Abstract
Introduction: The ongoing OPTIMISTmain study, an international, multicenter, stepped-wedge cluster randomized trial, aims to determine effectiveness and safety of low-intensity versus standard monitoring in thrombolysis-treated patients with mild-to-moderate acute ischemic stroke (AIS). An embedded process evaluation explored integration and impact of the intervention on care processes at participating US sites. Methods: A mixed-methods approach with quantitative and qualitative data was collected between September 2021 and November 2022. Implementer surveys were undertaken at pre- and post-intervention phases to understand the perceptions of low-intensity monitoring strategy. A sample of stroke care nurses were invited to participate in semi-structured interviews at an early stage of post-intervention. Qualitative data were analyzed deductively using the normalization process theory; quantitative data were tabulated. Results: Interviews with 21 nurses at 8 hospitals have shown low-intensity monitoring was well accepted as there were less time constraints and reduced workload for each patient. There were initial safety concerns over missing deteriorating patients and difficulties in changing established routines. Proper training, education, and communication, and changing the habits and culture of care, were key elements to successfully adopting the new monitoring care into routine practice. Similar results were found in the post-intervention survey (42 nurses from 13 hospitals). Nurses reported time being freed up to provide patient education (56%), daily living care (50%), early mobilization (26%), mood/cognition assessment (44%), and other aspects (i.e., communication, family support). Conclusions: Low-intensity monitoring for patients with mild-to-moderate AIS, facilitated by appropriate education and organizational support, appears feasible and acceptable at US hospitals.
Journal Section:
Original Paper
References
1.
Wardlaw
JM
, Murray
V
, Berge
E
, del Zoppo
GJ
. Thrombolysis for acute ischaemic stroke
. Cochrane Database Syst Rev
. 2014
;2014
(7
):CD000213
. doi: .2.
Summers
D
, Leonard
A
, Wentworth
D
, Saver
JL
, Simpson
J
, Spilker
JA
, et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient a scientific statement from the American Heart Association
. Stroke
. 2009
;40
(8
):2911
–44
. doi: .3.
Powers
WJ
, Rabinstein
A
, Ackerson
T
, Adeoye
OM
, Bambakidis
NC
, Becker
K
, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association
. Stroke
. 2018
;49
(3
):e46
–110
. doi: .4.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
. Tissue plasminogen activator for acute ischemic stroke
. N Engl J Med
. 1995
;333
(24
):1581
–7
. doi: .5.
Emberson
J
, Lees
KR
, Lyden
P
, Blackwell
L
, Albers
G
, Bluhmki
E
, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials
. Lancet
. 2014
;384
(9958
):1929
–35
. doi: .6.
Chang
ALE
, Llinas
EJ
, Chen
K
, Llinas
RH
, Marsh
EB
. Shorter intensive care unit stays?: the majority of post-intravenous tPA (tissue-type plasminogen activator) symptomatic hemorrhages occur within 12 hours of treatment
. Stroke
. 2018
;49
(6
):1521
–4
. doi: .7.
Faigle
R
, Butler
J
, Carhuapoma
JR
, Johnson
B
, Zink
EK
, Shakes
T
, et al. Safety trial of low-intensity monitoring after thrombolysis: optimal post tpa-iv monitoring in ischemic stroke (OPTIMIST)
. Neurohospitalist
. 2020
;10
(1
):11
–5
. doi: .8.
Ouyang
M
, Faigle
R
, Wang
X
, Johnson
B
, Summers
D
, Khatri
P
, et al. The main Optimal Post rTpa-Iv Monitoring in Ischemic Stroke Trial (OPTIMISTmain): protocol for a pragmatic, stepped wedge, cluster randomized controlled trial
. Cerebrovasc Dis
. 2023
:1
–8
. doi: .9.
Skivington
K
, Matthews
L
, Simpson
SA
, Craig
P
, Baird
J
, Blazeby
JM
, et al. A new frame work for developing and evaluating complex interventions: update of Medical Research Council guidance
. BMJ
. 2021
;374
:n2061
. doi: .10.
Clarke
DJ
, Godfrey
M
, Hawkins
R
, Sadler
E
, Harding
G
, Forster
A
, et al. Implementing a training intervention to support caregivers after stroke: a process evaluation examining the initiation and embedding of programme change
. Implement Sci
. 2013
;8
:96
. doi: .11.
Ouyang
M
, Anderson
CS
, Song
L
, Jan
S
, Sun
L
, Cheng
G
, et al. Implementing a goal-directed care bundle after acute intracerebral haemorrhage: process evaluation for the third INTEnsive Care Bundle with Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial study in China
. Cerebrovasc Dis
. 2022
;51
(3
):373
–83
. doi: .12.
Liu
H
, Lindley
R
, Alim
M
, Felix
C
, Gandhi
DB
, Verma
SJ
, et al. Family-led rehabilitation in India (ATTEND): findings from the process evaluation of a randomized controlled trial
. Int J Stroke
. 2019
;14
(1
):53
–60
. doi: .13.
Murray
E
, Treweek
S
, Pope
C
, Macfarlane
A
, Ballini
L
, Dowrick
C
, et al. Normalisation process theory: a framework for developing, evaluating and implementing complex interventions
. BMC Med
. 2010
;8
:63
. doi: .14.
Proctor
E
, Silmere
H
, Raghavan
R
, Hovmand
P
, Aarons
G
, Bunger
A
, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda
. Adm Pol Ment Health
. 2011
;38
(2
):65
–76
. doi: .15.
May
C
, Cummings
A
, Girling
M
, Bracher
M
, Mair
F
, May
C
, et al. Using normalization process theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review
. Implement Sci
. 2018
;13
(1
):80
. doi: .16.
Suri
H
. Purposeful sampling in qualitative research synthesis
. Qual Res J
. 2011
;11
(2
):63
–75
. doi: .17.
Nvivo
U
. Nvivo for qualitative research
. Available from: http://help-nv11.qsrinternational.com/desktop/concepts/using_nvivo_for_qualitative_research.htm (accessed by 08 22, 2023).18.
O’Brien
BC
, Harris
IB
, Beckman
TJ
, Reed
DA
, Cook
DA
. Standards for reporting qualitative research: a synthesis of recommendations
. Acad Med
. 2014
;89
(9
):1245
–51
. doi: .19.
Lengnick-Hall
R
, Gerke
DR
, Proctor
EK
, Bunger
AC
, Phillips
RJ
, Martin
JK
, et al. Six practical recommendations for improved implementation outcomes reporting
. Implement Sci
. 2022
;17
(1
):16
. doi: .20.
Fetters
MD
, Curry
LA
, Creswell
JW
. Achieving integration in mixed methods designs-principles and practices
. Health Serv Res
. 2013
;48
(6 Pt 2
):2134
–56
. doi: .21.
Johnson
RE
, Grove
AL
, Clarke
A
. Pillar integration process: a joint display technique to integrate data in mixed methods research
. J Mix Methods Res
. 2019
;13
(3
):301
–20
. doi: .22.
Fencl
JL
, Matthews
C
. Translating evidence into practice: how advanced practice RNs can guide nurses in challenging established practice to arrive at best practice
. Assoc periOperative Registered Nurse J
. 2017
;106
(5
):378
–92
. doi: .23.
Hines
S
, Ramsbotham
J
, Coyer
F
. The effectiveness of interventions for improving the research literacy of nurses: a systematic review
. Worldviews Evid Based Nurs
. 2015
;12
(5
):265
–72
. doi: .24.
Johnson
MJ
, May
CR
. Promoting professional behaviour change in healthcare: what interventions work, and why? a theory-led overview of systematic reviews
. BMJ Open
. 2015
;5
(9
):e008592
. doi: .25.
Grol
R
, Grimshaw
J
. From best evidence to best practice: effective implementation of change in patients’ care
. Lancet
. 2003
;362
(9391
):1225
–30
. doi: .26.
Office of Health Policy
. Impact of the COVID-19 pandemic on the hospital and outpatient clinician workforce: challenges and policy responses
. Issue Brief
. 2022
. Available from: https://aspe.hhs.gov/sites/default/files/documents/9cc72124abd9ea25d58a22c7692dccb6/aspe-covid-workforce-report.pdf27.
Yang
YT
, Mason
DJ
. COVID-19’s impact on nursing shortage, the rise of travel nurses, and price gouging
. Health Aff Forefront
. 2022
. Vol. 28
.28.
Lieberman
HR
, Bathalon
GP
, Falco
CM
, Kramer
FM
, Morgan
CA
3rd, Niro
P
. Severe decrements in cognition function and mood induced by sleep loss, heat, dehydration, and undernutrition during simulated combat
. Biol Psychiatry
. 2005
;57
(4
):422
–9
. doi: .29.
Wesselius
HM
, van den Ende
ES
, Alsma
J
, Ter Maaten
JC
, Schuit
SCE
, Stassen
PM
, et al. Quality and quantity of sleep and factors associated with sleep disturbance in hospitalized patients
. JAMA Intern Med
. 2018
;178
(9
):1201
–8
. doi: .30.
Lyden
P
. Using the National Institutes of Health Stroke Scale: a cautionary tale
. Stroke
. 2017
;48
(2
):513
–9
. doi: .31.
Hailemariam
M
, Bustos
T
, Montgomery
B
, Barajas
R
, Evans
LB
, Drahota
A
. Evidence-based intervention sustainability strategies: a systematic review
. Implement Sci
. 2019
;14
(1
):57
. doi: .32.
Madsen
TE
, Khoury
J
, Cadena
R
, Adeoye
O
, Alwell
KA
, Moomaw
CJ
, et al. Potentially missed diagnosis of ischemic stroke in the emergency department in the Greater Cincinnati/Northern Kentucky Stroke Study
. Acad Emerg Med
. 2016
;23
(10
):1128
–35
. doi: .© 2024 S. Karger AG, Basel
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
2024
You do not currently have access to this content.
