INTRODUCTION TO THE TOPICS
Introduction to the Topics
The Toolkit provides core standards for organisation of evidence-based services within a learning environment and support the delivery of holistic specialist SCI care to meet the needs of the SCI population at each stage of the continuum of care.
Topic 1: Person-centred care
Topic 1: Person-centred care
1. This topic includes three standards:
1.1 Services are organised and delivered around the needs of the person with SCI.
1.2 Persons with SCI are engaged, empowered and supported to share decision-making process about their own healthcare throughout their journey.
1.3 Persons with SCI are cared for in an appropriate environment dependent on individual need and clinical condition.
Topic 2: Organisation and delivery of SCI services
2. This topic includes six standards:
2.1. All persons with SCI have equal and timely access to a system of high-quality, specialised care to address their needs.
2.2. SCI Services are delivered by an integrated system across a continuum of care.
2.3. All services are delivered by a team of sufficient size, skill-mix and competencies for the level of care, specific setting and stage in the patient journey.
2.4. Services are delivered in a safe, accessible environment with appropriate facilities, equipment, essential medicines and assistive products for the level of service and patient needs.
2.5. SCI Services are resourced to meet the defined scope of service and the needs of persons sustaining and living with SCI.
2.6. Standardised data systems monitor and evaluate access, quality and continuity of care across all providers and health system levels to drive continuous improvement.
Topic 3: Pre-hospital care
Topic 3: Pre-hospital care
3. This topic includes three standards:
3.1. An agreed national protocol is available to guide the emergency management of a person with suspected SCI at the scene of injury ready for transportation to hospital.
3.2. Patients with suspected acute SCI will be transported from the site of injury to the nearest designated medical facility by the most appropriate mode of transportation available.
3.3. A formal handover using standardised information is provided by the first responders to the receiving team in the Emergency department.
Topic 4: Acute care
4. This topic includes five standards:
4.1. Upon admission to the acute hospital, a comprehensive assessment is conducted to confirm the diagnosis of SCI, as well as presence of associated injuries or comorbidities.
4.2. On confirmation of a SCI, the receiving physician/surgeon will contact the SCI specialist team.
4.3. In the acute setting, persons with SCI must be cared for by staff with experience and knowledge of SCI.
4.4. A person with a new diagnosis of SCI is managed in a safe, appropriate and supportive environment to minimise harm, further impairment and optimise function, participation and quality of life.
4.5. Standardised information is provided by the acute team in a formal handover to the receiving rehabilitation team.
Topic 5: Rehabilitation
5. This topic includes eight standards:
5.1. Comprehensive, multidisciplinary and person-centred assessment informs the design, provision and evaluation of an individualised SCI rehabilitation programme.
5.2. An integrated, evidence-based and person-centred rehabilitation programme is prepared to meet the identified needs and unique circumstances of each person with SCI.
5.3. A collaborative goal-planning process is conducted to identify key issues, set appropriate goals, review progress and update individual care plans.
5.4. A co-ordinated process of discharge planning commences at the first goal planning meeting.
5.5. All persons with SCI will have a bespoke education programme based on their individual needs and circumstances.
5.6. Rehabilitation services for persons with SCI are delivered by a competent multi-disciplinary team appropriate for the caseload, complexity and identified care.
5.7. Rehabilitation is delivered in a safe, accessible environment with adequate and appropriate facilities, equipment and assistive products for the level of service, case mix and individual patient need.
5.8. Evaluation of the person with SCI rehabilitation outcomes is undertaken at agreed time intervals.
Topic 6: Community reintegration
6. This topic includes five standards:
6.1. The SCI Services will identify and engage with required community services to facilitate discharge and reintegration.
6.2. The person with SCI is physically, psychologically and functionally prepared for discharge and all required rehabilitation goals have been achieved.
6.3. The SCI Team will work with the person with SCI and the relevant community agencies to facilitate and optimise participation.
6.4. Persons with SCI living in the community will be supported by personnel with the appropriate education and training.
6.5. Standardised information is provided by the discharge team in a formal handover to the receiving Community team.
Topic 7: Health maintenance and review
7. This topic includes three standards:
7.1. All persons with SCI will have an individualised programme of routine review, dependent on need.
7.2. The person with SCI will have on-going access to the SCI MDT, as required.
7.3. Outcomes for persons with SCI are evaluated by SCI Services using a common minimum data set at agreed time intervals.
Topic 8: Re-admission
8. This topic includes five standards:
8.1. A pre-admission assessment is conducted for each elective admission to the SCI Centre.
8.2. Where a person with SCI is to be admitted for a procedure unrelated to their SCI, the SCI Team can undertake an assessment and provide advice to the treating team.
8.3. Individual Care Plans are reviewed on admission.
8.4. The person with SCI is physically, psychologically and functionally prepared for safe discharge.
8.5. Standardised information is provided by the discharge team in a formal handover to the receiving Community team.
Topic 9: Special considerations
9. This topic includes six standards:
9.1. A child or young person with SCI has access to specialist SCI Services across the continuum of care, and a rehabilitation programme designed around their individual and family needs.
9.2. An older person with SCI has equitable access to specialist SCI Services across the continuum of care to meet their individual needs.
9.3. A person with SCI and other significant health needs (such as a severe brain injury, poly-trauma, major psychiatric disorder) has access to SCI and other key services with co-management in a safe and appropriate environment to meet their individual needs.
9.4. A person with SCI requiring long-term ventilatory assistance has access to specialist SCI Services for their unique needs.
9.5. A person with a new or established diagnosis of SCI who is approaching end-of-life and requires palliative care has access to SCI expertise and a programme of care reflecting their individual preferences and needs.
9.6. A person with SCI and bariatric needs (BMI ≥ 40) has access to specialist SCI Services for their unique requirements.
Topic 10: Workforce, planning, education and training
10. This topic includes six standards:
10.1. Recruitment practice ensures employment of the workforce with necessary skills and education to care for persons with SCI.
10.2. SCI Service Leaders work to optimise retention of a quality workforce to provide continuity and consistency in service provision.
10.3. A competency-based SCI curriculum is established.
10.4. Competency frameworks are established for each staff group across the continuum.
10.5. The workforce has access to continuing training and education.
10.6. SCI Centre Staff provide education at National, Regional and local level to support delivery of the clinical pathway across the continuum of care.
Topic 11: Service evaluation and quality improvement
11. This topic includes six standards:
11.1. All SCI Services commit to a programme of service evaluation and quality improvement to ensure and promote transparency, evaluation and shared learning across the organisation.
11.2. SCI Service Leaders undertake continuous and comprehensive assessment of service provision for people sustaining and living with SCI.
11.3. A Quality Improvement Plan is established from the assessment for the development of the SCI Service.
11.4. A framework and process for monitoring, evaluation, and review of the quality improvement programme is established.
11.5. A structured quality improvement programme is conducted by the multidisciplinary team to improve service structure, processes and outcomes.
11.6. Evidence and outcomes of QI programmes are disseminated and actioned across all organisations throughout the continuum of care.
Topic 12: Research and development
12. This topic includes three standards:
12.1. SCI Services demonstrate commitment to implementation of evidence-based practice.
12.2. SCI Service research programmes align with the interests and priorities of persons with SCI.
12.3. SCI Services demonstrate a commitment to research within a Learning Health System.