Dose and setting of rehabilitation received after stroke in Queensland, Australia: a prospective cohort study.

OBJECTIVE: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. DESIGN: This was a prospective observational cohort study. SETTING: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. SUBJECTS: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. METHODS: We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. MEASURES: Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. RESULTS: We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors. CONCLUSION: Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.

The impact of environmental enrichment in an acute stroke unit on how and when patients undertake activities.

OBJECTIVES:: To explore the effect of environmental enrichment within an acute stroke unit on how and when patients undertake activities, and the amount of staff assistance provided, compared with a control environment (no enrichment). DESIGN:: This is a substudy of a controlled before-after observational study. SETTING:: The study was conducted in an Australian acute stroke unit. PARTICIPANTS:: The study included stroke patients admitted to (1) control and (2) environmental enrichment period. INTERVENTION:: The control group received standard therapy and nursing care, which was delivered one-on-one in the participants' bedroom or a communal gym. The enriched group received stimulating resources and communal areas for mealtimes, socializing and group activities. Furthermore, participants and families were encouraged to increase patient activity outside therapy hours. MAIN MEASURES:: Behavioral mapping was performed every 10 minutes between 7.30 a.m. and 7.30 p.m. on weekdays and weekends to estimate activity levels. We compared activity levels during specified time periods, nature of activities observed and amount of staff assistance provided during patient activities across both groups. RESULTS:: Higher activity levels in the enriched group ( n = 30, mean age 76.7 ± 12.1) occurred during periods of scheduled communal activity ( P < 0.001), weekday non-scheduled activity ( P = 0.007) and weekends ( P = 0.018) when compared to the control group ( n = 30, mean age 76.0 ± 12.8), but no differences were observed on weekdays after 5 p.m. ( P = 0.324). The enriched group spent more time on upper limb ( P < 0.001), communal socializing ( P < 0.001), listening ( P = 0.007) and iPad activities ( P = 0.002). No difference in total staff assistance during activities was observed ( P = 0.055). CONCLUSION:: Communal activities and environmental resources were important contributors to greater activity within the enriched acute stroke unit.

Assessment and selection for rehabilitation following acute stroke: a prospective cohort study in Queensland, Australia.

OBJECTIVE: To describe current practice and investigate factors associated with selection for rehabilitation following acute stroke. DESIGN: Prospective observational cohort study. SETTING: Seven public hospitals in Queensland, Australia. SUBJECTS: Consecutive patients surviving acute stroke. MEASURES: Rehabilitation selection processes are assessment for rehabilitation needs, referral for rehabilitation and receipt of rehabilitation. Functional impairment following stroke is modified Rankin Scale (mRS). RESULTS: We recruited 504 patients, median age 73 years (interquartile range (IQR) = 62-82), between July 2016 and January 2017. Of these, 90% (454/504) were assessed for rehabilitation needs, 76% (381/504) referred for rehabilitation, and 72% (363/504) received any rehabilitation. There was significant variation in all rehabilitation selection processes across sites (P < 0.05). In multivariable analyses, stroke unit care (odds ratio (OR) = 2.7; 95% confidence interval (CI) = 1.1, 6.6) and post stroke functional impairment (severe stroke mRS 4-5: OR = 10.9; 95% CI = 4.9, 24.6) were associated with receiving an assessment for rehabilitation. Receipt of rehabilitation was more likely following assessment (OR = 6.5; 95% CI = 2.9, 14.6) but less likely in patients with dementia (OR = 0.2; 95% CI = 0.1, 0.9), end-stage medical conditions (OR = 0.4; 95% CI = 0.2, 0.8) or ischaemic stroke (OR = 0.4; 95% CI = 0.1, 0.9). The odds of receiving rehabilitation increased with greater impairment: OR = 3.0 (95% CI = 1.5, 4.9) for mRS 2-3 and OR = 12.5 (95% CI = 6.5, 24.3) for mRS 4-5. Among patients with mild-moderate impairment (mRS 2-3), 39/117 (33%) received no rehabilitation. CONCLUSIONS: There was significant inter-site variation in rehabilitation selection processes. The major factors influencing rehabilitation access were assessment for rehabilitation needs, co-morbidities and post-stroke functional impairment. Gaps in access to rehabilitation were found in those with mild to moderate functional impairment.

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before-after pilot study.

OBJECTIVES: To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events. DESIGN: Controlled before-after pilot study. SETTING: An acute stroke unit in a regional Australian hospital. PARTICIPANTS: Acute stroke patients admitted during (a) initial usual care control period, (b) an enriched environment period and (c) a sustainability period. INTERVENTION: Usual care participants received usual one-on-one allied health intervention and nursing care. The enriched environment participants were provided stimulating resources, communal areas for eating and socializing and daily group activities. Change management strategies were used to implement an enriched environment within existing staffing levels. MAIN MEASURES: Behavioural mapping was used to estimate patient activity levels across groups. Participants were observed every 10 minutes between 7.30 am and 7.30 pm within the first 10 days after stroke. Adverse and serious adverse events were recorded using a clinical registry. RESULTS: The enriched environment group ( n = 30, mean age 76.7 ± 12.1) spent a significantly higher proportion of their day engaged in 'any' activity (71% vs. 58%, P = 0.005) compared to the usual care group ( n = 30, mean age 76.0 ± 12.8). They were more active in physical (33% vs. 22%, P < 0.001), social (40% vs. 29%, P = 0.007) and cognitive domains (59% vs. 45%, P = 0.002) and changes were sustained six months post implementation. The enriched group experienced significantly fewer adverse events (0.4 ± 0.7 vs.1.3 ± 1.6, P = 0.001), with no differences found in serious adverse events (0.5 ± 1.6 vs.1.0 ± 2.0, P = 0.309). CONCLUSIONS: Embedding an enriched environment in an acute stroke unit increased activity in stroke patients.

Acute stroke patients not meeting their nutrition requirements: Investigating nutrition within the enriched environment.

BACKGROUND & AIMS: Malnutrition is common after stroke. We investigated the impact of environmental enrichment strategies on dietary intake and rates of malnutrition in an acute stroke unit. METHODS: We performed a before-after study. In standard care, meals were delivered to participants' rooms whilst in the enriched environment, communal meals with assistance were offered and nutritional intake reminders were placed at the patient bedside. Nutrition supplementation was provided to both groups if indicated. Breakfast and lunch meals were directly observed while remaining intake was calculated using food charts. Nutrition requirements were calculated for energy (ratio method), protein (1 g/kg) and proportion of requirements met. Malnutrition was assessed using the Subjective Global Assessment and body weight. ANCOVA adjusting for stroke severity was used to determine between group differences. Stepwise multivariable logistic regression was performed to assess predictors of nutritional outcomes, adjusting for intervention group, demographic, clinical and baseline nutritional factors. RESULTS: Neither standard care (n = 30, age 76.0yrs ± SD12.8) nor enriched environment (n = 30, age 76.7yrs ± SD12.1, p = 0.84) met daily requirements for energy (70.7% ± SD16.8 vs. 70.7% ± SD17.3, p = 0.94) or protein intake (73.2% ± SD18.6 vs. 69.8% ± SD17.3, p = 0.70). Mean body weight dropped: standard care 0.92 kg ± SD2.47 vs. enriched 0.64 kg ± SD3.12 (p = 0.53) and malnutrition increased: standard care 3.3%-26.6% vs. enriched 6.6%-13.3% (p = 0.07). Predictors of malnutrition on discharge in logistic regression models were: length of stay (p < 0.01) and protein (p < 0.01) or energy intake (p = 0.02). CONCLUSIONS: Acute stroke patients were not meeting nutritional requirements and losing body weight. The enriched environment showed no effect on nutritional intake. Malnutrition was associated with lower energy and protein intakes and increased length of stay.