Virginia Daggett

Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: Nursing admission screening tool versus National Institutes of Health Stroke Scale

This study assessed the positive and negative predictive values and the sensitivity and specificity of a nursing dysphagia screening tool and the National Institutes of Health Stroke Scale (NIHSS) for the identification of dysphagia for veterans hospitalized with ischemic stroke.A secondary objective of this study was to evaluate the speech-language pathology consult rate before and after the nursing admission dysphagia screening tool. This retrospective cohort study evaluated veterans admitted to one Department of Veterans Affairs medical center with ischemic stroke during the 6 months both before and after the implementation of a nursing dysphagia screening tool, which was part of the admission nursing template. Stroke severity was measured with the use of the retrospective NIHSS. Dysphagia diagnosis was based on speech-language pathology evaluations.Dysphagia was present in 38 of 101 patients (38%) with ischemic stroke. The nursing dysphagia screening tool had a positive predictive value of 50% and a negative predictive value of 68%, with a sensitivity of 29% and specificity of 84%. The use of the NIHSS to identify dysphagia risk had a positive predictive value of 60% and a negative predictive value of 84%.The NIHSS had better test characteristics in predicting dysphagia than the nursing dysphagia screening tool. Future research should evaluate the use of the NIHSS as a screening tool for dysphagia.

A review of health-related quality of life in adult traumatic brain injury survivors in the context of combat veterans.

Health-related quality of life (HRQOL) research in traumatic brain injury (TBI) populations is beginning to emerge in the literature. Because rehabilitation and reintegration issues are complex with TBI, especially with new combat veterans, it is critical that future HRQOL research be designed to consider these issues. Utilizing explicit definitions and a conceptual model of HRQOL can provide researchers with a holistic base on which to build interventions for successful patient outcomes. The conceptual model of HRQOL of C.E. Ferrans, J.J. Zerwic, J.E. Wilbur, and J.L. Larson (2005) is an exemplar model that presents clear definitions and encompasses domains of HRQOL relevant to TBI survivors and their families. This review was organized utilizing the model of HRQOL of Ferrans et al. The objective of this review was to identify gaps in current knowledge of HRQOL and TBI. These findings were then used to develop recommendations for future research with combat veterans who have sustained a TBI.

Needs and concerns of male combat Veterans with mild traumatic brain injury

Traumatic brain injury (TBI) has emerged as a major cause of morbidity among U.S. servicemembers who have served in Iraq and Afghanistan. Even mild TBI (mTBI) can result in cognitive impairments that can affect the community reintegration of Veterans postdeployment. The purpose of this study was to explore the needs and concerns of combat Veterans with mTBI to provide support for an mTBI-specific conceptual model (Conceptual Model in the Context of mTBI) derived from Ferrans et al.s health-related quality of life model and the TBI literature. Content analysis of qualitative interview data was conducted using a thematic matrix with a predetermined code list. Data saturation was achieved after interviews with eight male Veterans. Six key categories and predominant themes emerged: cognitive impairments, physical symptoms, emotions and behaviors, instrumental activities of daily living, interpersonal interactions, and community reintegration. Findings provide preliminary support for a new, context-specific conceptual model that has the potential to identify areas for future interventions to enhance community reintegration of combat Veterans with mTBI.

A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators

Background Quality indicator collection and feedback improves stroke care. We sought to determine whether quality improvement training plus indicator feedback was more effective than indicator feedback alone in improving inpatient stroke indicators. Methods We conducted a cluster-randomised quality improvement trial, randomising hospitals to quality improvement training plus indicator feedback versus indicator feedback alone to improve deep vein thrombosis (DVT) prophylaxis and dysphagia screening. Intervention sites received collaborative-based quality improvement training, external facilitation and indicator feedback. Control sites received only indicator feedback. We compared indicators pre-implementation (pre-I) to active implementation (active-I) and post-implementation (post-I) periods. We constructed mixed-effect logistic models of the two indicators with a random intercept for hospital effect, adjusting for patient, time, intervention and hospital variables. Results Patients at intervention sites (1147 admissions), had similar race, gender and National Institutes of Health Stroke Scale scores to control sites (1017 admissions). DVT prophylaxis improved more in intervention sites during active-I period (ratio of ORs 4.90, p<0.001), but did not differ in post-I period. Dysphagia screening improved similarly in both groups during active-I, but control sites improved more in post-I period (ratio of ORs 0.67, p=0.04). In logistic models, the intervention was independently positively associated with DVT performance during active-I period, and negatively associated with dysphagia performance post-I period. Conclusion Quality improvement training was associated with early DVT improvement, but the effect was not sustained over time and was not seen with dysphagia screening. External quality improvement programmes may quickly boost performance but their effect may vary by indicator and may not sustain over time.

Tele-rehabilitation to Promote Exercise in Veterans Post-Stroke: AnObservational Pilot Study

Objectives: The objectives of this study were to: 1) explore the feasibility of implementing in-home exercises via a tele-rehabilitation program for Veterans with stroke in Home-Based Primary Care (HBPC) in a single US Department of Veteran’s Affairs Medical Center (VAMC); and 2) assess exercise adherence and progression in Veterans with stroke during the program. Materials and Methods: Study participants completed 3 televideo visits and 5 telephone visits with a physical therapist (PT) over a 3 month period. Participants were instructed in an exercise program and were asked to report adherence with the exercise program and reasons for non-adherence per a standardized questionnaire throughout the program. Televideo visits were conducted using a video link installed on a lap top computer taken to the participant’s home and a desk-top computer at the PT work station. The Late Life Function and Disability Instrument (LLFDI) were used to assess self-report of disability and function at baseline and 3 months. Results: Six male Veterans with a mean age of 61 years enrolled in the study. Four study participants completed the intervention with an average exercise adherence rate of 90%. Self-reported reasons for non-adherence were lack of strength, lack of understanding and lack of needed assistance for the exercises. Increased exercise intensity was demonstrated by all 4 participants. Modest improvements in disability (7%) and function (6%) were reported on the LLFDI. Conclusions: Veterans with stroke were able to actively participate in a tele-rehabilitation program. Study participants reported good exercise adherence and improved disability/function thatwas not statistically significant as well as increased exercise intensity throughout the intervention. Based on these preliminary findings with a small sample, a tele-rehabilitation program aimed at p