Interventions for the uptake of evidence-based recommendations in acute stroke settings.

BACKGROUND: There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care. OBJECTIVES: To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date. SELECTION CRITERIA: We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations. MAIN RESULTS: We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes. AUTHORS' CONCLUSIONS: We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.

Retrospective analysis of factors influencing the implementation of a program to address unprofessional behaviour and improve culture in Australian hospitals.

BACKGROUND: Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. METHOD: Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. RESULTS: Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool ('Design quality and packaging'), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos ('Goals and Feedback', 'Access to Knowledge and Information'). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. CONCLUSION: Aspects of the inner setting (e.g., 'Leadership Engagement', 'Tension for Change') had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

Denial of Cerebrovascular Events in a National Clinical Quality Registry for Stroke: A Retrospective Cohort Study.

OBJECTIVES: To investigate cerebrovascular event (CVE) denials reported by registered patients to the Australian Stroke Clinical Registry, and to examine the factors associated with CVE denial. MATERIAL AND METHODS: CVE denials reported from January 1, 2017 to June 30, 2018 were followed up with hospitals to verify their discharge diagnosis. CVE denials were compared with all non-CVE denial registrants and a 5% random sub-sample of non-CVE deniers according to patient and clinical characteristics, quality of care indicators and health outcomes. Multilevel, multivariable logistic regression models were used. Factors explored were age, sex, stroke severity, type of stroke, treatment in a stroke unit, length of stay and discharge destination. Level was defined as hospital. RESULTS: Overall, 339/23,830 (<2%) CVE denials were reported during the 18-month period. Hospitals confirmed 117 (61%) of CVE denials as a verified diagnosis of stroke or transient ischaemic attack (TIA). Compared to non-CVE deniers, CVE deniers were younger, had a shorter median length of stay (four days versus one day) and were more likely to be diagnosed with a TIA (64%) compared to the other types of stroke (11% intracerebral haemorrhage; 20% ischaemic; 5% undetermined). CONCLUSION: Very few patients denied their CVE, with the majority of denials subsequently confirmed as eligible for registry inclusion. Diagnosis of a TIA and shorter length of stay were associated with CVE denial. These findings provide evidence that very few cases are incorrectly entered into a national registry, and highlight the characteristics of those unlikely to accept their clinical diagnosis where further education of diagnosis may be needed.

Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program.

OBJECTIVES: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria. DESIGN: Historical controlled cohort study comparing outcomes during a 12-month control period with those for the initial 12 months of full implementation of the VST program at each hospital. SETTING: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016. PARTICIPANTS: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals. MAIN OUTCOME MEASURES: Indicators for key processes of care, including symptom onset-to-arrival, door-to-first medical review, and door-to-CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke. RESULTS: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door-to-CT scan time (median, 25 min [IQR, 13-49 min] v 34 min [IQR, 18-76 min]) and door-to-needle time for stroke thrombolysis (73 min [IQR, 56-96 min] v 102 min [IQR, 77-128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period. CONCLUSIONS: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely.

An Exploratory RCT to Support Gamblers' Intentions to Stick to Monetary Limits: A Brief Intervention Using Action and Coping Planning.

The aim of this study was to investigate the feasibility and impact of an action and coping planning intervention deployed in gambling venues to improve adherence to expenditure limits. We conducted a 2-group parallel-block randomised controlled trial comparing one 20-min session of action and coping planning to an assessment alone. Gamblers who were intending to set a monetary limit on EGMs (n = 184) were recruited in venues and administered the intervention prior to gambling. Measures were adherence to self-identified gambling limits and adherence to expenditure intentions at 30-days post-intervention using the Time Line Follow-Back. The intervention was feasible in terms of recruitment and willingness of gamblers to engage in a pre-gambling intervention. Most gamblers enacted strategies to limit their gambling prior to entering the venue, albeit these limits were on average higher than the Australian low risk gambling guidelines. In terms of impact, the intervention did not improve adherence to limits at post or 30-day follow-up assessment. However, Moderate Risk/Problem Gamblers in the Intervention group spent less (a median of $60 less) than intended (median $100) within the venue. All intervention participants intended to spend significantly less in the 30 days after the intervention compared to the amount spent in the 30 days prior to the intervention. This reduction was not found for participants in the control group. A simple brief intervention appears feasible in gambling venues and have an impact on gambling intentions over the short term.

"It was terrible. I didn't set a limit": Proximal and Distal Prevention Strategies for Reducing the Risk of a Bust in Gambling Venues.

Although most gamblers set limits on their gambling and stick to them most of the time, there are times when limits are breached (a 'bust'). Little is known about the prevalence, reasons for and strategies to address busts despite associated harms with a single bust. This mixed methods study used an online survey with a sample of electronic gaming machine gamblers. A total of 104 gamblers were recruited from 11 Australian gambling venues and almost half (45%) reported a bust in the past 12 months. The amount of money spent on the bust ranged from $20 to $1500 AUD (M = $446, SD = $402). The presence of a bust was positively associated with the amount of money spent in the past 30 days, and self-reported greater gambling related harms and greater gambling severity. Reasons for busts included both distal (pre-venue) factors (i.e., negative affect, lapse in intentions to set a limit, needing to win money) and proximal (inside venue) factors (i.e., chasing losses, wins or spins, social facilitation and losing money too quickly). Bust-prevention strategies identified by participants were both distal (e.g., avoid gambling altogether, leave cards or cash at home, set a time or money limit) and proximal (e.g., walk away when losing and change the manner of gambling). As busts are relative to a priori limits, gamblers at any level of gambling severity can experience a bust. Repeated busts may be an indicator of loss of control and a progression towards problem gambling. Interventions need to focus on factors that mitigate the risk of a bust (e.g., pre-commitment) and that assist gamblers to stick to their limits all of the time.

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.

Building a flexible, voluntary donation panel: an exploration of donor willingness.

BACKGROUND: As blood collection agencies (BCAs) face recurrent shortages of varying blood products, developing a panel comprising donors who are flexible in the product they donate based on same-time inventory demand could be an efficient, cost-effective inventory management strategy. Accounting for prior whole blood (WB) and plasmapheresis donation experience, this article explores current donors' willingness to change their donation product and identifies the type of information required for such donation flexibility. STUDY DESIGN AND METHODS: Telephone interviews (mean, 34 min; SD, 11 min) were conducted with 60 donors recruited via stratified purposive sampling representing six donor groups: no plasma, new to both WB and plasma, new to plasma, plasma, flexible (i.e., alternating between WB and plasma), and maximum (i.e., high frequency alternating between WB and plasma) donors. Participants responded to hypothetical scenarios and open-ended questions relating to their and other donors' willingness to be flexible. Responses were transcribed and content was analyzed. RESULTS: The most frequently endorsed categories varied between donor groups with more prominent differences emerging between the information and support that donors desired for themselves versus that for others. Most donors were willing to change donations but sought improved donation logistics and information regarding inventory levels to encourage flexibility. The factors perceived to facilitate the flexibility of other donors included providing donor-specific information and information regarding different donation types. CONCLUSION: Regardless of donation history, donors are willing to be flexible with their donations. To foster a flexible donor panel, BCAs should continue to streamline the donation process and provide information relevant to donors' experience.

Negative experiences and donor return: an examination of the role of asking for something different.

BACKGROUND: Negative donation experiences, including vasovagal reactions, deter donor retention. However, whether this deterrence effect varies as a function of whole blood (WB) donation history and requests to donate the same or a different product remains unclear. STUDY DESIGN AND METHODS: The responses of 894 eligible WB donors who had been approached to convert to plasmapheresis and 954 eligible first-time plasmapheresis donors who had been surveyed on their last donation experience and their intention to donate plasma were considered. This information was matched with individual vasovagal reaction records, deferral category, WB donation history, and subsequent donation behavioral data obtained from the blood collection agency. RESULTS: Path analysis indicated that the application of a deferral and an officially recorded vasovagal reaction decreased donors' intentions to continue plasmapheresis donation, but had no effect on WB donors' intentions to convert to plasmapheresis. Consistent with past findings, vasovagal reactions occurred more frequently with female and inexperienced donors. CONCLUSION: Experiencing vasovagal reactions and deferrals may not universally deter donors from continuing to donate. Rather, the offer to convert to another form of donation-in this instance, plasmapheresis-after experiencing a negative donation event while donating WB may be sufficient to eliminate the deterrence effect on retention.

A novel approach to increasing inventory with the current panel: increasing donation frequency by asking for a different blood product.

BACKGROUND: Ongoing shortages of blood products may be addressed through additional donations. However, donation frequency rates are typically lower than medically possible. This preliminary study aims to determine voluntary nonremunerated whole blood (WB) and plasmapheresis donors' willingness, and subsequent facilitators and barriers, to make additional donations of a different type. STUDY DESIGN AND METHODS: Forty individual telephone interviews were conducted posing two additional donation pattern scenarios: first, making a single and, second, making multiple plasmapheresis donations between WB donations. Stratified purposive sampling was conducted for four samples varying in donation experience: no-plasma, new-to-both-WB-and-plasma, new-to-plasma, and plasma donors. Interviews were analyzed yielding excellent (κ values > 0.81) inter-rater reliability. RESULTS: Facilitators were more endorsed than barriers for a single but not multiple plasmapheresis donation. More new-to-both donors (n = 5) were willing to make multiple plasma donations between WB donations than others (n = 1 each) and identified fewer barriers (n = 3) than those more experienced in donation (n = 8 no plasma, n = 10 new to both, n = 11 plasma). Donors in the plasma sample were concerned about the subsequent reduced time between plasma donations by adding WB donations (n = 3). The no-plasma and new-to-plasma donors were concerned about the time commitment required (n = 3). CONCLUSION: Current donors are willing to add different product donations but donation history influences their willingness to change. Early introduction of multiple donation types, variation in inventory levels, and addressing barriers will provide blood collection agencies with a novel and cost-effective inventory management strategy.

Using an Extended Theory of Planned Behavior to Predict a Change in the Type of Blood Product Donated.

BACKGROUND: Demand for essential plasma-derived products is increasing. PURPOSE: This prospective study aims to identify predictors of voluntary non-remunerated whole blood (WB) donors becoming plasmapheresis donors. METHODS: Surveys were sent to WB donors who had recently (recent n = 1,957) and not recently donated (distant n = 1,012). Theory of Planned Behavior (TPB) constructs (attitude, subjective norm, self-efficacy) were extended with moral norm, anticipatory regret, and donor identity. Intentions and objective plasmapheresis donation for 527 recent and 166 distant participants were assessed. RESULTS: Multi-group analysis revealed that the model was a good fit. Moral norm and self-efficacy were positively associated while role identity (suppressed by moral norm) was negatively associated with plasmapheresis intentions. CONCLUSIONS: The extended TPB was useful in identifying factors that facilitate conversion from WB to plasmapheresis donation. A superordinate donor identity may be synonymous with WB donation and, for donors with a strong moral norm for plasmapheresis, may inhibit conversion.

Recruiting and retaining plasmapheresis donors: A critical belief analysis.

This paper identifies critical beliefs underpinning intentions to commence and continue plasmapheresis donation. Whole blood (n = 624) and first-time plasmapheresis (n = 460) donors completed a cross-sectional survey assessing the belief-base of the theory of planned behaviour and rated their plasmapheresis donation intentions. While the idea of red blood cells being returned was a key deterrent for all donors, critical beliefs underlying commencement and continuation in the plasmapheresis donor panel differed and varied as a function of blood donation history. Findings will assist the development of targeted persuasion messages to optimise recruitment and retention of plasmapheresis donors in a non-remunerated context.

Asking for something different from our donors: factors influencing persuasion success.

BACKGROUND: Demand for plasma-derived products, and consequently plasmapheresis donors, continues to increase. This study aims to identify the factors that facilitate the persuasion success of conversations with whole blood (WB) donors to convert to plasmapheresis donation within a voluntary nonremunerated context. STUDY DESIGN AND METHODS: Surveys were sent to WB donors after a plasmapheresis conversion conversation with a blood collection agency (BCA) staff member: in center (Sample 1) or via a call center (Sample 2). Participants reported the number of donor-initiated and BCA-initiated conversations about plasma, experienced in the prior 12 months. Perceptions of the most recent conversation, donor oriented and conversion oriented, were also reported. The BCA provided WB donation history for the prior 5 years. Participants' intentions to make a first plasmapheresis donation were captured and any subsequent plasmapheresis donation was objectively recorded. RESULTS: Conversion rates were higher for in-center than call center-based conversations. For both samples, path analyses revealed that intentions are associated with conversion. Prior WB donations are negatively associated, while donor-initiated and donor-orientated conversations are positively associated with conversion intentions. Results for agent-initiated conversations and conversion-orientated conversations were mixed across samples. CONCLUSION: Converting suitable WB donors to plasmapheresis is best achieved early in the donor's career using face-to-face conversations with collection center staff. BCAs should facilitate donor-initiated conversations through promotional campaigns that encourage donors to approach staff. Conversations that focus on donors' needs and welfare more effectively encourage conversion intentions than those perceived as pushing the requirements of the BCA.

Factors influencing the successful implementation of a novel digital health application to streamline multidisciplinary communication across multiple organisations for emergency care.

RATIONALE: Delivering optimal patient health care requires interdisciplinary clinician communication. A single communication tool across multiple pre-hospital and hospital settings, and between hospital departments is a novel solution to current systems. Fit-for-purpose, secure smartphone applications allow clinical information to be shared quickly between health providers. Little is known as to what underpins their successful implementation in an emergency care context. AIMS: To identify (a) whether implementing a single, digital health communication application across multiple health care organisations and hospital departments is feasible; (b) the barriers and facilitators to implementation; and (c) which factors are associated with clinicians' intentions to use the technology. METHODS: We used a multimethod design, evaluating the implementation of a secure, digital communication application (Pulsara™). The technology was trialled in two Australian regional hospitals and 25 Ambulance Victoria branches (AV). Post-training, clinicians involved in treating patients with suspected stroke or cardiac events were administered surveys measuring perceived organisational readiness (Organisational Readiness for Implementing Change), clinicians' intentions (Unified Theory of Acceptance and Use of Technology) and internal motivations (Self-Determination Theory) to use Pulsara™, and the perceived benefits and barriers of use. Quantitative data were descriptively summarised with multivariable associations between factors and intentions to use Pulsara™ examined with linear regression. Qualitative data responses were subjected to directed content analysis (two coders). RESULTS: Participants were paramedics (n = 82, median 44 years) or hospital-based clinicians (n = 90, median 37 years), with organisations perceived to be similarly ready. Regression results (F(11, 136) = 21.28, p = <0.001, Adj R2 = 0.60) indicated Habit, Effort Expectancy, Perceived Organisational Readiness, Performance Expectancy and Organisation membership (AV) as predictors of intending to use Pulsara™. Themes relating to benefits (95% coder agreement) included improved communication, procedural efficiencies and faster patient care. Barriers (92% coder agreement) included network accessibility and remembering passwords. PulsaraTM was initiated 562 times. CONCLUSION: Implementing multiorganisational, digital health communication applications is feasible, and facilitated when organisations are change-ready for an easy-to-use, effective solution. Developing habitual use is key, supported through implementation strategies (e.g., hands-on training). Benefits should be emphasised (e.g., during education sessions), including streamlining communication and patient flow, and barriers addressed (e.g., identify champions and local technical support) at project commencement.

Perceived deterrents to being a plasmapheresis donor in a voluntary, nonremunerated environment.

BACKGROUND: As demand for plasma-derived products increases internationally, maintaining a committed plasmapheresis panel membership is critical for blood collection agencies. This study addresses the current lack of knowledge regarding deterrents to the recruitment and retention of plasmapheresis donors in a voluntary nonremunerated environment. STUDY DESIGN AND METHODS: Nine focus groups (n = 84) and six individual interviews were conducted using semistructured schedules. Three focus groups were conducted with each category of eligible whole blood (WB) donors: those who had 1) declined to convert to plasmapheresis (DTC), 2) converted but lapsed to WB (LWB), and 3) converted and lapsed from the panel completely (LFP). Transcript analysis revealed distinct deterrent categories. RESULTS: The time required for plasmapheresis was a universally identified deterrent, with concerns of donation frequency expectations shared between DTC and LWB. LWB and LFP both reported excessive questioning and paperwork, and eligibility requirements as deterrents. Unique deterrents for DTC were a lack of accurate knowledge about safety and process. LWB reported concerns about plasmapheresis donation outcomes; however, they were more committed to continuing donation than LFP, who reported donation not being salient, being too busy, and poorer donation experiences. CONCLUSION: Providing information to address safety and health concerns should be the focus for successful conversion to plasmapheresis. Setting donation frequency expectations at levels to which donors are accustomed may improve evaluations of the cost/benefit ratio of conversion and retention. Involvement levels (i.e., importance, personal meaning of donation) may be the key differentiator between those donors who return to WB and those that lapse altogether.

Exploring the lived experience of families with a COVID-19 positive child: The journey from a critical grounded theory approach.

COVID-19 and associated public health policies have significantly disrupted the lives of both adults and children. Experiences of COVID-positive adults are well described but less is known about the experiences of families of children who receive a positive diagnosis, and the impact of public health policies on this experience. This study aimed to develop a framework to understand the lived experience of families with a child testing positive for COVID-19. We applied a qualitative study design, using grounded theory. The study took place in Melbourne, Australia between July and December 2020, during the first major Australian COVID-19 wave. Parents of children 0-18 years tested at a walk-in clinic at a paediatric tertiary referral hospital were invited to participate. Two interviewers jointly undertook in-depth interviews with parents of children who tested positive. Interviews were transcribed and two analysts used an inductive, critical realist analysis approach with NVivo and a virtual whiteboard. Results are presented incorporating a stratified reality (empirical, actual, real). Families described seven sequential stages of the COVID-19 positive testing journey: COVID-19 close to home; time to be tested; waiting for the test result; receiving the result; dealing with the diagnosis; coping with isolation; and moving forward/looking back. Our findings highlight how public health policies and messages targeting the general (adult) public were experienced by families. We provide a framework that families move through when their child tests positive for COVID-19. Within each phase, we report unmet needs and identify strategies to improve future pandemic planning for parents and children.

Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: A qualitative process evaluation.

RATIONALE: 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. AIM: To identify successes and challenges in the pre- and initial operations of the first Australian MSU service from an interdisciplinary perspective. METHODS: Process evaluation of the Melbourne MSU with a mixed-methods design. Purposive sampling 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. RESULTS: Participants representing executive/program 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. CONCLUSIONS: Successes and challenges of establishing a new MSU service extend beyond technical, to include operational and social aspects across prehospital and hospital environments.

Sustaining a New Model of Acute Stroke Care: A Mixed-Method Process Evaluation of the Melbourne Mobile Stroke Unit.

BACKGROUND: Internationally, Mobile Stroke Unit (MSU) ambulances have changed pre-hospital acute stroke care delivery. MSU clinical and cost-effectiveness studies are emerging, but little is known about important factors for achieving sustainability of this innovative model of care. METHODS: Mixed-methods study from the Melbourne MSU (operational since November 2017) process evaluation. Participant purposive sampling included clinical, operational and executive/management representatives from Ambulance Victoria (AV) (emergency medical service provider), the MSU clinical team, and receiving hospitals. Sustainability was defined as ongoing MSU operations, including MSU workforce and future model considerations. Theoretically-based on-line survey with Unified Theory of Acceptance and Use of Technology (UTAUT), Self Determination Theory (SDT, Intrinsic Motivation), and open-text questions targeting barriers and benefits was administered (June-September 2019). Individual/group interviews were conducted, eliciting improvement suggestions and requirements for ongoing use. Descriptive and regression analyses (quantitative data) and directed content and thematic analysis (open text and interview data) were conducted. RESULTS: There were 135 surveys completed. Identifying that the MSU was beneficial to daily work (ß=0.61), not experiencing pressure/tension about working on the MSU (ß=0.17) and thinking they did well working within the team model (ß=0.17) were significantly associated with wanting to continue working within the MSU model [R2=0.76; F(15, 60)=12.76, P<.001]. Experiences varied between those on the MSU team and those working with the MSU. Advantages were identified for patients (better, faster care) and clinicians (interdisciplinary learning). Disadvantages included challenges integrating into established systems, and establishing working relationships. Themes identified from 35 interviews were MSU team composition, MSU vehicle design and layout, personnel recruitment and rostering, communication improvements between organisations, telemedicine options, MSU operations and dispatch specificity. CONCLUSION: Important factors affecting the sustainability of the MSU model of stroke care emerged. A cohesive team approach, with identifiable benefits and good communication between participating organisations is important for clinical and operational sustainability.