Stroke is the third most common cause of death and largest cause of adult disability, costing the UK economy approximately £7 billion per annum. Clinical guidelines have emphasised the need to identify acute stroke as a clinical priority requiring specialist assessment and treatment (Royal College of Physicians, 2012). There has been increasing recognition of the importance of timely medical attention in acute stroke management to facilitate early diagnosis and determination of the aetiology of the stroke (ischaemic or haemorrhagic) in addition to planning treatment strategies aimed at reducing the brain damage caused by the stroke and preventing complications (Stone, 2002; Harbison et al, 2003; Nor et al, 2005). Indeed, ‘clot-busting’ treatment with thrombolysis within three hours of ischaemic stroke onset results in a 30% increase in the number of patients with no or minimal disability at three months (National Institute of Neurological Disorders and Stroke, 1995). It is widely acknowledged that a team-orientated collaborative approach to patient care on stroke units improves safety and outcomes, with significant reductions in patient death, dependency and institutionalisation (Stone, 2002; Kalra et al, 2000; Evans et al, 2001; Frisby et al, 2015; Stroke Unit Trialists' Collaboration, 2013). Effective interdisciplinary team-working across primary and secondary care interfaces also contributes to the delivery of safe and high-quality care (Birns et al, 2009; Royal College of Physicians, 2012).
Rapid transfer of stroke patients to a centre with a hyperacute stoke unit (HASU) has been shown to improve clinical outcome (Hunter et al, 2013). Pre-hospital ambulance paramedics are crucial to this process as first responders and they have been shown to provide diagnostic accuracy for acute stroke using specialist paradigms and in response to educational programmes (Harbison et al, 2003; Nor et al, 2004; Wojner-Alexandrov et al, 2005). However, paramedics have limited feedback on subsequent patient care and progress to improve their technical and non-technical skills in caring for this patient population. Whilst patient management skills of HASU staff have been shown to improve with experiential interprofessional learning programmes, no such intervention has yet been employed for paramedics (Roots et al, 2001; Ross et al, 2015). This article outlines the development of a bespoke hyperacute stroke educational programme for paramedics and assesses the feasibility and benefits of this intervention.
Methods
A dedicated stroke training course for paramedics was developed by a multidisciplinary working party, comprising healthcare professionals (from stroke clinician backgrounds) and educationalists, to address the technical and non-technical skills required in the acute management of stroke patients (Table 1). The course was delivered over one day at the St Thomas' Hospital, London HASU in 2011 (prior to the final configuration of the London Stroke model after which time St Thomas' Hospital ceased to function as a HASU) (Rudd, 2012) and was available to paramedics in London to attend on an individual basis in order to maximise learning outcomes. The training day was structured as a ‘work-shift’ enabling faculty input from all disciplines within the HASU, as well as accurately reflecting everyday clinical practice in this setting. Upon arrival, paramedics received a standardised introductory educational briefing and subsequently participated in clinical activities with multidisciplinary HASU staff, including doctor-led ward rounds and outpatient consultations, nurse-led patient care episodes, speech and language therapy, physiotherapy and occupational therapy-led patient rehabilitation sessions, and multidisciplinary patient management episodes in the emergency department.
| Technical skills | Non-technical skills |
|---|---|
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Upon completion of the course, attendees completed a standardised semi-structured questionnaire providing ‘free-text’ comments in response to questions about what they had learned on the course, which aspects of the course were useful, and how learning on the course might impact upon future practice. All the question responses were transcribed into a Microsoft Excel spreadsheet (version 14.1). Each response was kept as a separate datum point. All text was thematically analysed by author HH. Themes were developed by iteratively reading and re-grouping the data. Each coded theme was discussed and checked by author JB; any discrepancies were discussed, and if necessary, re-evaluated for alternatives. Once themes were finalised, the data were rechecked, and if necessary, recoded as appropriate. A single response could be and often was coded against multiple themes. Thematic analysis was employed as a primary evaluation of data collection in view of the opportunity to ‘generate interesting findings beyond the specific research questions for which the study was designed’ (Yardley et al, 2013).
Results
In total, 30 paramedics attended the training course over a three-month period, of which, 100% of candidates reported that the course was useful to their learning and training. Candidates' free-text completion of semi-structured questionnaires yielded 160 individual responses, which were coded into six themes (Table 2). Responses were related to technical and non-technical skills, both of which were judged not to have been taught as effectively by other learning media. Further analysis of the completed questionnaires revealed that two broad categories of ‘usefulness of observing clinicians performing assessments on patients' and ‘understanding of care pathways and treatment’ accounted for 48% of the 160 free-text responses. As exampled in Table 2, many of the comments had real-world transferability with reflections regarding past behaviour and planned alteration of future behaviour in clinical practice, rather than only with regard to the course.
| Theme | Percentage of para-medics providing free-text response | Example responses |
|---|---|---|
| Usefulness of observing clinicians performing assessments on patients | 93% | ‘It was good to see the assessment process for a patient before they are admitted to the HASU. In addition the doctor's questioning contained lots of useful tips for me to use’ |
| Understanding of care pathways and treatment | 73% | ‘Gained a better understanding of the care pathway and management of stroke’ |
| Ability to communicate with patients and families more confidently regarding the next stages of treatment and care | 17% | ‘…. which will help me to deal with any fears they may have about their future treatment and outlook’ |
| Increased awareness of more subtle signs of stroke | 13% | ‘Has opened my eyes to other signs and symptoms that strokes may cause’ |
| Localisation of intracranial pathology | 7% | ‘…. better understanding of where the brain attack may have occurred’ |
| Ability to communicate better with doctors at handover in A&E | 7% | ‘Help me to give more relevant information at “blue” calls’ ‘Aim for fuller history taking from family members to give better handover at hospital’ |
Discussion
This study demonstrated the feasibility of developing a HASU-based stroke specialist training course for paramedics working at the interface of community and hospital care. Management of acute stroke occurs in a ‘time-pressurised’ environment and presents its own unique complexities. Optimal treatment relies upon early recognition by patients (or those surrounding them) of an impairment, rapid assessment by paramedics and identification of stroke as a potential diagnosis, expedient transfer to a HASU, effective handover to HASU clinicians, and prompt review by stroke specialists. Paramedics are crucial members of this care pathway as delay or misdiagnosis may result in poor patient outcomes. As such, they require effective training tailored specifically to their learning needs.
Previous educational interventions for paramedics have concentrated on lectures and supervised practice sessions to improve pre-hospital stroke diagnostic accuracy with varying levels of success (Bray et al, 2005; Gordon et al, 2005; Frendl et al, 2009). This study, in contrast, provided paramedics with experiential learning opportunities, along the patient care pathway, in addition to initial didactic tuition, facilitating application of constructive alignment theory to produce a rounded and fit-for-purpose educational experience. It also focused on learning of non-technical skills that are rarely taught in more formal educational environments. The lack of any previous similar educational intervention perhaps identifies the barriers, perceived or real, that occur between pre-hospital teams and specialist hospital disciplines and it was encouraging that 100% of participants found the course to be useful to their learning and training. Thematic analysis of participant feedback also suggested that the provision of training by a hospital-based faculty in a secondary care setting was a feature that made this training programme a success. It served to engender a culture of multi-disciplinary team-working, removing barriers between hospital and pre-hospital teams, and allowed a greater appreciation of the care pathway a patient may follow. Recovery from a stroke is reliant on various complex factors which require the collective skills and combined knowledge of various healthcare professionals. Regulatory and professional bodies have strongly advocated collaborative learning and the concept of ‘interprofessionalism’ as one way of improving patient care. Indeed, the Berwick report on patient safety in the NHS highlighted that ‘collaborative learning through safety and quality improvement networks can be extremely effective and should be encouraged across the NHS’ (Department of Health, 2013).
Thematic analysis also demonstrated that paramedics perceived the most beneficial part of the course to be observation of stroke specialists' clinical assessments of stroke patients, thus helping to refine their own assessments and direct behavioural change for the future. Kirkpatrick described four levels of evaluating training programmes (Level 1: reaction; Level 2: learning; Level 3: behaviour; Level 4: results) (Kirkpatrick et al, 1998). This study pointed towards a potential for providing level 3 change with such educational intervention. Creating and delivering a training programme providing results (level 4) is a challenge, but one that may be achievable through experiential training (Roots et al, 2011; Ross et al, 2015). Further studies are required to assess retention of the skills gained from the course, subsequent attitudinal and behavioural changes and the impact of the course on future practice. This could be achieved by the use of pre- and post-test evaluation and longer term follow up.
The results of these pilot courses are promising, with positive reports from candidates with regard to real-world transferability of skills learnt. The strengths of the learning model employed include the planning of learning objectives relevant and useful to training, and its development by a multi-professional working party comprising educationalists and clinicians with specialist stroke expertise. In addition, the benefits of having the training day structured as a ‘work-shift’ included the varied stimuli for learning and the ability to observe a multidisciplinary team operating in a ‘real-world’ environment. Efforts were taken to achieve standardisation of course structure and this facilitates the format to be transferable to multiple centres. Despite this, variance of clinical caseload on the HASU on the day of course attendance may alter paramedic experience. The combination of quantitative and qualitative evaluation, however, sets the programme apart from previous educational strategies for pre-hospital responders to stroke that have employed a variety of learning modalities in a range of settings (Bray et al, 2005; Gordon et al, 2005; Frendl et al, 2009; Rae et al, 2011; Woodward et al, 2013; Advanced Stroke Life Support, 2016; Acute Stroke Online, 2016).
Limitations
The generalisability of the findings of the study, however, is limited by self-reporting bias, small sample size, a lack of formal post-course debrief and/or assessment of the participants' understanding and performance. However, self-efficacy rating is based on the principle of motivation theory, where individuals have a relatively good understanding of their own abilities and weaknesses, and a learner's rating has a good correlation with real world ability (Bandura, 1997). A significant challenge to this study was of a logistic nature, since scheduling study days for HASU staff and paramedics is difficult to coordinate. Nonetheless, this initiative was feasible in the context of a busy acute NHS Foundation Trust.
Conclusions
Given the crucial role paramedics play in the hyperacute stroke care pathway, where ‘time is brain’, it is important that pre-hospital providers are afforded the same training opportunities as HASU-based clinicians. This study demonstrated an experiential hyperacute stroke educational programme for paramedics to be feasible and have perceived learning benefits for the participants. Further studies in other centres are needed to assess reproducibility and, in view of the standardised approach, multi-centre studies could be undertaken. Although this study took place on a HASU, similar learning opportunities could be offered in a wide variety of acute healthcare settings, offering allied learning opportunities to pre-hospital providers.