Katherine E. Harding

Community ambulation before and after hip fracture: a qualitative analysis

Purpose. This qualitative study explored mobility levels around the home and in the community before and after hip fracture. Methods. Twenty-four people receiving rehabilitation after hip fracture were interviewed using an in-depth semi-structured format: 12 who were receiving rehabilitation as inpatients, and 12 who had been discharged home from inpatient rehabilitation and were continuing therapy as outpatients. The recorded interviews were transcribed and coded independently by two researchers. From these codes themes were developed. Results. Before their fracture, participants were independent about their houses, but their level of community ambulation had been reducing over recent months or years, often associated with another health problem. Participants who had returned home after inpatient rehabilitation for hip fracture reported much reduced levels of mobility both in their house and in the community compared with their pre-fracture performance. This reduced level of mobility was associated with psychological factors (fear, lack of confidence, frustration), physical factors (pain, the presence of another health problem) and social/environmental factors (reliance on daughter, and car). The level of optimism expressed by people receiving inpatient rehabilitation contrasted with the pessimism of those receiving outpatient rehabilitation. Conclusions. Patients living back in the community after hip fracture described a reduced level of functioning and a pessimism that contrasted with the optimism expressed by people who were still in the inpatient phase of rehabilitation. These findings, and the importance of psychological factors and social support, may be considered when designing rehabilitation strategies to support the successful transition of people to their community after hip fracture.

Not Enough Time or a Low Priority? Barriers to Evidence-Based Practice for Allied Health Clinicians

Introduction: Evidence‐based practice (EBP) is a key principle in the delivery of effective and high‐quality health care. Existing research suggests that allied health professionals are generally supportive of EBP but rarely participate in activities associated with EBP. Methods: This mixed‐method study used 8 focus groups of allied health professionals and managers and a questionnaire of all participants to explore the attitudes and barriers to EBP in a large metropolitan health service. Qualitative data were analyzed using a thematic analysis of focus group transcriptions. Questionnaire data were analyzed descriptively. Results: Fifty clinicians and 10 managers across 7 allied health disciplines participated in the study. The questionnaire identified that clinicians have a positive attitude but low participation in EBP. Qualitative data revealed that EBP was not highly valued by clinicians and managers or viewed as a core component of clinical care, with activities directly related to maintaining patient flow viewed as higher priorities. Lack of skills and resources and difficulty associated with implementing evidence into practice were further barriers. Discussion: Achieving higher uptake of EBP among allied health clinicians requires a cultural shift, placing higher value on these activities despite the challenging context of constant pressures to increase patient flow. Addressing EBP through small group projects rather than considering it to be an individual responsibility may be more acceptable to both clinicians and managers, with added benefits of peer support for both evaluating evidence and translation into practice.

Validity of the de Morton Mobility Index (DEMMI) for measuring the mobility of patients with hip fracture during rehabilitation

Purpose: Many patients suffer long term loss of mobility after hip fracture but there is no gold standard method for measuring mobility in this group. We aimed to validate a new mobility outcome measure, the de Morton Mobility Index (DEMMI) in a hip fracture population during inpatient rehabilitation. Method: The DEMMI was compared with the existing measures of activity limitation: 6 minute walk test, 6 metre walk test and Barthel Index on 109 consecutive patients admitted to rehabilitation after surgery for hip fracture. Patients were assessed by a physiotherapist at admission and discharge. Scale width, validity, minimal clinically important difference (MCID), responsiveness, and unidimensionality were investigated. Results: Evidence of convergent, discriminant and known groups validity were obtained for the DEMMI. Responsiveness was similar across instruments and the MCIDs were consistent with previous reports. A floor effect was identified for the 6 metre walk test and 6 minute walk test at hospital admission. Rasch analysis identified that the DEMMI maintains its unidimensional properties in this population. Conclusions: The DEMMI has a broader scale width than existing measures of activity limitation and provides a unidimensional measure of mobility for hip fracture patients during inpatient rehabilitation. Implications for Rehabilitation Loss of mobility is a common and significant problem following hip fracture. The de Morton Mobilitiy Index (DEMMI) is an effective instrument for measuring mobility in patients with hip fracture during rehabilitation The DEMMI is unidimensional, has a broader scale width than existing measures and offers an interval scale for measurement of mobility in hip fracture during rehabilitation

Prioritizing patients for Community Rehabilitation Services: do clinicians agree on triage decisions?

Objective: To evaluate agreement between independent clinician raters using a triage protocol to prioritize referrals for occupational therapy and physiotherapy within a community rehabilitation program. Design: The priority category allocated to consecutive referrals by one of six clinicians in the referral office was compared with a second rating made by an independent occupational therapist, blinded to the initial priority rating. Setting: A centralized referral office staffed by allied health and nursing professionals designed as a single point of access for sub acute and ambulatory services within a large metropolitan health network. Participants: 214 referrals for adults requiring community based occupational therapy or physiotherapy rehabilitation for orthopaedic, neurological or other conditions (such as falls or cardio-respiratory conditions). Main Measure: Agreement (weighted kappa = κw) between the two ratings. Results: Overall agreement was moderate (κw = 0.60), but disagreement occurred in 30% of cases. Professional discipline of the raters did not affect agreement. Agreement varied between diagnostic subgroups, with significantly lower agreement for referrals for rehabilitation following elective orthopaedic surgery (κw = 0.25) than the other categories combined. Differences in agreement were observed between the four triage categories, with the lowest observed agreement in the most urgent category. Conclusions: Clinicians in a centralized model of triage showed only moderate agreement when making decisions about client priority for community rehabilitation for occupational therapy and physiotherapy.

Effect of Triage on Waiting Time for Community Rehabilitation: A Prospective Cohort Study

OBJECTIVE To investigate how the allocation of referrals for a community rehabilitation service to triage categories affects waiting time from referral to first appointment, and whether other factors also contribute to variance in waiting time. DESIGN A prospective cohort study. SETTING A multidisciplinary outpatient community rehabilitation program within a large metropolitan health service. PARTICIPANTS Consecutive adult patients (N=379) commencing rehabilitation over a 3-month period. INTERVENTION Allocation of referrals to a triage category of 1 (most urgent) to 4 (least urgent) by allied health clinicians guided by a written protocol. MAIN OUTCOME MEASURE The primary outcome was waiting time from referral to service commencement. RESULTS The small group of patients (4%) allocated to the most urgent category had significantly shorter mean waiting times than the other 3 categories (mean, 4.8d vs 19.6, 26.6, and 19.4d for categories 2, 3, and 4, respectively). Regression analysis indicated that approximately 11% of the variance in waiting time was accounted for by the triage categories. Site of treatment (home or center) and diagnosis also made small contributions (4% combined) to variance in waiting time. CONCLUSIONS The triage process ensured rapid service for a small number of urgent referrals, but made little difference to the waiting time of the vast majority of patients. Given the resources required for triaging patients, the results of this study lead us to question the value of the triage system in this setting.

Discharge planning for patients receiving rehabilitation after hip fracture: A qualitative analysis of physiotherapists' perceptions

Purpose. To explore the perceptions of clinicians about walking requirements and discharge criteria for patients being discharged home in the community from rehabilitation after hip fracture. Methods. Twelve experienced clinicians (all females) (mean experience in rehabilitation 13 years) were interviewed using an in-depth semi-structured format. The recorded interviews were transcribed and coded independently by two researchers. From these codes themes were developed. Results. For discharge planning, all clinicians considered personal/psychosocial factors such as patient goals and social support. Almost all clinicians considered that the performance factor of safe and independent ambulation was important to consider when planning the patients discharge, but did not set specific distances or speeds. Clinicians expected that pain, a lack of confidence, and walking outdoors would affect the mobility at home but these factors were considered little in discharge planning. Conclusions. In planning discharge after rehabilitation for hip fracture, clinicians place more emphasis on the individual needs and goals of the patient than on specifying objective performance criteria that must be met. The expectation that lack of confidence could be a problem after returning home suggests that this factor could be considered more in discharge planning.

Triaging Patients for Allied Health Services: A Systematic Review of the Literature

Occupational therapists and other allied health clinicians often need to make decisions about the relative urgency of referrals, which patients should be seen first and, in some cases, whether patients require services at all. A systematic review of the literature was conducted to investigate the properties and outcomes of triage systems applied to patients referred to allied health services. Literature was searched through the CINAHL, EMBASE and MEDLINE databases (until March 2008), combining the key elements of ‘allied health’ and ‘triage’. Seven articles were identified that met the inclusion and exclusion criteria, and these were assessed against quality criteria and a process of descriptive synthesis applied for the purpose of analysis and comparison. The findings indicate that there has been little investigation of the outcomes of allied health triage systems. Studies that have assessed triage systems have focused largely on measurement properties and the majority of these have indicated poor to fair reliability. A first step in introducing allied health triage systems is to establish reliability, involving the patient directly in the assessment process. There is not yet sufficient evidence to recommend any particular triage system for application to allied health services.

Reducing waiting time for community rehabilitation services: a controlled before-and-after trial.

OBJECTIVE To investigate whether a simple alternative (specific timely appointments for triage [STAT]) to the more common approach of managing demand using a waitlist with a triage system could reduce waiting time for a community rehabilitation program (CRP) without adverse impacts on patient care. DESIGN A prospective, controlled before-and-after trial. Preintervention and postintervention data were collected for 6 months in 2 consecutive years. STAT was introduced at an intervention site and compared with a control site using a triaged waitlist. SETTING Two musculoskeletal CRP teams within a large metropolitan health service. PARTICIPANTS All patients referred to both sites during periods preintervention (n=483) and postintervention (n=488). INTERVENTION Under STAT, clinicians created a specified number of assessment times each week based on average referral numbers, and patients were immediately allocated an appointment on referral. MAIN OUTCOME MEASURES The primary outcome was the time from referral to first appointment; secondary outcomes included program duration, quality-of-life scores (using the EuroQol EQ-5D), and unplanned hospital admissions. RESULTS Waiting time decreased from a mean of 17.5 days to 10.0 days (P<.01) at the intervention site, with no significant change at the control site. Intervention site patients were over 3 times more likely to be seen within 7 days than control site patients (odds ratio, 3.3; 95% confidence interval, 2.2-4.9). Secondary outcomes did not differ significantly between groups. CONCLUSIONS A simple alternative to using a triaged waitlist to manage CRP referrals reduced waiting time without adversely affecting care. Results were sustained over 6 months with no additional resources.

Organisational benefits of a strong research culture in a health service: a systematic review

Objective The aim of the present study was to determine whether there is an association between having research culture in a health service and better organisational performance. Methods Using systematic review methods, databases were searched, inclusion criteria applied and study quality appraised. Data were extracted from selected studies and the results were synthesised descriptively. Results Eight studies were selected for review. Five studies compared health services with high versus low levels of research activity among the workforce. Three studies evaluated the effect of specific interventions focused on the health workforce. All studies reported a positive association between research activity and organisational performance. Improved organisational performance included lower patient mortality rates (two of two studies), higher levels of patient satisfaction (one of one study), reduced staff turnover (two of two studies), improved staff satisfaction (one of two studies) and improved organisational efficiency (four of five studies). Conclusions A stronger research culture appears to be associated with benefits to patients, staff and the organisation. What is known about this topic? Research investment in the health workforce can increase research productivity of the health workforce. In addition, investment in clinical research can lead to positive health outcomes. However, it is not known whether a positive research culture among the health workforce is associated with improved organisational performance. What does this paper add? The present systematic review of the literature provides evidence that a positive research culture and interventions directed at the health workforce are associated with patient, staff and organisational benefits. What are the implications for practitioners? For health service managers and policy makers, one interpretation of the results could be to provide support for initiatives directed at the health workforce to increase a research culture in health services. However, because association does not imply causation, managers need to interpret the results with caution and evaluate the effect of any initiatives to increase the research culture of the health workforce on the performance of their organisation.

A training programme did not increase agreement between allied health clinicians prioritizing patients for community rehabilitation

Objective: To evaluate the effect of formal training on agreement between clinicians making decisions on client priority. Setting: A centralized intake service receiving referrals for a community rehabilitation programme. Design: Agreement was measured between the priority categories allocated to consecutive referrals by one of five clinicians in the referral office compared with a second rating made by an independent occupational therapist, blinded to the initial priority rating. Data collection followed the implementation of four 1-hour workshops involving all raters, designed to increase consistency of triage decisions. Results were compared to a previous study conducted prior to the training. Participants: Two hundred and one consecutive referrals received for community rehabilitation services, triaged by experienced clinicians with allied health or nursing qualifications. Outcome measure: Agreement using weighted kappa (κw). Results: There was no change in agreement between clinicians after training, compared with a previous study in the same setting. Agreement remained moderate (κw = 0.50), with clinicians disagreeing on approximately 30% of referrals. Conclusions: Three out of 10 clients will receive a different priority rating and waiting time for rehabilitation services depending on which clinician in the referral office made the rating. This result was not improved by conducting a training programme.