A Hospital-based Managed Alcohol Program in a Canadian Setting.

OBJECTIVES: A managed alcohol program (MAP) is a harm reduction strategy that provides regularly, witnessed alcohol to individuals with a severe alcohol use disorder. Although community MAPs have positive outcomes, applicability to hospital settings is unknown. This study describes a hospital-based MAP, characterizes its participants, and evaluates outcomes. METHODS: A retrospective chart review of MAP participants was conducted at an academic hospital in Vancouver, Canada, between July 2016 and October 2017. Data included demographics, alcohol/substance use, alcohol withdrawal risk, and MAP indication. Outcomes after MAP initiation included the change in mean daily alcohol consumption and liver enzymes. RESULTS: Seventeen patients participated in 26 hospital admissions: 76% male, mean age of 54 years, daily consumption prehospitalization of a mean 14 alcohol standard drinks, 59% reported previous nonbeverage alcohol consumption, and 41% participated in a community MAP. Most participants were high risk for severe, complicated alcohol withdrawal and presented in moderate withdrawal. Continuation of community MAP was the most common indication for hospital-based MAP initiation (38%), followed by a history of leaving hospital against medical advice (35%) and hospital illicit alcohol use (15%). Hospital-based MAP resulted in a mean of 5 fewer alcohol standard drinks daily compared with preadmission ( P = 0.002; 95% confidence interval, 2-8) and improvement in liver enzymes, with few adverse events. CONCLUSIONS: Participation in a hospital-based MAP may be an effective safe approach to reduce harms for some individuals with severe alcohol use disorder. Further study is needed to understand who benefits most from hospital-MAP and potential benefits/harms following hospital discharge.

Gamification of dementia education in hospitals: a knowledge translation project.

This knowledge translation study qualitatively explores strategies that facilitated hospital staff engagement in online educational games for dementia education. Interdisciplinary staff (n = 2010) in 10 hospitals played online games to learn about basic communication techniques. We identified five facilitating strategies, E-GAME: Easy access to learning, Give both extrinsic and intrinsic rewards, Apply implementation science theory, Multiple tools, and Evaluation. This article offers useful tips for educators to innovate dementia education for practice improvement.

Implementation of an Acute Care COPD Exacerbation Patient Mobilization Tool. A Mixed-Methods Study.

Background: Improving the mobility of hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a priority of care. AECOPD-Mob is a clinical decision-making tool for physical therapists, especially those who are newly graduated or are new to caring for patients with AECOPDs in acute care settings. Although this tool has been available for several years, dissemination via publication is not sufficient to implement it in clinical practice.Objective: The primary objective of this study was to develop, implement, and evaluate different formats of AECOPD-Mob in an acute care setting.Methods: We used a mixed-methods, convergent parallel design. In addition to the paper format of AECOPD-Mob, we developed a smartphone app, a web-based learner module, and an in-service learning session. Newly graduated physical therapists (PTs) or PTs new to the practice area were recruited from urban acute care hospitals. Participants used the different formats for 3 weeks and then completed the Post-Study System Usability Questionnaire. User data were retrieved for the learning module. Participants participated in focus groups at 3 weeks and 3 months.Results: Eighteen (72% of eligible PTs, 100% female, 94% graduated within 3 yr) PTs participated. Post-Study System Usability Questionnaire scores for the learning module and smartphone indicated that participants were satisfied with these formats (median score 2.0 on 1-7 Likert Scale for both technology formats, lower scores indicating greater satisfaction). However, the participants reported in the focus group that the paper format was preferred over other formats. Concerns with the smartphone app included infection control and the perception of lack of professionalism when using a smartphone during clinical practice. The learning module and in-service were considered helpful as an introduction but not as an ongoing support. The paper format was seen as the most efficient way to access the necessary information and to facilitate communication between other members of the care team about the importance of mobility for hospitalized patients with AECOPDs.Conclusion: Newly graduated PTs strongly preferred the paper format of the AECOPD-Mob tool in the acute care setting. Future research will focus on knowledge translation strategies for other health disciplines.

Exploring the experience of inpatients with severe alcohol use disorder on a managed alcohol program (MAP) at St. Paul's Hospital.

BACKGROUND: Managed alcohol programs are a harm reduction approach for people with severe alcohol use disorder that provide alcohol in a structured setting. We examined the patient experience of receiving alcohol after the implementation of a hospital-based managed alcohol program. METHODS: Using an interpretative descriptive methodology, we conducted interviews with five patients. The criteria for enrollment included continuation of community managed alcohol program or provision of alcohol for stabilization in hospital and ability to provide consent. RESULTS: Five themes emerged in the analysis: (1) Reasons for alcohol use highlighting factors leading to alcohol consumption; (2) I'm very appreciative indicating participant's perception of hospital-based managed alcohol program; (3) From just vibrating to calm and It's kinda like a pacifier for me recognizing the impact of hospital-based managed alcohol program on managing withdrawal and on psychological health; (4) I have no need to go anywhere at all demonstrating engagement in healthcare; and (5) Might be nice to have a selection for other people indicating the need for a broader selection of alcohol. CONCLUSIONS: This study helped to explore the effectiveness of a hospital-based managed alcohol program as experienced by the patients. Overall, participants had a positive experience on hospital-based managed alcohol program. Their perceptions can be used to inform implementation of managed alcohol programs in other hospital settings.

Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

The sixth update of the Canadian Stroke Best Practice Recommendations for Transitions and Community Participation following Stroke is a comprehensive set of evidence-based guidelines addressing issues faced by people following an acute stroke event. Establishing a coordinated and seamless system of care that supports progress achieved during the initial recovery stages throughout the transition to the community is more essential than ever as the medical complexity of people with stroke is also on the rise. All members of the health-care team engaged with people with stroke, their families, and caregivers are responsible for partnerships and collaborations to ensure successful transitions and return to the community following stroke. These guidelines reinforce the growing and changing body of research evidence available to guide ongoing screening, assessment, and management of individuals following stroke as they move from one phase and stage of care to the next without "falling through the cracks." It also recognizes the growing role of family and informal caregivers in providing significant hours of support that disrupt their own lives and responsibilities and addresses their support and educational needs. According to Statistics Canada, in 2012, eight million Canadians provided care to family members or friends with a long-term health condition, disability, or problems associated with aging. These recommendations incorporate aspects that were previously in the rehabilitation module for the purposes of streamlining, and both modules should be reviewed in order to provide comprehensive care addressing recovery and community reintegration and participation. These recommendations cover topics related to support and education of people with stroke, families, and caregivers during transitions and community reintegration. They include interprofessional planning and communication, return to driving, vocational roles, leisure activities and relationships and sexuality, and transition to long-term care.

Exploring perceptions of stroke survivors and caregivers about secondary prevention: a longitudinal qualitative study.

Purpose: To explore the changes in perceived barriers and facilitators associated with participation in secondary prevention activities of stroke survivors and their caregivers over the early stroke recovery period.Method: We conducted two individual interviews (at 2 weeks and 6 months post-discharge) with stroke survivors and their family members. Using purposive sampling, participants were recruited from the stroke units of two acute care hospitals.Results: About 11 male and 8 female stroke survivors and nine caregivers participated in the study. Thematic analysis identified three themes. (1) "A soul searching experience" indicating that the stroke was anxiety provoking leading to a soul searching experience into exploring its causes to adopt a healthy lifestyle; (2) "Old habits die hard" revealing that stroke survivors encountered barriers to adopt healthy lifestyle changes; (3) "Making a fresh start" recognizing that participants were motivated to make their lifestyle healthier and most sustained some lifestyle changes over the past 6 months.Conclusion: Despite experiencing some barriers, stroke survivors adopted lifestyle changes transitioning through different stages of change. Stroke prevention education and interventions from experts would be helpful later in the rehabilitation phase (once at home) and adopting a patient-family centered approach may assist stroke survivors and their caregivers in the uptake of secondary stroke prevention activities.Implications for rehabilitationStroke is perceived as a soul searching experience by stroke survivors and their caregivers motivating them to enquire its causes and adopting lifestyle changes to prevent a future stroke.Despite experiencing some barriers, stroke survivors adopted lifestyle changes transitioning through different stages of change.Stroke prevention education and interventions from experts would be helpful later in the rehabilitation phase (once at home).Adopting a patient-family centered approach may assist stroke survivors and their caregivers in the uptake of secondary stroke prevention activities.

The de Morton mobility index is a feasible and valid mobility assessment tool in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease.

There is no accepted standard for measuring mobility in hospitalized patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The objective of this study was to assess convergent, discriminant, and known-group validity and floor/ceiling effects of the de Morton Mobility Index (DEMMI) in hospitalized patients with AECOPD. Individuals with AECOPD (n = 22) admitted to an acute care hospital medical ward were recruited. Data on the DEMMI, gait speed, daytime energy expenditure, step counts, 6-minute walk distance (6MWD), dyspnea, respiratory and heart rates, quality of life, and oxygen supplementation were collected on day 3 of admission. The DEMMI demonstrated convergent validity with the 6MWD and gait velocity measures (Spearman's ρ 0.69 and 0.61, respectively; p < 0.003) but not with measures of physical activity or respiratory impairment. Discriminant validity was present, with no correlation between the DEMMI and quality of life and resting heart rate. Known-group validity (gait aids vs. no gait aids) was demonstrated (p = 0.009). There was no floor effect but there was evidence of a possible ceiling effect (14% of participants received a perfect score). The DEMMI is feasible and showed moderate to strong validity with measures of observed physical function in hospitalized patients with AECOPD.

Determinants Influencing the Prestroke Health Behaviors and Cardiovascular Disease Risk of Stroke Patients: A Cross-Sectional Study.

BACKGROUND: Knowledge about stroke and stroke prevention may provide motivation to lead a healthy lifestyle to prevent stroke. The goal of this study is to quantify the knowledge of stroke and stroke prevention of patients with a recent stroke and its association with health behaviors and cardiovascular disease risk. METHODS: We conducted a prospective cross-sectional study utilizing consecutive stroke admissions at 2 hospitals in Vancouver, Canada. We included patients within 48-72 hours of admission. Stroke knowledge was measured prior to any hospital education. The Health-Promoting Lifestyle Profile II (HPLP II), a 52-item self-report scale was used to quantify health behavior for the week prior to the stroke. The cardiovascular risk score was calculated. Hierarchical multiple regression was used to assess the determinants of HPLP II and cardiovascular disease risk. RESULTS: We enrolled patients with primarily mild stroke (n = 100). The mean age of participants was 66.6 ± 13.6 years and 60% were male. The participants had poor knowledge of stroke symptoms and risk factors. In the first regression analysis, the final model explained 27% of the variance in health behavior (F (6, 93) = 5.69, p = <0.001) with only age and knowledge of risk factors as statistically significant variables. In the second regression analysis, the final model explained 15% of the variance in cardiovascular disease risk (F (7, 84) = 2.163, p = 0.046) with only physical activity remaining as a statistically significant variable. CONCLUSION: The findings would inform the development of novel programs to improve the knowledge and health behavior for prevention of stroke.

Effectiveness of interventions involving nurses in secondary stroke prevention: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Among members of the health care team, nurses play a large role in actively engaging stroke survivors in secondary stroke prevention programs. This systematic review and meta-analysis examines the effectiveness of interventions in which nurses have a primary role on modification of risk factors among stroke survivors. METHODS: We systematically searched for randomized controlled trials in relevant databases investigating the role of nurses in secondary stroke prevention. Meta-analyses were conducted using Cochrane Review Manager Software. The mean pooled effect size, a 95% confidence interval (CI), and I-squared ( I2) for heterogeneity were calculated. RESULTS: Sixteen randomized controlled trials were included with a total of 3568 stroke and transient ischemic attack patients. After removing one outlier, the models demonstrated a statistically significant effect on reducing systolic blood pressure (SMD = -0.14 (95% CI = -0.23, -0.05), I2 = 0%; p = 0.002, six studies, n =1885) and diastolic blood pressure (SMD = -0.16 (95% CI = -0.27, -0.05), I2 = 0%; p = 0.003, four studies, n =1316). The interventions also significantly improved physical activity (five studies, n=1234), diet (three studies, n=425), medication adherence (two studies, n=270), and knowledge of risk factors (three studies, n=516). However, there was no effect on smoking cessation or reduction in use of alcohol. CONCLUSION: We found that interventions in which nurses had a primary role were effective on improving medical and behavioral risk factors, as well as knowledge of risk factors as part of secondary prevention of stroke.

"Stepping Up" Activity Poststroke: Ankle-Positioned Accelerometer Can Accurately Record Steps During Slow Walking.

BACKGROUND: As physical activity in people poststroke is low, devices that monitor and provide feedback of walking activity provide motivation to engage in exercise and may assist rehabilitation professionals in auditing walking activity. However, most feedback devices are not accurate at slow walking speeds. OBJECTIVE: This study assessed the accuracy of one accelerometer to measure walking steps of community-dwelling individuals poststroke. DESIGN: This was a cross-sectional study. METHODS: Two accelerometers were positioned on the nonparetic waist and ankle of participants (N=43), and walking steps from these devices were recorded at 7 speeds (0.3-0.9 m/s) and compared with video recordings (gold standard). RESULTS: When positioned at the waist, the accelerometer had more than 10% error at all speeds, except 0.8 and 0.9 m/s, and numerous participants recorded zero steps at 0.3 to 0.5 m/s. The device had 10% or less error when positioned at the ankle for all speeds between 0.4 and 0.9 m/s. LIMITATIONS: Some participants were unable to complete the faster walking speeds due to their walking impairments and inability to maintain the requested walking speed. CONCLUSIONS: Although not recommended by the manufacturer, positioning the accelerometer at the ankle (compared with the waist) may fill a long-standing need for a readily available device that provides accurate feedback for the altered and slow walking patterns that occur with stroke.

Capturing step counts at slow walking speeds in older adults: comparison of ankle and waist placement of measuring device.

OBJECTIVE: It is important for older adults to be physically active, but many older adults walk slowly. This study examined the accuracy of a commercially available step-count device (Fitbit One) at slow speeds and compared the accuracy of the device when worn at the ankle and waist in older adults. METHODS: The Fitbit One was placed at the ankle and waist of participants (n=42; mean age 73 years) while they performed walking trials at 7 different speeds (0.3-0.9 m/s). Step counts obtained from video recordings were used as the gold standard comparison to determine the accuracy of the device. RESULTS: The ankle-worn device had significantly less error than the waist-worn device at all speeds. The percentage error of the ankle-worn device was less than 10% at speeds of 0.4-0.9 m/s and did not record zero steps at any speed. The percentage error of the waist-worn device was below 10% at only the 2 fastest speeds (0.8 and 0.9 m/s) and recorded zero steps for numerous participants at speeds of 0.3-0.5 m/s. CONCLUSION: The Fitbit One can accurately capture steps at slow speeds when placed at the ankle and thus may be appropriate for capturing physical activity in slow-walking older adults.