Dr Porter and Charge Nurse Cameron work in the stroke unit of the hospital and receive monthly reports from the Scottish Stroke Care Audit to update them on their unit’s performance against nationally agreed standards for stroke care. (See the Clinical standards, Clinical audit and Evidence based guidelines topic loops below for further information.)
When Dr Porter and Charge Nurse Cameron received their monthly report in April they were disappointed as they felt that the data presented in the report did not reflect their performance in relation to the prescription of antiplatelets to the patients in the ward.
Topic Loops:
Searching for high quality evidence might be the right thing to do if you haven’t found a relevant guideline, however, this can be very time consuming. (See the Evidence and Evidence based guidelines topic loops on the right for information).
A simple literature search would combine the terms “stroke” AND “physiotherapy” AND “amount”
Q. What do the results of this search tell me? Select True or False for each statement.
Which ever method you used (i.e. by either looking at the national guideline or by undertaking a search for high quality evidence) you now know that there is no one clear simple answer to the question relating to the best amount of physiotherapy after stroke:
- From looking at the relevant SIGN guideline you know that increased intensity of intervention is recommended for gait problems, but not for upper limb function
- Royal College of Physicians guideline for stroke 2012 suggests 45 minutes of tharapy for 5 days a week if the patient continues to benefit and can tolerate this.
- Searching for high quality evidence has confirmed that there is a complex body of evidence and acknowledged uncertainties relating to this question
Your challenge is to put this in a simple way within your response to the letter of complaint!
Topic Loops:
The national guideline should bring together the best available evidence and make practical recommendations. Looking at this one document may mean that you don’t have to spend valuable time searching databases for evidence. It is always good to start here. (See the Evidence based guidelines topic loop on the right for further information.)
- You should familiarise yourself with the Scottish Stroke Care Standards
- There is no one section specifically addressing the amount of physiotherapy
- However there are sections within the guideline which address the intensity for some specific problems (Section 4.3.12 addresses intensity of interventions for improving upper limb function and Section 4.2.13 addresses intensity of interventions for improving gait: see Additional Information)
- The guideline recommends increased intensity of intervention to improve gait, but does not recommend increased intensity to improve upper limb function
So, the national guidelines do not provide one clear answer to the question relating to the best amount of physiotherapy after stroke. You may decide that this gives you enough information to write your response to the letter of complaint or you may feel that you still need more information.
If a national guideline does not answer your question, or doesn’t give you enough information to answer it fully, a search for high quality evidence addressing your question can be helpful. (See the Evidence topic loop on the right for further information.)
How would you perform a search for high quality evidence addressing your question about the amount of physiotherapy?
Topic Loops:
So far your letter seems fairly clear. The family have a legitimate complaint. There is good evidence and National standards to indicate that Mr Bloggs should have been admitted to your stroke unit. The audit data indicate that your hospital’s admission rate falls short of the standard but you have a local action plan to rectify this.
However addressing the family’s concern about the amount of physiotherapy Mr Bloggs received is more complex……..
Well done, you knew that the SSCA publishes the performance of your hospital against the national standards and criteria for admission to stroke units.
Your stroke unit does not meet the national standard, so now you wish to explain what is being done locally to address this.
Topic Loop:
Well done, you knew that the Cochrane Library would provide you with the information to support that statement in your letter.
Now you wish to provide the statistics for admission to your stroke unit.
Topic Loop:
Well done, your knowledge of clinical guidelines supports that statement in your letter.
Now you wish to explain where the evidence for these guidelines can be found.
Topic Loop:
Well done, your knowledge of the national standards and criteria supports that statement in your letter.
Now you wish to explain the basis for this standard.
Topic loop:
