In this chapter we fulfilled the objective to describe the stroke therapy delivered, the quality of processes of care and the stroke therapy workforce, and to quantify variation in therapy provision. The research questions addressed were as follows: How much stroke therapy is provided? How many stroke services include community-based stroke therapy? How many services have access to the wider MDT? What are stroke therapy staffing levels and working hours? What is the quality of therapy-related processes of care? How much variation exists in the amount of each therapy received?
The SSNAP records whether or not each patient was assessed for PT, OT or SLT within 72 hours of admission, and separately at each transfer, whether or not each patient required any of the therapies (including Psych), then the number of days on which they received therapy and the total duration of treatment on the days that patients received them. The SSNAP does not record whether or not a Psych assessment was completed, but does record whether or not patients’ mood and cognition have been screened before discharge.
There are two ways to quantify the amount of therapy a patient receives. A simple ratio of minutes per day with therapy would produce the average treatment per day on which they received treatment (i.e. the average session duration, assuming patients were only treated once per day). However, patients rarely received therapy every day and, as there was concern that reporting bias may be present, the primary measure of therapy amount was defined as ‘average therapy per day of stay’, for which total minutes of therapy per admission were divided by the LOS. This was done separately for inpatient and community-based teams. A secondary variable, the number of days on which the patient received therapy as a percentage of their stay, was also investigated. Owing to concerns about patient confidentiality, we were unable to obtain information from the SSNAP regarding the exact date of admission, as, in combination with other variables, it could identify the patient. This prevented more detailed analysis of the days on which therapy was received.
Assessment
shows the completeness of assessments. PT and OT assessments were completed for most patients (87.7% and 77.3%, respectively), whereas swallow and communication assessments were completed for < 50% of patients. Less than half of patients had a formal assessment of continence and a management plan in place, whereas approximately three-quarters of patients had a screening assessment of their mood and cognition at some point during their care.
Therapy requirements and provision
shows patients’ requirements for each therapy and whether or not they received it during their stay. Nearly all patients were considered to require inpatient PT (92%) and OT (88%), whereas just over half required SLT, but only 5% were considered to require Psych (at any point during their inpatient stay). The proportion of the patients’ inpatient stay in which they received therapy was low, ranging from 40% for PT and 5% for Psych. However, only ≈ 40% of patients required each therapy for their whole admission (39.6% for PT, 39.1% for OT, 40.9% for SLT and 39.8% for Psych). For those who did not require therapy for their whole admission, the median days on which they required therapy were 20 (IQR 41–72) days for PT; 20 (IQR 41–70) days for OT; 18 (IQR 38–68) days for SLT and 25 (IQR 49–82) days for Psych. Thus, patients received therapy on only 20–60% of the days on which they needed it. As reflects the multidisciplinary nature of stroke rehabilitation, most patients (87%) required input from two or three therapy disciplines.
Requirements for and provision of stroke therapy
The average duration of an inpatient treatment session (see ) varied from 31 minutes for SLT to 42 minutes for Psych. However, inpatients received therapy infrequently. On average, patients received PT on only 5 days, averaging 14 minutes per day of inpatient stay, and only one session of Psych, which amounted to an average of 2 minutes per day of inpatient stay.
During community-based stroke therapy (see ), the proportion of patients deemed to require each therapy was lower in PT, OT and SLT than for inpatient therapy, but higher for Psych. For all therapies, patients tended to receive community-based therapy less often (18% of stay for PT, 14% for OT, 9% for SLT and 3% for Psych); however, the average duration of a treatment session (47–51 minutes) and the average amount of therapy per day of ‘stay’ were similar, ranging from 12.0 minutes per day of ‘stay’ for Psych to 13.8 minutes per day of ‘stay’ for PT, indicating that patients tended to receive longer, less frequent treatment in the community than as an inpatient.
There were also differences in the average amount of therapy per day of stay between stroke team types (), with NRATs and NAITs generally providing a greater amount of therapy per day of stay than the RATs (RATa and RATc).
The average amount of therapy per day of stay in different types of inpatient stroke rehabilitation teams
There were marked differences in the average amount of therapy per day of stay provided in different types of community-based stroke teams (see ), with ESD teams providing much more therapy per day of stay than community rehabilitation or integrated rehabilitation team, for whom the amounts of therapy per day of stay were similar. The average amount of therapy per day of stay provided by ESD teams was less than that provided during inpatient stroke therapy.
Processes of care
The SSNAP records some therapy-related processes of care regarding MDT meetings, goal-setting and discharge planning. These are detailed in , after they have been matched to the relevant patient-level data and split into inpatient and community-based teams. Note, there was a high degree of missing data (as reporting was voluntary), so the value represents the number of the patients in inpatient teams for whom ‘yes’ was recorded (i.e. these processes of care took place). All but 2% had a MDT meeting to discuss and plan their care, with just under 100% indicating a physiotherapist, occupational therapist, doctor and nurse attended meetings, and 88%, 60% and 75% reporting SLT, social worker and ESD member were present, respectively. Only 38% had a psychologist present at the meetings. Of these meetings for community care teams, most included a physiotherapist, occupational therapist, speech and language therapist, nurse and a member of the ESD team (87%, 88%, 76%, 52% and 53%, respectively); however, psychologists, social workers and doctors attended less frequently (31%, 9.8% and 17%, respectively). Of the patients for whom it was recorded, 77% had rehabilitation goals identified and 74.8% had a joint health and social care plan in place.
Therapy-related processes of care during post-acute inpatient and community stroke per stay
The therapy workforce and models of service delivery
Details of the therapy workforce were extracted from the acute and post-acute organisational audits, which do not collect the same information for all types of stroke team. Thus, we cannot present the same information regarding therapy workforce for both inpatient and community-based teams.
For acute inpatient teams, that is RATa, RATc and NRATs, nearly all (n = 178, 97.3%) had access to a social worker within 5 days of referral: less than two-thirds (n = 112, 61.2%) had access to clinical Psych and almost three-quarters had access to an ESD and community stroke rehabilitation team [n = 135 (74%) and n = 128 (70.0%), respectively]. Most teams (n = 100, 56.4%) only provided therapy on weekdays: 11% (n = 21) provided one therapy in an extended service (i.e. over 6 or 7 days per week) and one-third of teams (n = 62, 34%) provided an extended service of two or more therapies. The therapies provided and the days on which they are available are not specified in SSNAP.
Inpatient therapy and nursing staffing levels reported in the 2014 acute organisational care audit24 are shown in . There are wide variations between the minimum and maximum staffing levels for each profession and the deployment of therapy and support workers.
Staffing levels in inpatient stroke teams
Staffing levels for community-based teams are shown in and are quoted as WTEs per 100 referrals, like inpatients they showed considerable variation in staffing levels but the numbers of doctors and psychologists were low (or non-existent) in most teams. Most teams appeared to include physiotherapists, occupational therapists and speech and language therapists. The staffing levels for nurses, social workers and support staff in community-based stroke teams are not recorded in SSNAP.
Staffing levels in community-based stroke teams
Discussion
In this chapter we provided a detailed description of inpatient and community-based stroke therapy, the quality of processes of care and the stroke therapy workforce which will act as a benchmark for service evaluation and development. We found that timely therapy assessments were the norm for PT, OT and SLT, and nearly all patients who required therapy received some therapy. However, although approximately three-quarters of patients received a screening assessment for their mood and cognition at some point during their inpatient stay, and given that the incidence of emotional and cognitive disorders after stroke is around 30%,33,34 the number who were thought to need and then received Psych was implausibly low at 5%. This suggests that other members of the MDT may underestimate the need for Psych input when services are not available. When patients did receive Psych, this was generally a single treatment session lasting around 45 minutes when an inpatient, and two treatment sessions when community based. This indicates that most patients received a detailed assessment without ongoing treatment. This is clearly a suboptimal situation. We also found staffing levels for psychologists were extremely low (approximately half of the levels recommended for hyper/acute stroke units in the national clinical guideline for stroke35) and few had any access to Psych services. This lack of access and inadequate staffing levels are an obvious explanation for the low level of recognition of need and Psych input. Another possibility is that other members of staff are providing this treatment. For example, occupational therapists often assess and treat cognitive problems. Patient feedback and recent policy initiatives have highlighted the impact of emotional and cognitive difficulties on ‘life after stroke’, the frequency with which their needs are unmet, and the need for increased access to support for emotional and cognitive difficulties.36 The results of this project further illustrates this need and suggests that improving Psych staffing levels and access to services may be one way to address this issue. Further research is needed to establish the most effective way to treat emotional and cognitive difficulties, and the most effective way to provide these services.
Very few patients received therapy daily, or even on every weekday, and so the amount of therapy per day of stay was well below the recommended levels of 45 minutes of each relevant therapy per day (according to need and capacity).35 The number of days on which patients received therapy was also low (ranging from 1 day for inpatient Psych to 7 days for community-based PT). Given that the average LOS for inpatients was 11 days and 41 days for community-based therapy, then most patients received very little therapy, not only because the treatment was too short but also too infrequent.
This was further illustrated by the paucity of ‘extended’ therapy services, that is provision of therapy outside the usual working week (i.e. 7 hours/weekday). Fewer than half of stroke teams offered an extended service and when this did occur, only one profession was available in most cases. The SSNAP does not record the professions involved or the nature of the therapy provided in extended services. There is some evidence that weekend PT and/or OT can reduce LOS, but does not appear to improve recovery in terms of disability.37 In addition, centralised hyperacute stroke services, which generally involve extended therapy provision, provide better quality care in terms of rapid therapy assessment than un-centralised services, which do not generally provide an extended service.38,39 However, we also noted differences between types of stroke teams in the amount of therapy provided per day of stay. Teams which did not, or rarely admitted stroke patients (NRATs and NAITs) appeared to provide more inpatient therapy on average than routinely admitting teams (RATa and RATc), and ESD teams provided more therapy than community or integrated rehabilitation teams, but less than inpatient teams. A key element of ESD, which is considered an important contributor to the superiority of ESD services over rehabilitation in hospital,40,41 is that ESD services should provide a similar amount of therapy (and other care) as would be provided in hospital.42 The results presented here suggest that this may not be achieved when ESD is implemented in real-world practice, and the amount of therapy per day of stay fell far below the levels recommended in national guidance.35 The ReAcT (Why do stroke survivors not receive Recommended amounts of AcTive therapy?) study has recently investigated the factors influencing therapy provision during inpatient care, highlighting the impact of organisational factors, such as therapists’ time management and information exchange.43 Our results suggest that a similar approach to investigate how therapy is organised, what is actually delivered during ESD and community rehabilitation, and the factors influencing the amount of therapy is delivered, is warranted.
An obvious candidate to influence the amount of therapy provided is staffing levels. There is, however, little evidence to guide recommendations regarding therapy staffing levels. The 2012 and 2016 national clinical guidelines for stroke18,35 make recommendations for acute and hyperacute stroke units (HASUs) (based on the work to centralise hyperacute stroke services in London and Manchester, which showed improved outcomes compared with non-centralised services).44,45 We found that average staffing levels were around the recommended levels for OT, PT and SLT, but also found wide variations for each profession and the deployment of therapy and support workers, suggesting that some services were understaffed and some may be considered overstaffed. The national clinical guidelines for stroke18,35 do not make any recommendations for staffing levels for rehabilitation or community-based teams. We have been unable to find any source of recommendation for specialist inpatient teams or CRTs, but an international consensus group for ESD services agreed recommendations for staffing in ESD teams.30 They recommend one WTE per 100 referrals for physiotherapists and OT, 0.4 WTE per 100 referrals for speech and language therapists and 0.1 WTE per 100 referrals for doctors. They do not make a recommendation for psychologists. The median figures in the current results are similar to these recommendations, but, like inpatient staffing levels, they are varied; thus, some teams were understaffed and some may be considered overstaffed.
The relationship between staffing levels and the amount of therapy provided is not as straightforward as many would assume. Over a decade ago, a comparison of stroke rehabilitation in four European countries showed that UK stroke patients received less therapy and had poorer outcomes but higher therapy staffing levels than those in Germany and Switzerland, even when confounding variables were controlled.9,17,46 The UK’s low dose of therapy was considered to be due to poor organisation, rather than lower staffing levels.16–19 More recently, the ReAcT study highlighted that, although therapy staffing levels undoubtedly played a part in the amount of therapy delivered, they were not the main determinant.43 The most significant factor influencing the amount and frequency of therapy was the way therapy was organised, specifically the time spent in information exchange and use of individual patient therapy timetables. Units that delivered (relatively) high doses of therapy had reorganised their service specifically to increase the amount of therapy provided. Further research and service improvement work needs to focus not only on increasing the amount of therapy patients receive, but also on the frequency with which they receive it, and the best way of organising and resourcing the therapy workforce to deliver it. Further research is needed to establish how to achieve this most effectively within each patient’s needs and capabilities.
Interestingly, few patients were considered to require therapy for all of their inpatient stay and one would expect a patient who needed therapy to be discharged once it was no longer necessary. The apparent gap between no longer needing therapy and discharge may be because other matters were preventing discharge such as medical problems, delays to getting community-based care in place, ineffective discharge planning, or therapists’ lack of ambition or low expectations of their patients’ potential abilities. Further research is needed to investigate the causes of this apparent delay in discharge and how to overcome it.
The SSNAP’s records regarding therapy and rehabilitation processes of care were often incomplete. However, the teams which recorded these items showed good completion routes: all inpatient teams set rehabilitation goals; and approximately three-quarters assessed continence and created a management plan, developed joint health and social care plans, and held regular MDT meetings to monitor and plan care. However, it should be noted that the SSNAP merely notes whether or not these activities took place, but not their content or efficiency. It is also possible that the proportion of teams that did not record these activities were not completing them, so if the whole stroke population is considered, access to these aspects of rehabilitation may be lower.
Limitations
This work is based on routinely collected observational data, which comes with limitations that should be noted. Although the SSNAP has stringent quality control processes, it is dependent on the accuracy of the original data entered, and may therefore be open to observer and reporter bias. Inconsistency in the way that therapists record therapy has been noted in previous studies,43,47 with a tendency to overestimate the duration of treatment sessions, and so the accuracy of estimates of the amount of therapy should be treated with some caution. However, the size of the database indicates that the effect of any individual biases should be negligible.
Some of the included measures contained high degrees of missing data, including social deprivation scores, NIHSS scores, response rates on the processes of care and relatively low uptake of response from community-based teams. Consequently, the data regarding these variables may not be representative of all stroke patients and stroke teams. We postulate that the stroke teams that complete all elements of the SSNAP may be ‘early adopters’ and well-organised services that may behave differently to the wider population of stroke teams. Thus, the results reported regarding these elements should be interpreted carefully.
The data set used in this project covered a period of change in UK stroke services, with many being reorganised to deliver hyperacute care and specialist community services. This means that some stroke teams may have changed classification during the study period. To prevent possible patient identification, the exact date of admission was not available and so the classification designated by the SSNAP at the mid-point of the study (June 2014) was applied, meaning potential misclassification in unit type for patients admitted at a different time period. To reduce misclassification, an experienced member of the SSNAP team was consulted and the definitions we produced vetted; however, misclassification may still be present.
