Integrated care pathways: outcome from inpatient rehabilitation following nontraumatic spinal cord lesion

BACKGROUND

Integrated care pathways (ICPs) map the predicted course of an episode of patient care. They detail the expected interventions during the episode and document departures from the expected pathway (variance). This study describes the use of an ICP to audit the rehabilitation of patients with nontraumatic spinal cord injury admitted between 1997 and 1999.

METHODS

The ICPs and outcomes of 85 patients with nontraumatic spinal cord injury admitted to the Neurorehabilitation Unit at the National Hospital for Neurology and Neurosurgery, Queen Square, London were analysed. Data extracted included diagnosis, level of the lesion and duration of stay. The numbers and categories of goals and the rates of goal achievement were extracted and the variance patterns analysed.

RESULTS

An average of 28 patients were admitted each year. The level of disability on admission and the duration of stay decreased over the three-year period, while the average patient age increased from 48 to 54 years. None of these changes were statistically significant. On average each patient had three new goals set each week. Ninety per cent of all goals were achieved; this was not dependent on the category of goal. Sixteen patients (19%) accounted for 58% of all nonachieved goals. These patients tended to have acute-onset disability. The number of variances fell from 15 to 7 over the three-year period.

CONCLUSIONS

The pathway enables monitoring of the rehabilitation process. As the Unit becomes more experienced there is a trend to shorter, more focused admissions with fewer variances. Specific groups of patients with particular needs can be identified. Future patients benefit from closure of the 'audit loop' and the implementation of clinical change based on information obtained from the ICP.

Goal-setting in rehabilitation: report of a workshop to explore professionals' perceptions of goal-setting

OBJECTIVE

To explore the views of therapists, nurses and doctors working in a variety of rehabilitation settings on the goal-setting process.

METHODS

Sixteen rehabilitation staff from three different settings attended a goal-setting workshop in which the difficulties associated with goal-setting were described with their potential solutions.

RESULTS

Five difficulties with goal-setting were identified. (1) Formal goal-setting was felt to be an activity unusual for many of the patients although intrinsic to the activity of many professional groups. (2) Goal-setting is often insensitive to people's roles in the community. (3) Goal-setting in the hospital environment does not transfer easily to the community. (4) External factors (e.g. staff turnover) over which staff felt they had little control were important in the success of a goal-setting programme. (5) Goals tend to be formulated and owned by the team, rather than the patient.

CONCLUSIONS

Goal-setting is a very satisfactory activity for the team but to be as successful for the patient their needs must be acknowledged. People with mild disability and a short inpatient stay have different needs to those with acute onset severe permanent disability and those with chronic or progressive disability admitted from the community. Comparison of both process and outcome effects of different types of goal-setting is an area for future study.

Neurological rehabilitation nursing: a review of the research

Neurological rehabilitation is increasingly seen as a specialist form of rehabilitation requiring specialist nursing knowledge. However, as in many areas of nursing, nurses in this field recognize that there is a need to increase their knowledge base to ensure that they provide the best and most up-to-date quality care for their patients and their families. To achieve high levels of competence, neurological rehabilitation nurses need to be aware of the existing body of research in this field so that they can make sound decisions regarding their practice and future research endeavours. This review aims to validate the existing knowledge base in this area by identifying and critically analysing research conducted in the area of neurological rehabilitation nursing during the decade 1988-1998 and by identifying any gaps and weaknesses that may be addressed by future research. Studies were included in the review if they examined an aspect of rehabilitation nursing, were concerned predominately with the neurological patient and were conducted in an in-patient setting. Research with a medical focus was not included and only research published in English was reviewed. Relevant research located examined the following areas: (1) the role of the rehabilitation nurse; (2) specific problems concerning the neurological rehabilitation patient; (3) specific nursing interventions; (4) rehabilitation nursing practice; (5) the delivery of rehabilitation programmes and team working; and (6) the family of the rehabilitation patient. The review concludes that research in this speciality remains limited both in quantity and quality. Most of the studies lack rigour and, because they were conducted at a single site, their generalizability to other clinical sites may be limited.

Development of a neurological rehabilitation environment: an observational study

BACKGROUND

Engagement in therapeutic activity among stroke inpatients is advocated by many rehabilitation professionals. However, there is a lack of published evidence to indicate whether this is currently being achieved.

OBJECTIVE

To investigate the extent and types of 'rehabilitation' activities on a new neurological rehabilitation ward, and examine change in patients' behaviour related to the new environment and new initiatives.

DESIGN

Five one-week observation periods were conducted over two years, with a total of 67 patients being observed. A comparison was made with results of an earlier study of stroke patients' activities conducted at the same hospital.

RESULTS

Patients spent an average 43 min per day with therapists (9% of the working day) and this was only marginally supplemented by self-exercise (2% of the working day--approximately 10 min). However, the provision of a new rehabilitation environment was associated with a marked decrease in the time patients spent at their bedsides, and a decrease in time spent passively gazing or watching others.

CONCLUSIONS

Overall there was some positive change in patients' behaviour. We suggest that structured guidance is required from the whole multidisciplinary team to stimulate more self-directed therapy practice and recreation.