Shaping the future of medical rehabilitation research: Using the interdisciplinary research model

This memorial lecture addresses the fundamental requirements for developing a framework for interdisciplinary rehabilitation research. The needs for funding, clinical trials, staffing, education, and infrastructure are examined from the vantage points of my experiences as an educator, investigator, chief executive officer, department chair, and dean. Developing an academic base for the specialty of physical medicine and rehabilitation and demonstrating our expertise in rehabilitation research are fundamental to academic acceptance and will enhance our ability to compete for future funding for our investigations.     

Patient-focused rehabilitation team cohesiveness in veterans administration hospitals

OBJECTIVE: To quantify the relation of hospital culture, 3 levels of leadership (hospital-level administrators, discipline-specific supervisors, attending physician on the team), and physician involvement to patient-focused rehabilitation team cohesiveness. DESIGN: Survey research. SETTING: 48 Veterans Administration hospitals (VAHs). PARTICIPANTS: Six hundred fifty members of 50 rehabilitation teams. INTERVENTIONS: Not applicable.Main outcome measures Scales measuring hospital culture, administrative support, supervisor expectations, attending physician support, and physician involvement (independent variables), and patient-focused rehabilitation team cohesiveness (dependent variable). Associations between scales were examined by using a hierarchical linear regression model. RESULTS: Patient-focused team rehabilitation cohesiveness was significantly (P<.05) associated with administrative support, supervisor expectations, attending physician support, and physician involvement (Wald chi(2)=1192.66, P<.0001) (R(2)=.6431). There was no statistically significant independent association with hospital culture. CONCLUSIONS: Expectations of discipline-specific supervisors and hands-on team leadership and involvement by the attending physician were associated to a significant degree with the extent to which rehabilitation teams in VAHs reported functioning in a cohesive manner. Higher functioning on patient-focused team cohesion indicates that patient services were likely delivered with greater interprofessional communication and joint effort.     

Satisfaction of members of interdisciplinary rehabilitation teams with goal planning meetings

OBJECTIVE: To study how satisfied members of interdisciplinary rehabilitation teams are with goal planning meetings. DESIGN: Survey. SETTING: A regional rehabilitation center for people with acute nonprogressive brain injuries in the United Kingdom. PARTICIPANTS: Forty-four rehabilitation professionals who participated in 31 goal-planning meetings held between January 1, 2001, and March 30, 2001. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Responses to a questionnaire about staff satisfaction with rehabilitation team meetings. RESULTS: Forty-four of 46 members of 21 different rehabilitation teams completed the questionnaires. They included 12 occupational therapists, 7 physiotherapists, 7 physicians, 6 nurses, 5 clinical psychologists, 5 speech pathologists, and 2 social workers. Median scores of different domains were as follows: participation, 13; behavior, 20; outcome, 14; and process, 16. Correlations between the participation and outcome domains (rho=.731, P=.01) and the process and outcome domains (rho=.384, P=.05) were significant. None of the domain scores correlated with features of the meetings. Scores given by chairpersons for participation (P=.001) and outcome (P=.047) were significantly higher than those given by other participants. CONCLUSIONS: Professionals were satisfied with the behavior of other participants and the process of goal-planning meetings. Satisfaction with outcome was related to satisfaction with the participation in and the process of the meetings. Chairpersons were more satisfied with the participation domain.     

Provider perspectives on rehabilitation of patients with polytrauma

Friedemann-Sánchez G, Sayer NA, Pickett T. Provider perspectives on rehabilitation of patients with polytrauma.

Objectives

To describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation.

Design

Qualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison.

Setting

The 4 VA polytrauma rehabilitation centers (PRCs).

Participants

Fifty-six purposefully selected PRC providers and providers from consulting services.

Interventions

Not applicable.

Main Outcomes Measures

Provider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves.

Results

According to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding.

Conclusions

The VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.     

Enhancing access of combat-wounded veterans to specialist rehabilitation services: the VA Polytrauma Telehealth Network

Darkins A, Cruise C, Armstrong M, Peters J, Finn M. Enhancing access of combat-wounded veterans to specialist rehabilitation services: the VA Polytrauma Telehealth Network.Operations Iraqi Freedom and Enduring Freedom have resulted in U.S. military personnel sustaining combat wounds of unprecedented severity and complexity that necessitate long-term rehabilitation. To meet what are often conflicting requirements in providing severely wounded veterans with timely and convenient access to specialist rehabilitation care, and to enable them to return to their local communities, the Veterans Health Administration has developed a state-of-the-art Polytrauma Telehealth Network that enhances access to such services by linking Veterans Administration rehabilitation facilities. This article describes the clinical, technical, and business process issues involved in the development of this network.     

早期康复治疗在地震伤员救治中的作用

目的探讨早期康复治疗在地震伤员救治中的作用。方法对转入的四川地震伤员:①成立抗震救灾治疗小组参与"爱心病房"全程查房及床边一对一治疗;②建立完善的地震伤员信息资料;③分类制定阶段性康复指导及治疗方案。结果接受近3月的康复治疗后,36例地震伤员在生命体征不稳定者(治疗前23例vs治疗后0例,P<0.01)、日常生活活动能力≤40分(治疗前32例vs治疗后4例,P<0.01)、心理情绪不稳定者(治疗前36例vs治疗后6例,P<0.01)都有明显改善;患者日常生活活动能力治疗前(28.75±14.61)与治疗后(75.83±19.55)比较,治疗后明显提高(P<0.01)。目前,已按照卫生部规定的出院标准出院。结论在综合医疗的同时,早期康复指导和治疗,避免或减轻了伤员残疾的发生,为其早日重返社会创造了条件。     

Interprofessional training and team function in patient-centred medical home: Findings from a mixed method study of interdisciplinary provider perspectives

ABSTRACT

Transitioning from profession-specific to interprofessional (IP) models of care requires major change. The Veterans Assessment and Improvement Laboratory (VAIL), is an initiative based in the United States that supports and evaluates the Veterans Health Administration’s (VAs) transition of its primary care practices to an IP team based patient-centred medical home (PCMH) care model. We postulated that modifiable primary care practice organizational climate factors impact PCMH implementation. VAIL administered a survey to 322 IP team members in primary care practices in one VA administrative region during early implementation of the PCMH and interviewed 79 representative team members. We used convergent mixed methods to study modifiable organizational climate factors in relationship to IP team functioning. We found that leadership support and job satisfaction were significantly positively associated with team functioning. We saw no association between team functioning and either role readiness or team training. Qualitative interview data confirmed survey findings and explained why the association with IP team training might be absent. In conclusion, our findings demonstrate the importance of leadership support and individual job satisfaction in producing highly functioning PCMH teams. Based on qualitative findings, we hypothesize interprofessional training is important, however, inconsistencies in IP training delivery compromise its potential benefit. Future implementation efforts should improve standardization of training process and train team members together. Interprofessional leadership coordination of interprofessional training is warranted.     

Promoting Evidence-Based Practice: The Influence of Novel Structural Change to Accelerate Translational Rehabilitation

ObjectiveTo evaluate changes in clinicians’ use of evidence-based practice (EBP), openness toward EBP, and their acceptance of organizational changes after a rehabilitation hospital transitioned to a new facility designed to accelerate clinician-researcher collaborations.DesignThree repeated surveys of clinicians before, 7-9 months, and 2.5 years after transition to the new facility.SettingInpatient rehabilitation hospital.ParticipantsPhysicians, nurses, therapists, and other health care professionals (n=410, 442, and 448 respondents at Times 1, 2, and 3, respectively).InterventionsImplementation of physical (architecture, design) and team-focused (champions, leaders, incentives) changes in a new model of care to promote clinician-researcher collaborations.Main Outcome MeasuresAdapted versions of the Evidence-Based Practice Questionnaire (EBPQ), the Evidence-Based Practice Attitudes Scale (EBPAS), and the Organizational Change Recipients’ Beliefs Scale (OCRBS) were used. Open-ended survey questions were analyzed through exploratory content analysis.ResultsResponse rates at Times 1, 2, and 3 were 67% (n=410), 69% (n=422), and 71% (n=448), respectively. After accounting for familiarity with the model of care, there was greater reported use of EBP at Time 3 compared with Time 2 (adjusted mean_t2=3.51, standard error (SE)=0.05; adj. mean_t3=3.64, SE=0.05; P=.043). Attitudes toward EBPs were similar over time. Acceptance of the new model of care was lower at Time 2 compared with Time 1, but rebounded at Time 3 (adjusted mean_t1=3.44, SE=0.04; adj. mean_t2=3.19, SE=0.04; P<.0001; adj. mean_t3=3.51, SE=0.04; P<.0001). Analysis of open-ended responses suggested that clinicians’ optimism for the model of care was greater over time, but continued quality improvement should focus on cultivating communication between clinicians and researchers.ConclusionsAccelerating clinician-researcher collaborations in a rehabilitation setting requires sustained effort for successful implementation beyond novel physical changes. Organizations must be responsive to clinicians’ changing concerns to adapt and sustain a collaborative translational medicine model and allow sufficient time, probably years, for such transitions to occur.     

The specialized role of the RN in the Program of All-inclusive Care for the Elderly (PACE) interdisciplinary care team

There is an increasing volume of literature supporting the Program of All-inclusive Care for the Elderly (PACE) as an innovative model of health care delivery for frail seniors. Registered Nurses (RN) hold an essential position among the PACE interdisciplinary teams (IDT) which serve as the foundational practice approach to patient care. There are currently 97 PACE programs in 31 states. Federal and respective state laws provide comprehensive specifications for IDT composition, minimum qualification of team members and services provided. The role of the RN is not fully defined beyond the requirement of periodic assessments. The intent of this study was to explore and describe the role of the nurse in PACE and to compare nursing care delivery models. Focused interviews and survey results show great variation in nursing roles as well as some common themes among nursing leaders for the vision of PACE nurses.     

Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan

Rathore FA, Farooq F, Muzammil S, New PW, Ahmad N, Haig AJ. Spinal cord injury management and rehabilitation: highlights and shortcomings from the 2005 earthquake in Pakistan.Recent natural disasters have highlighted the lack of planning for rehabilitation and disability management in emergencies. A review of our experience with spinal cord injury (SCI) after the Pakistan earthquake of 2005, plus a review of other literature about SCI after natural disasters, shows that large numbers of people will incur SCIs in such disasters. The epidemiology of SCI after earthquakes has not been well studied and may vary with location, severity of the disaster, available resources, the expertise of the health care providers, and cultural issues. A lack of preparedness means that evacuation protocols, clinician training, dedicated acute management and rehabilitation facilities, specialist equipment, and supplies are not in place. The dearth of rehabilitation medicine specialists in developing regions further complicates the issue, as does the lack of national spinal cord registries. In our 3 makeshift SCI units, however, which are staffed by specialists and residents in rehabilitation medicine, there were no deaths, few complications, and a successful discharge for most patients. Technical concerns include air evacuation, early spinal fixation, aggressive management to optimize bowel and bladder care, and provision of appropriate skin care. Discharge planning requires substantial external support because SCI victims must often return to devastated communities and face changed vocational and social possibilities. Successful rehabilitation of victims of the Pakistan earthquake has important implications. The experience suggests that dedicated SCI centers are essential after a natural disaster. Furthermore, government and aid agency disaster planners are advised to consult with rehabilitation specialists experienced in SCI medicine in planning for the inevitable large number of people who will have disabilities after a natural disaster.     

Early risk stratification of patients with major trauma requiring massive blood transfusion

Background

There is limited evidence to guide the recognition of patients with massive, uncontrolled hemorrhage who require initiation of a massive transfusion (MT) protocol.

Objective

To risk stratify patients with major trauma and to predict need for MT.

Designs

Retrospective analysis of an administrative trauma database of major trauma patients.

A regional trauma Centre

A regional trauma centres in Hong Kong.

Patients

Patients with Injury Severity Score ≥9 and age ≥12 years were included. Burn patients, patients with known severe anemia and renal failure, or died within 24 h were excluded.

Main outcome measures

Delivery of ≥10 units of packed red blood cells (RBC) within 24 h.

Results

Between 01/01/2001 and 30/06/2009, 1891 patients met the inclusion criteria. 92 patients required ≥10 units RBC within 24 h. Seven variables which were easy to be measured in the ED and significantly predicted the need for MT are heart rate ≥120/min; systolic blood pressure ≤90 mmHg; Glasgow coma scale ≤8; displaced pelvic fracture; CT scan or FAST positive for fluid; base deficit >5 mmol/L; hemoglobin ≤7 g/dL; and hemoglobin 7.1-10 g/dL. At a cut off of ≥6, the overall correct classification for predicting need for MT was 96.9%, with a sensitivity of 31.5% and specificity of 99.7%, and an incidence of MT of 82.9%. The area under the curve was 0.889.

Conclusion

A prediction rule for determining an increased likelihood for the need for massive transfusion has been derived. This needs validation in an independent data set.     

The needs of families of ICU trauma patients: an integrative review

BackgroundThe sudden, devastating, nature of traumatic injuries has a profound effect on patients and their families. When family needs are appropriately met in the intensive care units (ICU), families are empowered to support their injured relative (Blom et al., 2013). While the needs of families of general ICU patients have been examined the needs of trauma patients’ families are not known and may be unique.AimThe authors aimed to answer the question: “What are the needs of families of the adult ICU trauma patient?”MethodAn integrative review methodology was used.ResultsSixteen publications were included from ‘traumatic brain injury’ and ‘burns’ trauma subgroups. The themes of ‘information’; ‘making sense’; ‘hope’; ‘support’; ‘involvement’ and ‘protection’ were identified from the literature. ‘Protection’ was unique to trauma families, while the other themes concurred with those previously reported for general ICU families. This review was constrained by the lack of focused trauma patients’ families’ research, and was reliant on traumatic brain injury and burns subgroup studies. How the needs of these subgroups relate to other trauma patients’ families is not known, and worthy of further research.     

Historical exploration of the work and workload of the WW1 nurse in an Australian auxiliary hospital

BackgroundFollowing stabilisation in hospitals and on hospital ships wounded and sick servicemen in World War 1 were transferred to auxiliary (also known as convalescent) hospitals for convalescence and rehabilitation. Exploration of the work of the auxiliary (convalescent or rehabilitation) nurse is sparse.AimTo identify the Australian trained and untrained nurses and their nursing work in an Australian auxiliary hospital in England during WW1.MethodsDigitised primary and secondary sources were used to identify nurses and their work. To account for names and spelling variances a process of data validation was employed.FindingsFormally unrecognised, auxiliary (rehabilitation) nurses had a high patient load and worked long hours. Nursing activities spanned the acute, mental health and rehabilitation domains.DiscussionAnalogies can be made between perceptions of wartime auxiliary nursing work and the continued debate around contemporary rehabilitation nurses’ scope of practice.ConclusionThe complexity of WW1 auxiliary (rehabilitation) nurses’ work and workload was underestimated. Rehabilitative techniques gaining recognition today were embraced by auxiliary nurses over a century ago.     

Reliability of electronic versus manual wound measurement techniques

OBJECTIVE: To compare the accuracy and reliability of 3 wound measurement techniques, including linear and 2 electronic techniques--Visitrak and the VeV MD system. DESIGN: Repeated measures involving forty 2-dimensional "wounds" with a range of clinically relevant sizes were created using regular paper. Blinded observers measured the surface areas of wounds in 2 sessions, using 3 techniques. SETTING: Research department of a tertiary referral center. PARTICIPANTS: Four blinded observers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mixed linear models were fitted to determine interobserver and intraobserver variability. The average root mean square error (RMSE) for each measurement technique was determined to investigate the accuracy. RESULTS: Intraobserver variation was not significant in most measurement techniques. Interobserver variation was significant for all techniques. Linear measurements showed the highest RMSE, whereas VeV and Visitrak were comparable. CONCLUSIONS: Reliability of repeated wound measurements for all techniques can be achieved only with the same observer. Linear measurement has the least accuracy in evaluating wound size, VeV is slightly better than Visitrak for large wounds, and Visitrak is slightly better than VeV for small wounds. Our study shows that the use of electronic devices is superior to manual techniques to achieve valid measurements of wound area.     

创伤早期液体复苏终极标准的监控与探讨

目的 研究创伤救治复苏的评价指标及影响因素,探讨创伤患者早期液体复苏的终极标准与监控效应.方法 选择符合本项研究条件且需接受液体复苏者149例,采用损伤严重度评分(ISS)和急性生理学及慢性健康状况评分(APACHE Ⅱ)对其组织损伤程度和伤后病情危害状况进行评价与分组,收集液体复苏前、复苏后及结束等不同时间段的心率、血压、血氧饱和度、血气、血乳酸及中心静脉血氧饱和度或混合静脉血氧饱和度等,并记录每小时尿量,对应时间段的碱缺失及氧合指数等,分别比较监控指标的组间差异、时间效应及并发症或与预后的关系等.结果 救治24 h实现终极标准的全身指标有127例,细胞指标有112例,两者平均恢复时间比较差异有统计学意义(P<0.05);各监测指标24 h均实现终点目标者与>24 h或死亡者的APACHEⅡ分值比较差异具有统计学意义(P<0.01);并发症或死亡组实现终极目标的时间明显高于对照存活组,组间差异均有统计学意义(P<0.05或P<0.01).结论 创伤患者早期液体复苏不仅在于恢复生命体征的稳定,更重要是在血流动力学恢复正常的基础上,及时纠正组织灌流和细胞氧合不足,作为创伤救治复苏的终点目标.