Stroke Care In Settings Research Articles

Healthcare professionals’ perspectives on oral health care in acute stroke patients: a qualitative study

BackgroundStroke is a major public health problem, with the disabilities of the patients increasing their risk of poor oral health. Currently, in Ghana and Nigeria, no guideline exists for oral health care in stroke patients, while most of our acute stroke care settings have no documented protocol.AimThis study sought to understand the perspectives of healthcare professionals in Ghana and Nigeria about oral healthcare in acute stroke patients.MethodsA qualitative inductive approach was employed to explore healthcare professionals’ perspectives. After obtaining informed consent, in-depth interviews were conducted among doctors, nurses, and physiotherapists using semi-structured question guides. Participants’ responses were audiotaped for transcription and analysis. Interviews were conducted until data saturation was reached. Data were analyzed thematically to generate themes and sub-themes using an inductive approach.The resultsTwenty-five (25) health care professionals (HCP) aged 25–60 years with a mean age of 36.2 ± 4.2 years were interviewed. There were 15 (60.0%) males and 10 (40.0%) females. HCP included nurse practitioners 14 (56.0%), medical doctors 7 (28.0%), and physiotherapists 4 (16.0%). The HCP demonstrated adequate knowledge of stroke and considered oral health important for esthetic and clinical reasons. They, however, reported being unable to give it the required attention due to inadequate collaboration between the various professional cadres, insufficient equipment, and a skewed focus on other clinical needs of the acute stroke patients.ConclusionsThe findings indicate that HCPs perceived oral health care as very important among patients with acute stroke. However, they reported a lack of collaboration and integration of oral health care in routine stroke care as a major impediment.

The Swedish Stroke Self-Efficacy Questionnaire: translation and cross-cultural adaptation

ObjectiveTo translate and cross-culturally adapt the Stroke Self-Efficacy Questionnaire (SSEQ) from English to Swedish and to evaluate psychometric properties of the questionnaire.MethodsA cross-sectional study design, where the translation followed a process including initial translation, synthesis, backward translation, expert committee, and pretest. Content validity was assessed using Content validity index (CVI). Psychometric assessments included floor-ceiling effects and internal consistency.ResultsLanguage and cultural congruence were achieved, and content validity index scores were high (0.923-1). The psychometric evaluations provided acceptable outcomes concerning internal consistency, with Cronbach’s alpha scores for the total scale (0.902), the activities subscale (0.861) and the self-management subscale (0.818) respectively. Ceiling effects were evident, but no floor effects.ConclusionThis study found the Swedish version of the SSEQ promising as a tool for assessment of self-efficacy in a Swedish stroke care setting, although further psychometric assessments are recommended in future studies.

Developing Systems of Care for Stroke in Resource-limited Settings.

Although stroke prevention and treatment strategies have significantly advanced in recent years, implementation of these care elements in resource-limited settings can be challenging, since the burden of stroke is higher and access to stroke care is lower. Barriers to stroke care in resource-limited settings include insufficient prevention, reduced awareness of stroke symptoms, limited prehospital care and lack of triage systems, limited access to comprehensive stroke centers, inadequate personnel education, lack of staff and resources, as well as limited access to neuroimaging, thrombolytics, mechanical thrombectomy, neurosurgical care, and rehabilitation. Here, we suggest strategies to improve stroke care in these settings, including public health campaigns, protocols for prehospital notification, organized flow to specialized stroke centers, development of dedicated stroke units, and utilization of telemedicine and telerehabilitation. We also highlight the role of international organizations and governments in reducing the global burden of stroke.

Feasibility of Screening for Food Insecurity in an Outpatient Stroke Care Setting (P6-9.004)

<h3>Objective:</h3> To assess the feasibility of food insecurity (FI) screening and prevalence of other social determinants of health (SDOH) associated with FI among stroke survivors attending outpatient clinic visits in the Stroke Transitions Education and Prevention clinical program. <h3>Background:</h3> FI, defined as limited or uncertain access to adequate food due to economic hardship and social condition, is a SDOH resulting in barriers to a healthy diet. Stroke survivors at risk for FI are at higher risk for a recurrent stroke event. FI screening may help identify patients needing access to food resources as a preventive measure to reduce stroke reoccurrence. <h3>Design/Methods:</h3> Cross-sectional design. Patients presenting for their initial telemedicine, or in-person clinic visit were screened using the 2-item Hunger Vital Scale through electronic and paper-based self-report surveys between February 1-July 31, 2021. Multivariable logistic regression examined associations between SDOH and FI. <h3>Results:</h3> Among 476 stroke patients within the stroke clinic, 415 (87.2%) surveys were completed; 258 (62.2%) electronically and 157 (37.8%) paper-based. Overall, 13.9% of the patients experienced FI, and a higher prevalence of FI was observed among those who completed paper-based compared to electronic surveys (21.4% vs 9.9%, P=0.002). More Black patients (36.5%) reported FI compared to White (21.1%) and Hispanic (30.8%) patients (P&lt;0.05). Those who reported disability or unemployment had higher rates of FI compared to employed and retired patients (P=0.000). Black patients had higher odds of reporting FI compared to White patients (AOR=3.02, 95% CI: 1.04; 8.79). <h3>Conclusions:</h3> FI screening is feasible. FI is more prominent in the current sample of stroke survivors compared to the national average. SDOH prevalent characteristics, Black and unemployed patients, align with the literature on structural disparities affecting communities. The results provide information needed to create a social-risk informed index that can be used to target care in stroke survivors. <b>Disclosure:</b> Ms. Almohamad has nothing to disclose. Dr. Mofleh has nothing to disclose. Prof. Altema-Johnson has nothing to disclose. Ms. Ahmed has nothing to disclose. Dr. Fries has nothing to disclose. Ms. Okpala has nothing to disclose. Ms. Cohen has nothing to disclose. Prof. Hernandez has nothing to disclose. The institution of Dr. Sharrief has received research support from NIH. The institution of Dr. Sharrief has received research support from University of Houston . Dr. Sharrief has a non-compensated relationship as a Consultant with Abbot that is relevant to AAN interests or activities.

Abstract TP144: VARIANCE-S: Variability Of Assessed Bp Readings In Acute Neuro-intervention Cases And Its Effect On Outcomes Pertaining To Sex Differences

Introduction: Sex differences exist in thrombolytic stroke treatment and outcome and likely in endovascular thrombectomy (EVT). Previous analysis has shown a significant correlation of blood pressure variability (BPV) and sex. The purpose of this study was to assess sex differences in a sample of patients with good recanalization post-with EVT and examine the impact of BPV. Methods: We conducted a retrospective analysis of prospectively collected data from an IRB approved Stroke Registry of two academic Comprehensive Stroke Centers in Southern California between 2017 and 2022. Patients were included if they had 1) anterior circulation ischemic stroke due to large vessel occlusions (LVO) and 2) underwent successful EVT defined as a TICI 2b or 3 result. Male and female subjects were compared for age, sex, Hispanic ethnicity, initial NIHSS, history of HTN, current antihypertensive use, symptom onset to groin puncture time, door to groin puncture time, and symptomatic ICH (sICH), BPV, onset to groin, and door to groin . Good outcome was defined as mRS 0-2. Chi squared a t-test were used as appropriate. Results: We included 131 females and 124 males. There was a significant difference between males and females in: 1) history of a fib (76% v 64%, p=0.42); 2) atrial fibrillation during admission (36% v 50%, p=0.01); 3) age (male 67 v female 73 years, p&lt;0.001); 4) post-EVT SBP (137mmHg v 144mmHg, p-0.02). There was a significant difference in onset to groin (p=0.41), but no significant difference in door to groin (p=0.59). When adjusting for time of onset, there was no significant difference in thrombolysis prior to EVT between groups. There was no significant difference in sICH (6 male v 4% female, p=0.50), 90 day mRS (p=0.81); or discharge disposition (p=0.56). BPV was significantly correlated with sex but not significant for any interaction effect with the variables assessed. Conclusion: This study found no significant sex differences in outcome in this sample. The systems of care provided by an academic, CSC ensure that all patients’ care is expedited and provides the best opportunity for a good outcome in both sexes. Studies of sex differences in EVT treatment and outcome in multiple stroke care settings are vital to reduce disparities in care.

Risk Factors for Hemorrhagic Stroke among Adults in the Democratic Republic of the Congo: A Hospital-Based Study in a Limited Resource Setting.

The prevalence of stroke is increasing in sub-Saharan Africa. The scarcity of hospital-based stroke data in Lubumbashi (in the Democratic Republic of the Congo) led to the study, which was designed to describe the epidemiology of stroke and identify risk factors associated with hemorrhagic stroke among adult patients in Lubumbashi. This was a cross-sectional study of 158 adult patients admitted for stroke in the internal medicine department of Lubumbashi University Clinics from January 2018 to December 2020. Sociodemographic and clinical features, cardiovascular risk factors, and hospital mortality were collected. A logistic regression has determined the risk of developing a hemorrhagic stroke. Of 9,919 hospitalized patients, 158 had a stroke with a hospital prevalence of 1.6%; 86 (54.4%) patients had a hemorrhagic stroke while 72 (45.6%) had an ischemic stroke. Of which 41.1% (65/158) were women. The mean age was 60.8 ± 13.3 years. Main clinical signs were hemiplegia (63.3%), headache (48.7%), speech disorders (38.6%), and dizziness (38.6%). Hypertension (82.9%) and hyperglycemia (53.2%) were the most common risk factors. Inhospital mortality was 22.8%. After logistic regression, independent predictors for developing hemorrhagic stroke were hypertension (aOR = 8.19; 95% CI: 2.72-24.66; p < 0.0001) and atrial fibrillation (aOR = 4.89; 95% CI: 1.41-16.89; p = 0.012). This study highlights the high stroke mortality in a resource-limited hospital and the burden of hypertension in the development of hemorrhagic stroke. It illustrates the need to establish stroke care setting to improve the quality of stroke care.

Fluid biomarkers in stroke: From animal models to clinical care

Stroke is a leading cause of death and disability worldwide. Stroke prevention, early diagnosis, and efficient acute treatment are priorities to successfully impact stroke death and disability. Fluid biomarkers may improve stroke differential diagnostic, patient stratification for acute treatment, and post-stroke individualized rehabilitation. In the present work, we characterized the use of stroke animal models in fluid biomarker research through a systematic review of PubMed and Scopus databases, followed by a literature review on the translation to the human stroke care setting and future perspectives in the field. We found increasing numbers of publications but with limited translation to the clinic. Animal studies are very heterogeneous, do not account for several human features present in stroke, and, importantly, only a minority of such studies used human cohorts to validate biomarker findings. Clinical studies have found appealing candidates, both protein and circulating nucleic acids, to contribute to a more personalized stroke care pathway. Still, brain tissue complexity and the fact that different brain pathologies share lesion biomarkers make this task challenging due to biomarker low specificity. Moreover, the study design and lack of validation cohorts may have precluded a formal integration of biomarkers in different steps of stroke diagnosis and treatment. To overcome such issues, recent pivotal studies on biomarker dynamics in individual patients are providing added value to diagnosis and anticipating patients' early prognosis. Presently, the most consistent protein biomarkers for stroke diagnosis and short- and long-term prognosis are associated with tissue damage at neuronal (TAU), axonal (NFL), or astroglial (GFAP and S100β) levels. Most promising nucleic acids are microRNAs (miR), due to their stability in plasma and ease of access. Still, clinical validation and standardized quantitation place them a step behind compared protein as stroke biomarkers. Ultimately, the definition of clinically relevant biomarker panels and optimization of fast and sensitive biomarker measurements in the blood, together with their combination with clinical and neuroimaging data, will pave the way toward personalized stroke care.

Oral care practices in stroke: findings from the UK and Australia

AimsTo examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia.BackgroundPoor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries.DesignA cross-sectional survey.MethodsQuestionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times.ResultsCompleted questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents.ConclusionUnacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.

Risk factors, clinical outcomes and predictors of stroke mortality in Sierra Leoneans: A retrospective hospital cohort study

BackgroundStroke data from Sierra Leone is limited, despite the increase in global burden of the disease. The aim of this study was to assess the risk factors, clinical outcomes and predictors of stroke mortality at a tertiary hospital in Freetown, Sierra Leone. MethodsThis retrospective cohort study was conducted on stroke patients admitted at the Connaught Teaching Hospital between 1st January to December 31, 2018. Clinical data related to stroke, with variables including patients’ demographics, stroke subtype, vascular risk factors, modified Rankin Scale (mRS), and outcomes were documented. In-hospital mortality, associated risk factors and predictors of stroke were determined. The study was approved by the Sierra Leone Ethics and Scientific Review Committee. It was registered under Research Registry https://www.researchregistry.com/browse-the-registry#home/with the unique identifying number researchregistry6009. ResultWe studied 178 (95 male and 83 female) patients. The mean age was 59.8 ± 14.0 years, median was 58.1years (ranging: 29–88 years). The commonest risk factors were hypertension (84.3%), tobacco smoking (35.9%) and alcohol (31.4%). Ischemic stroke confirmed by CT scan was 76.3%. In-hospital mortality was 34.8% and at discharge, mean modified Rankin Score (mRS) was 3.89 ± 1.62. The independent predictors for stroke mortality were: hypertension [AOR = 2.2; C.I 95%: (1.32–3.80), p = 0.001], previous stroke [AOR = 2.31; C.I 95%: (1.43–5.74), p = 0.001], GCS < 8 [AOR = 6.06; C.I 95%: (3.17–12.79), p < 0.001], clinical diagnosis in the absence of imaging [AOR = 3.11; C.I 95%: (2.1–9.87), p = 0.001], hemorrhagic stroke [AOR = 2.96; C.I 95%: (1.96–9.54), p < 0.001], and aspiration pneumonia [(AOR = 3.03; C.I 95%:(1.44–6.36), p = 0.001]. Women had poorer outcome than men. ConclusionThis study highlights a high stroke mortality in a resource limited hospital, with some stroke patients having difficulties in accessing Computer Tomogram (CT) scan services. It illustrates the need to establish a stroke care setting to improve the quality of stroke care.

Scoping review of acute stroke care management and rehabilitation in low and middle-income countries

BackgroundStroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care.MethodsAn interpretative scoping literature review based on Arksey and O’Malley’s five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries.ResultsA total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization.ConclusionsThere is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.

E-Poster Viewing

Free accessAbstractFirst published online May 22, 2019E-Poster ViewingVolume 4, Issue 1_supplhttps://doi.org/10.1177/2396987319845581

Effect of early supported discharge after stroke on patient reported outcome based on the Swedish Riksstroke registry

BackgroundThe efficacy of early supported discharge (ESD) has not been tested in current stroke care setting, which provide relatively short hospital stays, access to hyper-acute therapies and early carotid stenosis interventions. This study aimed to compare patient-reported outcome measures (PROM) among patients with stroke that received modern stroke unit care with or without ESD.MethodsObservational study of 30,232 patients with first-ever stroke registered in the Riksstroke registry in Sweden, between 1 January 2010 and 31 December 2013. Patient characteristics were collected from the Riksstroke and Statistics Sweden databases. The primary outcome was satisfaction with the rehabilitation at 3 months after discharge. Secondary outcome were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toileting and dressing) at 3 months after the stroke. We used separate multivariable logistic regression models for each PROM variable to analyze associations between PROMs and ESD/no ESD.ResultsThe ESD group comprised 1495 participants: the control group comprised 28,737 participants. Multivariable logistic regression models of PROMs showed that, compared to controls, the ESD group was more satisfied with rehabilitation after discharge (OR: 1.78, 95% CI: 1.17–2.49), experienced less dysthymia/depression (OR: 0.68, 95% 0.55–0.84) and showed more independence in mobility (OR: 1.50, 95% CI: 1.17–1.92), toileting (OR: 1.30, 95%CI: 1.05–1.61), and dressing (OR: 1.23, 95%CI: 1.02–1.48).ConclusionIn the setting of modern stroke unit care, ESD appeared to have positive effects on stroke rehabilitation, in the subacute phase.

Burnout syndrome: are stroke neurologists at a higher risk?

Burnout syndrome is a work-related psychological response, characterized by emotional exhaustion, depersonalization and low professional accomplishment. The study aimed to evaluate the prevalence of burnout syndrome in neurologists in the State of Paraná, Brazil, dividing them into stroke neurologists and non-stroke neurologists. We performed a crosssectional observational study, with a quantitative approach, based on the online Maslach Burnout Inventory - Human Services Survey questionnaire. A total of 74 neurologists were evaluated, 44.6% of whom had burnout syndrome, predominantly among females and stroke neurologists. Both the stroke neurologist and non-stroke neurologist groups had medium degrees of emotional exhaustion and depersonalization; however, while stroke neurologists had high professional accomplishment, non-stroke neurologists had mean-to-low scores of professional accomplishment. There was a proportional relationship between age and emotional exhaustion. Female neurologists also reported lower professional accomplishment levels. Burnout is prevalent among the neurologists of Paraná, corroborating the results previously reported in other studies. There seems to be no significant difference between those neurologists who work in the emergency stroke care setting compared with those who don't.

Stroke networks and telemedicine: An Italian national survey.

Stroke is the leading cause of disability and death. Nowadays, clinical benefits of stroke units and thrombolysis in ischemic stroke are evidence-based. Also the benefit of endovascular treatment for acute ischemic stroke has been established. Telemedicine has been used to improve access to care by allowing a neurologist at a remote location to interact with the patient and their family members. Prior studies have shown that the use of telemedicine for acute ischemic stroke is not only safe and effective, but it also increases the utilization of tPA, improving patient outcomes. This study aimed to investigate the diffusion of telemedicine in Italian stroke networks with an online questionnaire to assess: type of stroke care setting, Volume of thrombolysis- thrombectomy/year, access to stroke care between different hospitals, the presence of imaging sharing protocols within the network or patients dispatchment screening; type of network solutions. We have interviewed 24 Italian neurologists, working in large urban areas, from north southward, including Italian islands. In particular, these neurologists represented 14 different regions and 20 countries. A majority of neurologists replying to the survey (47.83%) worked in large general hospitals or smaller general hospitals (26%) and a smaller number of physicians (17.3%) were committed in University Hospital or (8.7%) independent foundation hospitals. The 60.87% of stroke networks involved in the survey had a low thrombolysis/year volume while the 30.43% had a thrombolysis/year volume above 100. According to the survey a local stroke network was established in 87.50% of cases. In the 45.83% of cases, the hospitals care is not homogeneous within the network. A network for the consultation of neuroimaging between hospitals is available in 33.33% of cases. Whitin those describing an active network for Teleconsult the 57.14% used personal devices, while only the 25 % use professional teleconference system, and in 25% of cases used medical devices. Our findings demonstrated a relevant diffusion of Teleconsult in Italian stroke networks. The systems adopted are mostly individual solutions not integrated in protocolled pathways. These findings may encourage a systematization of Telemedicine medical curricula to increase larger access to neurological consults.

Implementing Evidence-Based Practices for Acute Stroke Care in Low- and Middle-Income Countries.

Most strokes occur in low- and middle-income countries where resources to manage patients are limited. We explore the resources required to providing optimal acute stroke care and review barriers to implementing evidence-based stroke care in settings with limited resources using the World Stroke Organization's Global Stroke Services Action Plan framework. Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.

Stroke survivors' experiences of using the Graded Repetitive Arm Supplementary Program (GRASP) in an Australian acute hospital setting: A mixed-methods pilot study.

The Graded Repetitive Arm Supplementary Program (GRASP) has been designed to increase the frequency of upper limb therapy sessions occurring without the presence of a therapist. Its use has not been studied when implemented in acute care settings with patients presenting with a stroke within the first week of onset. To investigate patients' experiences of using the GRASP when provided within the first week in an acute stroke setting. A concurrent nested mixed methods design was used. Participants were assessed prior and post theGRASP implementation using the CAHAI-9, the UL-MAS, and the SIS 3.0 physical dimensions and interviewed regarding their GRASP experience. Participants (n=8, mean days post stroke=2.75days, SD=2.05 at recruitment, mean age=69.63years, SD=11.73) used the GRASP regularly while in the acute stroke care setting (mean GRASP use=28.44minutes/day, SD=20.40, range=10-45minutes, median=15minutes). The perceived benefits of the GRASP use reported by patients included 'it's good for your hand', 'they makes other jobs easier' and 'I've got to be doing something'. Categories regarding the participants' motivation to use the GRASP included 'to get my hand better', 'being able to do the things I did before' and 'to get out of here [the hospital]'. Participants experienced clinically significant changes in mean change scores of the CAHAI-9 and UL-MAS at the group level. Wilcoxon Signed Ranks Test revealed no statistically significant changes. A clinical trial to evaluate the effectiveness of the GRASP when provided to patients within the first week is recommended.

Clinical and cost effectiveness of enhanced oral healthcare in stroke care settings (SOCLE II): a pilot, stepped wedge, cluster randomized, controlled trial protocol.

Stroke-associated pneumonia, a leading cause of hospital-acquired infection after stroke, affects a fifth of stroke survivors annually. Associated with increased risk of death and poorer rehabilitation outcomes, research suggests a possible relationship between stroke-associated pneumonia and patients' oral health. The aim of this study is to evaluate the feasibility of a randomized controlled trial of the clinical and cost effectiveness of enhanced oral healthcare vs. usual oral healthcare for people in stroke care settings. Our pilot, multicentered, pragmatic, stepped wedge, cluster randomized controlled trial oral healthcare [Stroke Oral healthCare pLan Evaluation (SOCLE II)] will compare enhanced oral healthcare intervention and usual oral healthcare. Over 13 months, across 4 wards, we seek to recruit 400 patients (estimating an average of 23 beds per site and a 50% recruitment rate) and 60 nursing staff (estimating an average of 20 members of staff per site and a 75% recruitment rate). Initially, control data (usual oral healthcare) will be collected from all sites. In a randomized, stepped manner, wards will convert to deliver the enhanced oral healthcare intervention. Outcomes will be captured across dimensions of care (as recommended for evaluations of complex interventions) at baseline and weekly thereafter. Primary outcomes are pneumonia (patients), knowledge and attitudes (staff), and specialist dental referrals (service). Secondary outcomes include oral health quality of life, plaque, antibiotics, length of stay, death (patients), use of oral healthcare equipment and products, completed assessments, and documented oral healthcare plans (staff). As one of the first stepped wedge, cluster randomized, controlled trials in stroke care mapping of the complex intervention, our choice of primary and secondary outcomes and choice of trial design are described.

Caring for continence in stroke care settings: a qualitative study of patients’ and staff perspectives on the implementation of a new continence care intervention

Objectives: Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke. Design: Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis. Setting: Mixed acute and rehabilitation stroke ward. Participants: Stroke patients and nursing staff that experienced an enhanced continence care intervention. Results: Four themes emerged from patients’ interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients’ perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence. Conclusion: Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.

Response to Letter Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting”

Response: We thank Dr Duyff and Dr Groeneveld for their thoughtful comments regarding our collaborative publication in Stroke. (1 We deeply appreciate the great effort Dr Duyff, Dr Groeneveld, and others expended to help carry out this study. We thank our colleagues for pointing out some issues that may not be immediately clear from the original publication. This gives us the opportunity to give the readers of Stroke the additional details they may require to comprehend the article and its implications in full. Dr Duyff …

Letter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting”

HomeStrokeVol. 43, No. 8Letter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting” Ruurd F. Duyff, MD and Carel Groeneveld, MD Ruurd F. DuyffRuurd F. Duyff Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The Netherlands (Duyff, Groeneveld) Search for more papers by this author and Carel GroeneveldCarel Groeneveld Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The Netherlands (Duyff, Groeneveld) Search for more papers by this author Originally published7 Jun 2012https://doi.org/10.1161/STROKEAHA.112.660167Stroke. 2012;43:e73Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 To the Editor:Being one of the centers participating in the study, we read the article by Lahr et al,1 published online March 16, 2012 in Stroke, with great interest. They concluded that patients are more likely to be treated with thrombolysis in a centralized setting.We would like to make some remarks and add some recent figures from our own institution. First, of course, the authors are to be commended for their collaborative effort to investigate such a complex issue.In this case, the region functions as an instrumental variable,2 the assumption being that the regions are completely comparable in sociodemographic variables and burden of disease, etc. Almost certainly, this assumption is not correct, so there is potential for confounding and the authors hint at some disparities themselves. We would like to draw attention to the fact that the decentralized region is more rural, maybe accounting for the finding that in the decentralized model, use of emergency medical services and high prioritization were significantly lower.1The main difference in our view is the fact that in the decentralized setting, significantly fewer patients arrived in time for tissue-type plasminogen activator treatment, only 28% versus 44% in the centralized setting; whereas the proportion of patients arriving within 4.5 hours after stroke onset who were actually treated with tissue-type plasminogen activator was exactly the same: 50%. Also, functional outcome and complications were similar. This is a remarkable feat, considering it was achieved by many smaller community hospitals compared with 1 tertiary stroke center. It is, however, in line with the findings of the SITS-MOST study.3 As the authors also state, the proportion of patients treated in the decentralized model was higher than was reported previously, and we think it is likely to grow. From our own stroke registry, we have the figure for 2011: 20% of all patients presenting with ischemic stroke were treated with alteplase and the median door-to-needle time was only 35 minutes; these figures compare very favorably with national and international data.1,4,5Another significant finding was the shorter onset-to-door time in the decentralized model, even after compensating for the longer door-to-needle time and leading to a slightly shorter onset-to-needle time in the decentralized model (120 minutes versus 124 minutes, not significant); this is of course the result of significantly shorter travel distances to hospital. Combined with shortening door-to-needle times in community hospitals like ours, this leads to shorter onset-to-needle times and possibly better outcome in the decentralized setting, although this remains to be investigated.We would like to stress the importance of the prehospital factors, as these caused the main differences between the models; public awareness needs to be raised so more patients can benefit from treatment. For policymakers, this should be the main finding of this study and not the hasty conclusion that thrombolysis treatment should be centralized everywhere. This would not only do us wrong, but also other community hospitals like ours, which happen to have 24-hour dedicated stroke care.Essentially, intravenous thrombolysis is a low-tech treatment that can be administered safely in hospitals that are near the patient.3,5Ruurd F. Duyff, MDCarel Groeneveld, MD Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The NetherlandsSources of FundingNone.DisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org).Correspondence to Ruurd F. Duyff, MD, Ziekenhuis De Tjongerschans, Neurology, Thialfweg 44, Heerenveen 8441 PW, Netherlands. E-mail [email protected]nl