Evidence-Based Practice: Initiating an Acute Stroke Care Unit in a Hospital Emergency Department - Essay Example

? EVIDENCE-BASED PRACTICE: INITIATING AN ACUTE STROKE CARE UNIT IN A HOSPITAL EMERGENCY DEPARTMENT Table of Contents Page Introduction…………………………………………………………………………3 Search Strategy……………………………………………………………………...6 Evidences……………………………………………………………………………8 Barriers to and Issues in Implementation…………………………………………...11 Implementation Process……………………………………………………………..13 Conclusion…………………………………………………………………………..15 References…………………………………………………………………………..16 Evidence-Based Practice: Initiating an Acute Stroke Care Unit in a Hospital Emergency Department Among a hospital’s various departments one of, if not the busiest would be the emergency department due to the numerous and varied situations that each admitted patient would have. In order to accomplish the task of providing timely care for as many patients as possible, it is recommended that facilities have enough patient bays, equipment and knowledgeable attending staff as suited to the influx of patients. True to their values of providing excellent health care and actively seeking new ways of doing things better through progressive and integrative ways, Joondalup Private Hospital can cater to a large number of admittances through their Emergency Department. Joondalup Private Hospital, formerly Joondalup Health Campus is currently the largest healthcare facility in Perth’s suburbs and as such can accommodate over 80,000 patients annually due to their enhanced and enlarged Emergency Department, as well as their 24-hour acute care services, After Hours General Practitioner Clinic and comprehensive pathology and radiology services (Department of Health, Government of Western Australia, 2013; Ramsay Health Care, 2013). It is expected that in order for the Emergency Department to function well and remain organised, multidisciplinary teams are established to select the appropriate treatment for each patient, and with a culture that fosters teamwork and communication between various disciplines, Joondalup Private Hospital is able to cultivate the ability of its staff to provide the most applicable care for patients, while at the same time ensuring that the patients admitted become healed in the timeliest way possible. Joondalup Private Hospital may be the largest facility with an impressive Emergency Department, but it is still a relatively new facility and its Emergency Department can still benefit from the implementation of evidence-based practices with regards to the formation of much more specific care teams in comparison with teams that do not have specialisations. This is because some diseases such as stroke and transient ischaemic attacks which are some of the leading causes of death and disability especially among the elderly are rather difficult to detect and yet need prompt medical attention may not always be given to patients (Gabrielli, Layon, & Yu, 2013). In order to prevent events such as hospital readmission among stroke patients from happening in the future, it is recommended that Joondalup Private Hospital create a pilot acute stroke team or unit to immediately address the needs of patients who got admitted due to recent bouts with stroke or transient ischaemic attacks, and compare recent from previous data gathered if readmission rates for such patients decrease or increase, and assess whether there is feasibility in maintaining the acute stroke team. If results of the pilot acute stroke care unit coincides with the effects based on the results of evidence-based practices and recommendations of various stroke care and monitoring guidelines, these stroke care units can increase the value of Joondalup Private Hospital’s Emergency Department, as there is a greater likelihood of improving the health and well-being of patients that suffered stroke, transient ischaemic attacks or other related diseases by prolonging their lifespan and preventing them from becoming disabled and continuously needing assistance from others. This is important to note since at present, Joondalup Private Hospital does not have a dedicated acute stroke care unit, but taking into account evidence-based practices suggesting the effectiveness of an acute stroke care unit in improving patient health and quality of life, this can also be an opportunity for the hospital’s executive team to come together and form the emergency department’s pilot acute care team and in-hospital care pathways to test whether the evidence-based practice of a functional acute stroke care unit significantly improves response times in providing stroke treatment, as well as decrease hospital readmission rates for these patients. Many earlier studies support the creation of support units such as acute stroke care units, and various guidelines have recommended the implementation of a dedicated stroke unit and of designing an easy-to-understand stroke care pathway to allow faster response times by the team in preventing further damages from the stroke, as well as to hasten patient discharge from the hospital (American Stroke Association Task Force, 2005; Bravata, et al., 2010; Demaerschalk, 2004; Indredavik, et al., 2000; Jorgensen, et al., 1995; Kwan & Sandercock, 2003; National Institute for Health and Care Excellence, NICE, 2008; National Stroke Foundation, 2010; Phillips, Eskes, & Gubitz, 2002; Teasell, et al., 2012). However, due to the lack of initiatives and bringing up the importance of having a team dedicated to respond to patients admitted either from stroke or transient ischaemic attacks, this prevents the formation of in-hospital care pathways along with acute stroke care units and hospitals only keep relying on a general emergency response unit or team which could only assist patients as they arrive, not according to their needs (Donnan, Davis, & Levi, 2003). Aside from slight delays due to the lack of a care pathway used as a guide in giving pharmacological treatment such as anticoagulants or anti-platelet medicine to stroke or transient ischaemic attack sufferers, because there is no team specialised in specifically monitoring the progress and providing other outpatient needs of these patients, it is likely that they could get discharged without having enough briefing on preventive or reductive measures in stroke recurrence, and it is expected that another incident could occur within a few days or more after hospital discharge (The European Stroke Organization, 2008). Such results can be considered to be the end-product of evidence-to-practice gaps, implementation barriers and lack of incentives if the protocols are not updated according to recent evidence-based practices (Grol & Wensing, 2004; Kwan & Sandercock, 2003). Search Strategy In order to formulate a clinical question and to aid in finding useful keywords for the literature search, PICO (patient or problem, intervention, comparison, outcome) shall be used to identify who the patient and the problem is, interventions currently available, comparisons with alternative interventions, and the desired outcome for the alternative interventions (Howlett, Rogo, & Shelton, 2013). For this study, the person and problem of interest would be stroke or transient ischaemic attack patients admitted through hospital emergency departments, the intervention currently available is getting treatment from general emergency personnel and protocols, the alternate intervention is getting treatment from dedicated or specialised acute stroke care units, and the desired outcomes would be a reduction in patient readmission rates due to stroke recurrence and decrease in mortality and morbidity rates among stroke or transient ischaemic attack patients. Using such information, the answerable clinical question for this study would be: “Is there a significant improvement in the health, lifespan, and quality of life of stroke and transient ischaemic attack patients treated through acute stroke care units as compared to general emergency admissions?” Using medical databases such as PubMed, Medline, The Cochrane Database of Systematic Reviews, The Cumulative Index to Nursing and Allied Health, and Google Scholar, the following terms were used in finding articles relevant to the PICO questions: ("stroke"[MeSH Terms] OR "stroke"[All Fields] OR ("acute"[All Fields] AND "stroke"[All Fields]) OR "acute stroke"[All Fields]) AND care[All Fields] AND unit[All Fields] AND ("stroke"[MeSH Terms] OR "stroke"[All Fields]) AND ("transient ischaemic attack"[All Fields] OR "ischemic attack, transient"[MeSH Terms] OR ("ischaemic"[All Fields] AND "attack"[All Fields] AND "transient"[All Fields]) OR "transient ischaemic attack"[All Fields] OR ("transient"[All Fields] AND "ischemic"[All Fields] AND "attack"[All Fields])) A total of 2220 citations were found using the various search engines, however only 26 were considered to be relevant to the study and included in the evidence based on the following search criteria: Level of evidence I (Meta-analysis/systematic review/at least one randomised controlled trial) or II (Well-designed non-randomised controlled trial/well-designed experimental trial) Study involves the assessment of either or both: a care pathway or/and an acute stroke care unit in the Emergency Department Only clinical trials involving humans (intent to treat) Measurable outcomes are mentioned in the paper Studies conducted beginning 1995 Only studies written in English Of the 26 selected articles, 21 were of level of evidence I (Meta-analysis/systematic review/at least one randomised controlled trial) and the remaining 5 were of level of evidence II (Well-designed non-randomised controlled trial/well-designed experimental trial). The use of level I and II evidences were to increase the credibility of the evidences for the implementation of new practices, while the long timeline is used in order to incorporate and compare earlier results from studies that concluded that the creation of an acute stroke care facility or team contributes to the improvement of stroke and transient ischaemic attack survivors. Evidences In 1995, Jorgensen and colleagues tried to determine the effect of having specialised stroke units in two communities: Bisbepjerg and Frederiksberg, through a randomised controlled experiment (level of evidence I) and found out that while factors such as age, sex, marital status, pre-stroke residence and stroke severity do not differ significantly among the two groups. However the presence of a stroke unit significantly reduced the in-hospital morbidity (odds ratio 0.50, 95% confidence interval), case fatality rate (odds ratio 0.45), 6-month mortality (odds ratio 0.57), 1-year mortality (odds ratio 0.59), and discharge rate to a nursing home (odds ratio 0.61). Length of hospital stay was also reduced by 30%, saving 1313 bed-days per 100 stroke patients (Jorgensen, et al., 1995). Similar results were also reported by Indredavik and colleagues in 2000 using randomised, controlled trials (level of evidence I) comparing patients in an extended stroke unit service and in ordinary stroke unit service. After 26 weeks, a significantly greater number of patients from the extended stroke unit service (65%) were reported to be globally independent, compared with 51.9% from the ordinary stroke unit using a 95% confidence interval (Indredavik, et al., 2000). There were also more extended stroke unit patients staying at home compared to ordinary stroke unit (74.4% versus 55.6%), as well as having more patients institutionalised in the ordinary stroke unit (40%) compared to the extended stroke unit patients (23.1%). In addition, patients from the extended stroke unit stayed shorter in the hospital (18.6 days average) compared to ordinary stroke unit patients (31.1 days average), suggesting that there are better outcomes for patients in specialised stroke units compared to ordinary or generic emergency or stroke units. These two experimental studies were able to show that having a dedicated stroke care unit in hospitals can provide better quality treatment to patients, as well as reduce their hospital stays and morbidity rates. Lastly, Panella and colleagues performed random controlled trials (level of evidence I) in 2012 to compare randomly-selected hospital workers in 14 hospitals trained for 6 months using clinical pathways as opposed to those without training and performing the usual care or treatment. Their results showed that despite the lack of significant differences between 30-days mortality for both experimental sets, patients of hospital workers using clinical pathways had significantly lower risk of mortality at 7 days (odds ratio 0.10, confidence interval 95%) and lower rates of adverse functional outcomes or recurrent strokes (odds ratio 0.42) (Panella, et al., 2012). Their study shows how clinical pathways can be used in conjunction with stroke care units to reduce incidences of strokes among admitted patients. Other studies of level of evidence II can also contribute to the body of evidences regarding the increase in lifespan, quality of life, and reduced morbidity and mortality rates among patients of dedicated acute stroke care units. Cho and colleagues (2012) studied the impact of the establishment of a designated cerebrovascular centre in South Korea, and found out that coordination between hospitals without acute stroke care units and those that have such designated facilities increased from 198 to 244, as well as decreasing the coordination time from 8 minutes to 4 minutes (95% confidence interval), which translates to faster treatment responses for patients once they arrive in the designated stroke care centres. Similarly, Benavente and colleagues (2013) were able to generate similar results in Spain, wherein a total of 1470 hospital days were prevented simply through using early stroke detection and care pathways, as well as having only 10.6% vascular events and 6.2% recurrence rates, respectively. Similar studies were conducted in the US by Cramer and colleagues (2012) wherein through non-randomised trials they were able to conclude that by incorporating features of comprehensive stroke centres to hospitals, provision of appropriate reperfusion therapies can be given to either stroke or transient ischaemic attack patients promptly. However, there is still a need to improve the care guidelines since only 25% of total number of patients (n=553) were able to receive treatment in less than 60 minutes and such delays could still affect the outcome of such treatments. In relation to these studies, the remaining two levels of evidence II clinical trials were able to find which factors can affect the provision of acute stroke care among patients. Lin and colleagues (2012) initiated the use of emergency medical services notification system and found out that old age, diabetes mellitus and peripheral vascular disease could affect rapid treatment responses for patients. Similarly, Suljic, Mehicevic and Gavranovic (2013) also reported similar results, adding that recurrent stroke and patient confusion can affect early diagnosis of stroke in emergency departments. Of the remaining accepted articles for this report, 18 studies were composed of meta-analyses and systematic reviews that contribute to the existence of evidence-based practice in implementing a stroke unit in hospitals. Five of these were systematic reviews obtained from the Cochrane Database, while the remaining 13 were meta-analyses and systematic reviews by authors found from other databases. Of the 5 systematic reviews from Cochrane, 3 delved on care pathways and 2 reviews focused on the effects of stroke services in reducing secondary stroke occurrence. The 3 care pathway reviews concluded that clinical pathways in stroke treatment can reduce in-hospital complications, increase survival rates, and regain independence (Kwan & Sandercock, 2004; Langhorne, 2013; Rotter, et al., 2010). On the other hand, the stroke services reviews concluded that aside from increasing the lifespan of stroke patients, the presence of stroke service units also increase the likelihood of patient treatment adherence, reduction in recurrent vascular events, and increased independence of patients after discharge (Fearon & Langhorne, 2012; Lager, et al., 2011). Of the 13 systematic and meta-analyses outside the Cochrane Database, the earliest ones or those published prior to 2008 (Alberts & Easton, 2004; American Stroke Association’s Task Force, 2005; Duncan, et al., 2005; Langhorne, et al., 2005) were used to create contemporary guidelines in the use of care pathways and stroke care units in hospitals. This is because around 2008 and in later years various agencies such as the UK’s National Institute for Health and Care Excellence, Australia’s National Stroke Foundation, and the European Stroke Organization, released full guidelines on stroke management based on systematic reviews of previously-published studies. In addition, these guidelines were further synthesised and analysed by other authors in order to condense the information and find common areas and grounds as further research recommendations. For example, reviews that systematically analyse the effectiveness of the reported guidelines based on different studies were able to further increase the reliability of the guidelines by generating results corresponding to the expectations of these published stroke management guidelines of increasing the lifespan and quality of life among stroke patients treated under stroke care units and reduction of recurrent stroke attacks (Langhorne, Bernhardt, & Kwakkel, 2011; McArthur, et al., 2011; Teasell, et al., 2012). In addition, other systematic reviews were able to identify other potential areas of improvement in the use of care pathways and stroke guidelines such as identifying the strengths of primary stroke care units and the weaknesses that can arise from lack of preparations prior to its formation, the importance of retraining personnel in realising the importance of implementing evidence-based practices and in performing proper procedures in finding out the best practices for their facility, as well as establishing quality indicators in measuring the performance of stroke care units among various hospitals (Chaudhry, et al., 2012; McGillivray & Considine, 2009; The European Implementation Score Collaboration, 2012). Barriers to and Issues in Implementation Even if there is enough evidence based on clinical trials to prove the effectiveness of creating a dedicated acute stroke care unit in Joondalup Private Hospital, it is also expected that various issues and barriers will arise in its effective implementation (Duncan, et al., 2005). While the hospital’s Emergency Department may be large enough to allow for an acute stroke care unit’s station, the establishment or the selection of the members of the unit itself might cause the issues. For one thing, the management must decide on how staffs will be assigned to the new care unit. The management needs to deliberate in choosing how the staffing or the selection of members of the new unit will commence: will they hire new employees and train them for the said care unit; will they select currently employed Emergency Department personnel from various disciplines and retrain them to form the new care unit; or will they train all Emergency Department personnel and rotate the members of the unit periodically? Such procedures may affect the number of available personnel at any given time, and the impact of increasing or decreasing the staff members must be taken into consideration in creating the acute stroke care team. In addition to the staffing procedures, it must also be made clear if there will be provisions for funding the salaries of the members of the care unit or if there will be no additional funds. If there will be additional funds, then hiring new employees and giving them training will be a better choice since the department does not have to lose some of its workforce in order to establish the acute stroke care unit, and work can continue as usual. Otherwise, the management must further deliberate if it will be worth it to lose some members of the workforce in order to save money while in the process of creating a new care unit in addition to the already existing emergency department. This can be dependent on various factors such as the number of admissions in relation to or directly caused by stroke or transient ischaemic attacks, the peak and off-peak seasons of emergency department visits, and if there is an adequate staffing during the peak seasons. If previous records show that a certain percentage of emergency admissions is due to stroke or similar diseases, the management can create a pilot unit to assess whether the number of admissions and patient complications can be reduced (American Stroke Association’s Task Force, 2005; Duncan, et al., 2005). If the Emergency Department can fully function even with a decrease in personnel, then employee shortage should not pose any problem. Otherwise, the least that the Emergency Department could do is to either create an ad-hoc acute stroke care team that will be tasked to respond immediately to admissions that have high percentages of being a stroke or similar illnesses, or simply create the team as part of the hospital’s research ventures to find out if having a specialised unit can be feasible or not. Lastly, if the management committee decides to simply make an ad-hoc acute stroke care team, guidelines such as how their work will be classified and rated according to existing performance evaluation measures must also be made clear for them, especially since it can be expected that there will be more admissions for ailments other than stroke or transient ischaemic attacks, and as such the workload for this ad-hoc team may vary from time to time. It is important for the management team to deliberate on this issue as thoroughly as they can, especially when the employees’ work schedules or workloads, team and individual performance, evaluations and ratings, their salaries and the hospital’s funds are at stake (Langhorne & Dennis, 2008). Once barriers and issues in the creation of an acute stroke care unit have been discussed and deliberated on, the implementation process can proceed next. Implementation Process Prior to the implementation process, meetings and deliberations within the Joondalup Private Hospital Executive Team and Organisation, the author and the panel of commentators or advisory group, and meetings between the author and the hospital’s Human Resources Manager, Organisational Development Manager and if possible the Medical Services Operations Director (or authorised representative) shall first be done. This is in order to: 1) allow the author to have the proposal for evidence-based practice health care be critiqued, gain feedback for revisions or improvements as well as approval by the author’s advisory committee prior to the proposal’s submission to the Joondalup Private Hospital Executive committee; 2) for both parties (the author and the Joondalup Private Hospital Executive committee) to talk formally about the possibility of implementing evidence-based practices within hospital settings; and 3) if it is possible, to find a compromise in the execution of the evidence-based practice of creating an acute stroke care unit for the hospital’s Emergency Department in accordance to existing guidelines or regulations. Such considerations are necessary because despite the existing evidence to support the creation of an acute stroke care unit among hospitals, other potential problems and issues must also be taken into consideration before the implementation of new evidence-based practices. These issues can include potentially by-passing existing hospital protocols and would thus need amendments prior to the implementation of the program, reviewing the specialisations of employees working in the Emergency Department in order to assess whether there is a valid need to hire additional employees specifically for the acute stroke care unit or if it is more feasible to simply create a temporary group until the care unit has earned merits, and if there is sufficient funds to allow the creation of such a care unit in the Emergency Department. If such issues are addressed during the early stages of meetings and deliberations, a better plan can be made which will not cause issues or problems within the hospital’s existing Emergency Department protocols, and a much more suitable care pathway and care unit can be created according to what the Emergency Department usually encounters. In turn, such initiatives in creating an acute stroke care unit that can rapidly respond to those suspected to be suffering from stroke or related diseases can improve the outcome for stroke or transient ischaemic attack patients admitted through the Emergency Department admitted in the future. Conclusion To conclude this study, based on various literature concerned with evidence-based practices and implementations there is a considerable amount of evidence that backs up the need for hospitals to form acute stroke care units in order to improve response times and results for admitted patients suffering from stroke, transient ischaemic attack, or similar illnesses. This is because there is no need for patients suffering from such illnesses to wait for the response of a hospital’s generalised response team, and by doing so the medication that they promptly need will be readily provided, saving their lives and improving their recovery rates in the process. Introducing this evidence-based method to Joondalup Private Hospital can add value to their emergency services through various ways: 1) having a dedicated acute stroke care unit that could respond rapidly and provide care for those potentially-suffering from stroke or other related ailments; and 2) improving the response times in giving medications to stroke or transient ischaemic attack patients and thereby reducing their likelihood of suffering cognitive impairment or disabilities. With stroke and other related illnesses considered to be some of the leading causes of death and disabilities, the creation of an acute stroke care unit can allow Joondalup Private Hospital to bridge the gap between evidence-based practice and actual implementation, while reducing morbidity and improving the quality of life of patients, thereby keeping in tune with the hospital’s vision of providing excellent health care and values of integrative and constructive working relationships while actively seeking ways of doing things better. References Alberts, M., & Easton, J. (2004). Stroke best practices: a team-based approach to evidence-based care. The Journal of the National Medical Association, 96(4), 5-20. American Stroke Association's Task Force. (2005). Recommendations for the establishment of stroke systems of care. Circulation, 111, 1078-1091. Benavente, L., Calleja, S., Larrosa, D., Vega, J., Mauri, G., Pascual, J., & Lahoz, C.H. (2013). 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