Rehabilitation referral process in acute stroke: decision-making of multidisciplinary teams and rehabilitation assessors

Abstract

Stroke is a medical emergency that can result in significant loss of independence and impact upon all aspects of a person’s life. Patients who have a stroke are often treated in a hospital on an acute stroke unit by a multidisciplinary team, with many then requiring rehabilitation to address the impacts of stroke. There are multiple types of rehabilitation available after stroke, and the acute multidisciplinary team are often involved in complex clinical decision-making processes regarding referral to rehabilitation. These referrals are in turn received by rehabilitation assessors who engage in their own decision-making processes to determine acceptance into their service/s. The literature suggests that decisions about referral and acceptance to rehabilitation are often based on subjective assessments of rehabilitation potential, as well as consideration of contextual factors, and may not always reflect patients’ rehabilitation needs. Inequities in access to rehabilitation, as well as observed variations in practice, highlights the need for in-depth exploration of the processes involved, particularly how clinicians engage in rehabilitation referral and acceptance decision-making. The aims of this research were to: 1) explore the decision- making processes and experiences of acute stroke teams, around referral to post-stroke rehabilitation, and 2) explore the decision-making processes and experiences of rehabilitation assessors, about acceptance of patients with stroke, for rehabilitation.An ethnography was conducted across five acute stroke units in Queensland, Australia. Observational data were collected at each site to describe the context and practices of the multidisciplinary teams: field notes were completed, key documents analysed, and observations and audio recordings were made at the key meeting of the acute stroke team at each site. Interviews were also conducted with 32 clinicians from a range of health professions, both acute and rehabilitation, who were involved in rehabilitation referral and acceptance decision-making for patients with stroke.There was significant variation in the team structure and processes of the acute stroke units, as well as in the types of rehabilitation available to patients. Seven key themes arose from the study. The theme “Everyone needs rehab, but...” explores the findings that most clinicians believed that all patients with stroke could benefit from rehabilitation, however decisions about rehabilitation referrals and acceptance were complex, subject to revision, and did not always have an ideal solution. The second theme, “Can they participate, and get the most out of it?”, explores how the patient’s context, including their potential and goals for rehabilitation, was considered by all clinicians. “Sometimes you have to convince them”, describes how patients and families generally were not involved in the decision-making processes, as clinicians tended to make decisions within the multidisciplinary team, and then present the ‘plan’ to the patient. The context of the acute stroke unit played a role in shaping decisions, as did the processes and effectiveness of the acute multidisciplinary team – these are explored in the themes “Our unit is quite unique” and “Positive team environment”. The rehabilitation context, particularly in regard to service availability, influenced referral initiation and acceptance and is discussed in the theme “This is a precious resource”. The final theme, “Keeping the conversation open”, explores the influence of relationships between the acute and rehabilitation services on referral decisions, and how clinicians experience the decision-making process.This research adds to the knowledge base with in-depth descriptions of the processes and experiences of clinicians involved in post-stroke rehabilitation decision-making. It found there is a high degree of complexity around referral and acceptance decisions, access to rehabilitation varies across the state, and patients are not actively involved in the process. Facilitators of effective decision-making include well-functioning teams, presence of rehabilitation liaison services, and positive relationships between acute and rehabilitation services. Although it did not capture patient and family perspectives, nor all occasions of decision-making, the research has provided insights previously absent from the literature. Future research directions include investigating interventions to support the facilitators of effective decision-making, understanding the patient experience, investigating the barriers to shared decision-making in this context, evaluating the legitimacy of the influence of contextual factors in decision-making, and investigating whether gaps in rehabilitation services match those reported by clinicians in the current study, as well as those potentially reported by patients.