Provision Of Stroke Care Research Articles

Concentrating stroke care provision in the Czech Republic: The establishment of Stroke Centres in 2011 has led to improved outcomes

This article describes policy processes that have led to the re-organisation of stroke care in the Czech Republic since 2011, which has been part of a broader process of care concentration in several medical fields. Currently, stroke care is provided by 13 Comprehensive and 32 Primary Stroke Centres. The paper explains factors that supported the reform implementation, reviews implications, and discusses future challenges.Mandatory reporting of quality indicators, the introduction of a benchmarking system, integration with pre-hospital emergency care, and the introduction of countrywide patient triage have supported more timely treatment for stroke patients and better quality of care. Data from the Stroke Care Quality Indicators of the Czech Stroke Society show positive trends in many areas: the number of patients treated with intravenous thrombolysis quadrupled in eight years, with 26.4 % of all acute stroke patients receiving thrombolysis in 2018. Czech Republic now ranks third in Europe in the number of thrombolysis per population and second in the number of mechanical thrombectomies per population. The Czech experience provides an example of positive outcomes of concentrated stroke care, while highlighting the importance of proper implementation processes. In particular, it is essential to involve stakeholders and to provide reputational incentives through continuous benchmarking.

Post-Stroke Quality of Life Outcomes After Instituting New Stroke Care Quality Indicators

Background: In 2013 the Israel Ministry of Health identified the care and treatment of acute cerebral ischemic stroke as failing to achieve expected standards. The Ministry decided to raise standards by defining and instituting, nationwide, a battery of linked care quality indicators to be applied across all relevant facilities and contexts. Five indicators were selected for five key junctures in the AIS care process.
 Methods: This paper presents and analyses the effects of the implementation of these new care quality indicators on the post-discharge quality of life outcomes of Israeli stroke sufferers. The patient sample comprises patients from Israel’s Central region, where stroke care provision and access is relatively high, and from the peripheral North region, where provision and access are limited.
 Results: Those who were not treated with thrombolytic treatment and/or cerebral blood vessel catheterization, those who suffered severer strokes, women, the older age groups, non-Jews and North region residents display significantly worse physical functioning outcomes and worse quality of life outcomes on all indicators.
 Conclusions: Stroke care access and provision disparities translate into significantly higher rates of post-discharge disability, impaired physical and social functioning, and a lower quality of life.
 The effectiveness of healthcare improvement by the deployment of care indicators is closely associated with the lifestyle, socio-demographic and socioeconomic status of different population groups. The effective implementation of quality care indicators also relies heavily on closing the access and provision gaps between the populations living in central and peripheral areas. Two obvious directions for action are to expand and improve the rehabilitation care network and to combat the age discrimination in hospital stroke treatment.

Does the physical environment matter? - A qualitative study of healthcare professionals’ experiences of newly built stroke units

ABSTRACT Purpose: Organized care in specialist stroke units is fundamental for achieving better outcomes for persons with stroke. Although the importance of the physical environment for health and well-being is well recognized, research regarding how environmental features can influence stroke care is limited. The aim was to elucidate healthcare professionals’ experiences of the physical environment in newly built stroke units with respect to stroke care.Methods: Healthcare professionals (n = 42) representing eight professions participated in semi-structured, face-to-face interviews. Qualitative content analysis was used.Results: The physical environment both facilitated and restricted the professionals’ ability to provide stroke care. Five categories were identified: “Working towards patient engagement in single rooms”, “Hampered rehabilitation in an environment not always adapted to patients’ difficulties”, “Addressing patients’ psychosocial needs in the environment”, “Ensuring patient safety by using the environment in accordance with individual needs”, and “Collaboration and task fulfilment—a challenge due to care unit design”.Conclusions: The healthcare professionals viewed the physical environment mainly in relation to stroke patients’ specific needs, and several environmental features were considered poorly adapted to meet these needs. The physical environment is essential to high-quality care; thus, the process of planning and designing stroke units should be based on existing evidence.

Traveling the Path to Stroke Caregiver Readiness

Family members are often poorly prepared to assume the caregiving role post-stroke leaving them feeling overwhelmed, frustrated, and abandoned by the healthcare system leading to physical, mental, and emotional strain. To address this, we developed and tested the Preparedness Assessment for the Transition Home after stroke (PATH-s) instrument based on a theoretical framework for improving stroke caregiver readiness. Consecutive studies were conducted over the past 10 years to 1) develop the caregiver readiness theoretical model identifying gaps in caregiver preparation in 80 interviews with caregivers and stroke survivors as they transitioned home from inpatient rehabilitation care; 2) develop and validate the PATH-s instrument with 183 caregiver-stroke survivor dyads, and 3) develop and implement a corresponding catalogue of interventions developed in consultation with 5 expert rehabilitation nurse case managers to improve stroke caregiver readiness. The Improving Caregiver Readiness Model has 2 preparedness domains; commitment and capacity and six sub-domains. In a factor analysis each domain/sub-domain subscale in the PATH-s demonstrated satisfactory internal consistency (a=0.69-0.86). The overall mean score was 3.11 (range 1.68 to 4.00) with high internal consistency reliability (a=0.90). The PATH-s is highly correlated with the Preparedness for Caregiving Scale. The stroke survivor’s total FIM score at discharge had a small but significant correlation with the PATH-s. Case managers find the PATH-s results and corresponding interventions helpful in tailoring transitional care plans. Caregivers worldwide describe the negative impacts of providing stroke care post-discharge. The Path to Stroke Caregiver Readiness Program shows promise for improving stroke caregiver preparation for discharge home.

Satisfaction with stroke care among dementia patients with stroke: A Swedish register study

AbstractBackgroundPrevious studies showed that patient satisfaction with stroke care relates to age, care demands, functioning, mood, quality of life, and self‐rated health. Dementia and stroke are frequent comorbidities. It is still unknown how satisfied dementia patients are with stroke care compared to non‐dementia patients. Our study aimed to compare the satisfaction with stroke care between dementia and non‐dementia patients.MethodsIn this longitudinal observational registry study, 5,932 dementia patients (2007‐2017) who suffered a first stroke after dementia diagnosis were compared with 39,457 non‐dementia stroke patients (2007‐2017). Data on stroke was obtained through the Swedish Stroke Register (Riksstroke), linked to the Swedish Dementia Registry (SveDem), the Swedish National Patient Register and the Swedish Prescribed Drug Register. Questionnaires were completed by patients themselves, patients with the help of caregivers, patients’ family, or healthcare staffs on behalf of the patient three months after stroke. Outcomes comprised satisfaction with acute stroke care at hospital, inpatient rehabilitation, outpatient rehabilitation, healthcare staff’s attitude, communication with doctors and stroke information.ResultsCompared to non‐dementia patients, dementia patients who answered the questionnaire themselves reported lower odds of satisfaction with acute stroke care at hospital 0.72 (0.61 – 0.87), healthcare staff’s attitude 0.80 (0.67 – 0.97), communication with doctors 0.80 (0.68 – 0.95 ), and stroke information 0.63 (0.53 – 0.76); but not regarding inpatient rehabilitation 0.95 (0.77 – 1.19), or outpatient rehabilitation 0.96 (0.76 ‐1.23). When patients answered the questionnaire with the help of their caregivers, dementia patients reported significantly lower satisfaction for all items. Differences between dementia and non‐dementia patients disappeared in proxy‐reported satisfaction, except for family‐reported satisfaction with outpatient rehabilitation and stroke information, which was significantly lower in dementia group.ConclusionLower satisfaction in the dementia group is a sign of unfulfilled care needs among dementia patients. Further studies on the provision of stroke care for dementia patients and their care demands should be performed.

Stroke Systems of Care During the COVID-19 Epidemic in Kobe City

BackgroundThe novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems’ ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. MethodsThis was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. ResultsDuring the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. ConclusionKobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes

BackgroundEmergency departments (ED) are challenging environments but critical for early management of patients with stroke. PurposeTo identify how context affects the provision of stroke care in 26 Australian EDs. MethodNurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. FindingsCollectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. DiscussionFuture assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

The StrokeCog study: development and description of a cognition-focused psychological intervention to address cognitive impairment following stroke

Objective To describe the process of developing a cognitive rehabilitation intervention for patients with post-stroke cognitive impairment (PSCI) and to describe the intervention prior to evaluation in a pilot randomised controlled trial (RCT). Method: The Medical Research Council framework, ‘Developing and evaluating complex interventions’, was used to develop the cognitive rehabilitation intervention. We conducted a combined analysis of the existing evidence base for PSCI rehabilitation alongside qualitative exploration of the perspectives of stroke survivors, their families, and healthcare professionals providing stroke care, on the necessary components for a cognitive rehabilitation intervention for PSCI. The Template for Intervention Description and Replication checklist was used as a structural framework for the description of the intervention. Results: The intervention comprises a five-week intervention integrating group-based activities, supported by a clinical neuropsychologist, with home-based activities to encourage self-efficacy through the practice of adjustment and compensatory strategies learned in the group format to achieve the patients’ identified goals in managing their PSCI. Conclusion: A cognitive rehabilitation intervention for patients with PSCI has been developed and described. We are in the process of developing a structured intervention manual to standardise the content and delivery of the intervention for further testing in a pilot RCT.

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

Background Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes. 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. 8, No. 34. See the NIHR Journals Library website for further project information.

Maintaining stroke care in Europe during the COVID-19 pandemic: Results from an international survey of stroke professionals and practice recommendations from the European Stroke Organisation.

IntroductionThe coronavirus disease 2019 (COVID-19) pandemic has been placing an overwhelming burden on health systems, thus threatening their ability to operate effectively for acute conditions in which treatments are highly time sensitive, such as cerebrovascular disorders and myocardial infarction. As part of an effort to reduce the consequences of this outbreak on health service delivery to stroke patients, the European Stroke Organisation has undertaken a survey aimed at collecting information on the provision of stroke care during the pandemic.MethodsCross-sectional, web-based survey, conducted from 26 March through 1 April 2020 among stroke care providers, focused on reorganisation of health services, the delivery of acute and post-acute stroke care and the availability of personal protective equipment.ResultsA total of 426 stroke care providers from 55 countries completed the survey, most of whom worked in Europe (n = 375, 88%) and were stroke physicians/neurologists (n = 334, 78%). Among European respondents, 289 (77%) reported that not all stroke patients were receiving the usual care in their centres and 266 (71%) estimated that functional outcomes and recurrence rates of stroke patients would be negatively affected by the organisational changes caused by the pandemic. The areas considered as being most affected were acute care and rehabilitation. Most professionals had to adapt their activities and schedules and more than half reported shortage of protective equipment.DiscussionStrategies to maintain availability of stroke care during the COVID-19 outbreak are crucial to prevent indirect mortality and disability due to suboptimal care.ConclusionEuropean Stroke Organisation proposes a set of targeted actions for decision makers facing this exceptional situation.

Perceived challenges in delivering comprehensive care for patients following stroke: a qualitative study of stroke care providers in Guangdong Province, China

Purpose To understand the challenges in delivering comprehensive care for patients recovering from stroke in Guangdong Province, China. Methods A cross-sectional qualitative study was conducted in two tertiary hospitals with different socio-economic characteristics in Guangdong Province, Southern China. Interviews were conducted with 16 stroke care providers including doctors, nurses, rehabilitation therapists and care workers. The interviews were audiotaped, transcribed and translated from Mandarin to English. Thematic analysis was used to draw out descriptive and analytical themes relating to care providers’ experiences of existing routine stroke care services and the perceptions of challenges in delivering comprehensive stroke care. Results The interviews with stroke care providers highlighted three key factors that hinder the capacity of the two hospitals to deliver comprehensive stroke care. First, expertise and knowledge regarding stroke and stroke care are lacking among both providers and patients; second, stroke care systems are not fully integrated, with inadequate coordination of the stroke team and inconsistency in care following discharge of stroke patients; third, stroke patients have insufficient social support. Conclusions While comprehensive stroke care has become a priority in China, our study highlights some important gaps in the current provision of stroke care. IMPLICATIONS FOR REHABILITATION Comprehensive integrated stroke care is essential to maximize the effectiveness of stroke services and in China it needs to be further improved. Multidisciplinary stroke care systems should strengthen collaborations across all relevant disciplines and should include a clear role for registered nurses. Follow-up care after discharge needs more engagement with family caregivers.

Abstract TP311: Organizational Culture Drives Confidence in Implementing Telestroke Care

Background: In its first 18 months, the VA National Telestroke Program (NTSP) conducted 800 consults at 30 sites. Data from staff at participating sites are collected in anonymous surveys. We aimed to determine factors associated with confidence in providing stroke care at these sites, and whether confidence is associated with performance on NTSP quality indicators. Methods: Surveys were sent to providers at participating sites at baseline (BL) and 6 - 12 months post-NTSP implementation (post-I). Survey questions included items about confidence providing stroke care and items from the Organizational Readiness to Change Assessment (ORCA). Confidence (0-10) was dichotomized into fully confident (mean score of 10) and not fully confident sites (mean <10). ORCA score was averaged by site. Covariates included site performance, volume, and time in the NTSP. We used a Kruskal Wallis analysis to examine the association of BL variables with post-I confidence, and a Pearson correlation test to examine the association between performance indicators and confidence. Results: 16 sites, with 54 staff members total responding (57% nurses, 26% providers, 17% administrators/other), had BL and post-I data. Five sites were fully confident at the post-I assessment, the remaining 11 had mean confidence scores 8.32 - 9.5. Site confidence improved over time (mean 7.97 at BL vs. 9.44 post-I, p = 0.004), but confidence was not associated with site performance on any NTSP indicator. Higher ORCA scores were significantly associated with post-I confidence (mean ORCA 4.46 vs. 4.01, p=0.04). Fully confident sites also had shorter NTSP participation times (mean 5.40 months in the fully confident sites vs. 13.45, P=0.01). BL confidence, rurality, and consultation volume were not associated with post-I confidence. Periodic retraining was the most commonly suggested program addition. Conclusions: Organizational culture, but not performance or consult volume, is significantly associated with staff confidence in providing stroke care via telestroke. The finding that less confident sites have longer participation times suggests that planned retraining should be a part of telestroke programs to help sustain site confidence in providing stroke care.

Abstract TMP44: Ethnic Differences in Informal Caregiving After Stroke: The Brain Attack Surveillance in Corpus Christi (BASIC) Project

Background and Aims: We studied informal (non-paid) caregiving after stroke in a population-based study to determine if differences occurred between Mexican Americans (MAs) and non-Hispanic whites (NHWs). MAs are a less affluent population than NHWs. Family members who provide caregiving may need to interrupt educational and occupational goals to provide this care, which may perpetuate socioeconomic disparities between minority and majority populations. Methods: Between October, 2014 and December, 2016, stroke subjects in Texas, USA, were interviewed 90 days after stroke to determine if family or friends provided informal, unpaid caregiving, and for which activities of daily living (ADLs) they required help. Chi-square tests were used to assess the association of ethnicity and whom provided the caregiving, as well as ethnicity and the ADLs for which they required help. Ethnic differences between MAs and NHWs in receiving informal caregiving were determined using logistic regression. The odds ratio (OR, 95% CI) is reported with NHW as the referent group. Results: 473 subjects answered the caregiving questions. There were no significant differences among the two ethnic groups with respect to age, sex, NIHSS score, marital status, or insurance. MAs were more likely to require help compared with NHWs for walking (p=0.0008), bathing (p=0.0004), hygiene (p=0.0018), eating (p=0.0059), dressing (p<0.0001), moving (p=0.0015) and toileting (p=0.0007). Among all subjects, 144 (30%) received informal caregiving (35% of 300 MAs versus 22% of 173 NHWs). There were no significant ethnic differences among which family member provided the caregiving. MAs were more likely to have informal caregiving OR=1.87 (95% CI 1.11-3.13) adjusted for age, sex, NIHSS, education, insurance and marital status. Conclusions: In this population-based study, MAs required more help than NHWs for assistance with ADLs, and MAs were more likely to receive this help through informal, unpaid caregiving than NHWs. Efforts to help minority and low-resource populations provide stroke care are needed.

Abstract WP276: Variation in Treatment Times for Patients With LVO - The Massachusetts Statewide Experience

Introduction: Acute ischemic stroke guidelines recommend endovascular therapy (EVT) for select patients with large vessel occlusion (LVO). A committee of stroke care providers from across MA pooled data to evaluate LVO related care and improve stroke systems of care. We sought to determine variation in care and factors associated with timeliness of Door To Start of Revascularization (first pass)(DTR). Methods: We analyzed 2018 patient-level Get with the Guidelines-Stroke data from 7 of 8 MA EVT-capable centers who provided consent for us to pool the data. Factors affecting DTR times were compared with univariate analysis (Kruskal-Wallis and t-tests as appropriate) and in linear regression models to identify those independently associated with DTR times, adjusted for patient characteristics and clustering by hospital. Variables included age, stroke severity, arrival on (M-F 7a-7p) vs. off hours, mode of arrival (EMS from scene vs interhospital transfer), and hospital EVT volume. Results: Median DTR for 317 patients from 7 centers was 89 (IQR 59-128) min. Site-specific median DTR times varied from 58 (IQR 30-93) to 137.5 (IQR 80.5-171.5) min. In univariate comparisons, median DTR times were shorter after interhospital transfer than EMS from scene (74 (IQR 45-108) vs. 114 (IQR 89-151) min, p<0.001). After controlling for other characteristics, stroke severity, mode of arrival, and off-hours arrival were significantly associated with DTR times, but hospital EVT volume was not (Table). Conclusion: Analysis of GWTG-Stroke data for MA demonstrates variability in hospital-level DTR times, with LVO patients presenting during off hours/holidays experiencing delays in DTR. Reassuringly, patients with more severe strokes were more likely to have shorter DTR times. While hospital EVT volume was not significant, this may be due to small sample size. This variability in performance suggests opportunities for improvement in the MA stroke systems of care.

Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives.

Background and ObjectiveEfforts to improve the adoption of evidence‐based interventions for optimal patient outcomes in low‐/middle‐income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals’ views on strategies to improve quality stroke care for people who had a stroke in a LMIC.MethodsA qualitative interview study design was adopted. A semi‐structured interview guide was used to conduct in‐depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data.ResultsA number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers.ConclusionClosing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context‐specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.

My Stroke Journey: From Self-Advocacy to Patient Advocacy.

My Stroke Journey: From Self-Advocacy to Patient Advocacy.

Implementing Caregiver Support Programs in a Regional Stroke System.

Background and Purpose- Family caregivers play a central role in the recovery of people with stroke. They need support to optimize the care they provide and their own health and well-being. Despite support from the literature and best practice recommendations, healthcare systems are not formally adopting caregiver programs. This study aimed to describe system-level facilitators and barriers to caregiver support program implementation in a regional stroke system. Methods- Using a qualitative descriptive study design, focus groups were conducted with regional rehabilitation specialists, education coordinators, community and long-term care specialists, and regional/district program directors. Semi-structured interviews were conducted with regional medical directors, health professionals providing stroke care in acute care, rehabilitation and community settings, regional health executives, and primary care leaders. Data were analyzed using inductive thematic analysis. Results- Four focus groups (n=43) and 29 interviews were conducted. We identified 4 themes related to caregiver program implementation: (1) establishing the need for caregiver education and support in an integrated healthcare system; (2) incorporating caregiver programs into the system of care across the care continuum; (3) uncertainty regarding ownership and responsibility for implementation; and (4) addressing regional variations related to access, availability, and culture. Conclusions- This study provides a comprehensive understanding of organization and system-level considerations for implementing caregiver programs in a regional stroke system. Program implementation requires evidence to establish the need for caregiver programs, practical strategies, and establishing ownership to incorporate programs into existing healthcare systems, and consideration of regional variations across healthcare systems. Ultimately, adopting programs to support caregivers will improve recovery in people with stroke and caregiver well-being.

Organizational Culture Drives Confidence in Implementing Telestroke Care

Background and Hypothesis: During the past two years, the Veteran Affairs’ National Telestroke Program (NTSP) has conducted 800 teleconsultations at 30 participating sites. Site perceptions of the NTSP are collected in surveys at the time of the program entry and 6-12 months later. This study aims to determine factors associated with the confidence in providing stroke care among staff at participating hospitals, and whether confidence is associated with site performance on program quality indicators.
 Experimental Design: Web-based surveys were sent to participating sites at baseline and post implementation. Survey questions pertained to a site’s confidence providing stroke care, organizational readiness to change (ORCA assessment), buy-in of clinical services, and the impact of the program. Individual responses were averaged at each site. Confidence was scored from zero to ten and was dichotomized into fully confident (10) and not fully confident sites (<10). Site performance on key indicators of program quality were obtained from the NTSP data. A Kruskal Wallis analysis examined the association of baseline variables with postimplementation confidence.
 Results: 54 individuals (57% nurses, 26% providers, and 7% administrators) from 16 sites had baseline and post-implementation data. Five sites were fully confident at the postimplementation assessment. The other 11 had confidence scores ranging from 8.32 to 9.5. Higher ORCA scores were significantly associated with post-implementation confidence (mean ORCA 12.2 vs. 6.8, p=0.04). Sites with longer NTSP participation were less likely to be fully confident, (mean 10.6 months vs. 3.8, P=0.01). Baseline confidence, rurality, and volume were not associated with post-implementation confidence, nor was post-implementation confidence associated with measurements of site performance.
 Conclusion: Higher ratings of site organizational culture was associated with higher postimplementation confidence in providing stroke care. This suggests that an individual site’s context is a larger driver of the confidence in program implementation than volume or program performance. In addition, the finding that sites with longer time spent in the NTSP had lower post-implementation confidence suggests sites may benefit from periodic retraining to sustain confidence in their ability to provide stroke care.

The challenge to providing stroke care and rehabilitation in Malawi

# Background Much research activity throughout the world has advanced on acute stroke care interventions, however, patients in low- and middle-income countries (LMICs) benefit less from stroke care practices due to continuing challenges. The aim of this study was to systematically explore stroke care provision challenges at the largest referral hospital in Malawi, from the perspectives of service providers, patients with stroke and their caregivers. # Methods A qualitative exploratory study with purposefully-selected participants explored challenges to stroke care from the perspectives of service providers, patients with stroke, and caregivers through focus-group discussions. Semi structured interviews were also conducted with physicians for patients with stroke. Thematic analysis was used to categorize the data. # Results Four key themes emerged: 1) lack of effective implementation of stroke care approaches due to lack of recognition and priority in critical care medicine, limited interprofessional contacts, communication disarray among providers, and lack of follow-up after discharge, particularly from rehabilitation professionals; 2) erratic and insufficient physiotherapy treatment due to limited referrals by physicians, limited visibility of physiotherapists in the hospital, and lack of proper service planning by physiotherapists; 3) Patient-mix challenges from intermingling patients with varying conditions, risking both physical harm and the development of nosocomial infections, and; 4) resource limitations from inadequate qualified service providers, limited medical supplies, unreliable equipment, and lack of warm bedding for patients. # Conclusions This study presented the challenges to stroke care provision, from structural, practice, and resource perspectives. There is a need to put in place context specific, and implementable care protocols to facilitate holistic care for patients with stroke. Economically possible structural needs for instance introduction of stroke-specific care wards in the referral hospitals could improve quality of stroke care services in Malawi.

How can the World Stroke Organization (WSO) optimize education in stroke medicine around the world? Report of the 2018 WSO Global Stroke Stakeholder Workshop.

Education in stroke is relevant to stroke survivors, clinicians, care providers, and healthcare system administrators and is of special importance in resource-limited settings. The World Stroke Organization Education Committee undertook a program of work, culminating in a focused workshop, to establish the key educational priorities, and work toward maximizing the WSOs impact on the global burden of stroke. A facilitated workshop took place during the World Stroke Congress in Montreal, Canada in October 2018. The workshop was developed using opinions on priority topics for World Stroke Organization educational activities obtained from web-based surveys of World Stroke Organization Members, supplemented by interviews with international stroke support organizations. The workshop included over 50 international participants, selected to represent a balance of age, gender, geographical region, and different levels of health resources. Participants also included members of the World Stroke Organization Education Committee, the World Stroke Academy, stroke support organizations, and the International Journal of Stroke editorial board. The workshop focused on understanding more about educational needs (at all levels), with emphasis on resource-limited settings. Three broad questions were posed: (1) What are the key educational needs: (a) in your region, (b) from your perspective (e.g. stroke support organization)? (2) Do the current educational activities offered by World Stroke Organization and WSA meet your needs? (3) What could World Stroke Organization/World Stroke Academy offer in your region that would meet your needs? The facilitated discussions were recorded, and the results transcribed and summarized by members of the World Stroke Organization Education Committee. Five key needs were identified: 1. Collaborative interdisciplinary, training in both stroke care and how to advocate for stroke. 2. Educational materials provided in a wider range of formats that could be adapted to local circumstances and clinical practices. 3. Educational activities for healthcare providers and stroke support organizations organized regionally, with the World Stroke Organization providing organizational support, and a pool of experts, therapists, nurses, etc. to deliver locally relevant materials. 4. Clear and authoritative online resources, where it is easy to find key policy and protocol guidance. 5. A range of online interactive education and training resources to help build knowledge and competence in stroke care. The results of the workshop have been presented to the World Stroke Organization Board and will be used to help to guide the educational initiatives of the World Stroke Organization and World Stroke Academy going forward.