575335
research-article2015
CRE0010.1177/0269215515575335Clinical RehabilitationTyson et al.
CLINICAL REHABILITATION
Article
The effect of a structured programme to increase patient activity during inpatient stroke rehabilitation: A Phase I cohort study
Clinical Rehabilitation 1–8 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215515575335 cre.sagepub.com
SF Tyson1, L Burton1,2 and A McGovern2
Abstract Objective: To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation. Design: A longitudinal cohort design. Setting: Three inpatient stroke rehabilitation services. Subjects: Stroke survivors receiving inpatient rehabilitation. Intervention: A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource. Main measures: Patients’ recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients’ and therapists’ diaries, or timetables (if used) to measure patient activity levels Results: At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day (p = 0.0001). The time spent in all types of recorded activity increased (p = 0.0001–0.002), except psychology where the increase did not reach significance (p = 0.670). Conclusions: A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource. Keywords Planning rehabilitation, everyday physical activity, stroke, implementation Received: 14 October 2014; accepted: 7 February 2015
1School
of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK 2Greater Manchester Strategic Clinical Network, Stockport, UK
Corresponding author: SF Tyson, Stroke Research Centre, School of Nursing, Midwifery & Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. Email: [email protected]
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
2
Clinical Rehabilitation
Introduction It is well-established that the amount of therapy patients’ undertake is key to the effectiveness of stroke rehabilitation; the more the better.1–4 Despite this, numerous publications over several decades have noted that stroke patients spend only a small proportion of their day in therapy and, even during inpatient rehabilitation, most of their day is spent inactive and alone, with little indication of improvement over the years.5–12 As exercise and the intensive practice of functional tasks are the most effective interventions to promote motor recovery after stroke,13 there is an imperative to find ways to maximise patients’ opportunities to be active and exercise during rehabilitation. The importance of activity and the amount of therapy was clearly demonstrated in the ‘Collaborative Evaluation of Rehabilitation in Stroke across Europe’ (CERISE) project, which compared patient outcomes, the amount and type of therapy received (using behavioural mapping techniques), and patients’ activity during stroke rehabilitation in four European countries.14–16 They reported that, although the type of therapy did not differ between countries, recovery was greatest in countries where patients received most therapy and were most active during the day. Furthermore, this was related to the way therapists worked and how the rehabilitation unit was organised rather than staffing levels or patient characteristics. The importance of service organisation for levels of therapy and patient activity was further illustrated in more recent reports from the AVERT (A Very Early Rehabilitation Trial) collaboration, which compared mobilisation practices.17,18 National clinical guidelines recommend that stroke rehabilitation should include strategies to maximise activity and opportunities to practice functional tasks, and suggest minimum levels of therapy,19 but there has been little published work regarding interventions to achieve this (see Ada et al.20 for a summary of possible interventions). A notable exception is a recent study of a programme to facilitate nurses to promote stroke patients’ structured independent practice of four interventions (muscle strengthening, sitting balance and reaching, getting up from a chair, and walking)
which showed dramatic increases the time patients spent in therapeutic activities.21 As part of a programme called IMProving REhabilitation for Stroke (IMPRES), we sought to improve patient inactivity and access to therapy during inpatient stroke rehabilitation without additional resources. Here, we report the Phase I modelling work to develop the intervention, consider feasibility and acceptability, and conduct a ‘proofof-concept’ evaluation of the impact on the amount of recorded therapy and patient activity to decide progression to Phase II trials are warranted.
Method A cohort design was used in which data from consecutive patients in the participating stroke rehabilitation services were evaluated for a two-week period before and after implementation of the IMPRES project. This process is summarised in Figure 1. All the inpatient stroke services in a large UK city (n = 7) were invited to participate and three agreed to do so. One of the participating services included stroke rehabilitation units at three different hospital sites. Data regarding the number of treatment/activity sessions and the time spent (in 15 minutes blocks) in occupational therapy, physiotherapy, speech and language therapy, psychology, washing and dressing practice, social activities, educational activities, patient-led therapy (independent structured activity or exercises), and therapeutic group work were recorded. This was extracted contemporaneously from records kept as part of standard care, including patient treatment records, patients’ diaries or timetables (if used), and therapists’ diaries. The information was transferred to a data return form by a member of the multidisciplinary stroke team. In some sites, this was a single individual who extracted all the data for all activities for all patients. In others, different professionals completed the data form for the activities that related to their profession and an individual collated the data. Data were included from all patients who were medically stable, fit for rehabilitation, and not receiving palliative care. Although we sought ethical approval from the local committee of the
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
3
Tyson et al.
Data regarding the amount and type of patient activity and therapy received was recorded for all patients receiving in-patient stroke rehabilitation in the participating rehabilitation services over a two week period
The elements of IMPRES programme were developed and implemented at each service over a12 month period. This included (detailed in Table 1): • • • •
Individualised patient timetables Structured independent practice therapeutic group activities social activities
using well-established service improvement techniques: • • • • • •
an internal ‘project champion’ process mapping ‘plan, do, study, act (PDSA) cycles action planning frequent communication between stakeholders open discussion to support problem-solving and celebrate success
Data regarding the amount and type of patient activity and therapy received were recorded for all patients receiving in-patient stroke rehabilitation in the participating rehabilitation units over a two week period
Figure 1. The process of implementation and evaluation of the IMPRES programme.
National Research Ethics Service, their view was that the project did not require approval as it was considered a service improvement project. This meant consent was not required from patients or
staff, but the services’ data protection policies meant that we were unable to collect any personal patient-related data or data that could identify the stroke service.
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
4
Clinical Rehabilitation
Table 1. Detailing the additional activities implemented in the stroke unit without additional resource. Stroke service
Additional activities implemented
Stroke rehabilitation service 1
Individualised patient timetables; structured independent practice; ‘Wii-Fit’ exercise sessions; carers’ stroke education sessions. Individualised patient timetables, structured independent practice; seated exercise group; breakfast club; group to discuss newspapers and current affairs; communication group; ‘WiiFit’ exercise sessions; board games; hand and eye coordination exercises; bingo; cards and dominoes; physiotherapy exercise group; film club; healthy eating group; carers’ stroke education group; upper limb exercise group; one-to-one information and support sessions with the Stroke Association (national charity for stroke survivors and their families); befriending/buddying with stroke survivors. Individualised patient timetables; structured independent practice; breakfast club; physiotherapy exercise group; art class; social communication group, peer support group; sensory retraining group; patient and carer sensory group; carers’ stroke education sessions; film club.
Stroke rehabilitation service 2 (includes rehabilitation units in three different sites)
Stroke rehabilitation service 3
The duration (time spent) and number of sessions of each type of activity before and after implementation of the IMPRES programme were compared using independent t-tests and chi-square tests.
The IMPRES programme The IMPRES intervention contained two main parts. First individualised patient timetables were introduced, and then structured activities were developed (in addition to the usual therapy provision). These are detailed in Table 1. The individualised timetables covered a sevenday week, with the day divided into one-hour blocks between 8 am and 6 pm, with a dedicated hour for lunch in the middle of the day. Once a week, the therapists and senior nurses worked together to populate the patients’ timetable with their planned therapy, activities, and any other plans (such as leaving the unit for a scan, meetings, or relatives/visitors’ needs) to ensure patients were not overloaded, avoid duplication of activities, and clashes with nursing or medical care needs. Having introduced the timetables in to everyday practice, structured activities were developed. This
needed to be achieved without displacing individual therapy treatment sessions and without additional resources (in terms of equipment or staff). In addition to the patients’ usual individual one-to-one therapy sessions, each discipline within the multi-disciplinary team committed to provide at least one therapeutic group activity per week, to organise patient-led practice of exercises and functional tasks outside therapy sessions (referred to as ‘independent practice’), and to consider adding social events. Each hospital developed activities that were suitable for their environment, model of service delivery, staff competencies, and interests. Once established, the group activities were usually led by therapy or rehabilitation assistants or hospital volunteers. At the weekly timetabling meetings, the multidisciplinary team allocated individual treatment sessions, group therapy, independent practice periods, and social activities to each patient as appropriate to their level of ability and needs. To facilitate structured independent practice, each therapist involved in the IMPRES programme developed at least one set of instructions for an activity or exercises for patients to practice independently outside individual and group therapy sessions. These were collated and shared between
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
5
Tyson et al. the participating sites. Further exercises and activities were added to this ‘library’ throughout the project. Suitable exercises and activities were prescribed for each patient by members of the team and time for their completion added to their timetable. These ‘prescribed activities’ were shared with visitors, therapy assistants, nurses, and ward volunteers who encouraged completion of the tasks during the timetabled independent practice sessions. Nursing therapy continued to promote activity at weekends as therapy services were only available during the working week.
Implementation of the IMPRES programme After the initial data collection phase, IMPRES was implemented iteratively in each hospital over a 12-month period using service improvement methods, such as process mapping, action planning, and ‘plan, do, study, act’ (PDSA) cycles.22–25 In each hospital, a senior member of the multidisciplinary team was identified as the internal project leader (or ‘project champion’), whose role was to be the internal driving force for implementation and a point of contact between the clinical and research teams. They joined monthly web conferences to share progress and difficulties, and to seek solutions to overcome any barriers.22–25 As stated, the changes needed to be made without displacing individual therapy treatment sessions and without additional resources in terms of equipment or staff. However, there were additional time demands on the project champions to lead and drive implementation, including training and professional development to enable assistants, volunteers, and nurses to supervise group and social activities and independent practice sessions, and for multidisciplinary timetabling sessions. These time resources were realised, in large part, by increasing the use of group therapy and involving nonqualified staff, which released the senior staff to manage the change in service delivery. An additional resource was the time given by the project team (i.e. the authors) to oversee the project. The timetabling process demonstrated to the teams how little activity patients were often
undertaking and highlighted the need for change. This required an increase in multidisciplinary cooperation. Processes were developed to promote multidisciplinary communication, strengthen teamworking, teach nurses, assistants and volunteers, and manage the change in workload. To accommodate the more structured approach to patient activity, staff frequently needed to structure their working day more specifically to ensure they were available to provide the planned treatment and activities. In some hospitals, staff started to use a timetable to plan their own time and workload. Staff in all services were unwilling to involve patients and/or relatives in the timetabling process, but all shared the timetables with the patients once complete. Informal feedback from the staff suggested that their reluctance to involve the patients was due to concerns that patients may request a degree or type of activity they could not provide. Finally, a change in culture was also sometimes required to counter the hospitals’ predominant, risk-averse approach, which tended to enforce patient passivity and inactivity20 (such as infection control, minimal moving and handling, falls prevention, and health and safety).
Results A total of 1493 consecutive daily patient treatment records, involving 2888 treatment or activity sessions, were evaluated; 915 daily records involving 1635 sessions took place in the two-week evaluation period before the IMPRES programme was implemented and 578 daily records involving 1253 sessions took place in the evaluation period after implementation. Implementation of the IMPRES programme led to significant increases in patient activity. Before implementation, patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation, this rose by 62 minutes to 123 minutes (SD = 88) (p
research-article2015
CRE0010.1177/0269215515575335Clinical RehabilitationTyson et al.
CLINICAL REHABILITATION
Article
The effect of a structured programme to increase patient activity during inpatient stroke rehabilitation: A Phase I cohort study
Clinical Rehabilitation 1–8 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215515575335 cre.sagepub.com
SF Tyson1, L Burton1,2 and A McGovern2
Abstract Objective: To develop an intervention and undertake a proof-of-concept evaluation of its feasibility, acceptability, and impact on recorded patient activity levels during inpatient stroke rehabilitation. Design: A longitudinal cohort design. Setting: Three inpatient stroke rehabilitation services. Subjects: Stroke survivors receiving inpatient rehabilitation. Intervention: A programme designed to increase patient activity, including individualised patient timetables, independent practice, therapeutic group work, and structured social activities was developed and implemented without additional resource. Main measures: Patients’ recorded activity levels were compared for two weeks before and after implementation of the programme. Data regarding the estimated time spent in different types of activity were extracted from patient treatment records, patients’ and therapists’ diaries, or timetables (if used) to measure patient activity levels Results: At baseline, recorded activity levels were low; patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation of the programme, recorded activity levels significantly increased to a mean of 123 minutes (SD = 88) per day (p = 0.0001). The time spent in all types of recorded activity increased (p = 0.0001–0.002), except psychology where the increase did not reach significance (p = 0.670). Conclusions: A structured programme can significantly increase recorded patient activity levels during inpatient stroke rehabilitation without additional resource. Keywords Planning rehabilitation, everyday physical activity, stroke, implementation Received: 14 October 2014; accepted: 7 February 2015
1School
of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK 2Greater Manchester Strategic Clinical Network, Stockport, UK
Corresponding author: SF Tyson, Stroke Research Centre, School of Nursing, Midwifery & Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. Email: [email protected]
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
2
Clinical Rehabilitation
Introduction It is well-established that the amount of therapy patients’ undertake is key to the effectiveness of stroke rehabilitation; the more the better.1–4 Despite this, numerous publications over several decades have noted that stroke patients spend only a small proportion of their day in therapy and, even during inpatient rehabilitation, most of their day is spent inactive and alone, with little indication of improvement over the years.5–12 As exercise and the intensive practice of functional tasks are the most effective interventions to promote motor recovery after stroke,13 there is an imperative to find ways to maximise patients’ opportunities to be active and exercise during rehabilitation. The importance of activity and the amount of therapy was clearly demonstrated in the ‘Collaborative Evaluation of Rehabilitation in Stroke across Europe’ (CERISE) project, which compared patient outcomes, the amount and type of therapy received (using behavioural mapping techniques), and patients’ activity during stroke rehabilitation in four European countries.14–16 They reported that, although the type of therapy did not differ between countries, recovery was greatest in countries where patients received most therapy and were most active during the day. Furthermore, this was related to the way therapists worked and how the rehabilitation unit was organised rather than staffing levels or patient characteristics. The importance of service organisation for levels of therapy and patient activity was further illustrated in more recent reports from the AVERT (A Very Early Rehabilitation Trial) collaboration, which compared mobilisation practices.17,18 National clinical guidelines recommend that stroke rehabilitation should include strategies to maximise activity and opportunities to practice functional tasks, and suggest minimum levels of therapy,19 but there has been little published work regarding interventions to achieve this (see Ada et al.20 for a summary of possible interventions). A notable exception is a recent study of a programme to facilitate nurses to promote stroke patients’ structured independent practice of four interventions (muscle strengthening, sitting balance and reaching, getting up from a chair, and walking)
which showed dramatic increases the time patients spent in therapeutic activities.21 As part of a programme called IMProving REhabilitation for Stroke (IMPRES), we sought to improve patient inactivity and access to therapy during inpatient stroke rehabilitation without additional resources. Here, we report the Phase I modelling work to develop the intervention, consider feasibility and acceptability, and conduct a ‘proofof-concept’ evaluation of the impact on the amount of recorded therapy and patient activity to decide progression to Phase II trials are warranted.
Method A cohort design was used in which data from consecutive patients in the participating stroke rehabilitation services were evaluated for a two-week period before and after implementation of the IMPRES project. This process is summarised in Figure 1. All the inpatient stroke services in a large UK city (n = 7) were invited to participate and three agreed to do so. One of the participating services included stroke rehabilitation units at three different hospital sites. Data regarding the number of treatment/activity sessions and the time spent (in 15 minutes blocks) in occupational therapy, physiotherapy, speech and language therapy, psychology, washing and dressing practice, social activities, educational activities, patient-led therapy (independent structured activity or exercises), and therapeutic group work were recorded. This was extracted contemporaneously from records kept as part of standard care, including patient treatment records, patients’ diaries or timetables (if used), and therapists’ diaries. The information was transferred to a data return form by a member of the multidisciplinary stroke team. In some sites, this was a single individual who extracted all the data for all activities for all patients. In others, different professionals completed the data form for the activities that related to their profession and an individual collated the data. Data were included from all patients who were medically stable, fit for rehabilitation, and not receiving palliative care. Although we sought ethical approval from the local committee of the
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
3
Tyson et al.
Data regarding the amount and type of patient activity and therapy received was recorded for all patients receiving in-patient stroke rehabilitation in the participating rehabilitation services over a two week period
The elements of IMPRES programme were developed and implemented at each service over a12 month period. This included (detailed in Table 1): • • • •
Individualised patient timetables Structured independent practice therapeutic group activities social activities
using well-established service improvement techniques: • • • • • •
an internal ‘project champion’ process mapping ‘plan, do, study, act (PDSA) cycles action planning frequent communication between stakeholders open discussion to support problem-solving and celebrate success
Data regarding the amount and type of patient activity and therapy received were recorded for all patients receiving in-patient stroke rehabilitation in the participating rehabilitation units over a two week period
Figure 1. The process of implementation and evaluation of the IMPRES programme.
National Research Ethics Service, their view was that the project did not require approval as it was considered a service improvement project. This meant consent was not required from patients or
staff, but the services’ data protection policies meant that we were unable to collect any personal patient-related data or data that could identify the stroke service.
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
4
Clinical Rehabilitation
Table 1. Detailing the additional activities implemented in the stroke unit without additional resource. Stroke service
Additional activities implemented
Stroke rehabilitation service 1
Individualised patient timetables; structured independent practice; ‘Wii-Fit’ exercise sessions; carers’ stroke education sessions. Individualised patient timetables, structured independent practice; seated exercise group; breakfast club; group to discuss newspapers and current affairs; communication group; ‘WiiFit’ exercise sessions; board games; hand and eye coordination exercises; bingo; cards and dominoes; physiotherapy exercise group; film club; healthy eating group; carers’ stroke education group; upper limb exercise group; one-to-one information and support sessions with the Stroke Association (national charity for stroke survivors and their families); befriending/buddying with stroke survivors. Individualised patient timetables; structured independent practice; breakfast club; physiotherapy exercise group; art class; social communication group, peer support group; sensory retraining group; patient and carer sensory group; carers’ stroke education sessions; film club.
Stroke rehabilitation service 2 (includes rehabilitation units in three different sites)
Stroke rehabilitation service 3
The duration (time spent) and number of sessions of each type of activity before and after implementation of the IMPRES programme were compared using independent t-tests and chi-square tests.
The IMPRES programme The IMPRES intervention contained two main parts. First individualised patient timetables were introduced, and then structured activities were developed (in addition to the usual therapy provision). These are detailed in Table 1. The individualised timetables covered a sevenday week, with the day divided into one-hour blocks between 8 am and 6 pm, with a dedicated hour for lunch in the middle of the day. Once a week, the therapists and senior nurses worked together to populate the patients’ timetable with their planned therapy, activities, and any other plans (such as leaving the unit for a scan, meetings, or relatives/visitors’ needs) to ensure patients were not overloaded, avoid duplication of activities, and clashes with nursing or medical care needs. Having introduced the timetables in to everyday practice, structured activities were developed. This
needed to be achieved without displacing individual therapy treatment sessions and without additional resources (in terms of equipment or staff). In addition to the patients’ usual individual one-to-one therapy sessions, each discipline within the multi-disciplinary team committed to provide at least one therapeutic group activity per week, to organise patient-led practice of exercises and functional tasks outside therapy sessions (referred to as ‘independent practice’), and to consider adding social events. Each hospital developed activities that were suitable for their environment, model of service delivery, staff competencies, and interests. Once established, the group activities were usually led by therapy or rehabilitation assistants or hospital volunteers. At the weekly timetabling meetings, the multidisciplinary team allocated individual treatment sessions, group therapy, independent practice periods, and social activities to each patient as appropriate to their level of ability and needs. To facilitate structured independent practice, each therapist involved in the IMPRES programme developed at least one set of instructions for an activity or exercises for patients to practice independently outside individual and group therapy sessions. These were collated and shared between
Downloaded from cre.sagepub.com at GEORGIAN COURT UNIV on May 9, 2015
5
Tyson et al. the participating sites. Further exercises and activities were added to this ‘library’ throughout the project. Suitable exercises and activities were prescribed for each patient by members of the team and time for their completion added to their timetable. These ‘prescribed activities’ were shared with visitors, therapy assistants, nurses, and ward volunteers who encouraged completion of the tasks during the timetabled independent practice sessions. Nursing therapy continued to promote activity at weekends as therapy services were only available during the working week.
Implementation of the IMPRES programme After the initial data collection phase, IMPRES was implemented iteratively in each hospital over a 12-month period using service improvement methods, such as process mapping, action planning, and ‘plan, do, study, act’ (PDSA) cycles.22–25 In each hospital, a senior member of the multidisciplinary team was identified as the internal project leader (or ‘project champion’), whose role was to be the internal driving force for implementation and a point of contact between the clinical and research teams. They joined monthly web conferences to share progress and difficulties, and to seek solutions to overcome any barriers.22–25 As stated, the changes needed to be made without displacing individual therapy treatment sessions and without additional resources in terms of equipment or staff. However, there were additional time demands on the project champions to lead and drive implementation, including training and professional development to enable assistants, volunteers, and nurses to supervise group and social activities and independent practice sessions, and for multidisciplinary timetabling sessions. These time resources were realised, in large part, by increasing the use of group therapy and involving nonqualified staff, which released the senior staff to manage the change in service delivery. An additional resource was the time given by the project team (i.e. the authors) to oversee the project. The timetabling process demonstrated to the teams how little activity patients were often
undertaking and highlighted the need for change. This required an increase in multidisciplinary cooperation. Processes were developed to promote multidisciplinary communication, strengthen teamworking, teach nurses, assistants and volunteers, and manage the change in workload. To accommodate the more structured approach to patient activity, staff frequently needed to structure their working day more specifically to ensure they were available to provide the planned treatment and activities. In some hospitals, staff started to use a timetable to plan their own time and workload. Staff in all services were unwilling to involve patients and/or relatives in the timetabling process, but all shared the timetables with the patients once complete. Informal feedback from the staff suggested that their reluctance to involve the patients was due to concerns that patients may request a degree or type of activity they could not provide. Finally, a change in culture was also sometimes required to counter the hospitals’ predominant, risk-averse approach, which tended to enforce patient passivity and inactivity20 (such as infection control, minimal moving and handling, falls prevention, and health and safety).
Results A total of 1493 consecutive daily patient treatment records, involving 2888 treatment or activity sessions, were evaluated; 915 daily records involving 1635 sessions took place in the two-week evaluation period before the IMPRES programme was implemented and 578 daily records involving 1253 sessions took place in the evaluation period after implementation. Implementation of the IMPRES programme led to significant increases in patient activity. Before implementation, patients undertook a mean of 61 minutes (SD = 39) of activity per day. After implementation, this rose by 62 minutes to 123 minutes (SD = 88) (p
