Josephine Me Gibson

Focus of nursing in critical and acute care settings: prevention or cure?

The fluidity of the boundaries of critical and acute care can lead to challenges for nurses working on acute general wards when caring for post-critical care patients and for those in whom a critical care situation arises during a period of acute care. The development and use of critical care skills pose special difficulties for acute care nurses, because of the acuteness and infrequency of such incidents and the diversity of skills the nurses need to possess. Nonetheless, critical care is an important component of an acute ward nurses repertoire, particularly in relation to preventing episodes of critical illness. It might be expected that the increased provision of high dependency units and the formation of postoperative care teams would relieve some of this pressure, but such developments are, in fact, more likely to create an increase in overall patient acuity. They may, in addition, lead to an over-reliance on the use of such facilities and must be implemented carefully in order to bridge, rather than widen, the gap between acute and critical care. Critical care is used in this paper as a global term, to encompass all settings where patients are usually more highly dependent and critically ill than patients on general wards. It includes intensive therapy, high-dependency, coronary care and other specialist critical care units.

Callers' experiences of making emergency calls at the onset of acute stroke: a qualitative study

Background Rapid access to emergency medical services (EMS) is essential at the onset of acute stroke, but significant delays in contacting EMS often occur. Objective To explore factors that influence the callers decision to contact EMS at the onset of stroke, and the callers experiences of the call. Methods Participants were identified through a purposive sample of admissions to two hospitals via ambulance with suspected stroke. Participants were interviewed using open-ended questions and content analysis was undertaken. Results 50 participants were recruited (median age 62 years, 68% female). Only one of the callers (2%) was the patient. Two themes were identified that influenced the initial decision to contact EMS at the onset of stroke: perceived seriousness, and receipt of lay or professional advice. Two themes were identified in relation to the communication between the caller and the call handler: symptom description by the caller, and emotional response to onset of stroke symptoms. Conclusions Many callers seek lay or professional advice prior to contacting EMS and some believe that the onset of acute stroke symptoms does not warrant an immediate 999 call. More public education is needed to improve awareness of stroke and the need for an urgent response.

“Can you send an ambulance please?”: a comparison of callers’ requests for emergency medical dispatch in non-stroke and stroke calls

Background Identifying ‘true stroke’ from an emergency medical services (EMS) call is challenging, with over 50% of strokes being misclassified. In a previous study, we examined the relationship between callers’ descriptions of stroke symptoms to the emergency medical dispatcher and the subsequent classification and prioritisation of EMS response. The aim of this subsequent study was to explore further the use of keywords by callers when making emergency calls, comparing stroke and non-stroke calls. Methods All non-stroke calls to one EMS dispatch centre between 8 March 2010 and 14 March 2010 were analysed. These were compared with the stroke calls made to one EMS dispatch centre between 1 October 2006 and 30 September 2007. Content analysis was used to explore the problems described by the caller, and findings were compared between non-stroke and stroke calls. Results 277 non-stroke calls were identified. Only eight (3%) callers mentioned stroke, 12 (4%) and 11 (4%) mentioned limb weakness and speech problems, respectively, while no caller mentioned more than one classic stroke symptom. This contrasted with 473 stroke calls, where 188 (40%) callers mentioned stroke, 70 (15%) limb weakness and 72 (15%) speech problems, and 14 (3%) mentioned more than one classic stroke symptom. Conclusions People who contact the EMS about non-stroke conditions rarely say stroke, limb weakness, speech problems or facial weakness. These words are more frequently used when people contact the EMS about stroke, although many calls relating to stroke patients do not mention any of these keywords.

People's experiences of the impact of transient ischaemic attack and its consequences: qualitative study.

AIM This paper is a report of a study of how peoples experiences of transient ischaemic attack affect their perception of their health and their uptake of health maintenance measures. BACKGROUND Transient ischaemic attack is a well-recognized warning sign of subsequent stroke, but early diagnosis and management of risk factors can substantially reduce this risk. Even though the physical effects of a transient ischaemic attack are transient, it is known to negatively affect quality of life. However, no qualitative studies have explored the impact of transient ischaemic attack on peoples everyday lives. METHODS Sixteen participants were recruited from a vascular surgery clinic in a district general hospital in North West England. All had a recent transient ischaemic attack. A qualitative grounded theory study using detailed interviews (n = 21) was conducted. FINDINGS Participants experienced conflict between acknowledgement of the transient ischaemic attack as a significant illness episode with implications for their long-term health, and denial of its seriousness. Although they often ignored the initial signs, participants also experienced fear due to increased awareness of their risk of stroke. Often, they believed that they were having a permanent stroke. Many participants were prompted to seek medical advice by a family member or acquaintance. Having a transient ischaemic attack negatively changed their perception of their health and their quality of life, but some also viewed it as a positive event that had warned of their stroke risk and enabled them to take up health maintenance measures. CONCLUSIONS Having a transient ischaemic attack permanently changes peoples quality of life and their perception of their health, despite the transience of the symptoms. The ability of people to make positive health changes after a transient ischaemic attack to some extent ameliorates the negative effects of being aware of their heightened stroke risk. Their appreciation of their quality of life may also be enhanced. The transience of the symptoms and lack of knowledge of transient ischaemic attacks lead to delays in seeking medical advice.

‘It was like he was in the room with us’: patients’ and carers’ perspectives of telemedicine in acute stroke

Telemedicine can facilitate delivery of thrombolysis in acute stroke. The aim of this qualitative study was to explore patients’ and carers’ views of their experiences of using a stroke telemedicine system in order to contribute to the development of reliable and acceptable telemedicine systems and training for health‐care staff.

The impact of education and training interventions for nurses and other health care staff involved in the delivery of stroke care:An integrative review

OBJECTIVES The aim of this review was to explore the impact of stroke education and training of nurses and other health care staff involved in the delivery of stroke care. DESIGN We performed an integrative review, following PRISMA guidance where possible. DATA SOURCES We searched MEDLINE, ERIC, PubMed, AMED, EMBASE, HMIC, CINAHL, Google Scholar, IBSS, Web of Knowledge, and the British Nursing Index from 1980 to 2016. REVIEW METHODS Any intervention studies were included if they focused on the education or training of nurses and other health care staff in relation to stroke care. Articles that appeared to meet the inclusion criteria were read in full. Data were extracted from the articles, and the study quality assessed by two researchers. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance. RESULTS Our initial search identified 2850 studies of which 21 met the inclusion criteria. Six studies were randomised controlled trials, and one was an interrupted time series. Fourteen studies were quasi-experimental: eight were pretest-posttest; five were non-equivalent groups; one study had a single assessment. Thirteen studies used quality of care outcomes and eight used a patient outcome measure. None of the studies was identified as having a low risk of bias. Only nine studies used a multi-disciplinary approach to education and training and nurses were often taught alone. Interactive education and training delivered to multi-disciplinary stroke teams, and the use of protocols or guidelines tended to be associated with a positive impact on patient and quality of care outcomes. CONCLUSIONS Practice educators should consider the delivery of interactive education and training delivered to multi-disciplinary groups, and the use of protocols or guidelines, which tend to be associated with a positive impact on both patient and quality of care outcomes. Future research should incorporate a robust design.

Eating well, living well and weight management: A co-produced semi-qualitative study of barriers and facilitators experienced by adults with intellectual disabilities

Adults with intellectual disabilities in England experience health inequalities. They are more likely than their non-disabled peers to be obese and at risk of serious medical conditions such as heart disease, stroke and type 2 diabetes. This semi-qualitative study engaged adults with intellectual disabilities in a co-production process to explore their perceived barriers and facilitators to eating well, living well and weight management. Nineteen participants with intellectual disabilities took part in four focus groups and one wider group discussion. They were supported by eight of their carers or support workers. Several barriers were identified including personal income restrictions, carers’ and support workers’ unmet training needs, a lack of accessible information, inaccessible services and societal barriers such as the widespread advertising of less healthy foodstuffs. A key theme of frustration with barriers emerged from analysis of participants’ responses. Practical solutions suggested by participants included provision of clear and accessible healthy lifestyle information, reasonable adjustments to services, training, ‘buddying’ support systems or schemes and collaborative working to improve policy and practice.

Integrating acute stroke telemedicine consultations into specialists’ usual practice: a qualitative analysis comparing the experience of Australia and the United Kingdom

BackgroundStroke telemedicine can reduce healthcare inequities by increasing access to specialists. Successful telemedicine networks require specialists adapting clinical practice to provide remote consultations. Variation in experiences of specialists between different countries is unknown. To support future implementation, we compared perceptions of Australian and United Kingdom specialists providing remote acute stroke consultations.MethodsSpecialist participants were identified using purposive sampling from two new services: Australia’s Victorian Stroke Telemedicine Program (n = 6; 2010–13) and the United Kingdom’s Cumbria and Lancashire telestroke network (n = 5; 2010–2012). Semi-structured interviews were conducted pre- and post-implementation, recorded and transcribed verbatim. Deductive thematic and content analysis (NVivo) was undertaken by two independent coders using Normalisation Process Theory to explore integration of telemedicine into practice. Agreement between coders was M = 91%, SD = 9 and weighted average κ = 0.70.ResultsCross-cultural similarities and differences were found. In both countries, specialists described old and new consulting practices, the purpose and value of telemedicine systems, and concerns regarding confidence in the assessment and diagnostic skills of unknown colleagues requesting telemedicine support. Australian specialists discussed how remote consultations impacted on usual roles and suggested future improvements, while United Kingdom specialists discussed system governance, policy and procedures.ConclusionAustralian and United Kingdom specialists reported telemedicine required changes in work practice and development of new skills. Both groups described potential for improvements in stroke telemedicine systems with Australian specialists more focused on role change and the United Kingdom on system governance issues. Future research should examine if cross-cultural variation reflects different models of care and extends to other networks.

The journey from transient ischaemic attack to clinic: Qualitative study of people's response to symptoms and routes to assessment

Introduction: Aphasia affects a third of stroke survivors (~5.6 million worldwide annually). The social and emotional impact of aphasia makes timely and effective rehabilitation vital. Speech and language therapy benefits recovery; however the specific patient, stroke, aphasia and intervention factors which optimise recovery and rehabilitation are unclear. We will explore these uncertainties in our RELEASE study (NIHR HS&DR 14/04/22). In Phase I of this study we aimed to create a large, collaborative, international database of individual patient data (IPD) from pre-existing aphasia research. Method: Eligible datasets included IPD of ≥10 people with stroke-related aphasia, with time poststroke specified and aphasia severity data. Contributions were invited from international, multidisciplinary, aphasia research collaborators via the EU COST funded Collaboration of Aphasia Trialists. We also conducted a systematic search of the literature [Cochrane Stroke Group Trials, MEDLINE, CINAHL, AMED, Cochrane Library Databases (CDSR, DARE, CENTRAL, HTA), EMBASE, LLBA and SpeechBITE from inception to Sept 2015 for additional datasets. Two independent reviewers considered full texts, a third resolved any conflicts. Results: As of June 2016 our database included 2,531 IPD from 11 countries (33 datasets). Nine were in the public domain. Following the systematic search of 5,272 records (of which 75 duplicates, 2,395 reference titles and 965 abstracts were excluded) further datasets were identified and the investigators of these datasets invited to collaborate. Conclusion: We succeeded in creating a large, collaborative, international aphasia database of preexisting IPD. A systematic search process to identify additional datasets eligible for inclusion supplemented more informal dataset recruitment methods.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.Introduction: Repetitive task training involves the active practice of task-specific motor activities. We updated our Cochrane Review published in 2007. Method: We searched MEDLINE (01/10/2006 – 08/03/2016), EMBASE (01/10/2006 – 07/03/2016) and the Cochrane Stroke Trials Register (04/03/2016). 2 authors independently screened abstracts, extracted data and appraised trials. Quality of evidence within each study and outcome group was determined using the Cochrane Collaboration Risk of Bias Tool (CCRBT) and GRADE criteria. Results: 29 trials with 1759 participants were included. Results were statistically significant for arm function (standardised mean difference (SMD) 0.25, 95% CI 0.11 to 0.40), hand function (SMD 0.28, 95% CI 0.12 to 0.44), sitting balance/reach (SMD 0.28, 95% CI 0.01 to 0.55), walking distance (MD 38.80, 95% CI 24.75 to 52.86), walking speed (SMD 0.33, 95% CI 0.18 to 0.49), functional ambulation (SMD 0.26, 95% CI 0.08 to 0.43), sit-to-stand (Standardised effect 0.35, 95% CI 0.13 to 0.56), lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48), standing balance/reach (SMD 0.27, 95% CI 0.09 to 0.45) and global motor function (SMD 0.38, 95% CI 0.11 to 0.65). Follow-up measures were significant for both upper and lower limb outcomes up to 6 months post-treatment. Conclusion: Repetitive task training resulted in improvement in upper and lower limb function; improvements were sustained up to 6 months post-treatment. Further research should focus on the type and amount of training, including measuring the number of repetitions performed.

Patients' needs following transient ischaemic attack: A mixed methods study of patients’ carers’ and healthcare professionals’ views

Introduction: Aphasia affects a third of stroke survivors (~5.6 million worldwide annually). The social and emotional impact of aphasia makes timely and effective rehabilitation vital. Speech and language therapy benefits recovery; however the specific patient, stroke, aphasia and intervention factors which optimise recovery and rehabilitation are unclear. We will explore these uncertainties in our RELEASE study (NIHR HS&DR 14/04/22). In Phase I of this study we aimed to create a large, collaborative, international database of individual patient data (IPD) from pre-existing aphasia research. Method: Eligible datasets included IPD of ≥10 people with stroke-related aphasia, with time poststroke specified and aphasia severity data. Contributions were invited from international, multidisciplinary, aphasia research collaborators via the EU COST funded Collaboration of Aphasia Trialists. We also conducted a systematic search of the literature [Cochrane Stroke Group Trials, MEDLINE, CINAHL, AMED, Cochrane Library Databases (CDSR, DARE, CENTRAL, HTA), EMBASE, LLBA and SpeechBITE from inception to Sept 2015 for additional datasets. Two independent reviewers considered full texts, a third resolved any conflicts. Results: As of June 2016 our database included 2,531 IPD from 11 countries (33 datasets). Nine were in the public domain. Following the systematic search of 5,272 records (of which 75 duplicates, 2,395 reference titles and 965 abstracts were excluded) further datasets were identified and the investigators of these datasets invited to collaborate. Conclusion: We succeeded in creating a large, collaborative, international aphasia database of preexisting IPD. A systematic search process to identify additional datasets eligible for inclusion supplemented more informal dataset recruitment methods.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.Introduction: Repetitive task training involves the active practice of task-specific motor activities. We updated our Cochrane Review published in 2007. Method: We searched MEDLINE (01/10/2006 – 08/03/2016), EMBASE (01/10/2006 – 07/03/2016) and the Cochrane Stroke Trials Register (04/03/2016). 2 authors independently screened abstracts, extracted data and appraised trials. Quality of evidence within each study and outcome group was determined using the Cochrane Collaboration Risk of Bias Tool (CCRBT) and GRADE criteria. Results: 29 trials with 1759 participants were included. Results were statistically significant for arm function (standardised mean difference (SMD) 0.25, 95% CI 0.11 to 0.40), hand function (SMD 0.28, 95% CI 0.12 to 0.44), sitting balance/reach (SMD 0.28, 95% CI 0.01 to 0.55), walking distance (MD 38.80, 95% CI 24.75 to 52.86), walking speed (SMD 0.33, 95% CI 0.18 to 0.49), functional ambulation (SMD 0.26, 95% CI 0.08 to 0.43), sit-to-stand (Standardised effect 0.35, 95% CI 0.13 to 0.56), lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48), standing balance/reach (SMD 0.27, 95% CI 0.09 to 0.45) and global motor function (SMD 0.38, 95% CI 0.11 to 0.65). Follow-up measures were significant for both upper and lower limb outcomes up to 6 months post-treatment. Conclusion: Repetitive task training resulted in improvement in upper and lower limb function; improvements were sustained up to 6 months post-treatment. Further research should focus on the type and amount of training, including measuring the number of repetitions performed.