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Background Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects. Methods Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge’s g ) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/Function , Activity , and Participation levels of the International Classification of Functioning. Results Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects ( g  = 0.46; 95% CI: 0.33–0.59, p  < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function ( g  = 0.41; 95% CI: 0.28–0.55; p  < 0.01) and Activity outcomes ( g  = 0.47; 95% CI: 0.34–0.60, p  < 0.01), while Participation outcomes failed to reach significance ( g  = 0.38; 95% CI: -0.29-1.04, p  = 0.27). Superior benefits for Body Structure/Function ( g  = 0.56) and Activity outcomes ( g  = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results ( k  = 4) suggested small to medium effects for cognitive outcomes ( g  = 0.41; 95% CI: 0.28–0.55; p  < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury. Conclusion VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.

Background Virtual reality technologies show potential as effective rehabilitation tools following neuro-trauma. In particular, the Elements system, involving customized surface computing and tangible interfaces, produces strong treatment effects for upper-limb and cognitive function following traumatic brain injury. The present study evaluated the efficacy of Elements as a virtual rehabilitation approach for stroke survivors. Methods Twenty-one adults (42–94 years old) with sub-acute stroke were randomized to four weeks of Elements virtual rehabilitation (three weekly 30–40 min sessions) combined with treatment as usual (conventional occupational and physiotherapy) or to treatment as usual alone. Upper-limb skill (Box and Blocks Test), cognition (Montreal Cognitive Assessment and selected CogState subtests), and everyday participation (Neurobehavioral Functioning Inventory) were examined before and after inpatient training, and one-month later. Results Effect sizes for the experimental group ( d  = 1.05–2.51) were larger compared with controls ( d  = 0.11–0.86), with Elements training showing statistically greater improvements in motor function of the most affected hand ( p  = 0.008), and general intellectual status and executive function ( p  ≤ 0.001). Proportional recovery was two- to three-fold greater than control participants, with superior transfer to everyday motor, cognitive, and communication behaviors. All gains were maintained at follow-up. Conclusion A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke. The magnitude of training effects, maintenance of gains at follow-up, and generalization to daily activities provide compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner. Trial registration this pilot study was not registered.

Early and accurate identification of factors that predict post-stroke cognitive outcome is important to set realistic targets for rehabilitation and to guide patients and their families accordingly. However, behavioral measures of cognition are difficult to obtain in the acute phase of recovery due to clinical factors (e.g. fatigue) and functional barriers (e.g. language deficits). The aim of the current study was to test whether single channel wireless EEG data obtained acutely following stroke could predict longer-term cognitive function. Resting state Relative Power (RP) of delta, theta, alpha, beta, delta/alpha ratio (DAR), and delta/theta ratio (DTR) were obtained from a single electrode over FP1 in 24 participants within 72 hours of a first-ever stroke. The Montreal Cognitive Assessment (MoCA) was administered at 90-days post-stroke. Correlation and regression analyses were completed to identify relationships between 90-day cognitive function and electrophysiological data, neurological status, and demographic characteristics at admission. Four acute qEEG indices demonstrated moderate to high correlations with 90-day MoCA scores: DTR (r = -0.57, p = 0.01), RP theta (r = 0.50, p = 0.01), RP delta (r = -0.47, p = 0.02), and DAR (r = -0.45, p = 0.03). Acute DTR (b = -0.36, p < 0.05) and stroke severity on admission (b = -0.63, p < 0.01) were the best linear combination of predictors of MoCA scores 90-days post-stroke, accounting for 75% of variance. Data generated by a single pre-frontal electrode support the prognostic value of acute DAR, and identify DTR as a potential marker of post-stroke cognitive outcome. Use of single channel recording in an acute clinical setting may provide an efficient and valid predictor of cognitive function after stroke.

We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs). In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8–25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2–5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44). Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.

Background Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes. Methods A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE. Results Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses’ attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes. Conclusions Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes. Trial registration PROSPERO CRD42019130446.

Background Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury-respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. Methods This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. Results There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18-0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04-0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61-9.45), physiotherapy OR 2.17 (95% CI 1.52-3.11), ICU doctor OR 6.13 (95% CI 3.94-9.55), ICU liaison OR 55.75 (95% CI 17.48-177.75), pain team OR 8.15 (95% CI 5.52 --12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64-3.94) and regional analgesia OR 8.8 (95% CI 3.39-22.79), incentive spirometry OR 8.3 (95% CI 4.49-15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43-39.2) in the intervention group compared to the control group in the post- period. Conclusion The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. Trial registration ANZCTR: ACTRN12618001548224, approved 17/09/2018

Background In the context of expanding digital health tools, the health system is ready for Learning Health System (LHS) models. These models, with proper governance and stakeholder engagement, enable the integration of digital infrastructure to provide feedback to all relevant parties including clinicians and consumers on performance against best practice standards, as well as fostering innovation and aligning healthcare with patient needs. The LHS literature primarily includes opinion or consensus-based frameworks and lacks validation or evidence of benefit. Our aim was to outline a rigorously codesigned, evidence-based LHS framework and present a national case study of an LHS-aligned national stroke program that has delivered clinical benefit. Main text Current core components of a LHS involve capturing evidence from communities and stakeholders (quadrant 1), integrating evidence from research findings (quadrant 2), leveraging evidence from data and practice (quadrant 3), and generating evidence from implementation (quadrant 4) for iterative system-level improvement. The Australian Stroke program was selected as the case study as it provides an exemplar of how an iterative LHS works in practice at a national level encompassing and integrating evidence from all four LHS quadrants. Using this case study, we demonstrate how to apply evidence-based processes to healthcare improvement and embed real-world research for optimising healthcare improvement. We emphasize the transition from research as an endpoint, to research as an enabler and a solution for impact in healthcare improvement. Conclusions The Australian Stroke program has nationally improved stroke care since 2007, showcasing the value of integrated LHS-aligned approaches for tangible impact on outcomes. This LHS case study is a practical example for other health conditions and settings to follow suit.

Background Keeping best practice guidelines up-to-date with rapidly emerging research evidence is challenging. ‘Living guidelines’ approaches enable continual incorporation of new research, assisting healthcare professionals to apply the latest evidence to their clinical practice. However, information about how living guidelines are developed, maintained and applied is limited. The Stroke Foundation in Australia was one of the first organisations to apply living guideline development methods for their Living Stroke Guidelines (LSGs), presenting a unique opportunity to evaluate the process and impact of this novel approach. Methods A mixed-methods study was conducted to understand the experience of LSGs developers and end-users. We used thematic analysis of one-on-one semi-structured interview and online survey data to determine the feasibility, acceptability, and facilitators and barriers of the LSGs. Website analytics data were also reviewed to understand usage. Results Overall, the living guidelines approach was both feasible and acceptable to developers and users. Facilitators to use included collaboration with multidisciplinary clinicians and stroke survivors or carers. Increased workload for developers, workload unpredictability, and limited information sharing, and interoperability of technological platforms were identified as barriers. Users indicated increased trust in the LSGs (69%), likelihood of following the LSGs (66%), and frequency of access (58%), compared with previous static versions. Web analytics data showed individual access by 16,517 users in 2016 rising to 53,154 users in 2020, a threefold increase. There was also a fourfold increase in unique LSG pageviews from 2016 to 2020. Conclusions This study, the first evaluation of living guidelines, demonstrates that this approach to stroke guideline development is feasible and acceptable, that these approaches may add value to developers and users, and may increase guideline use. Future evaluations should be embedded along with guideline implementation to capture data prospectively.

Background Variation in hospital stroke care is problematic. The Quality in Acute Stroke (QASC) Australia trial demonstrated reductions in death and disability through supported implementation of nurse-led, evidence-based protocols to manage fever, hyperglycaemia (sugar) and swallowing (FeSS Protocols) following stroke. Subsequently, a pre-test/post-test study was conducted in acute stroke wards in 64 hospitals in 17 European countries to evaluate upscale of the FeSS Protocols. Implementation across countries was underpinned by a cascading facilitation framework of multi-stakeholder support involving academic partners and a not-for-profit health organisation, the Angels Initiative (the industry partner), that operates to promote evidence-based treatments in stroke centres. .We report here an a priori qualitative process evaluation undertaken to identify factors that influenced international implementation of the FeSS Protocols using a cascading facilitation framework. Methods The sampling frame for interviews was: (1) Executives/Steering Committee members, consisting of academics, the Angels Initiative and senior project team, (2) Angel Team leaders (managers of Angel Consultants), (3) Angel Consultants (responsible for assisting facilitation of FeSS Protocols into multiple hospitals) and (4) Country Co-ordinators (senior stroke nurses with country and hospital-level responsibilities for facilitating the introduction of the FeSS Protocols). A semi-structured interview elicited participant views on the factorsthat influenced engagement of stakeholders with the project and preparation for and implementation of the FeSS Protocol upscale. Interviews were recorded, transcribed verbatim and analysed inductively within NVivo. Results Individual ( n  = 13) and three group interviews (3 participants in each group) were undertaken. Three main themes with sub-themes were identified that represented key factors influencing upscale: (1) readiness for change (sub-themes: negotiating expectations; intervention feasible and acceptable; shared goal of evidence-based stroke management); (2) roles and relationships (sub-themes: defining and establishing roles; harnessing nurse champions) and (3) managing multiple changes (sub-themes: accommodating and responding to variation; more than clinical change; multi-layered communication framework) . Conclusion A cascading facilitation model involving a partnership between evidence producers (academic partners), knowledge brokers (industry partner, Angels Initiative) and evidence adopters (stroke clinicians) overcame multiple challenges involved in international evidence translation. Capacity to manage, negotiate and adapt to multi-level changes and strategic engagement of different stakeholders supported adoption of nurse-initiated stroke protocols within Europe. This model has promise for other large-scale evidence translation programs.

Background Non-communicable diseases (NCDs) are a major global health and economic burden. Precision medicine has merged as a promising approach for treating NCDs by tailoring health interventions to individual profiles. Despite rapid advances, its effective implementation remains slow. This systematic review aimed to examine the implementation landscape for delivering precision medicine interventions, services, or programs for NCDs, focusing on barriers, facilitators, strategies, and outcomes. Methods Comprehensive searches were performed in PubMed, Embase, CINAHL, and Web of Science until November 2024. The search strategy comprised of four key concepts, i.e. precision medicine, NCDs, implementation, and public health. Articles published from 2014 onwards were included. Extracted data included study characteristics, populations, precision medicine intervention details, and information related to implementation. Relevant data were coded to implementation science frameworks and taxonomies. These included the updated Consolidated Framework for Implementation Research (CFIR 2.0), Expert Recommendations for Implementing Change (ERIC), and Proctor’s outcomes framework. The QuADs tool was used to assess the risk of bias of included studies. Results A total of 10,039 records were identified, with 8,684 abstracts and 463 full texts screened. Of these, 68 studies met the inclusion criteria. While 64 studies reported implementation determinants [i.e. barriers ( n  = 61) and/or facilitators ( n  = 40)], approximately two-thirds proposed or implemented strategies that were primarily based on intuition. Key barriers identified included ‘access to knowledge and information’ ( n  = 34) and ‘work infrastructure’ ( n  = 21) within the Inner Setting, and ‘financing’ ( n  = 20) within the Outer Setting. While financial burdens were clearly attributed to patients and healthcare settings, there was less clarity and strategic direction regarding potential funding sources to support implementation strategies. Implementation Outcomes were reported in 46 instances, with Adoption being the most frequent. Service Outcomes, particularly Effectiveness, were generally positive, as were patient outcomes, primarily, mortality and morbidity. Conclusion Despite growing interest in precision medicine for treating NCDs, implementation evidence remains theoretically fragmented, making it difficult to identify implementation success patterns. Future efforts adopting targeted strategies and robust outcome evaluation, guided by implementation science, are needed to support effective integration of precision medicine into routine healthcare.