IMPORTANT, PLEASE READ CAREFULLY

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1
IMPORTANT, PLEASE READ CAREFULLY
• This is an example of an assessment that received a high-range mark (a High Distinction).
• This is a summary of a Cochrane Review used in 2019 and is NOT one of the three reviews that can be used in 2020.
• This is not a source document and cannot be used as a reference. No information should be copied from this assessment.
• This assessment has been marked in TURNITIN. Therefore, any information copied from this report and submitted through TURNITIN will be captured and could result in a serious accusation of academic misconduct or plagiarism.
• NOTE: the requirements for this assessment have changed since last year and there are differences such as word count which has increased this year.
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1. Background
   In 2015-16, stroke resulted in over 37,000 hospitalisations in Australia (Australian Institute of Health and Welfare, 2018). After a stroke, very early mobilisation (VEM) is utilised in some stroke units and recommended in some clinical guidelines. However, it is unclear if this practice of getting patients up and out of bed so early directly improves outcomes.
   As a student nurse, I found this topic relevant to me as it will assist me in my future practice. If I was to care for a person who has just had a stroke, I would be able to utilise the evidence in this review to inform my decisions on their care. This would ensure that I am doing my best to ensure my patient recovers well and survives after their stroke.
2. Objectives
   This review aims to determine if, after a stroke, outcomes are better for patients who mobilise within 48 hours (VEM) after the onset of symptoms as opposed to mobilisation after 48 hours (usual care).
3. Interventions
   The main intervention in this review is very early mobilisation (VEM). VEM is defined as mobilising activities occurring within 48 hours after the onset of stroke symptoms. On average, the VEM group began mobilising 18.5 hours after their stroke. Mobilisation activities could be delivered by any member of staff on the stroke ward and can include sitting out of bed, standing, walking, and getting on and off the toilet.
   The primary outcomes were death or a poor outcome. A poor outcome was defined as the patient remaining dependent or requiring care in a nursing home or hospital. The primary outcome was measured at a scheduled follow-up and at a three-month follow-up.
4. Results
   Nine randomised controlled trials were included in this review. These trials all began VEM within 48 hours yet used various approaches to mobilising, including differing durations and intensities.
   Eight of the nine trials had primary outcome data at the end of scheduled follow-up. This data suggested that for death or a poor outcome (primary outcomes) there was found to be no significant difference between VEM and delayed mobilisation.
   The largest trial, with 80% of the review’s participants, found at the three-month follow-up an increased risk of death or remaining dependent. This trial suggested that shorter, more frequent episodes of mobilisation may be associated with better outcomes.
   For the VEM group of participants there was found to be some low-quality evidence of higher ADL scores and shorter stays in hospital. The quality of this evidence is said to be low as the data was less reliable and likely to be biased.
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5. Conclusions
   Survival and recovery after a stroke were found to be not improved by VEM. There is some low-quality evidence of VEM shortening the participant’s stay in hospital. However, in the largest trial, it was suggested that there may be an increased risk of death or disability in mobilising within 24 hours of symptoms. The authors concluded that there needs to be more research around this potential risk and described other reviews carried out more recently that came to similar conclusions: that VEM before 24 hours provided no benefit to outcomes.
   Looking at the results of the review, I agree with the authors conclusions of there being no significant difference between the VEM group and the usual care group. I also noted that there could be a potential for more research around whether mobilisation around 24 hours would be most beneficial for recovery from stroke.
6. Implications for practice
   Nurses are directly involved in the recovery of patients who have had a stroke through planning and implementing their care. By now being empowered with the knowledge that mobilising a patient within 24 hours after a stroke may be of no benefit, and potentially cause harm, that practice can be avoided.
   This review contributes to evidenced-based practice by showing that an intervention currently in practice is not supported by the data. Very early mobilisation that is recommended in some stroke recovery guidelines should be reviewed as it does not improve outcomes and could contribute to increased risk of death or dependency.
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   References
   Australian Institute of Health and Welfare. (2018). Australia’s health 2018 (Australia’s health
   series no. 16). Retrieved from https://www.aihw.gov.au/getmedia/7c42913d-295f-4bc9-9c24-4e44eff4a04a/aihw-aus-221.pdf.aspx?inline=true
   Langhorne, P., Collier, J. M., Bate, P. J., Thuy, M. N. T., & Bernhardt, J. (2018). Very early
   versus delayed mobilisation after stroke (Review). Cochrane Database of Systematic Reviews, 2018(10), 1-71. doi: 10.1002/14651858.CD006187.pub3.