What is the role of dual antiplatelet therapy after high risk transient ischaemic attack or minor stroke? Specifically, does dual antiplatelet therapy with a combination of aspirin and clopidogrel lead to a greater reduction in recurrent stroke and death over the use of aspirin alone when given in the first 24 hours after a high risk transient ischaemic attack or minor ischaemic stroke? An expert panel produced a strong recommendation for initiating dual antiplatelet therapy within 24 hours of the onset of symptoms, and for continuing it for 10-21 days. Current practice is typically to use a single drug

ObjectiveProvision of a discharge care plan and prevention therapies is often suboptimal. Our objective was to design and pilot test an interdisciplinary, organisational intervention to improve discharge care using stroke as the case study using a mixed-methods, controlled before–after observational study design.SettingAcute care public hospitals in Queensland, Australia (n=15). The 15 hospitals were ranked against a benchmark based on a composite outcome of three discharge care processes. Clinicians from a ‘top-ranked’ hospital participated in a focus group to elicit their success factors. Two pilot hospitals then participated in the organisational intervention that was designed with experts and consumers.ParticipantsHospital clinicians involved in discharge care for stroke and patients admitted with acute stroke or transient ischaemic attack.InterventionA four-stage, multifaceted organisational intervention that included data reviews, education and facilitated action planning.Primary and secondary outcome measuresThree discharge processes collected in Queensland hospitals within the Australian Stroke Clinical Registry were used to select study hospitals: (1) discharge care plan; (2) antihypertensive medication prescription and (3) antiplatelet medication prescription (ischaemic events only). Primary measure: composite outcome. Secondary measures: individual adherence changes for each discharge process; sensitivity analyses. The performance outcomes were compared 3 months before the intervention (preintervention), 3 months postintervention and at 12 months (sustainability).ResultsData from 1289 episodes of care from the two pilot hospitals were analysed. Improvements from preintervention adherence were: antiplatelet therapy (88%vs96%, p=0.02); antihypertensive prescription (61%vs79%, p<0.001); discharge planning (72%vs94%, p<0.001); composite outcome (73%vs89%, p<0.001). There was an insignificant decay effect over the 12-month sustainability period (composite outcome: 89% postintervention vs 85% sustainability period, p=0.08).ConclusionDischarge care in hospitals may be effectively improved and sustained through a staged and peer-informed, organisational intervention. The intervention warrants further application and trialling on a larger scale.

Assessment and selection for rehabilitation following acute stroke: a prospective cohort study in Queensland, Australia. Objective To describe current practice and investigate factors associated with selection for rehabilitation following acute stroke. Design Prospective observational cohort study. Setting Seven public hospitals in Queensland, Australia. Subjects Consecutive patients surviving acute stroke. Measures Rehabilitation selection processes: assessment for rehabilitation needs, referral for rehabilitation, receipt of rehabilitation. Functional impairment following stroke: modified Rankin Scale (mRS). Results We recruited 504 patients, median age 73 years (IQR 62, 82) between July 2016 and January 2017. Of these, 90% (454/504) were assessed for rehabilitation needs, 76% (381/504) referred for rehabilitation, and 72% (363/504) received any rehabilitation. There was significant variation in all rehabilitation selection processes across sites (p<0.05). In multivariable analyses (Odds Ratio; 95% CI), stroke unit care (2.7; 1.1, 6.6) and post stroke functional impairment (severe stroke mRS 4-5: 10.9; 4.9, 24.6) were associated with receiving an assessment for rehabilitation. Receipt of rehabilitation was more likely following assessment (6.5; 2.9, 14.6) but less likely in patients with dementia (0.2; 0.1, 0.9), end-stage medical conditions (0.4; 0.2, 0.8) or ischaemic stroke (0.4; 0.1, 0.9). The odds of receiving rehabilitation increased with greater impairment: Odds Ratio 3.0 (1.5, 4.9) for mRS 2-3 and 12.5 (6.5, 24.3) for mRS 4-5. Among patients with mild-moderate impairment (mRS 2-3), 39/117 (33%) received no rehabilitation. Conclusions There was significant inter-site variation in rehabilitation selection processes. The major factors influencing rehabilitation access were assessment for rehabilitation needs, co-morbidities and post stroke functional impairment. Gaps in access to rehabilitation were found in those with mild to moderate functional impairment.

Objective: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes. Design: This was a prospective observational cohort study. Setting: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study. Subjects: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017. Methods: We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry. Measures: Dose of rehabilitation – time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up. Results: We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7–7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7–3.8) compared to no rehabilitation, after adjustment for baseline factors. Conclusion: Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.

Aims and Objectives To critically appraise relevant literature on the lived experiences of registered nurses caring for adults with intellectual disability in the acute care setting in Australia to determine current knowledge and gaps in the literature. Background People with intellectual disability have the right to the highest attainable health care the same as everyone else. However, inequities still exist in the delivery of health care across the globe, including Australia that result in poorer health outcomes for this population group. Part of the problem is a lack of understanding of the complexities of ID care due to an absence of ID specific content in undergraduate curricula. Design Integrative literature review. Methods Electronic databases were searched for relevant empirical and theoretical literature. Additional articles were found by reviewing reference lists of selected articles resulting in ten articles for review. Selected articles were critically appraised using JBI critical appraisal tools. Data were analysed using comparative thematic analysis. PRISMA checklist completed the review. Results Two main themes emerged from the data that informed the gap in knowledge: (a) Defining nursing practice; and (b) Confidence to practice. Conclusions There was limited qualitative research published on the topic. International studies revealed that a lack of understanding of the ID condition due to inadequate education left registered nurses feeling underprepared, unsupported and struggling to provide optimal care. No studies were located on the phenomenon within the Australian context. A study exploring the lived experiences of RNs in Australia is needed to offer a deeper understanding of the phenomenon that will help inform practice. Relevance to practice Including ID care in national undergraduate and postgraduate nursing curricula must become a nursing educational and professional priority to support nurses more fully in their practice to ensure patients with ID receive the highest attainable standard of nursing care.