As part of a review of the national guidelines for stroke (NICE guideline ‘Stroke Rehabilitation in Adults’ CG162 - recommendations 1.2.16 and 1.2.17), it was decided to assess the implementation, effectiveness and perceived benefit of group therapy sessions on the stroke rehabilitation unit.
The project was carried out for the month of September 2017. The outcomes were measured through a data collection tool and patient and therapist questionnaires.
- Stroke rehabilitation in adults (CG162)
Aims and objectives
Based on the 28 bedded Stroke Unit at Leighton Hospital, Crewe, the rehabilitation therapy team introduced group therapy sessions as a project in September 2017 and audited the results.
Stroke therapy group sessions were implemented to:
- Improve patients experience, improve the 24 hour rehabilitation approach-by increasing therapy input patients receive
- Reduce patient time spent inactive on the ward
- Promote rehabilitation to wider multi-disciplinary team (MDT)
- Facilitate training of therapy assistants and junior members of the team in a supportive environment.
Key aims and objectives were set to measure the new stroke therapy group project against NICE guideline for stroke rehabilitation in adults: (CG162).
- To measure the benefits of group therapy on improving patient contacts
- To review the impact of group work on the 24 hour approach on the ward
- To review the impact of group work on emotional support for patients.
- To run a group for 5 days of the week to ascertain whether this is a realistic standard to achieve long term.
- Achieve 45 minute treatment therapy treatments, and review practicality of groups being delivered additionally to this.
Intensity of stroke rehabilitation relates to NICE recommendation 1.2.16: Offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate, and where functional goals can be achieved.
If more rehabilitation is needed at a later stage, tailor the intensity to the person's needs at that time. This relates to NICE recommendation 1.2.17: Consider more than 45 minutes of each relevant stroke rehabilitation therapy 5 days per week for people who have the ability to participate and continue to make functional gains, and where functional goals can be achieved.
Repetitive task training relates to NICE recommendation 1.9.23: Offer people repetitive task training after stroke on a range of tasks for upper limb weakness (such as reaching, grasping, pointing, moving and manipulating objects in functional tasks) and lower limb weakness (such as sit-to-stand transfers, walking and using stairs).
Reasons for implementing your project
Before the project was implemented patients received therapy treatments individually by 1-4 therapists depending on need, and often had 1 session of physiotherapy a day. Occasional ad hoc groups occurred but no local standard was agreed.
Due to staffing levels for occupational therapy, patients were often unable to be seen on a daily basis. Baseline assessments included feedback from the MDT and patients regarding day to day experience on the ward. Data was collected on daily contacts, and the number of sessions received a day.
We thought that group work would improve the efficiency of the service by:
- Allowing increased patient contacts
- Improving compliance with the SSNAP audit
- Allowing more patients to be seen by less therapists
- Provide training and support for therapy assistants and junior members of the team.
This will lead to increased productivity, and allow more appropriate use of therapist time according to their job role and banding. By increasing the opportunity to practice and therapy input received, patients would spend less time inactive on the ward. This should also lead to a reduction in length of stay, and associated cost saving, due to improved carryover of treatments. The 28 bedded stroke unit at Leighton hospital has 20 stroke rehabilitation beds and 8 acute stroke beds, providing care for people living in Cheshire and beyond.
How did you implement the project
We carried out the project in September 2017. Although it was implemented by physiotherapy, the groups also allowed joint working with Occupational Therapy within the group setting. We introduced the project to the team, with an explanation of aims and objectives. Initially some concerns were raised regarding change of working practice, and the ability to run groups when short staffed. To overcome this we assigned a project lead who took responsibility for the introduction and implementation of the groups, and supporting other team members. No extra staff were funded for this project, we looked at improving efficiency of current staffing levels.
Other issues were the timing of groups- initially they were at various times, and compliance would be limited during visiting, or receiving other interventions. Therefore we introduced a set time for the groups. This allowed ward staff to know the groups were taking place on a daily basis, so patients could be toileted/ready for the group, and the therapists both running the group and managing their caseload could manage their day more efficiently.
Following feedback from staff members and patients, we used different groups to incorporate more patients’ needs, allowing a wider range of patients to access the groups and also prevent boredom of repetition. The whole team were used to bring patients through to the group to ensure a timely start and finish, but this also allowed for additional gait or transfer practice to and from the groups. This promoted training to the HCA’s for specific handling, so these transfers could be practiced effectively throughout the 24 hour day, and promote awareness of patient goals. Each group was run by at least 1 qualified therapist and an assistant. All groups were based in the therapy gym, and included bed exercises, upper limb and balance groups, with components adapted to individual needs (NICE recommendations 1.2.16, 17 and 1.9.23).
The project exceeded initial aims and objectives. 15 group sessions ran in total in September 2017, limited to 4 days a week initially due to attendance at the ward MDT. The NICE guideline is for 45 minute therapy sessions over 5 days, and the project demonstrated that group work could be provided over 5 days.
For physiotherapy treatments the group activity was, in addition to the 1:1, 45 minute therapy sessions received 5 days a week meeting NICE guideline CG162, recommendation 1.2.17. From October 2017 the groups were held over 5 days.
From the 15 sessions:
- 750 extra minutes of treatment
- 60 extra treatments
- 57 of these were in addition to patient individual sessions. 100% of the sessions ran for 45 minutes or longer therefore adhering to national guidelines. 100% of patients saw benefit in group work- extremely positive patient feedback received (see attached supporting material).
We achieved initial aims of increasing patient contacts, improving the 24 hour approach to rehab and patients being more active. The groups proved an excellent platform for training and supporting assistants and junior members of the team. The aim of the project was also to establish a local standard of how many groups a week was achievable and beneficial. Initially this we looked at this over 4 days and increased to 5. We introduced different groups, an upper limb group, bed exercises group, gym ball and a balance group. Patients took part in individually modified tasks/exercises specific to their goals and needs set by the leading therapist within the groups.
Since the project a kitchen based baking/breakfast group has also been introduced on the ward. What exceeded expectation was how important the groups have been on patients moods (1.5) and staff morale. Patients were highly motivated within the groups, encouraging and supporting each other and were able to talk to other people in similar situations.
Staff morale also improved with a more therapeutic 24 hour rehabilitation approach. Being able to see more patients with less therapists meant improved use and efficiency of therapist time across the day and the creation of joint working and training within the groups.
Key learning points
Key learning from carrying out this project is a local standard has been created that 5 days a week therapy groups is achievable on the stroke unit. This will take commitment and ownership from the whole therapy team to ensure this is achieved long term. A success of the project is that the groups have continued.
Lessons were learnt during the implementation of the project and changes were made. It would be recommended to stick to a set time for groups. This improved attendance, allowed patients to know when they would be attending, ward staff were able to support patients to be ready to attend, and this allowed all therapists on the ward to plan their days efficiently. This also allowed the time to be protected. It was found it was important to gain a balance for the patients of group work and individual sessions, to ensure quality of input and progression.
The aim is to run the groups additionally to daily individual sessions to increase activity and benefits to the patients, however at times the groups can allow more patients to be seen in a day. It’s also important to consider patients may be having 3 sessions of therapy a day before the groups (including speech and language therapy, occupational therapy and, physiotherapy) so coordination/ timetabling is essential, and each patient is considered individually to assess their physical and emotional suitability to participate in the group sessions. This should ensure patients receive appropriate rest.
It's beneficial to have a project lead / group champion to introduce and support staff with the implementation of and sustain momentum of a new project. A development of the groups would be to add an education and secondary prevention component. By starting active group therapy within the hospital setting this may support and promote on going fitness and exercise on discharge empowering the patient to manage secondary prevention. With ongoing support then in the community this physical activity can be continued and could be a development of this project.