Dr Elizabeth Lynch, Research Fellow, Adelaide Nursing School, Faculty of Health and Medical Sciences and joint winner of the 2018 HSRAANZ Impact Award
Background: Stroke is the leading cause of adult disability in Australia. One in 6 Australians will have a stroke at some point in their life, and nearly two-thirds of stroke survivors need assistance for their regular daily activities. Rehabilitation after stroke can help to address disability and maximise function and quality of life. It has been reported that there are not enough stroke rehabilitation services available, yet prior to 2015, no data were available to quantify the degree of unmet rehabilitation need after stroke in Australia.
Methods: Between 2012-2015, we ran a cluster-randomised trial at 10 hospitals, aiming to improve the way rehabilitation needs were identified, and the way referrals to rehabilitation services were being made. The Assessment for Rehabilitation Tool (a nationally endorsed evidence-based decision-making tool) was introduced at all sites. The effectiveness of a one-off education session and provision of the Assessment for Rehabilitation Tool was compared to the effectiveness of a multifaceted approach for improving the way rehabilitation needs of stroke survivors are identified and managed.
Clinical practice was observed, staff were interviewed, and medical records were audited. Findings were presented regularly at local, national and international conferences.
Results: Judgements about stroke survivors’ rehabilitation needs tended to be based on whether staff expected that the stroke survivor would be able to access a rehabilitation service. Rehabilitation needs were frequently not identified for stroke survivors whose needs fell outside the scope of the current rehabilitation services, for example people with severe stroke or comorbid dementia. Both the education intervention and the multifaceted intervention improved the way rehabilitation needs were identified, but did not change the proportion of patients who were referred to rehabilitation services, nor the proportion of patients who accessed rehabilitation. Some acute hospital staff reported reluctance to refer all patients with rehabilitation needs to rehabilitation services for fear of damaging their relationship with the rehabilitation service providers.
We have collaborated with Australia’s peak stroke body, the Stroke Foundation, to advise on wording of the national Stroke Audit. This has enabled the collection of information on a national level about how rehabilitation needs of stroke survivors are being identified and managed, and objective reasons why rehabilitation is not indicated or why rehabilitation is not accessed. These contributions to the Stroke Audit have facilitated data collection about unmet rehabilitation needs in Australia, which may be used to advocate for increased stroke rehabilitation services.
The Australian Stroke Clinical Guidelines were recently updated and were released in 2017. Elizabeth Lynch was invited to draft the section regarding assessment of rehabilitation needs. The Stroke Clinical Guidelines now explicitly recommend use of the Assessment for Rehabilitation Tool and recommend that every person with rehabilitation needs be referred to a rehabilitation service. The impact of the new Stroke Clinical Guidelines has yet to be evaluated.
This project was led by Elizabeth Lynch as her PhD, supported by supervisors Professor Susan Hillier (UniSA), Professor Dominique Cadilhac (Monash University) and Dr Julie Luker (UniSA). The project was supported by the Agency for Clinical Innovation (New South Wales) and the Stroke Foundation. The Assessment for Rehabilitation Tool was developed and disseminated by the Australian Stroke Coalition.
Dr Elizabeth Lynch is an experienced stroke rehabilitation physiotherapist. She has been awarded state and national awards for her work implementing evidence-based practices in stroke rehabilitation settings.
Liz completed her PhD in 2015, which used mixed methods to explore and improve how rehabilitation needs are assessed after stroke. She was awarded an NHMRC Early Career Research Fellowship (commenced 2018) and she is currently investigating how to effectively implement the 2017 Stroke Clinical Guidelines and how partnerships with patients can be incorporated into implementation projects. Liz is based at the Adelaide Nursing School, University of Adelaide and is affiliated with the NHMRC Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery.