NIHR Applied Research Collaboration (ARC) East Midlands, School of Medicine, University of Nottingham, Nottingham, England.
School of Medicine, University of Nottingham, Nottingham, England.
BMC Health Serv Res. 2023 Mar 28;23(1):299. doi: 10.1186/s12913-023-09290-1.
Stroke Early Supported Discharge (ESD) involves provision of responsive and intensive rehabilitation to stroke survivors at home and it is recommended as part of the stroke care pathway. Core components have been identified to guide the delivery of evidence-based ESD, however, service provision in England is of variable quality. The study sought to understand how and in what conditions the adoption of these components drives the delivery of responsive and intensive ESD services in real world settings.
This qualitative study was part of a wider multimethod realist evaluation project (WISE) conducted to inform large-scale ESD implementation. Overarching programme theories and related context-mechanism-outcome configurations were used as a framework to guide data collection and analysis. Six case study sites were purposively selected; interviews and focus groups with ESD staff members were conducted and analysed iteratively.
We interviewed 117 ESD staff members including clinicians and service managers. Staff highlighted the role of certain core components including eligibility criteria, capacity, team composition and multidisciplinary team (MDT) coordination in achieving responsive and intensive ESD. Regardless of the geographical setting, adhering to evidence-based selection criteria, promoting an interdisciplinary skillset and supporting the role of rehabilitation assistants, allowed teams to manage capacity issues and maximise therapy time. Gaps in the stroke care pathway, however, meant that teams had to problem solve beyond their remit to cater for the complex needs of patients with severe disabilities. Adjusting MDT structures and processes was seen as key in addressing challenges posed by travel times and rural geography.
Despite variations in the wider service model of operation and geographical location, the adoption of core components of ESD helped teams manage the pressures and deliver services that met evidence-based standards. Findings point to a well-recognised gap in service provision in England for stroke survivors who do not meet the ESD criteria and emphasise the need for a more integrated and comprehensive stroke service provision. Transferable lessons could be drawn to inform improvement interventions aimed at promoting evidence-based service delivery in different settings.
ISRCTN: 15,568,163, registration date: 26 October 2018.
脑卒中早期支持出院（ESD）涉及为居家脑卒中幸存者提供响应性和强化康复治疗，这被推荐作为脑卒中护理路径的一部分。已经确定了核心组成部分来指导基于证据的 ESD 的实施，然而，英国的服务提供质量参差不齐。本研究旨在了解这些组成部分的采用方式和条件如何推动在实际环境中提供响应性和强化 ESD 服务。
这项定性研究是更广泛的多方法真实评估项目（WISE）的一部分，旨在为大规模 ESD 实施提供信息。总体计划理论和相关的背景-机制-结果配置被用作指导数据收集和分析的框架。六个案例研究地点是有目的选择的；对 ESD 工作人员进行了访谈和焦点小组讨论，并进行了迭代分析。
我们采访了 117 名 ESD 工作人员，包括临床医生和服务经理。工作人员强调了某些核心组成部分的作用，包括资格标准、能力、团队组成和多学科团队（MDT）协调，以实现响应性和强化 ESD。无论地理位置如何，坚持基于证据的选择标准、促进跨学科技能集和支持康复助理的角色，都允许团队管理能力问题并最大限度地增加治疗时间。然而，脑卒中护理路径中的差距意味着团队必须超越其职权范围解决问题，以满足严重残疾患者的复杂需求。调整 MDT 结构和流程被视为解决旅行时间和农村地理带来的挑战的关键。
尽管服务运作的整体模式和地理位置存在差异，但 ESD 的核心组成部分的采用有助于团队应对压力并提供符合循证标准的服务。研究结果表明，在英格兰，对于不符合 ESD 标准的脑卒中幸存者，服务提供存在明显差距，强调需要提供更综合和全面的脑卒中服务。可以借鉴可转移的经验教训，为不同环境中促进基于证据的服务提供提供改进干预措施。
ISRCTN: 15,568,163，注册日期：2018 年 10 月 26 日。
