“Everyone needs rehab, but…”: exploring post-stroke rehabilitation referral and acceptance decisions

Abstract

Purpose

To explore the decision-making processes and experiences of acute and rehabilitation clinicians, regarding referral and acceptance of patients to rehabilitation after stroke.

Materials and methods

Multi-site rapid ethnography, involving observation of multidisciplinary case conferences, interviews with acute stroke and rehabilitation clinicians, and review of key documents within five (5) acute stroke units (ASUs) in Queensland, Australia. A cyclical, inductive content analysis was performed.

Results

Seven key themes were identified, revealing the complex nature of post-stroke rehabilitation referral and acceptance decision making. Although the majority of clinicians felt that all patients could benefit from rehabilitation, they acknowledged this could not always be the case. Rehabilitation potential and goals were considered by clinicians, but decision making was impacted by ASU context and team processes, rehabilitation service availability and access procedures, and the relationships between the acute and rehabilitation clinicians. Patients and families were not actively involved in the decision-making processes.

Conclusions

Post-stroke rehabilitation decision making in Queensland, Australia involves complex processes and compromise. Decisions are not based solely on patients’ rehabilitation needs, and patients and families are not actively involved in the decision-making process. Mechanisms are required to streamline access procedures, and improve shared decision making with patients.

IMPLICATIONS FOR REHABILITATION

• Referral decision making for post-stroke rehabilitation is complex and not always based solely on patients’ needs.

• Clear and straightforward access procedures and positive relationships between acute and rehabilitation clinicians have a positive impact on referral decision making.

• Stroke services should review their processes to ensure shared decision making is facilitated when patients require access to rehabilitation.

Keywords:

• Stroke
• rehabilitation
• decision-making
• referral
• access

Acknowledgements

We are exceedingly grateful to the clinicians who participated in this study, and to the patients and families on the wards at the time, who provided consent for data collection. The authors would like to thank the local site coordinators at each of the participating hospitals, for their practical support during data collection. We would also like to acknowledge Prof. Theresa Green, Dr Suzanne Kuys, Dr Eleanor Horton, Dr Benjamin Chen, and Mr Greg Cadigan for their roles in the wider BEEPRS project.

Ethics approval

Ethics approval was obtained from The Prince Charles Hospital Human Research Ethics Committee (HREC/16/QPCH/225) and the University of Queensland Human Research Ethics Committee (2016001563/HREC/16/QPCH/225).

Disclosure statement

None to declare.

Additional information

Funding

This research was supported by a grant from the Queensland Government, Department of Health – Clinical Excellence Division, Healthcare Improvement Unit.