Thames Valley Trauma Rehabilitation Network
Implementing the Rehabilitation Prescription – a discussion document
This document considers the implementation of the Rehabilitation Prescription in the Thames
Valley Trauma Rehabilitation Network. Its goal is to achieve full implementation of the
rehabilitation prescription whilst also achieving full engagement of all services, most of which
do not have rehabilitation as their main focus. Its primary new suggestion is that every patient
should be given a distinctive, well-constructed folder for storing all documents safely, and this
folder should contain both general information relevant to the patient and about the
rehabilitation prescription and the Network, and also specific information including the
rehabilitation prescription but also copies of all letters, summaries etc. The other innovation
idea is to ask the patient and/or relatives to complete a structured document on a computer,
this document becoming the most important part of the rehabilitation prescription. The
document concludes that eventually a computer based system is essential; no other system can
sustainably achieve all the goals of the prescription within the network. In the meantime paper
forms will be used. They must be obviously relevant, clearly written, free of jargon, well laid
out with simple questions and simple answer options where appropriate. The forms should
allow use of free text, and should allow attachment of other documents to minimize
duplication. Additionally initial implementation should ensure a robust system for registering
all patients with an International Severity Score of nine or more, and then for flagging every
patient in some way. Initially the prescription should be completed either when transferring
patients, or at three weeks (whichever is the earlier). The content should include full details of
all injuries and significant complications, all interventions, the current care needs and the
current level of patient function, and a summary of the expected prognosis and future
rehabilitation needs as far as these can be identified. A suggested set of forms is in an
appendix.
1.0
INTRODUCTION
One major innovation brought in by the Clinical Advisory Group on Major Trauma
Services was the concept to a Rehabilitation Prescription, and there has been much
discussion about what it is and how to implement it since. This document summarises
its purposes and suggests how it should be developed and used in the Thames Valley
Rehabilitation Network. The prescription is one of the two keys to a successful
network, the other being a network data-base which hopefully will house both the
prescription and information on all the resources available.
1.2
The Advisory Group described the prescription thus:
“A rehabilitation prescription describes the patient’s physical, cognitive and psycho-social needs,
framed in the context of their pre-injury life, and states how these will be addressed. The
prescription is an extension of a discharge/transfer summary and should include ongoing health
and social care plans (see section 4.3 6 within Ongoing Care and Reconstruction chapter).”
1.3
And the group outlined its main goal thus:
“In particular, the prescription should ensure that patients’ needs, and the plans made to address
these, are clear as patients move from one setting to another. This will help to minimise the risk
of these plans failing. The prescription should allow the identification of any unmet needs and
the reasons for this to enable system evaluation and targeted service development.”
Rehabilitation Prescription in Thames Valley. A discussion document.
1.4
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The Group also emphasised that the rehabilitation prescription:
needed to have a multidisciplinary input
should be reviewed and updated at intervals
covered services provided by social services and other organisation as well as health
should be given to the patient (and family)
could be used to audit the services provided
could set expectations and a direction of travel
would change in nature over the time of a patient’s journey
2.0
SOME PRACTICAL CONSIDERATIONS
If the rehabilitation prescription is to succeed, being used routinely by all services
involved with a patient after trauma, then it will need to fulfill certain criteria most of
which are not concerned with its content.
2.1
Its structure and content must be flexible and adaptable to the circumstances. For
example any prescription provided within 48 hours of trauma will necessarily be ‘high
level’, lacking some clinical detail and being quite uncertain about many future needs.
2.2
However adaptability is not an excuse for absent, erroneous or incomplete data. It does
mean that the extent of data may be limited, but it still requires that the data entered are
of high quality because the prescription may be the primary source of information.
2.3
The structure of any prescription must be clear and helpful, and should be immediately
apparent especially to a non-specialist. In other words, anyone looking at it should
rapidly be able to find the information that they want.
2.4
The structure needs to be coherent and logical, based on a good model of rehabilitation
and of illness.
2.5
The layout must also be clear, well laid out and easily assimilated, and it should not
attempt to cram information into every available space.
2.6
The questions asked/headings used should be written clearly and avoiding any jargon.
They should be self-contained, requiring minimal guidance if any. This prescription
must be understood by the patient, and by people from different professions working
in different specialities. It is a rehabilitation prescription, not a prescription for
rehabilitation specialists. Using phrases such as “needs Level I specialist rehabilitation
service” will mean nothing to most people, and guidance will not be used particularly if
every question requires guidance.
2.7
Where choices are listed, the list must cover the full range of possible answers using
clear, mutually exclusive options. Even so, an ‘other’ free-text option is usually wise.
And there must be ability to state ‘not known’ (and why), ‘not applicable’ (and why),
and ‘not appropriate’ (and why).
2.8
The prescription will change over time as (a) more information becomes available and
(b) the patient changes. There needs to be a way to avoid repeating entry of already
known information while not simply carrying forward inaccurate or out-of-date
information without formal checking.
Rehabilitation Prescription in Thames Valley. A discussion document.
2.9
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Thus the prescription needs to distinguish historical entries (i.e. no longer valid) from
previous entries (i.e. still valid) and probably from new entries (i.e. information not
previously entered).
2.10
In practice there are probably three choices:
 a set of paper-based prescriptions that apply at different times/places (e.g. at 48 hours,
on entry to a specialist in-patient unit, on transfer from a non-rehabilitation service to
another, similar service and so on
 a single paper-based prescription that is potentially very detailed, but allows gradual
completion with some indication of minimum data that must be inserted; this would
depend upon added pieces of paper to cover updates.
 An electronic, computer based system with the document/data being electronically
available across the network, with systems in place to note significant changes (when,
where, who by) and easily printed out to place in non-electronic notes and to give to
others
2.11
In the long-term the only system that has any chance of improving practice and
providing good feedback to the network is to have an electronic database. Paper-based
systems will fail rapidly: entries will be incomplete and often illegible; sheets will get
lost; copies to the network will not arrive on time or notat all; there will be difficulties in
data capture and analysis (secondary data entry into a data-base is simply wasteful);
there will be difficulties in tracking changes; etc etc
3.0
REHABILITATION PRESCRIPTION CONTENT – PURPOSES
Before considering the content of a rehabilitation prescription, one must discuss and
hopefully agree on the many and varied goals being given to this prescription. The
rehabilitation prescription is certainly much more than a simple prescription – a list of
individual actions that are needed at this point.
3.1
First it is inevitably going to become perhaps the only easily available record of a
patient’s pathway or journey up to the current situation. One major criticism of current
practice is the failure of staff and services to pass on relevant information when
transferring a patient on to another service. General Practitioners are acutely aware of
this, but it affects all transfers.
3.2
The requirement to produce and handover a full prescription at each transfer of care
should lead to a series of documents that record progress and change. And the
requirement to copy each one to others, especially GPs means that the GP at least will
have a full record. And the requirement to give a copy to the patient further increases
the likelihood of improved clinical information becoming available to everyone.
3.3
If an electronic data-base version were made mandatory on a Network data-base then
matters would be greatly improved and clinical risks markedly reduced.
3.4
Next, it will highlight the specific needs and risks faced by the patient at the time of
transfer. These might be used as criteria that should be satisfied before transfer, and
any transfer where a significant clinical risk is identified that cannot be met by the
receiving service should not be carried out.
Rehabilitation Prescription in Thames Valley. A discussion document.
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3.5
Identifying rehabilitation needs depends upon an assessment by clinicians who have
sufficient expertise to know what is appropriate. The prescription may identify both
specific, immediate short-term needs (e.g. to be started walking within two days) and
longer-term more general needs (e.g. she will need full assessment for a specialist
neurological rehabilitation in about a month, focused on cognitive problems). The
general needs will usually be for services, but it would be helpful to give a specific
reason or goal.
3.6
It is also vital that the prescription specifies any known risks; adverse events that are
reasonably likely to happen and that should be monitored and managed. The receiving
service should be able to manage all the risks.
3.7
Third the prescription is likely to set expectations in terms of eventual clinical recovery
(time, how much, etc). Initially this will necessarily be vague and very uncertain, but
even then if any certain limits can be specified then they should be. Expectation should
be given in terms of a range of outcomes and initially should always acknowledge
uncertainty.
3.8
Thus the main clinical goals are:
 To record important demographic and historic clinical data
 To record the present situation
 To specific the likely longer-term prognosis, acknowledging uncertainty but remaining
realistic
 To specify the rehabilitation needs, both specific and immediate and more general and
longer-term
 To specify the risks still extant at the time of transfer
4.0
REHABILITATION PRESCRIPTION – IMPLEMENTATION
The rehabilitation prescription’s goal is to improve the rehabilitation of each and every
patient. The rehabilitation prescription is going to be used primarily by clinical teams
who are not especially interested in or understanding of rehabilitation. Thus it offers
the opportunity to revolutionise rehabilitation services and practice; unfortunately it
also offers the opportunity to confirm pre-existing prejudices about rehabilitation
4.1
The key to success is to ensure that the first service to see the patient, usually but not
inevitably the Major Trauma Centre or a Trauma Unit completes the rehabilitation
prescription on every patient who has an ISS (International Severity Scale) score of nine
or greater. Therefore some other considerations must be taken into account .
4.2
First, the current requirement (or possibly only a suggestion) that the prescription is
completed within two working days of a patient becoming stable is likely to add a huge
pressure that will decrease positive involvement with the process.
4.3
The report from Clinical Advisory group stresses the need for early rehabilitation input,
but as far as I can see it does not suggest a prescription within 48 hours of stability. I
suspect this has been suggested later, as a way to ensure early rehabilitation
involvement.
Rehabilitation Prescription in Thames Valley. A discussion document.
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4.4
Thus, at the beginning at least, I strongly suggest that the requirement should be for a
rehabilitation prescription to be completed at the time of transfer out of acute services
or at three weeks, which ever is the earlier. Ideally it should occur at each transfer
between services (e.g. from Intensive Care Unit to the ward) but this is probably
imposing too much work in this initial stage.
4.5
Second, most teams that will have to complete it will have as their main focus other
legitimate concerns both relating to the patient – diagnosis and treatment of trauma,
maintaining physiological stability, alleviating pain – and relating to the service –
maintaining patient throughput, avoiding ‘delayed discharges’, reducing length of stay.
4.6
In this context the rehabilitation prescription risks becoming yet another ‘tick-box’
exercise, both in terms of ticking the box that says it has been completed as required,
and in terms of ticking boxes within any form.
4.7
At the same time, staff in all acute and non-rehabilitation teams are very committed to
achieving better patient outcomes and most are aware and agree that rehabilitation is
currently the weakest part of a patient’s pathway.
4.8
Thus to counter the risk of unwilling involvement (with poor and incomplete
completion of the prescription), the prescription must be appreciated as something that
benefits the patient and improves patient care, and does not duplicate anything already
done. It must be considered something that is worth completing even if it takes some
additional time or effort.
4.9
Thus, when initially introduced the prescription must make minimal demands upon
teams and must be seen to contain important, relevant information which will improve
patient care.
4.10
Thirdly, if this is to be successful at improving rehabilitation then the prescription must
be applied to each and every patient who is admitted after trauma with an ISS score of
nine or more. Good completion in a minority of patients will not succeed in improving
care for most patients.
4.11
Thus the Major Trauma Centre must have a simple robust way to identify patients who
need a rehabilitation prescription, and must have a simple robust way to ensure that the
team responsible for the patient knows that the patient is designated as requiring a
rehabilitation prescription. This also applies to Trauma Units who may well admit and
manage patients with levels of severity of ISS nine or greater.
4.12
This document cannot specify how this will be done. However the following methods
seems practical. Calculating an ISS score is relatively simple and can be achieved in the
Emergency Department (or whatever it is called in a hospital) within three hours. The
only requirement is to know that the ISS is nine or more; the actual score is not needed.
4.13
Therefore almost every patient who will require a prescription can be identified in the
admitting unit. At that point several possibly supporting options arise.
Rehabilitation Prescription in Thames Valley. A discussion document.
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4.14
First the paper notes can be marked with a distinctive marker (not already used by
some other register). A red square might be appropriate. For hospitals with an
electronic patient record, a specific flag should be used and this could be used in every
hospital if the Patient Administration system allows flagging of patients.
4.15
Second, a card with the patient’s ID (hospital number, NHS no or similar) could be
completed and sent to a rehabilitation coordinator or other person who could then enter
details into a computerized database.
4.16
Third, a separate computer database could be set up with immediate and easy access to
staff in the admitting department so that they could register the patient.
4.17
However it s achieved, it is imperative that the Major Trauma Centre and all
surrounding Trauma Units have in place mechanisms that allow quick registration of
every patient admitted with an ISS score of nine or greater.
4.18
Fourthly, a copy of the rehabilitation prescription must be given to the patient (and/or
family) as well as being given to the next service and to the General Practitioner. If this
is done well, the patient and/or the family will be able to start advocating for necessary
rehabilitation and they can monitor whether actions are undertaken. For example if the
prescription mentions a follow-up by the Trauma Service in six weeks, they can make
contact if no appointment arrives.
4.19
Thus it is important that the patient receives information about the purpose and content
of the rehabilitation prescription. They should also receive it within an identifiable and
physically robust container so that the paper is protected and the different sheets
remain together, especially because there should be additional prescriptions added
later.
4.20
Therefore the Major Trauma Centre (and to a lesser extent the Trauma Units) will need
to develop and have available suitable patient folders able to contain both the specific
rehabilitation prescription, and any other specific information (e.g. drugs on
transfer/discharge) and also more general information (e.g. about relevant voluntary
organisations)
5.0
REHABILITATION PRESCRIPTION CONTENT
Taking all of the matters discussed above into account, this section now suggests a
possible content for the rehabilitation prescription as used by the acute, receiving
trauma services. The important point is to ensure that information is available within
the patient’s rehabilitation prescription folder. Thus, if another document already
contains the information either it should be cut and pasted into the prescription, or a
hard copy should be added to the folder. The content of later prescriptions will be
considered separately.
5.1
The prescription obviously needs information that identifies the patient, the centre
producing the prescription, the date it was completed, the transfer destination, any
planned follow-up by the discharging service and the name and contact details of the
rehabilitation coordinator. The role of the coordinator must be explained in the general
information. It is likely to be limited to investigating and resolving failures in the
Rehabilitation Prescription in Thames Valley. A discussion document.
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overall system (e.g. failure of follow-up, failure to make a referral, failure of a service to
make contact).
5.2
The initial prescription must give full and complete details on all injuries, and all
significant complications (e.g. renal failure, respiratory failure, cerebral hypoxia,
seizures, skin pressure ulceration). Unfortunately these are not usually listed in a single
document, but it should not be difficult to do and would be a component of any high
quality discharge summary. If they are listed in a letter or summary, then it would be
appropriate simply to add that document or the relevant part.
5.3
It is vital to include all injuries, not just major ones and not just those of interest to the
particular team. For example a patient whose major problem is a head injury should
have recorded their fracture of the right humerus even if it was plated and is now
completely healed, and the major skin loss requiring grafting even if (a) it might be
obvious visually and (b) it is no longer a problem.
5.3
The initial prescription should also give a list of all major treatments/interventions
with sufficient detail to make the list useful. The minimum data would include date or
dates (e.g, if on a ventilator), name or nature of any operation or other significant
treatment, and any continuing management needed, or other concern specific to the
treatment (if any).
5.4
Again these details are rarely available on transfer, but should be easily compiled. And
again it must be complete. It should include matters such as a period in an intensive
care unit, a period on ventilation of renal dialysis etc.
5.5
Thirdly, the rehabilitation prescription should indicate any specific on-going care
needs. This would not include standard good care, but must include anything that is
specific. Examples would include: tracheostomy care, special one-to-one nursing of a
confused wandering patient, feeding and diet, and extra attention being paid to skin
care. This information would usually be written in a hand-over nursing care plan. A
typed copy could be placed in the patient’s rehabilitation prescription folder.
5.6
Next, and complementing the care plan, there should be a simple description of the
patient’s level of (in)dependence. This would best be achieved through using the
Barthel ADL (activities of daily living) index. Most people are familiar with it, it can be
completed by anyone knowing the patient with three minutes, and it relates closely to
nursing dependency.
5.7
There may be some extra areas of function that should be included, but simple
questions would cover these areas.
5.8
Fourthly there needs to be a free-text are where the team can describe any particular
areas of importance or concern, specifically including identified risks and how they are
being handled. These might cover anything from homelessness through emotional
distress, family distress, unduly optimistic expectations onto issues of Mental Capacity
and family disputes, or Advance Decision.
Rehabilitation Prescription in Thames Valley. A discussion document.
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5.9
Next there needs to be an area focused on prognosis and rehabilitation. Given that in
the early stages it is usually difficult to give accurate long-term prediction of either, this
will necessarily focus on short and medium term issues. Comments on possible longerterm needs would certainly be appropriate, but not required.
5.10
At this stage I strongly recommend that this is entirely free-text.
5.11
Finally it will be important to specify who (name, profession, grade and contact detail)
contributed to the prescription. This will allow the network to check on the process. It
will also give the next service the names of particular people who can be contacted in
the week after transfer for further information.
6.0
SUPPLEMENTARY INFORMATION
Effective rehabilitation requires an understanding of many personal characteristics of
the patient and their environment such as their interests, their job, their social network,
and their housing. Such information is usually notable by its absence from the medical
record. Immediately after trauma other issues take priority, and later no-one has
responsibility for collecting and collating this information. Individual members of the
healthcare team may well know parts, but it is not recorded in a systematic way.
6.1
One simple way to collect this information is to ask the patient and/or close relatives or
friends to do it. While not everyone will be able or willing to do this, it is likely that
substantial additional information would become available for 95% of patients.
6.2
Therefore I suggest that the rehabilitation folder is used to explain this, and that a
structured form is provided to each patient and/or close relative. Most people will be
sufficiently familiar with computers to use one to complete it. The ward should have a
computer for the patient or relatives to use, and the form could be given on a memory
stick (auto-encrypted?) to the family (for PC and Mac).
6.3
The information requested should cover all the important areas not so far covered.
These will be outlined.
6.4
Information about the physical environment at home, including who shares the
accommodation is an obvious and easy area to collect information on.
6.5
Information about the person’s likes and dislikes, major interests in life, values and
religious beliefs, strengths, attitudes to health care etc all have a great influence on
progress and rehabilitation. This might include a short biography (school, work etc).
6.6
Information on the patient’s social context is often of vital importance, and basic
information could be collected: family structure and relationships, any clubs or social
groups, friendships, partnership and children etc.
6.7
Next information about the person’s social activities and roles is of great importance.
This would include information about the job, if employed and information about other
social activities undertaken for pleasure.
Rehabilitation Prescription in Thames Valley. A discussion document.
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6.8
Finally it might be possible to gain some information about the expectations and fears
of the patient. This might help target rehabilitation treatments.
6.9
If the information comes from a relative or friend, the person giving it should be aware
that the patient will see it and may choose to alter it later.
Rehabilitation Prescription in Thames Valley. A discussion document.
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7.0
SUMMARY
The Rehabilitation Prescription is an exciting new concept that has yet to be tried. This
document considers its implementation in the Thames Valley Network. It is based on
several premises: completion of a shorter prescription on everyone is preferable to
patchy completion on many patients and complete failure to complete on some; using
or improving existing documents is preferable to duplication of information; asking
patients and relatives to give information directly is an under-used rsource; and
engagement of teams who are not focused on rehabilitation and yet who will complete
most prescriptions is essential and will be improved by making the prescription selfevidently of value and easy to complete.
7.1
The first major innovation suggested here is the introduction of a patient rehabilitation
prescription folder that is robust and able to store safely multiple sheets of paper. This
folder would contain general information, particularly about the prescription but also
relevant to their injuries, and the specific information relevant to the rehabilitation
prescription. The folder will need to be large enough to contain later prescriptions.
7.2
The second major innovation is to ask patients and/or their friends and relatives to
provide information directly. Rather than asking them for information, they should be
given a structured form to complete preferably on a ward computer or on a computer at
home.
Dated February 10th 2012
Dr Derick Wade, Director of Rehabilitation Thames Valley Rehabilitation Network
Consultant and Professor in Neurological Rehabilitation,
Oxford Centre for Enablement, Windmill Road, Oxford OX3 7HE
Tel: 01865-737306; Fax: 01865-737309;
email: derick.wade@ouh.nhs.uk and derick.wade@ntlworld.com