Sustaining a New Model of Acute Stroke Care: A Mixed-Method Process Evaluation of the Melbourne Mobile Stroke Unit

Document Type : Original Article

Authors

1 Public Health and Health Services Research, Stroke, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, VIC, Australia

2 Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia

3 Department of Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia

4 Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia

5 Austin Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia

6 Ambulance Victoria, Melbourne, VIC, Australia

7 Stroke Foundation, Melbourne, VIC, Australia

8 Department of Epidemiology and Preventive Medicine, Department of Paramedicine Monash University, Melbourne, Melbourne, VIC, Australia

9 Discipline of Emergency Medicine, University of Western Australia, Perth, WA, Australia

10 St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia

11 Nursing Research Institute, Australian Catholic University, Melbourne, VIC, Australia

Abstract

Background 
Internationally, Mobile Stroke Unit (MSU) ambulances have changed pre-hospital acute stroke care delivery. MSU clinical and cost-effectiveness studies are emerging, but little is known about important factors for achieving sustainability of this innovative model of care.

Methods 
Mixed-methods study from the Melbourne MSU (operational since November 2017) process evaluation. Participant purposive sampling included clinical, operational and executive/management representatives from Ambulance Victoria (AV) (emergency medical service provider), the MSU clinical team, and receiving hospitals. Sustainability was defined as ongoing MSU operations, including MSU workforce and future model considerations. Theoretically-based on-line survey with Unified Theory of Acceptance and Use of Technology (UTAUT), Self Determination Theory (SDT, Intrinsic Motivation), and open-text questions targeting barriers and benefits was administered (June-September 2019). Individual/group interviews were conducted, eliciting improvement suggestions and requirements for ongoing use. Descriptive and regression analyses (quantitative data) and directed content and thematic analysis (open text and interview data) were conducted.

Results 
There were 135 surveys completed. Identifying that the MSU was beneficial to daily work (β = 0.61), not experiencing pressure/tension about working on the MSU (β = 0.17) and thinking they did well working within the team model (β = 0.17) were significantly associated with wanting to continue working within the MSU model [R2 = 0.76; F(15, 60) = 12.76, P < .001]. Experiences varied between those on the MSU team and those working with the MSU. Advantages were identified for patients (better, faster care) and clinicians (interdisciplinary learning). Disadvantages included challenges integrating into established systems, and establishing working relationships. Themes identified from 35 interviews were MSU team composition, MSU vehicle design and layout, personnel recruitment and rostering, communication improvements between organisations, telemedicine options, MSU operations and dispatch specificity.

Conclusion 
Important factors affecting the sustainability of the MSU model of stroke care emerged. A cohesive team approach, with identifiable benefits and good communication between participating organisations is important for clinical and operational sustainability.

Keywords


  1. Meretoja A, Keshtkaran M, Saver JL, et al. Stroke thrombolysis: save a minute, save a day. Stroke. 2014;45(4):1053-1058. doi:1161/strokeaha.113.002910
  2. Meretoja A, Keshtkaran M, Tatlisumak T, Donnan GA, Churilov L. Endovascular therapy for ischemic stroke: save a minute-save a week. Neurology. 2017;88(22):2123-2127. doi:1212/wnl.0000000000003981
  3. Middleton S, Dale S, Cheung NW, et al. Nurse-initiated acute stroke care in emergency departments. Stroke. 2019;50(6):1346-1355. doi:1161/strokeaha.118.020701
  4. Meretoja A, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste M. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology. 2012;79(4):306-313. doi:1212/WNL.0b013e31825d6011
  5. Lachkhem Y, Rican S, Minvielle É. Understanding delays in acute stroke care: a systematic review of reviews. Eur J Public Health. 2018;28(3):426-433. doi:1093/eurpub/cky066
  6. Fassbender K, Walter S, Liu Y, et al. "Mobile stroke unit" for hyperacute stroke treatment. Stroke. 2003;34(6):e44. doi:1161/01.str.0000075573.22885.3b
  7. Walter S, Kostpopoulos P, Haass A, et al. Bringing the hospital to the patient: first treatment of stroke patients at the emergency site. PLoS One. 2010;5(10):e13758. doi:1371/journal.pone.0013758
  8. Fassbender K, Mathur S. The rapidly expanding field of prehospital stroke care In. Mobile Stroke Unit News. Vol 1: Prehospital Stroke Treatment Organisation; 2019.
  9. Coote S, Mackey E, Alexandrov AW, et al. The mobile stroke unit nurse: an international exploration of their scope of practice, education, and training. J Neurosci Nurs. 2022;54(2):61-67. doi:1097/jnn.0000000000000632
  10. Calderon VJ, Kasturiarachi BM, Lin E, Bansal V, Zaidat OO. Review of the mobile stroke unit experience worldwide. Interv Neurol. 2018;7(6):347-358. doi:1159/000487334
  11. Ebinger M, Kunz A, Wendt M, et al. Effects of golden hour thrombolysis: a Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke (PHANTOM-S) substudy. JAMA Neurol. 2015;72(1):25-30. doi:1001/jamaneurol.2014.3188
  12. Parker SA, Bowry R, Wu TC, et al. Establishing the first mobile stroke unit in the United States. Stroke. 2015;46(5):1384-1391. doi:1161/strokeaha.114.007993
  13. Ebinger M, Siegerink B, Kunz A, et al. Association between dispatch of mobile stroke units and functional outcomes among patients with acute ischemic stroke in Berlin. JAMA. 2021;325(5):454-466. doi:1001/jama.2020.26345
  14. Campbell BCV, Mitchell PJ, Churilov L, et al. Effect of intravenous tenecteplase dose on cerebral reperfusion before thrombectomy in patients with large vessel occlusion ischemic stroke: the EXTEND-IA TNK part 2 randomized clinical trial. JAMA. 2020;323(13):1257-1265. doi:1001/jama.2020.1511
  15. Kim J, Easton D, Zhao H, et al. Economic evaluation of the Melbourne mobile stroke unit. Int J Stroke. 2021;16(4):466-475. doi:1177/1747493020929944
  16. Gyrd-Hansen D, Olsen KR, Bollweg K, Kronborg C, Ebinger M, Audebert HJ. Cost-effectiveness estimate of prehospital thrombolysis: results of the PHANTOM-S study. Neurology. 2015;84(11):1090-1097. doi:1212/wnl.0000000000001366
  17. Dietrich M, Walter S, Ragoschke-Schumm A, et al. Is prehospital treatment of acute stroke too expensive? An economic evaluation based on the first trial. Cerebrovasc Dis. 2014;38(6):457-463. doi:1159/000371427
  18. Bagot KL, Purvis T, Hancock S, et al. Interdisciplinary interactions, social systems and technical infrastructure required for successful implementation of mobile stroke units: a qualitative process evaluation. J Eval Clin Pract. 2023. doi:1111/jep.13803
  19. Australian Bureau of Statistics. Regional Population, 2019-20 Financial Year. 2021. https://www.abs.gov.au/statistics/people/population/regional-population/2019-20. Accessed December 19, 2021.
  20. Zhao H, Coote S, Easton D, et al. Melbourne mobile stroke unit and reperfusion therapy: greater clinical impact of thrombectomy than thrombolysis. Stroke. 2020;51(3):922-930. doi:1161/strokeaha.119.027843
  21. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. doi:1093/intqhc/mzm042
  22. Strauss A, Corbin J. Basics of Qualitative Research Techniques. Thousand Oaks, CA: SAGE Publications; 1998.
  23. Venkatesh V, Morris MG, Davis GB, Davis FD. User acceptance of information technology: toward a unified view. MIS Q. 2003;27(3):425-478. doi:2307/30036540
  24. Shea CM, Jacobs SR, Esserman DA, Bruce K, Weiner BJ. Organizational Readiness for Implementing Change: a psychometric assessment of a new measure. Implement Sci. 2014;9:7. doi:1186/1748-5908-9-7
  25. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68-78. doi:1037//0003-066x.55.1.68
  26. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277-1288. doi:1177/1049732305276687
  27. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:1191/1478088706qp063oa
  28. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ. 1995;311(6996):42-45. doi:1136/bmj.311.6996.42
  29. Tzelgov J, Henik A. Suppression situations in psychological research: definitions, implications, and applications. Psychol Bull. 1991;109(3):524-536.
  30. Audebert H, Fassbender K, Hussain MS, et al. The PRE-hospital stroke treatment organization. Int J Stroke. 2017;12(9):932-940. doi:1177/1747493017729268
  31. Ambulance Victoria. Ambulance Victoria 2018-2019 Annual Report. Doncaster: Ambulance Victoria; 2019.
  32. Ambulance Performance and Policy Consultative Committee. Victoria's Ambulance Action Plan: Improving Services, Saving Lives: Final Report. Melbourne: Victorian Government; 2015.
  33. Marler JH, Fisher SL, Ke W. Employee self‐service technology acceptance: a comparison of pre‐implementation and post‐implementation relationships. Pers Psychol. 2009;62(2):327-358. doi:1111/j.1744-6570.2009.01140.x
  34. Koch PM, Kunz A, Ebinger M, et al. Influence of distance to scene on time to thrombolysis in a specialized stroke ambulance. Stroke. 2016;47(8):2136-2140. doi:1161/strokeaha.116.013057
  35. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. doi:1097/00001888-200512000-00005
  36. Dawson S, King L, Grantham H. Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emerg Med Australas. 2013;25(5):393-405. doi:1111/1742-6723.12120
  37. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005;293(19):2384-2390. doi:1001/jama.293.19.2384
  38. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79(2):186-194. doi:1097/00001888-200402000-00019
  39. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614-621. doi:1067/msy.2003.169
  40. Bladin CF, Kim J, Bagot KL, et al. Improving acute stroke care in regional hospitals: clinical evaluation of the Victorian Stroke Telemedicine program. Med J Aust. 2020;212(8):371-377. doi:5694/mja2.50570
  41. Rogers EM. Diffusion of Innovations. 5th ed. New York, NY: Simon & Schuster; 2003.
  42. Rajan SS, Baraniuk S, Parker S, Wu TC, Bowry R, Grotta JC. Implementing a mobile stroke unit program in the United States: why, how, and how much? JAMA Neurol. 2015;72(2):229-234. doi:1001/jamaneurol.2014.3618
  • Receive Date: 30 September 2022
  • Revise Date: 17 December 2022
  • Accept Date: 21 February 2023
  • First Publish Date: 22 February 2023