"It's hard to tell": the challenges of scoring patients on standardised outcome measures by multidisciplinary teams: a case study of neurorehabilitation

Comprehensive rehabilitation outcome measurement scale (CROMS): development and preliminary validation of an interdisciplinary measure for rehabilitation outcomes

INTRODUCTION

Comprehensive and interdisciplinary measurement of rehabilitation outcome is an essential part of the assessment and prognosis of a patient. Thus, this requires substantial contributions from the patient, their family and the rehabilitation professional working with them. Moreover, the measurement tool should be comprehensive and must consider the cultural compatibility, cost efficiency and contextual factors of the region.

METHODS

The Comprehensive Rehabilitation Outcome Measurement Scale (CROMS) was developed through consensus and followed the Delphi process incorporating inputs from various rehabilitation professionals. The domains and items were finalized using Principal Component Analysis (PCA). The tool was validated in two native languages and back-translated considering the semantic equivalence of the scale. Intra-class correlation coefficient was performed to determine the agreement between the therapist and patient-reported scales.

RESULTS

The final CROMS carries 32 comprehensive items that can be completed by the person with disability and the professional team. CROMS compares well to similar items on FIM (l ICC of 0.93) and has good internal consistency with a Cronbach's Alpha of 0.92 for both patient and therapist reported measures.

CONCLUSIONS

The 32 item CROMS is a tool that can potentially be used to evaluate the functional independence of various patient populations, predominantly patients with neurological disabilities.

Implications of Variability in Clinical Bedside Swallowing Assessment Practices by Speech Language Pathologists

Speech language pathology (SLP) clinical bedside swallowing assessments (CBSA) are a cornerstone of quality care for patients in acute hospitals who have dysphagia. The CBSA informs clinical diagnosis and decisions regarding further instrumental assessment, and is used to develop a management plan and monitor progress. However, self-report and retrospective research shows that SLPs are highly variable in their use of assessment components considered by experts to be important for quality CBSA, casting doubt on the validity and reliability of CBSA. This prospective study describes the components included by SLPs when designing a standardised evidence based dysphagia assessment protocol for acute care patients and observed patterns of component use. The findings confirm that SLPs use the CBSA for multiple purposes beyond diagnosis of aspiration risk and dysphagia presence/severity. They are highly variable in their use of certain components, but also demonstrate consistent use of a core set. It is apparent that SLPs prioritise the application of clinical reasoning to tailor their CBSA to the patient over following a highly structured item-based protocol. The variability in component use likely reflects a complex clinical reasoning process that draws on a wide variety of information combined with expert knowledge as is also observed in many other medical specialties. Rather than promoting the standardisation of CBSA protocols that constrain SLP practice to strict item-based assessment protocols, consideration should be given to promoting the value and facilitating the clinical reasoning process that supports the utility of the CBSA for diagnosis, patient centred management and treatment planning.

Everyday uses of standardized test information in a geriatric setting: a qualitative study exploring occupational therapist and physiotherapist test administrators' justifications

BACKGROUND

Health professionals are required to collect data from standardized tests when assessing older patients' functional ability. Such data provide quantifiable documentation on health outcomes. Little is known, however, about how physiotherapists and occupational therapists who administer standardized tests use test information in their daily clinical work. This article aims to investigate how test administrators in a geriatric setting justify the everyday use of standardized test information.

METHODS

Qualitative study of physiotherapists and occupational therapists on two geriatric hospital wards in Norway that routinely tested their patients with standardized tests. Data draw on seven months of fieldwork, semi-structured interviews with eight physiotherapists and six occupational therapists (12 female, two male), as well as observations of 26 test situations. Data were analyzed using Systematic Text Condensation.

RESULTS

We identified two test information components in everyday use among physiotherapist and occupational therapist test administrators. While the primary component drew on the test administrators' subjective observations during testing, the secondary component encompassed the communication of objective test results and test performance.

CONCLUSIONS

The results of this study illustrate the overlap between objective and subjective data in everyday practice. In clinical practice, by way of the clinicians' gaze on how the patient functions, the subjective and objective components of test information are merged, allowing individual characteristics to be noticed and made relevant as test performance justifications and as rationales in the overall communication of patient needs.

A cross-sectional assessment of stroke rehabilitation in Nebraska hospitals

OBJECTIVE

To assess the structure and process of stroke rehabilitation in Nebraska hospitals.

DESIGN

Cross-sectional mail survey using the Dillman tailored-design method of administration.

SETTING

Hospitals in Nebraska.

PARTICIPANTS

Approximately 77% of the 84 Nebraska hospitals that provide stroke rehabilitation are critical access hospitals (CAHs) that are limited to 25 beds. Our study sample of hospitals (N=53) included the 19 hospitals licensed for 47 to 689 beds (non-CAHs) and a stratified random sample of 34 of the 65 CAHs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Self-reported stroke rehabilitation team structure and processes, purposes of and barriers to the use of evidence-based standardized assessments, specific assessments used, and access to specialized stroke rehabilitation services and community resources.

RESULTS

Thirty-six (68%) of the 53 hospitals responded to the survey. Approximately 61% of the hospitals used an organized team to provide stroke rehabilitation; 8% of the hospitals-all non-CAHs-had a team dedicated to stroke rehabilitation. After adjusting for hospital size, having an organized team was significantly associated with the use of standardized assessments to improve communication, measure progress and outcomes, evaluate effectiveness of practice, and compare patient outcomes across conditions. Access to specialized stroke rehabilitation professionals and services was significantly greater in non-CAHs.

CONCLUSIONS

Hospital size and the presence of a team are determinants of the structure and process of stroke rehabilitation in Nebraska hospitals. Further research is needed to determine (1) whether team structure is a determinant of stroke rehabilitation outcomes across the continuum of care settings, (2) the needs of rural stroke survivors, and (3) whether technology can facilitate the use of stroke rehabilitation standardized assessments by rural health care professionals.

The influence of objective measurement tools on communication and clinical decision making in neurological rehabilitation

RATIONALE

Routine collection of outcome measures is advocated to improve quality of care. However, there has been scant investigation of how measurement tools are used in clinical practice and what impact they may have. This paper compares two neuro-rehabilitation teams, one which routinely used standardized measurement tools and the other which did not. We explore differences in communication and clinical decision making within multidisciplinary team (MDT) meetings to illuminate the influence measurement tools could have on clinical practice.

METHOD

Non-participant observation of MDT meetings in two neurological rehabilitation units in England. Semi-structured interviews were also carried out with at least one member of each profession in each team. Grounded theory techniques were used to analyse the data.

RESULTS

Differences in team members' communication within MDT meetings underscored differences in the process of clinical decision making within the teams. Using measurement tools provided a shared understanding to facilitate communication by focusing discussion on the patient's abilities rather than individual professionals' contributions. This led to differences in the way team members identified the nature and cause of patients' problems, monitored their progress and planned for discharge. They provided a 'neutral ground' to reach a shared perspective between professionals, thereby avoiding conflict. Externally, use of the tools enabled objective discussion with patients and their families about their progress and was a vehicle to facilitate giving bad news.

CONCLUSION

Using standardized measurement tools can promote a patient-focused approach to care, thus facilitating treatment planning and clinical decision making.

The use of measurement tools in clinical practice: an observational study of neurorehabilitation

Objective: To explore the way in which standardized measurement tools are used in day-to-day clinical practice.

Design: Non-participant observation and semi-structured interviews.

Setting: Hospital-based adult neurorehabilition unit.

Participants: The multidisciplinary team delivering rehabilitation in the unit.

Results: The multidisciplinary team used the measurement tools internally to establish the presence and severity of patients’ impairments and activity limitations; predict recovery and discharge destination; inform treatment planning and monitor progress. They were used externally to demonstrate service effectiveness; communicate with patients, families and external agencies; enable other providers to plan continuing care and resource needs, and inform audit and service development.

Conclusion: When used in everyday clinical practice by a multidisciplinary neurorehabilitation team, standardized measures were used to support and inform, rather than replace, clinical decision-making.