Early Supported Discharge Services Research Articles

Getting the message across; a realist study of the role of communication and information exchange processes in delivering stroke Early Supported Discharge services in England.

Stroke early supported discharge (ESD) involves the co-ordinated transfer of care from hospital to home. The quality of communication processes between professionals delivering ESD and external stakeholders may have a role to play in streamlining this process. We explored how communication and information exchange were achieved and influenced the hospital-to-home transition and the delivery quality of ESD, from healthcare professionals' perspectives. Six ESD case study sites in England were purposively selected. Under a realist approach, we conducted interviews and focus groups with 117 staff members, including a cross-section of the multidisciplinary team, service managers and commissioners. Great variation was observed between services in the type of communication processes they employed and how organised these efforts were. Effective communication between ESD team members and external stakeholders was identified as a key mechanism driving the development of collaborative and trusting relationships and promoting coordinated care transitions. Cross-boundary working arrangements with inpatient services helped clarify the role and remit of ESD, contributing to timely hospital discharge and response from ESD teams. Staff perceived honest and individualised information provision as key to effectively prepare stroke survivors and families for care transitions and promote rehabilitation engagement. In designing and implementing ESD, early stakeholder involvement ensured the services' fit in the local pathway and laid the foundations for communication and partnership working going forward. Findings highlighted the interdependency between services delivering ESD and local stroke care pathways. Maintaining good communication and engagement with key stakeholders may help achieve a streamlined hospital discharge process and timely delivery of ESD. ESD services should actively manage communication processes with external partners. A shared cross-service communication strategy to guide the provision of information along to continuum of stroke care is required. Findings may inform efforts towards the delivery of better coordinated stroke care pathways.

Abstract WP53: Bringing Comprehensive Stroke Care Home: Supporting Early Supported Discharge

Background and Issues: Despite holding the highest certification as a Comprehensive Stroke Center, the project site's 'Discharge-to-Home' performance for ischemic stroke survivors ranked below the median compared to similar academic medical centers. Although an innovative Early Supported Discharge (ESD) program was available for patients who met geographical criteria, the utilization of these services was not optimal. Purpose: This Quality Improvement initiative aimed to investigate the impact of an early collaborative discharge planning process led by a multidisciplinary healthcare team on 'Discharge-to-Home' rates of ischemic stroke patients eligible for the site's ESD program, Homeward Stroke Recovery. Methods: Meleis' Transition Theory was used to shape the development of streamlined workflows, simplifying the identification of eligible patients and reducing the time taken to refer them to Homeward Stroke Recovery through enhancements to the electronic medical record system. Additionally, robust team education was provided to improve discharge coordination and improve the utilization of available ESD services. Existing system data was leveraged, and new data flows were created to monitor program-specific metrics. Descriptive statistics were used to examine the effect of an early collaborative discharge planning process on ‘Homeward Stroke Recovery Discharge Rates’ for ischemic stroke survivors. Results: There was a notable increase of 5.6% in the 'Homeward Stroke Recovery Discharge Rate' from Fiscal Year 2022 to Fiscal Year 2023 (rising from 43.9% to 49.5%). Conclusions: In conclusion, this Quality Improvement project successfully addressed the challenge of suboptimal 'Discharge-to-Home' rates for ischemic stroke patients eligible for the site’s ESD program. The observed 5.6% increase in the 'Homeward Stroke Recovery Discharge Rate' between Fiscal Year 2022 and Fiscal Year 2023 reflects the positive impact of the interventions performed, highlighting the importance of multidisciplinary teamwork and systematic improvements in healthcare delivery.

Healthcare professionals’ experiences of delivering a stroke Early Supported Discharge service – An example from Ireland

Objective To explore healthcare professionals’ experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic. Design Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis. Setting Nine Early Supported Discharge service sites in Ireland. Participants Purposive sampling identified 16 healthcare professionals. Results Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families. Conclusions Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

Why do some people with stroke not receive the recommended 45 min of occupational therapy and physiotherapy after stroke? A qualitative study using focus groups

ObjectivesTo generate qualitative data on the views of Occupational Therapists and Physiotherapists about why people do not receive the Royal College of Physicians’ recommended minimum of 45 minutes (min) of...

31 Stroke early supported discharge: continuing to improve patient and organisational outcomes

Abstract Background Approximately 6,000 people in Ireland had a stroke in 2020. Early Supported Discharge (ESD) is an international model of care for stroke patients. ESD improves patient outcomes while facilitating a faster discharge, through provision of stroke specific rehab at home. ESD can be expected to improve disability outcomes, quality of life and reduce length of hospital stay. A pilot ESD service was introduced in an acute hospital in 2021 and continues to provide stroke rehab for patients living within a 30-minute drive from an acute hospital. Methods A retrospective re-audit on routine data from 113 patients who partook in ESD from January 2021 to December 2022 from an acute hospital. Data was extracted from the ESD database and analysed. Results Implementation of an ESD service over 24 months between 2021 and 2022 achieved the following: (i) 50% increase in number of bed saving days between 2021 and 2022; (ii) In both 2021 and 2022, the percentage of stroke patients discharged with ESD was 25% of the total number of stroke patients; (iii) The average LOS of a stroke patient accepted to the ESD service continues to decrease. In 2021, average LOS for ESD patients was 11.7 days; 2022 it was 11 days; (iv) The number of stroke patients accepted by ESD service remains relatively unchanged. In 2021, 57 patients and in 2022, 56 patients were accepted to ESD and (v) Total FIM/FAM scores from admission to discharge with ESD continue to increase. In 2021, 8.1% increase in functional outcomes were recorded. In 2022, that increased to 9.5% demonstrating an improving independence levels when discharged with ESD. Conclusion The ESD service in an acute hospital continues to demonstrate Organisational and patient benefits. Participation in ESD rehabilitation impacted positively on functional performance as captured using the FIM-FAM. Ongoing implementation of ESD aims to continue to have a positive impact on length of patient stay, bed saving days and functional outcomes.

How do stroke early supported discharge services achieve intensive and responsive service provision? Findings from a realist evaluation study (WISE)

BackgroundStroke Early Supported Discharge (ESD) involves provision of responsive and intensive rehabilitation to stroke survivors at home and it is recommended as part of the stroke care pathway. Core components have been identified to guide the delivery of evidence-based ESD, however, service provision in England is of variable quality. The study sought to understand how and in what conditions the adoption of these components drives the delivery of responsive and intensive ESD services in real world settings.MethodsThis qualitative study was part of a wider multimethod realist evaluation project (WISE) conducted to inform large-scale ESD implementation. Overarching programme theories and related context–mechanism–outcome configurations were used as a framework to guide data collection and analysis. Six case study sites were purposively selected; interviews and focus groups with ESD staff members were conducted and analysed iteratively.ResultsWe interviewed 117 ESD staff members including clinicians and service managers. Staff highlighted the role of certain core components including eligibility criteria, capacity, team composition and multidisciplinary team (MDT) coordination in achieving responsive and intensive ESD. Regardless of the geographical setting, adhering to evidence-based selection criteria, promoting an interdisciplinary skillset and supporting the role of rehabilitation assistants, allowed teams to manage capacity issues and maximise therapy time. Gaps in the stroke care pathway, however, meant that teams had to problem solve beyond their remit to cater for the complex needs of patients with severe disabilities. Adjusting MDT structures and processes was seen as key in addressing challenges posed by travel times and rural geography.ConclusionsDespite variations in the wider service model of operation and geographical location, the adoption of core components of ESD helped teams manage the pressures and deliver services that met evidence-based standards. Findings point to a well-recognised gap in service provision in England for stroke survivors who do not meet the ESD criteria and emphasise the need for a more integrated and comprehensive stroke service provision. Transferable lessons could be drawn to inform improvement interventions aimed at promoting evidence-based service delivery in different settings.Trial registrationISRCTN: 15,568,163, registration date: 26 October 2018.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke.

Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals. A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis. Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD. The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

Early Supported Discharge for Older Adults Admitted to Hospital with Medical Complaints: A Qualitative Study Exploring the Views of Stakeholders.

Early supported discharge (ESD) is well established as a model of health service delivery for people with stroke. Emerging evidence indicates that ESD also reduces the length of stay for older medical inpatients. There is a dearth of evidence exploring the views of stakeholders on ESD as a model of care for older medical inpatients. The overall aim of this study is to explore the views and perceptions of older adults, family carers and healthcare professionals on the potential role of ESD for older adults admitted to hospital with medical complaints. Purposeful sampling was used to recruit older adults and family carers for interview. For Healthcare Professionals (HCPs), snowball purposeful sampling was used. Phone interviews took place following a semi-structured interview guide. Focus groups were moderated by A-MM. Braun and Clarke's approach to thematic analysis was used. Ethical approval was granted by the HSE Mid-Western Area Regional Ethics Committee in November 2021 (REC Ref. 096/2021). Fifteen HCPs took part across three focus groups, with six older adults and two family members participating in one-to-one interviews. Three themes were identified: 1. Pre-ESD experiences of providing and receiving older adult inpatient care, 2. Navigating discharge procedures from acute hospital services, 3. A vision for more integrated model of care and a medical ESD team. This study provided insight into the current discharge experiences of older adult care in the acute setting, the potential role for ESD in this population and the key factors that would need to be considered for the running of an ESD service for older adults admitted to hospital with medical complaints. This research highlights the barriers and facilitators to ESD for older medical inpatients from the perspectives of key stakeholders. Given the adverse outcomes associated with prolonged hospital stay, these findings will help inform the development of a feasibility trial, examining patient and process outcomes for older adults admitted to hospital with medical complaints who receive an ESD intervention.

Patient, carer and health worker perspectives of stroke care in New Zealand: a mixed methods survey

Purpose It is important to understand how consumers (person with stroke/family member/carer) and health workers perceive stroke care services. Materials and methods Consumers and health workers from across New Zealand were surveyed on perceptions of stroke care, access barriers, and views on service centralisation. Quantitative data were summarised using descriptive statistics whilst thematic analysis was used for free-text answers. Results Of 149 consumers and 79 health workers invited to complete a survey, 53 consumers (36.5%) and 41 health workers (51.8%) responded. Overall, 40/46 (87%) consumers rated stroke care as ‘good/excellent’ compared to 24/41 (58.6%) health workers. Approximately 72% of consumers preferred to transfer to a specialised hospital. We identified three major themes related to perceptions of stroke care: 1) ‘variability in care by stage of treatment’; 2) ‘impact of communication by health workers on care experience’; and 3) ‘inadequate post-acute services for younger patients’. Four access barrier themes were identified: 1) ‘geographic inequities’; 2) ‘knowing what is available’; 3) ‘knowledge about stroke and available services’; and 4) ‘healthcare system factors’. Conclusions Perceptions of stroke care differed between consumers and health workers, highlighting the importance of involving both in service co-design. Improving communication, post-hospital follow-up, and geographic equity are key areas for improvement. Implications for rehabilitation Provision of detailed information on stroke recovery and available services in the community is recommended. Improvements in the delivery of post-hospital stroke care are required to optimise stroke care, with options including routine phone follow up appointments and wider development of early supported discharge services. Stroke rehabilitation services should continue to be delivered ‘close to home’ to allow community integration. Telehealth is a likely enabler to allow specialist urban clinicians to support non-urban clinicians, as well as increasing the availability and access of community rehabilitation.

A qualitative study exploring how stroke survivors’ expectations and understanding of stroke Early Supported Discharge shaped their experience and engagement with the service

Purpose To explore how stroke survivors’ expectations and understanding of Early Supported Discharge (ESD) helped them make sense of their experiences, and shaped their engagement with the service. Methods Data were collected as part of a study of large-scale implementation of stroke ESD: the WISE realist mixed-methods study. Semi-structured interviews were conducted with five purposefully selected stroke survivors from six sites in England implementing stroke ESD (n = 30). Participants were aged 32–88 years (20 males). Interviews were audio recorded, transcribed verbatim and transcripts were analysed using reflexive thematic analysis. Results Three overarching themes were identified: (1) ESD as a post-stroke recovery tool, (2) desire to recover quickly, (3) psychosocial impact and support. Stroke survivors were uncertain about what to expect when they first entered the service, however, their experience of ESD exceeded their expectations and increased their engagement with the service. Stroke survivors especially valued the goal-oriented approach the team adopted. Rehabilitation at home was perceived as positive and practical, encouraging independence within real-life contexts. Psycho-social support played an important role in the stroke survivors’ rehabilitation. Conclusions Ensuring stroke survivors are fully informed about ESD and what to expect, optimises engagement with the services, improves experience and could enhance outcomes. IMPLICATIONS FOR REHABILITATION Informing stroke survivors about what to expect from ESD services could optimise engagement and improve their experience. The provision of personalised and target focussed therapy at home improves stroke survivors’ experience and could potentially accelerate recovery. Preparing stroke survivors early for discharge from ESD can reduce anxiety and enhance engagement with the service.

Can telerehabilitation services combined with caregiver-mediated exercises improve early supported discharge services poststroke? A study protocol for a multicentre, observer-blinded, randomized controlled trial

BackgroundRecovery of walking ability is an important goal for patients poststroke, and a basic level of mobility is critical for an early discharge home. Caregiver-mediated exercises could be a resource-efficient strategy to augment exercise therapy and improve mobility in the first months poststroke. A combination of telerehabilitation and face-to-face support, blended care, may empower patient-caregiver dyads and smoothen the transition from professional support to self-management. The Armed4Stroke study aims to investigate the effects of a caregiver-mediated exercise program using a blended care approach in addition to usual care, on recovery of mobility in the first 6 months poststroke.MethodsA multicentre, observer-blinded randomized clinical trial in which 74 patient-caregiver dyads will be enrolled in the first 3 months poststroke. Dyads are randomly allocated to a caregiver-mediated exercises intervention or to a control group. The primary endpoint is the self-reported mobility domain of the Stroke Impact Scale. Secondary endpoints include care transition preparedness and psychological functioning of dyads, length of inpatient stay, gait-related measures and extended ADL of patients, and caregiver burden. Outcomes are assessed at enrolment, end of treatment and 6 months follow-up.ResultsDuring 8 weeks, caregivers are trained to become an exercise coach using a blended care approach. Dyads will receive a tailor-made, progressive training program containing task-specific exercises focusing on gait, balance, physical activity and outdoor activities. Dyads are asked to perform the training program a minimum of 5 times a week for 30 min per session, supported by a web-based telerehabilitation system with instruction videos and a messaging environment to communicate with their physiotherapist.ConclusionsWe hypothesize that the Armed4Stroke program will increase self-reported mobility and independence in ADL, facilitating an early discharge poststroke. In addition, we hypothesize that active involvement of caregivers and providing support using blended care, will improve the care transition when professional support tapers off. Therefore, the Armed4Stroke program may complement early supported discharge services.Trial registrationNetherlands Trial Register, NL7422. Registered 11 December 2018.

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration Current Controlled Trials ISRCTN15568163. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

Evaluating stroke early supported discharge using cost-consequence analysis

Purpose To evaluate different stroke early supported discharge (ESD) services in different geographical settings using cost-consequence analysis (CCA), which presents information about costs and outcomes in the form of a balance sheet. ESD is a multidisciplinary service intervention that facilitates discharge from hospital and includes delivery of stroke specialist rehabilitation at home. Materials and methods Data were collected from six purposively sampled services across the Midlands, East and North of England. All services, rural and urban, provided stroke rehabilitation to patients in their own homes. Cost data included direct and overhead costs of service provision and staff travel. Consequence data included service level adherence to an expert consensus regarding the specification of ESD service provision. Results We observed that the most rural services had the highest service cost per patient. The main costs associated with running each ESD service were staff costs. In terms of the consequences, there was a positive association between service costs per patient and greater adherence to meeting the evidence-based ESD service specification agreed by an expert panel. Conclusions This study found that rural services were associated with higher costs per patient, which in turn were associated with greater adherence to the expert consensus regarding ESD service specification. We suggest additional resources and costs are required in order for rural services to meet evidence-based criteria. Implications for rehabilitation The main costs of an early supported discharge (ESD) service for stroke survivors were staff costs and these were positively associated with greater levels of rurality. Greater costs were associated with greater adherence to ESD core components, which has been previously found to enhance the effectiveness of ESD service provision. The cost-consequence analysis provides a descriptive summary for decision-makers about the costs of delivering ESD, suggesting additional resources and costs are required in order for rural services to meet evidence-based criteria.

Stroke early supported discharge: the impact of patients' characteristics and clinical profile on rehabilitation goal attainment and clinical outcomes

Background/aims Stroke early supported discharge services were introduced to provide a comprehensive stroke specialist therapy input, while reducing cost of acute care. Early supported discharge services resulted in better health-related outcomes. A consensus has not yet been established regarding specific early supported discharge patient characteristics and clinical profile. The main aim of this study was to establish evidence to support the development of an early supported discharge patient profile (demographics and clinical) and eligibility criteria to enable early supported discharge services achieve their purposes of reducing post-stroke disability and institutionalisation rates. This article outlines the relationship between early supported discharge patients' clinical profiles and clinical outcomes, in terms of disability, goal attainment and institutionalisation rates. Methods A retrospective review of data was implemented to determine whether specific early supported discharge patients' clinical profiles and characteristics correlate with clinical outcomes. Data were collected for patients admitted to the Suffolk Stroke Early Supported Discharge Service between August and October 2016, comprising patients' demographics and clinical profiles, including stroke type, Barthel Index and Modified Rankin Scale. Performance data were collected at the end of the early supported discharge service including therapy frequency and intensity, as well as clinical outcomes including the Goal Attainment Scale. Results Data were collected for 53 patients. Data were analysed for all patients in three groups: goals not achieved; goals achieved; and goals achieved to a higher level), according to the Goal Attainment Scale. A Chi-square test showed no significant difference with regard to sex and stroke side (P=0.27). Analysis of variance revealed no significant difference in age. Conversely, results showed a significant association between goal attainment and the stroke subtype, severity and length of hospital stay. Conclusions Specific clinical characteristics and disease profiles correlate with functional outcomes and could influence goal attainment and functional status. A specific patient cohort seems to benefit the most from early supported discharge services in terms of optimised functional outcomes and recovery.

A protocol for a qualitative synthesis exploring people with stroke, family members, caregivers and healthcare professionals experiences of early supported discharge (ESD) after stroke

Early supported discharge (ESD) facilitates a person with a stroke to be discharged from the acute hospital environment earlier than conventional care to continue their rehabilitation within the home with members of the multi-disciplinary team. A number of quantitative studies have highlighted benefits of ESD including a reduction in the length of inpatient stay, cost savings, as well as reducing long term dependency. This systematic review and qualitative synthesis explores the perspectives and experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals involved in the delivery of the service. A comprehensive literature search will be completed in the following databases CINAHL, PubMed Central, Embase, Medline, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journals, The Cochrane Library, PsycARTICLES and Scopus. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service will be included. Methodological quality will be appraised using the ten-item Critical Appraisal Skills Programme checklist for qualitative research by two independent reviewers with a third reviewer involved should differences of opinion arise. Findings will be synthesised using thematic synthesis. It is anticipated that the qualitative synthesis will provide a deeper understanding of the experiences of ESD which may serve to inform practice as well as assist in the development of new ESD services. PROSPERO registration: CRD42020135197 – 28/04/2020

A protocol for a qualitative synthesis exploring people with stroke, family members, caregivers and healthcare professionals experiences of early supported discharge (ESD) after stroke.

Early supported discharge (ESD) facilitates a person with a stroke to be discharged from the acute hospital environment earlier than conventional care to continue their rehabilitation within the home with members of the multi-disciplinary team. A number of quantitative studies have highlighted benefits of ESD including a reduction in the length of inpatient stay, cost savings, as well as reducing long term dependency. This systematic review and qualitative synthesis explores the perspectives and experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals involved in the delivery of the service. A comprehensive literature search will be completed in the following databases CINAHL, PubMed Central, Embase, Medline, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journals, The Cochrane Library, PsycARTICLES and Scopus. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service will be included. Methodological quality will be appraised using the ten-item Critical Appraisal Skills Programme checklist for qualitative research by two independent reviewers with a third reviewer involved should differences of opinion arise. Findings will be synthesised using thematic synthesis. It is anticipated that the qualitative synthesis will provide a deeper understanding of the experiences of ESD which may serve to inform practice as well as assist in the development of new ESD services. PROSPERO registration: CRD42020135197 - 28/04/2020.

Stroke survivors’ occupational performance and cognitive strategy use: A pilot exploration of strengths and difficulties using the Perceive Recall Plan Perform System of Task Analysis

Introduction The Perceive Recall Plan Perform System of Task Analysis is an ecological assessment of occupational performance and cognitive strategy application. This study aimed to describe occupational performance and cognitive strategies of stroke survivors in an early supported discharge service, compare the assessment with global measures of function and evaluate the feasibility of implementing the assessment in the early supported discharge setting. Method This study was a pilot study design and used consecutive sampling. Participants were assessed with the Perceive Recall Plan Perform System of Task Analysis and two global measures: the Functional Independence Measure and the Australian Modified Lawton’s Instrumental Activities of Daily Living Scale. Scores from the Perceive Recall Plan Perform System of Task Analysis were analysed by task mastery, sub-quadrants and quadrants, and correlations between the assessment and global measures were examined. Findings In this cohort ( n = 10), the Perceive Recall Plan Perform System of Task Analysis assessment required 47 minutes per task and identified reduced task mastery (mean = 55%, SD = 10%) with common difficulties in the perceive and plan domains. High to moderate correlations were identified between the plan quadrant and global measures ( p < 0.05). Conclusion Perceive Recall Plan Perform System of Task Analysis assessment can be successfully implemented by occupational therapists with stroke survivors receiving early supported discharge to measure occupational performance and identify strengths and difficulties in cognitive strategy application.

Effectiveness of Stroke Early Supported Discharge: Analysis From a National Stroke Registry.

Implementation of stroke early supported discharge (ESD) services has been recommended in many countries' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale. Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were "days to ESD" (number of days from hospital discharge to first ESD contact; n=6222), "rehabilitation intensity" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale. This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.

Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme

Objectives: To understand why most stroke patients receive little therapy. We investigated the factors associated with the amount of stroke therapy delivered. Methods: Data regarding adults admitted to hospital with stroke for at least 72 hours (July 2013–July 2015) were extracted from the UK’s Sentinel Stroke National Audit Programme. Descriptive statistics and multilevel mixed effects regression models explored the factors that influenced the amount of therapy received while adjusting for confounding. Results: Of the 94,905 patients in the study cohort (mean age: 76 (SD: 13.2) years, 78% had a mild or moderate severity stroke. In all, 92% required physiotherapy, 87% required occupational therapy, 57% required speech therapy but only 5% were considered to need psychology. The average amount of therapy ranged from 2 minutes (psychology) to 14 minutes (physiotherapy) per day of inpatient stay. Unmodifiable characteristics (such as stroke severity) dominated the variation in the amount of therapy. However important, modifiable organizational factors were the day and time of admission, type of stroke team, timely therapy assessments, therapy and nursing staffing levels (qualified and support staff), and presence of weekend or early supported discharge services. Conclusion: The amount of stroke therapy is associated with unmodifiable patient-related characteristics and modifiable organizational factors in that more therapy was associated with higher therapy and nurse staffing levels, specialist stroke rehabilitation services, timely therapy assessments, and the presence of weekend and early discharge services.

Unreported Summary Statistics in Trial Publications and Risk of Bias in Stroke Rehabilitation Systematic Reviews: An International Survey of Review Authors and Examination of Practical Solutions

Objective: Continuous outcome measures are essential in rehabilitation research. Incomplete reporting of their mean and standard deviation, required for meta-analysis, potentially introduces bias and imprecision if it prevents studies being included. We aimed to determine how often systematic reviewers encounter missing mean or standard deviation values and to recommend practical statistical solutions. Design: 1. Cross-sectional survey of systematic review authors. 2. Reanalysis of Cochrane review data to evaluate how accurately statistical methods for recovering missing mean or standard deviation values estimate the true meta-analysis treatment effect. Setting: Rehabilitation intervention systematic reviews. Participants: Cochrane stroke rehabilitation review authors; stroke patients. Interventions: Reanalysis of a Cochrane review of early supported discharge services. Main measures: Hospital length of stay. Results: Survey responses covered 53 of 70 Cochrane reviews. Almost all studied continuous outcome measures, 68% encountering missing summary statistics. Various solutions were attempted but 76% of meta-analyses omitted at least one study due to missing information. In the review reanalysis ( N = 1055), a method based on the minimum and maximum performed best in recovering missing standard deviations; a method based on the median, lower and upper quartiles successfully estimated a missing mean. Conclusion: Practical statistical methods help reduce risk of bias, maximise the evidence included in rehabilitation meta-analyses and offer a clear hierarchy of solutions to handling unreported mean and standard deviation values.