Exploring Stroke Care Delivery

Introduction

In the present study, a care-study has been delved in details, centered upon a central patient-episode of care experienced during a hospital stay, concerning a stroke course. In a majority of stroke cases, proper rehabilitation of patients in hospitals remains a challenge due to several barriers in the care-delivery and stroke-management process involving issues like pre-hospital based service delay, lacking hospital infrastructure, post-admission delay in service, lacking medical-response and fast response on the hospital's part (Good, et al., 2011). Thus the present study has focused upon an acute stroke based case study in form of a patient's narrative, discussing onto the management protocols followed by the service provider and the complications encountered by the service-user, as reconstruction of the patient's care delivery-pathway based events and the care delivered in the scenario. For conducting the study smoothly and for carrying out a detailed research, some stages has been conducted like interviewing the carer, documenting their narrative by obtaining proper patient consent and considering patient-capacity in question to involve patient family wherever needed. Following this 3 care elements have been concentrated upon, choosing them according to the selected carer-episode, providing due justification. Finally a thorough literature search of recent academic and research work from reputed and reliable international journals, including healthcare dissertation help, books, medical journals and hospital reports have been conglomerated, aligned with the care episode to critically assess the care-delivery provided to the service-user in terms of care experience received and service provided by the healthcare facility.

Case-Study of Service User

The patient is a 61 year old senior law-firm partner and practitioner, who suffered a heart attack during his breakfast unknown to his health condition and what the symptoms relayed. His wife admitted him to the nearest hospital, whereby his treatment and tests were prolonged for an alarming period of 3 days, till a proper diagnosis of his condition was arrived at. The hospital staffs and nursing practitioners were inhospitable to the patient's queries, relocating him from one ward to another, keeping him unattended and being unconcerned about his confusion, mental disparity and anxiety which were aggravated due to improper care and untimely service or medical response. Even though the patient received the right treatment, from the hospital, the fact that he did not receive timely medical care, or service delivery, worsened his health condition. Furthermore the hospital took decisions on its own without contacting the family-members or asking for patient's opinion whatsoever, adding in to his confusion and discomfort. The patient's needs were left unattended by nursing staff and his contact with his family was cut-off, in terms of following rigid hospital protocols. After his discharge, he was not provided any support or outpatient-rehabilitation services from the hospital or SNF (Skilled-Nursing-Facility). Later on from his GP help and a community-service the patient was healed back through long-term rehabilitation services.

Rationale

In UK most of the stroke cases, see patients suffering from improper rehabilitation within due to barriers in stroke-management and care-delivery processes namely - pre-hospital based service delay, lacking hospital infrastructure, post-admission delay in service, lacking medical-response and fast response on the hospital's part (Buurman, et al., 2012). Furthermore, several neurological, medical or psychological complications allied with stroke patients worsen the condition after an acute attack making rehabilitative care a necessity, which must be conducted efficiently by hospitals pre-discharge and post-discharge (Fekadu, et al., 2019). Such rehabilitative care is often not rigorously delivered to stroke patients from hospitals during the care-delivery processes. Thus the rationale of the present study can be understood, whereby the study undertakes the health hazard of stroke as the specific health issue. Through this care element, stroke rehabilitation and care upon a patient's narrative, will be discussed hence, to properly elucidate the management protocols followed and the complications encountered by the service-user. Also other selected care-elements for stroke, have been discussed in the present study namely - care philosophy or approach undertaken in present case study and the discrete intervention methods used for the patient.

Care-Elements considered in present scenario - Justification

In every stroke rehabilitation and care case, the primary goal remains to foster and encourage a patient's functional improvement alongside neurological recovery coupled with improvement in confidence. An organized stroke-care and management process, high intensity therapies and interventions, early-timed rehabilitation are essential factors all of which promote enhanced outcomes for the service-users. In the underlying sections, only the important elements for care have been selected which has proved to be highly important for stroke rehabilitation and care delivery for patients.

1. Stroke - care delivery management

In the present times, patients suffering from ischemic stroke post-hospital admission, do not undergo complete long-term routine rehabilitation services, which hampers their confidence in mobility, self-independent functions and lifestyle to lead a happy, healthy and normal life which they used to lead prior to the stroke condition (Lindsay, et al., 2014). Barriers in the process appear to be - financial constraints; pre-hospital care delay; lacking infrastructure; and allied psychological, physiological and acute medical conditions of stroke patients. Thus the study focused upon a stroke-care study for identifying proper care-management protocols through investigation of gaps within the service-delivery process in form of complications suffered by stroke patients. Recent studies show how the care-management-protocol for the stroke-patients remain lagging and sub-optimal behind the guidelines for lacking skills of staffs in form of nurse practitioners or lacking coordination amongst medical teams, improper treatment and diagnosis (Fekadu, et al., 2019). Also gaps exist in the service provided by clinical teams wherein proper preventive measures and timely rapid medical response is often not provided, which hamper patient health furthermore. More researches claim that in-hospital based complications remain common and in strong association with death risk and stroke-patient dependency. According to Langhorne, et al., (2000) Hospital-setup based complications are a primary reason in West Scotland with 85% patients experienced one complication at least during hospital stay and care (Buurman, et al., 2012). Also Kalra, et al., (1995) in their study showed that complication rate was successively higher in NHS Trust Bromley-Hospitals, UK, with 60% stroke patients suffered medical complications (Fekadu, et al., 2019). For efficient care-delivery to stroke-patients the following has been proved to be highly efficient:

a) admitting patients in specialized stroke-unit-care - helping in improvement of daily-life activities, overall mortality and length-of-stay in comparison to general-ward medical care. Certain features which stroke-unit-care must comprise of are: multidisciplinary and coordinated staffs; routinely scheduled meetings; regular carer involvement; early patient assessments and standardized protocols; effective diagnostic processes; early mobilization in patients; preventing complications; enhanced application of the 'best-evidences' and proper attention provided to the secondary-prevention based measures of patient safety (The elements of stroke rehabilitation, 2020).

b) early-mobilization- motor function, mobility and ambulation all improve due to this (The elements of stroke rehabilitation, 2020)

c) standard-intensity based physiotherapy and speech-language - this helps in improvement of outcomes in post-stroke scenarios

d) additional therapy in form of caregiver-support - improvement in functional outcomes

e) maintenance of 1 year rehabilitation services - post stroke services improve functional outcomes if continued over a year's time period post discharge

2. Care-delivery approach

Wellness relays an important arena in stroke care and wellness approaches to patient-care comprise of responsible mannerisms to provide care to stroke patients in a holistic way supporting patient families alongside for helping in achievement of optimal recovery in an individualized way (Edlin, and Golanty, 2015). However, there exists very few such multidimensional-stroke care programs and that is the prime reason why the holistic-care-approach has been considered as a care element in the present scenario. According to the report of Institute-of-Medicine, (2010), a holistic-care approach remains of prime necessity, considering present-day healthcare changes, and call-for-action measures presented in the report (Peterson-Burch, et al., 2017).

Holistic-wellness-approach

The nurse practitioners are positioned uniquely for serving patients, as leaders, advocates and interdisciplinary staffs in holistic recovery and stroke rehabilitation. Holistic nursing care approach refers to cultivation, recognition and timely integration of multidimensional and dynamic satisfaction levels together with peace in overall routine patient functioning, to promote holistic wellness and to improve outcomes by active and consistent empowerment of not just patients but their social-system, family and environment. During 2014, CARF (Commission-on-Accreditation-of-Rehabilitation-Facilities) suggested holistic assessment incorporation in rehabilitation and wellness of stroke patients, based upon Dr. Bill-Hettler's 6 Dimensions - emotional, social, occupational, spiritual, physical and intellectual (Nathenson, et al., 2014). Later on 2 more dimensions of wellness namely - financial and environmental wellness were added to the model. Thereby, in every stroke recovery case, a holistic-approach must be addressed focusing upon the individual's readiness towards change, individualizing the care-plan according to their personal wants, in a patient-centric and family-centric manner (Murphy, 2011). Success in outcomes is highly obtained when a primary dimension is focused initially till patient finds contentment within the area, following which the care-giver or nurse moves on to focus in the next/another dimension. In this way, all the dimensions of holistic-care-model are touched and completed to attain completeness in care provided.

3) Discrete-medical-Interventions for Ischemic stroke patients

For proper management of ischemic stroke care in patients speed of medical response and service delivery is highly critical. Hence rapid-relief in arterial occlusion to restore normalcy in blood flow, is a primary aspect of interventions in the present scenario, to prevent disability and save lives. CT scan and an MRI is the standard protocol and must be fast and available to patients for diagnosis, promoting 95% accuracy. For management and treatment of ischemic stroke, tPA (Tissue-Plasminogen-Activator) must be administered as fast as 4.5 hours post stroke onset, to prevent functional disability and reduce placebo risk by 13%; and is considered as standard protocol. Because the effects of treatment wanes at a rapid rate, hence swift-medical-response is of prime importance as per standard protocol, with timely treatment followed by rapid diagnosis, else risks of patient harm increases as time elapses. Also ESCAPE (Endovascular-treatment-for-Small-Core-and-Anterior-circulation-Proximal-occlusion-with-Emphasis-on-minimizing-CT-to-recanalization-times) Endovascular treatment, uses contemporary devices and is a proved successful treatment for treating ischemic strokes reducing mortality and morbidity (Goyal, et al., 2015). Also disabling and acute ischemic strokes in patients only make the thrombolysis treatment suitable, with a score more than that of 0, as per National-Institutes-of-Health-Stroke-Scale (NIHSS). However, if symptom diagnosis is not made rapidly or delayed, then thrombolysis treatment post 4.5 hours of onset, cannot be provided and considered ineligible, increasing patient risk. Ischemic strokes must be addressed by medical staffs and nursing practitioner team with urgency and aggressiveness, for preventing progression towards major stroke and prevention of recurrent strokes. Thus same day diagnosis of symptoms is mandatory, following cause-specific-therapy like anti-coagulation or carotid-revascularization (Coutts, et al., 2015). All these suggest that time is key, and rapid, aggressive diagnosis and treatment for providing fast medical-response and patient-care services is highly important for treating patients with ischemic strokes. Also Stroke-care-Units which are thoroughly organized providing care through multi-disciplinary-teams exclusively managing patients within dedicated wards is considered most effective and standard care protocol for ischemic stroke based care delivery.

Critical analysis of care and service delivered to service-user

In the present section, a critical analysis of service delivered to the patient, Michael, has been conducted to analyze the effectiveness of the service delivered to him, in comparison to the standard protocol of service delivery in case of stroke cases. The discharge practices, delegation practices as well as quality assurance based practices performed by the hospital facility has been delved in details.

1. Considering the 1st element of care-delivery management in strokes, especially ischemic strokes, the most efficient protocol comprised of admitting a stroke patient to stroke-care-units which are highly specialized to deal with stroke patients providing them the time-bound and fast services which such patients require (Tamm, et al., 2014). These care-units comprise of delegation and quality-assurance-practices like: multidisciplinary and coordinated staffs; routinely scheduled meetings; regular carer involvement; early patient assessments and standardized protocols; effective diagnostic processes; early mobilization in patients, which decrease patient mortality and risks of disability, being better staffed and more equipped than other wards in terms of diagnostic infrastructures. Early diagnosis, early mobilization in patients and multidisciplinary support provides rehabilitation to stroke patients for long-term even after discharge for 1 year or more, proving to be effective. In contrast, Michael was not shifted to a stroke-care-unit but to a general wad for the initial days of diagnosis and treatment. This was because of a lagging diagnosis of symptoms, he was undetected of his ischemic stroke condition, and this delayed the medical response provided to him which aggravated his condition further and made matters worse. However, he was shifted to a stroke-unit-care based ward, after ischemic stroke detection, but that followed after a 2 day period delay, which shows carelessness on part of delivery of medical-response and care-management in patients.

2. Considering care-delivery based approach, a patient-centric and family-centric-care approach is efficient in case of dealing with stroke patients which is holistic in all forms. The standard protocol of care-approach comprises of the CARF suggested 8 dimensions holistic-care-model, formulated by Dr. Bill-Hettler, taking in consideration the dimensions of - emotional, social, occupational, spiritual, physical, intellectual, financial and environmental wellness in patients (Nathenson, et al., 2014). The nurse practitioners play a prime role in advocating the care-approach concerning ischemic-stroke patients, prioritizing on one Dimension of care, achieving a patient's comfort over it, before moving on to another. The model aims of supporting a patient and patient-families in a way by the nurses, wherein a holistic development and empowerment of patients and their environment is brought forth. In the present scenario, the nursing practitioners and the service staffs, did not attend to Michael or do a thorough follow-up, ignoring his requests, his wants and needs and detached him for his comfort i.e. family support in dire times. They did not consult with family (his wife) about his therapy, treatment, tests or ward placements and his wife was not informed about his shift from general ward to stroke-ward. There was an instance where his wife has to follow-up the testing and diagnosis process, to prevent lagging and delay; a job which was needed to be conducted by the nurses. Nurses prevented him to contact with his family, on grounds of hospital protocol, and visiting-hours, instead of aligning to his individual care and needs, in helping him to make a phone call to his wife. Thus the nurses did not follow a patient-centric approach, a family-centric approach and thus definitely not a holistic-care-model-approach, failing to provide all the care-dimensions (Jasemi, et al., 2017). The service-staffs did however, performed their duty in conducting tests, in assessing the right disease diagnosis and in offering treatment, which though did not completely fulfill all delegation practices and post-discharge practices, did the job of stopping his stroke situation to discharge him later on.

3. Considering the 3rd element , to prevent disability and save lives, fast and immediate medical response is necessary for management of stroke patients; which was drastically unmet by the health-care facility wherein Michael suffered 1.5 days delays before his results came in which according to standard protocol must be conducted within 4.5 hours (Saver, et al., 2016). Also he was shifted to a proper stroke ward and his stroke was detected after 1 and half days, which refers to huge time lag and could have resulted in aggravating his situation causing permanent disability or mortality risk. However a proper NIHSS stroke-score test was conducted which came to 19 for Michael, suggesting that the proper treatment measure was taken by the hospital (Papathanasiou, et al., 2013). Also tPA was administered which followed the right treatment routine norm to him. However the time of tPA administration was far delayed which signified huge delays and time-gaps in providing medical-response.

Conclusion

In the present study, a care-narrative was collected in form of interview from an ischemic stroke patient named Michael, who was a 61 year old partner in a Law firm and a Law practitioner, suffering a stroke-attack for the first time in his life, wherein he remained confused of the symptoms. The care-management protocol followed by the health-care staffs and facility where he was administered has been critically assessed in the present context centering on 3 elements-of-care: care-delivery and management of ischemic stroke, care-delivery-approach followed and discrete medical-intervention followed. The same has been compared with standard medical practices of present day to conduct a final assessment as to how effective was the diagnosis, delegation and processes of quality-assurance as provided to the patient in the care episode.

References

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