Jane A. Anderson

Valid Items for Screening Dysphagia Risk in Patients With Stroke A Systematic Review

Background and Purpose— Screening for dysphagia is essential to the implementation of preventive therapies for patients with stroke. A systematic review was undertaken to determine the evidence-based validity of dysphagia screening items using instrumental evaluation as the reference standard. Methods— Four databases from 1985 through March 2011 were searched using the terms cerebrovascular disease, stroke deglutition disorders, and dysphagia. Eligibility criteria were: homogeneous stroke population, comparison to instrumental examination, clinical examination without equipment, outcome measures of dysphagia or aspiration, and validity of screening items reported or able to be calculated. Articles meeting inclusion criteria were evaluated for methodological rigor. Sensitivity, specificity, and predictive capabilities were calculated for each item. Results— Total source documents numbered 832; 86 were reviewed in full and 16 met inclusion criteria. Study quality was variable. Testing swallowing, generally with water, was the most commonly administered item across studies. Both swallowing and nonswallowing items were identified as predictive of aspiration. Neither swallowing protocols nor validity were consistent across studies. Conclusions— Numerous behaviors were found to be associated with aspiration. The best combination of nonswallowing and swallowing items as well as the best swallowing protocol remains unclear. Findings of this review will assist in development of valid clinical screening instruments.

Technology-Driven Interventions for Caregivers of Persons With Dementia A Systematic Review

Caregiving for a person with dementia can lead to physical and psychological morbidity. Technology-driven interventions hold the promise of convenient, low-cost methods of delivering psychosocial interventions. This systematic review examined the efficacy of technology-driven interventions for caregivers of persons with dementia. A search of Ovid Medline, PsychInfo, and EBSCO from 1990 to May 2012 resulted in the identification of 295 articles. After removal of duplicates, 271 articles were reviewed, based on the abstract and title alone; 32 were relevant or could not be fully assessed without assessing the entire article. Eight fully satisfied the inclusion/exclusion criteria. Each of these had some positive findings. However, there was large variability in the content and delivery of the interventions and inconsistency in measurement and variability of outcomes. Future studies should employ randomized control trial methodology and measure outcomes with commonly used measures to ensure feasibility of comparisons across the studies.

KNOWLEDGE MANAGEMENT: ORGANIZING NURSING CARE KNOWLEDGE

Almost everything we do in nursing is based on our knowledge. In 1984, Benner (From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984) described nursing knowledge as the culmination of practical experience and evidence from research, which over time becomes the “know-how” of clinical experience. This “know-how” knowledge asset is dynamic and initially develops in the novice critical care nurse, expands within competent and proficient nurses, and is actualized in the expert intensive care nurse. Collectively, practical “know-how” and investigational (evidence-based) knowledge culminate into the “knowledge of caring” that defines the profession of nursing. The purpose of this article is to examine the concept of knowledge management as a framework for identifying, organizing, analyzing, and translating nursing knowledge into daily practice. Knowledge management is described in a model case and implemented in a nursing research project.

Determining predictors of delayed recovery and the need for transitional cardiac rehabilitation after cardiac surgery

Purpose: To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery. Data sources: A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home. Conclusions: Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services. Implications for practice: Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment.

Prototype to practice: Developing and testing a clinical decision support system for secondary stroke prevention in a veterans healthcare facility.

A clinical decision support system that guides nurse practitioners and other healthcare providers in secondary stroke prevention was developed by a multidisciplinary team with funding received from the Veterans Health Administration Office of Nursing Services. This article presents alpha-testing results obtained while using an integrated model for clinical decision support system development that emphasizes end-user perspectives throughout the development process. Before-after and descriptive methods were utilized to evaluate functionality and usability of the prototype among a sample of multidisciplinary clinicians. The predominant functionality feature of the tool is automated prompting and documentation of secondary stroke prevention guidelines in the electronic medical record. Documentation of guidelines was compared among multidisciplinary providers (N = 15) using test case scenarios and two documentation systems, standard versus the prototype. Usability was evaluated with an investigator-developed questionnaire and one open-ended question. The prototype prompted a significant increase (P < .05) in provider documentation for six of 11 guidelines as compared with baseline documentation while using the standard system. Of a possible 56 points, usability was scored high (mean, 48.9 [SD, 6.8]). These results support that guideline prompting has been successfully engineered to produce a usable and useful clinical decision support system for secondary stroke prevention.

Evidence supporting the incorporation of the dietary approaches to stop hypertension (DASH) eating pattern into stroke self-management programs: a review.

ABSTRACT Stroke is a major source of mortality and morbidity in the United States. Nutrition can impact factors that increase the risk of stroke such as hypertension, obesity, elevated blood lipids, and diabetes. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) has developed the Self-Management to Prevent (STOP) Stroke Program to help veterans at risk for stroke and stroke recurrence. Patient initial feedback indicated a desire for more in-depth nutrition education in the STOP Stroke program. To address the needs of veterans living some distance from the MEDVAMC, a video teleconference program was developed and modified to include the Dietary Approaches to Stop Hypertension (DASH) diet nutrition concepts. This literature review summarizes the scientific evidence used to support the incorporation of the DASH eating pattern into the MEDVAMC STOP Stroke video teleconference program. Institutions can use this review to support development of similar nutrition education components for other stroke risk management programs.

Rapid Aspiration Screening for Suspected Stroke: Part 1: Development and Validation

OBJECTIVE To develop and validate a nurse-administered screening tool to identify aspiration risk in patients with suspected stroke. DESIGN Validity study comparing evidence-based swallowing screening items with the videofluoroscopic swallowing study (VFSS) results. SETTING A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS Consecutive patients (N=250) admitted with suspected stroke. INTERVENTIONS Patients were administered evidence-based swallowing screening items by nurses. A VFSS was completed within 2 hours of swallowing screening. MAIN OUTCOME MEASURES Validity relative to identifying VFSS-determined aspiration for each screening item and for various combinations of items. RESULTS Aspiration was identified in 29 of 250 participants (12%). Logistic regression revealed that age (P=.012), dysarthria (P=.001), abnormal volitional cough (P=.030), and signs related to the water swallow trial (P=.021) were significantly associated with aspiration. Validity was then determined on the basis of the best combination of significant items for predicting aspiration. The results revealed that age >70 years, dysarthria, or signs related to the water swallow trial (ie, cough, throat clear, wet vocal quality, and inability to continuously drink 90mL water) yielded 93% sensitivity and 98% negative predictive value. CONCLUSIONS The final validated tool, Rapid Aspiration Screening for Suspected Stroke, is a valid nurse-administered tool to detect risk of aspiration in patients presenting with suspected stroke.

A pilot test of videoconferencing to improve access to a stroke risk-reduction programme for Veterans

We conducted a pilot study to determine the feasibility of using videoconferencing for a programme of self-management to prevent stroke (V-STOP). A total of 37 Veterans with a history of stroke, or with multiple risk factors for stroke, were enrolled in the study from two rural sites. The V-STOP intervention consisted of 6 weekly sessions of self-management classes and clinic visits delivered via videoconferencing, with one or two individual telephone counselling sessions. Participants’ mean satisfaction scores were 4.7 out of 5, indicating very high approval of the programme. Attendance was 87%, almost twice as high as at an equivalent in-person programme. Access was improved as participants saved, on average, 160 km by travelling to a community centre instead of the main Veterans Administration facility. Stroke risk knowledge and self-management behaviours such as communication with healthcare providers significantly improved from baseline. Overall, videoconferencing is feasible for delivering self-management classes and clinic visits and the V-STOP programme shows promise as a method for delivery of self-management education and preventive care services to reduce stroke risk.

Accessibility, usability, and usefulness of a Web-based clinical decision support tool to enhance provider–patient communication around Self-management TO Prevent (STOP) Stroke

This article reports redesign strategies identified to create a Web-based user-interface for the Self-management TO Prevent (STOP) Stroke Tool. Members of a Stroke Quality Improvement Network (N = 12) viewed a visualization video of a proposed prototype and provided feedback on implementation barriers/facilitators. Stroke-care providers (N = 10) tested the Web-based prototype in think-aloud sessions of simulated clinic visits. Participants’ dialogues were coded into themes. Access to comprehensive information and the automated features/systematized processes were the primary accessibility and usability facilitator themes. The need for training, time to complete the tool, and computer-centric care were identified as possible usability barriers. Patient accountability, reminders for best practice, goal-focused care, and communication/counseling themes indicate that the STOP Stroke Tool supports the paradigm of patient-centered care. The STOP Stroke Tool was found to prompt clinicians on secondary stroke-prevention clinical-practice guidelines, facilitate comprehensive documentation of evidence-based care, and support clinicians in providing patient-centered care through the shared decision-making process that occurred while using the action-planning/goal-setting feature of the tool.

Feasibility and Effectiveness of an Integrated Cognitive Behavioral Treatment to Address Psychological Distress in a Stroke Self-Management Program

This is a case-study of a Hispanic man who had an ischemic stroke and was participating in a stroke self-management (SSM) program. He was identified as having comorbid symptoms of anxiety and depression that were not addressed by the SSM program and was subsequently enrolled in the Enhance Psychological Coping after Stroke (EPiC) program. EPiC is a telephone-based cognitive-behavioral treatment integrating mental and stroke-related behavioral health principles that is delivered concurrent to the SSM program. Over the course of six sessions, the participant learned psychological symptom and behavioral monitoring, thought stopping, cognitive restructuring, deep breathing, calming thoughts, social support, and problem-solving skills aimed at overcoming barriers to engagement in behaviors taught in the SSM program. Client-centered psychological distress and behavioral health treatment goals were integrated into each session. The client demonstrated reduced anxiety symptoms and improved stroke SSM behaviors at 6, 12, and 18 weeks after the initiation of treatment. He also improved in disability, social role limitations, quality of life, and stroke self-efficacy at 18 weeks following the initiation of treatment. This case study demonstrates that incorporating an integrated cognitive behavioral treatment to an SSM program can be beneficial for decreasing psychological symptom barriers to SSM, which may reduce the risk of stroke recurrence.