A Process of Multidisciplinary Team Communication to Individualize Stroke Rehabilitation of an 84-Year-Old Stroke Patient

Abstract

Previously, we have used a multidisciplinary team (MDT) approach to individualize rehabilitation of very old stroke patients as a means to establish intervention points for addressing impaired activities of daily living (ADL). However, this previous study was limited because of a lack in describing the communication process over time. This case study characterized the MDT communication process in the rehabilitation of an 84-year-old patient over the course of 15 weeks. The MDT consisted of 3 nurses, 1 doctor, 6 therapists, and the patient/families. Meetings (15 minutes each) were held at 4, 6, 8, and 15 weeks following the patient’s admission. To individualize the rehabilitation, the communication process involved gaining knowledge about ADL impairments, sharing assessments, providing treatment options, and reflecting on desired treatment outcomes—a process termed KATR. The knowledge, assessment, treatment, and reflection (KATR) process established intervention points focusing on specific ADL impairments. The team members focused the interventions on the impaired ADL identified in the KATR process, and individualized rehabilitation was generated from the MDT information-sharing knowledge. In the initial meeting (Week 4), intervention points derived from the KATR process focused on rehabilitation of self-care impairments. These impairments improved by Week 15. By the last meeting, the MDT intervention points focused on mobility impairments. Having an organized communication process (i.e., KATR) facilitates individualization of rehabilitation without lengthy and frequent MDT meetings and enhances the quality of rehabilitation after a stroke.

Effectiveness of Family-Engaged Multidimensional Team Planning and Management for Recovery in Patients With Severe Stroke and Low Functional Status

“…The rehabilitation approach is described in Table 1. In phase I (week 1), a comprehensive multidimensional assessment was performed [13,16]. On the day of admission to the convalescent rehabilitation ward, a team consisting of rehabilitation specialists, the patient, and the patient’s family assessed the clinical, functional impairment, psychological, and environmental aspects, and recorded the following patient characteristics: (1) basic attributes, including the prestroke living situation (premorbid ADL status); (2) clinical features related to the stroke; and (3) functional impairment status (Table 1).…”

“…The case conference was attended by the patient’s neurosurgical attending physician, the chief nurse, the lead author, therapists (physical, occupational, and speech therapists), and the patient’s family in the early phase of admission [17]. On the basis of the multidimensional assessment, intervention points were identified in specific areas of ADLs that were expected to be improved by preferential and early interventions [13,16]. The intervention points were selected from 13 items in the motor FIM (mFIM) subscale, and targeted transfer, locomotion, self-care, and sphincter control.…”

Developing Skills in Intra-Workplace Rehabilitation Education: II

“…According to Takanashi, knowledge management (KM) is "a systematic approach to finding, understanding, sharing, or creating and utilizing value-creating knowledge in order to achieve organizational goals and objectives" [2]. This definition is also consistent with the process of rehabilitation practice at the organizational (or departmental) level, for example, in the promotion of team healthcare, and it is recommended that a knowledge management (KM) approach be applied [8] [9] [10]. The model is presented visually in Paper I and reproduced here [3].…”