Prioritizing patients for Community Rehabilitation Services: do clinicians agree on triage decisions?

Objective: To evaluate agreement between independent clinician raters using a triage protocol to prioritize referrals for occupational therapy and physiotherapy within a community rehabilitation program.

Design: The priority category allocated to consecutive referrals by one of six clinicians in the referral office was compared with a second rating made by an independent occupational therapist, blinded to the initial priority rating.

Setting: A centralized referral office staffed by allied health and nursing professionals designed as a single point of access for sub acute and ambulatory services within a large metropolitan health network.

Participants: 214 referrals for adults requiring community based occupational therapy or physiotherapy rehabilitation for orthopaedic, neurological or other conditions (such as falls or cardio-respiratory conditions).

Main Measure: Agreement (weighted kappa = κw) between the two ratings.

Results: Overall agreement was moderate (κw = 0.60), but disagreement occurred in 30% of cases. Professional discipline of the raters did not affect agreement. Agreement varied between diagnostic subgroups, with significantly lower agreement for referrals for rehabilitation following elective orthopaedic surgery (κw = 0.25) than the other categories combined. Differences in agreement were observed between the four triage categories, with the lowest observed agreement in the most urgent category.

Conclusions: Clinicians in a centralized model of triage showed only moderate agreement when making decisions about client priority for community rehabilitation for occupational therapy and physiotherapy.

Team assessment in stroke rehabilitation

Goal planning is one of the most universal approaches in rehabilitation, yet its application is much more than just setting specific behavior-focused goals. This article aims to emphasize the fundamental aspects of the process and reference the key literature in the area. At its heart, goal planning is about producing lasting behavior change, and the central role of the patient in the assessment and rehabilitation process is highlighted throughout. The team-based nature of assessment is promoted and the benefit of measuring verbal (a patient's knowledge of his or her condition and ability to instruct others in its management) as well as physical capability, as incorporated by one of the measures, is discussed. A hierarchical approach to the setting of goals is suggested so that individual patient need can be reflected in the process rather than setting goals which centre on specific professional skills. The article provides information about the long-term benefits for the patient and service that arise from this change of emphasis and maps the goal-planning process onto an adjustment model. Practical case examples of patient involvement in the assessment and goal-setting process are given.

Geriatric rehabilitation nursing: Developing a model

In this paper, we describe a geriatric rehabilitation nursing model developed on the basis of the nursing and rehabilitation literature. That literature comprised some 120 articles addressing the rehabilitation of elderly patients and the work done by nurses in that process, various philosophical questions and the results of geriatric rehabilitation. One-third of these articles has been evaluated on the strength of the articles' evidence, and these are discussed in this paper. The findings show that the main factors in geriatric rehabilitation nursing are the patient with health or functional problems and the nurse with professional values, knowledge and skills. The patient is part of a family and the nurse works as part of a multidisciplinary team. In the geriatric rehabilitation process, the patient and the nurse work in close interaction. The aims of rehabilitation depend upon the patient's commitment to the objective and upon the nurse's commitment to help the patient achieve that objective. A health orientation, goal-oriented work, nursing decision-making and a rehabilitative approach to work are all central to this effort. Work is organized in multidisciplinary teams where nurses have equal responsibilities with other professional staff. Testing and development of the model is ongoing.

Diagnosis in rehabilitation: woolly thinking and resource inequity

The diagnostic process in rehabilitation has traditionally been termed assessment. However the goals of assessment are no different to the goals of diagnosis in traditional medical practice. The purpose is, in both instances, to acquire sufficient information to understand the cause(s) of the presenting problem(s), to allow more-or-less specific intervention(s) to be undertaken and, where appropriate, to allow a prognosis to be given. The main difference is that in rehabilitation the presenting problems are limitations in activities and the main items investigated are impairment and contextual matters, whereas in medicine the presenting problems are symptoms, and the goals are the diagnosis and treatment of the underlying disease. Unfortunately it is commonly assumed that rehabilitation diagnosis is simple and unimportant. Consequently few resources are allocated by purchasers to the process of making a rehabilitation diagnosis, in comparison to the huge resources devoted to achieving disease diagnosis.

Stroke: non-motor sequelae, medical co-morbidity and patterns of intervention after referral to a special interest service

Stroke poses a considerable financial burden on the health services as well as contributing to enormous personal suffering. A study was undertaken in 100 patients over 65 years old in a geriatric unit. Neuro-radiology confirmed cerebral infarcts in 91 and 89 per cent had additional neuro-medical problems. Specific sequelae of stroke occurred in 53 per cent of which 21 per cent related to dysphagia. Among various treatments 61 per cent were referred for physiotherapy and occupational and speech/language therapy. Knowledge of the nature and timing of complications is important in planning stroke services and the input of early medical specialist assessment has been shown to influence mortality and rehabilitation outcome.