Rehabilitation assessments for patients with stroke in Australian hospitals do not always reflect the patients' rehabilitation requirements

Exploring the content and delivery of feedback facilitation co-interventions: a systematic review

BACKGROUND

Policymakers and researchers recommend supporting the capabilities of feedback recipients to increase the quality of care. There are different ways to support capabilities. We aimed to describe the content and delivery of feedback facilitation interventions delivered alongside audit and feedback within randomised controlled trials.

METHODS

We included papers describing feedback facilitation identified by the latest Cochrane review of audit and feedback. The piloted extraction proforma was based upon a framework to describe intervention content, with additional prompts relating to the identification of influences, selection of improvement actions and consideration of priorities and implications. We describe the content and delivery graphically, statistically and narratively.

RESULTS

We reviewed 146 papers describing 104 feedback facilitation interventions. Across included studies, feedback facilitation contained 26 different implementation strategies. There was a median of three implementation strategies per intervention and evidence that the number of strategies per intervention is increasing. Theory was used in 35 trials, although the precise role of theory was poorly described. Ten studies provided a logic model and six of these described their mechanisms of action. Both the exploration of influences and the selection of improvement actions were described in 46 of the feedback facilitation interventions; we describe who undertook this tailoring work. Exploring dose, there was large variation in duration (15-1800 min), frequency (1 to 42 times) and number of recipients per site (1 to 135). There were important gaps in reporting, but some evidence that reporting is improving over time.

CONCLUSIONS

Heterogeneity in the design of feedback facilitation needs to be considered when assessing the intervention's effectiveness. We describe explicit feedback facilitation choices for future intervention developers based upon choices made to date. We found the Expert Recommendations for Implementing Change to be valuable when describing intervention components, with the potential for some minor clarifications in terms and for greater specificity by intervention providers. Reporting demonstrated extensive gaps which hinder both replication and learning. Feedback facilitation providers are recommended to close reporting gaps that hinder replication. Future work should seek to address the 'opportunity' for improvement activity, defined as factors that lie outside the individual that make care or improvement behaviour possible.

REVIEW REGISTRATION

The study protocol was published at: https://www.protocols.io/private/4DA5DE33B68E11ED9EF70A58A9FEAC02 .

Clinical and functional determinants of appropriate rehabilitation referrals after stroke: a single-center retrospective cohort study

BACKGROUND

Rehabilitation is currently the best available treatment for post-stroke disability. There is, however, great variability in the proportion of patients accessing rehabilitation across high-income countries suggesting that factors not explained by facilities availability or guidelines diversity may intervene in decision-making.

OBJECTIVES

To evaluate which factors are associated with appropriate post-stroke rehabilitation referrals in a tertiary stroke unit setting.

METHODS

Retrospective single-center cohort study including patients admitted to the Stroke Unit of the "Santa Maria della Misericordia" University Hospital, Udine (IT) from January 1st to December 31st, 2019. Information regarding stroke severity (National Institute of Health Stroke Scale), functional assessment (modified Rankin scale [mRS] and Barthel index [BI]), length of hospital stay, and rehabilitation pathway was collected. Outcome was defined as referral to the appropriate rehabilitation pathway. Appropriateness was assessed comparing patient clinical information at discharge against local criteria for intensive vs. extensive rehabilitation. A mixed-linear effect model was built to explore NIHSS, mRS, and BI variation over time. Multivariable logistic regression was used to estimate the adjusted-odds ratio (OR) and 95% confidence interval (CI 95%) of appropriate assignment to rehabilitation pathways.

RESULTS

288 patients were included in the study (age 73.1 years, males 57.9%) and in 75.7%, the rehabilitation pathway assignment was appropriate. NIHSS at discharge was lower compared to admission but no effect of rehabilitation assignment was evident, while mRS scores at discharge and at three months were 2.6 (CI 95% 2.2; 3.0) and 2.1 (CI 95% 1.8; 2.5) higher compared to admission (p < 0.0001). Rehabilitation assignment effect on mRS was time dependent, resulting in an additional - 0.6 (CI 95% - 1.0; - 0.2) lowering at discharge for those appropriately assigned (p = 0.003), with a trend for significance at three months (p = 0.08). BI score was higher at discharge (p < 0.0001), and appropriate assignment was associated with higher scores (p = 0.01). Multivariate analysis showed that the OR of appropriate rehabilitation pathway assignment were reduced by higher mRS (0.60 [CI 95% 0.48; 0.76], p < 0.0001) and increased by higher NIHSS (1.11 [CI 95% 1.04; 1.19], p = 0.001) scores at discharge. The latter finding might be explained by the rehabilitation assessment focus on post-stroke motor symptoms captured by NIHSS.

CONCLUSIONS

Higher mRS and lower NIHSS levels at discharge were independent predictors for inappropriate rehabilitation assignment after stroke in our cohort. These findings may reflect a therapeutic bias toward patients with higher post-stroke disability in a rehabilitation framework heavily tilted on post-stroke motor symptoms.

Assessment of rehabilitation following subarachnoid haemorrhage in China: findings from the Chinese Stroke Center Alliance

BACKGROUND

Rehabilitation improves functional recovery in subarachnoid hemorrhage (SAH) patients, and assessing patients for rehabilitation is the first step in this process. However, little is known about clinical practice in China regarding the assessment and provision of rehabilitation for patients with SAH.

METHODS

To identify patients hospitalized with SAH and to analyze rehabilitation assessment rates, we used data for 11,234 SAH patients admitted to 861 hospitals from the China Stroke Center Alliance from August 2015 to July 2019. We examined factors for rehabilitation assessment and analyzed the relationship between rehabilitation assessment and outcomes in these patients.

RESULTS

Among 11,234 patients with SAH, 6,513 (58.0%) were assessed for rehabilitation. Assessed patients had an increased length of stay (mean ± SD days: 17.3 ± 12.5 versus 11.6 ± 10.5, P = 49.4), a higher Glasgow Coma Scale (GCS) score on admission (mean ± SD GCS score: 12.3 ± 3.8 versus 11.8 ± 4.4, P = 12.2), and were more likely to be admitted to the stroke unit (19.6% versus 13.8%, P = 15.6). In multivariable analysis, factors associated with an increased likelihood of a rehabilitation assessment (p < 0.05) included a longer length of stay (odds ratio [OR], 1.04; 95% confidence interval (CI), 1.04 to 1.05) and care such as dysphagia screening (OR, 1.88; 95% CI, 1.73 to 2.04), DVT prophylaxis (OR, 1.56; 95% CI, 1.41 to 1.72) and vessel evaluation (OR, 1.80; 95% CI, 1.63 to 1.98). For the multivariate analysis of outcomes, patients undergoing rehabilitation assessment had a longer length of stay (OR, 1.96; 95% CI, 1.81 to 2.12), a higher modified Rankin Scale (mRS) score at discharge (OR, 1.49; 95% CI, 1.36 to 1.64), and higher rates of discharge to a rehabilitation center (OR, 3.23; 95% CI, 1.81-5.75).

CONCLUSION

More than two-fifths of SAH patients were not assessed for rehabilitation. Rates vary considerably among hospital grades, and there is a need to improve adherence to recommended care for SAH patients.

Ethical Issues in Medical Rehabilitation: The Dilemma of Who to Admit

ABSTRACT

Ethical allocation of scare medical resources is a ubiquitous challenge in many, if not all, medical specialties. The field of physical medicine and rehabilitation is no exception and presents its own unique dilemmas. We report on a small inpatient rehabilitation unit at a large university medical center with a large catchment area representing a vast range of socioeconomic classes. The decision of whom to admit is a constant challenge. We review the existing literature regarding ethical considerations in rehabilitation department admission criteria and attempt to analyze criteria used to admit patients to a general physical medicine and rehabilitation ward. Finally, we discuss our medical center approach to the ethical dilemma of admission priority. A systemic search was conducted in six sources (PubMed, Google Scholar, ScienceDirect, Cochrane Library, LILACS, Embase). Searches were limited to English language articles with no date restriction, reflecting all available data. A reviewer applied the inclusion criteria to identify relevant articles.This review highlights a number of important ethical issues in evaluation and selection criteria that may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation. Further high-quality empirical studies and reviews of ethical admission practice with regard to rehabilitation acceptance are required.

The use of self-management strategies for stroke rehabilitation: a scoping review

INTRODUCTION

Self-management is generally considered a dynamic and collaborative process by individuals and caregivers to manage a chronic condition. Self-management has recently emerged as a promising strategy for stroke rehabilitation. This scoping review aims to examine and summarize self-management strategies utilized by stroke survivors for stroke rehabilitation.

METHODS

PubMed, Scopus, CINAHL (EBSCO), Embase, and ProQuest were searched for articles published between January 2010 and December 2021. Studies were selected if they were published in English in a peer-reviewed journal, utilized a non-experimental research design, and focused on adult stroke survivors. All relevant information from the included articles was extracted in a systematic way using a pre-developed data extraction form. Two authors performed data extraction and quality evaluation independently. All issues were resolved through discussion among the authors.

RESULTS

We narratively summarized the findings of 15 quantitative, qualitative, and mixed-method studies, including a total of 1,494 stroke survivors. The stroke survivors used a range of self-management strategies for their stroke rehabilitation, including domains related to lifestyle, social support, communication, knowledge and information, and goal-setting. Gender, age, stroke-related disability, fatigue, self-management education, social support, and communication with others were found to be associated with self-management use in stroke rehabilitation.

CONCLUSIONS

This scoping review provides an important overview on stroke survivors' use of self-management strategies and their experience. Their use of self-management strategies is complicated and multifaceted, comprising several domains and involving a diverse range of approaches and personal experiences. However, we identified several gaps in the literature and more research is required.

Perspectives and Experiences of Cardiac Rehabilitation after Stroke—A Qualitative Study

Cardiac rehabilitation (CR) after stroke has been proven to be a safe and feasible secondary prevention intervention. Limited qualitative data capture people’s experiences and perceptions of attending CR following stroke, but with none addressing translational aspects when CR is delivered as routine clinical care. Using a phenomenological, qualitative approach, four semi-structured focus groups were conducted with 15 individuals (60% male) who had completed CR during their stroke care pathway. Our inductive thematic analysis identified five themes. The first centred on recognising stroke as a cardiovascular disease and the applicability of CR post-stroke. The second addressed how peer understanding, camaraderie, and medical supervision created a safe and supportive environment. The third identified how the programme-built confidence supported longer-term healthy lifestyle choices in physical activity, diet, and smoking. The penultimate theme addressed the period from hospital discharge to attending CR as a time of uncertainty where many participants experienced cognitive difficulties, mood disturbances, and mental fatigue without adequate support. Lastly, participants identified unmet needs in their care pathway that included a lack of information about their referral to CR, the programme content, and accessing local supports ahead of CR. Ongoing and unmet needs both during and after CR related to self-management of secondary prevention medications, neurological issues, post-stroke fatigue, and the lack of structured support following CR completion.

Age-Related Disparities in the Quality of Stroke Care and Outcomes in Rehabilitation Hospitals: The Australian National Audit

INTRODUCTION

Stroke affects all ages. Despite increased incidence in those <65 years, little is known about age-based differences in inpatient rehabilitation management and outcomes.

OBJECTIVES

To investigate management and outcomes, comparing younger (<65 years) and older (≥65 years) patients with stroke, who received inpatient rehabilitation.

METHODS

Multicentre, cross-sectional study using data from Australian hospitals who participated in the Stroke Foundation national stroke rehabilitation audit (2016-2018). Chi-square tests compared characteristics and care by age. Multivariable regression models were used to compare outcomes by age (e.g. length of stay). Models were adjusted for sex, stroke type and severity factors.

RESULTS

7,165 audited cases from 127 hospitals; 23% <65 years (66% male; 72% ischaemic stroke). When compared to older patients, younger patients were more likely male (66% vs 52%); identify as Aboriginal or Torres Strait Islander (6% vs 1%); be less disabled on admission; receive psychology (46% vs 34%) input, and community reintegration support, including return to work (OR 1.47, 95% CI 1.03, 2.11), sexuality (OR 1.60, 95% CI 1.39, 1.84) and self-management (OR 1.39, 95% CI 1.23, 1.57) advice. Following adjustment, younger patients had longer lengths of stay (coeff 3.54, 95% CI 2.27, 4.81); were more likely to be independent on discharge (aOR 1.96, 95% CI 1.68, 2.28); be discharged to previous residences (aOR 1.64, 95% CI 1.41, 1.91) and receive community rehabilitation (aOR: 2.27, 95% CI 1.91, 2.70).

CONCLUSIONS

Age-related differences exist in characteristics, management and outcomes for inpatients with stroke accessing rehabilitation in Australia.

Targeted rehabilitation may improve patient flow and outcomes: development and implementation of a novel Proactive Rehabilitation Screening (PReS) service

Rehabilitation programmes can be delivered to patients receiving acute care (‘in-reach rehabilitation’) and/or those who have completed acute care but experience ongoing functional impairments (‘subacute rehabilitation’). Access to these programmes depends on a rehabilitation assessment, but there are concerns that referrals for this assessment are often triggered too late in the acute care journey. We describe a Proactive Rehabilitation Screening (PReS) process designed to systematically screen patients during an acute hospital admission, and identify early those who are likely to require specialist rehabilitation assessment and intervention. The process is based on review of patient medical records on day 5 after acute hospital admission, or day 3 after transfer from intensive care to an acute hospital ward. Screening involves brief review of documented care needs, pre-existing and new functional disabilities, the need for allied health interventions and non-medical factors delaying discharge. From May 2017 to February 2019, the novel screening process was implemented as part of a service redesign of the rehabilitation consultation service. Four thousand consecutive screens were performed at the study site. Of those ‘ruled in’ by screening as needing a rehabilitation assessment, 86.0% went on to receive inpatient rehabilitation interventions. Of those ‘ruled out’ by screening, 92.1% did not go on to receive a rehabilitation intervention, while 7.9% did receive some form of rehabilitation intervention. Of all patients accepted into a rehabilitation programme (n=516), PReS was able to identify 53.6% (n=282) of them before the acute care teams made a referral (based on traditional criteria). In conclusion, we have designed and implemented a systematic, PReS service in one metropolitan Australian hospital. The process described was found to be time efficient and feasible to implement in an acute hospital setting. Further, it appeared to identify the majority of patients who went on to receive formal inpatient rehabilitation interventions.

Expectations of individuals with neurological conditions from rehabilitation: A mixed-method study of needs

Background

Knowledge of the specific expectations of patients with neurological conditions (NCs) from rehabilitation helps in setting attainable goals. Such expectations may vary from situation to situation. There are no studies investigating rehabilitation expectations amongst individuals with NCs in Nigeria.

Objectives

The aim of our study was to explore the rehabilitation expectations of individuals with NCs.

Method

This convergent mixed-methods study comprised a cross-sectional survey of 105 individuals with NCs and two sessions of Focus Group Discussions (FGDS) amongst eight individuals with NCs. The modified Needs Assessment Questionnaire was used to assess rehabilitation needs as a proxy for rehabilitation expectations, whilst disability was assessed using the World Health Organization Disability Assessment Schedule 2.0. Quantitative data were summarised using descriptive statistics and analysed using inferential statistics at p < 0.05. Thematic analysis was conducted on the qualitative data.

Results

Sixty-one (58.1%) stroke survivors, 33 (31.4%) individuals with spinal cord injury (SCI) and 11 (10.5%) with traumatic brain injury (TBI) aged 46.48 ± 15.91 were surveyed. The need for social/recreational activity was the most expressed need (100%) amongst the participants. Mobility was reported as an important need constituting a barrier to enjoying life by 93 (88.6%) participants. Individuals with SCI expressed the greatest needs compared with the other two groups. Needs were significantly correlated with severity of disability (p < 0.05). Four overarching themes (physical health, financial, healthcare services/rehabilitation and emotional/social) representing major areas of needs emerged from the FGD data.

Conclusion

Individuals with NCs in Nigeria have specified expectations of rehabilitation. Disability was a major driver of these expectations, irrespective of NC subtype.

Clinical implications

Rehabilitation programmes for individuals with NCs should target expressed needs or expectations of each patient cohort and minimise disabilities associated with these conditions.

Community Rehabilitation Outcomes for Different Stroke Diagnoses: An Observational Cohort Study

Objective

To determine the differences in functional and cognitive rehabilitation gains made in community-based rehabilitation following a stroke based on stroke diagnosis (left or right hemisphere, hemorrhagic, or ischemic).

Design

A 12-month follow-up observational retrospective cohort study.

Setting

Staged community-based brain injury rehabilitation.

Participants

Clients (N=61) with hemorrhagic left brain stroke (n=10), hemorrhagic right brain stroke (n=8), ischemic left brain stroke (n=27), or ischemic right brain stroke (n=16) participating in rehabilitation for at least 12 months.

Intervention

Not applicable.

Main Outcome Measures

The Mayo-Portland Adaptability Inventory-4 (MPAI-4) was completed at admission and 12 months post admission to staged community-based brain injury rehabilitation by consensus of a multidisciplinary team.

Results

After 12 months in staged community-based brain injury rehabilitation, the study population made significant gains in Total (P<.001) and across Ability (P<.001) and Participation (P<.001) subscales of the MPAI-4. All diagnostic groups made significant gains in Participation T-scores, and no groups made significant gains in Adjustment. The ischemic left and right hemisphere stroke groups also made significant gains in Ability and Total T-scores from admission to 12 months. Clients with ischemic left hemisphere stroke had more severe limitations in motor speech (P<.05) than clients with right hemisphere stroke at admission and/or review and were also more impaired in verbal communication (P<.01) than the hemorrhagic right hemisphere group at admission.

Conclusions

There are some differences in outcomes on presentation to rehabilitation based on type of stroke; there are also differences in rehabilitation gains. Improvement in physical ability does not always translate to improvement in social participation and independence; those with right brain stroke need further assistance to translate physical gains into participatory outcomes.

The realization of robotic neurorehabilitation in clinical: use of computational intelligence and future prospects analysis

Introduction: Although there is a need for rehabilitation treatment with the increase in the aging population, the shortage of skilled physicians frustrates this necessity. Robotic technology has been advocated as one of the most viable methods with the potential to replace humans in providing physical rehabilitation of patients with neurological impairment. However, because the pioneering robot devices suffer several reservations such as safety and comfort concerns in clinical practice, there is an urgent need to provide upgraded replacements. The rapid development of intelligent computing has attracted the attention of researchers concerning the utilization of computational intelligence algorithms for robots in rehabilitation. Areas covered: This article reviews the state of the art and advances of robotic neurorehabilitation with computational intelligence. We classified advances into two categories: mechanical structures and control methods. Prospective outlooks of rehabilitation robots also have been discussed. Expert opinion: The aggravation of global aging has promoted the application of robotic technology in neurorehabilitation. However, this approach is not mature enough to guarantee the safety of patients. Our critical review summarizes multiple computation algorithms which have been proved to be valuable for better robotic use in clinical settings and guide the possible future advances in this industry.

Selection of discharge destination for patients with moderate-to-severe traumatic brain injury

OBJECTIVES

To investigate criteria acute care interdisciplinary providers use to select discharge destination for patients with traumatic brain injury (TBI).

DESIGN

Cross-sectional, exploratory survey study.

METHODS

Data were collected from interdisciplinary providers at a U.S. Level I trauma centre via electronic survey. We invited 199 providers to participate and 27 responded (13.5% response rate). Responses were received from physicians and physical, occupational, and speech therapists.

RESULTS

Findings showed variability in standard criteria and clinical judgment criteria providers used to select discharge destination for patients with TBI receiving acute care. There was limited agreement on standard criteria used to select discharge destination. Findings showed some agreement between providers on clinical judgment criteria used to select home as discharge destination and to prevent discharge to home. Most common clinical judgment criteria included therapists' recommendations on discharge location, patient's level of independence in activities of daily living, planned family support and ventilator dependence. Agreement on clinical judgment criteria became more limited when stratifying by discipline, frequency of patient care and experience.

CONCLUSIONS

Findings on clinical judgment criteria providers use to select acute care discharge destination for patients with TBI are inconclusive.

Patients With Greater Stroke Severity and Premorbid Disability Are Less Likely to Receive Therapist Consultations and Intervention During Acute Care Hospitalization

BACKGROUND

A substantial number of patients with stroke never receive acute care therapy services, despite the fact that therapy after stroke reduces the odds of death and disability and improves patients' functioning.

OBJECTIVE

The aim of this study was to estimate the proportion of and factors associated with receipt of therapist consultations and interventions during acute care hospitalization following ischemic and hemorrhagic stroke.

DESIGN

This was a single-center longitudinal observational study.

METHODS

Adults with a diagnosis of ischemic or hemorrhagic stroke (N = 1366) were enrolled during their hospitalization in an acute stroke center in a large metropolitan area. The main outcomes were receipt of therapist consultations, interventions, or both.

RESULTS

Participants with acute hemorrhagic stroke (intracerebral: odds ratio [OR] = 0.34 [95% CI = 0.19-0.60]; subarachnoid: OR = 0.52 [95% CI = 0.28-0.99]) and with greater stroke severity by National Institutes of Health Stroke Scale (NIHSS) score (NIHSS score of > 15: OR = 0.34 [95% CI = 0.23-0.51]) were less likely to receive therapist consultations. Participants with moderate stroke severity (NIHSS score of 6-15: OR = 1.43 [95% CI = 1.01-2.33]) were more likely to receive therapy interventions. Those who were able to ambulate before admission were more than 5 times as likely to receive therapy interventions (OR = 5.08 [95% CI = 1.91-13.52]). Also, participants with longer lengths of stay (ie, more intensive care unit and non-intensive care unit days) were more likely to receive therapist consultations and interventions. Tests or procedures were the most common reasons for unsuccessful attempts to complete therapist consultations.

LIMITATIONS

Lack of operational and qualitative data prohibited detailed explorations of barriers to delivery of therapist consultations and interventions.

CONCLUSIONS

Approximately 1 in 4 participants with acute stroke received neither a consultation nor an intervention. Efforts to improve the delivery of acute care therapy services are needed to optimize care for these people.

Patient and service factors associated with referral and admission to inpatient rehabilitation after the acute phase of stroke in Australia and Norway

Background

Unequal access to inpatient rehabilitation after stroke has been reported. We sought to identify and compare patient and service factors associated with referral and admission to an inpatient rehabilitation facility (IRF) after acute hospital care for stroke in two countries with publicly-funded healthcare.

Methods

We compared two cohorts of stroke patients admitted consecutively to eight acute public hospitals in Australia in 2013–2014 (n = 553), and to one large university hospital in Norway in 2012–2013 (n = 723). Outcomes were: referral to an IRF; admission to an IRF if referred. Logistic regression models were used to identify and compare factors associated with each outcome.

Results

Participants were similar in both cohorts: mean age 73 years, 40–44% female, 12–13% intracerebral haemorrhage, ~ 77% mild stroke (National Institutes of Health Stroke Scale < 8). Services received during the acute admission differed (Australia vs. Norway): stroke unit treatment 82% vs. 97%, physiotherapy 93% vs. 79%, occupational therapy 83% vs. 77%, speech therapy 78% vs. 13%. Proportions referred to an IRF were: 48% (Australia) and 37% (Norway); proportions admitted: 35% (Australia) and 28% (Norway). Factors associated with referral in both countries were: moderately severe stroke, receiving stroke unit treatment or allied health assessments during the acute admission, living in the community, and independent pre-stroke mobility. Directions of associations were mostly congruent; however younger patients were more likely to be referred and admitted in Norway only. Models for admission among patients referred identified few associated factors suggesting that additional factors were important for this stage of the process.

Conclusions

Similar factors were associated with referral to inpatient rehabilitation after acute stroke in both countries, despite differing service provision and access rates. Assuming it is not feasible to provide inpatient rehabilitation to all patients following stroke, the criteria for the selection of candidates need to be understood to address unwanted biases.

Is there a relationship between postural alignment and mobility for adults after acquired brain injury? A systematic review

PRIMARY OBJECTIVE

To examine the relationship between postural alignment and mobility skills for adults after acquired brain injury (ABI).

METHODS

Systematic review of the literature. Seven electronic databases, grey literature and reference lists of the shortlisted publications were searched. Studies were included if participants were adults with ABI, both postural alignment and mobility were measured and analysis included a relationship between alignment and mobility. Those that met the inclusion criteria were assessed with a critical appraisal tool. The review was registered with PROSPERO, registration number CRD42015019867.

RESULTS

Seven observational studies were included that had examined a relationship between postural alignment and mobility after ABI. Critical appraisal scores were moderate to strong. While some studies reported that improved postural alignment was related to improved mobility after ABI, results varied and there was insufficient evidence to answer the primary question. Heterogeneous study designs did not allow meta-regression.

CONCLUSIONS

A small amount of observational evidence exists for a relationship between postural alignment and mobility after ABI. Results vary, with some studies reporting that a more stable, upright trunk correlates with better mobility, and others providing conflicting or ambiguous results. Further research is needed to establish the relationship between postural alignment and mobility skills after ABI.

Advancing Evidence-Based Practice in Physical Therapy Settings: Multinational Perspectives on Implementation Strategies and Interventions

It is of critical importance that findings from the wealth of clinical physical therapist research are transferred into clinical practice without unnecessary delays. There is a lack of knowledge about strategies that can be used to effectively implement physical therapist research findings and evidence-based practice (EBP) into everyday clinical practice in different national settings and contexts. The purpose of this article is to contribute to knowledge about effective strategies for implementing EBP that have been studied in different national physical therapy settings. The specific aims of this article are to share experiences and provide a current multinational perspective on different approaches and strategies for implementing EBP and to highlight important considerations and implications for both research and practice. Six research studies from various settings in 3 countries are described and synthesized. Key characteristics of the studies and intervention components are tabulated and mapped to the Cochrane Effective Practice and Organisation of Care taxonomy. Commonalities and differences are presented. The implementation strategies described were: a theory-based guideline implementation tailored to identified barriers and facilitators; a multifaceted EBP training package; journal clubs; a multifaceted strategy comprising contextualized procedures, protocols, and standardized resources; barrier identification, education, audit, feedback, and reminders; and contextualized guidelines. Commonalities were the use of a multifaceted approach, educational measures, and clinical guidelines. Key outcomes across the studies were improved attitudes and increased awareness, knowledge, skills, and confidence in EBP; better access to clinical practice guidelines and other EBP resources; identification of barriers that could be targeted in future implementation activities; earlier referrals; and use of recommended outcome measures. The article can serve as a template for other physical therapist researchers in designing implementation studies, as well as to inform policies and practice for health care managers and decision makers who are looking for ways to implement research findings in their organizations.

Education-only versus a multifaceted intervention for improving assessment of rehabilitation needs after stroke; a cluster randomised trial

Background

In 2011, more than half of the patients with stroke in Australian hospitals were not assessed for the need for rehabilitation. Further, there were no recommended criteria to guide rehabilitation assessment decisions. Subsequently, a decision-making tool called the Assessment for Rehabilitation Tool (ART) was developed. The ART was designed to assist Australian hospital clinicians to identify the rehabilitation needs of patients with stroke using evidence-based criteria. The ART was released and made freely available for use in 2012. This study evaluated the effectiveness of an education-only intervention (1 onsite education session and distribution of the ART) and a multifaceted intervention (2 or more onsite education sessions, distribution of the ART, audit and feedback, barrier identification, site-specific strategy development, promotion of interdisciplinary teamwork, opinion leaders and reminders) for improving assessments of rehabilitation needs after stroke.

Methods

Ten hospitals in 2 states of Australia were randomly assigned to an education-only or a multifaceted intervention. Medical records were audited by assessors blinded to group allocation before and after the implementation period. Difference in the proportion of patients assessed for rehabilitation before and after the intervention was analysed using mixed-effects logistic regression analysis, with time period as the dependent variable, an interaction between intervention type and time included to test for differences between the interventions, and hospital included as the random effect to account for patient clustering.

Results

Data from 586 patients (284 pre-intervention; 302 post-intervention; age 76 years, 59 % male) showed that the multifaceted intervention was not more effective than education-only in improving the proportion of patients whose rehabilitation needs were assessed (reference category education-only; odds ratio 1.29, 95 % confidence interval 0.63–2.67, p = 0.483). Post-intervention, the odds of a patient’s rehabilitation needs being assessed was 3.69 times greater than pre-intervention (95 % confidence interval 2.57–5.30, p < 0.001). Evidence-based criteria were not consistently used when patients were deemed to have no rehabilitation needs.

Conclusions

A multifaceted intervention was not more effective than education-only in improving the assessment of rehabilitation needs of patients with stroke. Further interventions are required to ensure that all patients are assessed for the need for rehabilitation using evidence-based criteria.

Trial registration

ANZCTR (Australian New Zealand Clinical Trials Registry), ACTRN12616000340437

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0487-2) contains supplementary material, which is available to authorized users.

A qualitative study using the Theoretical Domains Framework to investigate why patients were or were not assessed for rehabilitation after stroke

Objective:

To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke.

Design:

Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework.

Setting:

Eight acute stroke units in two states of Australia.

Subjects:

Health professionals working in acute stroke units.

Interventions:

Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway.

Results:

Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain ‘social and professional role’); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation (‘belief about consequences’); the influence of the unit’s relationships with other groups including rehabilitation teams (‘social influences’ domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices (‘knowledge’ domain).

Conclusion:

This study has identified that health professionals’ perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

Inequities in access to rehabilitation: exploring how acute stroke unit clinicians decide who to refer to rehabilitation

PURPOSE

Less than half of the patients with stroke in Australian hospitals are assessed by rehabilitation specialists. We sought to explore how clinicians working in acute stroke units (ASUs) determine which patients to refer to rehabilitation services.

METHOD

Qualitative descriptive study. Team meetings were observed and medical records were reviewed over four weeks at two ASUs. Focus groups were conducted with staff from eight ASUs in two states of Australia.

RESULTS

Rehabilitation was mentioned in team meetings for 50/64 patients (78%) during the observation period. Rehabilitation referrals were organised for 47 patients (94%) for whom rehabilitation was discussed (74% of the sample); and for no patients when rehabilitation was not discussed. Factors identified that influenced whether referrals were organised included the anticipated discharge destination; severity of stroke; staff expectations of the patient's recovery; and if there was advocacy by families about rehabilitation. Clinicians tended to refer the patients they considered would be accepted by the rehabilitation service. Staff at two ASUs expressed concern that referring all patients with stroke-related deficits to rehabilitation would be unfavourable with rehabilitation providers.

CONCLUSIONS

Decisions made by ASU staff regarding who to refer to stroke rehabilitation are often not solely based on patients' rehabilitation requirements. Implications for Rehabilitation Not all patients on acute stroke units (ASUs) who may have benefited from rehabilitation were offered rehabilitation referrals. Criteria for rehabilitation referrals need to be made explicit and discussed openly with consumers, ASU clinicians and rehabilitation specialists. A change in rehabilitation assessment practices is required to provide data regarding the unmet rehabilitation needs of patients with stroke. New models of rehabilitation service delivery or increased rehabilitation services may be required to meet the rehabilitation needs of all patients with stroke.