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Evaluating and improving care

Integrated care pathways

Integrated care pathway development

This area of work involves the development of multi-disciplinary integrated care pathways (ICPs). The ICPs are based on systematic reviews of the published evidence, to manage symptoms in the context of severe brain injury. Their purpose is not only to improve management, but also to form a basis for monitoring and assessment on which to measure the effectiveness of interventions prospectively.

ICPs developed and published by the department to date

  • Management of hemiplegic shoulder pain
  • Use of botulinum toxin in the management of spasticity following acquired brain injury
  • Management of depression following acquired brain injury
The benefits of this approach to patient care have been determined through a rolling process of audit. An additional aspect has been the design and evaluation of instruments for assessing both pain and depression in patients with communication deficits.


ICP for management of hemiplegic shoulder pain

Shoulder pain is a common and distressing problem for many patients with neurological conditions such as stroke. It may not immediately be evident in people with communication impairments who have difficulty conveying information about pain. To improve management of this problem, we have introduced documentation in the shape of a proforma and associated evidence based guidelines which:

  • Prompts timely assessment of hemiplegic shoulder pain
  • Guides the choice of intervention according to the presentation of pain
  • Provides space for regular recording of assessment and intervention details
  • Enables the course of management to be followed for individual patients
Three rounds of audit have been carried out to assess performance on 18 quality standards. We have found that introducing the proforma has improved standards of documentation and demonstrated a positive outcome in over half of our patients.


Outputs from study

A key output of this work is an information pack designed for rehabilitation professionals and which is available on request from the Regional Rehabilitation Unit. The pack includes:

  • Service guidelines and clinical guidelines for the management of hemiplegic shoulder pain
  • A flow chart summarising the care pathway over its designated timescale
  • Handling, support and pain management protocols for different presentations of pain
  • Two Screening and evaluation questionnaires:
    • Northwick Park Ability to Complete a Questionnaire (AbilityQ)
    • Northwick Park Shoulder Pain Questionnaire (ShoulderQ)
  • Northwick Park Hemiplegic Shoulder Pain Protocol incorporating:
    • Proforma for recording process of care
    • Assessment and management forms
Further outputs include publications in peer-reviewed journals and presentations to rehabilitation professionals, both locally and at national and international conferences.


Use of botulinum toxin in the management of spasticity

A number of studies have been conducted using both retrospective and prospective data. On the Regional Rehabilitation Unit at Northwick Park Hospital we have developed an integrated care pathway (ICP) for focal spasticity treatment using botulinum toxin and have then been able to use data from this to inform the future development of a more holistic spasticity management ICP. The ICP therefore provides a systematic method of recording the process and outcome of intervention in a consistent manner. Key elements of the programme were:

  • Systematic recording of intervention
  • Recording of appropriate therapy interventions
  • Outcome measurement
  • Development of a Patient Group Directive for non-medical administration of botulinum toxin
  • Implementation of Goal Attainment Scaling


Outputs from study

  • National guidelines for management of spasticity
  • local clinical guidelines for the management of focal spasticity
  • A flow chart summarising the care pathway
  • Proforma for recording process of care
  • Assessment and management forms
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