Perceived risks and benefits

Therapists and nurses associated mobilising patients within 24 hours and at a higher intensity with the risk of doing “too much too soon” (ID 019,

Physiotherapist) and an increase in patient falls as opposed to more direct medical risks. The majority of staff that mentioned medical risks such as changes in blood pressure were nurses and doctors.

“…probably most blood pressure flux [fluctuation] would be the thing that would intuitively concern us if people lost their blood pressure responses and if they stand up and their blood pressure falls then it may extend any deficit and that sort of thing.”

(ID 9, Doctor)

A few nurses believed that if a patient was going to deteriorate, this would happen regardless of them receiving VEM or not. Increased fatigue, “if that counts as risk” (ID 010, Doctor), was linked with an increase in mobilisation of patients. Staff at one hospital had been involved in a study investigating the effects of augmented therapy recalled the recurring fatigue patients allocated to the intervention group experienced.

“…and that was just physio, but they were also timetabled to have OT and if appropriate still having speech therapy. So some of them were actually physically tired.”

(ID 26, Physiotherapist, non-VEM)

Therapists aimed for a balance between rest and activity for patients which may partly explain this concept of “too much too soon”. Rest was seen to have an important role in patient rehabilitation. Increasing the intensity of mobilisation may influence this balance and result in patient exhaustion or “knock the patient back”. Staff did not specify an optimal length of time for mobilisations

such as the sitting in a chair seeing it more dependent on the preference of the individual patient. It was acknowledged that the impact of remaining in one posture for prolonged periods of time may begin to counter any positive effects that being upright may have as the scenario in the following extract explains.

“I know he wants to be sitting but actually it's working against him just now because, because he was so busy fixing everything, when you tried to stand him up he couldn't, he just kept, he was half bent over and whatever so it was around sort of saying to the girls I know he is saying that he wants to be sitting up all the time but actually he needs to go and lie down for a wee while because he needs to get stretched out.”

(ID 19, Physiotherapist, VEM)

On the other hand, risks associated with bed rest were more readily identified by staff and included higher risk of medical complications, a poorer recovery, increased length of acute stay and reducing the patient’s rehabilitation

potential.

“I think that any rehab potential would be just significantly decreased – its just means that they would have progressed in the way that they would have done and if they had not had that earlier input”.

(ID 1, Physiotherapist, VEM)

Again doctors were the only professional group to question this way of thinking believing that it lacked hard evidence.

“Yeah I guess there would be…in the longer term there would be a risk of less mobility and…ehm…contractures and things went on that long but you would suspect that there would be an increased risk of chest infections or DVTs if people well less mobilised yet that is not convincingly proven.”

(ID 9, Doctor)

One team shared their experience of a patient who had a stroke whilst on holiday abroad and had not been mobilised during his acute hospital stay. When the patient was transferred back to Scotland stroke unit staff were horrified that bed rest was still in practice:

“And he found that really stressful, he wanted to get up and do

something. So I just thought that was really interesting, we can't believe somebody being kept in bed for two whole weeks post-stroke.”

(ID 12, Physiotherapist, VEM)

Patient safety was high on the agenda for staff when discussing the mobilisation of acute stroke patients in particular those patients with perceptual or cognitive issues or were agitated. An increase in the number of staff injuries were also connected with increased patient mobilisation if it was not performed correctly.

ID 3: “…there are the ones that are so unsafe to be…you they would be better out of bed but maybe its just not possible…and they try to get up and walk.

ID 4:…because of their perceptual difficulties…we would still get them up, get them out and moving…but it may be getting them up to sit and back to bed because they are safer in bed than in a chair.”

Focus group 1 (ID3 – Nurse, VEM; ID4 – Physiotherapist, VEM)

Two previous studies have revealed conflicting evidence regarding opinions of early mobilisation and stroke type. One study revealed that HCPs had more concern over mobilising patients with a haemorrhage than patients with ischemic stroke,¹⁷⁹ while the other showed that HCP opinion to mobilise early was not influenced by stroke type.¹⁷⁸ The immediate reaction of staff in this study was that their opinion of the VEM would remain the same regardless of stroke type. Nurses and therapists stated that stroke type was often not known at the time they currently mobilise the patient anyway. On further probing staff did go on to state a “little” concern for mobilising haemorrhagic strokes within 24 hours with a potential of further bleed. This didn’t necessarily equate to staff excluding VEM but adopting a more cautious approach to mobilising these

patients for the first time; haemorrhagic stroke patients were viewed to have a more variable clinical presentation than ischaemic strokes and likely to require extra monitoring.

R: “I would say we are still a little more cautious with haemorrhages but um we obviously monitor everybody um, keep an eye but I do think um we are more, more aware.

I: And why do you think that is?

R: I don't know just in case there is a further um, a further haemorrhage, in case anything…gets worse.”

(ID 23, Physiotherapist, non-VEM)

There was strong agreement that if VEM were shown to be effective for a subgroup of patients this would compromise the care of other patients not receiving VEM. The following two extracts shows that this consensus was evident within focus groups (FG5, first extract) and across focus groups (FG 4, second extract) and interviews (PI1, third extract).

ID 19: “I think it's hard to, you know, what we’ve said and what I’ve sort of reported back er to my managers and whatever is that if we, you know, if we use AVERT as a, as an example, if we have a patient in the

interventions group on AVERT then the other patients suffer as a result of that, you know, especially if they are in the higher level groups, you know, because tell all you to deliver what you need to deliver for the trial then somebody else...

ID 20: Is not going to get their session.

ID 19:...you know, gets their session shorter or they just don't get seen that day or whatever um, you know…”

Focus group 5 (ID 19 – Physiotherapist; VEM, ID 20 – Nurse, VEM; ID 21 - Nurse, VEM)

“So if you then feel that you're concentrating more on a certain patient or a certain group of patients, something else has got to give, because you're going to have to drop something else to do that. So at what cost is that going to be?”

(ID 17, Physiotherapist, non-VEM)

“I was very much how would people feel lying across from somebody that's getting loads of attention and like support and things whereas you got it once a day, do you know what I mean, you’d be a bit like mmm”.

(ID 24, Nurse, non-VEM)

The flipside to this argument was that an evidence-base for VEM may actually strengthen the campaign to get patients onto the stroke pathway more quickly.

The focus for staff was to deliver good stroke care whether the patient received VEM or not.

“Um, it’s meant that in general terms, we’re getting people imaged quicker than we would have otherwise, even if they’ve not, um, even if they’re not getting thrombolysis, um, we’re getting people to the stroke

units quicker than we did as well, so, so, it’s, probably is a side benefit – all the patients that aren’t getting thrombolysis or even, aren’t even getting assessed with thrombolysis, are getting a better deal.”

(ID 22, Doctor)

Staff highly valued early rehabilitation and believed that it provided benefits to patients. The same benefits, yet with additive effect, were seen for VEM.

“Ehmm...I guess the quicker they start the quicker they back on their feet which should translate to better functional outcome, shorter hospital stay and less risk of early complications would be the guess.”

(ID 9, Doctor)

This additive effect of VEM may only be observed in subgroups of patient.

“…there are some patients that would very much benefit from it and there’s others that, you know, might not make a huge difference in the overall outcome.”

(ID 30, Occupational Therapist, non-VEM)

One of the most frequently mentioned benefits of VEM was the improvement of the patient’s mood. Staff believed getting patients up provided them with the stimulation of the ward environment and a sense of ‘normality’. It allowed them to engage in their surroundings and if they were sitting up or mobilising more frequently around the ward that would give them more opportunity to interact with other patients. The risks and benefits of VEM as identified by staff are summarised in Table 5-4.

Table 5-4 Perceived risks and benefits of VEM

Perceived benefits of VEM Perceived risk of VEM Perceived risks of bed-rest

• Improve patient mood

• Improve patient confidence

• Improve patient motivation

• Increase interaction between patients

• Stroke extension

• Fluctuation in blood pressure

• Increase in patient falls

• Increase in staff injury

• Impact on service i.e. other patients

• Unrealistic perceptions for patient

• False impression of recovery for families

• Increase risk of immobility related complications;

• Increase length of acute hospital stay

• Reduce rehabilitation potential

• Reduce long term recovery Ranked in order of frequency i.e. improve patient mood was the most frequently reported benefit of VEM