JCPSLP Vol 16 Issue 1 2014

SLP practice in brain injury rehabilitation

us, the experience and clinical expertise of SLPs working within BIRUs may be utilised to help develop a knowledge base. The purpose of this study was to begin to investigate current service delivery practices of SLPs working within BIRUs in Australia, with a focus on identifying types of intervention provided by SLPs, as well as investigating how SLPs provide their services within BIRUs. This research grew from a SLP quality activity and benchmarking project within a BIRU service, responding to a clinical service need to identify service delivery and therapeutic intervention practices within other BIRUs, to assist in reviewing and maximising BIRU SLP services. Methods This study had ethical clearance from the Queensland Health Metro South Human Research Ethics Committee. Participants Participants were SLP teams or services (n = 8) within dedicated adult inpatient/sub-acute BIRUs within Australia. Individual SLPs working within BIRUs were identified by the investigator from online databases (e.g., professional and health service websites), previous benchmarking contacts, SLP brain injury interest groups, phone and email contacts. SLPs that identified their service provided other service delivery models for adult brain injury rehabilitation (e.g., acute/critical care; outpatient, community or transition services, vocational services) were excluded. Of the ten BIRU centres identified, SLPs from eight centres participated in this study. This included seven BIRUs and one inpatient rehabilitation centre that identified itself as providing significant statewide service to adults with brain injury, but was not an exclusive brain injury service. The centres included private and publically funded units from five states across Australia. Procedure SLPs who had been identified as working within Australian BIRUs were contacted via email and/or telephone and invited to participate in a survey regarding their SLP team’s service delivery practices in BIRU. SLPs approached from all ten units agreed to participate in the survey, and were sent the survey electronically (via email), with one response from each unit requested. Reminder emails to participants were utilised to maximise the response rate. SLPs from eight units returned completed responses and consented to participate in this research. Surveys were completed by a member of the BIRU SLP team; respondents included both clinicians and managers who reported on the practice of their SLP team. Survey responses were returned electronically or mailed in hard copy and were identifiable to the investigator; results were de-identified for reporting. Instrument/Measure The survey was designed to investigate a range of aspects of clinical service delivery of SLPs in BIRUs, and record and reflect the responses of the SLP team working within each BIRU (not those of the individual therapist). Survey questions were designed to incorporate aspects of service delivery and clinical practice reported in international SLP brain injury guidelines and service documents (ASHA, 2004; RCSLT, 2006), and were influenced by Brougham et al.’s (2011) study into SLP therapy practice in inpatient rehabilitation in adult spinal cord injury rehabilitation.

Within Australia, national professional guidelines do not exist to govern speech-language pathology (SLP) clinical practice within ABI/TBI rehabilitation. Consequently, clinical practice and “best practice” guidelines from international colleagues help guide SLP practice in Australian BIRUs (Academy of Neurologic Communication Disorders and Sciences [ANCDS], 2013; American Speech-Language- Hearing Association [ASHA], 2004; ASHA, n.d.a; ASHA, n.d.b; Katz et al., 2002; Royal College of Speech Language Therapists [RCSLT], 2006; Ylvisaker, Hanks & Johnson- Greene, 2003). While these guidelines provide direction for SLP service provision during rehabilitation for adults with ABI/TBI, including assessment, goals and types of inter­ ventions, they are not specific to the Australian health system. Overall, there is limited research internationally regarding specific SLP rehabilitation practice and service delivery during sub-acute brain injury rehabilitation; information regarding types of interventions utilised by SLPs during this timeframe is scarce. One multidisciplinary study from the Traumatic Brain Injury Models System (TBIMS) into rehabilitation outcomes and therapy intensity in TBI investigated the service delivery practices of allied health staff (including SLPs) in three brain injury specific rehabilitation centres over a seven year period (Cifu, Kreutzer, Kolakowsky-Hayner, Marwitz & Englander, 2003). Cifu et al. (2003) identified that 94% of all patients accessed SLP services, and that the average intensity of SLP services was 35 minutes per day (including direct and indirect patient contact times); however, specific aspects of service delivery including types of therapeutic interventions and prioritisation methods were not reported. More recently, Steel, Ferguson, Spencer and Togher (2013) have investigated the clinical practice of Australian SLPs in early (inpatient) TBI rehabilitation. This study, however, focused primarily on SLP assessment of patients with cognitive-communication disorders during post traumatic amnesia, rather than general service provision, and was not specific to sub-acute rehabilitation. Specific recommendations are available for evidence- based SLP interventions in ABI/TBI, including cognitive- communication disorders, cognition and executive functioning interventions (Cicerone et al., 2011; Cullen et al., 2011; MacDonald & Wiseman-Hakes, 2010; Welch- West, Ferri, Aubut & Teasell, 2011). This research, however, tends to encompass patients beyond the sub-acute phase of rehabilitation (i.e., patients who are further along in their recovery and participating in therapy at an outpatient or day hospital setting). The validity and clinical efficacy of utilising these interventions has not been formally investigated within the inpatient setting. This is not surprising, given the challenges of investigating therapy interventions during the “spontaneous recovery” timeframe. With health services increasingly under pressure to deliver efficient, evidence-based and cost-effective services, there is a need begin to identify those interventions and practices that provide the best rehabilitation outcomes for patients during sub-acute rehabilitation. Before research into the effectiveness of specific treatments within a BIRU setting can occur, information regarding current service delivery models and clinical practice activities needs to be known. While formal studies are currently unable to guide

Anna Copley (top) and Emma Finch

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JCPSLP Volume 16, Number 1 2014

Journal of Clinical Practice in Speech-Language Pathology