Improving Assessment, Diagnosis, and Management of Urinary Incontinence and Lower Urinary Tract Symptoms on Acute and Rehabilitation Wards That Admit Adult Patients: Protocol for a Before-and-After Implementation Study.

BACKGROUND: Urinary incontinence (UI) and lower urinary tract symptoms (LUTS) are commonly experienced by adult patients in hospitals (inpatients). Although peak bodies recommend that health services have systems for optimal UI and LUTS care, they are often not delivered. For example, results from the 2017 Australian National Stroke Audit Acute Services indicated that of the one-third of acute stroke inpatients with UI, only 18% received a management plan. In the 2018 Australian National Stroke Audit Rehabilitation Services, half of the 41% of patients with UI received a management plan. There is little reporting of effective inpatient interventions to systematically deliver optimal UI/LUTS care. OBJECTIVE: This study aims to determine whether our UI/LUTS practice-change package is feasible and effective for delivering optimal UI/LUTS care in an inpatient setting. The package includes our intervention that has been synthesized from the best-available evidence on UI/LUTS care and a theoretically informed implementation strategy targeting identified barriers and enablers. The package is targeted at clinicians working in the participating wards. METHODS: This is a pragmatic, real-world, before- and after-implementation study conducted at 12 hospitals (15 wards: 7/15, 47% metropolitan, 8/15, 53% regional) in Australia. Data will be collected at 3 time points: before implementation (T0), immediately after the 6-month implementation period (T1), and again after a 6-month maintenance period (T2). We will undertake medical record audits to determine any change in the proportion of inpatients receiving optimal UI/LUTS care, including assessment, diagnosis, and management plans. Potential economic implications (cost and consequences) for hospitals implementing our intervention will be determined. RESULTS: This study was approved by the Hunter New England Human Research Ethics Committee (HNEHREC Reference No. 18/10/17/4.02). Preimplementation data collection (T0) was completed in March 2020. As of November 2020, 87% (13/15) wards have completed implementation and are undertaking postimplementation data collection (T1). CONCLUSIONS: Our practice-change package is designed to reduce the current inpatient UI/LUTS evidence-based practice gap, such as those identified through national stroke audits. This study has been designed to provide clinicians, managers, and policy makers with the evidence needed to assess the potential benefit of further wide-scale implementation of our practice-change package. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/22902.

Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice.

OBJECTIVE: To study the correlation between adherence to recommended management and good recovery outcomes in an Australian cohort of inpatients receiving rehabilitation. DESIGN: Processes of care were audited and included those recommended in the Australian Clinical Guidelines for Stroke Rehabilitation and Recovery. SETTING: National audit data from 68 rehabilitation units were used, with each hospital contributing up to 40 consecutive cases. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Discharged home or an increase of greater than or equal to 22 in FIM scores between admission and discharge. Multivariable logistic regression models controlling for patient clustering were used to assess the associations between adherence to recommended management and recovery outcomes (dependent variables). RESULTS: Hospitals contributed 2119 patients (median age 75y, 53% men). We found that rehabilitation units providing evidence-based management (eg, treatment for sensorimotor impairment 38%, hypertonicity 56%, mobility 94%, and home assessments 71%) were more likely to provide better recovery outcomes for people with stroke. A discharge FIM score of 100 was clinically relevant and was strongly correlated with whether or not a patient was discharged home. We found very good correlation between admission and discharge FIM scores in stroke rehabilitation. CONCLUSIONS: This is one of the first study comparing adherence to recommended management in Australian rehabilitation units and stroke recovery outcomes based on national audit data. Novel findings include the significance of an FIM score between 80 and 100 and the clinical significance of various management processes.

Stroke patients' experience with the Australian health system: a qualitative study.

BACKGROUND: Consumer feedback about experiences with the health system is integral to service planning and is consistent with growing interest in patient-centred care. PURPOSE: To explore the experiences of community-dwelling stroke survivors at one, three and five years using a community-based, cross-sectional study. METHODS: The quantitative study was comprised of 90 participants post-stroke (3 cohorts, each including 30 participants). Qualitative interviews were undertaken with 12 participants (4 participants from each cohort). This paper presents findings from the qualitative component of the project. FINDINGS: The majority of participants in each cohort were independent and a high proportion required community services. Qualitative data identified varied experiences with the health system, including knowledge about stroke, communication with the health system, and influences on transition home. IMPLICATIONS: The results presented identify the need for ongoing health professional education to enhance stroke service delivery. There is a particular need to address stroke risk-factor modification and to ensure close collaboration with patients and other health professionals with regard to rehabilitation processes. Results identify experiences with health systems up to five years post-stroke. Occupational therapy can play an essential role in post-stroke education and in rehabilitation focused on adjustment to stroke.

Exploring poststroke mood changes in community-dwelling stroke survivors: a qualitative study.

OBJECTIVE: To explore the long-term experience of mood changes in community-dwelling stroke survivors at 1, 3, and 5 years after stroke. DESIGN: A qualitative study using a modified grounded theory approach. The primary data collection method was semi-structured interviewing. SETTING: Community-dwelling stroke survivors in metropolitan Newcastle, NSW, Australia. PARTICIPANTS: Twelve community-dwelling stroke survivors (6 men, 6 women; age range 43-92y; 4 participants from each cohort) discharged from a tertiary referral hospital. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Qualitative outcomes were participants' perceptions using in-depth, semi-structured interviews with participants from 3 community-based cohorts of stroke survivors at 1, 3, and 5 years poststroke. RESULTS: Four main categories of mood change were described by participants including feelings of frustration, reduced self-efficacy, dependency, and loss. Factors that modulated these mood changes included the presence or absence of insight, hope for the future, faith, and support. A modified grounded theory approach was used for data analysis using a process of constant comparison. CONCLUSIONS: Mood changes continued well beyond discharge and in some cases commenced after discharge in this sample of stroke survivors. Use of qualitative methodology extends our understanding of the extent and nature of low mood after stroke. There is a need for enhanced services to monitor and address low mood.

Community-dwelling stroke survivors: function is not the whole story with quality of life.

OBJECTIVE: To compare function and quality of life in community-dwelling stroke survivors at 1, 3, and 5 years after stroke. DESIGN: A community-based, cross-sectional study of 3 retrospective cohorts. SETTING: Community-dwelling stroke survivors in Australia. PARTICIPANTS: The 3 cohorts comprised 30 participants each at 1, 3, and 5 years poststroke discharge from a tertiary referral hospital. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Stroke severity, comorbidity, medications used, and demographic information were recorded. Poststroke function was assessed using the Modified Rankin Scale, Mini-Mental State Examination, Stroke Impact Scale, and Multidimensional Scale of Perceived Social Support. RESULTS: This cross-sectional study provides insights into trends in stroke survivors over time. A high proportion of stroke survivors use community services, even those who are independent with activities of daily living. Although there was little attrition in medication use over time except for warfarin, this was from a baseline of suboptimal compliance and adherence with stroke preventive therapies. Stroke survivors report high levels of perceived social support; however, emotional well-being was low overall. The data suggest that those who are independent at 1 year tend to remain independent, although this was an extrapolation from serial cross-sections and needs to be explored in a longitudinal study. CONCLUSIONS: Stroke survivors' function does not change significantly over time. A high proportion of survivors require community services. The development of needs-related effective long-term service delivery models is required.

2: Rehabilitation of patients after stroke.

Stroke is the third highest cause of death and the leading cause of chronic disability in adults in Australia. Studies show clear advantages of treatment of patients in the acute phase of stroke in a dedicated stroke unit. Rehabilitation after stroke is a continuum, starting within days of stroke onset and ending only when it no longer produces any positive effect. More than half the 75% of patients who survive the first month after a stroke will require specialised rehabilitation. Effective rehabilitation relies on a coordinated, multidisciplinary team approach. Regular team meetings, as well as meetings with the patient, his or her family and carers, are essential. Improvements in function after stroke are the result of recovery within the ischaemic penumbra, resolution of cerebral oedema, neuroplasticity, and compensatory strategies learnt by the patient. Evidence supporting rehabilitation programs is based on evaluation of the multidisciplinary approach, or on the effect of a particular discipline (eg, speech therapy), rather than on individual components of treatment. When the patient is discharged from a formal rehabilitation program, the general practitioner's role becomes paramount. GPs can help patients deal with the consequences of stroke, such as depression, and any comorbidities. GPs may also provide counselling on issues ranging from interpersonal and sexual relationships, through ability to drive again, and vocational and recreational activities.