Rethnam Venesha, Hayward Kathryn S, Bernhardt Julie, Churilov Leonid
Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.
National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Melbourne, VIC, Australia.
Front Neurol. 2021 Feb 5;12:606525. doi: 10.3389/fneur.2021.606525. eCollection 2021.
Early mobilization, out-of-bed activity, is a component of acute stroke unit care; however, stroke patient heterogeneity requires complex decision-making. Clinically credible and applicable CPGs are needed to support and optimize the delivery of care. In this study, we are specifically exploring the role of clinical practice guidelines to support individual patient-level decision-making by stroke clinicians about early mobilization post-stroke. Our study uses a novel, two-pronged approach. (1) A review of CPGs containing recommendations for early mobilization practices published after 2015 was appraised using purposely selected items from the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) tool relevant to decision-making for clinicians. (2) A cross-sectional study involving semi-structured interviews with Australian expert stroke clinicians representing content experts and CPG target users. Every CPG was independently assessed against the AGREE-REX standard by two reviewers. Expert stroke clinicians, invited via email, were recruited between June 2019 to March 2020.The main outcomes from the review was the proportion of criteria addressed for each AGREE-REX item by individual and all CPG(s). The main cross-sectional outcomes were the distributions of stroke clinicians' responses about the utility of CPGs, specific areas of uncertainty in early mobilization decision-making, and suggested parameters for inclusion in future early mobilization CPGs. In 18 identified CPGs, many did not adequately address the "Evidence" and " AGREE-REX items. Out of 30 expert stroke clinicians (11 physicians [37%], 11 physiotherapists [37%], 8 nurses [26%]; median [IQR] years of experience, 14 [10-25]), 47% found current CPGs "too broad or vague," while 40% rely on individual clinical judgement and interpretation of the evidence to select an choice of action. The areas of uncertainty in decision-making revealed four key suggestions: (1) more granular descriptions of patient and stroke characteristics for appropriate tailoring of decisions, (2) clear statements about when clinical flexibility is appropriate, (3) detailed description of the intervention dose, and (4) physical assessment criteria including safety parameters. The lack of specificity, clinical applicability, and adaptability of current CPGs to effectively respond to the heterogeneous clinical stroke context has provided a clear direction for improvement.
早期活动，即离床活动，是急性卒中单元护理的一个组成部分；然而，卒中患者的异质性需要复杂的决策。需要临床可信且适用的临床实践指南（CPG）来支持和优化护理服务。在本研究中，我们专门探讨临床实践指南在支持卒中临床医生针对卒中后早期活动进行个体患者层面决策方面的作用。我们的研究采用了一种新颖的双管齐下的方法。（1）对2015年后发布的包含早期活动实践建议的CPG进行综述，使用从《指南研究与评价-推荐卓越性评估（AGREE-REX）》工具中特意挑选的与临床医生决策相关的条目进行评估。（2）一项横断面研究，涉及对代表内容专家和CPG目标用户的澳大利亚卒中专家临床医生进行半结构化访谈。每篇CPG由两名评审员根据AGREE-REX标准独立评估。通过电子邮件邀请的卒中专家临床医生于2019年6月至2020年3月期间招募。综述的主要结果是每篇CPG和所有CPG针对每个AGREE-REX条目的标准达成比例。横断面研究的主要结果是卒中临床医生对CPG效用、早期活动决策中特定不确定领域的回答分布，以及对纳入未来早期活动CPG的建议参数。在18篇已确定的CPG中，许多没有充分涉及“证据”和AGREE-REX条目。在30名卒中专家临床医生中（11名医生[37%]，11名物理治疗师[37%]，8名护士[26%]；中位[四分位间距]经验年限，14[10 - 25]年），47%的人认为当前的CPG“过于宽泛或模糊”，而40%的人依靠个人临床判断和对证据的解读来选择行动方案。决策中的不确定领域揭示了四条关键建议：（1）更详细地描述患者和卒中特征，以便适当地调整决策；（2）明确说明何时临床灵活性是合适的；（3）详细描述干预剂量；（4）包括安全参数在内的体格检查标准。当前CPG缺乏特异性、临床适用性和适应性，无法有效应对卒中临床的异质性情况，这为改进提供了明确方向。
