Hazard perception skills of young drivers with Attention Deficit Hyperactivity Disorder (ADHD) can be improved with computer based driver training: An exploratory randomised controlled trial.

BACKGROUND: Young drivers with Attention Deficit Hyperactivity Disorder (ADHD) are at higher risk of road traffic injuries than their peers. Increased risk correlates with poor hazard perception skill. Few studies have investigated hazard perception training using computer technology with this group of drivers. OBJECTIVES: *Determine the presence and magnitude of the between-group and within- subject change in hazard perception skills in young drivers with ADHD who receive Drive Smart training. *Determine whether training-facilitated change in hazard perception is maintained over time. METHODS: This was a feasibility study, randomised control trial conducted in Australia. The design included a delayed treatment for the control group. Twenty-five drivers with a diagnosis of ADHD were randomised to the Immediate Intervention or Delayed Intervention group.The Immediate Intervention group received a training session using a computer application entitled Drive Smart. The Delayed Intervention group watched a documentary video initially (control condition), followed by the Drive Smart computer training session. The participant's hazard perception skill was measured using the Hazard Perception Test (HPT). FINDINGS: After adjusting for baseline scores, there was a significant betweengroup difference in post-intervention HPT change scores in favour of the Immediate Intervention group. The magnitude of the effect was large. There was no significant within-group delayed intervention effect. A significant maintenance effect was found at 6-week follow-up for the Immediate Intervention group. CONCLUSIONS: The hazard perception skills of participants improved following training with large effect size and some maintenance of gain. A multimodal approach to training is indicated to facilitate maintenance. A full-scale trial is feasible.

Longitudinal employment outcomes of an early intervention vocational rehabilitation service for people admitted to rehabilitation with a traumatic spinal cord injury.

STUDY DESIGN: Longitudinal cohort design. OBJECTIVES: First, to explore the longitudinal outcomes for people who received early intervention vocational rehabilitation (EIVR); second, to examine the nature and extent of relationships between contextual factors and employment outcomes over time. SETTING: Both inpatient and community-based clients of a Spinal Community Integration Service (SCIS). METHODS: People of workforce age undergoing inpatient rehabilitation for traumatic spinal cord injury were invited to participate in EIVR as part of SCIS. Data were collected at the following three time points: discharge and at 1 year and 2+ years post discharge. Measures included the spinal cord independence measure, hospital anxiety and depression scale, impact on participation and autonomy scale, numerical pain-rating scale and personal wellbeing index. A range of chi square, correlation and regression tests were undertaken to look for relationships between employment outcomes and demographic, emotional and physical characteristics. RESULTS: Ninety-seven participants were recruited and 60 were available at the final time point where 33% (95% confidence interval (CI): 24-42%) had achieved an employment outcome. Greater social participation was strongly correlated with wellbeing (ρ=0.692), and reduced anxiety (ρ=-0.522), depression (ρ=-0.643) and pain (ρ=-0.427) at the final time point. In a generalised linear mixed effect model, education status, relationship status and subjective wellbeing increased significantly the odds of being employed at the final time point. Tertiary education prior to injury was associated with eight times increased odds of being in employment at the final time point; being in a relationship at the time of injury was associated with increased odds of being in employment of more than 3.5; subjective wellbeing, while being the least powerful predictor was still associated with increased odds (1.8 times) of being employed at the final time point. CONCLUSIONS: EIVR shows promise in delivering similar return-to-work rates as those traditionally reported, but sooner. The dynamics around relationships, subjective wellbeing, social participation and employment outcomes require further exploration.

Selection for rehabilitation: acute care discharge patterns for stroke and orthopaedic patients.

This study aimed to develop predictive models to assist clinicians working in acute care to determine which stroke and lower limb orthopaedic patients should be discharged to nursing homes, inpatient rehabilitation, or home. The subjects were 223 patients with stroke and 125 patients with lower limb orthopaedic problems, aged 60 years and over, and the 22 acute care and rehabilitation clinicians who cared for these patients. Patient status was measured within 72 hours of discharge using the Adult FIM(SM) (Guide for the Uniform Data Set for Medical Rehabilitation, 1993) and ten additional items from either the RICFAS (Rehabilitation Institute of Chicago, 1987) or developed for this research. Four mathematical models were developed to predict discharge destination using stepwise discriminant function analysis. Using between three and seven items from the FIM(SM) alone or FIM(SM) plus additional variables, these models correctly classified between 74.9% and 80.5% of patients. In conclusion, clinicians are offered a selection of models to guide their discharge destination decisions for two large groups of patients. While these models cannot replace clinical judgement, they increase the transparency of decisions. The use of objective models to guide clinical decisions are essential, particularly given increasing pressure to justify patient access to costly rehabilitation services.

Using a head-mounted video camera to study clinical reasoning.

Studies of clinical reasoning are essential if we are to extend our knowledge of occupational therapy practice, better communicate our work to clients and colleagues, and reveal to our students the nuances of therapy that cannot be gained from texts. However, accessing therapists' clinical reasoning is not an easy task because these cognitive processes can be studied only indirectly. The aim of this article is to promote the study of clinical reasoning by reviewing a new approach to data collection in this field. To achieve this purpose, the article outlines current data collection methods, such as the think-aloud method written notes, free recall, and audio-assisted and video-assisted recall. A novel method involving a head-mounted video camera is described, and details are provided on a modified approach to debriefing using video-assisted recall. Anecdotes from the authors experience of using this technology illustrate the text.

Trauma-rehabilitation connections: discharge and admission decisions for children.

Paediatric discharge coordinators and rehabilitation admission coordinators were surveyed about how children are selected for rehabilitation. The following areas are covered: (1) the decision process, and how children are selected for rehabilitation; (2) who is involved in making acute-care discharge and rehabilitation admission decisions; (3) factors that guide selection of children for rehabilitation; and (4) satisfaction with referral practices. Surveys were completed by 30 trauma discharge and rehabilitation admission coordinators, recruited from paediatric trauma units and paediatric/general rehabilitation units nationwide. Most respondents were satisfied with transfers, although some voiced concerns about constraints placed on referrals by insurance. Even when inpatient rehabilitation was clearly needed, 40% said insurance status still affected whether children were admitted. There was little evidence that any uniform criteria are used to make decisions. Half had no training in discharge/admission planning and half did not base decisions on functional assessments. Although guidelines are increasingly used in clinical decision-making, few are available concerning critical decisions about which children receive inpatient rehabilitation following trauma.

Decision polarization among rehabilitation team recommendations concerning discharge housing for stroke patients.

This study sought to identify if decision polarization effects were operating in rehabilitation teams when making discharge housing recommendations for stroke patients. Using a Social Judgment Theory approach, individual clinicians were asked to nominate discharge housing for stroke patients. Teams were then assembled and clinicians repeated the task. The research was conducted at a sample of seven in-patient rehabilitation hospitals. The subjects were 74 clinicians who formed 13 teams. All subjects were volunteers, and represented the following professions: medicine, nursing, occupational therapy, physical therapy, speech therapy, and social work. A casebook which described 50 hypothetical stroke patients in terms of eight attributes was devised for the study. Subjects made housing recommendations to these patients using a 7-point scale. When compared to individual clinicians' recommendations, it was found that team housing recommendations made by all 13 teams polarized towards both more supported and, in the other extreme, more independent types of housing. However, teams placed a stronger emphasis on supported housing when compared with individual clinician decisions. This decision polarization suggests that housing recommendations made to patients may reflect team processes as well as patient needs. Rehabilitation teams should be aware of this negative team dynamic so that steps to minimize decision polarization can be taken.

Admitting paediatric trauma patients to rehabilitation following acute care: decision making practices in the USA and Australia.

Paediatric patient access to rehabilitation services following trauma has significant long-term implications for clients, their families and the community. The aim of this research was to examine and compare the process by which patients are discharged from acute care and enter rehabilitation in the USA and Australia. The subjects were 31 American and 29 Australian discharge and rehabilitation admission coordinators. Subjects were surveyed about how they currently make trauma to rehabilitation referrals for children. Clinicians in both countries considered the severity of a child's injury and their social situation the most important factors when determining placement for a child. However, there were differences between Australian and US respondents in terms of how important they considered the factor 'medical coverage'. In addition, it was found that clinicians are not consistently using both standardized assessments and formal guidelines to assist them to determine which children should receive rehabilitation following acute care. Benefits of this research include a greater understanding of clinician discharge and admission decision making, and the equity of such decisions. However, further research is required on the influence of payment systems on access to paediatric rehabilitation.

Rehabilitation teams decisions on discharge housing for stroke patients.

For older people who have had a stroke, appropriate housing can promote independence and well being. However, suboptimal team accommodation recommendations may result in placement of an individual where their needs are not met, and their skills are not maximized. Although clinical judgments regarding patient discharge are routinely made by rehabilitation teams, this area has received limited research attention. This study examines how rehabilitation teams determine the most appropriate housing to recommend to stroke patients after their discharge from hospitals. A Social Judgment Theory approach was used to document and analyze the accommodation recommendations and policies of 13 rehabilitation teams (clinician n = 74). Teams were asked to consider 50 hypothetical stroke patients, and determine the most appropriate discharge housing to recommend to these patients. Each stroke patient was described in terms of 8 attributes: mobility status, ability to manage their own affairs, patient's choice of housing, personal activity of daily living (ADL) skills, domestic and community ADL skills, general health status, social situation, and premorbid living arrangements. Clinicians were provided with a response scale on which to record their recommendations. The results showed considerable yet reliable differences among teams concerning recommendations made, and judgment policies adopted. Although the highly structured and hypothetical nature of this research limits the external validity of findings, the results suggest that teams may also face difficulties with housing recommendations in the more complex clinical environment. Further studies to assess actual clinical team decision making are needed. Such studies could lead to the development of a standardized research-based protocol to help teams formalize and optimize their housing recommendations.