Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial

Background High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. Methods We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UK based ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053. Findings Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited 1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min (IQR 45–116). 597 (52%) patients had ischaemic stroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) had transient ischaemic attack, and 297 (26%) had a non-stroke mimic at the final diagnosis of the index event. In the GTN group, participants’ systolic blood pressure was lowered by 5·8 mm Hg compared with the sham group (p<0·0001), and diastolic blood pressure was lowered by 2·6 mm Hg (p=0·0026) at hospital admission. We found no difference in mRS between the groups in participants with a final diagnosis of stroke or transient ischaemic stroke (cohort 1): 3 (IQR 2–5; n=420) in the GTN group versus 3 (2–5; n=408) in the sham group, adjusted common odds ratio for poor outcome 1·25 (95% CI 0·97–1·60; p=0·083); we also found no difference in mRS between all patients (cohort 2: 3 [2–5]; n=544, in the GTN group vs 3 [2–5]; n=558, in the sham group; 1·04 [0·84–1·29]; p=0·69). We found no difference in secondary outcomes, death (treatment-related deaths: 36 in the GTN group vs 23 in the sham group [p=0·091]), or serious adverse events (188 in the GTN group vs 170 in the sham group [p=0·16]) between treatment groups. Interpretation Prehospital treatment with transdermal GTN does not seem to improve functional outcome in patients with presumed stroke. It is feasible for UK paramedics to obtain consent and treat patients with stroke in the ultraacute prehospital setting. Funding British Heart Foundation

Universal Pressure Ulcer Prevention Bundle with WOC Nurse Support

Patricia Finch-Gutherie, Assistant Professor of Nursing, received a $4,000 APDC Research and Scholarly Activities grant for a study, Universal Pressure Ulcer Prevention Bundle with WOC Nurse Support, which aims to advance knowledge to prevent pressure ulcers in hospitalized critical care patients

Forming interprofessional teams and clarifying roles

Discussion about the process of forming interprofessional teams in a clinical scholar progra

Experiences of caregivers caring for a family member who is using hemodialysis

In this qualitative phenomenological study using a purposive sample, six caregivers of patients on hemodialysis were interviewed about their experiences of caring for a family member who uses hemodialysis. Six major themes and 12 subthemes were identified. Perceptions of caregivers are that caregiving is hard work and stressful; however, caregivers found the experience to be meaningful, even though the stress may interfere with their own health status. Study limitations include a small sample that may not represent the entirety of caregivers\u27 perspectives. Implications for practice include developing informal and formal support systems and exercise programs that help this population manage the stress associated with caregiving for family members using hemodialysis

The Contribution of Micro- and Macro-Context on Team Collaboration and Performance

Patricia Finch-Guthrie, Co-Director for Interprofessional Education, Research, and Practice, Janet Benz, Assistant Professor of Interprofessional Education, and Kathrine Campbell, Assistant Professor of Interprofessional Education, are awarded $2,500 by the GHR Internal Grant Program to explore the interplay of micro- and macro-contexts that contribute to team collaboration and performance. At St. Catherine University, healthcare students are prepared to collaborate and to conduct interprofessional evidence based practice (IEBP), meeting the interprofessional education competencies. IEBP improves patient care in which multiple disciplines work together to solve problems with evidence. While interprofessional education in the classroom is important, students working alongside practicing clinicians and faculty is more effective. St. Catherine University created the Interprofessional Evidence-based Clinical Scholar Program (IECSP), which includes teams of interprofessional students, faculty, and clinicians working to address practice concerns with IEBP, such as uncontrolled pain, ventilator acquired pneumonia, and urinary tract infections. The original program was developed in acute care and was not designed to address contextual differences. Little is known about how to create a clinical scholar program that is transferable to a variety of organizations with different missions and visions, cultures, resources, leadership structures, types of disciplines, and community relationships or regional or national influences. This project will contribute to the knowledge base of IEBP and implement science that includes a focus on context

Interprofessional education and team-based learning in a research methods course

This article describes team-based pedagogical strategies for a hybrid, four-credit research methods course with students from nursing, exercise, and nutrition science. The research problem of concussion in football, a socially relevant and controversial topic, was used to explore interprofessional perspectives and develop shared problem solving. The course was designed using permanent teams, readiness assurance, application exercises, and peer evaluation to facilitate student achievement of competencies related to interprofessional collaboration and research application. Feedback from students, faculty, and the Readiness for Interprofessional Learning Scale was used to evaluate the learning innovation

An interprofessional pain diary in transitional care: A feasibility studyNo Title

Understanding pain perceptions in older adults is important for pain management. An interprofessional team conducted a feasibility project to examine whether a pain diary designed for older adults in a transitional care unit offered a more holistic description of the pain experience