Addressing complexity when developing an education program for the implementation of a stroke Electronic Medical Record (EMR) enhancement.

BACKGROUND: Digital interventions in health services often fail due to an underappreciation of the complexity of the implementation. This study develops an approach to address complexity through an evidenced-based, theory-driven education and implementation program for an Electronic Medical Record (EMR) digital enhancement for acute stroke care. METHODS: An action research approach was used to design, develop, and execute the education and implementation program over several phases, with iterative changes over time. The study involved collaboration with multiple statewide and local key stakeholders and was conducted across two tertiary teaching hospitals and a regional hospital in Australia. RESULTS: Insights were gained over five phases. Phase 1 involved a review of evidence that supported blended learning strategies for the education and training of staff end-users. In Phase 2, contextual assessment was conducted via observation of study sites, providing awareness of local context variability and insight into key implementation considerations. The Non-adoption, Abandonment, Scale-Up, Spread and Sustainability (NASSS) framework assisted in Phase 3 to identify and manage the key domains of complexity. Phase 4 involved the design of the program which included group-based training and an e-learning package, endorsed and evaluated by key leaders. Throughout implementation in Phase 5, further barriers were identified, and iterative changes were tailored to each context. CONCLUSIONS: The NASSS framework, combined with a multi-phased approach employing blended learning techniques, context evaluations, and iterative modifications, can serve as a model for generating theory-driven and evidence-based education strategies that adresss the complexity of the implementation process and context.

The Effect of the Electronic Health Record on Interprofessional Practice: A Systematic Review.

BACKGROUND: Interprofessional practice and teamwork are critical components to patient care in a complex hospital environment. The implementation of electronic health records (EHRs) in the hospital environment has brought major change to clinical practice for clinicians which could impact interprofessional practice. OBJECTIVES: The aim of the study is to identify, describe, and evaluate studies on the effect of an EHR or modification/enhancement to an EHR on interprofessional practice in a hospital setting. METHODS: Seven databases were searched including PubMed, Scopus, Web of Science, CINAHL, Cochrane, EMBASE, and ACM Digital Library until November 2021. Subject heading and title/abstract searches were undertaken for three search concepts: "interprofessional" and "electronic health records" and "hospital, personnel." No date limits were applied. The search generated 5,400 publications and after duplicates were removed, 3,255 remained for title/abstract screening. Seventeen studies met the inclusion criteria and were included in this review. Risk of bias was quantified using the Quality Assessment Tool for Studies with Diverse Designs. A narrative synthesis of the findings was completed based on type of intervention and outcome measures which included: communication, coordination, collaboration, and teamwork. RESULTS: The majority of publications were observational studies and of low research quality. Most studies reported on outcomes of communication and coordination, with few studies investigating collaboration or teamwork. Studies investigating the EHR demonstrated mostly negative or no effects on interprofessional practice (23/31 outcomes; 74%) in comparison to studies investigating EHR enhancements which showed more positive results (20/28 outcomes; 71%). Common concepts identified throughout the studies demonstrated mixed results: sharing of information, visibility of information, closed-loop feedback, decision support, and workflow disruption. CONCLUSION: There were mixed effects of the EHR and EHR enhancements on all outcomes of interprofessional practice, however, EHR enhancements demonstrated more positive effects than the EHR alone. Few EHR studies investigated the effect on teamwork and collaboration.

Acute stroke patients not meeting their nutrition requirements: Investigating nutrition within the enriched environment.

BACKGROUND & AIMS: Malnutrition is common after stroke. We investigated the impact of environmental enrichment strategies on dietary intake and rates of malnutrition in an acute stroke unit. METHODS: We performed a before-after study. In standard care, meals were delivered to participants' rooms whilst in the enriched environment, communal meals with assistance were offered and nutritional intake reminders were placed at the patient bedside. Nutrition supplementation was provided to both groups if indicated. Breakfast and lunch meals were directly observed while remaining intake was calculated using food charts. Nutrition requirements were calculated for energy (ratio method), protein (1 g/kg) and proportion of requirements met. Malnutrition was assessed using the Subjective Global Assessment and body weight. ANCOVA adjusting for stroke severity was used to determine between group differences. Stepwise multivariable logistic regression was performed to assess predictors of nutritional outcomes, adjusting for intervention group, demographic, clinical and baseline nutritional factors. RESULTS: Neither standard care (n = 30, age 76.0yrs ± SD12.8) nor enriched environment (n = 30, age 76.7yrs ± SD12.1, p = 0.84) met daily requirements for energy (70.7% ± SD16.8 vs. 70.7% ± SD17.3, p = 0.94) or protein intake (73.2% ± SD18.6 vs. 69.8% ± SD17.3, p = 0.70). Mean body weight dropped: standard care 0.92 kg ± SD2.47 vs. enriched 0.64 kg ± SD3.12 (p = 0.53) and malnutrition increased: standard care 3.3%-26.6% vs. enriched 6.6%-13.3% (p = 0.07). Predictors of malnutrition on discharge in logistic regression models were: length of stay (p < 0.01) and protein (p < 0.01) or energy intake (p = 0.02). CONCLUSIONS: Acute stroke patients were not meeting nutritional requirements and losing body weight. The enriched environment showed no effect on nutritional intake. Malnutrition was associated with lower energy and protein intakes and increased length of stay.

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before-after pilot study.

OBJECTIVES: To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events. DESIGN: Controlled before-after pilot study. SETTING: An acute stroke unit in a regional Australian hospital. PARTICIPANTS: Acute stroke patients admitted during (a) initial usual care control period, (b) an enriched environment period and (c) a sustainability period. INTERVENTION: Usual care participants received usual one-on-one allied health intervention and nursing care. The enriched environment participants were provided stimulating resources, communal areas for eating and socializing and daily group activities. Change management strategies were used to implement an enriched environment within existing staffing levels. MAIN MEASURES: Behavioural mapping was used to estimate patient activity levels across groups. Participants were observed every 10 minutes between 7.30 am and 7.30 pm within the first 10 days after stroke. Adverse and serious adverse events were recorded using a clinical registry. RESULTS: The enriched environment group ( n = 30, mean age 76.7 ± 12.1) spent a significantly higher proportion of their day engaged in 'any' activity (71% vs. 58%, P = 0.005) compared to the usual care group ( n = 30, mean age 76.0 ± 12.8). They were more active in physical (33% vs. 22%, P < 0.001), social (40% vs. 29%, P = 0.007) and cognitive domains (59% vs. 45%, P = 0.002) and changes were sustained six months post implementation. The enriched group experienced significantly fewer adverse events (0.4 ± 0.7 vs.1.3 ± 1.6, P = 0.001), with no differences found in serious adverse events (0.5 ± 1.6 vs.1.0 ± 2.0, P = 0.309). CONCLUSIONS: Embedding an enriched environment in an acute stroke unit increased activity in stroke patients.

The effect of an enriched environment on activity levels in people with stroke in an acute stroke unit: protocol for a before-after pilot study.

BACKGROUND: Clinical practice guidelines advocate engaging stroke survivors in as much activity as possible early after stroke. One approach found to increase activity levels during inpatient rehabilitation incorporated an enriched environment (EE), whereby physical, cognitive, and social activity was enhanced. The effect of an EE in an acute stroke unit (ASU) has yet not been explored. METHODS/DESIGN: We will perform a prospective non-randomized before-after intervention study. The primary aim is to determine if an EE can increase physical, social, and cognitive activity levels of people with stroke in an ASU compared to usual care. Secondary aims are to determine if fewer secondary complications and improved functional outcomes occur within an EE. We will recruit 30 people with stroke to the usual care block and subsequently 30 to the EE block. Participants will be recruited within 24-72 h after onset of stroke, and each block is estimated to last for 12 weeks. In the usual care block current management and rehabilitation within an ASU will occur. In the EE block, the ASU environment will be adapted to promote greater physical, social, and cognitive activity. Three months after the EE block, another 30 participants will be recruited to determine sustainability of this intervention. The primary outcome is change in activity levels measured using behavioral mapping over 12 h (7.30 am to 7.30 pm) across two weekdays and one weekend day within the first 10 days of admission. Secondary outcomes include functional outcome measures, adverse and serious adverse events, stroke survivor, and clinical staff experience. DISCUSSION: There is a need for effective interventions that starts directly in the ASU. The EE is an innovative intervention that could increase activity levels in stroke survivors across all domains and promote early recovery of stroke survivors in the acute setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry, ANZCTN12614000679684.