Stroke Ward Research Articles

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.

Patients’ expectations towards going home with a very early supported discharge and home rehabilitation after stroke

Background: After a life-altering event such as stroke, the return home from hospital is an important transition. Previous studies have shown that this transition gives rise to mixed expectations with both uncertainty and hope for the future. However, the hospital stays in these studies were longer than the present average length of hospital stay after stroke in Sweden. This reduced hospital stay implies shorter time to prepare for discharge both for the patient and the professionals. With shorter hospital stays, a well-prepared discharge routine focusing on the expectations and the needs of the patients could help bridge the gap between the hospital and the home. Therefore, more knowledge about patients’ expectations is needed. Purpose: To describe patients’ expectations towards going home with a very early supported discharge and home rehabilitation after stroke. Methods:Thiswas an interview study nestedwithin a randomized controlled trial; Gothenburg very early supported discharge (GOTVED), comparing very early supported discharge from an acute stroke ward and home rehabilitation, with usual care after stroke. A consecutive sample of 10 participants was recruited from the intervention group in GOTVED. Interviews were conducted before discharge and the material analysed with qualitative content analysis. Results: The analysis resulted in four categories and 11 subcategories, which showed that a complexity existed with regards to the participants expectations about their return home. On one hand, the study participants expected it to feel new and unknown to return home and worried not to manage under these new conditions. On the other hand, they had confidence in the new situation and longed for returning to their familiar home environment and to care for themselves. A fear to have new stroke after coming home was mentioned, but this was overshadowed by their wish to return back home and to resume their usual routines. To restart with their old habits was expected to be challenging, and different strategies to cope with the situation was described. The expectations towards the role of the very early supported discharge (VESD) team varied greatly. However, some participants were unfamiliar with the intervention and their own role in the rehabilitation process. Even though the participants assumed that the regular visits from the VESD team would increase the feeling of being secure at home, they also expected that the intervention would interfere with the way they usually lived their life. Conclusion(s): The participants’ had mixed expectations towards going home with a very early supported discharge and home rehabilitation after stroke. This diversity of expectations was found both individually and between the persons. Implications: The person’s narratives about going home should be in focus when preparing for discharge after stroke. Such an approach can reveal the individual needs and expectations and thereby facilitate the transition home, thus being an important aid to bridge the gap between the hospital and the home.

Encouraging self-feeding in patients on a stroke ward

Up to half of people who have had a stroke are dependent on others to eat effectively. This can lead to reduced food intake, poor nutrition, reduced body weight and depression. Lower resistance to infection can also result in lengthy hospital stays. Some patients do not ask for the assistance they need to eat because they want to maintain a sense of self-worth. Traditionally, acute stroke interventions to improve eating function have taken a biomedical approach but this action research study focused on the development of individual, multiprofessional feeding care plans. Magnetic whiteboards with markers and magnets were placed above each bed so staff, patients and their families could share communication about eating.

Protocol Driven Stroke Ward And Stroke Registry Results In Increased Rate Of Thrombolysis In Acute Stroke Care (P4.311)

Protocol Driven Stroke Ward And Stroke Registry Results In Increased Rate Of Thrombolysis In Acute Stroke Care (P4.311)

Establishment Of Stroke Ward Results In Immediate Reduction Of Major Complications (P5.143)

Establishment Of Stroke Ward Results In Immediate Reduction Of Major Complications (P5.143)

The development of a psychology service on an inpatient stroke ward

This work was carried out as an audit and service evaluation project. It was approved by Betsi Cadwaladr University Health Board Audit Department.

Achieving eating independence in an acute stroke ward: Developing a collaborative care plan

Aim: This article outlines the development and implementation of a collaborative feeding care plan (FCP) for stroke patients in an acute stroke ward. The aim of this pilot study was to evaluate the impact of an ecological intervention to improve eating independence in an acute stroke ward environment. Methods: An action research approach comprising seven stages—determine the initial problem, develop the care plan, act, reflect and monitor progress, evaluate, reflect, and refine plan—was used to track environmental changes during the development and implementation of the FCP in an acute stroke ward in an Australian regional hospital. During the evaluation phase, six allied health staff completed a survey on the FCP. The staff also completed an observation assessment integrating the Eating Disability Scale, Functional Independence Measure and Canadian Occupational Performance Measure with 12 participants with acute stoke (participants with FCP=6; participants without FCP=6). Results: The FCP group showed significant improvements in upper limb independence (p=0.046), when comparing mean admission scores (3.5±0.97) with discharge scores (4.17±2.14). Clinically significant improvements in levels of collaboration between health professionals were also demonstrated. Conclusions: The changes in team collaboration and the patient's upper limb independence indicate how environmental change can influence acute stroke patient outcomes. It is recommended that this study be expanded to further explore the effect of ecological interventions and change.

Abstract T P271: Establishment of Stroke Ward Results in Immediate Reduction of Major Complications

Background and Purpose: Randomized controlled trials have consistently shown that stroke units decrease both mortality and morbidity compared with conventional care in general medical wards. There are however limited data on the specific types of in-hospital medical complications and their effect on outcomes. The objective of this study was to determine whether establishing a specialized geographically defined Stroke Ward results in reducing the major complications in patients suffering from acute stroke within the same hospital system. Methods: This is a prospective study from January 2014 till July 2014. Data was collected from a web-based stroke registry in two phases. In phase 1 (from January 1, 2014 till March 08, 2014), we collected data of stroke patients admitted at in the medical wards. In phase 2, a protocol-based multidisciplinary care Stroke Ward became operational where most of the patients were admitted. Outcomes measures were number and type of complications, mortality, discharge disposition, and length of stay, and were adjusted for age, sex, and medical co-morbidities. Results: There were 130 admissions in phase 1 and 345 in phase 2. Commonest complications included, aspiration pneumonia 29% vs 12% (p<0.001) and pressure ulcers in 35% vs 11% (p<0.001). Average length of stay decreased from 12 days to 4 days (p<0.001). In phase 1, 70 % of patients were discharged home, while 23% were transferred to rehabilitation while in phase 2, 75% of patients were discharged home, while 18% patients were sent to rehabilitation. Ninety percent of complications happened in medical wards, mainly in patients who over stayed in emergency department (more than 8 hours) waiting for bed in Stroke Ward or medical floor. Conclusion: A protocol based multidisciplinary care Stroke Ward care significantly reduces common early complications of acute stroke. It also helps in significantly reducing the length of stay, saving total bed days at a tertiary care hospital, hence improving the overall care of these patients.

Abstract W P387: Neurological Correlates Of Brain Function After Acute Stroke--A Dense Array EEG Study

INTRODUCTION: Measures of brain function can complement assessment of injury to inform clinical decision-making after stroke, but the most useful metrics remain uncertain. An acute stroke alters brain function in widespread areas. We therefore reasoned that a whole brain measure of brain function would be better related to behavioral deficits than a regional measure of brain function. METHODS: In 24 patients hospitalized for acute stroke, resting EEG (256 leads) was recorded for 3 min at the bedside and analyzed offline. Two EEG measures of brain function were extracted: [1] whole brain connectivity, which found the EEG frequency (from 1-30 Hz) and seed point (from among the 256 leads) that best fit whole brain coherence with total NIHSS scores, using a partial least squares regression model; and [2] regional brain activity, which found the EEG frequency and lead where spectral power was most strongly correlated with total NIHSS scores. Analyses were repeated focused on NIHSS motor subscores (Q4-6). All models were validated using a leave-one-out approach. RESULTS: The 24 patients were age 60.9±13.1yr, 3.5 ± 2.9 d post-onset (range 3hr-12d), and were studied in settings that included ER, ICU, and stroke ward. Whole brain EEG connectivity explained a large fraction of the variance in total NIHSS scores (r^2=0.72); this was achieved in the 2-4 Hz range, with seed over ipsilesional motor cortex, and with model predicting higher NIHSS score when this seed had greater coherence with contralesional frontal/motor regions. Regional brain activity, by comparison, explained a smaller fraction of variance (r^2=0.51), with maximal correlation between total NIHSS and regional EEG power found using a lead over contralesional motor cortex, at 2 Hz. Similar results for whole brain EEG connectivity were obtained when modeling NIHSS motor subscores in the 14 subjects with motor deficits (validated r^2=0.71). CONCLUSIONS: Dense array EEG recordings could be obtained early after stroke, rapidly and reliably, and at the bedside in widespread hospital settings. Whole brain connectivity measures corresponded to behavioral state better than measures of regional brain activity do. Results support the utility of EEG as a bedside method for evaluating brain functional status after stroke.

Chapter 35 - Hearing disorders in stroke

Stroke may affect all levels of the auditory pathway and lead to hearing reception and/or perception deficits. Sudden-onset hearing loss after stroke of the vertebrobasilar territory and/or low brainstem is one of the less frequent neurologic impairments, while cortical or central deafness is even rarer. However, studies of populations with stroke indicate that hearing loss is very common, while in the general population, a past history of stroke increases the likelihood of having hearing loss. Auditory-processing deficits after stroke are less well studied than hearing loss and possibly underdocumented. Auditory dysfunction may impact on patient communication and may even predict long-term patient outcome after stroke. Despite this, clinical guidelines for auditory assessments after stroke are rudimentary. This chapter reviews the available information of auditory function in patients with stroke. On the basis of the information available, it is suggested that screening the patient's hearing before the patient leaves the stroke ward with a short test and a minimum set of hearing-related questions and subsequently screening the patient's hearing needs with targeted questions at the chronic stage of stroke may be a cost-effective bare-minimum assessment approach to addressing the hearing needs of this complex population.

“Ward talk”: Nurses’ interaction with people with and without aphasia in the very early period poststroke

Background: Nursing staff are the most frequent communication partners, after family members, for people in hospital poststroke, and they play an essential role in the multidisciplinary team. Recent research has found that patients are more cognitively and socially active when wards provide an “enriched environment” as compared to standard care. Therefore, language enrichment on acute wards is now being considered as a possible way to discourage “learned nonuse” of language in people with aphasia.Aims: This study involved an exploration of the nature of nurses’ interactions with three patients on an acute stroke ward, two with aphasia and one without, in order to understand the nature of the communicative environment in more detail.Methods & Procedures: Following all necessary ethics approval processes and consents, continuous video recordings of 7.5 hr each were run for three male patients (two aged 68 years and one aged 48 years) on the acute stroke ward within a teaching hospital in an Australian city. Two had left hemisphere strokes resulting in a Wernicke’s aphasia (WAB AQ = 47) and a global aphasia (WAB AQ = 9.2) and one had a right hemisphere stroke and no aphasia. All instances of interaction with nurses over that period were transcribed orthographically and analysed at a discourse level using a speech function analysis based on a systemic functional linguistic framework.Outcomes & Results: Overall, nurses made most of the opening moves, used closed questions, controlled the conversational floor, and did not generally interact about issues other than physical care. The patients with aphasia had restricted opportunity to use continuing and developing moves and most commonly fell into a pattern of closed question and simple response. There was little evidence of communicative repair by nurses and few supported conversation strategies employed. Patterns of moves identified through the speech function analysis revealed the disempowered position of the patients with aphasia compared to the patient without who used a wider range of speech functions that demonstrated more assertive interactions.Conclusions: This study suggests that nurses, in their role as key communication partners on the acute stroke ward, could help counter the development of learned nonuse by integrating more effective communication strategies into their daily care routines. Further conversation partner training could relieve communication breakdown and frustration and increase opportunities for satisfying conversational exchanges in this setting.

Multi-disciplinary team meetings in stroke rehabilitation: an observation study and conceptual framework

Objective: To explore how multi-disciplinary team meetings operate in stroke rehabilitation. Design: Non-participant observation of multi-disciplinary team meetings and semi-structured interviews with attending staff. Setting and participants: Twelve meetings were observed (at least one at each site) and 18 staff (one psychologist, one social worker; four nurses; four physiotherapists four occupational therapists, two speech and language therapists, one stroke co-ordinator and one stroke ward manager) were interviewed in eight in-patient stroke rehabilitation units. Results: Multi-disciplinary team meetings in stroke rehabilitation were complex, demanding and highly varied. A model emerged which identified the main inputs to influence conduct of the meetings were personal contributions of the members and structure and format of the meetings. These were mediated by the team climate and leadership skills of the chair. The desired outputs; clinical decisions and the attributes of apparently effective meetings were identified by the staff. A notable difference between the meetings that staff considered effective and those that were not, was their structure and format. Successful meetings tended to feature a set agenda, structured documentation; formal use of measurement tools; pre-meeting preparation and skilled chairing. These features were often absent in meetings perceived to be ineffective. Conclusions: The main features of operation of multi-disciplinary team meetings have been identified which will enable assessment tools and interventions to improve effectiveness to be developed.

Abstract W P232: Lower Rates of Delirium in Stroke Units May Reflect Selection Bias

Introduction: Studies of delirium after acute stroke focus on stroke units (SUs). A protective effect of SUs against delirium has been suggested. We hypothesized that selection bias against medically complex patients accounts for this apparent effect. Methods: An observational cohort of acute ischemic stroke patients was screened for post-stroke delirium. Delirium was diagnosed using the Confusion Assessment Method (CAM). Key patient variables were prospectively recorded including initial NIHSS score and medical complications. Univariate associations with delirium were identified and a logistic regression model was developed for the entire cohort. Separate logistic regression models were also developed for non-stroke unit (NSU) and SU patients. The SU consisted of a specialized stroke ward, step-down stroke unit, and a neuroscience ICU. Results: Over 10 months 246 patients (56% male, mean 65 years, 29% in NSUs) met inclusion criteria. Delirium occurred in 30 (12%) patients and was less frequent in the SU (8.0% vs 22.5%, p=0.002). Frequency of CAM checks differed between NSU and SU (median 4.1 vs 3.7 per day; p=0.03). NSU patients had similar NIHSS scores as SU patients (median [interquartile range], 3 [1-8] vs 3 [1-5]; p=0.18) but more ICU admissions (48% vs 27%, p=0.001) and more infections (18% vs 9.7%, p=0.06). In the entire cohort, initial NIHSS (OR 1.07, 95% CI 1.02-1.13; p=0.006), cardioembolic stroke mechanism (OR 3.0, 95% CI 1.3-6.9; p=0.009) and SU care (OR 0.39, 95% CI 0.17-0.88; p=0.02) predicted delirium after correcting for covariates, including frequency of CAM checks. In the NSU model, age (OR 1.06, 95% CI 1.01-1.11; p=0.02) and infections (OR 6.8, 95% CI 1.5-30.2; p=0.01) were associated with delirium. Only cardioembolic stroke mechanism (OR 5.4, 95% CI 1.7-16.7; p=0.003) was associated with delirium in the SU model. Conclusion: Associations with delirium after acute ischemic stroke differ between NSU and SU patients. Stroke patients treated in NSUs are fundamentally different than SU patients. Given the potential for residual confounding, the lower incidence of delirium after stroke in SUs than NSUs may reflect selection bias rather than a specific effect of SU care.

Changes in Activity Levels in the First Month after Stroke

[Purpose] To quantify the activity levels of individuals in an acute stroke ward, and to determine if their activity levels change within the first month after stroke. [Methods] In this pilot study, participant activity was monitored prospectively over a single day from 8 a.m. to 5 p.m. on two separate occasions. Individuals with confirmed stroke > 18 years of age and less than 15 days post-stroke at the time of recruitment were eligible for inclusion in this study. Activity was recorded using an electronic device. The first day was scheduled within 15 days and the second at four weeks post-stroke. We looked at the following activity categories: number of transitions, and the times spent lying, sitting and in dynamic activity. [Results] Sixteen individuals were included in this study with a median age of 79.5 years (interquartile range 62.5 to 85). Fifty-six % of the participants had mild, 31% had moderate and 13% had severe stroke, according to the NIHSS score. There were no significant changes in number of transitions, or times spent in dynamic activity and lying and sitting. [Conclusion] Activity levels were low at an acute stroke ward and did not significantly change within the first month.

Measuring Activity Levels at an Acute Stroke Ward: Comparing Observations to a Device

Background. If a simple system of instrumented monitoring was possible early after stroke, therapists may be able to more readily gather information about activity and monitor progress over time. Our aim was to establish whether a device containing a dual-axis accelerometer provides similar information to behavioural mapping on physical activity patterns early after stroke. Methods. Twenty participants with recent stroke ≤2 weeks and aged >18 were recruited and monitored at an acute stroke ward. The monitoring device (attached to the unaffected leg) and behavioural mapping (observation) were simultaneously applied from 8 a.m. to 5 p.m. Both methods recorded the time participants spent lying, sitting, and upright. Results. The median percentage and interquartile range (IQR) of time spent lying, sitting, and upright recorded by the device were 36% (15–68), 51% (28–72), and 2% (1–5), respectively. Agreement between the methods was substantial: Intraclass Correlation Coefficient (95% CI): lying 0.74 (0.46–0.89), sitting 0.68 (0.36–0.86), and upright 0.72 (0.43–0.88). Conclusion. Patients are inactive in an acute stroke setting. In acute stroke, estimates of time spent lying, sitting, and upright measured by a device are valid.

A Clinical Database as a Multi-disciplinary Instructional Tool

The use of clinical databases is becoming increasingly common. We introduce a real-time clinical database named SINAP (Stroke Improvement National Audit Programme) which was originally deployed as a research database. We addressed its educational application in a hospital. We visited a leading stroke ward in the UK, which had a hyper acute stroke facility, and investigated the current operation and application of the SINAP database. The ward contained a hyper acute stroke unit with 12 beds and a 20-bed stroke unit. About 400 patients were treated in three months (January-March, 2011). The SINAP database was used not only for research reports but also for conferences concerning patient management, and it facilitated learning by clinical staff at the hospital. Databases which record clinical data relevant to performance and quality are an effective tool for improving the quality of treatment and care, as well as for training staff in clinical practice. Considering the wide-spread use of information technologies in primary care, such utilization of clinical data seems appropriate and effective to improve the quality of practice.

Stroke Patients’ Awareness of Risk and Readiness to Change Behaviors

Purpose: Behavior change is an important component of secondary stroke prevention. The transtheoretical model, which describes behavior change as occurring through a series of stages, may be a useful way of assessing patients’ readiness to change behavior. The model has been successfully applied to other chronic conditions and argues that people progressing “forward” through the stages are more likely to successfully change their behavior. The aim of this study was to describe stroke patients’ readiness to change behaviors for stroke-related risk factors using this model, in the absence of a behavior modification intervention. Method: Patients (n = 27) from an acute stroke ward of a major metropolitan hospital in Brisbane, Australia, were interviewed prior to and at 3 months following hospital discharge regarding their awareness of stroke risk factors and their readiness to change stroke risk–related behaviors. Results: At both points in time, 30% of patients could not spontaneously nominate one or more stroke risk factors. Despite a trend of “forward” progression in stages of change between the 2 interviews for behaviors relating to hypertension, heart disease, and high cholesterol, there were no statistically significant changes over time for any of the behaviors. Patients’ readiness to change stroke risk–related behaviors differed for each risk factor. Conclusion: Acknowledging that patients’ readiness to change may differ for each risk factor may promote more effective facilitation of stroke secondary prevention behaviors.

‘Basic nursing tasks’ provide rich learning opportunities

I applaud Hayley Dawes for speaking out about being an ‘extra pair of hands’ on an understaffed stroke ward and feeling that her mentor had not pushed her development as a nursing student (reflections December 16). However, the demanding basic nursing tasks she describes, including making beds and getting commodes, are rich learning opportunities.

P01-289 - Use of the PHQ-9 as a screening tool for post-stroke depression

IntroductionFollowing a previous audit conducted at Bedford Hospital we found no formal screening tool for depression was used in post-stroke patients. The prevalence of depression in the sample of 63 patients was 28%. We recommended the implementation of the PHQ-9 questionnaire as a screening tool for depression in these patients.Objectives/AimsTo assess the effectiveness of the PHQ-9 as a screening tool for depression in stroke patients. To review whether implementing this screening tool has increased the prevalence of depression within this patient population.MethodAll patients admitted to the stroke ward in Bedford Hospital between 10/09/09 and 13/12/09 were included in the audit. Patients were screened two weeks after admission. Exclusion criteria were met if patients lacked mental capacity to be screened; the patient declined or was discharged or deceased within 2 weeks.ResultsOf 83 patients admitted, 18 (23%) were screened. Of these, 10 patients (53%) scored 5 or above, indicative of depression. One patient scored 10 indicative of moderate depression, and one patient scored 19 indicative of severe depression.ConclusionThe PHQ-9 questionnaire is useful as it clearly increased the prevalence of post-stroke depression. However noticeably there are a significant proportion of patients who could not be screened using this tool as it is a self report assessment. This includes those who lack capacity or have communicative difficulties as is common after a stroke.

CRITICAL CARE MANAGEMENT OF ACUTE ISCHEMIC STROKE

ABSTRACT Although most patients with acute ischemic stroke can be managed in an inpatient stroke ward or urgent care setting, about 15% to 20% will need admission to an intensive care unit. These patients require attention to airway and respiratory status, blood pressure, glucose, temperature, cardiac function, and in some cases, management of life-threatening cerebral edema. This review will discuss general principles in the critical care management of patients with acute ischemic stroke and apply these principles to common clinical scenarios.