Vulnerability in regionally ischemic human heart. Effect of the extracellular potassium concentration

Ventricular tachycardia and ventricular fibrillation are two types of cardiac arrhythmias that usually occur during acute ischemia and frequently lead to sudden death. Pro-arrhythmic mechanisms related to acute ischemia have been extensively investigated, although often in animal models rather than in human. In this work, we investigate how hyperkalemia affects the vulnerable window to reentry and the reentry patterns in the heterogeneous substrate caused by acute regional ischemia using an anatomically and biophysically detailed human biventricular model. The ischemic region was located in the inferolateral and posterior side of the left ventricle, mimicking the occlusion of the circumflex artery, and includes a wash-out zone not affected by ischemia located in the endocardium. Realistic heterogeneity and fiber anisotropy have been considered in the model. An electrophysiologically detailed human action potential model has been modified to simulate ischemic conditions. The model predicts the generation of sustained reentrant activity in the form of single and double circuits around an area of block within the ischemic zone for K+concentrations below 9 mM, with the reentrant activity corresponding to ventricular tachycardia in all cases. Our results also suggest that the wash-out zone is a potential pro-arrhythmic factor that favors sustained ventricular tachycardia

The prevention access and risk taking in young people (PARTY) project protocol: A cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice

Abstract Background There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing. Main outcomes: clinicians’ detection of risk-taking and emotional distress, young people’s intention to change and reduction of risk taking. Secondary outcomes: pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol. Methods PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff’s self-perceived competency in young people’s care and clinicians’ detection and response to risk taking behaviours and emotional distress in 14–24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation. Discussion The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months. Trial registration ISRCTN1605920

Understanding the role of external facilitation to drive quality improvement for stroke care in hospitals

The use of external facilitation within the context of multicomponent quality improvement interventions (mQI) is growing. We aimed to evaluate the influence of external facilitation for improving the quality of acute stroke care. Clinicians from hospitals participating in mQI (Queensland, Australia) as part of the Stroke123 study were supported by external facilitators in a single, on-site workshop to review hospital performance against eight clinical processes of care (PoCs) collected in the Australian Stroke Clinical Registry (AuSCR) and develop an action plan. Remote support (i.e., telephone/email) after the workshop was provided. As part of a process evaluation for Stroke123, we recorded the number and mode of contacts between clinicians and facilitators; type of support provided; and frequency of self-directed, hospital-level stroke registry data reviews. Analysis: We measured the association between amount/type of external facilitation, (i) development of action plans, and (ii) adherence to PoCs before and after the intervention using AuSCR data from 2010 to 2015. In total, 14/19 hospitals developed an action plan. There was no significant difference in amount or type of external facilitator support provided between hospitals that did, and did not, develop an action plan. There was no relationship between the amount of external facilitation and change in adherence to PoCs. Most (95%) hospitals accessed stroke registry performance data. In the Stroke123 study, the amount or type of external facilitation did not influence action plan development, and the amount of support did not influence the changes achieved in adherence to PoCs. Remote support may not add value for mQI

Improving quality and outcomes of stroke care in hospitals: Protocol and statistical analysis plan for the Stroke123 implementation study

Rationale: The effectiveness of clinician-focused interventions to improve stroke care is uncertain. Aims: To determine whether an organizational intervention can improve the quality of stroke care over usual care. Sample size estimates: To detect an absolute 10% difference in overall performance (composite outcome), a minimum of 21 hospitals and 843 patients per group was determined. Methods and design: Before and after controlled design in hospitals in Queensland, Australia. Intervention: Externally facilitated program (StrokeLink) using outreach workshops incorporating clinical performance feedback, patient outcomes (survival, quality of life at 90–180 days), local barrier assessments to best practice care, action planning, and ongoing support. Descriptive and multivariable analyses adjusted for patient correlations by hospital (intention-to-treat method). Context: Concurrent implementation of financial incentives to increase stroke unit access and use of the Australian Stroke Clinical Registry for performance monitoring. Study outcome(s): Primary outcome: net change in composite score (i.e. total number of process indicators achieved divided by the sum of eligible indicators for each cohort). Secondary outcomes: change in individual indicators, change in composite score comparing hospitals that did or did not develop action plans (per-protocol analysis), impact on 90–180-day health outcomes. Sensitivity analyses: hospital self-rated status, alternate cross-sectional audit data (Stroke Foundation). To account for temporal effects, comparison of Queensland hospital performance relative to other Australian hospitals will also be undertaken. Discussion: Twenty-one hospitals were recruited; however, one was unable to participate within the study time frame. Workshops were held between 11 March 2014 and 7 November 2014. Data are ready for analysis

A stepped-wedge cluster-randomized trial to improve adherence to evidence-based practices for acute stroke management

Background There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data. Methods STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change champions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and individual indicators (secondary outcome). Patient survival and disability 90–180 days after stroke were also compared. Results Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years; 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years; 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals’ action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05–1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50–2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05–1.53). Patient outcomes were unchanged. Conclusion External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care

Outcomes for patients with in-hospital stroke: a multicenter study from the Australian Stroke Clinical Registry (AuSCR)

Background: The quality of care and outcomes for people who experience stroke whilst in hospital for another condition has not been previously studied in Australia. Aims: To explore differences in long-term outcomes among patients with in-hospital events treated in stroke units (SUs) compared to those managed in other hospital wards. Methods: Forty-five hospitals participating in the Australian Stroke Clinical Registry between January 2010 and December 2014 contributed data. Survival of all patients with in-hospital stroke to 180 days after stroke and health-related quality of life, using EQ-5D-3L among 73% eligible, were compared using multilevel, multivariable regression models. Models were adjusted for age, sex, index of relative socioeconomic disadvantage, ability to walk, stroke type, transfer from another hospital, and history of stroke. Results: Among 20,786 stroke events, 1182 (5.1%) occurred in-hospital (median age 77 years, 49% male). Patients with in-hospital stroke treated in SUs died less often within 30 days (Hazard Ratio 0.56; 95% CI 0.39-0.81) than those not admitted to SUs. Survivors reported similar health-related quality of life between 90 and 180 days compared to those treated in other wards (coefficient = 0.01, 95% CI –0.06-0.09, P =.78). Patients managed in SUs more often received recommended management (e.g. swallowing screening). Conclusion: The benefits of SU care may extend to patients experiencing in-hospital stroke. Validation, including accounting for potential residual confounding factors, is required

Correction to: Hospital organizational context and delivery of evidence-based stroke care: a cross-sectional study

Following publication of the original article [1], the authors reported an error in one of the authors’ names. In this Correction the incorrect and correct author name are shown. The original article has been corrected

Quality of life is poorer for patients with stroke who require an interpreter : An observational Australian Registry study

Background and Purpose— In multicultural Australia, some patients with stroke cannot fully understand, or speak, English. Language barriers may reduce quality of care and consequent outcomes after stroke, yet little has been reported empirically. Methods— An observational study of patients with stroke or transient ischemic attack (2010–2015) captured from 45 hospitals participating in the Australian Stroke Clinical Registry. The use of interpreters in hospitals, which is routinely documented, was used as a proxy for severe language barriers. Health-Related Quality of Life was assessed using the EuroQoL-5 dimension-3 level measured 90 to 180 days after stroke. Logistic regression was undertaken to assess the association between domains of EuroQoL-5 dimension and interpreter status. Results— Among 34 562 registrants, 1461 (4.2%) required an interpreter. Compared with patients without interpreters, patients requiring an interpreter were more often women (53% versus 46%; P<0.001), aged ≥75 years (68% versus 51%; P<0.001), and had greater access to stroke unit care (85% versus 78%; P<0.001). After accounting for patient characteristics and stroke severity, patients requiring interpreters had comparable discharge outcomes (eg, mortality, discharged to rehabilitation) to patients not needing interpreters. However, these patients reported poorer Health-Related Quality of Life (visual analogue scale coefficient, −9; 95% CI, −12.38, −5.62), including more problems with self-care (odds ratio: 2.22; 95% CI, 1.82, 2.72), pain (odds ratio: 1.84; 95% CI, 1.52, 2.34), anxiety or depression (odds ratio: 1.60; 95% CI, 1.33, 1.93), and usual activities (odds ratio: 1.62; 95% CI, 1.32, 2.00). Conclusions— Patients requiring interpreters reported poorer Health Related Quality of Life after stroke/transient ischemic attack despite greater access to stroke units. These findings should be interpreted with caution because we are unable to account for prestroke Health Related Quality of Life. Further research is needed