PROSPECTIVE CROSS SECTIONAL STUDY:

REFERRAL OF STROKE PATIENTS TO

OCCUPATIONAL THERAPY DEPARTMENT
IN HSAH
ACKNOWLEDGEMENT

We would like to express our utmost gratitude and appreciation to the following
individuals / parties who had given us excellent cooperation and contribution in any
shape or form. Without them, this audit would not have been a success.
 Dr Harif Fadzilah bin Che Hashim, Director of Hospital Sultan Abdul Halim
 Dr Mithali Abdullah @ Jacqueline Sapen, Head of the Quality and Innovation
Unit, Hospital Sultan Abdul Halim and Clinical Audit Coordinator
 All occupational therapists who had participated
 All Sisters/ staff nurses

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CONTENT
No. Title Page
1. Title page 1
2. Acknowledgement 2
3. Content 3
4. Abstract 4
5. Introduction 5
6. Methodology 8
7. Result 10
8. Discussion 12
9. Strategy for change 14
10. Conclusion 17
11. References 18
12. Appendix 20

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ABSTRACT
Title:
Prospective Cross Sectional Study: Referral of Stroke Patients to Occupational Therapy
Department in HSAH
Authors:
Noor Emellia Jamaludin
Occupational Therapy Department, Hospital Sultan Abdul Halim, Sungai Petani, Kedah.
Overview:
All patients with acute stroke should ideally have access to stroke unit. They also should be
referred to Occupational Therapy (OT) Department within 72 hours after diagnosis of stroke is
made. On the other, these patients should be provided the minimum treatment
Objectives:
To determine if patient who suffer from acute stroke were referred within the appropriate time
frame and to determine if they received the minimum treatment from the Department of
Occupational Therapy.
Methodology:
This is a prospective study with cross sectional data collection of OT management for stroke
patients in Hospital Sultan Abdul Halim. The audit was conducted from 1st July 2010 until 31st
August 2010. Information collected were date of referral, reason for not referring patient and the
number of treatment modalities provided.
Results:
Only 56.6% of acute stroke cases were referred for OT interventions and out of those referred,
76.7% of them were referred within 72 hours. Most of the time (83.6%) the reasons for not
referring was not known as they were not documented. However, all of the patients who were
referred to OT Department received at least two treatment modalities.
Strategy for changes:
To improve the situation, strategies such as promoting the functions and roles of OT in the
management of acute stroke as well as to develop and establish clear and effective referral system
are proposed.
Conclusions:
Knowledge about occupational therapy functions in stroke rehabilitation needs to be improved in
order to get the desirable outcome of stroke patients. There should be a smart partnership between
the primary health care providers and occupational therapist.

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1.0 INTRODUCTION
1.1 Problem Statement

Occupational Therapy Guidelines for Stroke (2008) has defined stroke or cerebral
vascular accident as a disease of the cerebral vasculature in which a failure to supply
oxygen to brain cells, which are most susceptible to ischemic damage, lead to their
death. Health Informatics Centre – Planning and Developing Division of Ministry of
Health Malaysia (2009) recorded cerebral vascular disease as the fifth cause of death
in Ministry of Health hospitals with 8.43%. Anonymous (2010) stated that there are
estimating about 397,806 prevalence rates and about 51,887 incidence of stroke
annually (including new cases and recurrences) in Malaysia.

National Stroke Association of Malaysia (NASAM) (1995) defined occupational

therapy as a form of rehabilitation to enhance a person’s quality of life, which
focuses in improving the ability to perform activities of living, self care and
independence at work and leisure. According to Roland T. J. et al., (2008),
occupational therapy intervention should begin as soon as the medical condition is
stable. The occupational therapy interventions may include maintaining or
improving soft tissue properties of the upper limb. Susan Berg (2010) stated that
once the stroke patient is medically stable, occupational therapy activities usually
begin. The first occupational therapy activities are to provide education and coping
activities to the patient and caregiver.

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1.2 Objectives
This study aims to audit the general management of acute stroke patient in
Department of Occupational Therapy of Hospital Sultan Abdul Halim (HSAH). In
specific, the author attempts to:
I) Determine if patients who suffer from acute stroke were referred
within the appropriate time frame to the Department of Occupational
Therapy, HSAH.
II) Determine if patients who suffer from acute stroke received the
minimum treatment from the Department of Occupational Therapy,
HSAH after being referred.

1.3 Criteria and standard

No. Criteria Standard

1. Percentage of acute stroke should be referred to 100%
Occupational Therapy within 72 hours (3 days).
2. Numbers of treatment modalities provided to At least 2 treatment
the acute stroke patient in every session modalities in a
session

Nicole R. C. et al., (2004) stated that the therapist should be informed as soon as a
new stroke patient is admitted, to request physician referral and begin to see
patient within 36 to 48 hours after admission. Clinical Practice Guidelines –
Management of Stroke (2006), all patients with acute stroke should ideally have
access to stroke unit. There are also clear evidences that treatment of patient with
stroke in stroke units significantly reduces death, dependency, institutionalization
and length of hospital stay compared to treatment in a general medical ward.
However, there was no consensus on the time frame of referral of stroke patients

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 for occupational therapy interventions. Since, this is most likely the pioneer study on
referral of stroke patients for occupational therapy interventions in Ministry of
Health (MOH), thus the time frame is longer than that stated by Nicole R. C. et al.,
(2004). The time frame set is within 72 hours.

2.0 METHODOLOGY
2.1 Sampling population and sampling procedure
This is a prospective study with cross sectional data collection of occupational therapy
management for stroke patients in Hospital Sultan Abdul Halim. The audit was
conducted from 1st July to 31st August 2010.

The inclusion criteria are:

a. All stroke patients admitted to Hospital Sultan Abdul Halim
b. Adult patients aged 18 years old and above
The exclusion criteria are:
a. Death
b. Unstable patient as per physician clinical judgment

2.2 Treatment modalities

Treatment modality is the method of treatment provided for the stroke patient.
The minimum treatment modality shall be provided: At least 2 treatment modalities
for a single treatment session.
Some of the treatment modality that may use by an occupational therapist is patient
and family education, level of independency assessment, early mobilization and
cognitive stimulation.

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2.3 Documentation and clinical outcome
The following information was collected and documented in the data collection table
(Appendix 1 and Appendix 2).
a. Identification number
b. Date case diagnosed with stroke by referral unit
c. Date case referred to OT unit
d. Referral within 72 hours (3 days)
e. Reason for late referral/not referred
f. Discharged date
g. Number of treatment modalities received (Appendix 2)

This information was gathered form the patients’ case notes as well as the
Clinical Access in the Total Hospital Information System (THIS) by the audit team
staff.

2.4 Data analysis

All data collected will be analyzed by using Microsoft Excel 2003.

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3.0 RESULT
3.1 Demographic data
Table 1: Samples distribution: gender
Male Female
31 22
58.5% 41.5%

3.2 Primary outcomes

Table 2: Percentage of patient referred to Occupational Therapy unit

Number of patient in No of patient referred to No of patient referred
sample as per inclusion OT unit within 72 hours
criteria
53 30 (56.6%) 23 (76.7%)

Table 3: Reason for not referring or late referral

Pt discharged on weekend Unknown reason or not
documented
16.4% 83.6%

Table 4: Number of treatment modalities received

No of patient referred to OT unit No of patient received at least 2
treatment modalities
30 30 (100%)

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3.3 Summary of audit findings
There were 53 patients included in the study and only 30 (56.6%) were referred for
occupational therapy interventions by the primary team. Out of these 30 patients,
only 23 (76.7%) of patients with acute stroke were referred within 72 hours. In seven
of these patients, the audit team staff attempted to find out the reasons for not
referring. Most of the time (83.6%) the reasons for not referring such patients to
Occupational Therapy Department were not known as they were not documented.
In 16.4% of those not referred, the patients were not referred as the patients were
discharged during weekend. Nevertheless, for those who were referred to the
Occupational Therapy Department, all 30 of them received at least two treatment
modalities.

4.0 DISCUSSION

4.1 Late referral of patient and/or patient was not referred at all
Sacco RL. (1995) cited that early admission to stroke rehabilitation program results in
better prognosis at discharge and reduces length of hospitalization. Based on a study
done by Farooq AR. et al. (2009), the main cause of not referring patient or late
referral for stroke rehabilitation happened when the avoidable complications like
shoulder subluxation, depression, urinary tract infections, fall, contracture already set
in. This situation also happens in our hospital; the patients were either not referred or
referred late to Occupational therapy Department normally after their complications
have been stabilized.

4.2 Lack of awareness and knowledge of occupational therapy services for stroke
Lack of awareness and knowledge of OT functions and roles in managing patient
with acute stroke by health care providers could contribute to patients being either
not being referred to OT or referred later than the best practice.

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 The health care providers may think that patient with acute stroke could only be
referred to the OT once he/she is in stable condition. They may not know that
occupational therapy also plays important roles in managing unstable patient.
Interventions such as prescribing pressure garments (compressed stocking with
adequate pressure) and provide hand splinting is crucially important for every stroke
cases. Annals of Internal Medicine (2010) stated that the graduated compression
stockings are widely used to prevent deep venous thrombosis (DVT) in patients who
have limited mobility from conditions such as stroke. Medical News Today (2010)
stated that splinting such as ankle foot orthosis (AFO) can improve mobility after
stroke and preventing foot drop.

Health care providers may not only lack of awareness and knowledge about OT
services and functions. In addition to that, they may be hesitant to refer during the
weekend because they are not sure of the service provision. The occupational
therapists should provide sufficient information on how to refer the patient on
weekend. This will give them better understanding on how to make the appropriate
referral.

According to Warner et al. (2010), health care providers such as nurses should be
exposed to occupational therapy through informal and unstructured methods
consequently increasing the probability of missed referrals and inappropriate
referrals.

4.3 Inadequate referral

In some cases, the physicians refer the patient for physiotherapy intervention only.
Farooq AR. et al. (2009) stated that, stroke patient who were referred to
physiotherapy only will end up with regaining motor control and gait patterns but
other aspects like patient education, management of bowel and bladder
dysfunction, psychological evaluation and management of depression, prevention of

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 falls, mobility aids and adaptation prescription, vocational rehabilitation,
occupational therapy and community integration are not addressed adequately.

Patient with stroke should be review holistically. Health care providers shall evaluate
the patient not only from the physical side. According to American Heart Association
(2010), stroke affects the senses, motor activity, and speech, behavioral and though
patterns, memory and emotions. By referring the patient to one discipline will not
help the patient much. Adequate referral should be done according to patient
needs.

5.0 STRATEGY FOR CHANGE

From this audit, it was found that only a small percentage (56.6%) of patients with
acute stroke was referred for occupational therapy interventions. On the other
hand, one third of those referred, referral was done much later than 72 hours after
the diagnosis of stroke was made. One of the obvious reasons that patients with
acute stroke were either not referred or referred late was the patients have been
discharged during the weekends.

It appeared that the role and functions of the occupational therapists in the
management of acute stroke are still not clear. Perhaps, most often than not, health
care providers thought the occupational therapists only intervene to assist in
Activities of Daily Living (ADL). Therefore, the strategies for change will be on
promoting the functions and roles of occupational therapists in the management of
acute stroke as well as to develop and establish clear and effective referral system.

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 Table 5: Strategy for Change

No. Strategy for change Implementation Responsibility

1. Promoting the 1.1 CME: Head of department
functions and roles Regular CME (45-60 minutes briefing) Occupational
of occupational on roles of occupational therapy in Therapy
therapists in the stroke rehabilitation should be done
management of once in 3 months.
acute stroke 1.2 Formal training (courses, seminars Head of department
& workshops): Occupational
Seminars: twice a year Therapy
Workshop: twice a year
1.3 Regular bulletin on Occupational Head of department
Therapy Occupational
Therapy
2. Establish a A simple integrated rubberstamp for 1. Head of
rubberstamp stroke patient could be implemented. department
(Appendix 3) The rubberstamp chop shall be filled Occupational
up before the patient is discharged Therapy
from the ward. This rubberstamp 2. Head of
chop will ensure the patient has been department of
referred to other necessary Medicine
multidisciplinary team such as 3. Hospital Matron
occupational therapy, speech therapy,
physiotherapy, pharmacy and
dietitian. This kind of checklist has
been implemented before in the
Critical Care Unit for cardiac patients.
3. Regular monitoring Regular monitoring of stroke patients 1. Occupational
in the ward with regards to referral of Therapist on duty
patients to Occupational Therapy 2. Staff nurse in-
Department. charge

4. Formal education It would be an advantage to health 1. Head of

for nurses and care providers if they could attach to department
doctors in OT unit OT unit in order to improve their Occupational
understanding on OT function and Therapy
roles in managing patient with stroke. 2. Head of
department of
Medicine
3. Hospital Matron

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6.0 CONCLUSION
As a conclusion, the perception towards occupational therapy functions in stroke
rehabilitation needs to be change in order to get the desirable outcome of stroke
patients. There should be a smart partnership between the primary health care
providers and occupational therapist. There are various interventions that are offered
by occupational therapists to improve the quality of life of patient with stroke. There are
patient educations, aids and adaptation prescription and work return program. These
include the primary health care providers should make a referral within 72 hours of
stroke onset.

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7.0 REFERENCES
1. Anonymous (2008) Occupational Therapy – Concise Guidelines Stroke
Rehabilitation and Recovery. Retrieved on 5 September 2010 from
http://www.strokefoundation.com.au/component/option,com_docman/task
,doc_view/gid,115

2. Anonymous (2010). About stroke. Retrieved on 1 November 2010 from

http://www.strokeassociation.org/STROKEORG/AboutStroke/About-
Stroke_UCM_308529_SubHomePage.jsp

3. Diserens K. et al,. (2006) Early Mobilzation after Stroke. Retrieved on 5

September 2010 from
http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract
&ProduktNr=224153&Ausgabe=231961&ArtikelNr=93453

4. Farooq RA. et al,. (2009) Pit Falls of Stroke Rehabilitation: A Pakistani

Perceptive. Retrieved on 31st October 2010 from
http://www.pafmj.org/showdetails.php?id=227&t=o

5. Nicole C. R et al,. (2004) Physical Therapy Protocol for Acute Care Adult
Hemiplegia Retrieved on 5 September 2010 from http://www.pta-
kw.com/uploads/PT%20PROTOCOL%20_part2-Adult%20hemiplegia.pdf

6. Roland T.J. et al,. (2008) Role of Occupational Therapy After Stroke. Retrieved
on 5 September 2010 from
http://www.annalsofian.org/article.asp?issn=0972-
2327;year=2008;volume=11;issue=5;spage=99;epage=107;aulast=Rowland

7. Sacco RL. (1995) Risk factors and out comes for ischemic stroke. Retrieved on
1st November 2010 from
http://stroke.ahajournals.org/cgi/content/full/28/7/1507

8. Susan Berg (2010) Stroke – Occupational Therapy Activities. Retrieved on 5

September 2010 from http://www.ehow.com/way_5827473_stroke-
occupational-therapy-activities.html

9. Warner et al,. (2010) Nurse practitioners' awareness and knowledge of

occupational therapy services. Retrieved on 1 November 2010 from
http://gradworks.umi.com/14/84/1484747.html

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 8.0 APPENDIXES
APPENDIX 1
No. Patient ID / Patient Date case Date case Referral Reason for Date of
Name diagnosed referred to within 72 late discharged
with stroke by OT unit hours (3 referral/not
referral unit days) referred
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

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APPENDIX 2

No. Patient ID / Patient Date case Date case No of Complete

Name diagnosed referred to treatment minimum
with stroke by OT unit modalities treatment
referral unit modalities
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

17
19
20

APPENDIX 3 (Rubberstamp design)

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