The role of multidisciplinary team care in stroke rehabilitation

Transcription

1 Stroke rehabilitation z Multidisciplinary care The role of multidisciplinary team care in stroke rehabilitation David J Clarke MSc, PhD, RN Co-ordinated multidisciplinary team working has made a significant contribution to improvements in the quality of care within stroke services over the past five years. Here, Dr Clarke reviews the evidence for the efficacy of multi disciplinary team care in stroke rehabilitation within both inpatient services and community settings. Stroke is the third most common cause of death in the UK. It accounts for 11 per cent of all deaths and represents the largest cause of adult disability. Cerebral infarction causes about 85 per cent of strokes with the remaining 15 per cent being due to primary haemorrhage and subarachnoid haemorrhage (10 and 5 per cent respectively). 1 Following a first stroke, risk of recurrence is 26 per cent within five years and 39 per cent by 10 years. 2 Stroke can have a profound effect on patients, their spouses and other family members. In addition to impairment of upper and lower limb function and mobility, consequences can include cognitive, communication and visual field disturbances, role and relationship changes, psychological distress and the challenge of coping with long-term disability. The cost of stroke care to the NHS exceeds 3 billion a year. 3 The National Stroke Strategy 4 focused attention on improvements in care across the stroke pathway. The concept of time is brain increased awareness among commissioners and service providers that rapid access to specialist stroke services saves lives and improves outcomes. Pre-hospital and acute services have worked on improving recognition of stroke and have established rapid specialist assessment, including brain scans within one hour of arrival in the emergency department. This has contributed to earlier and more accurate diagnoses, resulting in increased use of thrombolysis where appropriate. Rates of thrombolysis are improving, particularly in London and the greater Manchester region where hyper-acute stroke services have been centralised. The Third International Stroke Trial (IST-3) 5 concluded that thrombolysis can be safely administered up to six hours after witnessed stroke onset, but also indicated that the time window for the most effective use of thrombolysis was three hours. Access, diagnostic, clinical and practical reasons mean that perhaps only per cent of patients benefit from this intervention at present. 1 Rehab ilitation therefore represents a key part of stroke care for the majority of patients and can make a significant contribution to improving their lives. The primary focus for this article is multidisciplinary team working in stroke as this is considered to be fundamental to delivering effective rehabilitation interventions. 1,3,4 The article draws predominantly on evidence relating to inpatient services but also highlights evidence related to the important contribution of early supported discharge (ESD) teams. Evidence for stroke rehabilitation Stroke care is underpinned by comprehensive clinical guidelines, 1,6 which draw on the best available evidence. Additional NICE Clinical Guidelines for Stroke Rehab ilitation were published in June These provide further and in some cases more specific direction for stroke teams. 7 However, despite a significant increase in research over the last 20 years, the evidence underpinning rehabilitation interventions remains limited in some areas. These areas include strategies for those with aphasia and dysarthria, and cognitive rehabilitation. 8 A recent systematic review 8 examined a wide range of evidence for stroke rehabilitation, identifying interventions that were or were likely to be beneficial, those of uncertain benefit and those where the effect was presently unknown. The review drew attention to three areas where strong evidence existed. Firstly, that rehabilitation should commence as early as possible after stroke. 9 Secondly, that repetitive task-oriented training targeted at goals or activities relevant to the needs of patients can contribute to functional recovery, 10 especially where training takes place in the patient s own environment. 11,12 Lastly, there was widespread agreement that increased intensity of training is beneficial. 13 This evidence supports the national guidelines and standards for the amount of therapy (where appropriate) that should be provided daily for each patient. 1,6 5

2 Multidisciplinary care z Stroke rehabilitation Patient initially admitted to a stroke unit Discussion with the patient about their diagnosis Patients treated for 90% of stay in a Stroke Unit Screening for swallowing disorders within 24 hours of admission Brain scan within 24 hours of stroke Commenced aspirin by 48 hours of admission Physiotherapy assessment within first 72 hours of admission Swallowing assessment by a speech and language therapist within 72 hours of admission Assessment by an occupational therapist within four working days of admission Rehabilitation goals agreed by the multidisciplinary team within five days of admission Patient weighed at least once during admission Mood assessed by discharge Table 1. The 12 key indicators of stroke care 1 Traditionally, therapy services were provided during office hours, five days per week. This will likely change to six or seven-day working in the near future. 1 Stroke service providers are being encouraged to examine how the wider multidisciplinary team can become involved in providing opportunities for patients to practice rehabilitation tasks as part of functional activity. Stroke teams and co-ordinated stroke rehabilitation Stroke teams in hospitals are made up of what can be thought of as core and periphery members. Core members are normally based on stroke units, or less commonly in an ESD team, which may be based on an inpatient unit or in a community setting. This core group includes physio therapists, occupational therapists, speech and language therapists, stroke physicians, nurses and healthcare assistants. Therapy assistants are trained to support physiotherapists or occupational therapists; generic rehabilitation assistants have training to support physiotherapists, occupational therapists, speech and language therapists, and nurses. ESD team membership also tends to reflect the core and periphery make up described above. It is increasingly common for stroke specialist nurses to work within multidisciplinary teams. At the acute end of the stroke pathway, these nurses take responsibility for initial assessment including the National Institutes for Health Stroke Scale, 14 initiating the diagnostic pathway, requesting CT scanning, and supporting treatment decision making, which may include administration of thrombolysis by physicians. In some hospitals, stroke coordinators (typically nurses or therapists) are core team members and work with patients, their families and the wider multidisciplinary team from admission to discharge, and in some cases also conduct the six-week and six-month post-stroke reviews. Other specialist nurses focus on secondary prevention and behaviour change advice. Therapy and nurse consultants typically have service development and management responsibility, but the role can include acute, rehabilitation and primary care stroke team liaison and support. 15 Stroke physicians focus on medical management and oversee patient care from admission through to follow up at six weeks; most advocate for and contribute fully to multidisciplinary team working in specialist stroke units. 1,8,16 Patient follow up at six months occurs in the community. In most NHS settings dieticians, clinical psychologists and social workers are not unit or ESD team-based and work more on the periphery of the multi disciplinary team. Early assessment of patients and appropriate referral prompted by the national clinical guidelines 1 and Sentinel Stroke National Audit Programme (SSNAP) standards 17 should ensure these professionals contribute to rehabilitation where specific needs are identified. Although arrangements vary across the UK, inpatient stroke unit and ESD team members work closely using a mixture of inreach, outreach and key worker systems to foster continuity in patient care. In some areas of the UK, the Stroke Association supports Stroke Information, Advice and Support workers. These individuals work with the core stroke team to offer practical advice and support to patients and their families in the days and weeks after the stroke; support may continue for up to one year post-stroke. Benefits of multidisciplinary team care There is unequivocal evidence of improved outcomes when patients are treated in a stroke unit by multi - disciplinary teams. 16 When compared with conventional care, organised inpatient stroke care resulted in long-term reductions in death, dependency and the need for institutional care. There is also good evidence that ESD teams facilitate earlier discharge to the home, increase the likelihood that patients will regain independence in activities that support daily living, and result in fewer patients requiring long-term institutional care. 8,18,19 These outcomes are associated with 6

3 Stroke rehabilitation z Multidisciplinary care established stroke unit or ESD team services, employing stroke skilled professionals who collaborate through regular multidisciplinary team meetings and have clearly defined stroke care pathways within the wider context of hospital or community care services. Policy makers expressly link improvement in quality of patient care with team-working. In the National Stroke Strategy, 4 six out of 20 quality improvement markers focus on co-ordinating rehabilitation professionals specialist skills and knowledge. Given the complexity of response to and recovery from neurological injury following stroke, it is self-evident that health professionals with specialist skills should work together to bring to bear their collective knowledge and skills for the benefit of patients. Stroke multidisciplinary teams are larger than many healthcare teams, so co-ordination and effective collaboration is important. Reported benefits of effective multidisciplinary team working include more patient-centred decision making, 20,21 a reduction in the fragmentation of care 22,23 and increased staff satisfaction, 24,25 as well as more efficient and effective use of resources. 26,27 However, policies, guidelines and research evidence do not themselves bring about change in health professionals behaviour; there has to be a commonly understood purpose and perceived or actual benefit at the individual and organisational level. 24,25 Effective multidisciplinary team working A major driver for quality improvement in stroke services nationally has been the SSNAP. 28 Conducted and published every two years since 1998, the audit provides a comprehensive summary of compliance with 12 key indicators of stoke care (see Table 1). Sentinel Stroke Audit scores have prompted commissioners, managers and multi - disciplinary teams to review and develop services. 28 Good practice has been shared, often supported through the NHS Improvement Stroke Programme. 29 In most cases, while an individual professional may take the lead for delivering on a key indicator, a multidisciplinary team approach is the most effective way of providing high-quality stroke services. 16,18 This is facilitated through multi - disciplinary team meetings, which should occur on one or more occasions each week and at which information on patients is shared, goals are discussed and discharge plans are considered. 1,6,28 Family meetings with representatives of the multi disciplinary team are not mandated but are commonly used to communicate with patients families and to involve them and the patient in goal setting. Regional and local initiatives An example of a co-ordinated and evidence-based response to complying with the SSNAP 17 standard for multidisciplinary team meetings and increasing their effectiveness is the development of the Greater Manchester Assessment of Stroke Rehabilitation (G-Master) toolkit. Manchester s 11 stroke rehabilitation units worked with the Greater Manchester and Cheshire Cardiac and Stroke Network and the University of Salford to develop the toolkit, which comprises agreed assessment tools and validated measurement scales. These are designed for use within multidisciplinary team meetings in stroke rehabilitation settings across the network to ensure a structured approach is used for information sharing and monitoring patient progress. 30 The toolkit also includes standards for stroke unit multidisciplinary teams to evaluate their team s activity. These address a wide range of issues including team climate, meeting structure, team member preparation, goal setting and documentation. Multidisciplinary team members report that implementation of the standards has improved communication within team meetings. This has been due in part to team members adhering to guidance on expected preparation for meetings and using standardised measures and information handover sheets to evaluate goal achievement and report on progress. 30 Focusing on clinical effectiveness can mean team processes are overlooked; the G- Master initiative draws attention to the contribution of these processes in multidisciplinary team working and in delivering effective care. Improving psychological care after stroke is important given that up to 30 per cent of patients will experience depression, around 20 per cent will experience anxiety and 35 to 60 per cent will have some element of cognitive impairment. 31 Assessment and appropriate referral are key to meeting patients needs for psychological care, but access to clinical psychologists and psychiatrists is acknowledged to be problematic for stroke services. 1,6,31 The Stepped Care approach developed by NHS Improvement Stroke 31 is designed to provide a structure within which the skills of core members of stroke multidisciplinary teams can be used effectively in assessment and implementation of simple interventions before referral to clinical psychologists or psychiatrists to step up to more complex interventions where these are required. The Royal Free Hospital in London introduced an emotional screening pathway as part of a multi - disciplinary team approach to inte- 7

4 Multidisciplinary care z Stroke rehabilitation grated care. 32 Therapists carry out emotional screening on a weekly basis with patients for whom they act as key workers. The approach has led to 100 per cent compliance with the SSNAP 17 standard for emotional screening, but more importantly, therapists report increased understanding of emotional issues, more confidence in talking about emotions and earlier identification of problems requiring referral to specialist services. 32 In turn, this benefits assessment of progress within the wider multidisciplinary team and helps to ensure goal setting is patient focused. The pathway is being introduced to all stroke services within the North Central London Cardiac and Stroke Network. 32 The Stroke REACH Early Discharge Scheme (Stroke REDS) operated by NHS Camden Provider Services 33 is a community-based example of effective team working. The scheme aims to ensure patients who are suitable for early supported discharge are provided with the same intensity of therapy they would have received as an inpatient. The Stroke REDS team operates an inreach service following receipt of referrals; discharge is then normally completed within 24 hours. The ESD team uses a key worker system and also works with other community services including the Carelink organisation and social care services. 33 After provision of six weeks of intensive rehabilitation by the interdisciplinary Stroke REDS team, patients are transferred to the community team with clearly defined rehabilitation goals and having established home-based therapy focused on increasing independence in daily living activities. The ESD team provides for continuity in rehabilitation, initially with the stroke unit multidisciplinary team and then after six weeks of ESD team intervention, with the wider community rehabilitation team. For patients, this continuity extends to the same team conducting the mandatory sixmonth review of their post-stroke progress and adaptation. 1,4 Reductions in length of stay of up to 10 days have been achieved for those who are suitable for the scheme; this has resulted in significant potential cost savings. 33 In addition, there have been measureable clinical benefits. These include maintained or improved independence on scales that measure level and specific areas of disability (Barthel scores), achievement of patient-agreed goals (measured using goal attainment scaling), improved extended activities of daily living scores and quality of life scores. Patient feedback in satisfaction surveys demonstrated 100 per cent agreement that care provided by this specialist interdisciplinary ESD team helped increase independence as far as was possible for individual patients. They also recognised that ESD team members worked together effectively to achieve this outcome. The project has been published as an exemplar of how a stroke specialist team initiative led to improved quality and productivity. 33 Looking forward Stroke services have delivered considerable improvements in the quality of care in the last five years. 1,3,29-33 Co-ordinated multidisciplinary team working has made a significant contribution to those improvements. The pace of change and demand for quality improvement in increasingly time-limited stroke rehabilitation will continue to challenge service providers. Significant investment has been made in the acute stages of the stroke pathway; attention now needs to focus again on rehabilitation in both secondary and primary care settings, with increased efforts to integrate hospital and community-based rehabilitation services. Continued support by commissioners and service managers for developing and maintaining multi - disciplinary and interdisciplinary working represents an appropriate and evidence-based investment in stroke rehabilitation. Declaration of interests None declared. Dr Clarke is a Lecturer in the School of Healthcare, University of Leeds and Research Fellow in the Academic Unit of Elderly Care and Rehabilitation, Bradford Royal Infirmary, Bradford References: 1. Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke, 4th Edition. Prepared by the Intercollegiate Stroke Working Party. London: Royal College of Physicians, Mohan KM, Wolfe CD, Rudd AD, et al. Risk and cumulative risk of stroke recurrence. A systematic review and meta-analysis. Stroke 2011;42: National Audit Office Progress in improving stroke care. London: The Stationery Office, Department of Health. The National Stroke Strategy. London: Department of Health, The IST-3 Collaborative Group. 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