Abstract
BackgroundOrganizational context is one factor influencing the translation of evidence into practice, but data pertaining to patients with acute stroke are limited. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes.MethodsThis was a mixed methods cross-sectional study. Among 19 hospitals in Queensland, Australia, a survey was conducted of the perceptions of stroke clinicians about their work using the Alberta Context Tool (ACT), a validated measure covering 10 concepts of organizational context, and with additional stroke-specific contextual questions. These data were linked to the Australian Stroke Clinical Registry (AuSCR) to determine the relationship with receipt of evidence-based acute stroke care (acute stroke unit admission, use of thrombolysis for those with acute ischemic stroke, receipt of a written care plan on discharge, and prescription of antihypertensive medications on discharge) using quantile regression. Exploratory cluster analysis was used to categorize hospitals into high and low context groups based on all of the 10 ACT concepts. Differences in adherence to care processes between the two groups were examined.ResultsA total of 215 clinicians completed the survey (50% nurses, 37% allied health staff, 10% medical practitioners), with 81% being in their current role for at least 1 year. There was good reliability (∞ 0.83) within the cohort to allow pooling of professional groups. Greater ACT scores, especially for social capital (μ 9.00, 95% confidence interval [CI] 4.86 to 13.14) and culture (μ 7.33, 95% CI 2.05 to 12.62), were associated with more patients receiving stroke unit care. There was no correlation between ACT concepts and other care processes. Working within higher compared to lower context environments was associated with greater proportions of patients receiving stroke unit care (88.5% vs. 69.0%) and being prescribed antihypertensive medication at discharge (62.5% vs. 52.0%). Staff from higher context hospitals were more likely to value medical and/or nursing leadership and stroke care protocols.ConclusionsOverall organizational context, and in particular aspects of culture and social capital, are associated with the delivery of some components of evidence-based stroke care, offering insights into potential pathways for improving the implementation of proven therapies.
Highlights
Stroke is a leading cause of premature death and disability worldwide [1]
A recent national audit of stroke care in Australia found that only 67% of hospitalized patients received stroke unit care, and only 13% of those with acute ischemic stroke (AIS) received thrombolytic treatment with intravenous recombinant tissue plasminogen activator [3], both of which have been shown to improve outcomes [6, 7]
Survey data obtained from staff at 19 acute care hospitals in Queensland, Australia, between November 2013 and September 2014 were linked to patient-level data of the national, prospective Australian Stroke Clinical Registry (AuSCR)
Summary
Stroke is a leading cause of premature death and disability worldwide [1]. Despite the widespread availability of systematic reviews, clinical guidelines, and national performance evaluations to support high-quality stroke care [2,3,4], evidence-practice gaps deny many patients from receiving recommended care [5]. No clear definition of context exists [8], we defined organizational context in relation to healthcare according to Rycroft-Malone 2004 with reference to the Promoting Action on Research Implementation in Health Services (PARIHS) framework [9], that is the internal or work environments in which healthcare is delivered This is distinct from outer context, that is factors beyond the healthcare organization such as social systems, policy, and legislation [8,9,10,11,12], and from individual features such as the skill level and role of staff [8]. We aimed to determine the associations of organizational context in relation to four important evidence-based stroke care processes
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