Factors affecting thrombolysis in acute stroke: longer door-to-needle (DTN) time in younger people? [Abstract No. 53]

Introduction: Shortening the time to delivery of IV thrombolysis improves patient outcomes and reduces adverse events. This research aimed to explore patient and service delivery factors that increase or decrease DTN time for thrombolysis. Method: We conducted a Service Evaluation from July 2011 to March 2013, using stroke data from SINAP and DASH databases. Data was provided by 6 acute trusts in Lancashire and Cumbria which used telemedicine, and 11 stroke services within the North East of England which instead used face-to-face. Our investigation concentrates on admissions to hospital occurring out of routine working hours, when resources are particularly constrained. Descriptive and inferential analyses, focusing on multivariate Cox regressions models selected using a forward stepwise approach, were then carried out to determine which factors impacted on DTN time, our main outcome variable. Results: After testing alternative specifications, our final model included these potential risk factors: mode of thrombolysis decision-making (either face-to-face or telemedicine); hospital; age; sex. Our results show that DTN time was strongly influenced by patient’s age (p<0.01), with older people receiving thrombolysis more quickly. Among the statistically significant variables, type of hospital (p<0.001) appeared to affect DTN times, together with patient’s sex (p¼0.01), suggesting that males had shorter DTN times. Conclusion: Older age was associated with shorter DTN times, with this effect being independent of other factors. Therefore, our research suggests that age played a predominant role in the delivery of thrombolysis, rather than solely through the choice of assessing acute strokethrough face-to-face or telemedicine

How is hydration assessed and managed in acute stroke? A qualitative study of healthcare staff’s knowledge, attitudes and experiences

Aims and Objectives To explore healthcare staff’s experiences of how dehydration is identified and managed in hospitalised patients after acute stroke, and facilitators and challenges to optimising hydration. Background Optimal hydration post-stroke reduces the risk of neurological deterioration and other complications. Patients are at risk of dehydration in acute stroke, particularly those with dysphagia. Design A descriptive qualitative study reported following the COREQ guidelines. Methods Semi-structured interviews, utilising patient vignettes, were conducted in 2018 (Apr-Oct) with a purposive sample of 30 multi-disciplinary staff members from two UK stroke units. Interviews were digitally recorded and transcribed verbatim. Content analysis identified common themes which were mapped to the Theoretical Domains Framework and the Behaviour Change Wheel. Results The themes mapped to twelve of the fourteen domains in the Theoretical Domains Framework. Participants believed that inadequate hydration management had potentially serious consequences, and described complex knowledge, skills and cognitive elements to effective hydration care. Participants felt that maintaining hydration was a multidisciplinary responsibility requiring good communication. Although the performance of initial dysphagia screening was reinforced by external audit, other areas of post-stroke hydration management were not; notably, there was no established method of assessing hydration. Barriers to maintaining good hydration included lack of staff, out-of-hours working patterns, low priority given to hydration, patients’ co-morbidities, and complex post-stroke disabilities such as dysphagia, aphasia, inattention and hemiparesis. Conclusion Findings highlighted the importance of assessing and maintaining hydration but identified barriers to, and variation in, clinical practice. To provide optimal care, barriers to the prevention and treatment of dehydration after stroke must be further understood and addressed. Relevance to Clinical Practice Multidisciplinary teamwork is important in hydration care after stroke, but clarity is required about the specific contributions of each team member. Without this, hydration care becomes ‘everybody’s and nobody’s job’

Assessing fidelity to complex interventions: the icons experience

Background Assessing fidelity to complex healthcare interventions in clinical trials is a challenging area. ‘ICONS' is a cluster randomised controlled feasibility trial of a systematic voiding programme (SVP), incorporating bladder training and prompted voiding, to promote post-stroke continence. Here we describe feasibility of one aspect of fidelity assessment: the day-to-day implementation of the SVP through analysis of clinical logs. Methods Nurses completed clinical logs daily, which included documenting: the toileting interval, proposed toileting times and times toileted. Clinical logs were sampled across trial sites. The original intention was to assess fidelity by exploring the degree of concordance between proposed times and times toileted. Initial analysis revealed the unfeasibility of this method due to documentation errors in toileting intervals and proposed times. Consequently, the planned method was changed to identification of key ‘quality indicators' (QIs) for documentation of practice. Results The need to revise the method of measurement demonstrates the difficulty in assessing fidelity. Assessment of clinical logs revealed low levels of adherence to key quality indicators. However, it is unclear whether this indicates poor fidelity or an imprecise method of fidelity assessment. Conclusion This study highlights challenges of assessing fidelity to complex interventions. Lessons learned will inform the measurement of fidelity in a future trial. Researchers should be aware that the practical implementation of complex healthcare interventions may not be exactly as intended. For ICONS, clinical logs constituted a proxy measure of day-to-day fidelity to the intervention: identification of alternative methods could be considered

Predictors of recognition of out of hospital cardiac arrest by emergency medical services call handlers in England: a mixed methods diagnostic accuracy study

Abstract: Background: The aim of this study was to identify key indicator symptoms and patient factors associated with correct out of hospital cardiac arrest (OHCA) dispatch allocation. In previous studies, from 3% to 62% of OHCAs are not recognised by Emergency Medical Service call handlers, resulting in delayed arrival at scene. Methods: Retrospective, mixed methods study including all suspected or confirmed OHCA patients transferred to one acute hospital from its associated regional Emergency Medical Service in England from 1/7/2013 to 30/6/2014. Emergency Medical Service and hospital data, including voice recordings of EMS calls, were analysed to identify predictors of recognition of OHCA by call handlers. Logistic regression was used to explore the role of the most frequently occurring (key) indicator symptoms and characteristics in predicting a correct dispatch for patients with OHCA. Results: A total of 39,136 dispatches were made which resulted in transfer to the hospital within the study period, including 184 patients with OHCA. The use of the term ‘Unconscious’ plus one or more of symptoms ‘Not breathing/Ineffective breathing/Noisy breathing’ occurred in 79.8% of all OHCAs, but only 72.8% of OHCAs were correctly dispatched as such. ‘Not breathing’ was associated with recognition of OHCA by call handlers (Odds Ratio (OR) 3.76). The presence of key indicator symptoms ‘Breathing’ (OR 0.29), ‘Reduced or fluctuating level of consciousness’ (OR 0.24), abnormal pulse/heart rate (OR 0.26) and the characteristic ‘Female patient’ (OR 0.40) were associated with lack of recognition of OHCA by call handlers (p-values < 0.05). Conclusions: There is a small proportion of calls in which cardiac arrest indicators are described but the call is not dispatched as such. Stricter adherence to dispatch protocols may improve call handlers’ OHCA recognition. The existing dispatch protocol would not be improved by the addition of further terms as this would be at the expense of dispatch specificity

Implementation—The Missing Link in the Research Translation Pipeline: Is It Any Wonder No One Ever Implements Evidence-Based Practice?

Despite the exponential growth in the evidence base for stroke rehabilitation, there is still a paucity of knowledge about how to consistently and sustainably deliver evidence-based stroke rehabilitation therapies in clinical practice. This means that people with stroke will not consistently benefit from research breakthroughs, simply because clinicians do not always have the skills, authority, knowledge or resources to be able to translate the findings from a research trial and apply these in clinical practice. This “point of view” article by an interdisciplinary, international team illustrates the lack of available evidence to guide the translation of evidence to practice in rehabilitation, by presenting a comprehensive and systematic content analysis of articles that were published in 2016 in leading clinical stroke rehabilitation journals commonly read by clinicians. Our review confirms that only a small fraction (2.5%) of published stroke rehabilitation research in these journals evaluate the implementation of evidence-based interventions into health care practice. We argue that in order for stroke rehabilitation research to contribute to enhanced health and well-being of people with stroke, journals, funders, policy makers, researchers, clinicians, and professional associations alike need to actively support and promote (through funding, conducting, or disseminating) implementation and evaluation research

Implementing the PREP2 algorithm to predict upper limb recovery potential after stroke in clinical practice: a qualitative study

Background Predicting motor recovery after stroke is a key factor when planning and providing rehabilitation for individual patients. The PREP2 algorithm has been developed to help clinicians predict upper limb functional outcome. Translating evidence-based interventions into clinical practice can be challenging and slow. However, shortly after its external local validation, PREP2 was successfully implemented into clinical practice at the same site in New Zealand. In parallel to further model validation, useful lessons can be learned from this experience to aid future implementation. Objective To explore how PREP2 was implemented in clinical practice within the Auckland District Health Board (ADHB) in New Zealand. Design A case study design using semi-structured interviews. Methods Nineteen interviews were conducted with clinicians involved in stroke care at ADHB. To explore factors influencing implementation, interview content was coded and analysed using the Consolidated Framework for Implementation Research. Strategies identified by the Expert Recommendations for Implementing Change (ERIC) project were used to describe how implementation was undertaken. Results Implementation of PREP2 was initiated and driven by therapists. Key factors driving implementation were the support given to staff from the implementation team; the knowledge, beliefs and self-efficacy of staff, and the perceived benefits of having PREP2 prediction information. Twenty-six ERIC strategies were identified relating to three areas: the implementation team, the clinical/academic partnerships and the training. Limitations Limitations included potential self-selection bias, reliance on clinicians’ ability to recall events, and potential social desirability bias affecting interview content. Conclusions The PREP2 prediction tool was successfully implemented in clinical practice at ADHB. Barriers and facilitators to implementation success have been identified, and implementation strategies described. Lessons learned can aid future development and implementation of prediction models in clinical practice

Wireless Sensor Network for Safe Transportation

Since dangerous goods have special physical and chemical properties, they can easily produce explosion, fire, poisoning and other accident due to a traffic collision or hazardous leak under a complex transport condition. Compared with ordinary traffic accidents, accident of dangerous goods transportation has greater risks and subsequent influence. Due to the huge transportation equipment and high freight volumes, once the accident occurred, it will be difficult to deal with the danger in the first place. Faced with such a grim situation, this paper develops a system to achieve real- time monitoring of dangerous goods transportation based on wireless sensor network (WSN). Combined with different kind of sensors, wireless communication technology and data fusion technology, a real-time monitor system is developed for dangerous good transportation. In addition to real- time monitoring, the system can analyze the state parameters obtained to check whether the vehicle is in a safe condition. The system has a real-time tracking, monitoring and early warning function which has important significance in curbing accidents and lowering the accident loss as far as possibl