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BackgroundDigital technologies such as mobile apps and robotics have the potential to involve stroke patients better in the care process and to promote self-management. However, barriers exist that constrain the adoption and acceptance of technology in clinical practice. Examples of barriers are privacy concerns, challenges regarding usability, and the perception that there is no need for health-related technology. To address these barriers, co-design can be used to enable patients to reflect on their experiences of a service and to tailor digital technologies to the needs and preferences of end users regarding content and usability. ObjectiveThis study aims to explore the perspectives of stroke patients toward how digital health technology could support self-management regarding health and well-being, as well as integrated stroke care. MethodsA qualitative study was conducted to understand patient perspectives. Data were collected in co-design sessions during the ValueCare study. Patients from a Dutch hospital who experienced an ischemic stroke (n=36) within the past 18 months were invited to participate. Data collection took place between December 2020 and April 2021 via one-to-one telephone interviews. A short self-report questionnaire was used to collect data on sociodemographics, disease-specific information, and technology use. All interviews were audio-taped and transcribed verbatim. The interview data were analyzed using a thematic approach. ResultsPatients held mixed attitudes toward digital health technologies. Some patients viewed digital technology as a convenient product or service, while others expressed no desire or need to use technology for self-management or care. Digital features suggested by stroke patients included (1) information about the causes of stroke, medication, prognosis, and follow-up care; (2) an online library with information regarding stroke-related health and care issues; (3) a personal health record by which patients can retrieve and manage their own health information; and (4) online rehabilitation support to empower patients to exercise at home. Regarding the user interface of future digital health technology, patients emphasized the need for easy-to-use and simple designs. ConclusionsStroke patients mentioned credible health information, an online library with stroke-related health and care information, a personal health record, and online rehabilitation support as the main features to include in future digital health technologies. We recommend that developers and designers of digital health for stroke care listen to the “voice of the stroke patients” regarding both functionality and the characteristics of the interface. International Registered Report Identifier (IRRID)RR2-10.1186/s12877-022-03333-8

Background: Action research (AR) starts with an existing practical situation with which there is a concern or potential for improvement. It seeks transformative change through the simultaneous process of doing research and undertaking actions, both of which are linked together by a critical reflective process. It simultaneously allows one to systematically investigate a given social situation while promoting democratic change and collaborative participation. AR approaches have been used for many years in business management and education. More recently, AR has become an increasingly popular method of inquiry in healthcare, particularly in nursing, to investigate professional practice while simultaneously; introducing innovations; planning and undertaking action; and evaluating new ideas. The overall goal is to augment collaboration whilst improving the patient experience and outcomes. Methods: The Arksey and O'Malley methodology framework will be used to guide this scoping review process: stage 1 will identify the research questions; the eligibility criteria and search strategy will be defined in stage 2; studies will then be selected in stage 3; data will be extracted and charted from these included studies in stage 4; stage 5 involves aggregating and summarising these results along with criteria relevant for health professionals and policy-makers. An optional consultation (stage 6) exercise may potentially be included. Conclusion: This scoping review will comprehensively map the evidence on the use of AR methodology by healthcare professionals and in healthcare team settings. It is predicted that the findings will inform researchers in carrying out future AR and highlight gaps in the literature. An article reporting the results of the completed scoping review will be submitted for publication to a scientific journal and presented at relevant national and international conferences.

The aim of this study was to co-create a definition and generic descriptors for person-centred coordinated care for Ireland generated from service users’ narratives. An overarching action research approach was used to engage and empower people to tangibly impact health policy and practice. Through focus groups and a qualitative survey, primary data were collected from a national sample of health services users, caregivers and health care service users’ representative groups. Thematic analysis was used to analyse the data. Three major themes were co-produced as essential care elements. These were: ‘My experience of healthcare’, ‘Care that I am confident in’ and ‘My journey through healthcare’. Through an IPPOSI partner project steering group and their membership groups’ contribution, these themes were further refined into a definition of person-centred coordinated care and nineteen related generic descriptors. Key findings demonstrate that within complex, fragmented healthcare systems, the subjective expectations of service users should be integrated into care delivery, with a scaffolding of services to meet service users’ needs between care settings and disciplines and over time.

Abstract Background A major healthcare reform agenda in Ireland is underway which underpins the establishment of a series of National Clinical Programmes (NCPs), which aim to take an evidence based approach to improve quality, access and value. The current study aimed to determine the enablers and barriers to implementation of the NCPs. Methods A qualitative methodology advocated by the Medical Research Council (MRC) framework on conducting process evaluations of complex interventions guided this research. Purposive sampling techniques were used to recruit participants from seven NCPs across both acute and chronic healthcare domains, comprised of orthopaedics, rheumatology, elective surgery, emergency medicine, paediatrics, diabetes and chronic obstructive pulmonary disease. A total of 33 participants were interviewed using a semi-structured interview guide. Participants included current and previous Clinical Leads, Programme Managers, Health Service Executive management, hospital Chief Executive Officers, representatives of General Practice, and a Nursing and a Patient representative. Thematic analyses was conducted. Results A range of factors of different combinations and co-occurrence were highlighted across a total of six themes, including (i) positive leadership, governance and clinical networks of the NCPs, (ii) the political and social context in which the NCPs operate, (iii) constraints on resources, (iv) a passive attitudinal resistance to change borne from poor consultation and communication, (v) lack of data and information technology, (vi) forces outside of the NCPs such as the general practitioner contract thwarting change of the model of care. Conclusions The MRC framework proved a useful tool to conduct this process evaluation. Results from this research provide real world experiences and insight from the people charged with implementing large-scale health system improvement initiatives. The findings highlight the need for measured responses that acknowledge both direct and non-direct challenges and opportunities for successful change. Combined, it is recommended that these elements be considered in the planning and implementation of large-scale initiatives across healthcare delivery systems, both in Ireland and internationally.

Introduction: Reorganisation of healthcare services into clinical networks has emerged in recent years as a mechanism to improve patient outcomes. In 2014, an International Working Group Report recommended the cessation of surgery in Northern Ireland (NI) for children with Congenital Heart Disease (CHD). This resulted in children from NI travelling to Great Britain (GB) to receive life-saving surgical intervention, a significant risk to the child and at great cost to the health services and families. The group made a number of recommendations that included the creation of an All-Island CHD Network to enable the CHD services in NI and Republic of Ireland (ROI) collaborate with each other and work as a single Network to achieve essential national and international standards for CHD service provision. Objectives: To develop an All-Island Congenital Heart Disease (CHD) Network to provide high quality and timely access to specialist cardiac services for all children and young people on the island of Ireland. The core objectives of the All-Island Congenital Heart Disease (CHD) Network are: a) Appropriate CHD treatment for all children and young people on the island of Ireland as close to home as deemed appropriate. b) Timely access to quality treatment through the creation of a single waitlist that is aligned to international wait times. c) Provision of a safe and sustainable model that serves the needs of children and families into the future. d) Development of a research and innovation hub that delivers best practice solutions utilising a unique genotype on an all-island approach. Methods: A framework for an all island clinical network for congenital heart disease was developed to manage the all-island service delivery model. This built on existing services and drew them together in a network of care which is service user focused and locally responsive. The basic concepts of the network are of partnership, service integration and formal arrangements. The network consists of linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, to ensure equitable provision of high quality, clinically effective services. Results: To date, all NI Cardiac Catheterisations are carried out in ROI. In addition, all NI emergency and urgent surgical cases have been transferred to ROI, thereby eliminating the need for children and families to travel to Great Britain to have their surgery performed which resulted in a negative experience for families. During 2018, it is planned to commence the transfer of elective surgical patients to the ROI waiting list, with the plan that there will be an all-island surgical waiting list in 2019. The Network model of care includes the development of services in regional centres, implementation of an all island CHD research strategy and the development of a joint training and education programme for health care professionals. Conclusions: The all-island CHD Network is a linked group of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, to ensure equitable provision of high quality, clinically effective services to this complex cohort of patients

Introduction: Socially excluded individuals have higher morbidity and mortality, use a disproportionate amount of healthcare resources and generate a large volume of potentially preventable healthcare and other costs compared to more privileged individuals. Through a person-centred, whole-system and multi-disciplinary approach to care delivery, integrated care improves care for people with complex needs who are likely to have poor outcomes. Homeless and other socially excluded individuals frequently need the input of multiple health and social care providers. The rehabilitation needs of these individuals have not been explored previously and this projects aim was to establish a baseline of need for this cohort. Design, subjects and setting: A prospective cohort study of cases presenting for discussion at an inclusion health multidisciplinary team meeting in an urban homeless service. Methods: All cases discussed at the inclusion health MDT were studied to identify demographics, inclusion health and rehabilitative needs over a 4 month period. Results: 97 cases were studied over the 4-month period. 66 (68%) were male and 31 (32%) were female. 15 (15%) were over 60 and 82 (85%) were under 60 (age range 18-80). The inclusion health needs of this population are diverse and complex. 50% of cases discussed were considered to have rehabilitation needs. 37% had a physical impairment the most common causes of which were fractures and chronic leg ulcers mainly in intravenous drug users and chronic alcoholics. 42% were considered to have a cognitive impairment. The aetiology of cognitive impairment was uncertain due to significant comorbidity and increased prevalence of mental health conditions. A history of learning disability was proposed in a number of cases. 20% of cases had both physical and cognitive impairments. 76% of individuals were currently addicted to alcohol or drugs. 63% had mental health needs including severe and enduring mental illnesses, and 71% had a chronic medical condition. Discussion: The inclusion health needs of this population are diverse and complex. A traditional rehabilitation programme would not suit the chaotic lifestyles of these individuals and often access requires a fixed address which none of these individuals have. Conclusion: The results of this study show that the rehabilitative needs of this cohort are significant and are not being met through traditional rehabilitation medicine models of care. Limitations: A detailed analysis of the specifics of the rehabilitative needs was not possible at this stage of the project and efforts are underway to identify a biopsychosocial needs assessment tool that can identify all the needs of individuals. We were also not able to assess if individuals had access to community based general rehabilitation services but it was the view of the MDT that a traditional rehabilitation programme would not suit the chaotic lifestyles of these individuals. Suggestions for future research: Development of innovative ways to assess and provide appropriate services to these individuals.

Background Patient experience is routinely collected in the clinical environment in many different ways throughout various person-provider encounters, but so far limited research focused on understanding the methods of using it to improve the quality of healthcare. This paper presents a protocol for a methodological scoping review examining the methods of obtaining, analysing, reporting, and using patient experience data for quality improvement in rehabilitation settings. Methods The scoping review will be conducted according to the guidelines from the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and the methodological framework by Arksey & O’Malley. A comprehensive search of the literature will be performed using a three-step search strategy: an initial limited search of two databases was already performed and helped to identified relevant key words and index terms. The developed search string will be adapted and applied across four databases. This will be followed by search of the reference lists of selected sources and hand-search relevant data-hubs. Studies with a clear focus on patient experience or feedback collected or used for healthcare improvement in rehabilitation context, will be included. A data extraction framework will be developed and piloted to guide the literature screening and data charting. Qualitative content analysis will be employed to address research questions and the results will be presented – beside the descriptive format - as a map of data in chart and tabular formats. Conclusions This scoping review will show the extent and scope of the literature on the applied methods of collecting, communicating, and using patient experience for quality improvement in post-acute rehabilitation settings and will evaluate and map the evidence on these topics. The findings will inform a research project entitled “An exploration into the use of patient experience to inform improvement in a National Rehabilitation Hospital”.

Abstract Background Globally, road traffic collisions (RTCs) are a common cause of death and disability. Although many countries, including Ireland, have road safety and trauma strategies, the impact on rehabilitation services is unclear. This study explores how admissions with RTC related injuries to a rehabilitation facility has changed over 5 years and how they contrast to major trauma audit (MTA) serious injury data from the same timeframe. Methods A retrospective review of healthcare records with data abstraction in accordance with best practice was performed. Fisher’s exact test and binary logistic regression were used to determine associations and statistical process control was used to analyse variation. All patients discharged with an International Classification of Diseases (ICD) 10 coded diagnosis of Transport accidents from 2014 to 2018 were included. In addition, serious injury data was abstracted from MTA reports. Results 338 cases were identified. Of these, 173 did not meet the inclusion criteria (readmissions) and were excluded. The total number analyzed was 165. Of these, 121 (73%) were male and 44 (27%) were female and 115 (72%) were under 40 years of age. The majority [128 (78%)] had traumatic brain injuries (TBI), 33 (20%) had traumatic spinal cord injuries and 4 (2.4%) had traumatic amputation The numbers varied over the time period of the study but showed normal variation and not special cause variation which suggests no significant impact of policy in the time frame. There was a large discrepancy between the number of severe TBIs reported in the MTA reports and the numbers admitted with RTC related TBI to the National Rehabilitation University Hospital (NRH). This suggests there may be many people not accessing the specialist rehabilitation services they require. Conclusion Data linkage between administrative and health datasets does not currently exist but offers huge potential for understanding the trauma and rehabilitation ecosystem in detail. This is required to better understand the impact of strategy and policy.

Abstract Background The brain–computer interface (BCI) race at the Cybathlon championship, for people with disabilities, challenges teams (BCI researchers, developers and pilots with spinal cord injury) to control an avatar on a virtual racetrack without movement. Here we describe the training regime and results of the Ulster University BCI Team pilot who has tetraplegia and was trained to use an electroencephalography (EEG)-based BCI intermittently over 10 years, to compete in three Cybathlon events. Methods A multi-class, multiple binary classifier framework was used to decode three kinesthetically imagined movements (motor imagery of left arm, right arm, and feet), and relaxed state. Three game paradigms were used for training i.e., NeuroSensi, Triad, and Cybathlon Race: BrainDriver. An evaluation of the pilot’s performance is presented for two Cybathlon competition training periods—spanning 20 sessions over 5 weeks prior to the 2019 competition, and 25 sessions over 5 weeks in the run up to the 2020 competition. Results Having participated in BCI training in 2009 and competed in Cybathlon 2016, the experienced pilot achieved high two-class accuracy on all class pairs when training began in 2019 (decoding accuracy > 90%, resulting in efficient NeuroSensi and Triad game control). The BrainDriver performance (i.e., Cybathlon race completion time) improved significantly during the training period, leading up to the competition day, ranging from 274–156 s (255 ± 24 s to 191 ± 14 s mean ± std), over 17 days (10 sessions) in 2019, and from 230–168 s (214 ± 14 s to 181 ± 4 s), over 18 days (13 sessions) in 2020. However, on both competition occasions, towards the race date, the performance deteriorated significantly. Conclusions The training regime and framework applied were highly effective in achieving competitive race completion times. The BCI framework did not cope with significant deviation in electroencephalography (EEG) observed in the sessions occurring shortly before and during the race day. Changes in cognitive state as a result of stress, arousal level, and fatigue, associated with the competition challenge and performance pressure, were likely contributing factors to the non-stationary effects that resulted in the BCI and pilot achieving suboptimal performance on race day. Trial registration not registered

Abstract Background The coronavirus 2019 pandemic placed unprecedented pressures on healthcare services and magnified ethical dilemmas related to how resources should be allocated. These resources include, among others, personal protective equipment, personnel, life-saving equipment, and vaccines. Decision-makers have therefore sought ethical decision-making tools so that resources are distributed both swiftly and equitably. To support the development of such a decision-making tool, a systematic review of the literature on relevant ethical values and principles was undertaken. The aim of this review was to identify ethical values and principles in the literature which relate to the equitable allocation of resources in response to an acute public health threat, such as a pandemic. Methods A rapid systematic review was conducted using MEDLINE, EMBASE, Google Scholar, LitCOVID and relevant reference lists. The time period of the search was January 2000 to 6th April 2020, and the search was restricted to human studies. January 2000 was selected as a start date as the aim was to capture ethical values and principles within acute public health threat situations. No restrictions were made with regard to language. Ethical values and principles were extracted and examined thematically. Results A total of 1,618 articles were identified. After screening and application of eligibility criteria, 169 papers were included in the thematic synthesis. The most commonly mentioned ethical values and principles were: Equity, reciprocity, transparency, justice, duty to care, liberty, utility, stewardship, trust and proportionality. In some cases, ethical principles were conflicting, for example, Protection of the Public from Harm and Liberty. Conclusions Allocation of resources in response to acute public health threats is challenging and must be simultaneously guided by many ethical principles and values. Ethical decision-making strategies and the prioritisation of different principles and values needs to be discussed with the public in order to prepare for future public health threats. An evidence-based tool to guide decision-makers in making difficult decisions is required. The equitable allocation of resources in response to an acute public health threat is challenging, and many ethical principles may be applied simultaneously. An evidence-based tool to support difficult decisions would be helpful to guide decision-makers.

Background Complexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.Objectives The aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision.Methods This scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O’Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).Results 2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused.Discussion Complexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies.Conclusion The study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area.Registration The scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).

Introduction: Primary care has the potential to address the challenges associated with the rise of chronic conditions and an aging population; however, General Practitioners are increasingly struggling to meet these demands. Fundamental to the provision of high-quality primary care is the role of the general practice nurse, who typically provides a wide range of services. Examining the current role of general practice nurses must be a first step to determining their educational needs for enhancing their long-term future contribution to primary care.Method: A survey design was used to explore the role of general practice nurses. A purposeful sample of general practice nurses (n=40) was undertaken between April and June 2019. Data were analysed using the Statistical Package for Social Science (SPSS V 25.0. Armonk, NY: IBM).Results: General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, and respiratory and cardiovascular issues. Challenges to future enhancement of the role were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources.Discussion: General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses and to attract future nurses into this important area. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Introduction: Co-design has been identified as a participatory method to create person-centred integrated healthcare services that align with older people’s values and lived experiences. Description: Existing guidelines on conducting co-design primarily focus on in-person methods with limited guidance on using digital methods to collect data. This gap in knowledge is particularly pertinent when co-designing with older people who can experience challenges with digital literacy and accessibility. This article uses the exemplar of a pilot site within a European co-design research project, aiming to create digital health technology to support integrated care, to describe the steps and considerations required when collaborating with older people in an online environment. Focus groups and one-to-one interviews were conducted utilising digital mediums of teleconferencing and telephone calls to engage and collaborate with older people. Discussion: Several preparatory steps are required to effectively bridge the digital divide and conduct co-design with older people including engaging gatekeepers, relationship and trust-building, assessing digital literacy levels, education and providing technological support. Conclusion: This article highlights the steps and considerations that researchers should be aware of when embarking on co-designing with older people in a digital setting. The authors describe their methods that promotes inclusivity and the empowerment of older people as equal collaborators in the research process. The co-design approach and recommendations can be applied to various research settings and wider areas of integrated care with this population.

Introduction: An in-depth understanding of patient perspectives contributes to high-quality, value-based health care. The aim of this study was to explore the values, needs, and preferences of stroke patients across the continuum of care. Methods: We performed a qualitative study, as part of the larger ValueCare study, involving 36 patients who have had ischemic stroke within the past 18 months at the time of recruitment. Data were collected between December 2020 and April 2021 via one-to-one telephone interviews. All interviews were audio-taped and transcribed verbatim. The interview data were analysed using a thematic approach. Results: The analysis resulted in five themes: (1) patients’ values about health care, (2) information and education, (3) psychological support, (4) follow-up care, and (5) continuity and coordination of care. Patients valued a compassionate professional who is responsive to their needs. Furthermore, patients indicated a need for tailored health information, psychosocial services, pro-active follow-up care and improved coordination of care. Discussion and conclusion: Stroke patients emphasised the need for tailored information, psychological support, pro-active follow-up, and improved coordination of care. It is advocated for professionals to use a value-based care approach in order to satisfy the individual needs of patients with regard to information, communication, and follow-up care.

Background: Digital health technology has been identified as a valuable tool to support older adults with frailty needs in their home setting. Despite the numerous technologies and evaluations of these innovations, a synthesis of the older person and family caregivers’ experience using technology for support self-management has not been conducted to date. Methods and analysis: A systematic review and meta-ethnography will be conducted in accordance with the PRISMA and eMERGe reporting guidelines. Four peer-reviewed empirical evidence databases will be searched (Medline (Ovid), CINAHL, EMBASE, PsycINFO) using a defined search strategy. Studies containing qualitative data on the experiences of older people or family caregivers of using digital health technology to support frailty care will be included. Covidence software will be used to screen studies and extract data. The Critical Appraisal Skills Programme (CASP) checklist for qualitative research will be used by two independent reviewers to appraise all included papers. A meta-ethnography will be undertaken in accordance with the seven-phase method described by Noblit and Hare: (1) Getting started, (2) Deciding what is relevant to the initial interest, (3) Reading the studies, (4) Determining how the studies are related, (5) Translating the studies into one another, (6) Synthesizing translations and (7) Expressing the synthesis. Discussion: To the best of our knowledge, this will be the first systematic review to integrate and synthesize the findings of qualitative studies of older citizens’ experience of digital health technology. The findings of this meta-ethnography will endeavour to inform future research, policy and clinical practice. In particular, the results will help to inform the design of future digital health technology to meet the needs of older adults. PROSPERO registration number: CRD42022314608.

Abstract Background Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP. Aim To explore the role of general practice nurses and their interest in becoming an ANP. Design A survey design. Method A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM). Results General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources. Conclusion General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Introduction Despite the use of a wide variety of improvement tools and approaches, healthcare organisations continue to struggle in several key areas. Complexity-informed approaches have the potential to offer health and social care a new paradigm for understanding, designing, implementing and evaluating solutions, yet so far has failed to gain the traction anticipated some years ago. There is a growing need for high quality syntheses of the existing knowledge base in this area and given the diversity of theory and approaches, a scoping review is the best approach to curate this knowledge.Methods A scoping review of relevant literature from January 2000 to present, using the refined Arksey and O’Malley six-stage framework will be conducted. This protocol will follow the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews. A three-step search strategy will be used. An initial search of databases will be undertaken to identify key search terms followed by an analysis of retrieved papers title and abstract text words, and of index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference lists of identified reports and articles will be searched. Authors of primary articles will be contacted and a search for grey material performed. Finally, a complete search strategy of one major database will be included.Ethics and dissemination As this is a scoping review, ethical approval is not required. The results of the scoping review will be published in a peer-reviewed journal and presented at national and international conferences and will guide a large research project investigating teamwork. All data will be stored in accordance with best General Data Protection Regulation practice.Registration This scoping review protocol has been registered with Open Science Framework.

Background: Traditional research approaches are increasingly challenged in healthcare contexts as they produce abstract thinking rather than practical application. In this regard, action research is a growing area of popularity and interest, essentially because of its dual focus on theory and action. However, there is a need for action researchers not only to justify their research approach but also to demonstrate the quality of their empirical studies. Therefore, the authors set out to examine the current status of the quality of extant action research studies in healthcare to encourage improved scholarship in this area. The aim of this scoping review is to identify, explore and map the literature regarding the application of action research in either individual, group or organisational domains in any healthcare context. Methods: The systematic scoping review will search the literature within the databases of CINAHL, PubMed and ABI/Inform within the recent five-year period to investigate the scientific evidence of the quality of action research studies in healthcare contexts. The review will be guided by Arksey and O'Malley’s five mandatory steps, which have been updated and published online by the Joanna Briggs Institute. The review will follow the PRISMA-ScR framework guidelines to ensure the standard of the methodological and reporting approaches are exemplary. Conclusion: This paper outlines the protocol for an exploratory scoping review to systematically and comprehensively map out the evidence as to whether action research studies demonstrate explicitly how the essential factors of a comprehensive framework of action research are upheld. The review will summarise the evidence on the quality of current action research studies in healthcare. It is anticipated that the findings will inform future action researchers in designing studies to ensure the quality of the studies is upheld.

Background: In Ireland, as in many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of chronic disease. Integrated care is an approach to healthcare systems delivery that aims to minimise fragmentation of patient services and improve care continuity. To this end, how best to integrate primary and secondary care is a challenge. This paper aims to undertake a scoping review of empirical work on the integration of primary and secondary care in relation to chronic disease management. Methods: A search was conducted of ‘PubMed’, ‘Cochrane Library’ and ‘Google Scholar’ for papers published between 2009–2019 using Arksey and O’Malley’s framework for conducing scoping reviews. Results: Twenty-two studies were included. These reported research from a wide range of healthcare systems (most commonly UK, Australia, the Netherlands), adopted a range of methodologies (most commonly randomised/non-randomised controlled trials, case studies, qualitative studies) and among patients with a range of chronic conditions (most commonly diabetes, COPD, Parkinson’s disease). No studies reported on interventions to address the needs of whole populations. Interventions to enhance integration included multidisciplinary teams, education of healthcare professionals, and e-health interventions. Among the effectiveness measures reported were improved disease specific outcomes, and cost effectiveness. Conclusion: With healthcare systems increasingly recognising that integrated approaches to patient care can enhance chronic disease management, considerable literature now informs how this can be done. However, most of the research published has focussed on specific diseases and their clinical outcomes. Future research should focus on how such approaches may improve health outcomes for populations as a whole.

Introduction Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may be punctuated by episodes of worsening symptoms, called exacerbations. Acute exacerbations of COPD (AECOPD) are detrimental to clinical outcomes, reduce patient quality of life and often result in hospitalisation and cost for the health system. Improved diagnosis and management of COPD may reduce the incidence of hospitalisation and death among this population. This scoping review aims to identify improvement interventions designed to standardise the hospital care of patients with AECOPD at presentation, admission and discharge, and/or aim to reduce unnecessary admissions/readmissions.Methods The review followed a published protocol based on methodology set out by Arksey and O’Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic database searches for peer-reviewed primary evidence were conducted in Web of Science, EMBASE (Elsevier) and PubMed. Abstract, full-text screening and data extraction were completed independently by a panel of expert reviewers. Data on type of intervention, implementation supports and clinical outcomes were extracted. Findings were grouped by theme and are presented descriptively.Results 21 articles met the inclusion criteria. Eight implemented a clinical intervention bundle at admission and/or discharge; six used a multidisciplinary care pathway; five used coordinated case management and two ran a health coaching intervention with patients.Conclusion The findings indicate that when executed reliably, improvement initiatives are associated with positive outcomes, such as reduction in length of stay, readmissions or use of health resources. Most of the studies reported an improvement in staff compliance with the initiatives and in the patient’s understanding of their disease. Implementation supports varied and included quality improvement methodology, multidisciplinary team engagement, staff education and development of written or in-person delivery of patient information. Consideration of the implementation strategy and methods of support will be necessary to enhance the likelihood of success in any future intervention.

The first Irish National Audit of stroke care by the Irish Heart Foundation (IHF) in 2008 found only one hospital had an acute stroke unit, less than 1% stroke patients got thrombolysis and death from stroke was 19%. The Irish National Stroke Programme (NSP) was set up in 2010 to modernise stroke care in the country and reduce by one the death and disability from stroke each day, through the implementation of international guidelines for management of stroke. The programme appointed joint neurology and geriatric medicine clinical leads, a senior public health doctor and senior stroke nurse as programme manager.NSP produced a Model of Care identifying five key areas for development: Prevention; Emergency Stroke Care; Acute Stroke Unit Care; Community Stroke Care and a stroke register. The NSP established the National Stroke Register (NSR) ,an essential tool to measure effect of implementation of the Model of Care;providing data for planning and resource requirements for individual &national stroke services, evaluation and clinical audits..The programme identified three national KPIs 1) 90% of acute stroke patients admitted to a stroke unit; 2) stroke patients to spend 90% of LOS in a stroke unit;3) a national thrombolysis rate of 12%. The KPIs were agreed nationally by Health service Executive and circulated to all hospital managers. The Stroke Programme identified clinical leads and supported a gap analysis in each acute hospital regarding acute stroke unit care and ability to deliver 24/7delivery of thrombolysis. Through this process key staff vacancies were prioritised and innovative solutions to 24/7 senior assessment ,like telemedicine piloted and supported In 2015 the second Irish National Audit on stroke confirmed the significant progress of the stroke programme whereby 21/27 acute hospitals now had an acute stroke unit and there was better processes of stroke care (Table 1 & 3). The national stroke register also showed significant improvement in KPIs where currently 69.2% of patients are admitted to an acute stroke unit and 11.8 % of patients received intravenous thrombolysis (Table 2). Both the independent IHF audit and national stroke audit also identified ongoing clinical challenges around care of swallow and mood assessment following stroke. The National Stroke Programme has now embarked on writing a funded pragmatic 5 year strategy to ‘make big stroke history’ with a focus on embedding recent high impact medical advances in the key areas of our stroke services ‘acute care and cure’, ‘Prevention’ , ‘restoration to living’ and ‘research and education.’ Table 1 : Irish Heart Foundation Stroke Audits IHF National Stroke Audit 2008 IHF National Stroke Audit 2015 Mortality 19% 14% Stroke Units 1% 85% CT Scanning 24/7 84% 100% Clinlead for Stroke 32% 85% Nurse Specialist 14% 85% Table 2: National stroke Register & KPIs National KPI s for stroke 2013 NSR 2017 NSR 1. Admission to stroke unit 64.1% 69.2% 2. >90% of LOS in stroke unit 57.2% 70.4% 3.Thrombolysis 11.3 11.8% Table 3 Processes of care in natiobnal stroke audits and regsiter Stroke Audit 2008 Stroke Audit 2015 NSR 2017 Swallow Screening 26% 29% 66% Mood Assessment 28% 33% 33% Aspirin within 48hrs 49%* 70% 76%