A comparison between reported and ideal patient-to-therapist ratios for stroke rehabilitation ()
1. INTRODUCTION
The incidence of stroke is estimated at approximately 110,000 cases per year in England with a range of 60% to 83% of patients achieving independence in self-care by one year after stroke [1]. The majority of patients surviving stroke however, experience upper limb motor impairment and reduced ability to perform basic activities [2]. Indeed, complete functional recovery of the upper limb was found to occur in only 5% to 34% of cases examined 6 months post-stroke [3].
The prioritization of stroke within the National Health Service (NHS) and proceeding changes in stroke care has resulted in a major improvement in the medical management of stroke such that hospital stay has seen a significant reduction from a mean of 23.7 days in 2008 to a mean of 19.5 days in 2010 [4]. The Sentinel Audit reported the median length of hospital stay was 10 days for patients [5]. However, functional recovery continues to present a considerable challenge. Moreover, discharge disability levels remain unchanged since 2008—58% of patients have a functional impairment on discharge from hospital. Based on a Barthel scored classification 22% of patients were mildly impaired, 14% were moderately impaired, 10% were severely impaired and 12% were very severely impaired on discharge from hospital [5]. The Sentinel Audit indicates that only a small proportion of patients are deemed appropriate for each of the therapies—physiotherapy (PT), occupational therapy (OT), and speech and language therapy (SALT)—during their hospital stay [5]. Nevertheless of those patients deemed appropriate only 32%, 31% and 18% received 45 minutes or more “per day” of each respective therapy during the weekday hospital stay [5,6].
This paper explores the extent of rehabilitation time provided to stroke patients using patient-to-therapist ratios. The findings reported here were extracted from the Work Package 1 (WP1) National Survey which was conducted under a larger Programme Grant for Applied Research (RP-PG-0707-10012) funded by the National Institute of Health Research (NIHR). The overall programme investigated Assistive Technologies in the Rehabilitation of the Arm after Stroke (ATRAS) and within that WP1 was tasked to determine current rehabilitation treatment methods and staffing resources for stroke rehabilitation. This information would be used to inform the treatment regime for the control arm of future ATRAS clinical trials. Ethical approval for WP1 was obtained from Bournemouth University.
2. METHOD
2.1. Survey Development
An Advisory Group of 12 stroke experts and a focus group attended by 30 stroke practitioners scoped the content and design of the survey. The focus group highlighted some potential difficulties with survey design such as the diversity of care settings, the multiple professions involved in care, the complexity of treating varying levels of impairment following stroke, and time constraints on the stroke team to complete a survey.
To address these issues, a two part survey was adopted that required input from the stroke team in each unit. Part A gathered demographic data about the care setting (e.g. acute or combined stroke unit); and the whole time equivalents (WTE) for all professions in the stroke team (e.g. WTE for PT, OT, SALT, Nurse, Medical). Part B provided a free script option to allow clinicians to describe the most common treatment interventions used in their unit for upper limb rehabilitation. Through an iterative development process the survey was pilot-tested and revised among the Advisory Panel and their associated stroke units before distribution to stroke units selected from the geographic areas covered by the 28 National Stroke Improvement networks. The data reported here is extracted from Part A of the ATRAS survey and used to derive patient-to-therapist ratios.
2.2. Survey Distribution
One objective of the survey was for national distribution in order to delineate the extent of stroke rehabilitation provided across the whole of England. This was achieved by collaborating with the 28 Stroke Improvement Networks to compile a contact list of stroke clinicians. Stroke Improvement Networks are national NHS networks that connect stroke practitioners around England to co-ordinate and support the stroke care pathway. However 9 networks were unable to collaborate with the researchers, therefore to cover these areas supplemental contact names were obtained through the South West Stroke Forum and searching through the NHS Consultant’s Guide for clinician contact details in those respective areas.
To have geographic representation of the network areas we used the straight-forward systematic sampling method and the Nth name selection technique (using a uniform interval of every 13th entry on the lists provided by each network) [7]. To cover the 28 network areas, 192 surveys were emailed to individual stroke care providers. However, this included multiple contacts within each team (e.g. a stroke consultant and a stroke co-coordinator) to increase awareness of the survey. The survey requested detailed input from the whole stroke team; therefore we specifically targeted clinicians who have a strong interest in stroke improvement as demonstrated by their involvement in the Stroke Improvement Networks. The original Dillman [8] approach was adopted to engage individuals with the project [9]. A minimum of 3 email prompts with non-responders was used and a minimum of 3 telephone follow-ups were made to participants if further clarification of their responses was needed.
2.3. Survey Participants
In total 54 completed surveys were returned by stroke teams to represent 20 of the 28 geographic network areas thus representing 71% national coverage. One survey was unsuitable for analysis as it described a protocol of treatments in a research situation and therefore, was not a typical clinical setting. The 53 surveys represented stroke teams who worked across 77 care setting—of which 37 identified as in-patient care (i.e. acute stroke units, combined stroke units, and stroke rehabilitation units) and 40 were post hospital care setting (e.g. Community Health Care, Outpatient Care). Despite several follow-ups with the respective stroke teams, only 51 of the 53 surveys reported annual patient numbers treated for stroke and from these, a total of 16,632 patients were treated per year by the participating teams—13,954 treated per annum during hospital care and 2678 treated during post hospital care.
2.4. Data Analysis
Surveys selected for this analysis were based on the following inclusion criteria: surveys completed by inpatient hospital care stroke teams; stroke teams self identifying as a discrete unit (e.g. acute stroke unit only); stroke teams with no missing data for staffing levels in their unit; and stroke teams provided full data per unit on average length of stay, number of beds and occupancy rates. However, and despite several follow-up phone calls to the stroke teams, some data fields remained incomplete. The researchers adopted the strategy of removing units with any missing data from further analysis rather than replacing the missing data with mean values which could lead to distortion when the intent of the analysis was to compare reported patient-to-therapist ratios to national guidelines. Consequently, this paper reports the data from 19 of the 37 in-patient hospital units.
Teams reported the WTE for all staff members (e.g. PT, OT, Nurse, SALT, and Medical) in the unit and the proportion and number of stroke patients treated annually. To isolate staffing levels and therapist time for stroke patients, the researchers adjusted staffing WTE accordingly to reflect stroke specific WTE only. For example, if a team indicated that the stroke patients treated annually in the unit represented 80% of all patients in the unit, the staffing WTE was adjusted accordingly. Thereafter, comparisons were made between reported patient-to-therapist ratios for PT, OT, and SALT derived from the survey data to ideal and aspirational ratios derived from Department of Health (DH) published guidelines for stroke unit staffing. The Stroke Strategy Staffing Assumptions grid published in the NHS Workforce Planning Resource [10], Nice Quality Standards Stroke Topic Expert Group Meeting [11] and the DH’s Progress in Improving Stroke Care [2] provides an ideal staffing WTE and an aspirational staffing WTE for stroke units. We used these staffing numbers to derive ideal patient-to-therapist ratios and aspirational patient-to-therapist ratios. We also used the terms “ideal” and “aspirational” to be consistent with the labels from the Stroke Strategy Staffing Assumptions grid. The staffing grid is presented in Table 1.
The basic formula used to derive the reported patientto-therapist ratio was:
365/LOS × OccR × 10/therapists per 10 beds = annual patient-to-therapist ratiowhere:
365 = days of the year;
LOS = average length of stay;
OccR = average occupancy rate;
10 = number of beds.
The components used to derive the reported, ideal, aspirational, and combined ratios for the formulas are presented in Table 2. Formula A used the average length of stay, occupancy rate and therapist-per 10 beds that was reported by the teams in each of the units. This represents the patient-to-therapist ratios that are experienced by teams in the stroke units. Formulas B and C used the average length of stay from the National Sentinel Audit, the Royal College of Surgeons (RCS) recommended occupancy rate, and the DH staffing levels assumptions and aspirations. This represents patient-to-therapist ratios that ought to be experienced if conditions (i.e. LOS, OccR and staffing) reached “ideal” or “aspirational” levels. Formula D represents a combined ratio for which we used the reported length of hospital stay and reported occupancy rates for each unit combined with the recommended DH staffing assumption. We used this formula to demonstrate that the high occupancy rate and longer hospital stay reported by the teams puts challenging demands on units to provide the recommended 45 minutes of therapy to patients even when the DH staffing assumptions are met.
Table 1. Staffing assumptions and aspirations for stroke units (whole-time equivalents per 10 beds).
Table 2. Components to derive reported, ideal, aspirational and combined patient-to-therapist ratios.
Table 3. Average staffing level per team converted to whole time equivalents per 10 beds.
The average staffing WTE for PT, OT and SALT in acute, combined and rehabilitation units respectively are presented in Table 3. The average number of beds for the three types of units was 27 for acute stroke units, 27 for combined stroke units, and 29 for stroke rehabilitation units (range of 14 - 40 beds per unit) and is comparable to the median number of beds (n = 26 beds) reported in the Sentinel Audit [5]. However, the average occupancy rate of 93% from this survey was higher than that recommended by RCS [12,13]. Indeed, the RCS states the maximum bed occupancy rate for general and acute units should not exceed 82% as this is a clear predictor of increased risk of infection, while the National Audit Office found occupancy rates to be approximately 86%. The 86% rate was used to derive ideal and aspirational ratios to better compare with the reported occupancy rates in the ATRAS survey.
3. RESULTS
Table 4 lists the ideal and aspirational patient-totherapist ratios which are represented as the dashed and solid lines respectively in each of the Figures 1-3. Figure 1 shows the patient-to-PT ratios in the units. Units were graphed geographically from North to South of England to preserve anonymity of the stroke teams. The ideal ratio (dashed line, Formula B) equaled 107 patients per PT treated annually. The aspirational ratio (solid line, Formula C) equaled 43 patients per PT treated annually. What Figure 1 shows is that few units met the patient-to-PT ratios expected by the DH. Only 6 of the 19 units (31%) were working within the ideal ratio and none of the units were within the DH staffing aspiration levels [10,11]. To make one further comparison, a combined ratio was derived using the reported numbers for average length of stay and occupancy rates in the ATRAS survey with the DH staffing assumption (see Formula D) to derive patient ratios that are shown as the darker bars in Figure 1. This shows that while the DH staffing assumptions may improve units’ ability to meet patient