Home-Based and Hospital-Based Stroke Rehabilitation - Assignment Example

Running Head: Multidisciplinary Stroke Rehabilitation Home Based and Hospital Based Stroke Rehabilitation Name: Grade Course: Tutor’s Name: 14th, Nov, 2009 Introduction There is no regularly curative treatment for stroke and so stroke patients have to be put under rehabilitation. When patients suffer from stroke, they lose their functional ability of the affected parts. The patients become disabled in some way and because there are no applicable medical treatments, their disability becomes a burden if not treated. Treatment of stroke is through rehabilitation interventions that ensure that patients regain the lost ability after suffering stroke (Legg, 2003). This interventions consider all types of stroke patients from the mildly disabled to severely disabled. It means that the interventions are vast and a multidisciplinary approach has to be developed to cater for all the patients. Most stroke rehabilitation programs take the form of a multidisciplinary program and this will be described even in the identified rehabilitation program. This paper aims at describing the multidisciplinary nature of a stroke rehabilitation program identified from Jhone hospital. The features of Jhone hospital will be described and compared to clinical guidelines for a stroke rehabilitation program. The multidisciplinary nature of a stroke rehabilitation program will therefore be explained to ensure the comparison reveals the multidisciplinary nature of the rehabilitation program identified. What is a multidisciplinary rehabilitation program? According to (Kumar, 2000), rehabilitation will only be successful if there are multiple disciplines are involved in the process. Rehabilitation teams should consist of rehabilitation and medicine specialized physicians, nurses, social workers, occupational therapists, speech language pathologist, assistive technology specialists, recreation therapists, orthotists, counselors and psychologists (Kumar, 2000). Multidisciplinary means a team of health professionals working within a medical model where the physician is regarded as the leader of the team (Kumar, 2000; Shuaib & Goldstein, 1999). Comparison will be based on the assessment and admission process, that is, at the hospital and the process as described in the stroke rehabilitation program clinical guidelines, the team meetings and objective settings, initial and outcome assessments and the outcomes of a stroke rehabilitation program. Assessment and Admission Process at Rehab A a) Disciplines involved, Roles and Communication In this rehabilitation program, it is the nurses who determine the patients to be transferred to JH hospital. This is done twice in a week (Tuesday and Thursday). The nurses determine if patients from other nursing homes and private hospitals should be referred to the JH hospital or not. On arrival at the hospital, the patients undergo an initial assessment which includes mental, physical, risk factors, and previous medication assessment. The nurses then develop files for each patient that will be used by other rehabilitation specialists for the therapy process. A second assessment is done by the doctor who also notes admission formalities and medication requirements (Rehab A) The program has other team members such as the dietitian who assesses the patients nutritional requirements after the initial assessment (if referred to them by the nurses) and the speech pathologists who assesses the patients’ speech impairment when referred (Shuaib & Goldstein, 1999). GP’s may too refer patients directly to the hospital. a) Comparison with the recommendations from the Clinical Guidelines for Stroke Rehabilitation and Recovery. The clinical guidelines for stroke rehabilitation and recovery indicate that there should be a team of rehabilitation specialists with appropriate skills to handle the patients by providing comprehensive and current programs of care for the disabilities of stroke in patients. The team which comprises the rehabilitation center professional and support staff should be adequate in number to handle the rehabilitation medicine service functions (AFRM, 2005). Adequacy of the staff is established by inpatient staff to patient ratio as described by the Australasian Faculty of Rehabilitation Medicine (AFRM, 2005). In Rehab A there is no established inpatient staff to patient ratio which gives the idea that the rehabilitation medicine service functions may not be accomplished adequately. The NSF clinical guidelines indicate that nurses should: conduct nursing assessments among other duties such as management of patient care characteristics (mobility, skin integrity, swallowing, and observations, avoidance of complications and control of pain), provision of centered care, provision of education and support, provision of coordination care assistance and help with discharge planning (2005). In rehab A, the patients undergo an initial assessment which includes mental, physical, risk factors, and previous medication assessment all conducted by the nurses. The nurses conduct a comprehensive assessment as indicated in the clinical guidelines. Other roles of Rehab A nurses are not indicated however, the roles are not included in the assessment and the admission process. The NSF clinical guidelines indicate that Doctors should be the ones to coordinate comprehensive medical care. Coordination of the doctor should ensure that stroke patients receive the good quality services by use of available resources (2005). Rehabilitation A’s doctor role does not include coordination however; consultation of other specialist to help assess the patients whenever necessary is done by the nurses. According to Rehab A’ assessment process, the dietitian, the speech pathologist or other specialists, are consulted to assess patients’ conditions when referred to by the nurses. The doctor conducts a second assessment indicating admission formalities and medication requirements. The rehabilitation team should consist of physiotherapists, Dietitians, Occupational therapists, Speech pathologists and Social workers forming an inpatient medical team that should work together with a general practitioner in ensuring care is provided in the hospital and in the community (NSF, 2005). Provision of care includes assessment of patients and this should also be done in union with a general practitioner. Rehabilitation A has all the specialists and it is also noted that they are consulted whenever necessary to help in the assessment. The general practitioner in Rehab A is the doctor. Team Meetings and Objective Settings at Rehab A a) Disciplines their Roles and Processes Involved Rehabilitation A has three types of meetings all which aim at helping the program achieve its aims. One is the quality assurance committee meetings in which the team meets once after every three months to discuss the fall incidences, the drug incidences and how to control them and the control of infections (Rehab A). Another meeting is the multidisciplinary team meeting that happens once in a week (Tuesday Morning). The rehabilitation’s consultant guides the meeting and is assisted by other members from other specialities. The meeting is meant to study and analyse the new patients, discuss and analyse the current patients’ progress and to develop discharge plans for patients with clear picture of improved progress according to their specific condition management goals. The patients are discharged based on the requirements guidelines for discharge of a stroke rehabilitation program. This meeting has specific objectives laid in accordance to each patient’s status and requirements. The last type of meeting is the Unit management meetings that take place once in a month. The objectives are to discuss affairs of staff inadequacies or shortfalls. This aims at ensuring that the rehabilitation unit is well managed with no or very few errors. The team members therefore plan and make decisions on how to manage the unit during these meetings considering patient views obtained from feedback forms. Suggestions for improvement and negative comments are forwarded to the quality assurance committee (Rehab A). b) Comparison with the recommendations from the Clinical Guidelines for Stroke Rehabilitation and Recovery According to the clinical guidelines, the team meetings are for discharge planning, integrated community care and transfer of care and should include the family. The family and team meetings should be held regularly with the stroke patient ensuring that they are also involved in the discharge planning, management and setting of goals (NSF, 2005). Carers of the patients are also encouraged to get involved in the management, goal setting and the rehabilitation process. Rehabilitation A has only holds three types of meetings and does not include the stroke patient and the carers as recommended by the clinical guidelines for stroke rehabilitation and recovery. As indicated above, it has three multidisciplinary meetings which are: quality assurance committee meeting that aims at controlling fall and drug incidences, Unit management meeting that concerns affairs of staff inadequacies or shortfalls and the multidisciplinary team meeting that is meant to study and analyse the new patients, discuss and analyse the current patients’ progress and to develop discharge plans for patients with clear picture of improved progress according to their specific condition management goals. This last meeting should be according to the clinical guidelines. It addresses the aims of the meetings as required by the clinical guidelines but does not include all the disciplines recommended to be included in such kind of meetings. Initial and Outcome Assessments a) Initial and Outcome Assessments used at Rehab A Rehabilitation A uses the National Institute of Health Stroke Scale (NIHSS) to measure the severity of stroke, the Reintegration to Normal Living Index to measure the Instrumental Activities of Daily Living, the Functional Independence Measure (FIM) to measure the self care activities of daily living and Elderly Mobility Scale (EMS) to assess mobility in elderly patients. The Berg Balance Scale (BBS) is used in the rehabilitation program to assess an individual patient’s ability to maintain balance while performing every day jobs related Activities of Daily Living (ADL). The mini-mental state examination (MMSE) measures the cognitive impairment and is used in this rehabilitation program (Rehab A). The program also uses Cognitive Harmonization Measures to assess the patient’s cognitive and perception ability and Stroke Impact Scale to measure the quality of life achieved (Goldstein, 2009). The speech pathologists have to assess the patient’s progress and note improvements at the end of the rehabilitation program. b) Comparison with the recommendations from the Clinical Guidelines for Stroke Rehabilitation and Recovery According to the clinical guidelines, stroke management should be based on the consequences of stroke. Stroke patients for example, always have reduced strength, spasticity and impaired cognitive ability among so many others. By improving the outcomes, the consequences of stroke are managed. The clinical guidelines provide recommendations on interventions and tools necessary for improving stroke rehabilitation outcomes. Initial and outcome assessment measures the improvements made by the rehabilitation program while the clinical guidelines provide interventions for making such improvements. The clinical guidelines recommend improvements on (which means assessment of): i. Sensorimotor impairements, which needs assessment of the following outcomes: The strength, Sensation, Contracture, Spasticity, Subluxation of the shoulder, cardiovascular fitness, Shoulder pain, falling and Swelling of the extremities (NSF, 2005). There is no assessment of the above Sensorimotor impairements outcomes evident in Rehab A. ii. The physical Activity which requires assessment of the following outcomes: Walking, standing up from a chair, Amount of practice, Sitting, Standing and Upper limb activity (NSF, 2005). Rehab A makes use of the Berg Balance Scale (BBS) to assess an individual patient’s ability to maintain balance while performing every day jobs related Activities of Daily Living (ADL). iii. Activities of daily living (ADL) which has to include Personal ADL and Instrumental ADL. Rehabilitation A acts according to the clinical guidelines in the assessment of Activities of Daily Living. It has the Reintegration to Normal Living Index to measure the Instrumental Activities of Daily Living and the Functional Independence Measure (FIM) to measure the self care activities of daily living. iv. Cognitive Capacities: According to the NSF, cognitive rehabilitation improves attention and alertness. This has been revealed by a systemic review on cognitive rehabilitation on cognitive impairments (level I Study). Cognitive capacity improvement involves improvement of the following cognitive impairments: Memory, Language, Orientation, Attention and concentration and Executive functions (NSF, 2005). Assessment therefore should be based on the outcomes of the above. Rehab A uses the mini-mental state examination (MMSE) to determine the cognitive impairment. v. Visuospatial/Perceptual capacities which has to consider the following outcomes: Neglect, Visual function, Agnosia and Apraxia (NSF, 2005). There is no indication that Rehab A uses any tool to assess Visuospatial/Perceptual capacities either initially of at the end of the rehabilitating program. vi. Communication which should assess the effectiveness of aphasia therapy, Dysarthria, verbal dyspraxia treatments and Dysphagia (NSF, 2005). It is indicated in rehab A that a speech pathologists assesses the patient’s progress which means the rehab program utilizes the speech pathologist evaluation of the patients’ communication progress. It is however not clear how the specific outcomes are assessed. vii. Hydration and nutrition considering malnutrition and dehydration levels viii. Mood which requires the assessment of mood determinants such as anxiety, depression and emotionalism (NSF, 2005). ix. Bladder and Bowel function that requires the assessment of the three common types of incontinences for the assessment of bladder function which include; functional incontinence, Urge incontinence and urinary retention and the assessment of bowel dysfunction symptoms (NSF, 2005). x. Medical which considers the following; Pyrexia, Sleep apnoea, Seizures, Deep vein thrombosis (DVT) and pulmonary embolism (PE) and Pain (NSF, 2005). xi. Secondary prevention which includes; Behaviour change, Blood pressure lowering therapy, Antiplatelet therapy, Anticoagulation, Cholesterol levels and Concordance with medication (NSF, 2005). xii. Complementary and alternative therapies: there are other therapies that can be used in a stroke rehabilitation program and their effectiveness should also be evaluated. Such therapies include; aromatherapy, acupuncture, conductive education, homoeopathy, naturopathy, traditional Chinese medicine, osteopathy, music therapy, reflexology and Reiki therapy (NSF, 2005). xiii. Palliation and death (NSF, 2005) Assessment outcomes vii to xiii have all not been included in rehab A as recommended by the clinical guidelines. Some of the recommendations are based on studies of different levels. In this section, only three studies will be mentioned as examples. According to the NSF there are so many studies that have shown the advantages of improving strength after a stroke for example the “progressive resistance exercises” of level II, “Electrical stimulation” also of level II and “Task-Specific training” also of level II (NSF, 2005 p.15). These lead to recommendation of assessing strength levels achieved after rehabilitation. Another example of another study used to create recommendations for stroke rehabilitation and recovery guidelines is that with the findings that “Joint position feedback in conjunction with conventional therapy improved the quality of reaching” (NSF, 2005 p.22). This according to the NSF is a level III study. The third example is the study that revealed that “Aphasia therapy should be commenced as early as possible following a stroke” which is indicated as a level I study (NSF, 2005 p. 28). Outcomes/Benefits of stroke rehabilitation program a) How are the Benefits Reported in Rehab A? The outcomes of rehabilitation are reported after an assessment of individual outcomes and comparison made to the goals of the program as well as the patient’s general goals (AFRM, 2005). The evaluation of the program outcomes is done by use of the assessment tools that measure various outcomes. The outcomes achieved at the end of the rehabilitation program are compared with the initial assessment results obtain upon admission of the patient into the rehabilitation program (White & Truax, 2007). The program also utilizes a patient satisfaction survey to determine the satisfaction of patients with the services offered. Rehabilitation A has evaluation process incorporated into the stroke rehabilitation’s intervention process. The program ensures follow-up of every patient while monitoring progress and in the end writing a report about it accomplishments at the end of the rehabilitation process (White & Truax, 2007). b) Comparison with the recommendations from the Clinical Guidelines for Stroke Rehabilitation and Recovery According to Goldstein, there are standardized assessments that should be used in stroke rehabilitation programs to assess the outcomes and individual patient progress of the rehabilitation program (2009). These standardized assessments are the ones that should be used for initial assessment so that progress can also be monitored and achievements recorded. According to the clinical guidelines, the assessment of the rehabilitation outcomes produces the benefits. Reporting such kind of information is therefore based o the interventions used and their benefits. There is no evidence showing how Rehab A reports its outcome benefits. The report however is based on the assessment outcome. My Learning Curve I have learnt that the multidisciplinary nature of a stoke rehabilitation program is meant to achieve different goals all which work towards achieving the general goals of the rehabilitation program one of which is the quality of life. In order to improve health related quality of life so many objectives have to be set. The individual patients have to be assessed, their conditions documented and handled differently, and monitored. Multidisciplinary rehabilitation offers an approach to treatment that meets all the objectives. It has different disciplines with different roles aimed at achieving different goals. The multidisciplinary rehabilitation leads to accomplishment of rehabilitation goals. Before this I knew a stroke rehabilitation program had to have certain interventions such as education, exercise, counseling and so on but never knew how these intervention goals were achieved. I now know the importance of a multidisciplinary rehabilitation program, the disciplines involved and some of the processes that help in the achievement of rehabilitation goals. Conclusion The aim of the paper as indicated above was to identify a rehabilitation program as a multidisciplinary stroke rehabilitation program. Multidisciplinary is explained as the use of various disciplines in a traditional medical program model to accomplish program missions. Such a model requires processes and teams in order to achieve its aims. In stroke rehabilitation, the processes, teams and other requirements are given as clinical guidelines. In the above discussion, stroke rehabilitation and recovery recommended guidelines have acted as a comparison measure to rehabilitation A’s multidisciplinary nature. Comparison has been done based on the assessment and admission process, that is, at the hospital and the process as described in the stroke rehabilitation program clinical guidelines, the team meetings and objective settings, initial and outcome assessments and the outcomes of a stroke rehabilitation program outlining those of rehabilitation A then comparing with the clinical guidelines. Rehabilitation A’ as a multidisciplinary stroke rehabilitation program is revealed by this. The adherence to the recommended clinical guidelines of stroke rehabilitation and recovery by rehab A is slightly low. This is as discussed in the first section of comparison that compares the disciplines involved in the assessment and admission processes of the rehabilitation. The rehabilitation program has no inpatient staff to patient ratio established for its assessment and admission processes. It also has no coordinator as recommended. The other sections (Outcomes/Benefits of stroke rehabilitation program, Team Meetings and Objective Settings at Rehab A and initial and outcome assessment) used to compare its conformity to a recommended stroke rehabilitation program also reveal its low level of adherence to guidelines. Reference List Australasian Faculty of Rehabilitation Medicine (AFRM) (2005). Standards 2005: Adult Rehabilitation Medicine Services in Public and Private Hospitals. Royal Australasian College of Physicians. Goldstein, L. B. (2009). A Primer on Stroke Prevention and Treatment: An Overview Based on AHA/ASA Guidelines. New York, US: John Wiley and Sons Kumar, S. (2000). Multidisciplinary Approach to Rehabilitation. England, UK: Elsevier Health Sciences. Legg, L. L. (2003). Evidence Behind Stroke Rehabilitation. Journal of Neurology, Neurosurgery, and Psychiatry, 74(Supplement 4). BMJ Publishing Group Ltd. Retrieved on 9th Nov, 2009 from: http://jnnp.bmj.com/cgi/content/full/74/suppl_4/iv18 National Stroke Foundation (NSF) (2007). Clinical Guidelines for Acute Stroke Management. National Stroke Foundation (NSF). (2005). Clinical Guidelines for Stroke Rehabilitation and Recovery. Australian Government. National Health and Medical Council. Shuaib, A. and Goldstein, L. B. (1999). Management of Acute Stroke. Volume 48 of Neurological Disease and Therapy. Boston, MA: Informa Health Care. White, B. S. and Truax, D. (2007). The Nurse Practitioner in Long-Term care: Guidelines for Clinical Practice. New York, US: Jones & Bartlett Publishers. Appendix A REHAB A (attached) Read More