Addressing inactivity after stroke: The Collaborative Rehabilitation in Acute Stroke (CREATE) study

Abstract

Background Stroke patients are often inactive outside of structured therapy sessions – an enduring international challenge despite large scale organizational changes, national guidelines and performance targets. We examined whether experienced-based co-design (EBCD) – an improvement methodology – could address inactivity in stroke units. Aims To evaluate the feasibility and impact of patients, carers, and staff co-designing and implementing improvements to increase supervised and independent therapeutic patient activity in stroke units and to compare use of full and accelerated EBCD cycles. Methods Mixed-methods case comparison in four stroke units in England. Results Interviews were held with 156 patients, staff, and carers in total; ethnographic observations for 364 hours, behavioral mapping of 68 patients, and self-report surveys from 179 patients, pre- and post-implementation of EBCD improvement cycles. Three priority areas emerged: (1) ‘Space’ (environment); (2) ‘Activity opportunities’ and (3) ‘Communication’. More than 40 improvements were co-designed and implemented to address these priorities across participating units. Post-implementation interview and ethnographic observational data confirmed use of new social spaces and increased activity opportunities. However, staff interactions remained largely task-driven with limited focus on enabling patient activity. Behavioral mapping indicated some increases in social, cognitive, and physical activity post-implementation, but was variable across sites. Survey responses rates were low at 12–38% and inconclusive. Conclusion It was feasible to implement EBCD in stroke units. This resulted in multiple improvements in stroke unit environments and increased activity opportunities but minimal change in recorded activity levels. There was no discernible difference in experience or outcome between full and accelerated EBCD; this methodology could be used across hospital stroke units to assist staff and other stakeholders to co-design and implement improvement plans.

Exploring liminality in the co-design of rehabilitation environments: The case of one acute stroke unit

“…Behavioural mapping data post implementation of codesigned changes, also confirmed the changes we saw in the space and environment of the units, with an increase in cognitive and social activity ( Jones et al, 2020 ). Additionally we found that stroke unit staff communicated more consistently about activity opportunities through leaflets and posters, highlighting activities available outside of structured therapy provision for example at weekends and evenings ( Jones et al, 2021 ).…”

Patient experiences of codesigned rehabilitation interventions in hospitals: a rapid review

“… 46 Evidenced-based codesign and accelerated evidenced-based codesign was implemented in one study to address inactivity in stroke units. 44 …”

Optimising rehabilitation and recovery after a stroke

“…In rehabilitation, patients commonly experience boredom and lack autonomy 29. The challenge of creating more active rehabilitation environments has led to several groups exploring new models like environmental enrichment30–32 and programme redesign to increase autonomy and engagement,33 with varying degrees of success 33…”

“…32 In rehabilitation, patients commonly experience boredom and lack autonomy. 33 The challenge of creating more active rehabilitation environments has seen a number of groups explore new models like environmental enrichment 34,35,36 and program redesign to increase autonomy and engagement, 37 with varying degrees of success. 37 Identifying effective strategies to meet best practice rehabilitation guidelines, including standardised screening and higher-intensity training is a priority to optimise stroke rehabilitation and will require a fundamental shift in current approaches.…”