Improving communicative access and patient experience in acute stroke care: An implementation journey.

INTRODUCTION: Patient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts. METHODS: The project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) - an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years. OUTCOMES: Examples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products - a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process. CONCLUSIONS: This implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.

Communicative Access Measures for Stroke: Development and Evaluation of a Quality Improvement Tool.

OBJECTIVES: To (1) develop a systems-level quality improvement tool targeting communicative access to information and decision-making for stroke patients with language disorders; and (2) evaluate the resulting tool-the Communicative Access Measures for Stroke (CAMS). DESIGN: Survey development and evaluation was in line with accepted guidelines and included item generation and reduction, survey formatting and composition, pretesting, pilot testing, and reliability assessment. SETTING: Development and evaluation were carried out in hospital and community agency settings. PARTICIPANTS: The project used a convenience sample of 31 participants for the survey development, and 63 participants for the CAMS reliability study (broken down into 6 administrators/managers, 32 frontline staff, 25 participants with aphasia). Eligible participants invited to the reliability study included individuals from 45 community-based organizations in Ontario as well as 4400 individuals from communities of practice. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Data were analyzed using kappa statistics and intraclass correlations for each item score on all surveys. RESULTS: A tool, the CAMS, comprising 3 surveys, was developed for health facilities from the perspectives of (1) administrators/policymakers, (2) staff/frontline health care providers, and (3) patients with aphasia (using a communicatively accessible version). Reliability for items on the CAMS-Administrator and CAMS-Staff surveys was moderate to high (kappa/intraclass correlation coefficients [ICCs], .54-1.00). As expected, reliability was lower for the CAMS-Patient survey, with most items having ICCs between 0.4 and 0.6. CONCLUSIONS: These findings suggest that CAMS may provide useful quality improvement information for health care facilities with an interest in improving care for patients with stroke and aphasia.