Exercise Rehabilitation Services Provided by Physiotherapy Departments in Cancer Care in Ireland

Aims This study aimed to identify the physiotherapy exercise rehabilitation services available to patients with cancer in Ireland and to identify barriers to the provision of services. Methods Physiotherapy department managers in specialised cancer centres, public and private hospitals and palliative care settings were surveyed to establish the availability of exercise rehabilitation services for patients with cancer. Results Of 40 managers contacted, 24 responded providing information about 26 services. Ten services employed a dedicated oncology physiotherapist. Exercise classes were offered to patients with cancer by five services, primarily within the palliative care setting. In the 17 hospitals which provided surgery, ten provided oncology specific post-operative exercise rehabilitation and one offered a prehabilitation programme. Limited human and physical resources and absence of established physiotherapy pathways were cited barriers to service provision. Conclusion Exercise rehabilitation is not an element of standard care for patients with cancer in Ireland.

Effects of Transferring to the Rehabilitation Ward on Long-Term Mortality Rate of First-Time Stroke Survivors: A Population-Based Study.

OBJECTIVE: To assess the long-term health outcomes of acute stroke survivors transferred to the rehabilitation ward. DESIGN: Long-term mortality rates of first-time stroke survivors during hospitalization were compared among the following sets of patients: patients transferred to the rehabilitation ward, patients receiving rehabilitation without being transferred to the rehabilitation ward, and patients receiving no rehabilitation. SETTING: Retrospective cohort study. PARTICIPANTS: Patients (N = 11,419) with stroke from 2005 to 2008 were initially assessed for eligibility. After propensity score matching, 390 first-time stroke survivors were included. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Cox proportional hazards regression model was used to assess differences in 5-year poststroke mortality rates. RESULTS: Based on adjusted hazard ratios (HRs), the patients receiving rehabilitation without being transferred to the rehabilitation ward (adjusted HR, 2.20; 95% confidence interval [CI], 1.36-3.57) and patients receiving no rehabilitation (adjusted HR, 4.00; 95% CI, 2.55-6.27) had significantly higher mortality risk than the patients transferred to the rehabilitation ward. Mortality rate of the stroke survivors was affected by age ≥65 years (compared with age <45y; adjusted HR, 3.62), being a man (adjusted HR, 1.49), having ischemic stroke (adjusted HR, 1.55), stroke severity (Stroke Severity Index [SSI] score≥20, compared with SSI score<10; adjusted HR, 2.68), and comorbidity (Charlson-Deyo Comorbidity Index [CCI] score≥3, compared with CCI score=0; adjusted HR, 4.23). CONCLUSIONS: First-time stroke survivors transferred to the rehabilitation ward had a 5-year mortality rate 2.2 times lower than those who received rehabilitation without transfer to the rehabilitation ward and 4 times lower than those who received no rehabilitation.

Associations between hospital-based rehabilitation for hip fracture and two-year outcomes for mortality and independent living: An Australian database study of 1,724 elderly community-dwelling patients.

OBJECTIVE: To compare rates of mortality, hospital readmissions and independent living status for 2 years following hip fracture in community-dwelling patients with and without hospital-based rehabilitation. DESIGN: Retrospective cohort study. METHODS: Administrative data-sets were linked for hospital treatment, residential aged care admissions, selected community services and date of death for community-dwelling hip fracture patients. Mortality, readmissions, residency within aged care facilities and independent living status at intervals up to 2 years were compared in multivariate logistic regression for patients with and without hospital-based rehabilitation. RESULTS: Age, sex and comorbidity distributions were similar for 1,050 patients who received rehabilitation and 674 patients who did not. Rehabilitation added 11 days to total hospital stay and $AUD 12,000 to hospital costs. Mortality at 90 days after hip fracture was 4.7% for rehabilitation patients vs 10.7% for others (p < 0.001), and 26.2% vs 37.2% (p < 0.001) at 2 years. Beyond 90 days there was no significant association between receipt of rehabilitation and the proportion of patients meeting criteria for independent living. Hospital readmissions in the year following the index fracture were not significantly different. CONCLUSION: In-hospital rehabilitation substantially increases total hospital costs. It is associated with improved early and late survival, but not with the likelihood of living independently for up to 2 years after hip fracture.

[Comparison of the effects of rehabilitation in stroke patients rehabilitated in stationary conditions and the home]. / Porównanie efektów rehabilitacji u chorych po Udarze mózgu usprawnianych w warunkach stacjonarnych i warunkach domowych.

UNLABELLED: Rehabilitation after stroke is to help the patient recover optimal physical condition, psychosocial and vocational. Standard of care is to ensure comprehensiveness and continuity of the rehabilitation process. THE AIM OF THE STUDY: Was to compare the effects of rehabilitation in stroke patients rehabilitated in the hospital and at home. MATERIAL AND METHODS: The 90 patients after ischemic stroke were examined. The first examined group (45 people) consisted ofpatients rehabilitated at the Department of Rehabilitation and Physical Medicine of the WAM University Hospital in Lodz. The second examined group number (45 people) consisted of patients waiting for admission to the Department of Rehabilitation, who were rehabilitated in environmental conditions. The patients were examined twice: first before the rehabilitation (study I) and then at the end of rehabilitation program (study II). Functional status was examined with the Barthel ADL Index and the Brunnstrom scale. RESULTS: Both individuals after stroke rehabilitated in hospital and those rehabilitated in environmental conditions achieved a significant improvement in functional of paretic limbs and improving independence in activities of daily living. However, the improvement observed in the hospital group was significantly higher. Better positive effects in patients included hospital rehabilitation is achieved through the implementation of comprehensive treatment of the involvement in the therapeutic process the entire interdisciplinary team. CONCLUSIONS: The comprehensive stationary rehabilitation significantly affected on improving the functional ability of stroke compared to those rehabilitated in environmental conditions. Rehabilitation at home, even though it is associated with certain restrictions is an important element in the overall process of rehabilitation.

Users' experiences of physiotherapy treatment in a semi-urban public hospital in Kenya.

INTRODUCTION: Physiotherapy practice in Africa faces a number of challenges, one of which is the limited number of therapists in most public hospitals. In Africa, physiotherapy is still mainly institution based with very little community-based practice, leading to lack of access to services for a large part of the population. This study explores users' perceptions of physiotherapy, challenges faced by users, possible options for management, and determines whether current physiotherapy practice in a rural Kilifi District general hospital in Kenya facilitates future self-management of chronic conditions. METHODS: Eight in-depth interviews, 3 focus groups discussions and 4 participant observations were conducted for data collection. All interviews and focus group discussions were recorded using a digital recorder, transcribed into the Swahili language and then translated into English. The transcriptions were imported to NVivo 9 (www.qsrinternational.com) for management and storage. Inductive data analysis was used to generate themes from the rich-text data of the transcriptions. RESULTS: Many of the users perceived physiotherapy as being effective. Challenges included distance from health facilities, negative experiences with some therapists, and lack of staff and equipment. Rehabilitation options included community- and home-based programs fostering self-management of chronic conditions. Current hospital practice lacks emphasis on self-management skills for patients with chronic conditions who can do their physiotherapy at home. CONCLUSIONS: Users' experiences of physiotherapy treatment in this rural hospital indicate that a host of challenges exist. In the face of these challenges, the needs of the users seemed to be compromised, especially those with chronic conditions. Rehabilitation services that are accessible and affordable would be better options in rural and low-resource settings. There is therefore need for community-based services that place emphasis on self-management of chronic conditions for fostering better health outcomes in rural communities.

Utilization of rehabilitation services for inpatient with cancer in Taiwan: a descriptive analysis from national health insurance database.

BACKGROUND: Cancer is a major cause of global morbidity and mortality. Since a high prevalence of functional impairments has been observed among cancer patients, rehabilitation has been proposed as a strategy to restore patients' functional independence. The increasing number of cancer patients combined with a growing need for rehabilitation may result in increased utilization of rehabilitation services. This study aimed to investigate the utilization of rehabilitation services among hospitalized cancer patients in Taiwan between 2004 and 2008. METHODS: Annual admissions and total inpatient expenditures for admissions with a cancer diagnosis were calculated from the National Health Insurance Research Database (NHIRD). Rehabilitation services used by cancer and non-cancer patients, as well as the distributions of rehabilitation service type among the different hospital departments were also analyzed. RESULTS: The percentages of inpatient admissions with a cancer diagnosis increased from 14.01% to 17.1% between 2004 and 2008. During 2004, 5.25% of all inpatient admissions received rehabilitation services; this percentage increased to 5.62% by 2008. Among cancer admissions, 2.26% to 2.62% received rehabilitation services from 2004 to 2008. By comparison, 5.68% to 6.24% of non-cancer admissions received rehabilitation services during this period. Of the admissions who received rehabilitation services, only 6.44% and 7.96% had a cancer diagnosis in 2004 and 2008, respectively. Sixty-one percent of rehabilitation services were delivered in the departments of orthopedics (25.6%), neurology (14.4%), rehabilitation (11.9%), and neurosurgery (9.2%). CONCLUSIONS: In Taiwan, the utilization of rehabilitation services during hospitalization increased from 2004 to 2008. Although this trend was noted for cancer and non-cancer admissions, the utilization of rehabilitation services was generally greater by non-cancer admissions. Despite the benefits of rehabilitation, the actual rehabilitation needs of cancer patients remain unmet.

Neumonía Nosocomial en el Post operatorio de Cirugía Cardiaca. ¿Cuál es el papel de la Fisioterapia? / Nosocomial Pneumonia in the Postoperative period of Cardiac Surgery. What is the role of Physiotherapy?

Las infecciones nosocomiales constituyen una constante problemática en instituciones de salud de todo el globo, haciéndose necesaria la implementación de medidas para reducir su frecuencia; en este marco; ¿podría la fisioterapia intensiva ejercer impacto en la frecuencia de las infecciones respiratorias en pacientes post operados de cirugía cardiaca? Tratando de dar respuesta a la pregunta, se desarrolló este estudio de casos y controles en 214 pacientes sometidos a cirugía cardiaca en el Hospital Central "Dr. Emilio Cubas" del Instituto de Previsión Social de Asunción, Paraguay (HCIPS), en 2 periodos: abril a noviembre de 2010 (n=112), con fisioterapia respiratoria y rehabilitadora de lunes a viernes en horario matutino, definidos como controles y el grupo de pacientes definido como casos (n=102), de junio a diciembre de 2011 con fisioterapia respiratoria y rehabilitadora intensiva, es decir, los 7 días de la semana, en turnos matutino y vespertino. Se pretende en ambos grupos determinar la frecuencia de neumonía nosocomial (NIH) en el post operatorio, identificar los agentes involucrados, comparar las diferencias encontradas tras la intensificación de las sesiones de fisioterapia. Ambos grupos de pacientes no presentan diferencias demográficas; el promedio de edad fue 61 años, las dos terceras partes corresponden al sexo masculino, aunque en el grupo de controles la frecuencia de enfermedad pulmonar obstructiva crónica (EPOC) fue de 9,8% (n=112), en el grupo de casos (n=102) fue de 23,5%. En el grupo de controles (n=112), el 50,9% presentó diagnóstico de NIH. El germen aislado con mayor frecuencia en hemocultivo fue S. aureus, en esputo fue el Acinetobacter baumanii seguido de Klebsiella pneumoniae y Pseudomonas aeruginosa. El 36,6% (n=112) presentó atelectasia. En el grupo de casos (n=102) el 37,3% presentó NIH, reducción significativa respecto a los controles (p=0,0308032719). La frecuencia de atelectasia se redujo a 20,6% tras fisioterapia intensiva (p=0,0044945953). Se registró una diferencia significativa para aparición de NIH en pacientes con atelectasia (p= 0,0000032703). Los gérmenes aislados con mayor frecuencia fueron: en hemocultivo: S. coagulasa negativa; en esputo: Pseudomonas aeruginosa y Klebsiella pneumoniae. La letalidad en casos (n=112; 11%) y controles (n=102; 13%) no registró diferencias significativas. Estudios similares realizados en otros países demuestran una menor prevalencia de NIH, letalidad variable y agentes etiológicos similares. Se rescata como dato positivo de nuestro estudio la reducción significativa en atelectasias y NIH, atribuible a la intensificación de la fisioterapia. Palabras clave: infecciones, neumonía, cirugía cardiaca.

Hospital-acquired infections (HAI) constituted a constant problem in health care facilities throughout the globe. Thus, it is important the implementation of policies to reduce or eliminate their frequency. Within this framework, could physical therapy play a role in the frequency of respiratory infections in patients after cardiac surgery? Trying to answer this question, we have developed this case control study in 214 patients whom underwent cardiac surgery in the Central Hospital "Dr. Emilio Cubas" from the Instituto de Previsión Social de Asunción, Paraguay (HCIPS). We divided this cohort in two groups: 1 -Controls: April to November of 2010 (n=112), patients within this cohort received respiratory therapy and rehabilitation from Monday to Fridays in the mornings. 2- Cases (n=102) from June to December 2011, receiving intensive respiratory therapy and rehabilitation 7 days a week in the morning and in the afternoons. We determine the frequency of hospital-acquired infections in the post-op of both groups; identify the organisms causing these infections and compare the differences we found after intensify the sessions of respiratory therapy. There were no demographics differences in either group, the median age were 61 years, two thirds were males and on the control group the prevalence of COPD was 9.8% (n=112), in the case group was of 23.5% (n=102). In the control group (n=112), 50.9% of cases were diagnosed with HAI. The organism isolated more frequently form blood cultures was S. aureus, from sputum Acinetobacter baumanii followed by Klebsiella pneumoniae y Pseudomonas aeruginosa. The 36,6% (n=112) of patients have atelectasias. In the case group (n=102) el 37, 3% had Hospital-acquired infections (HAI), which is a significative reduction respect the control group (p=0,0308032719). The frequency of atelectasias decreased to 20,6% after intensive physiotherapy (p=0,0044945953). A significative difference was found in patients with atelectasias and HAI (p=0,0000032703). The organism isolated more frequently from blood cultures was: S. coagulasa negativa; from sputum: Pseudomonas aeruginosa y Klebsiella pneumoniae. Mortality in the case group (n=112; 11%) and control group (n=102; 13%) was not significantly different. Similar studies in other countries show a less prevalence of HAI, variable mortality and similar organisms. A positive finding from our study is the significative reduction en atelectasias and HAI in patients who received intensive physical therapy. Key words: infections, pneumonía, cardiac surgery.

Physical therapy services utilization and length of stay for obese patients following traumatic leg fracture.

BACKGROUND: Obesity is an increasing epidemic that can complicate the treatment of simple injuries and can increase health care costs. The purpose of the present study was to determine whether obesity is a factor in the utilization of inpatient physical therapy services and length of stay following a traumatic lower leg fracture. METHODS: A retrospective study of patients admitted to the hospital in 2005 and 2006 with a primary discharge diagnosis of lower leg or ankle fracture was conducted. Inclusion criteria were age > or = 18 years, only 1 involved lower extremity, and nonweight-bearing on the affected extremity per physician orders. Patients were excluded from the study if they had a fibular fracture only, pathological fractures, multiple trauma, severe cardiac or vascular comorbidities, or cognitive impairments. Data were compiled into 3 categories on the basis of body mass index (BMI): < 30, 30-35, > 35. Physical therapy services were measured in 15-minute units of time. These data were analyzed by within-group and between-group comparisons and with regression analysis. RESULTS: A total of 181 patients with a primary discharge diagnosis of distal lower extremity or ankle fracture were included in the study. Patients with a BMI >35 used more physical therapy services (mean services, 9.8 units) than did patients with a BMI of 30-35 (mean services, 6.2 units) or a BMI <30 (mean services, 5.6 units) (P = .001). Length of stay was also highest among patients with a BMI >35. LIMITATIONS: Factors other than BMI may be associated with length of stay and physical therapy use and may confound the association. CONCLUSION: Previous studies have shown that there is an increase in health care utilization among the bariatric population. The present study demonstrates similar findings for physical therapy services. Increased length of stay and physical therapy utilization among the bariatric population also result in increased staff utilization and equipment costs.

Patient dissatisfaction with acute stroke care.

BACKGROUND AND PURPOSE: Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. METHODS: All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. RESULTS: The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). CONCLUSIONS: Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

Is waiting for rehabilitation services associated with changes in function and quality of life in children with physical disabilities?

OBJECTIVES: To determine whether longer waiting times for rehabilitation were associated with deterioration in child functional status and/or quality of life. METHODS: Parents of 124 children (mean age 45 months) with physical disabilities (e.g., cerebral palsy, global developmental delay, spina bifida) who were referred to pediatric rehabilitation centers were interviewed every three months, from referral until admission into the rehabilitation program. Information from parental interviews included socio-demographics, parental empowerment (Family Empowerment Scale), function (WeeFIM: Functional Independence Measure for Children), and quality of life (PedsQL). Data on date of referral, age, gender, and diagnosis were obtained from hospital databases. RESULTS: Half of the sample waited more than 9.1 months (95% confidence interval: 6.5-16.1) for admission to a public rehabilitation program. A total of 42% paid for some private services while waiting. Over the waiting period, there was statistically significant improvement in WeeFIM cognition and total scores but not in mobility scores. PedsQL psychosocial summary score declined over the waiting period (p< .05). CONCLUSION: Longer wait times for rehabilitation were associated with declining psychosocial quality of life. Reducing waiting times for rehabilitation services may allow rehabilitation specialists to address psychosocial problems for these children.

Use of physical therapy in patients hospitalized with a diagnosis of generalized weakness: a retrospective study.

In a retrospective analysis of data from a national database, we observed and compared the presence of complications, lengths of stay, inflation-adjusted charges, and discharge statuses of two groups of patients hospitalized with a primary diagnosis of generalized weakness who did or did not receive physical therapy (PT) services. From a sample of patients (n = 38,991 cumulative from 1988 through 2003) from the Nationwide Inpatient Sample (NIS), 2.3% of patients admitted to the hospital with generalized weakness received PT intervention. Patients hospitalized with a primary diagnosis of generalized weakness who received PT services were sicker, had more selected secondary complications, and were demographically and socioeconomically dissimilar from patients who did not receive PT services. Quantitative analyses indicate that PT patients had longer inpatient hospital stays, more nonroutine discharges, and higher inflation-adjusted charges. The results are consistent with the interpretation that outcomes such as those examined here (nonroutine discharge, length of stay, and charges at discharge) are related to referral patterns in which only the most serious comorbidities qualify patients for referral for PT intervention services.

Perfil de fisioterapeutas brasileiros que atuam em unidades de terapia intensiva / A profile of Brazilian physical therapists in intensive care units

Este estudo visou investigar o perfil dos fisioterapeutas que atuam nas unidades de terapia intensiva (UTIs) no Brasil, focalizando a direção do serviço, técnicas fisioterapêuticas empregadas e nível de autonomia em relação à ventilação mecânica invasiva e não-invasiva...

The purpose of this study was to outline a profile of physical therapits who work in intensive care units (ICU) in Brazil, focusing on service manegement, techniques used, and the degree of therapists'autonomy regarding invasive and non-invasive mechanical ventilation...

[Use of rehabilitation services by technology-dependent children and adolescents in a maternal and child hospital in Rio de Janeiro, Brazil]. / Utilização de serviços de reabilitação pelas crianças e adolescentes dependentes de tecnologia de um hospital materno-infantil no Rio de Janeiro, Brasil.

The objective of this study was to describe the dependence on technology and use of rehabilitation services by children and adolescents in a maternal and child hospital in Rio de Janeiro, Brazil. Using a cross-sectional design, the following variables were analyzed: gender and age of the children and adolescents, socioeconomic characteristics of the family, technology dependence, and use of rehabilitation services. The majority of the study population consisted of preschoolers (56.3%), boys (58.3%), residing in Greater Metropolitan Rio de Janeiro (89.3%), from low-income families (70.9%), and cared for mainly by their mothers (93.8%), who in turn have low schooling (54.2%) and are unemployed (89.6%). Of the entire study population, 22.9% were dependent on more than three different technologies, with medication as the most prevalent. Government and nonprofit institutions fund the rehabilitation, and physical therapists are the most widely used health professionals during treatment (60.4%). The target hospital provides all of the specialized medical treatment and most of the rehabilitation.

A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial.

QUESTION: Is additional Saturday physiotherapy intervention beneficial for inpatients undergoing rehabilitation? DESIGN: Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS: Two hundred and sixty-two inpatients undergoing rehabilitation in an Australian metropolitan hospital. INTERVENTION: The experimental group received physiotherapy intervention from Monday to Saturday and the control group from Monday to Friday. OUTCOME MEASURES: Primary outcomes were hospital and physiotherapy length of stay. Secondary measures were collected to reflect patient outcomes (health state, independence, activity, flexibility and strength) and burden of care (discharge destination, adverse events, and follow-up physiotherapy intervention). RESULTS: There was a 3.2 day reduction for the experimental group (95% CI -0.5 to 6.9) in hospital length of stay and a 2.5 day reduction (95% CI -0.9 to 5.9) in physiotherapy length of stay. There was no significant between-group difference in change from admission to discharge for most of the secondary patient outcomes (health state, independence, activity, flexibility). The risk of the experimental group being categorised as strong relative to the control group was 1.2 (95% CI 0.99 to 1.50). The risk of not being discharged home, of having an adverse event, or requiring follow-up physiotherapy intervention was no greater for the experimental group than the control group. CONCLUSION: The provision of additional Saturday physiotherapy intervention resulted in a trend to shorter hospital and physiotherapy length of stay without affecting patient outcome unfavourably or increasing burden of care, suggesting that a larger multicentre trial is warranted.

The effect of additional physiotherapy to hospital inpatients outside of regular business hours: a systematic review.

Provision of out of regular business hours (OBH) physiotherapy to hospital inpatients is widespread in the hospital setting. This systematic review evaluated the effect of additional OBH physiotherapy services on patient length of stay (LOS), pulmonary complications, discharge destination, discharge mobility status, quality of life, cost saving, adverse events, and mortality compared with physiotherapy only within regular business hours. A literature search was completed on databases with citation tracking using key words. Two reviewers completed data extraction and quality assessment independently by using modified scales for historical cohorts and case control studies as well as the PEDro scale for randomized controlled trials and quasi-randomised controlled trials. This search identified nine articles of low to medium quality. Four reported a significant reduction in LOS associated with additional OBH physiotherapy, with two articles reporting overall significance and two reporting only for specific subgroups. Two studies reported significant reduction in pulmonary complications for two different patient groups in an intensive care unit (ICU) with additional OBH physiotherapy. Three studies accounted for discharge destination and/or discharge mobility status with no significant difference reported. Quality of life, adverse events, and mortality were not reported in any studies. Cost savings were considered in three studies, with two reporting a cost saving. This systematic review was unable to conclude that the provision of additional OBH physiotherapy made significant improvement to patient outcomes for all subgroups of inpatients. One study in critical care reported that overnight physiotherapy decreased LOS and reduced pulmonary complications of patients in the ICU. However, the studies in the area of orthopaedics, neurology, postcardiac surgery, and rheumatology, which all considered additional daytime weekend physiotherapy intervention, did not provide strong evidence to indicate effective reduction in patient LOS or improving patient discharge mobility status or discharge destination. Investigation should continue in this area, but future trials should ensure factors such as random allocation, groups equal at baseline, blinded investigators, and proven intervention are included in the study design.

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: a comparison between four European rehabilitation centres.

PURPOSE: The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries. METHOD: Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units. RESULTS: The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units. CONCLUSIONS: Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.

Process of care and mortality of stroke patients with and without a do not resuscitate order in the West Midlands, UK.

OBJECTIVE: . To compare the process of care of stroke patients with and without a do not resuscitate (DNR) order. DESIGN: Retrospective case note review with prospective follow up of mortality. SETTING: Seven acute hospitals, with stroke units, in the West Midlands, UK. PARTICIPANTS: A random sample of patients (n = 702) admitted to hospital with acute stroke over a twelve month period. MAIN OUTCOME MEASURES: Case mix and process of care measures derived from the intercollegiate stroke audit package. Thirty day and one year mortality. RESULTS: About one-third (34%, 238/702) of stroke patients had DNR orders. The thirty-day mortality for DNR patients was 67% (160/238) versus 10% (46/449) for patients without DNR orders. DNR patients had significantly worse case-mix profile than non-DNR patients - median age 81 y vs 75y; fully conscious 36% vs 79%, able to walk 1% vs 21% and no loss of power in either arm 5% vs 24% (all p < 0.0001). DNR patients were more likely to be assessed early by a speech and language therapist (77% vs 59%, p < 0.001), but less likely to receive the majority of their care in a stroke/rehabilitation unit (20% vs 57%, p < 0.0001), or be cared for on a stroke unit or by a stroke team (42% vs 70%, p <0.0001), or had a description of the site of the cerebral lesion (31% vs 38%, p = 0.05) or be given aspirin (30% vs 42%, p = 0.007). CONCLUSIONS: Stroke patients with a DNR order are not receiving optimum care in that they are not being cared for on stroke units or by specialist teams. This may reflect the inadequate provision of specialist stroke services in the UK.

A qualitative study of the intra-hospital variations in incident reporting.

OBJECTIVE: To determine the relationship between variations in hospital incident reporting and the corresponding attitudes and participation of medical professionals. METHODS: An in-depth qualitative case study using semi-structured interviews with hospital managers and clinicians. Twelve participants were theoretically sampled based on their involvement with clinical risk management and patient safety. Twenty-five medical physicians and four risk leads were selected from the specialist hospital departments of Obstetrics, Anaesthesia, General Surgery, Acute Medicine, and Rehabilitation. The data were analysed to develop a descriptive account of the intra-hospital variations in reporting and the associated attitudes of physicians. SETTING: The research was conducted in a single acute National Health Service Hospital Trust in the English Midlands. RESULTS: The qualitative data revealed significant variations in the intra-hospital organization of incident reporting between medical specialities that corresponded with the attitudes and participation of medical staff. Specifically, it was found that medical doctors were more inclined to report incidents where the process of reporting was localized and integrated within medical rather than managerial systems of quality improvement. Underlying these variations, it is suggested that medical reporting is more likely when physicians have greater control or ownership of incident reporting, as this fosters confidence in the purpose of reporting, in particular its capacity to make meaningful service improvements whilst maintaining a sense of collegiality and professionalism.

Randomized controlled trial of an early discharge rehabilitation service: the Belfast Community Stroke Trial.

BACKGROUND AND PURPOSE: To compare a community-based multidisciplinary stroke team (CST) approach with hospital-based rehabilitation in terms of hospital stay, functioning, quality of life, and service use and costs. METHODS: Stroke patients who met pre-agreed criteria were allocated randomly to the CST service (n=59) or to usual inpatient rehabilitation and follow-up care (n=54). Assessments were completed at randomization and 12 months later. Caregiver strain and satisfaction (n=55) were also assessed. Cost data were collected for a subsample of 38 patients. RESULTS: Almost 80% of surviving patients (n=691) were discharged home and a small number (n=55) were readmitted. Approximately 17% (113/649) were randomized. There were no statistically significant differences in hospital duration, costs, or outcome measures at baseline and 12 months except for higher satisfaction reported by CST patients. Overall, both groups recorded improvement in most domains over time. Carers reported a high level of satisfaction although the level of strain among carers is cause for concern. The community group (n=18) cost less than the hospital group (n=20). CONCLUSIONS: A mixed model of hospital-based and community-based rehabilitation services is likely to lead to increased patient choice and satisfaction and a potential reduction in bed pressures for less severe stroke patients.

Adherence to rehabilitation in patients with low back pain.

This study investigated adherence to low back pain rehabilitation in the clinical setting. Adherence was assessed in 105 (71 male and 34 female) patients attending private physiotherapy clinics for rehabilitation of low back pain. Three aspects of adherence were measured over the 4-week study period: attendance at clinic-based rehabilitation sessions, adherence to a home exercise component of rehabilitation, and adherence to activities and advice during clinic-based rehabilitation. Rehabilitation outcome was measured using the Patients' Measure of Perceived Rehabilitation (McDonald & Hardy 1990) and the Physiotherapists' Measure of Perceived Rehabilitation (McDonald & Hardy 1990). It was found that patients attended 87.7% of their scheduled physiotherapy rehabilitation appointments and reported completing 71.6% of their prescribed home exercises. In relation to adherence to clinic-based rehabilitation activities (as measured by the Sport Injury Rehabilitation Adherence Scale, Brewer et al. 2000), patients scored an average of 11.6/15. Although no gender differences were found, compensable patients adhered significantly less to clinic-based rehabilitation activities than did their non-compensable counterparts. Further, it was found that higher levels of adherence to clinic-based activities significantly predicted both the patients' and physiotherapists' perception of degree of rehabilitation at the end of the 4-week rehabilitation period. These findings are discussed in relation to rehabilitation strategies for physiotherapists.