Client and clinical staff perceptions of barriers to and enablers of the uptake and delivery of behavioural interventions for urinary incontinence: qualitative evidence synthesis.

AIM: To evaluate factors influencing uptake and delivery of behavioural interventions for urinary incontinence from the perspective of clients and clinical staff. BACKGROUND: Behavioural interventions are recommended as first-line therapy for the management of urinary incontinence. Barriers to and enablers of uptake and delivery of behavioural interventions have not been reviewed. DESIGN: Qualitative evidence synthesis. DATA SOURCES: MEDLINE, EMBASE, CINAHL, PsychInfo, AMED (inception to May 2013); Proceedings of the International Continence Society (ICS) (2006-2013). REVIEW METHODS: Studies where data were collected from clients or staff about their experiences or perceptions of behavioural interventions were included. Two reviewers independently screened records on title and abstract. Full-text papers were obtained for records identified as potentially relevant by either reviewer. Two reviewers independently filtered all full-text papers for inclusion, extracted findings and critically appraised studies. We used an approach akin to Framework, using a matrix of pre-specified themes to classify the data and facilitate its presentation and synthesis. RESULTS: Seven studies involving 200 participants identified clients' views. Findings identified from at least one study of moderate quality included increased fear of accidents and convenience of treatment. Factors enabling participation included realistic goals and gaining control. Six studies involving 427 participants identified staff views. Findings identified from at least one study of moderate quality included staff education and perceptions of treatment effectiveness. Enabling factors included teamwork and experience of success. CONCLUSION: There is little detailed exploration of clients' experiences of, and responses to, behavioural interventions. Evidence for staff relates predominantly to prompted voiding in long-term residential care. Studies of the uptake and delivery of other behavioural interventions in other settings are warranted.

Parallel-Serial Memoing: A Novel Approach to Analyzing Qualitative Data.

The mechanisms by which talking therapies exert their beneficial effects are largely unknown. In exploring the process of a talking therapy, motivational interviewing (MI), when used to treat and prevent low mood in stroke survivors, we developed, what we believe to be, a novel approach to analyzing transcripts. We illustrate the method using qualitative data from MI sessions with 10 stroke survivors. The approach, drawing on grounded theory, incorporated processes of parallel and serial memoing among a team of researchers to allow a process of validation. This enabled us to describe session content and to develop theoretical interpretations of what was occurring in and across MI sessions. We found that this process can be used to integrate different perspectives in theory building, allowing for a richer description and more robust theoretical interpretation. Others can use and adapt this approach to develop insights into their own inquiry.

Motivational Interviewing Post-Stroke: An Analysis of Stroke Survivors' Concerns and Adjustment.

Our earlier research demonstrated that participation in four sessions of motivational interviewing (MI) early post-stroke has a positive impact on stroke survivors' mood. However, the theoretical underpinnings of MI in supporting adjustment (rather than its traditional use in supporting behavior change) require clarification. This article describes a content analysis of MI transcripts for 10 participants in our previous study, to identify the focus of discussions (patient "concerns") and potential effective components of our MI approach. Patients' post-stroke concerns were shown in 16 categories, including frustration, family impact, and getting well. There was a pattern of change discourse across sessions: "Sustain talk" (reasons for not changing) reduced from Session 1 onward, "change talk" (intent to change) increased then reduced, and "change expressed" (changes achieved) increased from Sessions 1 to 4. MI facilitates healthy adjustment post-stroke in some patients, in turn affecting mood, but clarification of how this effect is achieved requires further exploration.

Assessing fidelity to treatment delivery in the ICONS (Identifying Continence OptioNs after Stroke) cluster randomised feasibility trial.

BACKGROUND: The implementation of strategies to monitor and enhance treatment fidelity is of paramount importance in trials of complex interventions. A recent framework published by the National Institutes of Health Behavior Change Consortium recommends addressing five areas of treatment fidelity, one of which is delivery of treatment. This study aimed to explore fidelity to treatment delivery of the ICONS intervention (a systematic voiding programme [SVP]). This included exploring the feasibility of a method to assess fidelity to treatment delivery and collecting preliminary evidence of the level of fidelity to SVP delivery in order to inform strategies for improving fidelity in a future trial. METHODS: Delivery of treatment was recorded by nurses through completion of daily clinical logs, which included: a voiding interval, proposed voiding times and actual voiding times. The a priori method for assessment of fidelity - comparing actual voiding times with proposed voiding times - was trialled on a small amount of data. Due to errors in documentation of the voiding intervals and proposed voiding times it was not possible to assess fidelity directly as planned. A new method was devised, which included identification of 'key quality indicators'. RESULTS: This new approach to assessing fidelity used key quality indicators based upon presence of the data needed to make the comparison between proposed and actual voiding times. The proportion of clinical logs with correct documentation of voiding intervals and proposed voiding times was less than 40 %. For clinical logs with correct documentation, an actual voiding time within 30 min of the proposed voiding time was identified on approximately 55 % of occasions. CONCLUSIONS: Lessons learnt from this study have implications for the future ICONS definitive trial and for other trials of complex interventions. Implementation of a complex intervention may often deviate from what is intended. While careful consideration should be given to the best method of fidelity assessment, an iterative approach allowing flexibility to adapt pre-planned methods is recommended within feasibility trials. As fidelity to treatment delivery in the ICONS feasibility trial appeared to be relatively low, more attention to implementation strategies will be required in the definitive trial. TRIAL REGISTRATION: Identifier: ISRCTN08609907 ; date registered: 07/07/2010.

Identifying continence options after stroke (ICONS): a cluster randomised controlled feasibility trial.

BACKGROUND: Urinary incontinence (UI) affects half of patients hospitalised after stroke and is often poorly managed. Cochrane systematic reviews have shown some positive impact of conservative interventions (such as bladder training) in reducing UI, but their effectiveness has not been demonstrated with stroke patients. METHODS: We conducted a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP) for the management of UI after stroke. Stroke services were randomised to receive SVP (n = 4), SVP plus supported implementation (SVP+, n = 4), or usual care (UC, n = 4).Feasibility outcomes were participant recruitment and retention. The main effectiveness outcome was presence or absence of UI at six and 12 weeks post-stroke. Additional effectiveness outcomes included were the effect of the intervention on different types of UI, continence status at discharge, UI severity, functional ability, quality of life, and death. RESULTS: It was possible to recruit patients (413; 164 SVP, 125 SVP+, and 124 UC) and participant retention was acceptable (85% and 88% at six and 12 weeks, respectively). There was no suggestion of a beneficial effect on the main outcome at six (SVP versus UC: odds ratio (OR) 0.94, 95% CI: 0.46 to 1.94; SVP+ versus UC: OR: 0.62, 95% CI: 0.28 to 1.37) or 12 weeks (SVP versus UC: OR: 1.02, 95% CI: 0.54 to 1.93; SVP+ versus UC: OR: 1.06, 95% CI: 0.54 to 2.09).No secondary outcomes showed a strong suggestion of clinically meaningful improvement in SVP and/or SVP+ arms relative to UC at six or 12 weeks. However, at 12 weeks both intervention arms had higher estimated odds of continence than UC for patients with urge incontinence. CONCLUSIONS: The trial has met feasibility outcomes of participant recruitment and retention. It was not powered to demonstrate effectiveness, but there is some evidence of a potential reduction in the odds of specific types of incontinence. A full trial should now be considered. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN08609907, date of registration: 7 July 2010.

"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.

Training emergency services' dispatchers to recognise stroke: an interrupted time-series analysis.

BACKGROUND: Stroke is a time-dependent medical emergency in which early presentation to specialist care reduces death and dependency. Up to 70% of all stroke patients obtain first medical contact from the Emergency Medical Services (EMS). Identifying 'true stroke' from an EMS call is challenging, with over 50% of strokes being misclassified. The aim of this study was to evaluate the impact of the training package on the recognition of stroke by Emergency Medical Dispatchers (EMDs). METHODS: This study took place in an ambulance service and a hospital in England using an interrupted time-series design. Suspected stroke patients were identified in one week blocks, every three weeks over an 18 month period, during which time the training was implemented. Patients were included if they had a diagnosis of stroke (EMS or hospital). The effect of the intervention on the accuracy of dispatch diagnosis was investigated using binomial (grouped) logistic regression. RESULTS: In the Pre-implementation period EMDs correctly identified 63% of stroke patients; this increased to 80% Post-implementation. This change was significant (p=0.003), reflecting an improvement in identifying stroke patients relative to the Pre-implementation period both the During-implementation (OR=4.10 [95% CI 1.58 to 10.66]) and Post-implementation (OR=2.30 [95% CI 1.07 to 4.92]) periods. For patients with a final diagnosis of stroke who had been dispatched as stroke there was a marginally non-significant 2.8 minutes (95% CI -0.2 to 5.9 minutes, p=0.068) reduction between Pre- and Post-implementation periods from call to arrival of the ambulance at scene. CONCLUSIONS: This is the first study to develop, implement and evaluate the impact of a training package for EMDs with the aim of improving the recognition of stroke. Training led to a significant increase in the proportion of stroke patients dispatched as such by EMDs; a small reduction in time from call to arrival at scene by the ambulance also appeared likely. The training package has been endorsed by the UK Stroke Forum Education and Training, and is free to access on-line.

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.

Postal and face-to-face administration of stroke outcome measures: can mixed modes be used?

BACKGROUND AND PURPOSE: Different modes of administration are used to collect stroke outcomes, even within the same study, potentially leading to different results. We investigated the effect of administration mode (postal questionnaire; face-to-face interview) on self-reports of activities of daily living and mood. METHODS: The study was nested within a poststroke motivational interviewing trial. Activities of daily living (Barthel; Nottingham Extended) and mood (General Health Questionnaire; Yale) were collected at 3 and 12 months via postal questionnaire. Participants were approached to respond again via face-to-face interview. Paired t tests (McNemar test) and intraclass correlation coefficients (Cohen κ) were used, with 95% CI, to compare scores (items). RESULTS: Forty-four participants consented. Only Barthel scores were significantly different; they were 1.0 (95% CI, 0.5-1.6) higher face-to-face. The intraclass correlation coefficient for the Barthel was 0.90; for the other scales it was between 0.83 and 0.87. The Yale κ was 0.72. CONCLUSIONS: Modes of administration might be used interchangeably, albeit in conjunction with corrections for the Barthel.

'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.

Promoting stroke-specific education.

Stroke is the most common cause of adult neurological disability in the UK. This article describes the reasons for the establishment of the UK Forum for Stroke Training and the Stroke-Specific Education Framework. It illustrates how these initiatives can be used to access a range of endorsed, stroke-specific courses to develop excellence in stroke care and multidisciplinary teamwork, as demanded by the Department of Health's National Stroke Strategy.

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.

The 12-month effects of early motivational interviewing after acute stroke: a randomized controlled trial.

BACKGROUND AND PURPOSE: The purpose of this study was to determine whether motivational interviewing (MI), a patient-centered counseling technique, can benefit patients' mood and mortality poststroke. METHODS: This was a single-center, open, randomized, controlled trial. The setting was a hospital with a stroke unit. Four hundred eleven consecutive patients on the stroke register were >18 years old, not known to be moving out-of-area postdischarge, not receiving psychiatric or clinical psychology intervention, and were without severe cognitive or communication problems preventing participation in interviews. All patients received usual stroke care. Patients in the intervention group also received 4 individual, weekly sessions of MI. The primary outcome was the proportion of patients with normal mood measured by the 28-item General Health Questionnaire (normal <5; low ≥5) using a mailed questionnaire at 12 months poststroke. RESULTS: At 12-month follow-up (including imputed data), 37.7% patients in the control group and 48.0% patients in the intervention group had normal mood. Twenty-five (12.8%) of 195 patients in the control group and 13 (6.5%) of 199 patients in the intervention group had died. A significant benefit of motivational interviewing over usual stroke care was found for mood (P=0.020; OR, 1.66; 95% CI, 1.08 to 2.55) and mortality (P=0.035; OR, 2.14; 95% CI, 1.06 to 4.38). CONCLUSIONS: Results suggest that motivational interviewing improves patients' mood and reduces mortality 12 months poststroke. CLINICAL TRIAL REGISTRATION: URL: www.controlled-trials.com. Unique identifier: ISRCTN54465472.

Study protocol: ICONS: identifying continence options after stroke: a randomised trial.

BACKGROUND: Urinary incontinence following acute stroke is common, affecting between 40%-60% of people in hospital after a stroke. Despite the availability of clinical guidelines for urinary incontinence and urinary incontinence after stroke, national audit data suggest incontinence is often poorly managed. Conservative interventions (e.g. bladder training, pelvic floor muscle training and prompted voiding) have been shown to have some effect with participants in Cochrane systematic reviews, but have not had their effectiveness demonstrated with stroke patients. METHODS/DESIGN: A cluster randomised controlled pilot trial designed to assess the feasibility of a full-scale cluster randomised trial and to provide preliminary evidence of the effectiveness and cost-effectiveness of a systematic voiding programme for the management of continence after stroke. Stroke services will be randomised to receive the systematic voiding programme, the systematic voiding programme plus supported implementation, or usual care. The trial aims to recruit at least 780 participants in 12 stroke services (4 per arm). The primary outcome is presence/absence of incontinence at six weeks post-stroke. Secondary outcomes include frequency and severity of incontinence, quality of life and cost-utility. Outcomes will be measured at six weeks, three months and (for participants recruited in the first three months) twelve months after stroke. Process data will include rates of recruitment and retention and fidelity of intervention delivery. An integrated qualitative evaluation will be conducted in order to describe implementation and assist in explaining the potential mediators and modifiers of the process. TRIAL REGISTRATION: ISRCTN: ISRCTN08609907

Stroke knowledge and awareness: an integrative review of the evidence.

BACKGROUND: the recognition of stroke symptoms by the public and activation of the emergency medical services (EMS) are the most important factors in instigating pre-hospital stroke care. Studies have suggested that poor recognition of the warning signs of stroke is the main cause of delay in accessing the EMS. METHODS: an integrative review of published studies about stroke knowledge and awareness was performed by searching online bibliographic databases, using keywords, from 1966 to 2008. Studies were included in the review if they focussed on risk factors, signs and symptoms, action and information. Each study was reviewed by two researchers (SJ and MJ). RESULTS: we identified 169 studies of which 39 were included in the review. The ability to name one risk factor for stroke varied between studies, ranging from 18% to 94% when asked open-ended questions and from 42% to 97% when asked closed questions. The ability to name one symptom ranged from 25% to 72% when asked open-ended questions and from 95% to 100% when asked closed questions. When asked what action people would take if they thought they were having a stroke, between 53% and 98% replied that they would call the EMS. People generally obtained information about stroke from family and friends. Older members of the population, ethnic minority groups and those with lower levels of education had consistently poor levels of stroke knowledge. CONCLUSIONS: generally, levels of knowledge about recognising and preventing stroke were poor. Nevertheless, most participants stated they would contact the EMS at the onset of stroke symptoms.

Changing stroke mortality trends in middle-aged people: an age-period-cohort analysis of routine mortality data in persons aged 40 to 69 in England.

BACKGROUND: In the UK, overall stroke mortality has declined. A similar trend has been seen in coronary heart disease, although recent reports suggest this decline might be levelling off in middle-aged adults. AIM: To investigate recent trends in stroke mortality among those aged 40-69 years in England. METHODS: The authors used routine annual aggregated stroke death and population data for England for the years 1979-2005 to investigate time trends in gender-specific mortalities for adults aged 40 to 69 years. The authors applied log-linear modelling to isolate effects attributable to age, linear 'drift' over time, time period and birth cohort. RESULTS: Between 1979 and 2005, age-standardised stroke mortality aged 40 to 69 years dropped from 93 to 30 per 100,000 in men and from 62 to 18 per 100,000 in women. Mortality was higher in older age groups, but the difference between the older and younger age groups appears to have decreased over time for both sexes. Modelling of the data suggests an average annual reduction in stroke deaths of 4.0% in men and 4.3% in women, although this decrease has been particularly marked in the last few years. However, we also observed a relative rate increase in mortality among those born since the mid-1940s compared with earlier cohorts; this appears to have been sustained in men, which explains the levelling off in the rate of mortality decline observed in recent years in the younger middle-aged. CONCLUSIONS: If observed trends in middle-aged adults continue, overall stroke mortalities may start to increase again.

Physiological monitoring in acute stroke: a literature review.

AIM: This paper is a report of a review of the literature that considers how physiological parameters may affect outcome after stroke and the implications of this evidence for monitoring. BACKGROUND: Throughout the world, the incidence of first-ever stroke is approximately 200 per 100,000 people per year [Sudlow et al. (1997). Stroke 28, 491]. Stroke is the third most common cause of mortality [Sarti et al. (2000). Stroke 31, 1588] and causes 5.54 million deaths worldwide [Murray & Lopez (1997). Lancet 349, 268]. Physiological monitoring is considered a fundamental component of acute stroke care. Currently, the strength of evidence to support its use and identify its components is unclear. Nurse-led physiological assessment and subsequent interventions in acute stroke may have the potential to improve survival and reduce disability. DATA SOURCES: Online bibliographic databases from 1966 to 2007, including MEDLINE, EMBASE, CINAHL, AMED, Cochrane and ZETOC, were searched systematically. We identified 475 published papers relating to blood pressure, oxygen saturation and positioning, blood glucose and body temperature. REVIEW METHODS: Titles and abstracts were reviewed independently by two reviewers and 61 relevant studies were read in full. The quality of included studies was assessed and proformas were used to record detailed data. A narrative synthesis described how the evidence from the papers could inform our understanding of physiological parameters and their association with outcome. RESULTS: Current evidence suggests that patient outcome is worse when physiological parameters deviate from 'normal' in the acute phase of stroke. CONCLUSIONS: The evidence supports the need for monitoring and recording of blood pressure, oxygen saturation (including consideration of positioning), blood glucose and body temperature in the acute phase of stroke. This review has reinforced the importance of monitoring physiological parameters in the acute phase of stroke and adds support to the recommendation that monitoring should play a key role within nursing care.

The use of nurses' and carers' observations in the identification of poststroke depression.

AIM: This paper is a report of a study to determine the accuracy and utility of an observational screening tool (Signs of Depression Scale), when rated by nurses and carers for detecting depression in patients who have recently had a stroke. BACKGROUND: Depression following a stroke is common and adversely affects recovery and rehabilitation. Identifying depression when patients have communication and cognitive difficulties is especially problematic. Screening tools which rely solely on observation may be beneficial in this group. METHOD: A cross-sectional study of people admitted with an acute stroke compared a clinical diagnosis of depression by a psychiatrist (the gold standard) with the Signs of Depression Scale completed by nurses and carers. The agreement between nurses' and carers' ratings was also explored. Data were collected over 10 months (December 2004-October 2005). FINDINGS: Seventy-one patients were included in the study, median age 70 [inter-quartile ranges (IQR) 59-76], including 40 (56.3%) males. The psychiatrist classified 25/71 (35.2%) patients as depressed. Using the recommended cut-point of 2 or more on the Signs of Depression Scale, the nurse and carer respectively rated 27/71 (38.0%) and 18/30 (60.0%) patients as potentially depressed. The proportion of patients correctly identified as depressed by the test (sensitivity) when rated by nurses was 64%, and the proportion of patients not depressed who were correctly identified by the test (specificity) was 61%, whereas carers achieved sensitivity 90% and specificity 35%. The optimal cut-point for carers was higher at 4 or more. Inter-rater agreement on the Signs of Depression Scale between nurses and carers was fair (ICC = 0.43, 95% CI: 0.09-0.68). CONCLUSION: The Signs of Depression Scale is easily completed by clinical staff, although we found the sensitivity when completed by nurses to be low. Information from carers shows potential to improve screening and it is important for nurses to value the knowledge and skills of carers in detecting depression following a stroke. Further refinement of the Signs of Depression Scale, with accompanying research, is required.

The recognition and emergency management of suspected stroke and transient ischaemic attack.

In April 2006, the National Pre-hospital Guidelines Group produced suspected stroke and transient ischaemic attack guidelines to complement the National clinical guidelines for stroke. These concise guidelines contain recommendations from the group and the Intercollegiate Working Party for Stroke. This article serves as an introduction to the guidelines for healthcare staff working in emergency care.

Evaluation of a single-item screening tool for depression after stroke: a cohort study.

OBJECTIVES: To determine the accuracy and utility of a single-item screening tool for depression (the Yale, taken from the Yale-Brown Obsessive Compulsive Scale) in patients who have recently had a stroke. DESIGN: Comparison of a clinical classification of depression with a screening tool in a defined cohort. SETTING: A large teaching hospital in Liverpool, UK. SUBJECTS: One hundred and twenty-two consecutive people admitted with an acute stroke who did not have severe cognitive or communication problems, and who were still in hospital in the second week post stroke. MAIN MEASURES: Classification of depression using the Montgomery-Asberg Depression Rating Scale was compared with the Yale, a single-item screening tool. RESULTS: When comparing the classification of depression according to the Montgomery-Asberg Depression Rating Scale and the response to the Yale we found that at week 2 the Yale had a sensitivity of 86% (57/66), a specificity of 84% (46/55), a positive predictive value of 86% (57/66) and a negative predictive value of 84% (46/55), with an overall efficiency of 85% (103/121); prevalence of depression was 54% (according to the Montgomery-Asberg Depression Rating Scale). At month 3 the Yale had a sensitivity of 95% (52/55), a specificity of 89% (32/36), a positive predictive value of 93% (52/56) and a negative predictive value of 91% (32/35), with an overall efficiency of 92% (84/91); prevalence of depression was 60%. CONCLUSIONS: The Yale, which only requires a 'yes' or 'no' answer to a single question, may prove a useful screening tool in identifying possible depression in people with stroke both two weeks and three months post stroke.