Continuing allied health professional (AHP) clinical education is essential to ensure high-quality patient care; however, the effectiveness of current education programs is unclear. This review aimed to determine whether AHP education programs improve the knowledge of AHPs, change their clinical practice behavior, and/or improve patient-related clinical outcome and to identify important components of these programs.
BACKGROUND: Understanding factors that influence the transition to permanent residential aged care following a stroke or transient ischemic attack may inform strategies to support people to live at home longer. We aimed to identify the demographic, clinical, and system factors that may influence the transition from living in the community to permanent residential care in the 6 to 18 months following stroke/transient ischemic attack. METHODS: Linked data cohort analysis of adults from Queensland and Victoria aged ≥65 years and registered in the Australian Stroke Clinical Registry (2012–2016) with a clinical diagnosis of stroke/transient ischemic attack and living in the community in the first 6 months post-hospital discharge. Participant data were linked with primary care, pharmaceutical, aged care, death, and hospital data. Multivariable survival analysis was performed to determine demographic, clinical, and system factors associated with the transition to permanent residential care in the 6 to 18 months following stroke, with death modeled as a competing risk. RESULTS: Of 11 176 included registrants (median age, 77.2 years; 44% female), 520 (5%) transitioned to permanent residential care between 6 and 18 months. Factors most associated with transition included the history of urinary tract infections (subhazard ratio [SHR], 1.41 [95% CI, 1.16–1.71]), dementia (SHR, 1.66 [95% CI, 1.14–2.42]), increasing age (65–74 versus 85+ years; SHR, 1.75 [95% CI, 1.31–2.34]), living in regional Australia (SHR, 31 [95% CI, 1.08–1.60]), and aged care service approvals: respite (SHR, 4.54 [95% CI, 3.51–5.85]) and high-level home support (SHR, 1.80 [95% CI, 1.30–2.48]). Protective factors included being dispensed antihypertensive medications (SHR, 0.68 [95% CI, 0.53–0.87]), seeing a cardiologist (SHR, 0.72 [95% CI, 0.57–0.91]) following stroke, and less severe stroke (SHR, 0.71 [95% CI, 0.58–0.88]). CONCLUSIONS: Our findings provide an improved understanding of factors that influence the transition from community to permanent residential care following stroke and can inform future strategies designed to delay this transition.
Background: The advanced hand activities item of the Motor Assessment Scale (Upper Limb items, UL-MAS) includes the 'lines' and 'dots' tasks, which require skilful pencil use. Prior Rasch analysis studies identify these two tasks as the most difficult to achieve for stroke survivors compared with the other advanced hand activities. Yet it is unknown if healthy, older adults can perform these two tasks.Objectives: To describe the performance of older adults' without stroke on the 'lines' and 'dots' tasks, relationship between age and task performance, and relationship between writing speed and performance on the 'lines' task.Methods: Cross-sectional study design. A sample of healthy older Australians (n = 120) aged between 60 and 99 years completed the UL-MAS 'lines' and 'dots' tasks and wrote two sentences using pencil.Results: Fifty-four participants (45%) failed the UL-MAS 'lines' task. Differences in line drawing performance across age groups were statistically significant (chi-square = 9.02, df = 3, p = .03). Eleven participants (9%) failed the 'dots' task, mostly from the 90 to 99 year age group. Participants who passed the 'lines' task wrote sentences faster than participants who failed (p<.001).Conclusion: Older adults may not pass the UL-MAS 'lines' and 'dots' tasks due to age and individual skill level.
The Australian and New Zealand living stroke management guidelines provide timely, evidence-based updates to recommendations Stroke is a leading cause of adult disability in Australia, with an estimated 27 428 incident strokes occurring each year, or one every 19 minutes.1 Compared with urban areas, the incidence of stroke is 17% higher in rural communities, where access to specialist stroke care is less likely.1 This makes the need for easily accessible, up-to-date, evidenced-based clinical practice guidelines for stroke care essential. The first Australian clinical guidelines for stroke were published in 2003 (acute) and 2005 (post-acute). These were updated in 2007, 2010 and most recently in 2017 following traditional methods, including endorsement by the National Health and Medical Research Council (NHMRC). In 2017, the guidelines moved from being published in a static (pdf) format, to being published online using the Making GRADE the Irresistible Choice (MAGICapp) platform (https://magicevidence.org).2 Traditional cycles of guideline updates which involve recommendations based on the best available evidence at the time of publication are problematic because new evidence can mean that recommendations quickly become outdated. In 2018, the Stroke Foundation and Cochrane Australia were awarded funding to test a model of living guidelines for stroke management. These were the first Australian living clinical guidelines and are the first and only living stroke guidelines worldwide. Subsequent living guidelines include those for diabetes,3 maternal and perinatal health,4 and COVID-19.5 The stroke guidelines are published online at https://informme.org.au/guidelines/clinical-guidelines-for-stroke-management, to guide day-to-day stroke care in Australia and New Zealand. The 2017 update of the static stroke guidelines consisted of 392 individual recommendations including practice points across eight chapters addressing 89 topics. Each topic was structured into a PICO (patient, intervention, comparator, outcome) format to address an aspect of care, for example, the use of cholesterol-lowering therapy for secondary prevention of stroke. The living stroke guidelines project commenced in July 2018. The structures in place for the 2017 static guidelines update were adapted and expanded to fit living guidelines methods. A full description of the methods is published elsewhere.6 In brief, each month the results of published new studies are reviewed by the project team. Where new evidence is deemed to potentially impact one or more recommendations, the project team works with clinical experts to update evidence-to-decision frameworks (benefits and harms and certainty of evidence component) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method (https://gdt.gradepro.org/app/handbook/handbook.html), and draft changes to recommendations and background text. Draft changes go through a rigorous review process, culminating in submission to the NHMRC for approval (median time from initiation to submission is about 6 months). Clinical indicators collected as part of the National Stroke Audit and the Australian Stroke Clinical Registry are monitored over time to evaluate adherence to aspects of the guidelines. The living clinical guidelines for stroke are developed in accordance with NHMRC standards, including the use of the GRADE method for recommendations. The MAGICapp platform presents the recommendations and related information in a multilayered, transparent format. MAGICapp allows users to review all previous versions of each recommendation for full transparency. Any new or updated recommendations are flagged as such within the platform for a period of 6–12 months. A summary of updates is also maintained online (https://informme.org.au/guidelines/living-guidelines-updates). Since the 2017 update to the static guideline, a total of 35 new or updated recommendations have been made. Just under half (16) of the changes are new recommendations (five strong, 10 weak, and one practice point), with updates to 19 recommendations (12 without change to the direction or grade of recommendation, six upgraded strength, and one downgraded strength [from weak recommendation for to weak recommendation against]). New and updated strong recommendations are presented in the Box. All new and updated recommendations are reported in the Supporting Information and are described in brief below. The first living guideline recommendation, developed after the 2017 update but before the start of the funded living guidelines project, extended the time window for endovascular clot retrieval to 24 hours for specific clinical presentations.11 Additionally, based on results from new studies,12-14 the recommended time window for safe administration of alteplase has been extended to 9 hours post-stroke and a new recommendation made about safe use of alteplase for stroke of unknown onset time. Both recommendations are based on favourable perfusion imaging. Two new recommendations have been made for the use of tenecteplase as an alternative to alteplase within 4.5 hours of stroke onset15 or for large vessel occlusions.16 Ticagrelor in combination with aspirin commenced within 24 hours of symptom onset and continued for the first 30 days may now be used for acute antiplatelet therapy for people with minor ischaemic stroke or transient ischaemic attack,17 although this should be considered secondary to a strong recommendation for aspirin plus clopidogrel for the first 21 days. The recommendation for oxygen therapy has been updated to include a specific threshold (92% blood oxygen saturation on room air), above which routine use of supplemental oxygen therapy is not recommended.18 There is a new recommendation for the use of telestroke services to assist in patient assessment and decision making for the use of thrombolysis and/or endovascular clot retrieval for people presenting to hospitals where medical specialist services are not available.19, 20 Finally, there is a new recommendation that clarifies that patients not receiving nasogastic feeding do not require head elevation and may be managed in any position.21 Several recommendations have been updated regarding secondary prevention. The first specifies a target of < 1.8 mmol/L for low density lipoprotein levels for people with ischaemic stroke.22 The recommendation for management of patent foramen ovale now specifies that where this is considered the likely cause of stroke, percutaneous closure should occur.23 People who were taking antiplatelet therapy before experiencing an intracerebral haemorrhage may be safely recommenced, although the optimal timing for this is not clear.24 Left atrial appendage occlusion may be considered for the management of atrial fibrillation if there is a genuine contraindication to anticoagulation.25 Non-pharmacological interventions to reduce stroke risk factors include exercise training as well as individual support and counselling, and the final new recommendation suggests that people with stroke should follow a Mediterranean style diet.26 The most significant updated recommendation pertains to the use of selective serotonin reuptake inhibitors (SSRIs) to reduce disability after stroke. New large trials27, 28 found SSRIs did not reduce disability and were associated with a small risk of harm, and therefore are no longer recommended for routine use in this context but may still be relevant specifically to prevent or treat depression. The recommendations for management of motor weakness and difficulty standing have been updated. These updates include greater specificity in the types of training modalities that are recommended. Finally, new recommendations for specific interventions to improve memory function, and for the use of telehealth as an alternative mode of rehabilitation service delivery29 have been made. Due to an increase in the number of published high quality, albeit small trials, it is now recommended that acupuncture may be considered for the management of shoulder pain after stroke.30 Minor changes have also been made in preventing or managing swelling in the arms or legs. Major updates to the guidelines over the past four years have occurred, ensuring the recommendations are current. Importantly, there have been no cases in which a recommendation for an intervention has been downgraded from a strong to a weak recommendation. Furthermore, no recommendation has been changed multiple times. Important new recommendations have been made regarding lifesaving therapy such as extension of the time window for endovascular clot retrieval and the administration of alteplase for thrombolysis. The key benefit of living guidelines is the ability to rapidly update recommendations in response to new evidence. As a case example, results from the EXTEND trial demonstrating the safety and efficacy of thrombolysis up to 9 hours after stroke were published in May 2019,12 followed soon after by a systematic review and individual patient data meta-analysis.13 By November 2019, our updated recommendation had completed the full development, review and public consultation process and was endorsed by the NHMRC and disseminated to key end-user organisations; a total time of less than six months. While it is hard to estimate the direct and definitive impact of rapid guideline updates, based on trial outcomes and reported patient numbers, we estimate that about 320 Australians each year may be saved from premature death or disability following a severe stroke based on the updated recommendations for endovascular clot retrieval from 6–24 hours after symptom onset (unpublished data). Rapid guideline updates as part of a living model are almost certain to have played a significant role by expediting local and state-wide system changes. Further work to quantify the impact, including the potential economic impact and return-on-investment, of the living guidelines compared with traditional guideline updates is planned. Since 2007, we have had national, standardised systems of monitoring adherence to the clinical guideline recommendations in Australia. Specifically, these systems include the National Stroke Audit (detailed cross-sectional audits of acute care and inpatient rehabilitation every alternate year) and the Australian Stroke Clinical Registry, whereby adherence to the national acute care standards is continuously monitored, including patient outcomes 90–180 days after stroke. These data permit reliable assessment of practice change and health outcomes over time to inform economic and other impact assessments. However, preliminary findings of the independent evaluation indicate that end users of the living stroke management guidelines report have increased trust in and likelihood of accessing and following the guidelines compared with the traditional, periodically updated guideline model (Wiles L, Zurynski Y, Hibbert P, et al. Living stroke guidelines evaluation. Australian Institute of Health Innovation, 2021. Unpublished report). Importantly, living guidelines provide currency of advice. The experience with stroke as well as other guidelines3-5 demonstrates that the rigour of the methods does not need to be compromised when living modes are adopted. The GRADE method is as appropriate for living guidelines as for traditional, periodic guidelines. NHMRC support is also vital in ensuring living guidelines continue to meet its standards. Sustainability remains the key challenge for the living stroke guidelines. Collaboration with major stroke guideline groups in Europe and North America may improve guideline efficiency and sustainability, but although discussions have been undertaken, no formal projects have been forthcoming as only a few groups currently use the GRADE method. However, there has been strong collaboration and sharing of knowledge and experience with other national guideline groups as part of the Australian Living Evidence Consortium (https://livingevidence.org.au/). Compared with the costs of updating the stroke guidelines every five years, our initial experience indicates the living model is likely to have similar overall costs, but with the significant benefits of increased trust and use from clinicians. Ongoing, secure funding for this new model is now required for stroke along with similar guidelines for other high burden diseases. The Australian and New Zealand living guidelines for stroke management are the first of their kind globally. A number of important changes have occurred in the guideline recommendations. Our model of continual evidence surveillance and timely updates to recommendations is feasible, but sustainability remains a challenge. Now that we have started down this road, the message from guideline end users is that a return to the old model of static updates is no longer acceptable, and ongoing long term investment in living guidelines must be prioritised. It is important to note that due to the living nature of these guidelines, the information presented in this article is correct at the time of writing but may have been updated since. The living stroke guidelines project is a partnership between the Stroke Foundation and Cochrane Australia and Monash University, funded by the Australian Government through the Medical Research Future Fund. The funders played no role in the development of the methods, in the writing of the report, or in the decision to submit the article for publication. With gratitude and thanks to the hours of volunteer time provided by 108 clinical expert working party members and the 28 consumer advisory group members: the living guidelines are not possible without you. We also acknowledge members of the steering committee who have been instrumental in the living guidelines process: in addition to the co-authors, we acknowledge Kevin English, Lisa Murphy and Fiona Simpson. A comprehensive list of contributors is available at https://informme.org.au/Guidelines/Clinical-Guidelines-for-Stroke-Management/Guidelines-supporting-documents. Sandy Middleton receives funding from NHMRC Investigator Grant APP1196352. Natasha Lannin is supported by a National Heart Foundation of Australia Future Leader Fellowship (102055). Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australian University Librarians. No relevant disclosures. Not commissioned; externally peer reviewed. Participant interview questionnaire Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
PURPOSE: To test the feasibility of a handwriting retraining program with adults after stroke; specifically the feasibility of: (i) recruiting people with stroke to the study, (ii) delivering the handwriting retraining program and (iii) outcome measures of handwriting performance. METHOD: A quasi-experimental pre-test post-test design was used. A four-week, home-based handwriting retraining program was delivered by an occupational therapist using task-specific practice. Legibility, speed, pen control and self-perception of handwriting were measured at baseline and completion of the program. Legibility was scored by a blinded rater. RESULTS: Seven adults with stroke were recruited (eligibility fraction 43% of those screened, and enrolment fraction 78% of those eligible). There were no dropouts. Although, recruitment was slow the intervention was feasible and acceptable to adults with stroke. No statistically or clinically significant changes in legibility were reported in this small sample, but a ceiling effect was evident for some outcome measures. The study was not powered to determine efficacy. CONCLUSIONS: Delivery of a four-week handwriting intervention with eight supervised sessions in the community was feasible; however, recruitment of an adequate sample size would require greater investment than the single site used in this pilot. Implications for Rehabilitation Handwriting difficulty is common following hemiparesis after stroke, however research addressing handwriting retraining for adults with stroke is lacking. A four-week home-based handwriting program using task-specific practice and feedback was feasible to deliver and appropriate for adults with stroke. Improving handwriting legibility and neatness across a range of tasks were important goals for adults with handwriting impairment.
Implementation of evidence-informed rehabilitation of the upper limb is variable, and outcomes for stroke survivors are often suboptimal. We established a national partnership of clinicians, survivors of stroke, researchers, healthcare organizations, and policy makers to facilitate change. The objectives of this study are to increase access to best-evidence rehabilitation of the upper limb and improve outcomes for stroke survivors. This prospective pragmatic, knowledge translation study involves four new specialist therapy centers to deliver best-evidence upper-limb sensory rehabilitation (known as SENSe therapy) for survivors of stroke in the community. A knowledge-transfer intervention will be used to upskill therapists and guide implementation. Specialist centers will deliver SENSe therapy, an effective and recommended therapy, to stroke survivors in the community. Outcomes include number of successful deliveries of SENSe therapy by credentialled therapists; improved somatosensory function for stroke survivors; improved performance in self-selected activities, arm use, and quality of life; treatment fidelity and confidence to deliver therapy; and for future implementation, expert therapist effect and cost-effectiveness. In summary, we will determine the effect of a national partnership to increase access to evidence-based upper-limb sensory rehabilitation following stroke. If effective, this knowledge-transfer intervention could be used to optimize the delivery of other complex, evidence-based rehabilitation interventions.
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