A Quality Improvement Project on Agitation Management in the Emergency Department.

INTRODUCTION: Agitation is common in the emergency department. When agitation is not detected early, patients can become aggressive and violent, potentially leading to restraint use and subsequent injury. The goals of the project were early detection and management of patient agitation, reduction of restraint use in the emergency department, and determination of the usability of the Behavioral Activity Rating Scale. METHODS: This quality improvement project was assessed using a pre- and posttest single unit design, comparing 4 months of postimplementation data to historic controls at the same time of year in the previous year. The intervention was implementing the Behavioral Activity Rating Scale in the ED electronic medical record. Data were collected through retrospective chart review and nurse survey. From September through December of both 2017 and 2018, data were collected on restraint use. The 4-month 2018 data collection period included measures of Behavioral Activity Rating Scale documentation and the System Usability Scale survey for nurses to measure ease of usability of the Behavioral Activity Rating Scale. RESULTS: The Behavioral Activity Rating Scale was documented frequently (n = 4 867 documentations) by emergency nurses to assess patients with behavioral health and medical complaints (n = 780). Nurses identified 18 episodes of violent behavior in behavioral health patients on the Behavioral Activity Rating Scale (2.31%) and applied restraints 18 times. The most common chief complaints for patients who were identified as violent was suicidal ideation (n = 6; 33.33%). In 2017, there were 20 episodes of restraint use during the same time period, a nonsignificant difference (χ2 = 0.72; P = 0.40). However, only 2 patients were kept in restraints longer than 1 day in 2018 compared with 8 in 2017. Emergency nurses found the Behavioral Activity Rating Scale to be usable in the structured usability assessment (µ = 83.46; SD = 11.73). DISCUSSION: The Behavioral Activity Rating Scale is a usable tool for emergency nurses to assess for patient agitation. With the incorporation of agitation management interventions, the ED team can potentially manage agitation before violence occurs. Further studies are needed on the use of agitation or aggression assessment tools for managing patient behavioral activity such as aggression in the emergency department.

Clinimetric properties of a novel feedback device for assessing gait parameters in stroke survivors.

INTRODUCTION: Community-dwelling stroke survivors tend to become less physically active over time. There is no 'gold standard' to measure walking activity in this population. Assessment of walking activity generally involves subjective or observer-rated instruments. Objective measuring with an activity monitor, however, gives more insight into actual walking activity. Although several activity monitors have been used in stroke patients, none of these include feedback about the actual walking activity. FESTA (FEedback to Stimulate Activity) determines number of steps, number of walking bouts, covered distance and ambulatory activity profiles over time and also provides feedback about the walking activity to the user and the therapist. AIM: To examine the criterion validity and test-retest-reliability of the FESTA as a measure of walking activity in patients with chronic stroke. To target the properties of the measurement device itself and thus exclude effects of behavioral variability as much as possible evaluation was performed in standardized activities. METHODS: Community-dwelling individuals with chronic stroke were tested twice with a test-retest interval varying from two days to two weeks. They performed a six-minute walk test and a standardized treadmill test at different speeds on both testing days. Walking activity was expressed in gait parameters: steps, mean-step-length and walking distance. Output data of the FESTA on the treadmill was compared with video analysis as the criterion measurement. Intraclass Correlations Coefficients (ICCs) and Mean Relative Root Squared Error (MRRSE) were calculated. RESULTS: Thirty-three patients were tested to determine criterion validity, 27 patients of this group were tested twice for test-retest reliability. ICC values for validity and reliability were high, ranging from .841 to .972. CONCLUSION: This study demonstrated good criterion validity and test-retest-reliability of FESTA for measuring specific gait parameters in chronic stroke patients. FESTA is a valid and reliable tool for capturing walking activity measurements in stroke, and has applicability to both clinical practice and research.

The impact of PRAISEDD on adherence and initiation of heart health behaviors in senior housing.

OBJECTIVE: Building on prior theoretical work and research, we developed a community-based intervention, People Reducing Risk And Improving Strength through Exercise, Diet, and Drug Adherence (PRAISEDD), a three-phase program which was implemented in 2009. The purpose of this study was to report on Phase III, the Inoculation Phase, of the PRAISEDD program and explore participant experiences. DESIGN AND SAMPLE: This was a descriptive, qualitative study focused on exploring participation in heart healthy PRAISEDD classes. Ten residents participated in the focus group, all of whom attended at least one PRAISEDD session. MEASURES: Qualitative data were obtained at the end of the 12 months during which Phase III was implemented. Descriptive data were gathered to describe the number of initial PRAISEDD participants and the number of new participants who came to classes. RESULTS: Nine codes were identified and reduced to two themes: motivators to participate in exercise classes; and factors that decrease willingness to participate. The Phase III monthly PRAISEDD inoculation classes were attended by 10-12 residents, the majority of whom participated in Phase I of PRAISEDD. CONCLUSION: We were able to engage new participants in classes during Phase III, and qualitative findings provided important recommendations for future work.

Exercise intervention research in stroke: optimizing outcomes through treatment fidelity.

BACKGROUND: Demonstrating the treatment fidelity of an intervention is a key methodological requirement of any trial testing the impact of the intervention. PURPOSE: The purpose of this report was to serve as a model for evaluating treatment fidelity in stroke exercise intervention studies and to provide evidence for treatment fidelity in the Exercise Training for Hemiparetic Stroke Intervention Development Study. METHODS: Treatment fidelity was evaluated based on study design, training of interventionists, and delivery and receipt of the intervention. RESULTS: There were some concerns about design fidelity as the control group and intervention group traveled to the study location together and received different exercise programs in the same facility. With regard to training of interventionists, observations were utilized to help maintain adherence to the protocol. There was strong support for the delivery and receipt of the intervention with participants exposed to the anticipated number of exercise sessions. As per study protocol, there was evidence that progress toward the proposed physical activity goal was made. Treatment fidelity findings are reported using cumulative data rather than at points throughout the study. Thus the findings may be conservative with regard adherence, for example, to time spent in exercise. CONCLUSION: In addition to assurance of true testing of the intervention in this study, treatment fidelity of this work provides a useful model for replication and critically important information to better understand the type, dose, and length of exposure to exercise interventions that is needed to optimize stroke recovery.

Pilot testing of the PRAISEDD intervention among African American and low-income older adults.

BACKGROUND AND RESEARCH OBJECTIVE: The incidence of cardiovascular disease (CVD) is particularly high among African American (AA) older adults, and these individuals are least likely to have access to CVD prevention activities. The purpose of this study was to test the feasibility of People Reducing Risk and Improving Strength through Exercise, Diet and Drug Adherence (PRAISEDD), which is geared at increasing adherence to CVD prevention behaviors among AA and low-income older adults. METHODS: This feasibility study was conducted in a senior housing site, using a single-group repeated-measures design and testing physical activity, diet, medication adherence beliefs and behaviors, and blood pressure at baseline and after a 12-week intervention period. Of 22 participants, mean (SD) age was 76.4 (7.6) years, and most were female (64%) and AA (86%). An intention-to-treat analysis was used. RESULTS: There were significant decreases in systolic (P = .02) and diastolic blood pressure (P = .01) and a nonsignificant trend toward improvement in cholesterol intake (P = .09). There were no changes in time spent in moderate-level physical activity, sodium intake, medication adherence, or self-efficacy and outcome expectations across all 3 behaviors. CONCLUSION: The PRAISEDD intervention was feasible in a group of AA and low-income older adults and, after 12 weeks, resulted in improvements in blood pressure. Future research is needed to test a revised PRAISEDD intervention using a randomized controlled design, a larger sample, and a longer follow-up period. The PRAISEDD intervention should be revised to incorporate environmental and policy changes that influence CVD prevention behaviors and explore the impact of social networking as it relates to diffusion of the intervention among participants in low-income housing facilities.

Progressive adaptive physical activity in stroke improves balance, gait, and fitness: preliminary results.

PURPOSE: We conducted a non-controlled pilot intervention study in stroke survivors to examine the efficacy of low-intensity adaptive physical activity to increase balance, improve walking function, and increase cardiovascular fitness and to determine whether improvements were carried over into activity profiles in home and community. METHOD: Adaptive physical activity sessions were conducted 3 times/week for 6 months. The main outcomes were Berg Balance Scale, Dynamic Gait Index, 6-Minute Walk Test, cardiovascular fitness (VO2 peak), Falls Efficacy Scale, and 5-day Step Activity Monitoring. RESULTS: Seven men and women with chronic ischemic stroke completed the 6-month intervention. The mean Berg Balance baseline score increased from 33.9+/-8.5 to 46+/-6.7 at 6 months (mean+/-SD; p=.006). Dynamic Gait Index increased from 13.7+/-3.0 to 19.0+/-3.5 (p=.01). Six-minute walk distance increased from 840+/-110 feet to 935+/-101 feet (p=0.02). VO2 peak increased from 15.3+/-4.1 mL/kg/min to 17.5+/-4.7 mL/kg/min (p=.03). There were no significant changes in falls efficacy or free-living ambulatory activity. CONCLUSION: A structured adaptive physical activity produces improvements in balance, gait, fitness, and ambulatory performance but not in falls efficacy or free-living daily step activity. Randomized studies are needed to determine the cardiovascular health and functional benefits of structured group physical activity programs and to develop behavioral interventions that promote increased free-living physical activity patterns.

The Feasibility and Impact of the EMOVE Intervention on Self-efficacy and Outcome Expectations for Exercise in Epilepsy.

The purpose of this pilot study was to evaluate the feasibility of the self-efficacy based Epilepsy-Motivate and Outcome Expectations for Vigorous Exercise (EMOVE) intervention and report on the preliminary efficacy of this intervention aimed at improving exercise behaviors in adults with epilepsy. Methods: A single-group, repeated-measures design was used in 30 outpatients. Data were collected at baseline and 12 weeks after the intervention. Participant outcomes included Self-Efficacy and Outcome Expectations for Exercise in Epilepsy, Beck Depression Inventory-II, Quality of Life in Epilepsy Inventory-31, seizure frequency, average daily steps, and body mass index. Daily number of steps was measured using a wrist-worn activity monitor. Feasibility data were assessed using evidence of treatment fidelity including intervention delivery, receipt, and enactment. Results: Participants were single (63%), white (53%), female (63%), had a mean (SD) age of 46.7 (13) years (range, 26-68 years), had low levels of self-efficacy (mean, 5.10; range, 0-10) and high outcome expectations (mean, 3.90; range, 0-5), took under the recommended 10 000 steps per day (mean, 5107), and had an average of 6 seizures per month. Postintervention testing showed statistical improvement in depressive symptoms (mean [SD], 9.95 [9.47]; P < .05). There were no significant differences found for the other study outcomes. Our study showed the EMOVE intervention was feasible. Study participants had improved depressive symptoms. Future research should focus on increasing the sample size, improving exercise performance through group or individualized exercise sessions, and adding a control group to better evaluate the relationship between the intervention and improved depressive symptoms.

Motivators for treadmill exercise after stroke.

PURPOSE: The purpose of this qualitative study was to explore factors that motivated older adults with ischemic stroke to engage in a task-oriented treadmill aerobic exercise (T-AEX) intervention study. METHOD: Participants included community-dwelling individuals post stroke with mild-to-moderate hemiparetic gait deficits who completed a 6-month T-AEX study. A total of 29 participants attended focus groups or individual telephone interviews. RESULTS: Thirty-nine codes were identified and were reduced to 8 themes: personal goals supported by 7 codes, psychological benefits supported by 8 codes, physical benefits supported by 10 codes, research-associated supervised treadmill exercise benefits supported by 5 codes, objective and verbal encouragement received supported by 4 codes, social support related to exercise supported by 2 codes, improvement in instrumental activities of daily living supported by 2 codes, and self-determination supported by 1 code. All themes reflected factors that influenced subjects' willingness to participate in the study and adhere to the exercise intervention. Of the themes identified, personal goals, physical benefits, and psychological benefits occurred most frequently. CONCLUSION: This qualitative study provides information that may be used to enhance motivation to exercise in individuals with stroke and promote carryover and integration of exercise behaviors into everyday life.

Implementation of the Agitated Behavior Scale in the Electronic Health Record.

PURPOSE: The purpose of the study was to implement an Agitated Behavior Scale through an electronic health record and to evaluate the usability of the scale in a brain injury unit at a rehabilitation hospital. DESIGN: A quality improvement project was conducted in the brain injury unit at a large rehabilitation hospital with registered nurses as participants using convenience sampling. METHODS: The project consisted of three phases and included education, implementation of the scale in the electronic health record, and administration of the survey questionnaire, which utilized the system usability scale. FINDINGS: The Agitated Behavior Scale was found to be usable, and there was 92.2% compliance with the use of the electronic Electronic Agitated Behavior Scale. CONCLUSION: The Agitated Behavior Scale was effectively implemented in the electronic health record and was found to be usable in the assessment of agitation. CLINICAL RELEVANCE: Utilization of the scale through the electronic health record on a daily basis will allow for an early identification of agitation in patients with traumatic brain injury and enable prompt interventions to manage agitation.

Automated Fall Detection Technology in Inpatient Geriatric Psychiatry: Nurses' Perceptions and Lessons Learned.

ABSTRACTHospitalized older adults are at high risk of falling. The HELPER system is a ceiling-mounted fall detection system that sends an alert to a smartphone when a fall is detected. This article describes the performance of the HELPER system, which was pilot tested in a geriatric mental health hospital. The system's accuracy in detecting falls was measured against the hospital records documenting falls. Following the pilot test, nurses were interviewed regarding their perceptions of this technology. In this study, the HELPER system missed one documented fall but detected four falls that were not documented. Although sensitivity (.80) of the system was high, numerous false alarms brought down positive predictive value (.01). Interviews with nurses provided valuable insights based on the operation of the technology in a real environment; these and other lessons learned will be particularly valuable to engineers developing this and other health and social care technologies.

Cardiovascular risk in survivors of stroke.

BACKGROUND: Stroke survivors are at significant risk for recurrent stroke and cardiovascular disease. Inadequately managed modifiable risk factors increase the threat of recurrent stroke, development of new comorbidities, and double the risk of premature mortality. The purpose of this study was to determine the prevalence of modifiable cardiovascular risk factors in stroke survivors who completed a research screening evaluation for entry into exercise rehabilitation studies. The sample collected between January 2001 and June 2005 evaluated 364 community-dwelling men and women aged 34 to 88 years living in Baltimore, Maryland. METHODS: Each participant's risk profile was evaluated from data obtained during a medical history and physical examination and from laboratory analysis of a fasting blood sample. Current practice guidelines were used to define risk categories. RESULTS: Ninety-nine percent of participants had at least one suboptimally controlled risk factor. Ninety-one percent had two or more concurrent risk factors inadequately treated. Eighty percent of the participants had prehypertension or hypertension, 67% were overweight or obese, 60% had suboptimal low-density lipoprotein, 45% had impaired fasting glucose, 34% had low high-density lipoprotein, and 14% were current smokers, while reportedly receiving routine medical care. CONCLUSIONS: These findings confirm that cardiovascular risk factors remain inadequately managed in stroke survivors, increasing the chance for repeat stroke and cardiovascular event. Systematic assessment of this vulnerable population is imperative at every healthcare encounter.

Ambulatory activity intensity profiles, fitness, and fatigue in chronic stroke.

PURPOSE: The purpose of this study was to describe household and community ambulatory activity profiles and their relationship to fatigue and cardiovascular fitness in a sample of men and women with chronic hemiparetic stroke. METHOD: We quantified community-based ambulatory activity profiles in terms of step counts and intensity, along with cardiovascular fitness and fatigue severity, in a convenience sample of 79 men and women with chronic hemiparetic stroke. RESULTS: As captured by daily step activity monitoring, participants demonstrated extremely low step counts (1389 +/- 797 steps/day), and almost no step activity at high intensity (78 +/- 168 steps/day at a rate of >or=30 steps/ minute). Mean high intensity activity constituted less than 3 minutes/day. The mean VO2 peak was 13.02 +/- 4.26 mL/kg/min, consistent with profound aerobic deconditioning. Total, low, and high intensity ambulatory activity were associated with VO2 peak. Mean fatigue severity was 3.28 +/- 1.36 on a scale of 7.00, with 42% of the sample reporting severe fatigue. There were no statistically significant correlations between fatigue severity and ambulatory activity or fitness measures. CONCLUSION: Our results show that step activity intensity is strongly associated with cardiovascular fitness, lending credence to the hypothesis that rehabilitation interventions that build aerobic conditioning can influence daily activity. The challenge is to appreciate the features of ambulatory behavior after stroke and to use this information to integrate both exercise interventions and behavioral components into the successful translation of structured activities into home and community routines.

Confidentiality challenges and good clinical practices in human subjects research: striking a balance.

The Health Insurance Portability and Accountability Act (HIPPA) has been fully implemented in clinical practice and research settings. Although subject confidentiality has always been a concern, clinical researchers must now take extra care to attend to the mandates of privacy while also minding good clinical practice guidelines. Unanticipated conflicts may arise as a result of these dual priorities. This article presents two examples of potential challenges to confidentiality with comment from the bioethical perspective.

Reliability and Validity of the Self-Efficacy for Exercise in Epilepsy and the Outcome Expectations for Exercise in Epilepsy Scales.

PURPOSE: The purpose of this study was to test the psychometric properties of the revised Self-Efficacy for Exercise With Epilepsy (SEE-E) and Outcome Expectations for Exercise with Epilepsy (OEE-E) when used with people with epilepsy. METHODS: The SEE-E and OEE-E were given in face-to-face interviews to 26 persons with epilepsy in an epilepsy clinic. RESULTS: There was some evidence of validity based on Rasch analysis INFIT and OUTFIT statistics. There was some evidence of reliability for the SEE-E and OEE-E based on person and item separation reliability indexes. CONCLUSIONS: These measures can be used to identify persons with epilepsy who have low self-efficacy and outcome expectations for exercise and guide design of interventions to strengthen these expectations and thereby improve exercise behavior.

Stroke prevention and management in older adults.

Stroke is the third leading cause of death and a foremost cause of serious, long-term disability in the United States. As cardiovascular and metabolic disease incidence rises with age, older people are more likely to experience strokes. Age is the single most important risk factor for stroke. For each successive 10 years after age 55, the stroke rate more than doubles in both men and women. However, stroke is not an inevitable consequence of aging. By identifying and modifying risk factors in older people, nurses can partner with other providers to reduce the incidence, morbidity, and mortality associated with stroke in older adults. Control of hypertension, resolution of dyslipidemia, management of diabetes mellitus, anticoagulation for atrial fibrillation, promotion of exercise and healthy diet, and cessation of cigarette smoking are of particular importance in older adults. Recognition of stroke symptoms, access to emergency evaluation and treatments, and participation in comprehensive rehabilitation may determine stroke outcomes in aging. This article presents stroke risk factors and primary and secondary prevention in the context of aging, with special considerations in the identification and management of acute stroke, recovery, and rehabilitation for older adults who survive stroke.

Fatigue after stroke: relationship to mobility, fitness, ambulatory activity, social support, and falls efficacy.

Fatigue is common and persistent in stroke survivors, yet it is not known how mobility deficits, fitness, or other factors, such as social support, relate to fatigue severity, or whether subjective fatigue contributes to reduced ambulatory activity. The severity of fatigue in a sample of 53 community-dwelling subjects with chronic hemiparetic stroke was examined, and relationships among fatigue and mobility deficit severity, cardiovascular-metabolic fitness, ambulatory activity, social support, and self-efficacy for falls were identified. Measures included the Fatigue Severity Scale, timed 10-meter walks, the Berg Balance Scale, submaximal and peak VO2, total daily step activity derived from microprocessor-linked Step Activity Monitors, the Medical Outcomes Study Social Support Survey, and the Falls Efficacy Scale. Forty-six percent of the sample had severe fatigue. Fatigue showed no relationship to ambulatory activity. Fatigue severity was associated with the Berg Balance Scale (p < .01) and falls efficacy (p < .01), but not with cardiovascular fitness variables. Patients with elevated fatigue severity scores had lower social support (p < .05) and poorer falls efficacy scores (p < .05) than patients reporting less fatigue. Only falls efficacy was predictive of fatigue severity (r2 = 0.216, p < .01). Further studies are needed to evaluate whether rehabilitation strategies that include not only fitness and mobility interventions, but also social/behavioral and self-efficacy components, are associated with reduced fatigue and increased ambulation.

Steps after stroke: capturing ambulatory recovery.

BACKGROUND AND PURPOSE: Nearly two thirds of stroke survivors have deficits impairing ambulatory recovery. Conventional mobility outcome measures such as timed walks and functional independence measure (FIM) do not quantify free-living ambulatory behavior. This study compared step activity monitoring (SAM) with established instruments to assess ambulatory recovery across the outpatient subacute stroke rehabilitation phase. METHODS: We measured FIM mobility subscale, SAM-derived daily steps, Stroke Impact Scale (SIS) mobility scores, and timed walks in 11 subjects after discharge from inpatient rehabilitation and again 3 months later. RESULTS: Significant improvement was measured in free-living step activity (mean gain 80%; P=0.001) but not with timed walks (P=0.4), FIM (P=0.08), or SIS mobility scales (P=0.3). CONCLUSIONS: Microprocessor-linked SAM is a sensitive indicator of ambulatory recovery that measures improvements not captured by other conventional outcome instruments.

Fatigue and stroke.

Under disabling conditions such as stroke, fatigue may worsen other symptoms and impede full participation in a rehabilitation program. The functional improvement needed to regain mobility and independence may be impacted significantly by fatigue. This article explores the symptom of fatigue and its relation to stroke from a rehabilitation perspective. It examines theoretical models, operational definitions, fatigue as a response to stroke, assessment and measurement instruments, symptom management strategies, and future research directions.

People reducing risk and improving strength through exercise, diet, and drug adherence (PRAISEDD): a case report on long-term single site adoption.

African-American and low-income older adults have heightened risk for cardiovascular disease (CVD). Culturally and socially congruent community-based programs can promote risk-reduction behaviors, including physical activity (PA), and can demonstrate durability. The purpose was to increase lifestyle PA and promote self-management of CVD risk factors in a sample of at-risk older adults and to sustain a PA program within low-income housing. Exercise and education sessions were conducted three times/week for 12 weeks. A community champion was trained to carry on the classes thereafter, with monthly inoculation visits by a nurse and exercise trainer. Outcome measures included attendance and CVD risk factor control. This ongoing community-based program, incorporating peer leadership, inoculation visits, and self-efficacy enhancement, has been sustained for over 3 years with classes one to two times per week and routine attendance of about 12-18 residents. PRAISEDD demonstrates that a community-based PA program can be maintained using within-community leadership, periodic involvement of health care experts, and social support and self-efficacy enhancement.

Impact of treadmill exercise on efficacy expectations, physical activity, and stroke recovery.

Stroke survivors are at high risk for cardiovascular mortality which can be in part mitigated by increasing physical activity. Self-efficacy for exercise is known to play a role in adoption of exercise behaviors. This study examines self-reported psychological outcomes in a group of 64 stroke survivors randomized to either a 6-month treadmill training program or a stretching program. Results indicated that, regardless of group, all study participants experienced increased self-efficacy (F = 2.95, p = .09) and outcome expectations for exercise (F = 13.23, p < 0.001) and improvements in activities of daily living as reported on the Stroke Impact Scale (F = 10.97, p = .002). No statistically significant between-group differences were noted, possibly because of the fact that specific interventions designed to enhance efficacy beliefs were not part of the study. Theoretically based interventions should be tested to clarify the role of motivation and potential influence on exercise and physical activity in the stroke survivor population.