Stroke Inpatient Rehabilitation Team Conferences: Leadership and Structure Improve Patient Outcomes.

Consensus on how rehabilitation teamwork and services are optimally coordinated continues to be a work in progress. One area of recent research has been inpatient-rehabilitation team conferences in stroke. The prevalence of Americans living with stroke is expected to gradually increase as the U.S. population ages, as will the related direct and indirect costs. Effective interdisciplinary team conferences during acute-stroke inpatient-rehabilitation are key to managing long-term costs while improving functional outcomes. Effective team conferences help to identify patients at risk for medical complications and institutionalization and help to determine interventions that will focus on patients' medical, physical, cognitive, emotional, and social barriers to recovery and barriers to a community/home disposition. This scoping review paper identifies and analyzes literature on theory and structure of effective teams with the focus on stroke interdisciplinary rehabilitation team conferences and offers suggestions for improvement. Potential flaws of commonly used team conference formats are described. Studies are outlined showing associations between stroke patient outcomes and better care coordination and leadership in medical teamwork; and 2 examples of successful interdisciplinary team conference models used in stroke inpatient-rehabilitation are provided that support a case for a proactive, conscious structure to team conferences. Given the complexity of many stroke patients' clinical care, greater attention to team functioning, and especially team conference leadership and structure, may be a promising area of focus to improve the quality of health care services for people with stroke.

Recurrent discitis in the acute rehab setting: a case report.

INTRODUCTION: Discitis is an infection of the intervertebral disc space that can lead to paralysis, sepsis, epidural abscess, or other life-threatening complications if left untreated and may sometimes present with limited laboratory abnormalities to clue a diagnosis. CASE PRESENTATION: We present a case of a 67-year-old female in an acute rehabilitation setting who had presenting symptoms of sudden unexplained back pain refractory to pain control. She had a previous history of discitis and multiple failed knee replacement surgeries secondary to MSSA infections. Although vitals and basic labs were within normal limits, we recognized the clinical presentation as an indicator to order inflammatory markers (CPR and ESR), which were elevated compared to levels on admission, and subsequently ordered imaging and blood cultures to detect a case of recurrent worsening discitis. DISCUSSION: We highlight the presentation of recurrent discitis and necessary low threshold needed to detect such recurrence in patients with a previous history of discitis that have sudden unexplained back pain with no other usual physical or laboratory indicators of infection.

Toward spanning the quality chasm: an examination of team functioning measures.

OBJECTIVE: To examine the effect of 5 measures of team functioning on patient outcomes. DESIGN: Observational, exploratory, measurement. Team functioning surveys and patient outcomes collected 1 year apart in a clinical trial were analyzed. The findings are discussed in context of the domains of team functioning, team effectiveness, and quality improvement. SETTING: 27 Veterans Affairs medical centers. PARTICIPANTS: Staff (t1: N=356; t2: N=273) on inpatient teams and patients (t1: N=4266; t2: N=3213) treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Five measures of team functioning (Physician Engagement, Shared Leadership, Supervisor Team Support, Teamness, and Team Effectiveness scales) and 3 measures of patient outcomes (functional improvement, discharge destination, and length of stay) were assessed at 2 time points with hierarchical generalized linear models to evaluate the association between team functioning measures and changes in patient outcomes. RESULTS: Associations (P<.05) between team functioning measures and patient outcomes were found for 3 of the 15 analyses over the study period. Higher Physician Engagement scale score was associated with lower length of stay (P=.017), and increased scores on Teamness and Team Effectiveness scales correlated with higher rates of community discharge (P=.044 and .049, respectively). CONCLUSIONS: This exploratory analysis revealed trends that team functioning corresponds with patient outcomes in clinically relevant patterns. An increase in community discharge and a decrease in length of stay were associated with higher scores of team functioning. Here, we find evidence that modifiable attributes of team functioning have a measurable effect on patient outcomes. Such findings are promising and support the need for further research on team effectiveness.

Analytical review: focus on fall screening assessments.

BACKGROUND: Falls and their associated injuries profoundly impact health outcomes, functional independence, and health care expenses, particularly for the ever-increasing elderly population. This systematic search and review assessed the current evidence for the role of fall screening assessments. OBJECTIVE: To review the current evidence for fall risk screening assessments in community-dwelling (outpatient), inpatient medical and surgical wards, inpatient rehabilitation centers, and postrehabilitation outpatient settings. DATA SOURCES: MEDLINE and Embase (January 1980 to December 2012). STUDY SELECTION: Prospective validation studies of acute medical or surgical inpatients, acute rehabilitation inpatients, outpatients who completed acute inpatient rehabilitation, or community-dwelling elderly. DATA EXTRACTION: Sensitivity, specificity, positive predictive value, negative predictive value, receiver operating characteristics with area under the curve. RESULTS: We summarized key findings from 6 literature reviews. We then identified 31 articles: 12 studies in community setting, 13 in the acute medical inpatient or surgical inpatient setting, and 6 studies in the rehabilitation setting. Twenty-two studies not previously reviewed were included, and 9 studies previously reviewed were considered relevant and were included to allow comparison with data from the studies not previously reviewed. CONCLUSION: We recommend consideration of 7 assessment tools to be used in conjunction with overall clinical evaluation to assess falls risk: the Timed Up and Go Test with a cutoff of >12.34 seconds and Functional Gait Assessment among community-dwelling elderly; St Thomas Risk Assessment Tool in medical inpatients <65 years old and surgical inpatients; Hendrich fall risk model II in medical inpatients; 10-Minute Walk Test in patients in poststroke rehabilitation; and Berg Balance Scale or the Step Test in patients in poststroke rehabilitation who had fallen during their inpatient stay.

Polypharmacy and the role of physical medicine and rehabilitation.

Polypharmacy and inappropriate prescribing practices lead to higher rates of mortality and morbidity, particularly in vulnerable populations, such as the elderly and those with complex medical conditions. Physical medicine and physiatrists face particular challenges given the array of symptoms treated across a spectrum of conditions. This clinical review focuses on polypharmacy and the associated issue of potentially inappropriate prescribing. The article begins with a review of polypharmacy along with relevant aspects of pharmacokinetics and pharmacodynamics in the elderly. The adverse effects and potential hazards of selected medications commonly initiated and managed by rehabilitation specialists are then discussed with specific attention to pain medications, neurostimulants, antipsychotics, antidepressants, antispasmodics, sleep medications, and antiepileptics. Of particular concern is the notion that an adverse effect of one medication can mimic an indication for another and lead to a prescribing cascade and further adverse medication events. Appropriate prescribing practices mandate an accurate, current medication list, yet errors and inaccuracies often plague such lists. The evidence to support explicit (medications to avoid) and implicit (how to evaluate) criteria is presented along with the role of physicians and patients in prescribing medications. A brief discussion of "medication debridement" or de-prescribing strategies follows. In the last section, we draw on the essence of physiatry as a team-based endeavor to discuss the potential benefits of collaboration. In working to optimize medication prescribing, efforts should be made to collaborate not only with pharmacists and other medical specialties but with members of inpatient rehabilitation teams as well.

Measuring team process for quality improvement.

BACKGROUND: Even though team care is pivotal to stroke rehabilitation, we have few tools to measure team process. Process measures of team functioning would benefit stroke rehabilitation outcomes and quality improvement (QI). OBJECTIVE: To improve measures of team process and evaluate their potential for use in rehabilitation research and QI. METHODS: We use item response theory (IRT) to analyze and revise selected scales from the Team Functioning Survey administrated to rehabilitation staff (n=365 at 31 VA hospitals) as part of a national clinical trial (NCT00237757). Revised scales were evaluated for reliability (Cronbach's alpha) and validity (correlations, predictions of patient outcomes). RESULTS: Eight scales (60 items) were selected from the TFS for analyses based on their specificity to rehabilitation and potential utility in process improvement. Factor analyses supported the dropping of 2 scales and the combining of 2 scales. As indicated by the IRT analyses of scale psychometric properties, poor performing scale items were dropped and item response categories modified needed areas for further development were identified. Cronbach's alpha for the resultant best 5 scales was good. Intercorrelations varied among scales but were mostly in the moderate ranges. Two of the scales predicted patient outcomes of mFIM™ gain or discharge disposition. CONCLUSION: The analyses resulted in measures of 5 central components of team functioning: physician support, shared leadership, supervisor team support, teamness, and team effectiveness. IRT enables the scales to be refined and strengthened for use in outcome research and QI. The scales are proposed as another step toward understanding and enhancing team process.

The interdisciplinary team and polytrauma rehabilitation: prescription for partnership.

Optimal outcomes for polytrauma survivors depend on the integration of complex medical, psychosocial, financial, educational, and vocational resources across diverse specialties and multiple medical centers, programs, and organizations and all in a setting of high public visibility and family involvement. Well-functioning teams are critical to service integration, and teams are more effective in supportive hospital environments. Here, we offer a model of team functioning relevant to polytrauma and outline a team training program to improve services. Furthermore, we propose a partnership among the team, hospital administrators, and national leaders and with patients and their families. Integrated care requires partnerships among the various stakeholders, and those working in polytrauma have a unique opportunity to create an updated paradigm of the team approach responsive to the complexities of contemporary health care.

Team training and stroke rehabilitation outcomes: a cluster randomized trial.

OBJECTIVE: To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes. DESIGN: A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups. SETTING: Thirty-one Veterans Affairs medical centers. PARTICIPANTS: A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention. INTERVENTION: The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process. MAIN OUTCOME MEASURES: Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS). RESULTS: For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge. CONCLUSIONS: Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757).

Utility of Treatment Implementation methods in clinical trial with rehabilitation teams.

Clinical trials of rehabilitation interventions pose unique challenges to researchers. Treatments can be technically complex, often requiring a multidisciplinary team of professions. This article demonstrates the application of Treatment Implementation (TI) methods in a rehabilitation team-training intervention conducted with 29 team leaders (12 medical doctors, 4 physical therapists, 3 speech-language pathologists, 2 occupational therapists, 3 kinesiotherapists, 2 registered nurses, 1 social worker, 1 program coordinator, and 1 administrator) from 15 Department of Veterans Affairs hospitals. We describe the intervention along with the influence of three TI categories (delivery, receipt, and enactment) on the design and implementation of the team-training intervention. Positive findings from the use of TI methods include (1) consistent and accurate presentation of intervention components and (2) evidence of study participants' receipt and enactment of intervention strategies.

Team functioning and patient outcomes in stroke rehabilitation.

OBJECTIVE: To evaluate the relationship between rehabilitation team functioning and stroke patient outcomes. DESIGN: Prospective observational study. SETTING: Veterans Administration (VA) inpatient and subacute rehabilitation units. PARTICIPANTS: Forty-six VA rehabilitation teams, including 530 rehabilitation team members from 6 disciplines (medicine, nursing, social work, physical therapy, occupational therapy, speech language pathology) and 1688 stroke patients treated by the teams. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Ten scales assessing team member perceptions of team functioning (communication, perceived effectiveness, physician involvement, physician support, teamness, utility of quality information, innovation, interprofessional relationships, order and organization, task orientation) and 3 primary patient outcome variables-functional improvement, discharge home, and length of rehabilitation stay (LOS). RESULTS: Three of the 10 measures of team functioning were significantly associated with patient functional improvement ( P <.05): task orientation, order and organization, and utility of quality information. One measure of team functioning-effectiveness-was significantly associated with LOS ( P <.05). None of the team variables predicted discharge destination. Aspects of team functioning that were important to outcomes differed depending on the outcome of interests. Efforts directed toward improving team activities and relationships, including collaborative planning and problem solving and the use of feedback information, may enhance rehabilitation treatment effectiveness. CONCLUSIONS: Characteristics of team functioning predict selected rehabilitation outcomes.

Patient-focused rehabilitation team cohesiveness in veterans administration hospitals.

OBJECTIVE: To quantify the relation of hospital culture, 3 levels of leadership (hospital-level administrators, discipline-specific supervisors, attending physician on the team), and physician involvement to patient-focused rehabilitation team cohesiveness. DESIGN: Survey research. SETTING: 48 Veterans Administration hospitals (VAHs). PARTICIPANTS: Six hundred fifty members of 50 rehabilitation teams. INTERVENTIONS: Not applicable. Main outcome measures Scales measuring hospital culture, administrative support, supervisor expectations, attending physician support, and physician involvement (independent variables), and patient-focused rehabilitation team cohesiveness (dependent variable). Associations between scales were examined by using a hierarchical linear regression model. RESULTS: Patient-focused team rehabilitation cohesiveness was significantly (P<.05) associated with administrative support, supervisor expectations, attending physician support, and physician involvement (Wald chi(2)=1192.66, P<.0001) (R(2)=.6431). There was no statistically significant independent association with hospital culture. CONCLUSIONS: Expectations of discipline-specific supervisors and hands-on team leadership and involvement by the attending physician were associated to a significant degree with the extent to which rehabilitation teams in VAHs reported functioning in a cohesive manner. Higher functioning on patient-focused team cohesion indicates that patient services were likely delivered with greater interprofessional communication and joint effort.

Geriatrics and physical medicine and rehabilitation: common principles, complementary approaches, and 21st century demographics.

The demographic changes occurring in the United States transcend the capabilities of any specific medical specialty to provide optimum care for the elderly. This commentary discusses a statement of principles drafted by representatives of the American Academy of Physical Medicine and Rehabilitation who collaborated with members of 9 other medical and surgical specialties. In this commentary, we argue that geriatrics and physical medicine and rehabilitation (PM&R) share common principles and complementary approaches. We urge physiatrists and other rehabilitation professionals to address the needs of elderly patients and recommend that these principles be incorporated into PM&R practice.

The influence of hospital culture on rehabilitation team functioning in VA hospitals.

A conceptual model of rehabilitation effectiveness, in which team functioning is influenced by hospital culture, has been previously suggested by several authors of this study. The current study tested the efficacy of the hospital culture portion of the model using survey data from 523 rehabilitation team members and 162 administrators from 50 participating Veterans Administration Hospitals (VAHs). We assessed four types of hospital culture (personal, dynamic, formal, and production-oriented) using an instrument developed originally for a Competing Values Model. Rehabilitation team members and administrators perceived three of the four hospital cultures differently (p < 0.0001), agreeing only on production-oriented culture. With the use of VAH dominant culture as the independent variable, statistically significant differences were found among all nine measures of team functioning (dependent variables). The major contrast was between personal versus formal hospital culture types.