Team working in Rehabilitation for neurological problems
…..a European perspective
Vera Neumann
Scope of talk
Evidence concerning value of teams in rehabilitation: From scientific literature Personal experience
What makes a good team?multidisciplinary team structure:
Who does what? Who should lead?
Are teams really needed?
Potential disadvantages:Patients may feel overwhelmedTime-wastingIncreased use of (scarce) resourcesIncreased costs
Clinical teams - rationale
Clinical work needs a broad range of knowledge & skills:
selection of treatment options, often from a diverse range. Management of, for example, back pain may include medication, therapy and/or surgery. Which approach?
Co-ordination of varied interventions to achieve agreed goals
Critical evaluation & frequent revision of plans/goals
Rationale for MDTs
will any single team member have all skills needed?
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Evidence for teams in rehabilitation
From scientific literature – searched Medline & other databases 1996-2008 Musculoskeletal rehabilitation Cardio-respiratory .. Neurological ..
Personal experience
Multidisciplinary teams in musculoskeletal rehabilitationClinical field Reviewer/1st author Studies (numbers
of participants)MDT more effective?
Generalised pain - fibromyalgia
Karjalainen K, 2008
7 RCTs(1050) “little evidence”
low back pain – multidisciplinary biopsychosocial intervention
Guzman J, 2008 10 RCTs(1964) Better function & pain control
Following hip fracture
Cameron ID, 2008 9 RCTs & quasi-randomised CTs (1887)
uncertain
Multidisciplinary teams in cardio-respiratory rehabilitation
Clinical field Reviewer/1st author
Studies (numbers of participants)
MDT more effective?
Coronary heart disease multidisciplinary disease management
McAlister FA, 2002
12 (9803) Fewer admitted, better control of risk factors but MI recurrence & survival same
Chronic disabling lung disease –outpatient multidisciplinary rehabilitation
Griffiths TL, 2000 1 RCT (200) lower hospital & home visit rates better walking & health status
heart failure – community MDT treatment v usual care
Stewart S, 2000 1 RCT (200) Fewer admitted, better diet & drug compliance, survival same
Multidisciplinary teams in neurological rehabilitationClinical field Reviewer/1st author Studies (numbers
of participants)MDT more effective?
Multiple sclerosis – Inpatient MDT
Khan F, 2008 8 RCTs (747) better activity participation, impairment unchanged
brain injury – community MDT v information only
Powell J, 2002 1 RCT (110) Probably better than info alone
Severe TBI – MDT v standard hospital care
Semylen JK 1998 1 quasi-random CT (56)
Yes & carers less distressed
MDTs in Spinal cord injury rehabilitation?
Very little published evidence…
1. Stroke Unit Trialists' Collaboration. Stroke 1997
MDTs in stroke – the evidence1
3249 patients in Sweden, Finland, Australia, Canada & UK randomised to stroke units with MDT working or routine care where only 277/1346 exposed to multidisciplinary rehabilitation.
Stroke units (with MDTs) showed: Better survival in 1st 4 weeks, especially in those with
severe stroke – Barthel <15/100 on admission fewer neurological, cardiovascular & immobility-related
deaths. Not due to medication. Less likely to need institutional care because less
dependant. (attributable to more carer involvement in rehab?)
JRM 42 ; 2010
European position paper
Personal experience
Chapel Allerton Hospital, Leeds, UK post-acute rehabilitation following acquired neurological
(brain) injury. 20 beds, ~140 patients/year.MDT including: Nurses doctors Psychologists Physiotherapists Occupational therapists Speech & Language Therapists social workers
How our team works - 1
Team decision on acceptance based on patient’s needs potential for
improvement resources
Rehabilitation goals set with patient
How our team works - 2
Assessment – recorded against standardised measures at weekly meetings
Multi-, inter- or trans-disciplinary input to address these
How our team works - 3
MDT meets patient & family to review progress plan further
rehabilitation plan hospital discharge
Referred on to community services such as Community Brain Injury, Stroke or Multiple sclerosis teams
Centre for the Rehabilitation of the Paralysed – CRP
What CRP does
physiotherapy
Making own equipment
Getting ready for home
Returning to work
Scope of talk
Evidence concerning value of teams in rehabilitation
What makes a good team? Outcome of ESPRM multidisciplinary workshop From psychology & management literature
multidisciplinary team structure: Who does what? Who should lead?
Vilnius, Lithuania. Sept 2011
ESPRM congress workshop on teamwork
Our task
To define each MDT member’s roleCore competenciesContribution to teamin 3 situations:
Mobilisation in the acute setting following trauma
training communication skills in the post-acute setting
Community reintegration for those with long-term needs
Results?
What makes a team successful? physiotherapists’ views
Communication Cooperation Common goals members want to work in a team listen to each other respect and trust each other speak a common language That each team member take the responsibility for their
own professional competence and implement it
Occupational therapists’ views
Leader ship Size of the team Organization support the team Clear roles, responsibilities and functions Time structure Values shared Communication Competences needed Skills to be able to solve conflicts Time for team building Effective documentation routines Attitudes towards teamwork
Doctors’ views
Agreed aims Agreement & understanding on how best to
achieve these [avoiding jargon unique to a particular profession]
Appropriate range of knowledge & skills for the agreed task
Mutual trust & respect Willingness to share knowledge & expertise &
speak openly
What makes a good team? Evidence from elsewhere
Dalley J. Clin Rehab 2001
What can go wrong? Interdisciplinary working
Semi-structured interviews with experienced rehabilitation nurses concerning their perceptions of physiotherapists (PTs):
PTs concerned with mobility only whereas nurses see themselves as concerned with patients’ general well-being
valued PT expertise in lifting & handling Frustrated that expertise not shared with them
didn’t know why particular techniques had been selected had difficulty getting patients to do things they had seen patients
do with PTs Couldn’t respond to patients’ & Drs’ questions
Therefore nurses didn’t continue mobility rehabilitation eg at weekends
Literature review
Literature review on teams & collaboration in paediatric rehabilitation in health & educational settings (Nijhuis. Clin Rehab 2007)
Working in Teams – report from British Psychological Society (2001)
agreed aims and direction
Tower of Babel - Breugel
good communication, avoiding jargon
appropriate range of knowledge & skills for the agreed task
Strimmer for haircut?
mutual trust & willingness to share information
a thorny question!
Leadership???
Misconceptions about doctors’ roles in teams in UK
Doctors think they hold “ultimate responsibility” - can be sued if
things go wrong! GMC perpetuated this belief in UK
but rejected by law courts (Montgomery 92)instead have a duty to provide adequate information,
training & support to others Each professional has individual responsibility to
uphold their profession’s standards
Role of doctor in teams?
Doctors tend to have: Knowledge & skills to
predict secondary problems & prognosis
broad training & perspective
training in critical analysis
Examples: Is it safe to transfer
patient to rehabilitation unit or to discharge home?
Does patient need a different treatment modality?
Is a new treatment evidence-based, effective & safe?
Team working in rehabilitation - summary
Reasonable evidence that MDTs achieve better results in low back pain, cardio-respiratory disorders & certain fields of neurological rehabilitation
Theoretical basis for good team-working well-described in other settings
limited evidence concerning key components of successful teams in rehabilitation
Leadership…open to debate!