GM Spasticity Audit - Service Organisation Audit Tool: inpatient teams

(Please complete one form only per service)

Ward Name(Required)

Trust responsible for Team(Required)

Is spasticity routinely considered for all patients with neurological motor weakness?

If compliant, what process is in place to provide assurance?

Please select all that apply

Training

GM Spasticity Proforma

Supervision

Local Audit

Which members of the locality MDT are involved in spasticity management? Please state band/WTE where applicable.

Rehab Medicine Doctor

Non-Medical Injector

Physiotherapist

Occupational Therapist

Nurse

Orthotist

Other (Please State)

Is the MDT able to provide or access second-line interventions on the ward?

Orthoses

Full Compliance

Partial compliance because - resource is available but pathway is not coordinated, Limited stock options, limited capacity, limited resource

None compliance because - no capacity within the team, workforce not trained to provide orthoses, no orthotic resource within the team, no referral pathway in place to access orthotics

Oral Anti-Spasticity Agents

Choose multiple as required

Full Compliance

Partial compliance because - oral agents are available but pathway not coordinated, limited due to availability of workforce.

None compliance because - no capacity within the team to offer review/assessment, no prescribers within the workforce, no pathway in place to access prescribers such as Rehab Medicine Doctors or GP

Botulinum Toxin

Choose multiple as required

Full Compliance

Partial compliance because - available but pathway not coordinated, administration of toxin offered on a goodwill basis, limited capacity to provide toxin.

None compliance because - no capacity within the team, workforce not trained to provide botulinum toxin, no pathway in place to access trained medical or non-medical injector for botulinum toxin

Which healthcare professionals deliver botulinum toxin in your locality?

Rehab Medicine Doctor

Non-Medical Injector

Stroke Consultant

If the injecting clinician is a non-medical injector, have they completed the following training requirements stipulated by the national guidelines:

a) Attended a botulinum toxin training course

Choose multiple as required

Full Compliance

Partial compliance because - NMI is currently in training

None compliance because - NMI has not accessed a formal training course

b) Been observed assessing and injecting a minimum of 5 pts with arm and 5 pts with leg spasticty related problems?

Choose multiple as required

Full Compliance

Partial compliance because - NMI has completed some observed injections but not all required.

None compliance because - NMI has not been observed.

c) Been trained to use the relevant localisation techniques (EMG, electrical stimulation or ultrasound)

Choose multiple as required

Full Compliance

Partial compliance because - NMI has limited access to relevant equipment, NMI has received training in some but not all relevant techniques.

None compliance because - NMI has not been trained to utilise any localisation techniques.

Is there access to EMG / electrical stimulation / ultrasound equipment as required?

Choose all that apply

Full Compliance

Partial compliance because - equipment not always available, some localisation options available but not all,

None compliance because - no equipment available, no-one is trained to utilise localisation equipment

Which is most frequently used on the ward?

EMG

Muscle Stimulation

Ultrasounds

Are there pathways in place to access third-line interventions outside of the ward?

Intrathecal baclofen service

Full Compliance

Partial compliance because - limited pathway in place to access ITB clinic

None compliance because - no referral pathway in place to access ITB clinic

Orthopaedic / Plastic Surgery

Full Compliance

Partial compliance because - limited referral pathway in place to access orthopaedic surgical services

None compliance because - no referral pathway in place to access orthopaedic surgical services

Neuro-Surgery

Full Compliance

Partial compliance because - limited referral pathway in place to access neurosurgical services

None compliance because - no referral pathway in place to access neurosurgical services

Does the locality service routinely provide written information to patients and carers on managing spasticity?

Choose all that apply

Full Compliance

Partial compliance because - written information is provided some of the time

None compliance because - no resource available, written information is never provided

Is there an onward referral pathway in place for spasticity management following IP management?

Choose all that apply

Full Compliance

Partial compliance because - limited pathway in place

None compliance because - no pathway in place

What does this look like?

Thank you for completing the survey

Name

This field is for validation purposes and should be left unchanged.

GM Spasticity - Inpatient Teams Organisation Audit

Is the MDT able to provide or access second-line interventions on the ward?

If the injecting clinician is a non-medical injector, have they completed the following training requirements stipulated by the national guidelines:

Are there pathways in place to access third-line interventions outside of the ward?

Thank you for completing the survey