Factors influencing selection for rehabilitation after stroke: a questionnaire using case scenarios to investigate physician perspectives and level of agreement.

OBJECTIVES: To explore the key factors involved in decision making when selecting patients for rehabilitation after stroke and to examine the level of agreement among physician assessors regarding admission to rehabilitation. DESIGN: Questionnaire. SETTING: Health services with rehabilitation units in Victoria, Australia. PARTICIPANTS: Rehabilitation unit physicians. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Questionnaire with 2 components: the clinical and nonclinical factors that influence decision making and clinical case scenarios. RESULTS: Responses were received from 17 physicians from 12 of the 18 health services in Victoria. The most influential clinical factors listed by the respondents were prognosis, social supports, anticipated discharge destination, age, and anticipated length of stay. Key nonclinical factors were prioritization of internal health service referrals, patient's residence, and workforce capacity. Analysis of the clinical scenarios of patients with severe stroke showed that there was variability in the responses, with high levels of agreement for some cases and low levels for others. Almost all respondents agreed that prognosis was a key factor, yet, within the case scenarios, the reasons given for accepting or not accepting the patient demonstrated different opinions on the prognosis of the case presented. CONCLUSIONS: The decision-making processes in selection for rehabilitation and the factors that influence that decision require further investigation to optimize the use and outcomes from rehabilitation resources.

How much and where: assessment of knowledge level of the application of cricoid pressure.

INTRODUCTION: Application of cricoid pressure is a frequently used technique in both rapid sequence intubation in multiple settings and in a more controlled setting in the operating room. In a survey of emergency department personnel performed at the University of Michigan, it was found that there is a knowledge deficit in the recommended force and the anatomic localization of cricoid pressure. Participants in the original study, which included emergency nurses, medical residents, and attending physicians, rated their training in cricoid pressure as poor or nonexistent. A review of the literature shows that, although cricoid pressure is used during endotracheal intubation to protect against regurgitation of gastric contents, many people applying cricoid pressure do not have a good knowledge of where to apply the pressure or how much pressure to apply to be effective. Because cricoid pressure is applicable in areas other than the emergency department, our study surveys personnel in emergency medical services/flight crew; emergency, intensive care unit, and operating room nurses; and respiratory therapists. Even though the use of cricoid pressure is no longer recommended, it is still routinely used. Although applying cricoid pressure is a simple procedure, persons using it must be thoroughly trained and retrained to prevent complications. METHODS: When we replicated the University of Michigan study at a 254-bed tertiary care facility, a potential of 325 staff members were given access to an online survey using the questions in the original survey. Staff were assigned to a HealthStream module and sent an invitation through their employee e-mail account. The module included a link to the questionnaire, and demographic data were gathered. The module was optional and results confidential. RESULTS: Operating room nurses were most likely to receive supervised instruction on anesthetized patients. These operating room nurses also showed the highest overall knowledge level about the application technique of cricoid pressure. DISCUSSION: There continues to be a lack of knowledge about the application of cricoid pressure during intubation. There is an opportunity for collaboration between staff and academic educators to allow for additional theoretical as well as hands-on practice.

The utility of short-term goal achievement as an early indicator of discharge destination in people admitted to neurological rehabilitation with severe functional deficits.

PURPOSE: This study investigates whether short-term goal achievement in the early phase of neurological rehabilitation is an accurate indicator of discharge destination in patients with severe disability in comparison to change in scores in the motor domain of the Functional Independence Measure (FIM motor). METHOD: A prospective observational cohort study. PARTICIPANTS: A consecutive sample of 53 patients admitted to rehabilitation with a neurological diagnosis and FIM motor score below 47.Measures: Short-term goal achievement and FIM motor change in the first 2 weeks following admission and discharge destination. RESULTS: Short-term goal achievement showed good prognostic utility [area under the curve (AUC) of 0.75; 95% confidence intervals (CI) 0.6, 0.89] for discharge destination, dichotomized as home or semi-independent living versus nursing home care, similar to that demonstrated by change in FIM motor scores (AUC of 0.69; 95% CI 0.55, 0.84), p = 0.55. A cut-off was established for short-term goal achievement at more than half of goals achieved, with an AUC of 0.73 (95% CI 0.58, 0.87); sensitivity 71.4% and specificity 74.4%. CONCLUSIONS: Short-term goal achievement in the early phase post-admission is a good indicator of the person's potential to return home.Implications for RehabilitationShort-term goal setting should be a key practice feature of neurological rehabilitation.Goal achievement is an indicator of a person's potential to return home or to semi-independent living in people with severe neurological deficits.Evaluation of short-term goal achievement may inform the ongoing rehabilitation program and discharge planning.