Eileen Cowey

Urinary catheterization in acute stroke: clinical realities. A mixed methods study:

Objective: To determine what influences the decision to insert an indwelling urinary catheter in acute stroke patients. Design: A prospective casenote review and semi-structured interviews were conducted and corporate catheterization policy in the study sites was investigated. Setting: Three teaching hospitals, typical of stroke service provision in most developed countries. Subjects: Casenotes from 70 consecutive acute stroke admissions; 50 doctors, nurses and physiotherapists working in acute stroke units and medical receiving units. Results: Stroke patients were catheterized for output monitoring, relief of urinary retention or, especially for older patients, continence-related issues. Half of all catheterizations occurred in acute stroke units. Continence and catheterization were considered less important than other aspects of acute stroke care. No catheterization policy or standardized continence assessment tool was in use. Documentation was often lacking. Patients and relatives were not fully involved in the decision to catheterize. Continence assessment and catheterization practices varied widely. Complex unwritten rules relating to gender proliferated. Such rules demonstrated heuristic problem-solving could potentially cause conflict. Decisions to catheterize ‘belonged’ to doctors or nurses depending upon clinical indications. Clinical assessment and specialist referrals were often seen as ‘not my job’. Conclusions: Clear corporate policy on catheterization is required to direct practice. Use of standardized continence assessment tools is recommended to set and monitor standards of care. Documentation relating to urinary catheterization needs to improve.

Top 10 research priorities relating to stroke nursing: a rigorous approach to establish a national nurse‐led research agenda

AIM To determine the top 10 research priorities specific to stroke nursing. BACKGROUND It is important that stroke nurses build their research capability and capacity. This project built on a previous James Lind Alliance prioritization project, which established the shared stroke research priorities of stroke survivors, carers and health professionals. DESIGN Research priority setting project using James Lind Alliance methods; a survey for interim prioritization and a consensus meeting for final priority setting. METHODS Between September - November 2014, stroke nurses were invited to select their top 10 priorities from a previously established list of 226 unique unanswered questions. These data were used to generate a list of shared research priorities (interim priority setting stage). A purposefully selected group of stroke nurses attended a final consensus meeting (April 2015) to determine the top 10 research priorities. RESULTS During the interim prioritization stage, 97 stroke nurses identified 28 shared priority treatment uncertainties. At the final consensus meeting, 27 stroke nurses reached agreement on the top 10 stroke nursing research priorities. Five of the top 10 questions relate to stroke-specific impairments and five relate to rehabilitation and long-term consequences of stroke. CONCLUSIONS The research agenda for stroke nursing has now been clearly defined, facilitating nurses to undertake research, which is of importance to stroke survivors and carers and central to supporting optimal recovery and quality of life after stroke.

Impact of a clinical pathway on end-of-life care following stroke: A mixed methods study

Background: Death after stroke is common, but little is known about end-of-life care processes in acute stroke units. Aim: (1) To identify family and health-care worker perceptions of an end-of-life care pathway for patients who die after acute stroke. (2) To determine whether patients with fatal stroke judged to require an end-of-life care pathway differ from patients with fatal stroke who die without introduction of such a pathway. Design: Mixed methods study integrating qualitative semistructured interviews with quantitative casenote review. Setting/participants: In four Scottish acute stroke units, 17 relatives of deceased stroke patients and 23 health-care professionals were interviewed. Thematic analysis used a modified grounded theory approach. Multivariate analysis was performed on casenote data, identified prospectively from 100 consecutive stroke deaths. Results: Deciding pathway use was a consultative process, occurring within normal working hours. Families were commonly involved and could veto or trigger aspects of end-of-life care. Families sometimes felt responsible for decisions such as pathway use, resuscitation or hydration. Families were often led to expect their relative’s death early in the post-stroke period. Prolonged dying processes, particularly where patients had severe dysphagia, added to distress for families. Preferences for place of care were discussed infrequently. No link was found between demographic or clinical characteristics and care pathway use. Conclusion: Distressing stroke-related clinical problems dominated relatives’ concerns rather than use of the end-of-life care pathway. At times, relatives felt primarily responsible for key aspects of decision-making. Relatives often felt unprepared for a prolonged dying process after stroke, particularly where patients had persistent major swallowing difficulties.

Outcomes, experiences and palliative care in major stroke: a multicentre, mixed-method, longitudinal study

BACKGROUND: Case fatality after total anterior circulation stroke is high. Our objective was to describe the experiences and needs of patients and caregivers, and to explore whether, and how, palliative care should be integrated into stroke care. METHODS: From 3 stroke services in Scotland, we recruited a purposive sample of people with total anterior circulation stroke, and conducted serial, qualitative interviews with them and their informal and professional caregivers at 6 weeks, 6 months and 1 year. Interviews were transcribed for thematic and narrative analysis. The Palliative Care Outcome Scale, EuroQol-5D-5L and Caregiver Strain Index questionnaires were completed after interviews. We also conducted a data linkage study of all patients with anterior circulation stroke admitted to the 3 services over 6 months, which included case fatality, place of death and readmissions. RESULTS: Data linkage (n = 219) showed that 57% of patients with total anterior circulation stroke died within 6 months. The questionnaires recorded that the patients experienced immediate and persistent emotional distress and poor quality of life. We conducted 99 interviews with 34 patients and their informal and professional careers. We identified several major themes. Patients and caregivers faced death or a life not worth living. Those who survived felt grief for a former life. Professionals focused on physical rehabilitation rather than preparation for death or limited recovery. Future planning was challenging. “Palliative care” had connotations of treatment withdrawal and imminent death. INTERPRETATION: Major stroke brings likelihood of death but little preparation. Realistic planning with patients and informal caregivers should be offered, raising the possibility of death or survival with disability. Practising the principles of palliative care is needed, but the term “palliative care” should be avoided or reframed.

Is Palliative Care Appropriate for All People After Major Stroke

Background and Aims: Outcomes for stroke patients are improved by reducing time to, and increasing accessibility of, stroke-specialist consultation and treatments (e.g. delivery of thrombolysis). Telemedicine is a way that this can be facilitated, especially outside routine working hours. This study compared the timeliness of treatment and short-term patient outcomes when telemedicine or face-to-face assessment was used as part of the decision process of administering thrombolysis to patients affected by stroke. Method: Stroke data from SINAP and DASH databases between July 2011 and March 2013 was provided from six trusts in Lancashire and Cumbria which used telemedicine for the assessment of acute stroke, and eleven trusts within the North East of England which assessed patients face-to-face. Data was analysed from 220 stroke patients who received thrombolysis; this was restricted to those admitted out-of-hours as this was when telemedicine would normally be used. Results: The results showed that stroke patients assessed via telemedicine had a subsequent longer door-to needle time in comparison to those assessed via traditional face-to-face methods (95%CI: -32.43 to -11.15 minutes). Also, no significant differences were found between telemedicine and face-to-face assessments on patient outcomes such as length of stay in hospital (95%CI: -10.29 to 3.23 days), stay in stroke unit (95%CI: -10.42 to 3.01 days), rate of complications (OR 95%CI: 0.33 to 1.82) or discharge destination (OR 95%CI: 0.30 to 1.11). Conclusion: Patients assessed by telemedicine have a longer door-toneedle time than those assessed face-to-face. However, whether assessment was via telemedicine or face-to-face does not appear to affect short-term patient outcomes.

Decision to insert an indwelling urinary catheter in newly diagnosed stroke patients

Introduction: In recent years new rehabilitation techniques have emerged such as constraint-induced therapy, biofeedback therapy and robot-aided therapy, as alternatives to conventional physical therapies. Robotic techniques allow precise recording of movements and application of forces to the affected limb, making it a valuable tool for motor rehabilitation. In addition, robot-aided therapy can utilise visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task such as a game. This paper presents the development and evaluation of whole-arm robot-aided therapy, using a purpose designed robotic system for upper limb rehabilitation facilitating selective functional reaching and grasping movements in a reach-grasp-transport-release sequence with a task-oriented paradigm incorporating visual, audio, haptic and performance feedback. Method: A clinical pilot study with a total duration of twelve weeks was conducted with four stroke impaired subjects at the sub-acute phase of recovery. Subjects were exposed to sixteen hours of robotic intervention. Clinical outcome measures were used to assess therapy effectiveness on the recovery of the stroke participants prior to the study, during the study and on study completion. Results: The results obtained from the clinical outcome measures showed substantial gains in favour of the robot-aided intervention. The clinical outcome results show higher gains when compared to other robotic sub-acute studies targeting only proximal arm segments. Conclusion: The study demonstrated the feasibility and potential of reach and grasp therapy for stroke neurorehabilitation in the treatment of patients with upper limb hemiplegia and is a good indicator that this strategy should be pursued.Observational gait analysis is frequently used by clinicians but has been shown to have moderate reliability particularly in relation to joint angles. The siliconCOACH movement analysis software utilises a digital image to determine joint angles, taken from a video. One study to date has investigated the reliability of knee joint angles using siliconCOACH but this was not during walking. The aim of this study was to determine the inter-rater reliability of siliconCOACH dynamic knee joint angles in stroke patients.Knee hyperextension during gait is a common abnormality following stroke. The siliconCOACH movement analysis software has been developed to enable joint angles to be determined from a digital image taken from a video. The aim of this study was to determine the pattern of knee joint angles during the stance phase in stroke patients.