Shared learning database

Mid Cheshire Hospitals NHS Foundation Trust
Published date:
May 2019

The project reviews the development of a visual scanning wall for the use with stroke patients with visual inattention / neglect at Leighton Hospital, Crewe. NICE guideline - Stroke rehabilitation in adults: Clinical guideline [CG162] was implemented as part of this project. Section 1.4.3 regarding assessing the effect of visual neglect after stroke on functional tasks, and 1.4.4 use of intervention for visual neglect after stroke were considered and implemented in particular. NICE guideline 162 has helped shape stroke care and best practise within the stroke unit at Leighton Hospital.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of this project was to investigate a novel assessment of visual inattention / neglect post stroke, by creating a therapy scanning wall. This was done with the aim to review patients interacting with the wider environment, using fixed images on a wall set to a specific pattern, representing the visual field. In clinical practice, a limitation of small scale table top assessments and screens has been seen in detecting visual inattention. Another aim was to create a more standardised option for assessment than verbal prompting of the changing environment.

The following objectives were set to measure the introduction of  the therapy scanning wall in line with NICE guideline S’troke rehabilitation in adults’ (clinical guideline CG162):

  • Create an assessment tool for visual inattention
  • Establish its feasibility of use within the therapy setting
  • To gain increased knowledge of the effects of visual inattention in the wider environment
  • Learn from findings and develop the tool as appropriate

NICE guideline - Stroke rehabilitation in adults: Clinical guideline [CG162] was implemented with this project.

1.4.3 Assess the effect of visual neglect after stroke on functional tasks such as mobility, dressing, eating and using a wheelchair, using standardised assessments and behavioural observation.

The functional assessments are standard practices. The introduction of the scanning wall followed this guideline to see how patients interact with their environment, observations of behaviour and see if it was possible to develop a standardised assessment on a larger scale.

1.4.4 Use interventions for visual neglect after stroke that focus on the relevant functional tasks, taking into account the underlying impairment. For example:

  • interventions to help people scan to the neglected side.

The scanning wall was introduced to see if this would help patients scan to the neglected side. As the project developed this became a possible treatment option, which may have carryover into function.

Reasons for implementing your project

Before the project was implemented patients with visual neglect were assessed on the stroke unit, during function and ADLs, using the Alberts test and behavioural observation.  These were reviewed as a baseline assessment. Standardised assessments are carried out using either A4 or A3 paper on a table in front of the patient, however people are more likely to compensate by scanning if things are very close together within their visual field and therefore visual inattention is not always detected (Appelros et al. 2003). Paper screens only assess visual inattention in peripersonal space, but not within extrapersonal space (Plummer et al. 2003). Therefore the paper screens are not always representative of what is observed behaviourally. Functional tasks tend to also be reviewed at either a sink or with a small table in front, especially for the less mobile patients. It has been seen that how a person interacts with their environment is how visual neglect impacts on function.  Due to this it was thought a change was needed and the scanning wall was created.

The idea of a scanning wall was discussed with stroke specialist therapist and consultants, and was well supported.

This project is based on the 28 bedded Stroke Unit at Leighton Hospital, Crewe. Leighton Hospital had 354 inpatient stroke patients from April 2017- March 2018.

How did you implement the project

The scanning wall was designed prior to purchase of wall stickers (£60). It was created in a quiet environment, minimising the influence of auditory stimulus. The centre point of the wall marked with a small, red picture. The design separates the visual quadrants and has the same number of pictures to scan in each quadrant. These pictures were placed on 3 circles within this like a target.  Picture placement was carefully measured.

13 pictures are on each side of the centre point, with 5 pictures in each quadrant. Each quadrant is divided by pictures in a straight line to mark the quadrants, 3 to the left (birds) and 3 to the right (butterflies), with a tree as the centre point, with its trunk  marking the vertical line and a further 4 pictures (clouds) above the tree on the vertical line. The pictures were chosen to make sense in a scene, however were individually identifiable (by colour / number). Not including the tree, a total of 30 pictures were included on the wall.

Suitable patients were identified for the project from therapy assessments and sessions were in addition to standard therapy. Patients were screened with the Alberts test to allow for comparison.

Patients were read a brief instruction before entering the room. They sat on a chair at a set point, directly facing the middle of the wall to ensure consistency. The person questioning sat directly behind the patient so not to influence scanning from a visual or auditory cue. The patient was asked to name the individual picture they could see.

Initially patients were assessed using the wall on admission and discharge, however the project developed to using the wall for treatment as well. They were encouraged to scan, through verbal prompts, for example “the tree is in the middle of the wall”- to prompt them past mid line, if they still were unable to scan, they were then prompted to scan one picture at a time. They were then asked questions e.g. “how many birds can you see, what colour is the helicopter?”

Generated hypothesis: a learning effect of scanning the picture would occur through prompted practice. Observations were made to see if a patient was able to scan through memory. For example, if a patient would recall there were a certain number of birds on the picture, or they expected to see a certain picture there.

A paper recording sheet was created using a photograph of the wall, and pictures identified were marked. The number of pictures seen, and observations of how they scanned was recorded.

Key findings

Initial aims and objectives of investigating the possible benefits of the scanning wall for assessment of stroke patients with visual inattention were achieved. The project developed to include the visual scanning wall as a treatment. It became an effective environmental assessment tool and treatment option.

Data was collected from October to December 2018, for patients with visual inattention in therapy assessment. 3 patients were reviewed for assessment on admission and discharge. A further 6 patients used the wall for treatment. This project and data collection is ongoing.

All patients showed an improvement in scanning from admission to discharge.

4 out of 9 patients showed significant visual inattention when using the wall however they marked through all lines on the Alberts test. A further 3 people who marked their Alberts test past midline, were unable to track past midline on the wall.

1 patient marked the far right lines on the Alberts test, matching with them only naming the far right pictures on the wall. On discharge they were able to scan to midline on the wall, and showed some improvements with the Alberts test but not to midline.

2 patients used a systematic approach, also seen with the Alberts test, starting with their dominant side and scanning from right to left, naming the pictures that could be seen vertically before scanning further. 1 of these patients missed all the pictures on the left lower quadrant.

5 of the 6 patients using the wall for treatment showed carry over between sessions, supporting the idea of the learning effect. These patients had no or minor cognitive impairment.  1 patient with marked visual inattention improved within a session, and showed carryover over a longer period. Memory problems could be a limiting factor.

The use of the scanning wall for assessment helped understanding of the patient’s deficit, and shaped treatment plans within standard therapy.

Increased postural orientation was noted, with increased spatial awareness of the effected side.

Patients with severe cognitive and language problems were not included in the project due to barriers of use. This project suggests some patients with these problems could engage with the wall through gesture. The paper assessment tool has proved simple to complete.

Using standard prompts and set up allows assistants to carry out treatments, improving the efficiency and productivity of the workforce.

The wall improved patient experience.

Key learning points

Key learning for this project is that for the initial small number of patients an effective assessment and treatment option for visual inattention post stroke has been created.

It can be seen that small scale table top screens have limitations for initial assessment with visual inattention, and that the scanning wall could give a more accurate representation of the visual inattention deficit within the wider environment/extrapersonal space.

This initial information gained is based on a small number of patients, and therefore the project is ongoing to gain a greater understanding of possible benefits and feasibility of use. Further quantitative and qualitative data is being collected.

I would advise other organisations thinking of creating a scanning wall, to create this in a quiet area, as this was essential to its use, the consistent set up and written cues allowed this to be repeatable. We considered painting the design on the wall, however the wall stickers gave us more flexibility in initial set up, and could be changed/ varied in the future. The development of the scanning wall is in addition to current standard practise and not replacing this.

The scanning wall offers a relatively low cost option for an assessment and treatment for visual inattention compared with developing computerised options.

Further assessment of the scanning wall use could look at variable positioning and closer interaction on the wall to see the impact on the learning effect. I would advise completion of training sessions with the MDT around the use of a wall. The wall has remained a set picture for this project, however it could be looked at with changing pictures, but this may impact the learning effect. The wall was created to look at visual scanning, but further cognitive use could be introduced, such as putting pictures out of context, and looking at what’s wrong.

Contact details

Natalie Sharp
Therapy Team Manager for Stroke
Mid Cheshire Hospitals NHS Foundation Trust

Secondary care
Is the example industry-sponsored in any way?