Kyaw Nyein

The UK FIM+FAM: development and evaluation

Background and aims: The aim of this study was to develop and evaluate the UK version of the Functional Assessment Measure (UK FIM+FAM). Design: Before and after evaluation of inter-rater reliability. Development: Ten ‘troublesome’ items in the original FIM+FAM were identified as being particularly difficult to score reliably. Revised decision trees were developed and tested for these items over a period of two years to produce the UK FIM+FAM. Evaluation: A multicentre study was undertaken to test agreement between raters for the UK FIM+FAM, in comparison with the original version, by assessing accuracy of scoring for standard vignettes. Methods: Baseline testing of the original FIM+FAM was undertaken at the start of the project in 1995. Thirty-seven rehabilitation professionals (11 teams) each rated the same three sets of vignettes – first individually and then as part of a multidisciplinary team. Accuracy was assessed in relation to the agreed ‘correct’ answers, both for individual and for team scores. Following development of the UK version, the same vignettes (with minimal adaptation to place them in context with the revised version) were rated by 28 individuals (nine teams). Results: Taking all 30 items together, the accuracy for scoring by individuals improved from 74.7% to 77.1% with the UK version, and team scores improved from 83.7% to 86.5%. When the 10 troublesome items were taken together, accuracy of individual raters improved from 69.5% to 74.6% with the UK version (p<0.001), and team scores improved from 78.2% to 84.1% (N/S). For both versions, team ratings were significantly more accurate than individual ratings (p<0.01). Kappa values for team scoring of the troublesome items were all above 0.65 in the UK version. Conclusion: The UK FIM+FAM compares favourably with the original version for scoring accuracy and ease of use, and is now sufficiently well-developed for wider dissemination.

The Northwick Park Dependency Score (NPDS): a measure of nursing dependency in rehabilitation

Background: Disability scores, such as the Functional Independence Measure (FIM) and Barthel Index, have been shown to correlate with care needs but cannot be used to assess them directly, as they do not indicate the number of people required to help with a task, nor the time taken. The Northwick Park Dependency Score (NPDS) is an ordinal scale that can be used to assess impact on nursing time. It takes 3–5 minutes to complete. Together with a short set of additional questions, it may be used directly to assess care needs in the community and to facilitate discharge planning. Aims: To develop and evaluate the NPDS for use in a rehabilitation setting. Methods: (1)Development: Following a survey of existing instruments, tasks were selected on the basis of their impact on nursing time and divided into Basic Care Needs (BCN) and Special Nursing Needs (SNN). Cut-off points were devised to reflect the number of helpers needed and time taken. Following evaluation of the NPDS version 5, minor changes were made to produce version 6 which was re-evaluated on a smaller scale. (2)Evaluation: Inter-rater and intra-rater reliability were tested in a cohort of 23 inpatients using five senior nurses. Analysis included assessment of degree of association, significant differences, absolute agreement, and agreement ±1 level. Although there is no gold standard, the BCN section should correlate inversely with independently assessed Barthel scores. Re-evaluation of version 6 was undertaken using the same method of analysis in a cohort of 21 patients using three senior nurses. Results: On initial evaluation inter-rater reliability testing showed an excellent level of association in total composite score between each pair of nurses (rho = 0.73–0.92, p <0.01) and agreement ±1 level for individual items ranged from 73 to 100%. Significant disagreements were in six items. On reevaluation following minor modification, high levels of association were still seen for total BCN, SNN and composite scores both between and within raters, with very satisfactory levels of agreement for individual items. The BCN section of the NPDS showed good inverse correlation with Barthel scores (rho = 0.91, p <0.01).

The Northwick Park Care Needs Assessment (NPCNA): a directly costable outcome measure in rehabilitation

Background: The Northwick Park Dependency Score (NPDS) has been shown to be valid, reliable and practical to use. It was designed to be used together with a short set of additional questions to inform care needs in the community and facilitate discharge planning. Aim: To develop a conversion formula to translate information derived from the NPDS into a generic assessment of care needs in the community – the Northwick Park Care Needs Assessment (NPCNA) – and to evaluate its potential as a directly costable measure of outcome in rehabilitation. Setting: An inpatient neurorehabilitation unit for young patients with brain injury. Method: Part 1, Development: For each task in the NPDS, a set of assumptions was developed to reflect the number of people, the time taken and the frequency of help required. Tasks were collected into a daily timetable and minimum and maximum allocations made for each time slot. From this the weekly care hours can be calculated. A range of care package categories and their approximate costs were identified, and a simple set of criteria developed with experienced community care planners to determine the circumstances under which each category is applied. Part 2, Evaluation: The assumptions and derived care package were evaluated in a prospective comparative study in 35 cases. Timetables of care needs were drawn up using (a) the NPDS-derived Care Needs Assessment (NPCNA) and (b) detailed structured interview with an independent assessor. The weekly hours of care, care package and approximate cost were then determined for each set of timetables, by a third independent assessor, applying the formula described according to strict rules. Results: Assessment of the total weekly hours of care showed an excellent correlation between the two methods (rho 0.90, p<0.01) with no significant differences. There was also a high correlation in the category of care package allotted and thus the weekly cost of care (rho 0.73, p<0.01). Conclusion: The NPCNA provides a simple measure of care needs in total care hours, as well as a timetable of care from which a care package can be directly planned and costed. It has potential use, therefore, as an instrument that can demonstrate directly the effectiveness of rehabilitation in reducing the cost of continuing care in the community.

Can a Barthel score be derived from the FIM

Objective: To establish whether a Barthel score derived by translation from the motor items of the Functional Independence Measure (FIM) would equate to the directly scored measure. Design: Conversion criteria for motor item scores on the FIM scale to Barthel scores were first developed. To test these criteria, 40 consecutive patients were assessed for Barthel and FIM scores by the multidisciplinary team who were unaware of the conversion criteria. The derived Barthel score was compared with the directly scored Barthel Index. Results: A very high degree of correlation was observed between total scores of the direct and derived Barthel (Spearmans rho = 0.99), which is highly significant, and no significant differences were seen between scores for any of the individual items (Wilcoxon signed rank test). Item by item analysis across the study population was undertaken to confirm the conversion criteria. Absolute agreement between the two methods ranged from 75 to 100% and kappa values from 0.53 to 1.0. Conclusions: This study demonstrates that a Barthel Index can be derived from the motor items of the FIM and there is a good agreement with the directly assessed Barthel score. Although a larger study may help to delineate the exact conversion criteria for one item, the current system provides an accurate and usable translation of the total score and serves as a major step towards achieving a common language in outcome measurement for rehabilitation.

Complex specialized rehabilitation following severe brain injury: a UK perspective.

This article describes the setup of brain injury rehabilitation services in the United Kingdom within the context of the National Health Service. The rehabilitation services are broadly divided into local general rehabilitation services, specialist district rehabilitation services, and complex specialized rehabilitation services. The Department of Health published the National Service Framework for Long-Term Neurological Conditions in 2005, setting out the 11 quality requirements to ensure provision of lifelong patient-centered care. A network of rehabilitation services, cited as a model of good practice by the Department of Health, including specialist inpatient and community outreach services for patients with complex brain injury, with research embedded within the clinical program and close collaboration between the clinicians and researchers are described.

The Northwick Park Care Needs Assessment (NPCNA): a measure of community care needs: sensitivity to change during rehabilitation

Objectives: To determine whether the Northwick Park Care Needs Assessment (NPCNA) is sensitive to change occurring during rehabilitation and provides a reliable estimate of care needs in the community, and to compare the NPCNA with the Functional Independence Measure (FIM). Design: Prospective cohort study. Setting: Postacute neurorehabilitation unit for young patients with complex disabilities. Subjects: Thirty-nine consecutive patients with brain injury admitted over six months. Measurements and methods: The NPCNA was assessed on admission and at discharge. Two subsets of patients were also assessed (a) at three-month follow-up in the community (n = 15), and (b) both in hospital and in the home environments at the discharge time point (n = 28). Data were compared with FIM scores on admission and discharge. Results: The median total weekly care hours fell from 52 hours (interquartile range (IQR) 25–66) on admission, to 17 hours (IQR 6–46) on discharge (p<0.001). There was a median reduction of approximate weekly cost of care from £600 (IQR £224–824) to £168 (IQR £56–280) (p<0.001). These benefits were sustained at follow-up, and the NPCNA measured in hospital at discharge gave a good estimation of the care hours and weekly cost of care in the community at three months after discharge. There was no significant correlation with FIM gain. Conclusions: In this study the NPCNA, measured while the patient was still in hospital, gave a good estimation of care needs in the community and was sensitive to change occurring during rehabilitation in patients with severe complex disabilities.

Poster 37 Long-Term Follow-up of Profoundly Brain-Injured Young Adults Discharged to Specialist Nursing Home Care

headache information, 32% with midline shift and 32% with skull fracture had persistent headaches at all three time points. Conclusions: Early moderate to severe headache was associated with skull fracture, as well as mid-line shift and presence of extraaxial fluid. Persistent headache was associated with midline shift and skull fracture. Further analysis of possible relationship between imaging findings and headache is warranted.