Protocol for audit of current Filipino practice in rehabilitation of stroke inpatients

Figures & data

Figure 1 Flow chart of hospital recruitment process.

Abbreviation: PARM, Philippine Academy of Rehabilitation Medicine.

Table 1 Current practice audit items

Demographic data

• Name

• Age

• Sex

• Marital status and family supports

• Address

• Occupation

• Handedness

• Religion

Medical history

• Type of stroke

• Deficits present

◦ Level of consciousness

◦ Best gaze

◦ Visual field cut

◦ Facial paralysis

◦ Movement arm

◦ Movement leg

◦ Sensory

◦ Aphasia

◦ Dysarthria

◦ Apraxia

◦ Neglect

• National Institutes of Health Stroke Severity Scale

• Date of stroke

• Involved hemiplegic side

• Comorbidities (diabetes mellitus, hypertension, cholesterol levels)

• Presence of medical complications

◦ Hypertensive crisis

◦ Restroke

◦ Myocardial infarction

◦ Renal complications

◦ Pneumonia (nosocomial)

• Presence of rehabilitation complications

◦ Aspiration pneumonia

◦ Deep vein thrombosis

◦ Skin breakdown

◦ Contracture formation

◦ Constipation

Date of rehabilitation referral

Early mobility

Number of treatment sessions during inpatient rehabilitation

Applied plan of care (clinical indicators)

• ROM exercises

◦ PROM

◦ AAROM

◦ AROM

• Progressive resistive exercises (bed mobility and positioning, transfer training, sitting balance and tolerance, sit to stand, standing balance and tolerance, ambulation inside/bars, ambulation outside/bars with or without assistive device)

Increase in exercise intensity whilst in rehabilitation

Evidence of assessing for factors which need to be reported for increasing exercise intensity

• Severity of stroke

• Medically stable (criteria to be determined)

• Mental status (MMSE)

• Level of function (FIM)/Barthel Index

Comprehensive discharge summary outlining rehabilitation outcomes

• Measures of outcome

◦ Modified Rankin Scale data, Barthel Index, functional activity training (bed mobility, sitting, transfers, standing, gait, feeding training, pre-speech training, cognitive training)

◦ Frequency and duration of treatment

• Date of medical discharge

• Evidence of plans for ongoing outpatient rehabilitation

Functional status on discharge

• Sitting

• Transfers

• Standing

• Ambulating (parallel bars, outside parallel bars, with assist, without assist, with assistive device, without assistive device)

• Feeding by NGT

Special assessments

1. Pressure sore assessment

Present at time of referral to rehabilitation?

IF YES

• Location of pressure ulcer

• Size of pressure sore

• Grade of pressure sore based on NPUAP

IF NO

• Is the patient at high risk for developing pressure sores based on the Braden Risk Assessment Scale (high, moderate, low risk)

IF PATIENT IS AT HIGH RISK, are any of the following measures being implemented:

• Pressure-relieving mattress

• Proper bed positioning

• Bed turning every 2 hours

• Proper transfer techniques

• Protective dressing and padding

Pressure sore present on discharge from rehabilitation?

2. Dysphagia

Bedside swallow screening

• Date

• Who performed the test

• Presence of dentures

• Results of test and recommendations

• NGT insertion

• Gastrostomy insertion

Date of referral to rehab

• Date seen by speech pathologist/occupational therapist

• Recommended measures

◦ Barthel Index

◦ Canadian Occupational Performance Measure

• Recommendations made

Instrumentation used and results

• Modified barium swallow studies

◦ Dates of assessment

◦ Results of each assessment

Discharge status

• With NGT

• With gastrostomy

• Died

Diet

• Diet during hospital stay

◦ NPO

• Per orem

◦ Details

• Diet on discharge

◦ Discharge instructions

Note: Copyright © 2013. Dove Medical Press. Adapted from Gonzalez-Suarez C, Dizon J, Grimmer K, et al. Implementation of recommendations from the PARM stroke in-patient rehabilitation guideline: a plan of action. Clinical Audit. 2013;5:77–89.¹³

Abbreviations: ROM, range of movement; AAROM, active-assistive range of motion; AROM, active range of movement; PROM, passive range of movement; MMSE, Mini-Mental State Examination; FIM, Functional Independence Measure; NPUAP, National Pressure Ulcer Advisory Panel; NGT, nasogastric tube; NPO, nil per os (nil by mouth).

Table 2 Auditing guideline: definitions of process indicators and auditing requirements

1. Swallow assessment (screen) within 24 hours of admission
Definitions	Swallowed screening involves:
	• A screening of swallowing undertaken by a trained health professional
	• “Within 24 hours” is the time from admission to hospital to documented time of screening
	• Swallowing is screened using a validated screening instrument
	• Documentation of outcome of screening, ie, a description of whether or not the patient failed the screening
	• Documentation of the action required following outcome of screening, ie, if failed screen, then referral to rehabilitation medicine and speech pathologist for formal assessment and remain “nil per orem”
Data elements	Compliance requires documented evidence of a response to each of the elements:
	• Validated instrument used
	• Outcome of screening recorded
	• Action required following outcome of screening recorded
	• Time of screening
	Patients with an impaired level of consciousness or designated as requiring palliative care are considered to have impaired swallowing and compliance with this indicator is deemed to have occurred if there is “documentation of the action required following the outcome of the assessment”
Numerator	Number of stroke patients with documented evidence of swallow screen conducted within 24 hours of admission, during audit period
Denominator	All stroke patients admitted to hospital during the audit period
Exceptions	Not applicable for patients who had died in the ED or had been designated as “palliation only” while in ED
2. Referral to rehabilitation medicine when patient is medically stable
Definitions	Documented referral to rehabilitation medicine when patient is medically stable
	Such assessment usually involves use of validated and reliable assessment tools
Data elements	Compliance requires documented evidence of:
	• Assessment by attending physician
	• Documentation of outcome of assessment by attending physician
	• Date and time of referral
Numerator	Number of stroke patients with referral to rehabilitation medicine
Denominator	Total number of stroke patients admitted to hospital during audit period
Exception	Not applicable for patients who had died or had been designated as “palliation only”, or were in ICU within the first 48 hours of admission
3. Increasing intensity of exercise according to tolerance of patient
Definitions	Documented mobilization starting with supportive care with low intensity exercise such as range of motion exercise progressing to stroke mobilization rehabilitation, which is the period of rehabilitation when patients are given functional exercise related to walking and starts with the patient learning to sit up on the bed. This is done by a physical therapist
Data elements	Compliance requires documented evidence of:
	• Patient’s assisted or unassisted mobilization
	• Time of first mobilization
	• Use of a validated and reliable assessment tool (Functional Independent Measure)
Numerator	Number of stroke patients with documented progression of mobilization
Denominator	Total number of stroke patients admitted to hospital during audit period
Exceptions	Not applicable to patients who had a delayed admission (longer than 24 hours between stroke onset and hospital admission), those who had died or had been designated as “palliation only” in the first 24 hours, or were ordered to rest in bed by medical staff
4. Pressure care risk assessment followed by regular evaluation on prevention of pressure sores
Definitions	Documented pressure care risk assessment using validated and reliable tool in evaluation of stroke patients
	Regular evaluation will be performed every 5 days
Data elements	Compliance requires documented evidence of a response to each of the elements:
	• Validated instrument used (Braden Assessment tool)
	• Outcome of assessment recorded
	• Action required following outcome of assessment recorded
Numerator	Number of patients with documented pressure care risk assessment done on a regular basis (once every 5 days)
Denominator	Total number of applicable stroke patients admitted to hospital during audit period
Exception	Not applicable for patients who had died or had been designated as “palliation only”
5. Providing appropriate pressure-relieving aids and strategies to prevent pressure sores
Definitions	Documented provision of strategies to prevent pressure sores such as: pressure-relieving mattress, use of proper positioning, turning, and transferring techniques and judicious use of barrier sprays, lubricants, and protective dressings, and padding to avoid skin injury due to maceration, friction, or excessive pressure
Data elements	Compliance requires documented evidence of a response to each of the elements:
	• Documented evidence of providing pressure relieving aids and strategies
	• Use of validated tool to assess presence of pressure sore (Bates Jensen Wound Assessment)
	• Grading of pressure sore if present based on the National Pressure Ulcer Advisory Panel
	• Outcome of assessment recorded
	• Action required following outcome of assessment recorded
Numerator	Number of applicable stroke patients with documented provision of pressure relieving aids
Denominator	Total number of applicable stroke patients admitted to hospital during audit period with evidence of impaired function
Exception	Not applicable for patients who had died or had been designated as “palliation only”
6. Patient/carers provided with a discharge plan
Definitions	Documented evidence that patient received a plan outlining care in the community after discharge. The specific care plan should address one or more of the following:
	• Monitoring and managing symptoms and signs of illness including risk management if symptoms develop or become worse
	• Managing the impacts of illness on their lifestyle, emotions, and interpersonal relationships
	• Adherence to treatment regimes
	• Contact details for services to which the patient has been referred or follow-up appointments and community support contacts
Data elements	Compliance with this indicator requires
	• Documented evidence of a care plan having been provided to any patient who is going home
Numerator	Number of applicable stroke patients with care plan provided to patient/family prior to hospital discharge during audit period
Denominator	Total number of applicable stroke patients discharged directly to home from the acute hospital during audit period
Exception	Not applicable for patients who had died or had been designated as “palliation only”

Notes: Copyright © 2014. Adapted from National Stroke Foundation. Acute Stroke services Framework, 2008: a Framework to Enable the Delivery and Monitoring of Optimal Acute Stroke Care Across Australia. Melbourne: National Stroke Foundation; 2008. Available from: http://strokefoundation.com.au. Accessed November 26, 2011.¹⁷ These definitions will be used to determine whether or not process indicators have been met.

Abbreviations: ED, emergency department; ICU, intensive care unit.

Figure S1 Consent form for attending physician.

Abbreviation: NG, nasogastric.

Figure S2 Data information sheet.

Abbreviations: AV, arteriovenous; NG, nasogastric; NIHSS, National Institutes of Health Stroke Scale; PARM, Philippines Academy of Rehabilitation Medicine.

Gonzalez-SuarezCDizonJGrimmerKImplementation of recommendations from the PARM stroke in-patient rehabilitation guideline: a plan of actionClinical Audit201357789

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National Stroke FoundationAcute stroke services framework, 2008: a framework to enable the delivery and monitoring of optimal acute stroke care across AustraliaMelbourneNational Stroke Foundation2008 Available from: http://strokefoundation.com.auAccessed November 26, 2011

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