Referral to rehabilitation following traumatic brain injury: a model for understanding inequities in access

Identifying inequities in access to health care requires critical scrutiny of the patterns and processes of care decisions. This paper describes a conceptual model. derived from social problems theory. which is proposed as a useful framework for explaining patterns of post-acute care referral and in particular, individual variations in referral to rehabilitation after traumatic brain injury (TBI). The model is based on three main components: (1) characteristics of the individual with TBI, (2) activities of health care professionals and the processes of referral. and (3) the contexts of care. The central argument is that access to rehabilitation following TBI is a dynamic phenomenon concerning the interpretations and negotiations of health care professionals. which in turn are shaped by the organisational and broader health care contexts. The model developed in this paper provides opportunity to develop a complex analysis of post-acute care referral based on patient factors, contextual factors and decision-making processes. It is anticipated that this framework will have utility in other areas examining and understanding patterns of access to health care. (C) 2002 Elsevier Science Ltd. All rights reserved.

The template: A cooperative approach to evaluating community rehabilitation services

This article describes a workshop and consultation process utilized by four community rehabilitation services and other stakeholders. This process led to the development of an evaluation Template upon which to plan a service evaluation. The Template comprises a number of guiding questions within three broad domains. These are, the people domain (pertaining to the client, their disability, their family and service context), the program domain (pertaining to the service and its activities), and the perspective domain (pertaining to the broader social and community context). It is suggested that the Template, the process by which it was developed, and the guidelines for its use will have relevance to rehabilitation managers, administrators, and others involved in evaluation of community rehabilitation services.

Classifying client goals in community-based ABI rehabilitation: a taxonomy for profiling service delivery and conceptualizing outcomes

Purpose: To develop, confirm and trial a framework for analysing the content of goals set within community-based rehabilitation. This framework (taxonomy) is proposed as a tool to assist in service evaluation and outcome exploration. Method: Qualitative thematic analysis and categorization of 1765 rehabilitation goal statements in a four phase process of synthesis, refinement, verification and application. Results: A taxonomy of goal content was developed comprising 21 categories within five domains, utilizing 125 descriptors. The taxonomy demonstrated good inter-rater consistency and was able to discriminate between similar but related data sets comprising goal statements. Conclusion: Structured analysis of the content of goal setting (particularly in community rehabilitation) utilizing a framework such as the proposed taxonomy has considerable potential as a 'window' into service delivery to broaden the parameters of existing service evaluation and to more clearly link outcome exploration to intervention.

Standing with assistance of a tilt table in intensive care: A survey of Australian physiotherapy practice

Although tilt tables are used by physiotherapists to reintroduce patients to the vertical position, no quantitative evidence is available regarding their use within intensive care units (ICUs) of Australian hospitals. The purpose of this study was to evaluate the use of tilt tables in physiotherapy management of patients in ICUs across Australia. Ninety-nine physiotherapists working in Australian public ICUs were contacted via mail and asked to complete a questionnaire regarding their use of tilt tables in practice. Reasons for the use of the tilt table, contraindications, commonly used adjuncts, monitoring, and outcome measures were also investigated. Eighty-six questionnaires were returned (87% response). The tilt table was used by 58 physiotherapists (67.4%). The most common reasons for inclusion of tilt table treatment were to: facilitate weight bearing (94.8% of those who tilt); prevent muscle contractures (86%); improve lower limb strength (81%); and increase arousal (70%). The tilt table was most frequently applied to patients with neurological conditions (63.8%) and during long-term ICU stay (43.1%). Techniques often combined with tilt table treatment included upper limb exercises (93.1%) and breathing exercises (86.2%). Standing with assistance of the tilt table is used by the majority of physiotherapists working in Australian ICUs. A moderate level of agreement is demonstrated by physiotherapists regarding indications to commence tilt table treatment and adjunct modalities combined with standing with assistance of the tilt table.

Meeting in the middle: Improving communication in primary health care consultations with people with an intellectual disability

The increased presence and participation in Australian society of people with an intellectual disability provides challenges for the provision of primary health care. General practitioners (GPs) identify themselves as ill equipped to provide for this heterogeneous population. A major obstacle to the provision of appropriate health care is seen as inadequate communication between the GP and the person with an intellectual disability, who may or may not be accompanied by a carer or advocate. This qualitative study in which five GPs, three people with intellectual disability, seven carers and two advocates (parent and friend) were interviewed was conducted in Brisbane, Australia. The aim was to better understand the factors that have an impact upon the success of communication in a medical consultation. Findings suggested that GPs were concerned with the aspects of communication difficulties which influenced their ability to adequately diagnose, manage and inform patients. Implications for practice management were also identified. People with intellectual disability reported frustration when they felt that they could not communicate adequately with the GP and annoyance when they were not included in the communication exchange. Carers were strong advocates for the person with intellectual disability, but indicated insufficient skill and knowledge to provide the level of assistance required in the consultation. The outcome was a model of cooperation that outlined the responsibilities of all players in the medical encounter, prior to, during and after the event.

Effects of patient-focused care on seclusion in a psychiatric intensive care unit

The objective of the study was to evaluate whether the introduction of patient-focused nursing care affected the number of seclusions and the length of time patients spent in seclusion, in an acute psychiatric unit. The study used a pre-intervention–post-intervention design and was conducted in an eight-bed locked unit within a large regional general hospital in Queensland, Australia. The medical records of all people who were secluded as part of their management while in hospital, during two 6-month periods, were retrospectively reviewed. Changes to the ways in which nurses conducted their daily activities were implemented during the time between the data collection periods. There were no differences between the groups with respect to the number of times a patient was secluded. However, following implementation of patient-focused care, there was a reduction in the length of time for which patients were secluded. The only change in medication administration was that post-implementation, Haloperidol was used in fewer seclusion episodes. The findings indicate that changes to nursing practice may result in closer monitoring of patients and a reduction in the time patients spend secluded in acute inpatient psychiatric settings.

Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

Multisite, quality-improvement collaboration to optimise cardiac care in Queensland public hospitals

Objective: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration. Design: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003. Setting: Nine public hospitals in Queensland. Study populations: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF). Intervention: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group. Main outcome measure: Changes in process-of-care indicators between baseline and post-intervention periods. Results: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving β-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF. Conclusion: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.

Optimising care of acute coronary syndromes in three Australian hospitals

Objective. To improve quality of in-hospital care of patients with acute coronary syndromes using a multifaceted quality improvement program. Design. Prospective, before and after study of the effects of quality improvement interventions between October 2000 and August 2002. Quality of care of patients admitted between 1 October 2000 and 16 April 2001 (baseline) was compared with that of those admitted between 15 February 2002 and 31 August 2002 (post-intervention). Setting. Three teaching hospitals in Brisbane, Australia. Study participants. Consecutive patients (n = 1594) admitted to hospital with acute coronary syndrome [mean age 68 years (SD 14 years); 65% males]. Interventions. Clinical guidelines, reminder tools, and educational interventions; 6-monthly performance feedback; pharmacist-mediated patient education program; and facilitation of multidisciplinary review of work practices. Main outcome measures. Changes in key quality indicators relating to timing of electrocardiogram (ECG) and thrombolysis in emergency departments, serum lipid measurement, prescription of adjunctive drugs, and secondary prevention. Results. Comparing post-intervention with baseline patients, increases occurred in the proportions of eligible patients: (i) undergoing timely ECG (70% versus 61%; P = 0.04); (ii) prescribed angiotensin-converting enzyme inhibitors (70% versus 60%; P = 0.002) and lipid-lowering agents (77% versus 68%; P = 0.005); (iii) receiving cardiac counselling in hospital (57% versus 48%; P = 0.009); and (iv) referred to cardiac rehabilitation (17% versus 8%; P < 0.001). Conclusions. Multifaceted approaches can improve care processes for patients hospitalized with acute coronary syndromes. Care processes under direct clinician control changed more quickly than those reliant on complex system factors. Identifying and overcoming organizational impediments to quality improvement deserves greater attention.

Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral. (C) 2004 Elsevier Ltd. All rights reserved.

Rehabilitation after total knee replacement via low-bandwidth telemedicine: the patient and therapist experience

After a total knee replacement, inadequate rehabilitation is associated with poor physical outcomes and a reduced longevity of the knee prosthesis. We have developed a low-bandwidth telemedicine system to enable rehabilitation services to be delivered directly to the home of patients in rural and remote areas. We have examined the experience of clinical physiotherapists and of 31 participants who received treatment via the system. High levels of satisfaction were reported by participants (mean responses >7 on a 10 cm visual analogue scale). The service was found to be effective, safe and easy to use, and it integrated well into current clinical practice. The study demonstrates the potential for delivering physiotherapy services via low-bandwidth Internet connections.