated that the majority (90%) of participants scored in the normal range (> or = 26) on the MMSE (m = 27.9 sd 2.15). However, more than half (55%) of participants had some degree of cognitive impairment based on MoCA scores of < 26 (m = 23.65 sd = 4.082). MoCA scores demonstrated a wider range (Range = 16) compared to the range of MMSE scores (Range = 8). MoCA scores were significantly (p = < 0.05) lower than the MMSE scores. Findings from this pilot study suggest that the MoCA test will identify more deficits in cognition among SPC clients diagnosed with cerebrovascular disease. Further investigation is underway to determine the implications of these deficits on SPC clients' abilities to follow medication and other treatment regimens.

Nurse case management to improve risk reduction outcomes in a stroke prevention clinic.

Stroke prevention clinic health care professionals are mandated to provide early access to neurological consultation and treatment, diagnostic testing, and behavioural risk factor management for clients with transient ischemic attack or mild non-disabling stroke. Clinic nurses collaborate with clients and interprofessional teams to support risk factor reduction to prevent recurrent stroke events. Although hypertension is the most important modifiable risk factor for stroke, broader evidence indicates that adherence to prescribed medications may be less than 50%. One clinic identified a need to improve risk factor outcomes through identifying clients with uncontrolled hypertension, cognitive, self-eficacy and/or adherence characteristics predictive of non-achievement of blood pressure targets. To address this need, an expanded nurse case management care delivery model was pilot tested for feasibility in a participant sample of 20 clients. Motivational interviewing and self-management approaches were combined with interventions designed to improve adherence:facilitation of the simplification of medication routines, providing memory cues and home self-monitoring equipment, counselling, and six-month nursing follow-up. Results demonstrated that an expanded nurse case management model of care delivery is feasible with only a modest impact on clinic resources. At six months, there were significant reductions in blood pressure and increases in medication self-efficacy and adherence for selected clients identified with high risk for stroke and non-achievement of treatment outcomes.

Best practices in stroke care.

In 2001, the Ontario Ministry of Health and Long-Term Care introduced the Ontario Stroke Strategy by designating regional stroke centres across the province. The primary role of these centres is to coordinate stroke care within the region and across the care continuum in keeping with best practices. Concurrently, Trillium Health Centre was identifying best practice projects to support its ongoing quest for excellence. With Trillium designated as a regional stroke centre, acute ischemic stroke care was an obvious choice for a best practice project. The aim of the project was to improve access to care and quality of care for stroke patients from emergency through acute care to in-patient rehabilitation. The team chose the rapid cycle change methodology. This approach to quality improvement advocates the testing of a series of small changes (i.e., process improvement ideas) in tandem with measurements to assess the impact of the change to drive further process improvements. The project was deemed a success, resulting in significant improvements in the timeliness and quality of care.

Bringing innovation to stroke care: development of a comprehensive stroke unit.

Much work has been done in the past 10 years to research and document best practices in stroke care along the continuum of care. The challenge now for stroke care practitioners is to turn those best practices into reality in a clinical setting. In spite of a general understanding and acceptance of the benefits to the patient, an organization's culture and limited access to resources can frustrate our best efforts to introduce best practices at the bedside. Trillium Health Centre, a community hospital serving a diverse community of more than one million people, has turned best practice stroke care guidelines into reality by developing a 14-bed comprehensive stroke unit. This innovative approach to care uses specialized stroke teams, an interdisciplinary approach to care, and a single unit where the patient remains in the same bed throughout the acute and rehabilitation stages of care. Commitment to the new delivery model by formal leaders, informal leaders, and front-line staff and a supportive organizational structure contributed to an expedited and successful implementation. All changes were implemented without an increase in the overall resources assigned to the unit. Early results show that the average length of stay is shorter than the national standard and that provider and patient satisfaction have improved.

Motivating for infrastructure change: toward a communicatively accessible, participation-based stroke care system for all those affected by aphasia.

UNLABELLED: This paper provides a rationale for changing the base upon which healthcare services for individuals with stroke and aphasia can be provided. It is a nuts-and-bolts summary of the interactions between the Aphasia Institute and the West Greater Toronto Stroke Network who worked together to effect meaningful change. Further, the article provides a practical set of guidelines for others to use, should they wish to effect such change. LEARNING OUTCOMES: As a result of reading this article, the participant will be able to (1) develop a strong rationale changing the infrastructure related to healthcare services for individuals and families who have incurred stroke and aphasia; (2) describe the activities undertaken at the Aphasia Institute for accomplishing these changes; (3) refer to a practical set of guidelines for effecting infrastructural change.