Stroke Rehabilitation Guidelines Research Articles

Post-stroke lateropulsion in Australia and New Zealand: a survey investigating current knowledge, priorities and practice

ABSTRACT Background Post-stroke lateropulsion is prevalent and associated with poor rehabilitation outcomes, but evidence to guide rehabilitation of affected stroke survivors is limited. Current post-stroke lateropulsion rehabilitation practice across Australia and New Zealand has not been previously described. Objectives This study aimed to describe lateropulsion rehabilitation practice in Australia and New Zealand, determine clinicians,’ educators’ and researchers’ opinions about the need for educational resources to guide best-practice, and to identify current barriers to, and enablers of, optimal rehabilitation delivery. Methods This cross-sectional survey was distributed to stroke rehabilitation clinicians, educators and researchers across Australia and New Zealand using Qualtrics. Data were described using frequency distributions and Chi-squared tests. Responses to open-ended questions were summarized for reporting. Results The final analyses included 127 surveys. Most participants (93%) were physiotherapists. The importance of identifying and assessing post-stroke lateropulsion was noted by 97.6% of participants; however routine lateropulsion assessment was reported by only 60.6% of respondents. About 93.6% of participants indicated that lateropulsion should be targeted as a rehabilitation priority. Limitations in knowledge and skill among clinicians and insufficient evidence to guide rehabilitation were noted as barriers to best-practice rehabilitation delivery. Most respondents (95.2%) indicated that lateropulsion management should be included in stroke rehabilitation guidelines. Conclusions A sample of clinicians, educators, and researchers involved in stroke rehabilitation across Australia and New Zealand have indicated that lateropulsion should be targeted as a rehabilitation priority. Knowledge and skill were identified as barriers to best-practice rehabilitation implementation, which could be improved by addressing lateropulsion in clinical practice guidelines.

Comparative global analysis of stroke rehabilitation recommendations across income levels

ObjectiveSuccessful implementation of stroke rehabilitation guidelines demands high-quality practice standards tailored to targeted sociodemographic contexts. The primary objective is to determine the quality differences in post-stroke rehabilitation practice guidelines (PGs), when comparing high-income countries (HIC) and low or middle-income countries (LMIC). Study Design and SettingWe conducted a scoping review of PGs in English or Spanish, published between 2012 and 2021, and providing recommendations on post-stroke rehabilitation. We used Search engines, databases, guideline libraries, gray literature, and references from previous reviews on post-stroke rehabilitation as sources of evidence. Quality assessment of PGs was performed using 6P’s, ELSE, IOM, and AGREE II instruments. We evaluated each item using a scale between 0 to 3, based on the confidence of adherence to the standard. For AGREE II, we followed the instruction manual for scoring. At least two reviewers were independently involved in every step of the process. A cloud-based spreadsheet was used to chart data. We compared the results of PGs originating from HIC with those from LMIC. ResultsThe inclusion criteria were met by 35 documents, which were subjected to evaluation. The study included 21 documents from HIC and 14 from middle-income countries (MIC). No manuscripts from low-income countries were available for inclusion in the study. The quality of PGs from MIC was found to be lower, in terms of methodological rigor and adherence to international recommendations for guidelines development. PGs from both groups of countries failed to include all target audiences and stakeholders (according to the 6P’s criteria) and integration of ethical, legal, social, and economic considerations. ConclusionThere are gaps in the quality and availability of stroke rehabilitation guidelines worldwide, especially in LMIC. Designing and providing financial support for the implementation of high-quality guidelines will contribute to more effective implementation strategies in stroke rehabilitation programs and lead to improved patient outcomes.

Extended reality to assess post-stroke manual dexterity: contrasts between the classic box and block test, immersive virtual reality with controllers, with hand-tracking, and mixed-reality tests

BackgroundRecent technological advancements present promising opportunities to enhance the frequency and objectivity of functional assessments, aligning with recent stroke rehabilitation guidelines. Within this framework, we designed and adapted different manual dexterity tests in extended reality (XR), using immersive virtual reality (VR) with controllers (BBT-VR-C), immersive VR with hand-tracking (BBT-VR-HT), and mixed-reality (MD-MR).ObjectiveThis study primarily aimed to assess and compare the validity of the BBT-VR-C, BBT-VR-HT and MD-MR to assess post-stroke manual dexterity. Secondary objectives were to evaluate reliability, usability and to define arm kinematics measures.MethodsA sample of 21 healthy control participants (HCP) and 21 stroke individuals with hemiparesis (IHP) completed three trials of the traditional BBT, the BBT-VR-C, BBT-VR-HT and MD-MR. Content validity of the different tests were evaluated by asking five healthcare professionals to rate the difficulty of performing each test in comparison to the traditional BBT. Convergent validity was evaluated through correlations between the scores of the traditional BBT and the XR tests. Test-retest reliability was assessed through correlations between the second and third trial and usability was assessed using the System Usability Scale (SUS). Lastly, upper limb movement smoothness (SPARC) was compared between IHP and HCP for both BBT-VR test versions.ResultsFor content validity, healthcare professionals rated the BBT-VR-HT (0[0–1]) and BBT-MR (0[0–1]) as equally difficult to the traditional BBT, whereas they rated BBT-VR-C as more difficult than the traditional BBT (1[0–2]). For IHP convergent validity, the Pearson tests demonstrated larger correlations between the scores of BBT and BBT-VR-HT (r = 0.94;p < 0.001), and BBT and MD-MR (r = 0.95;p < 0.001) than BBT and BBT-VR-C (r = 0.65;p = 0.001). BBT-VR-HT and MD-MR usability were both rated as excellent, with median SUS scores of 83[57.5–91.3] and 83[53.8–92.5] respectively. Excellent reliability was found for the BBT-VR-C (ICC = 0.96;p < 0.001), BBT-VR-HT (ICC = 0.96;p < 0.001) and BBT-MR (ICC = 0.99;p < 0.001). The usability of the BBT-VR-C was rated as good with a median SUS of 70[43.8–83.8]. Upper limb movements of HCP were significantly smoother than for IHP when completing either the BBT-VR-C (t = 2.05;p = 0.043) and the BBT-VR-HT (t = 5.21;p < 0.001).ConclusionThe different XR manual tests are valid, short-term reliable and usable tools to assess post-stroke manual dexterity.Trial registrationhttps://clinicaltrials.gov/ct2/show/NCT04694833; Unique identifier: NCT04694833, Date of registration: 11/24/2020.

Stroke Inpatient Rehabilitation Environments: Aligning Building Construction and Clinical Practice Guidelines Through Care Process Mapping.

Stroke inpatient rehabilitation is a complex process involving stroke survivors, staff, and family utilizing a common space for a shared purpose: to optimize recovery. This complex pathway is rarely fully described. Stroke care is ideally guided by Clinical Practice Guidelines, and the rehabilitation built environment should serve to optimize care delivery, patient and staff experience. We aimed to articulate the inpatient stroke rehabilitation process of care in a series of process maps, and to understand the degree to which current stroke clinical and building construction (ie, design) guidelines align to support inpatient stroke rehabilitation. We used the Value-Focused Process Engineering methodology to create maps describing the events and activities that typically occur in the current stroke inpatient rehabilitation service model. These maps were completed through individual and group session consultations with stroke survivors, architects, policy makers, and clinical experts. We then determined which sections of the Australian Stroke Rehabilitation Guidelines and the Australasian Health Facility Design Guidelines could be aligned and applied to the process maps. We present a summary process map for stroke inpatient rehabilitation, alongside detailed process maps for 4 different phases of rehabilitation (admission, a normal weekday, a weekend day, and discharge) using Value-Focused Process Engineering notation. The integration of design and clinical guidelines with care pathway maps revealed where guidelines lack detail to be readily linked to current stroke inpatient care practice, providing an opportunity to design stroke inpatient rehabilitation spaces based on the activities occurring within them. Our findings highlight gaps where clinical and design experts should work together to use guidelines to their full potential; and to improve the process of planning for future stroke rehabilitation units.

Usability of Functional Electrical Stimulation in Upper Limb Rehabilitation in Post-Stroke Patients: A Narrative Review.

Stroke leads to significant impairment in upper limb (UL) function. The goal of rehabilitation is the reestablishment of pre-stroke motor stroke skills by stimulating neuroplasticity. Among several rehabilitation approaches, functional electrical stimulation (FES) is highlighted in stroke rehabilitation guidelines as a supplementary therapy alongside the standard care modalities. The aim of this study is to present a comprehensive review regarding the usability of FES in post-stroke UL rehabilitation. Specifically, the factors related to UL rehabilitation that should be considered in FES usability, as well a critical review of the outcomes used to assess FES usability, are presented. This review reinforces the FES as a promising tool to induce neuroplastic modifications in post-stroke rehabilitation by enabling the possibility of delivering intensive periods of treatment with comparatively less demand on human resources. However, the lack of studies evaluating FES usability through motor control outcomes, specifically movement quality indicators, combined with user satisfaction limits the definition of FES optimal therapeutical window for different UL functional tasks. FES systems capable of integrating postural control muscles involving other anatomic regions, such as the trunk, during reaching tasks are required to improve UL function in post-stroke patients.

Moderate-intensity exercise versus high-intensity interval training to recover walking post-stroke: protocol for a randomized controlled trial

BackgroundStroke results in neurologic impairments and aerobic deconditioning that contribute to limited walking capacity which is a major barrier post-stroke. Current exercise recommendations and stroke rehabilitation guidelines recommend moderate-intensity aerobic training post-stroke. Locomotor high-intensity interval training is a promising new strategy that has shown significantly greater improvements in aerobic fitness and motor performance than moderate-intensity aerobic training in other populations. However, the relative benefits and risks of high-intensity interval training and moderate-intensity aerobic training remain poorly understood following stroke. In this study, we hypothesize that locomotor high-intensity interval training will result in greater improvements in walking capacity than moderate-intensity aerobic training.MethodsUsing a single-blind, 3-site randomized controlled trial, 50 chronic (> 6 months) stroke survivors are randomly assigned to complete 36 locomotor training sessions of either high-intensity interval training or moderate-intensity aerobic training. Main eligibility criteria are age 40–80 years, single stroke for which the participant received treatment (experienced 6 months to 5 years prior to consent), walking speed ≤ 1.0 m/s, able to walk at least 3 min on the treadmill at ≥ 0.13 m/s (0.3 mph), stable cardiovascular condition (American Heart Association class B), and the ability to walk 10 m overground without continuous physical assistance. The primary outcome (walking capacity) and secondary outcomes (self-selected and fast gait speed, aerobic fitness, and fatigue) are assessed prior to initiating training and after 4 weeks, 8 weeks, and 12 weeks of training.DiscussionThis study will provide fundamental new knowledge to inform the selection of intensity and duration dosing parameters for gait recovery and optimization of aerobic training interventions in chronic stroke. Data needed to justify and design a subsequent definitive trial will also be obtained. Thus, the results of this study will inform future stroke rehabilitation guidelines on how to optimally improve walking capacity following stroke.Trial registrationClinicalTrials.govNCT03760016. Registered on November 30, 2018.

Timing is everything: Exercise therapy and remote ischemic conditioning for acute ischemic stroke patients.

Physical exercise is a promising rehabilitative strategy for acute ischemic stroke. Preclinical trials suggest that exercise restores cerebral blood circulation and re-establishes the blood–brain barrier’s integrity with neurological function and motor skill improvement. Clinical trials demonstrated that exercise improves prognosis and decreases complications after ischemic events. Due to these encouraging findings, early exercise rehabilitation has been quickly adopted into stroke rehabilitation guidelines. Unfortunately, preclinical trials have failed to warn us of an adverse effect. Trials with very early exercise rehabilitation (within 24 h of ischemic attack) found an inferior prognosis at 3 months. It was not immediately clear as to why exercise was detrimental when performed very early while it was ameliorative just a few short days later. This review aimed to explore the potential mechanisms of harm seen in very early exercise administered to acute ischemic stroke patients. To begin, the mechanisms of exercise’s benefit were transposed onto the current understanding of acute ischemic stroke’s pathogenesis, specifically during the acute and subacute phases. Then, exercise rehabilitation’s mechanisms were compared to that of remote ischemic conditioning (RIC). This comparison may reveal how RIC may be providing clinical benefit during the acute phase of ischemic stroke when exercise proved to be harmful.

Health Policy and Health Services Delivery in the Era of COVID-19.

Health Policy and Health Services Delivery in the Era of COVID-19.

Do clinical guidelines guide clinical practice in stroke rehabilitation? An international survey of health professionals

Purpose To identify health professionals awareness of stroke rehabilitation guidelines, and factors perceived to influence guideline use internationally. Methods Online survey study. Open-ended responses were thematically analysed, guided by the Consolidated Framework for Implementation Research. Results Data from 833 respondents from 30 countries were included. Locally developed guidelines were available in 22 countries represented in the sample. Respondents from high-income countries were more aware of local guidelines compared with respondents from low- and middle-income countries. Local contextual factors such as management support and a culture of valuing evidence-based practice were reported to positively influence guideline use, whereas inadequate time and shortages of skilled staff inhibited the delivery of guideline-recommended care. Processes reported to improve guideline use included education, training, formation of workgroups, and audit-feedback cycles. Broader contextual factors included accountability (or lack thereof) of health professionals to deliver rehabilitation consistent with guideline recommendations. Conclusion While many health professionals were aware of clinical guidelines, they identified multiple barriers to their implementation. Efforts should be made to raise awareness of local guidelines in low- and middle-income countries. More attention should be paid to addressing local contextual factors to improve guideline use internationally, going beyond traditional strategies focused on individual health professionals. IMPLICATIONS FOR REHABILITATION Systems are required so people and organisations are held accountable to deliver evidence-based care in stroke rehabilitation. Locally developed stroke rehabilitation guidelines should be promoted to boost awareness of these guidelines in low- and middle-income countries. In all regions, strategies to influence or adapt to the local setting, are required to optimise guideline use.

A multifaceted continuing professional development intervention to move stroke rehabilitation guidelines into professional practice: A feasibility study

ABSTRACT Introduction Rehabilitation post-stroke is critical for maximizing patient outcomes. This study assessed the feasibility of implementing and evaluating a continuing professional development (CPD) intervention aimed at increasing the uptake of stroke best practice guidelines among physiotherapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) in six university-affiliated stroke rehabilitation centers in Quebec, Canada. Method Twelve stroke best practice recommendations with reflective tools were sent weekly by e-mail. Participants’ eligibility criteria included: a) profession; b) practicing more than 1 year in a stroke rehabilitation program; c) fluency in French or English; and d) basic computer literacy. Feasibility (operationalized via participation, satisfaction and relevance), cognitive impact, perceived application in practice and expected patient outcomes were measured over 24 weeks using three questionnaires and analyzed using descriptive statistics. Results The sample totaled 62 of 133 eligible (47%) clinicians. Satisfaction, relevance and cognitive impact of delivered information varied across disciplines and recommendations. Agreement with the recommendations was high across disciplines. On average, three-interdisciplinary recommendations (related to post-stoke depression, post-stoke fatigue and patients’ and caregivers’ learning needs) were rated as the most relevant for at least one patient. The majority of clinicians would use the recommendations for a specific patient and expected health benefits by applying those recommendations. Conclusion This study demonstrated the feasibility of assessing the impact of a CPD intervention in stroke rehabilitation uptake and informed the design of a research program aimed at increasing the use of stroke evidence-based rehabilitation interventions.

Evidence-Based Guidelines and Clinical Pathways in Stroke Rehabilitation-An International Perspective.

A high societal burden and a considerable increase in stroke-related disability was globally observed over the last 3 decades, and is expected to continue implying a major challenge for societies around the word. Structured multidisciplinary stroke rehabilitation reduces stroke-related disability both in older and younger stroke survivors of either sex and independent of stroke severity. In addition, there is rapidly increasing evidence to support the clinical effectiveness of specific stroke rehabilitation interventions. Evidence-based guidelines help to promote best possible clinical practice. Inherent difficulty for their provision is that it takes enormous efforts to systematically appraise the evidence for guidelines and their regular updates, if they should not be at risk of bias by incomplete evidence selection. A systematic review of the pertaining literature indicates that the currently published stroke rehabilitation guidelines have a national background and focus and represent the health care situations in high-income countries. Societies around the globe would benefit from central evidence sources that systematically appraise the available evidence and make explicit links to practice recommendations. Such knowledge could facilitate a more wide-spread development of valid comprehensive up-to-date evidence-based national guidelines. In addition, the development of genuine international evidence-based stroke rehabilitation guidelines that focus on therapeutic approaches rather than organizational issues, could be used by many to structure regional or local stroke rehabilitation pathways and to develop their resources in a way that will eventually achieve effective stroke rehabilitation. Such international practice recommendations for stroke rehabilitation are currently under development by the World Federation for NeuroRehabilitation (WFNR).

Abstract WP180: Association Between Medicare Reform and Access to Rehabilitation in Ischemic Stroke Patients

Introduction: In 2010, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Rule, requiring IRF patients to tolerate 3 hours of daily therapy (PT &amp;OT/SLP). If unable, rehab at a skilled nursing facility (SNF) is recommended, contrasting the 2016 AHA Stroke Rehabilitation Guidelines for optimal recovery. Hypothesis: Stroke patients are more likely to receive rehab at a SNF compared to an IRF after implementation of the CMS 2010 IRF PPS Rule. Methods: We calculated the proportion of stroke patients discharged to IRF vs home and SNF vs home using prospectively collected registry data from Get with the Guidelines - Stroke, for a cohort of ischemic (85.7%) and hemorrhagic (14.3%) stroke patients between 2008 and 2015 (n=1,962,933). Univariate analyses compared stroke severity by NIHSS, sociodemographic/clinical characteristics and in hospital rehabilitation assessments. Multivariable regression modeling assessed the association between CMS 2010 IRF PPS Rule and age, teaching versus non-teaching hospital and US geographic region. Results: Post CMS 2010 IRF PPS Rule, 1 out of 15 ischemic stroke patients had lower IRF rehab odds (OR 0.94; 95%CI 0.92-0.95; P&lt;0.0001); 1 out of 9 ischemic stroke patients had higher SNF rehab odds (OR 1.12, 95% CI 1.10-1.14; P&lt;0.0001). Multivariable regression - ischemic stroke: Across all ages, in the South, Northeast and at teaching hospitals, the odds of IRF rehab decreased and the odds of SNF rehab increased after implementation of CMS 2010 IRF PPS Rule (Fig 1 &amp; 2). Conclusions: Ischemic stroke patients, with similar clinical histories &amp; stroke severity, had decreased odds of inpatient rehabilitation facility rehab and increased odds of skilled nursing facility rehab after implementation of the CMS 2010 IRF PPS Rule. Additional studies analyzing the effects of low intensity SNF rehab versus IRF rehab on return home and long-term disability are needed.

Perspectives of health care professionals on the facilitators and barriers to the implementation of a stroke rehabilitation guidelines cluster randomized controlled trial

BackgroundThe Stroke Canada Optimization of Rehabilitation by Evidence Implementation Trial (SCORE-IT) was a cluster randomized controlled trial that evaluated two knowledge translation (KT) interventions for the promotion of the uptake of best practice recommendations for interventions targeting upper and lower extremity function, postural control, and mobility. Twenty rehabilitation centers across Canada were randomly assigned to either the facilitated or passive KT intervention. The objective of the current study was to understand the factors influencing the implementation of the recommended treatments and KT interventions from the perspective of nurses, occupational therapists and physical therapists, and clinical managers following completion of the trial.MethodsA qualitative descriptive approach involving focus groups was used. Thematic analysis was used to understand the factors influencing the implementation of the recommended treatments and KT interventions. The Clinical Practice Guidelines Framework for Improvement guided the analysis.ResultsThirty-three participants were interviewed from 11 of the 20 study sites (6 sites from the facilitated KT arm and 5 sites from the passive KT arm). The following factors influencing the implementation of the recommended treatments and KT interventions emerged: facilitation, agreement with the intervention – practical, familiarity with the recommended treatments, and environmental factors, including time and resources. Each of these themes includes the sub-themes of facilitator and/or barrier. Improved team communication and interdisciplinary collaboration emerged as an unintended outcome of the trial across both arms in addition to a facilitator to the implementation of the treatment recommendations. Facilitation was identified as a facilitator to implementation of the KT interventions in the passive KT intervention arm despite the lack of formally instituted facilitators in this arm of the trial.ConclusionsThis is one of the first studies to examine the factors influencing the implementation of stroke recommendations and associated KT interventions within the context of a trial. Findings highlight the important role of self-selected facilitators to implementation efforts. Future research should seek to better understand the specific characteristics of facilitators that are associated with successful implementation and clinical outcomes, especially within the context of stroke rehabilitation.

Inpatient Rehabilitation Outcomes in Patients With Stroke Aged 85 Years or Older.

In the United States, people 85 years of age or older have a growing number of strokes each year, and this age group is most at risk for disability. Inpatient rehabilitation facilities (IRFs) adhere closest to post-acute stroke rehabilitation guidelines and have the most desirable outcomes compared with skilled nursing facilities. As stroke is one of the leading causes of disability, knowledge of postrehabilitation outcomes is needed for this age group, although at present such information is limited. The purpose of this study was to describe functional and discharge outcomes after IRF rehabilitation in people with stroke aged 85 years or older. A serial, cross-sectional design was used. Inpatient Rehabilitation Facility-Patient Assessment Instrument data were analyzed beginning in 2002 for the first 5.5 years after implementation of the prospective payment system and included 71,652 cases. Discharge function, measured using the Functional Independence Measure (FIM), and community discharge were the discharge outcome measures. Sample description used frequencies and means. Generalized estimating equations (GEEs) with post hoc testing were used to analyze the annual trends for discharge FIM and community discharge by age group (85-89, 90-94, 95-99, and ≥100 years). Risk-adjusted linear and logistic GEE models, with control for cluster, were used to analyze the association between both outcome measures and age group. Over 5.5 years, mean discharge FIM scores decreased by 3.6 points, and mean achievement of community discharge decreased 5.5%. Approximately 54% of the sample achieved community discharge. Continuous and logistic GEEs revealed factors associated with discharge outcomes. Results obtained using an observational design should not be viewed as indicating causation. The lack of control for a caregiver may have altered results. The very elderly people admitted to IRF stroke rehabilitation made functional gains, and most were able to return to the community.

Stroke and Nursing Home care: a national survey of nursing homes

BackgroundAlthough stroke is recognised as a major factor in admission to nursing home care, data is lacking on the extent and nature of the disabilities and dependency in nursing homes arising from stroke. A national study conducted in nursing homes can quantify the number of residents with stroke in nursing homes, their disability and levels of dependency.MethodsA cross-sectional survey research design was used. A total of 572 public and private nursing homes were identified nationally and a stratified random selection of 60 nursing homes with 3,239 residents was made. In half of the nursing homes (n = 30) efforts were made to interview all residents with stroke Survey instruments were used to collect data from residents with stroke and nursing home managers on demography, patient disability, and treatment.ResultsAcross all nursing homes (n = 60), 18% (n = 570) of the residents had previously had a stroke. In homes (n = 30), where interviews with residents with stroke (n = 257), only 7% (n = 18) residents were capable of answering for themselves and were interviewed. Data on the remaining 93% (n = 239) residents were provided by the nursing home manager. Nurse Managers reported that 73% of residents with stroke had a high level of dependency. One in two residents with stroke was prescribed antidepressants or sedative medication. Only 21% of stroke residents were prescribed anticoagulants, 42% antiplatelets, and 36% cholesterol lowering medications. Stroke rehabilitation guidelines were lacking and 68% reported that there was no formal review process in place.ConclusionsThis study provides seminal findings on stroke and nursing home services in Ireland. We now know that one in six nursing home residents in a national survey are residents with a stroke, and have a wide range of disabilities. There is currently little or no structured care (beyond generic care) for stroke survivors who reside in nursing homes in Ireland.

Development of an acute stroke care pathway in a hospital with stroke unit

Introduction Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU). Methods Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides. Results The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document. Conclusions A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

Implantación de una vía clínica para la atención del ictus agudo en un hospital con unidad de ictus

IntroductionCare pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU). MethodsMembers of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides. ResultsThe following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document. ConclusionsA stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

Prevention of secondary stroke in VA: Role of occupational therapists and physical therapists

Occupational therapists (OTs) and physical therapists (PTs) have the opportunity and obligation to advocate secondary stroke prevention via health promotion (HP) behaviors. This prospective survey of Department of Veterans Affairs (VA) OTs and PTs determined whether they know about VA stroke rehabilitation guidelines and whether they integrate secondary stroke prevention into poststroke rehabilitation care. Questions revolved around knowledge of VA guidelines, inclusion of stroke risk-factor modification, and HP education to patients. Thirty-four surveys (45%) were returned from six facilities. Participants included 12 OTs and 22 PTs. Half (53%) of the therapists were aware of the VA guidelines and nearly half (48%) provided HP activities to patients; PTs were significantly more likely to do so than OTs (p = 0.02). Half of the queried therapists were unaware of the VA guidelines; increasing therapists' education about the guidelines and the necessity of HP and secondary stroke prevention may reduce veterans' risk of a second stroke. Because many stroke risk factors are modifiable and stroke survivors spend a great deal of time with the rehabilitation therapist, OTs and PTs can and should provide such education to reduce the risk of a second stroke.

Review criteria for stroke rehabilitation outcomes

Objectives: To develop review criteria from the Agency for Health Care Policy and Research Stroke Rehabilitation Guidelines, to review chart records from three sites of care, and to evaluate the interrater and intrarater reliability for the chart review. Design: A descriptive cross-sectional study using a convenience sample. Setting: Charts for abstraction were obtained from three sites of care: home health care, nursing facilities, and inpatient rehabilitation centers. Participants: Charts were included in the study from the three sites of care if the following conditions were met: (1) the client's first admission to a rehabilitation setting; (2) the client's care was Medicare reimbursed; (3) the client lived in the community prior to the stroke; and (4) the client was receiving skilled rehabilitation services. Measures: Review criteria, developed directly from the AHCPR Stroke Rehabilitation guidelines, consisted of 11 global quality criteria representative of comprehensive multidisciplinary rehabilitative care. There were approximately 150 variables, comprised of specific criteria to measure each of the 11 global quality criteria plus comprehensive demographic and client-specific information. Results: Results of this study suggest that differences exist in documentation of care across the three sites of care. There was difficulty in obtaining adequate numbers of home health charts. Intrarater reliability, using Cohen's Kappa, was .78 and interrater reliability was .64. Conclusions: Based on chart documentation, there is variability in the process of stroke rehabilitation care across nursing facilities, inpatient rehabilitation facilities, and home health. This variability can be reliably assessed by chart review. This study provides the impetus for future research specifically evaluating the associations between documentation of the processes of care and patient outcomes.

Can clinical practice guidelines increase the cost-effectiveness of geriatric rehabilitation?

The need for guidelines stems from the human and economic burdens of disabilities, from variations in practice patterns, and from controversy over the effectiveness of rehabilitation. This article describes the development of the stroke rehabilitation guidelines and highlights several recommendations that have implications for geriatric rehabilitation more generally. It then describes a pilot test of resulting review criteria and a study in progress that is examining the extent to which rehabilitation referrals after acute strokes follow guideline recommendations. Finally, it closes by underscoring several policy challenges that will be critical to achieving more cost-effective use of rehabilitation resources.