HYDERABAD, INDIA — Work organizational factors and not patient factors were the major determinants influencing the frequency and intensity of the provision of therapy to acute stroke patients, a qualitative case study series involving UK stroke units finds.
"So in this study it was very striking. It wasn't about patients and their fatigue or their readiness or their ability [to participate in therapy]," David Clarke, PhD, lecturer in stroke care at the University of Leeds, United Kingdom, told delegates here at the World Stroke Congress (WSC) 2016. "It was work organizational factors" that were the major barriers to provision of care.
He said established working practices and professional cultures can be resistant to change but may be addressed through patient-focused work reorganization and staff development using methods of service improvement.
Studies have shown that increased frequency and intensity of therapies are associated with improved outcomes in the first 6 months after stroke. In the United Kingdom, the recommendation is for 45 minutes daily, 5 days a week, of occupational, physical, and speech-language therapy each. However, national audits consistently report that these targets are not being met. The Recommended Amount of Active Therapy (ReAcT) study set out to discover the reasons.
The investigators studied eight National Health Service stroke units in England, performing about 1000 hours of general observations and 434 patient-specific observations. They analyzed therapy records and performed semi-structured interviews with staff and patients/caregivers. Among the units observed, there were hyperacute, acute, and rehabilitation units, and a mixture of types, with the number of beds ranging from 24 to 68.
Audit ratings ranged from AAA to DDD, with a mix of in-between ratings based on number of daily minutes in which patients received each of the three kinds of therapy. Only two units achieved an AAA rating.
Among 77 patients typical of stroke unit residents, 49 were interviewed, as were 50 of 53 caregivers and 130 of 193 staff. Staff members were 16% male, and the group had a mean age of 35.6 years.
Staff Factors Biggest Impediments
The researchers found seven major factors affecting the provision of care to patients: organization of the therapists' working day, time spent in non–patient contact activity, patient factors, staffing levels and deployment, limited use of timetabling of therapy, limited knowledge of evidence for increased frequency and intensity of therapy, and influence of national audits.
The first two factors — both of a systemic, organizational nature — were the greatest impediments to providing care up to national standards. Across the eight stroke units, each staff member spent 1.3 to 8.6 hours per day in non–patient contact activities of information exchange among staff.
As one would expect, the minimum time spent in information exchange was reflected in the audit ratings. The worst-performing unit had a DDD rating, where workers were spending 8.6 hours per day in non–patient contact activities. Staff in the two units with AAA ratings spent 1.3 and 3.8 hours per day on such activities. Staff time not spent talking to each other left more time for patient therapy.
Exacerbating the problem, most units adhered to traditional 8-hour work days, with the time available for therapy further eroded by protected meal times, documenting therapy, and performing audit data entry. Actual time available for therapy was less than 5 hours per day for each staff member.
Staffing levels in general were inadequate. Seven of eight units had less than the number of recommended physical and occupational therapists, and all eight were deficient in speech-language therapists.
Dr Clarke said that there was limited evidence that the principle of "more therapy more frequently is associated with better outcomes" influenced the planning and delivery of therapy.
However, two units undertook service reorganizations. One reviewed and substantially reduced the time devoted to non–patient contact activities and also increased patient contact time by extending the work day with staggering of start and finish times. Both units simplified and standardized entry of audit data and used national audit performance ratings in business cases to target therapist staffing increases.
Only one unit used electronic records, which provided a substantial advantage in that paper-based units often required staff to enter the same information on different forms up to three times whereas electronic records could automatically repopulate the information.
Given the magnitude of the problem, "a shift in therapists' thinking and practice towards patient-centered rather than therapist-centered working in many UK stroke units is required," Dr Clarke advised.
Session chair Patrik Michel, MD, head of the stroke center at Lausanne University Hospital in Switzerland, noted that the units were slightly understaffed, but the main problem was that "the organization of their therapy needs can be improved" to reduce workers' time on bureaucracy and paperwork.
"Quality improvement is always both an internal and external process," requiring both internal quality improvement standards and systems as well as external audits, he told Medscape Medical News. "Of course, the improvement process itself is at risk of creating bureaucracy, so the internal audits should be both simple and be done without much bureaucratic efforts."
Professor Michel said another interesting finding of the study is that the professionally trained therapists seemed not to be aware of the scientific evidence that more intensive therapy leads to better outcomes. "So there is some work to be done as well on that level," he said.
The study had no commercial funding. Dr Clarke and Professor Michel have disclosed no relevant financial relationships.
World Stroke Congress (WSC) 2016. Presented October 28, 2016.
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