Audit Stroke Referral_ Occupational Therapy_11.11

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PROSPECTIVE CROSS SECTIONAL STUDY:

REFERRAL OF STROKE PATIENTS TO

OCCUPATIONAL THERAPY DEPARTMENT

IN HSAH



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ACKNOWLEDGEMENT

We would like to express our utmost gratitude and appreciation to the following

individuals / parties who had given us excellent cooperation and contribution in any

shape or form. Without them, this audit would not have been a success.

Dr Harif Fadzilah bin Che Hashim, Director of Hospital Sultan Abdul Halim

Dr Mithali Abdullah @ Jacqueline Sapen, Head of the Quality and Innovation

Unit, Hospital Sultan Abdul Halim and Clinical Audit Coordinator

All occupational therapists who had participated

All Sisters/ staff nurses



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CONTENT

No. Title Page

1. Title page 1

2. Acknowledgement 2

3. Content 3

4. Abstract 4

5. Introduction 5

6. Methodology 8

7. Result 10

8. Discussion 12

9. Strategy for change 14

10. Conclusion 17

11. References 18

12. Appendix 20



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ABSTRACT

Title:

Prospective Cross Sectional Study: Referral of Stroke Patients to Occupational Therapy

Department in HSAH

Authors:

Noor Emellia Jamaludin

Occupational Therapy Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah.

Overview:

All patients with acute stroke should ideally have access to stroke unit. They also should be

referred to Occupational Therapy (OT) Department within 72 hours after diagnosis of stroke is

made. On the other, these patients should be provided the minimum treatment

Objectives:

To determine if patient who suffer from acute stroke were referred within the appropriate time

frame and to determine if they received the minimum treatment from the Department of

Occupational Therapy.

Methodology:

This is a prospective study with cross sectional data collection of OT management for stroke

patients in Hospital Sultan Abdul Halim. The audit was conducted from 1st

July 2010 until 31st

August 2010. Information collected were date of referral, reason for not referring patient and the

number of treatment modalities provided.

Results:

Only 56.6% of acute stroke cases were referred for OT interventions and out of those referred,

76.7% of them were referred within 72 hours. Most of the time (83.6%) the reasons for not

referring was not known as they were not documented. However, all of the patients who were

referred to OT Department received at least two treatment modalities.

Strategy for changes:

To improve the situation, strategies such as promoting the functions and roles of OT in the

management of acute stroke as well as to develop and establish clear and effective referral system

are proposed.

Conclusions:

Knowledge about occupational therapy functions in stroke rehabilitation needs to be improved in

order to get the desirable outcome of stroke patients. There should be a smart partnership between

the primary health care providers and occupational therapist.



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1.0 INTRODUCTION

1.1 Problem Statement

Occupational Therapy Guidelines for Stroke (2008) has defined stroke or cerebral

vascular accident as a disease of the cerebral vasculature in which a failure to supply

oxygen to brain cells, which are most susceptible to ischemic damage, lead to their

death. Health Informatics Centre – Planning and Developing Division of Ministry of

Health Malaysia (2009) recorded cerebral vascular disease as the fifth cause of death

in Ministry of Health hospitals with 8.43%. Anonymous (2010) stated that there are

estimating about 397,806 prevalence rates and about 51,887 incidence of stroke

annually (including new cases and recurrences) in Malaysia.

National Stroke Association of Malaysia (NASAM) (1995) defined occupational

therapy as a form of rehabilitation to enhance a person’s quality of life, which

focuses in improving the ability to perform activities of living, self care and

independence at work and leisure. According to Roland T. J.et al

., (2008),occupational therapy intervention should begin as soon as the medical condition is

stable. The occupational therapy interventions may include maintaining or

improving soft tissue properties of the upper limb. Susan Berg (2010) stated that

once the stroke patient is medically stable, occupational therapy activities usually

begin. The first occupational therapy activities are to provide education and coping

activities to the patient and caregiver.



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1.2 Objectives

This study aims to audit the general management of acute stroke patient in

Department of Occupational Therapy of Hospital Sultan Abdul Halim (HSAH). In

specific, the author attempts to:

I) Determine if patients who suffer from acute stroke were referred

within the appropriate time frame to the Department of Occupational

Therapy, HSAH.

II) Determine if patients who suffer from acute stroke received the

minimum treatment from the Department of Occupational Therapy,

HSAH after being referred.

1.3 Criteria and standard

No. Criteria Standard

1. Percentage of acute stroke should be referred to

Occupational Therapy within 72 hours (3 days).

100%

2. Numbers of treatment modalities provided tothe acute stroke patient in every session

At least 2 treatmentmodalities in a

session

Nicole R. C. et al ., (2004) stated that the therapist should be informed as soon as a

new stroke patient is admitted, to request physician referral and begin to see

patient within 36 to 48 hours after admission. Clinical Practice Guidelines –

Management of Stroke (2006), all patients with acute stroke should ideally have

access to stroke unit. There are also clear evidences that treatment of patient with

stroke in stroke units significantly reduces death, dependency, institutionalization

and length of hospital stay compared to treatment in a general medical ward.

However, there was no consensus on the time frame of referral of stroke patients



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for occupational therapy interventions. Since, this is most likely the pioneer study on

referral of stroke patients for occupational therapy interventions in Ministry of

Health (MOH), thus the time frame is longer than that stated by Nicole R. C. et al .,

(2004). The time frame set is within 72 hours.

2.0 METHODOLOGY

2.1 Sampling population and sampling procedure

This is a prospective study with cross sectional data collection of occupational therapy

management for stroke patients in Hospital Sultan Abdul Halim. The audit was

conducted from 1st

July to 31st

August 2010.

The inclusion criteria are:

a. All stroke patients admitted to Hospital Sultan Abdul Halim

b. Adult patients aged 18 years old and above

The exclusion criteria are:

a.

Deathb. Unstable patient as per physician clinical judgment

2.2 Treatment modalities

Treatment modality is the method of treatment provided for the stroke patient.

The minimum treatment modality shall be provided: At least 2 treatment modalities

for a single treatment session.

Some of the treatment modality that may use by an occupational therapist is patientand family education, level of independency assessment, early mobilization and

cognitive stimulation.



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2.3 Documentation and clinical outcome

The following information was collected and documented in the data collection table

(Appendix 1 and Appendix 2).

a. Identification number

b. Date case diagnosed with stroke by referral unit

c. Date case referred to OT unit

d. Referral within 72 hours (3 days)

e. Reason for late referral/not referred

f. Discharged date

g. Number of treatment modalities received (Appendix 2)

This information was gathered f orm the patients’ case notes as well as the

Clinical Access in the Total Hospital Information System (THIS) by the audit team

staff.

2.4 Data analysis

All data collected will be analyzed by using Microsoft Excel 2003.



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3.0 RESULT

3.1 Demographic data

Table 1: Samples distribution: gender

Male Female

31 22

58.5% 41.5%

3.2 Primary outcomes

Table 2: Percentage of patient referred to Occupational Therapy unit

Number of patient insample as per inclusion

criteria

No of patient referred toOT unit

No of patient referredwithin 72 hours

53 30 (56.6%) 23 (76.7%)

Table 3: Reason for not referring or late referral

Pt discharged on weekend Unknown reason or not

documented

16.4% 83.6%

Table 4: Number of treatment modalities received

No of patient referred to OT unit No of patient received at least 2

treatment modalities

30 30 (100%)



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3.3 Summary of audit findings

There were 53 patients included in the study and only 30 (56.6%) were referred for

occupational therapy interventions by the primary team. Out of these 30 patients,

only 23 (76.7%) of patients with acute stroke were referred within 72 hours. In seven

of these patients, the audit team staff attempted to find out the reasons for not

referring. Most of the time (83.6%) the reasons for not referring such patients to

Occupational Therapy Department were not known as they were not documented.

In 16.4% of those not referred, the patients were not referred as the patients were

discharged during weekend. Nevertheless, for those who were referred to the

Occupational Therapy Department, all 30 of them received at least two treatment

modalities.

4.0 DISCUSSION

4.1 Late referral of patient and/or patient was not referred at all

Sacco RL. (1995) cited that early admission to stroke rehabilitation program results in

better prognosis at discharge and reduces length of hospitalization. Based on a studydone by Farooq AR. et al. (2009), the main cause of not referring patient or late

referral for stroke rehabilitation happened when the avoidable complications like

shoulder subluxation, depression, urinary tract infections, fall, contracture already set

in. This situation also happens in our hospital; the patients were either not referred or

referred late to Occupational therapy Department normally after their complications

have been stabilized.

4.2 Lack of awareness and knowledge of occupational therapy services for stroke

Lack of awareness and knowledge of OT functions and roles in managing patient

with acute stroke by health care providers could contribute to patients being either

not being referred to OT or referred later than the best practice.



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The health care providers may think that patient with acute stroke could only be

referred to the OT once he/she is in stable condition. They may not know that

occupational therapy also plays important roles in managing unstable patient.

Interventions such as prescribing pressure garments (compressed stocking with

adequate pressure) and provide hand splinting is crucially important for every stroke

cases. Annals of Internal Medicine (2010) stated that the graduated compression

stockings are widely used to prevent deep venous thrombosis (DVT) in patients who

have limited mobility from conditions such as stroke. Medical News Today (2010)

stated that splinting such as ankle foot orthosis (AFO) can improve mobility after

stroke and preventing foot drop.

Health care providers may not only lack of awareness and knowledge about OT

services and functions. In addition to that, they may be hesitant to refer during the

weekend because they are not sure of the service provision. The occupational

therapists should provide sufficient information on how to refer the patient on

weekend. This will give them better understanding on how to make the appropriate

referral.

According to Warner et al. (2010), health care providers such as nurses should be

exposed to occupational therapy through informal and unstructured methods

consequently increasing the probability of missed referrals and inappropriate

referrals.

4.3 Inadequate referral

In some cases, the physicians refer the patient for physiotherapy intervention only.Farooq AR. et al. (2009) stated that, stroke patient who were referred to

physiotherapy only will end up with regaining motor control and gait patterns but

other aspects like patient education, management of bowel and bladder

dysfunction, psychological evaluation and management of depression, prevention of



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falls, mobility aids and adaptation prescription, vocational rehabilitation,

occupational therapy and community integration are not addressed adequately.

Patient with stroke should be review holistically. Health care providers shall evaluate

the patient not only from the physical side. According to American Heart Association

(2010), stroke affects the senses, motor activity, and speech, behavioral and though

patterns, memory and emotions. By referring the patient to one discipline will not

help the patient much. Adequate referral should be done according to patient

needs.

5.0 STRATEGY FOR CHANGE

From this audit, it was found that only a small percentage (56.6%) of patients with

acute stroke was referred for occupational therapy interventions. On the other

hand, one third of those referred, referral was done much later than 72 hours after

the diagnosis of stroke was made. One of the obvious reasons that patients with

acute stroke were either not referred or referred late was the patients have beendischarged during the weekends.

It appeared that the role and functions of the occupational therapists in the

management of acute stroke are still not clear. Perhaps, most often than not, health

care providers thought the occupational therapists only intervene to assist in

Activities of Daily Living (ADL). Therefore, the strategies for change will be on

promoting the functions and roles of occupational therapists in the management of acute stroke as well as to develop and establish clear and effective referral system.



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Table 5: Strategy for Change

No. Strategy for change Implementation Responsibility

1. Promoting the

functions and roles

of occupational

therapists in the

management of

acute stroke

1.1 CME:

Regular CME (45-60 minutes briefing)

on roles of occupational therapy in

stroke rehabilitation should be done

once in 3 months.

Head of department

Occupational

Therapy

1.2 Formal training (courses, seminars

& workshops):

Seminars: twice a year

Workshop: twice a year

Head of department

Occupational

Therapy

1.3 Regular bulletin on Occupational

Therapy

Head of department

Occupational

Therapy2. Establish a

rubberstamp

(Appendix 3)

A simple integrated rubberstamp for

stroke patient could be implemented.

The rubberstamp chop shall be filled

up before the patient is discharged

from the ward. This rubberstamp

chop will ensure the patient has been

referred to other necessary

multidisciplinary team such as

occupational therapy, speech therapy,

physiotherapy, pharmacy anddietitian. This kind of checklist has

been implemented before in the

Critical Care Unit for cardiac patients.

1. Head of

department

Occupational

Therapy

2. Head of

department of

Medicine

3. Hospital Matron

3. Regular monitoring Regular monitoring of stroke patients

in the ward with regards to referral of

patients to Occupational Therapy

Department.

1. Occupational

Therapist on duty

2. Staff nurse in-

charge

4. Formal education

for nurses and

doctors in OT unit

It would be an advantage to health

care providers if they could attach to

OT unit in order to improve their

understanding on OT function and

roles in managing patient with stroke.

1. Head of

department

Occupational

Therapy

2. Head of

department of

Medicine

3. Hospital Matron



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6.0 CONCLUSION

As a conclusion, the perception towards occupational therapy functions in stroke

rehabilitation needs to be change in order to get the desirable outcome of stroke

patients. There should be a smart partnership between the primary health care

providers and occupational therapist. There are various interventions that are offered

by occupational therapists to improve the quality of life of patient with stroke. There are

patient educations, aids and adaptation prescription and work return program. These

include the primary health care providers should make a referral within 72 hours of

stroke onset.



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7.0 REFERENCES

1. Anonymous (2008) Occupational Therapy – Concise Guidelines Stroke

Rehabilitation and Recovery. Retrieved on 5 September 2010 from

http://www.strokefoundation.com.au/component/option,com_docman/task

,doc_view/gid,115

2. Anonymous (2010). About stroke. Retrieved on 1 November 2010 from

http://www.strokeassociation.org/STROKEORG/AboutStroke/About-

Stroke_UCM_308529_SubHomePage.jsp

3. Diserens K. et al,. (2006) Early Mobilzation after Stroke. Retrieved on 5

September 2010 from

http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ProduktNr=224153&Ausgabe=231961&ArtikelNr=93453

4. Farooq RA. et al,. (2009) Pit Falls of Stroke Rehabilitation: A Pakistani

Perceptive. Retrieved on 31st

October 2010 from

http://www.pafmj.org/showdetails.php?id=227&t=o

5. Nicole C. R et al,. (2004) Physical Therapy Protocol for Acute Care Adult

Hemiplegia Retrieved on 5 September 2010 from http://www.pta-

kw.com/uploads/PT%20PROTOCOL%20_part2-Adult%20hemiplegia.pdf

6. Roland T.J. et al,. (2008) Role of Occupational Therapy After Stroke. Retrieved

on 5 September 2010 from

http://www.annalsofian.org/article.asp?issn=0972-

2327;year=2008;volume=11;issue=5;spage=99;epage=107;aulast=Rowland

7. Sacco RL. (1995) Risk factors and out comes for ischemic stroke. Retrieved on

1st

November 2010 from

http://stroke.ahajournals.org/cgi/content/full/28/7/1507

8. Susan Berg (2010) Stroke – Occupational Therapy Activities. Retrieved on 5September 2010 from http://www.ehow.com/way_5827473_stroke-

occupational-therapy-activities.html

9. Warner et al,. (2010) Nurse practitioners' awareness and knowledge of

occupational therapy services. Retrieved on 1 November 2010 from

http://gradworks.umi.com/14/84/1484747.html



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8.0 APPENDIXES

APPENDIX 1

No. Patient ID / Patient

Name

Date case

diagnosed

with stroke by

referral unit

Date case

referred to

OT unit

Referral

within 72

hours (3

days)

Reason for

late

referral/not

referred

Date of

discharged

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20



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APPENDIX 2

No. Patient ID / Patient

Name

Date case

diagnosed

with stroke by

referral unit

Date case

referred to

OT unit

No of

treatment

modalities

Complete

minimum

treatment

modalities

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18



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APPENDIX 3 (Rubberstamp design)

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20



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Documents

Audit Stroke Referral_ Occupational Therapy_11.11