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PATIENT CATEGORISATION TOOL(PCAT)SELF-SERVICE TRAINING SLIDESUK ROC & NCASRIProfessor Lynne Turner-Stokes DM FRCPRegional Hyper-acute Rehabilitation UnitNorthwick Park HospitalWatford Road, Harrow, Middx. HA1 3UJLynne.turner-stokes@doctors.org.uk

Glossary NCASRI – National Clinical Audit Specialist Rehabilitation for patientswith complex needs following major injury PCAT – Patient Categorisation Assessment Tool TARN – Trauma Audit and Research Network UK ROC – United Kingdom Rehabilitation Outcome Collaborative

CONTENT Background Structure of tool Tool completion Decision making process Psychometric properties

Background The Patient Categorisation Tool (PCAT) was developed from thedescriptions within the NHSE Standard Contract for specialisedrehabilitation for patients with highly complex needs -ServiceSpecification /04/d02-rehab-pat-high-needs-0414.pdf)for identification of patients with Category A or B needs requiringon-going specialist rehabilitation It is primarily a checklist of rehabilitation needs It has an ordinal tool scoring system ranging from 17-50

Structure of PCAT –Table 1 The tool provides a checklist to assist clinical decision reasoning to identifypatients with Category A or B needs The PCAT tool contains 2 tables Table 1 contains 4 columns Column 1 – lists 16 domains(each rated on a score of 1-3) subdivided into Specialist medical or neuropsychiatric needs & intensity Clinical needs - physical, tracheostomy/ventilatory, swallowing/nutrition,communication, cognitive, behavioural, mood/emotion, complex disabilitymanagement, social/discharge planning, family support, emotional load on staff Additional needs – Vocational rehabilitation, Medico-legal issues and specialistequipment Column 2 – contains the descriptions of types of need for Category A needs Column 3 – contains the descriptions of types of need for Category B needs Column 4 – contains the descriptions of types of need for Category C needs

Structure of PCAT –Table 2 The second table is on page 2 and contains Service level required Category Expected duration of admission Funding source Purchase type Name of assessor Date of assessment

Interpretation of PCAT Descriptors Throughout the tool the following terms are used: Complex, unstable, severe needs - requiring expertise of aspecialist rehabilitation unit with appropriate staffing/facilitiessuch as provided by a Level 1 tertiary service Routine, stable, moderate needs - requiring expertise of aspecialist rehabilitation unit with appropriate staffing/facilitiessuch as provided by a Level 2 specialist rehabilitation service Normal, higher function, stable or no problem – needs can bemanaged in a Level 3 rehabilitation service

Completion of PCAT From April 2013 full itemised scoring of the tool has been amandatory requirement for Level1/2 services The tool should be completed by a Consultant in RehabilitationMedicine/Neuropsychiatry /- input from the therapy team It is completed: Prior to referral to a specialist rehabilitation unit by a Major TraumaCentre (MTC) AND/OR Following admission to a Level 1/2 specialist rehabilitation unit All sections of the tool should be completed and then entered into TARN (patients assessed in the Major Trauma Centre)/ ORION AND/OR UK ROC database (patients admitted to rehabilitation unit)

Item Selection Tool completion requires indication (by use of the tick boxes) of themost appropriate descriptor/s for each domain Some domains are mutually exclusive whilst others may have relevantdescriptors in both Category A and B columns E.g Intensity – patient may need 5 therapy disciplines (Category A) for 2025 hours total therapy time per week (Category B) All relevant descriptors can be indicated, if the patient does not haveCategory A or B needs for a domain this can be left blank or forcompleteness of the tool Category C option may be selected E.g Tracheostomy – the patient does not have a tracheostomy – either leavedomain blank or tick “no tracheostomy” in Category C column For consistency and comparability only the descriptors provided shouldbe used and no additional descriptors added

Scoring guidelinesMedical/surgical needsCategory DescriptorGuidelinesComplex specialist investigation/interventionRequires neurosurgical intervention and/or investigationsat specialist centreAMedically/surgically unstablee.g uncontrolled seizures/diabetes or sympatheticstorming/sepsis– may need emergency access to HDU/ITUintervention. Must have access to Acute CareAComplex on-going needs for coordinatedtrauma careSevere traumatic injury requiring surgical/vascular/orthopaedic/neurosurgical on-going interventionBRoutine ion can be completed in SpecialistRehabilitation settingCurrently well but potentially unstablePeriods of instability e.g pyrexia, seizures etc. but largelycontrolledBActive on-going trauma care managementMay require surgical/vascular/orthopaedic review whilston specialist rehabilitation unitCNo investigation/interventionRoutine bloods/X-Rays may be required infrequentlyCMedically stableNo immediate medical issuesCTrauma Care largely complete – review onlyOn-going trauma care can be managed on an out-patientor phone call basisAB

Scoring guidelinesNeuropsychiatric needsCategory DescriptorGuidelinesAComplex/unstable psychiatric needsSevere psychiatric problems, suicidal ideation – needs expertiseof a cognitive/behavioural unit and 1-1 interventionAHigh Risk ManagementRequires expertise of cognitive/behavioural unit – needs 1-1supervisionATreatment under section of the MHACurrently sectioned under MHA for own/other safetyBPsychiatric condition stable but needsmonitoringPsychiatric condition well managed with therapyinput/medication but requires regular intervention frompsychiatrist/psychologistMedium Risk ManagementSome concerns with psychiatric problems but can be managedwith advice from psychiatrist on a ad hoc basis or input from apsychologistCNo psychiatric conditionNo history/symptoms of psychiatric conditionCLow or no riskMay or may not have some psychiatric condition but can bemanaged in any environmentB

Scoring guidelinesIntensityCategory DescriptorGuidelinesA 5 therapy disciplinesRequires daily therapy intervention from the inter-disciplinaryteam. At least 5 unit funded therapy disciplines involved eachweek e.g. Physiotherapy, Occupational therapy, SpeechTherapy, Dietitian, Psychology and/or social workerA 25 hours total therapy time per weekHigh therapy input – approximately 6 hours per dayARequires 1-1 supervisionCan not be left unsupervised at any time due to concerns forsafety/abscondingA 2 trained therapists to treat at onetimeRequires either joint sessions (2 or more disciplines involved)or 2 trained therapists from same discipline (e.g 2/3 Physio’sfor all sessions)4 therapy disciplinesRequires weekly therapy intervention from 4 different therapydisciplines (funded establishment)B20-25 hours total therapy time per weekStandard therapy input, approximately 4-5 hours per dayC1-3 therapy disciplinesRequires weekly therapy intervention from 1-3 differenttherapy disciplines (funded establishment)C 20 hours total therapy time per weekLow therapy input, less than 4 hours dailyB

Scoring guidelinesPhysical NeedsCategory DescriptorGuidelinesAComplex postural tone/contracture management24 hour postural management programme in place/regular tilttabling. Complex spasticity management. Bespoke splintingA 2 to handleRequires 3 or more staff for all physical needsAHighly complex musculoskeletal/trauma/pain managementissuesReferral to on-site pain management team. Regular analgesia/painassessmentAComplex amputee needs (Multi-limb, high tech etc)Management of phantom pain. Bespoke prosthesisBRoutine physical issuesRegular physiotherapy intervention – strength training etcB1 to handleAssistance of 1 for most physical needs. E.g. transfers/mobilityBModerately complex musculoskeletal/trauma/painmanagement issuesPain management programme in place with regular reviewBStandard specialist amputee needsRegular prosthetic review. Management of artificial limbCHigher function problemsAble to walk independently with walking aid/prostheisCStandard musculoskeletal/trauma/ pain management issuesPain managed with regular exercises and analgesiaCNo physical issues

Scoring guidelinesTracheostomy/Ventilatory NeedsCategoryDescriptorGuidelinesAUnstable tracheostomy requiring intensive suctionExcessive secretions and/or recurrent mucousplugging of tracheostomy, fluctuating saturation levelsAOxygen saturation monitoring programmeConstant oxygen saturation recording. CPAP may berequiredAActive weaning programmeCuff deflated for periods during the day, capping oftracheostomyAAssisted ventilationPortable ventilatory support e.g. NIPPYBTracheostomy in situ but stableMaintained with regular suctioning/tube changesCNo tracheostomyMay need tracheostomy dressings followingtracheostomy removal only.

Scoring guidelinesSwallowing/NutritionCategory DescriptorGuidelinesAComplex swallowing evaluation (e.g. FEES)At high risk of aspiration/ silent aspiration. Undergoing investigation such as FEESAComplex nutritional requirements requiringintensive dietary support/interventionEnteral/Parenteral feeding, frequent monitoring ofelectrolytesBEnteral feeding programmeOn an established enteral feeding regime – requiresregular reviewBModerate monitoring – e.g progressiveconsistency, dietary contentPuree/soft/normal diet/thickened fluids /supplements. Changing consistency/textureBDietary education (e.g. healthy eating, weightreduction)Weekly weight recording/ dietary advice for patientand familyCNormal or stable modified dietEstablished dietary intake.CAble to eat independently or with supervisionfrom care staffMay need help to open packs/cut up food or needmonitoring for speed of eating/drinking to ensuresafe eating/drinkingCStandard dietary/weight monitoring only

Scoring sAComplex communication needs requiring specialistevaluationLocked-in syndrome assessment – eye gaze etc.Severe expressive/receptive dysphasiaAComplex communication needs requiring complexcommunication aid set-up provisionAlternative and Augmentative communicationrequiredBModerate communication issues with some listenerburden, but able to communicate basic needs & ideasPicture charts, alphabet chart or light-writer toassist with communicationCHigher function problems onlyOccasional word finding difficulties/someclarification may be required for effectivecommunicationCNo problems with communication

Scoring guidelinesCognitive needsCategoryDescriptorGuidelinesASevere cognitive problems requiring intensivesupport for carryover/orientation etcOn day-to-day basis requires prompting/guidancewith all basic needs e.g washing & dressingsequencingASevere cognitive problems requiring complexcognitive/neuropsychological assessmentBModerate cognitive problems requiring structuredenvironment, strategiesOrientation board. Day to day timetable. Visualprompts/clues/remindersBRoutine cognitive assessment e.g. by OTDay-to-day functional table top assessmentsCHigher function problems onlyFunctions independently for most of the time butmay need some occasional help e.g forcommunity navigation or extended activities ofdaily livingCNo cognitive problems