Healthcare professionals' experiences of delivering a stroke Early Supported Discharge service - An example from Ireland.

OBJECTIVE: To explore healthcare professionals' experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic. DESIGN: Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis. SETTING: Nine Early Supported Discharge service sites in Ireland. PARTICIPANTS: Purposive sampling identified 16 healthcare professionals. RESULTS: Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families. CONCLUSIONS: Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

A qualitative evidence synthesis exploring people after stroke, family members, carers and healthcare professionals' experiences of early supported discharge (ESD) after stroke.

OBJECTIVE: Early supported discharge (ESD) after stroke has been shown to generate significant cost savings and reduce both hospital length of stay, and long-term dependency. This study aimed to systematically review and synthesise qualitative studies of the experiences and views of ESD from the perspective of people after stroke, their family members, carers and healthcare professionals. METHOD: A systematic search of eleven databases; CINAHL, PubMed Central, Embase, MEDLINE, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journal, The Cochrane Library, PsycARTICLES and SCOPUS, was conducted from 1995 to January 2022. Qualitative or mixed methods studies that included qualitative findings on the perspectives or experiences of people after stroke, family members, carers and healthcare professionals of an ESD service were included. The protocol was registered with the Prospero database (Registration: CRD42020135197). The methodological quality of studies was assessed using the 10-item CASP checklist for qualitative studies. Results were synthesised using Thomas and Harden's three step approach for thematic synthesis. RESULTS: Fourteen studies were included and five key themes were identified (1) ESD eases the transition home, but not to community services, (2) the home environment enhances rehabilitation, (3) organisational, and interprofessional factors are critical to the success of ESD, (4) ESD is experienced as a goal-focused and collaborative process, and (5) unmet needs persisted despite ESD. CONCLUSION: The findings of this qualitative evidence synthesis highlight that experiences of ESD were largely very positive. The transition from ESD to community services was deemed to be problematic and other unmet needs such as information needs, and carer support require further investigation.

An appraisal of healthcare accreditation agencies and programs: similarities, differences, challenges and opportunities.

BACKGROUND: The study, following similar reviews in 2000 and 2010, presents an update of knowledge about external evaluation agencies and accreditation programs. OBJECTIVE: The study aim was to investigate the current profile of external evaluation agencies identifying their program features, and significant changes and challenges.

A protocol for a qualitative synthesis exploring people with stroke, family members, caregivers and healthcare professionals experiences of early supported discharge (ESD) after stroke.

Early supported discharge (ESD) facilitates a person with a stroke to be discharged from the acute hospital environment earlier than conventional care to continue their rehabilitation within the home with members of the multi-disciplinary team. A number of quantitative studies have highlighted benefits of ESD including a reduction in the length of inpatient stay, cost savings, as well as reducing long term dependency. This systematic review and qualitative synthesis explores the perspectives and experiences of those involved in ESD including people with stroke, family members, caregivers as well as the healthcare professionals involved in the delivery of the service. A comprehensive literature search will be completed in the following databases CINAHL, PubMed Central, Embase, Medline, PsycINFO, Sage, Academic Search Complete, Directory of Open Access Journals, The Cochrane Library, PsycARTICLES and Scopus. Qualitative or mixed methods studies that include qualitative data on the perspectives and experiences of people with stroke, family members, caregivers and healthcare professionals of an ESD service will be included. Methodological quality will be appraised using the ten-item Critical Appraisal Skills Programme checklist for qualitative research by two independent reviewers with a third reviewer involved should differences of opinion arise. Findings will be synthesised using thematic synthesis.    It is anticipated that the qualitative synthesis will provide a deeper understanding of the experiences of ESD which may serve to inform practice as well as assist in the development of new ESD services. PROSPERO registration: CRD42020135197 - 28/04/2020.

Leveraging the full value and impact of accreditation.

Providing high quality and safe patient care is a challenge in the current rapidly changing and complex health care environment. A variety of independent tools and methodologies contribute to this effort, e.g. regulatory requirements, quality improvement tools and accreditation methodologies. A concern is that each alone will not achieve the tipping point in health care quality that is required. This paper suggests that the methodology and application of accreditation have the potential to be the force to bring these approaches into alignment and ultimately measurably improve the quality of care.

Efficacy of a cognitive stimulation therapy programme for people with dementia.

OBJECTIVES: Cognitive stimulation therapy (CST) has been shown to produce improvements in cognition and quality of life which compare favourably with trials of cholinesterase inhibitors. The aim of the present study was to evaluate the efficacy of CST, replicating the methods of Spector et al in the British Journal of Psychiatry in 2003 in a smaller sample using a control group engaged in routine activities. METHODS: Eligible participants (mild to moderate dementia; MMSE range 10-23) were randomised to CST group or control conditions. Pre- and post-intervention testing was undertaken by assessors who were blind to condition. Measures included MMSE, CDR (sum of boxes), ADAS-cog, RAID (anxiety), abbreviated GDS (depression), QoL-AD, and the CAPE Behaviour Rating Scale (BRS). Analysis was by non-parametric statistics. Occupational therapists facilitated two sessions per week for seven weeks in two long-term care facilities and the same programme was run by the activity co-ordinator in a nursing home unit. RESULTS: Fourteen CST and 13 control participants completed the study. Between group difference scores analysis showed that the CST group improved compared to controls on MMSE (Mann-Whitney U = 32, p = 0.013) and on the QoL-AD which just fell short of significant (U=51.5, p = 0.055). Qualitatively, therapists noted that CST participants demonstrated good interaction and enthusiasm in the group environment, with continuity and carryover between sessions. CONCLUSIONS: Even though the sample sizes are small the current study is consistent with the Spector et al's findings in 2003 of beneficial effects in people with dementia following CST. The programme is recommended as an intervention for people with mild to moderate dementia.

Disclosure of patient safety incidents: a comprehensive review.

PURPOSE: Adverse events are increasingly recognized as a source of harm to patients. When such harm occurs, problems arise in communicating the situation to patients and their families. We reviewed the literature on disclosure across individual and international boundaries, including patients', healthcare professionals' and other stakeholders' perspectives in order to ascertain how the needs of all groups could be better reconciled. DATA SOURCES: A systematic review of the literature was carried out using the search terms 'patient safety', 'medical error', 'communication', 'clinicians', 'healthcare professionals' and 'disclosure'. All articles relating to either patients' or healthcare professionals' experiences or attitudes toward disclosure were included. RESULTS: Both patients and healthcare professionals support the disclosure of adverse events to patients and their families. Patients have specific requirements including frank and timely disclosure, an apology where appropriate and assurances about their future care. However, research suggests that there is a gap between ideal disclosure practice and reality. Although healthcare is delivered by multidisciplinary teams, much of the research that has been conducted has focused on physicians' experiences. Research indicates that other healthcare professionals also have a role to play in the disclosure process and this should be reflected in disclosure policies. CONCLUSIONS: This comprehensive review, which takes account of the perspectives of the patient and members of the care team across multiple jurisdictions, suggests that disclosure practice can be improved by strengthening policy and supporting healthcare professionals in disclosing adverse events. Increased openness and honesty following adverse events can improve provider-patient relationships.

Gli3Xt-J/Xt-J mice exhibit lambdoid suture craniosynostosis which results from altered osteoprogenitor proliferation and differentiation.

Gli3 is a zinc-finger transcription factor whose activity is dependent on the level of hedgehog (Hh) ligand. Hh signaling has key roles during endochondral ossification; however, its role in intramembranous ossification is still unclear. In this study, we show that Gli3 performs a dual role in regulating both osteoprogenitor proliferation and osteoblast differentiation during intramembranous ossification. We discovered that Gli3Xt-J/Xt-J mice, which represent a Gli3-null allele, exhibit craniosynostosis of the lambdoid sutures and that this is accompanied by increased osteoprogenitor proliferation and differentiation. These cellular changes are preceded by ectopic expression of the Hh receptor Patched1 and reduced expression of the transcription factor Twist1 in the sutural mesenchyme. Twist1 is known to delay osteogenesis by binding to and inhibiting the transcription factor Runx2. We found that Runx2 expression in the lambdoid suture was altered in a pattern complimentary to that of Twist1. We therefore propose that loss of Gli3 results in a Twist1-, Runx2-dependent expansion of the sutural osteoprogenitor population as well as enhanced osteoblastic differentiation which results in a bony bridge forming between the parietal and interparietal bones. We show that FGF2 will induce Twist1, normalize osteoprogenitor proliferation and differentiation and rescue the lambdoid suture synostosis in Gli3Xt-J/Xt-J mice. Taken together, we define a novel role for Gli3 in osteoblast development; we describe the first mouse model of lambdoid suture craniosynostosis and show how craniosynostosis can be rescued in this model.

Involving consumers in accreditation: the Irish experience.

BACKGROUND: Following the 2004 review of the Acute Care Accreditation Scheme, the Irish Health Services Accreditation Board (IHSAB) decided to increase the level of consumer involvement in the accreditation process by including consumers as members of the review teams assessing healthcare organizations. Such consumers were known as service user (SU) surveyors where SUs were defined as any person who has used the Irish health system, i.e. a patient or relative/carer, etc. OBJECTIVE: Consumer surveyors first participated in surveys in 2005 and a total of seven surveys took place that year. An evaluation of the role and participation of the consumer surveyor was conducted in 2006. METHODS: All stakeholder groups were consulted, i.e. consumer and peer review surveyors, applicant organizations and IHSAB staff, and a combination of qualitative and quantitative techniques was used. RESULTS: Stakeholders considered that consumer involvement introduced greater objectivity and credibility. Characteristics such as good communication and interpersonal skills, excellent powers of observation and objectivity were identified as important traits for consumer surveyors. There were some issues in relation to the clarity and consistency of their role in terms of the rating of criteria and their contribution to the accreditation report. There was support among the stakeholder groups for greater consumer involvement in the process by participating in additional tours and interviews. CONCLUSION: The evaluation highlights that the introduction of consumer surveyors has been successful but illustrates that their role and level of involvement in the process may need to be re-examined.

Expression patterns of Hedgehog signalling pathway members during mouse palate development.

Hedgehog signalling regulates morphogenesis of many developing organs. Sonic hedgehog (Shh) signalling has been shown to regulate the growth and morphogenesis of the palatal shelves prior to their elevation and fusion. Here, we show that Shh expression is limited to a thickened palatal oral epithelium prior to palatal shelf elevation. After palatal shelf elevation above the tongue, Shh is expressed only in small areas of thickened palatal oral epithelium that corresponded to developing rugae. The receptor Ptc1 and a regulator of Hh signalling Hhip1 are expressed in the mesenchyme adjacent to the palatal oral epithelium so that the highest level of transcripts localize to the palatal mesenchyme surrounding the Shh-expressing thickened epithelium. Smoothened and transcriptional effectors Gli1-3, and Hh regulator Gas1 are expressed widely in the palatal mesenchyme. No differences were found in the expression patterns of Hh pathway members along the anterior-posterior axis of the developing palate.

Disruption of Fgf10/Fgfr2b-coordinated epithelial-mesenchymal interactions causes cleft palate.

Classical research has suggested that early palate formation develops via epithelial-mesenchymal interactions, and in this study we reveal which signals control this process. Using Fgf10-/-, FGF receptor 2b-/- (Fgfr2b-/-), and Sonic hedgehog (Shh) mutant mice, which all exhibit cleft palate, we show that Shh is a downstream target of Fgf10/Fgfr2b signaling. Our results demonstrate that mesenchymal Fgf10 regulates the epithelial expression of Shh, which in turn signals back to the mesenchyme. This was confirmed by demonstrating that cell proliferation is decreased not only in the palatal epithelium but also in the mesenchyme of Fgfr2b-/- mice. These results reveal a new role for Fgf signaling in mammalian palate development. We show that coordinated epithelial-mesenchymal interactions are essential during the initial stages of palate development and require an Fgf-Shh signaling network.