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?

                     Website for this imageSinger/Songwriter,

One-Man Band (and the world's oldest child prodigy)oldstogie.com•Full-size image•215 × 215 (

Infinityx larger), 85KB•More sizes•Search by image•Similar imges

.

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!

Thank you

For further information please contact

vera.neumann@leedsth.nhs.uk