Benefits of the SMART Assessment for PDOC patients and clinicians

Having qualified SMART Assessors as part of our multidisciplinary team in our specialist neurological services brings measurable benefits to individuals with prolonged disorders of consciousness (PDOC) and their families.

In this EveryExpert article we speak to newly qualified and experienced assessors about their training, how the SMART assessment is being implemented at their services and the positive impact this is having on residents.

What is SMART?

The Sensory Modality Assessment and Rehabilitation Technique (SMART) is an award-winning clinical investigative tool for the assessment and rehabilitation of people with PDOC following severe brain injury.

Pioneered at the RHN (Royal Hospital for NeuroDisability) in London, the SMART identifies any potential awareness in adults with severe brain damage who are in a low conscious state. It also identifies the functional and communication capabilities of patients in a minimally conscious state. The SMART has been clinically designed and is standardised. It is an extended assessment and investigation of behavioural responses, culminating in a measurable intervention and/or management strategy.

Why is SMART the most well-regarded assessment for PDOC?

Ady Capener is Therapy Manager and Senior Occupational Therapist (OT) at The Dean Neurological Centre in Gloucester, a specialist rehabilitation and disability management service for people living with a range of different and complex neurological conditions. As an experienced SMART Assessor, Ady also helps train clinicians in the SMART assessment and explains how its unique approach gives the individual the best chance to respond and the clinician the best opportunity to understand and support patients.

Ady says: “At The Dean we work with a very complex patient group, which requires specialist knowledge and skills. The SMART assessment provides a structure for that, it has been standardised and validated and gone through rigorous testing to make sure that when you are assessing you follow a standard and do it in a certain way. It’s more than just an assessment. It’s more like an ethos and an overview on how you should treat and assess individuals. It doesn't just give you the assessment, it gives you treatment options, which makes you think about things that you need to make sure are as optimal as possible before you do an assessment. So for example that could be reviewing someone's medication, positioning, medical stability, considering if they’ve got any infections, or had any seizures?”

Ady says: “When completing the SMART assessment we assess the individual during rest periods and then during periods of stimulation, so this ensures that we get to know the person really well. We consult the whole MDT and the individual’s family is also involved, because they may respond differently to family members. It is all recorded and included. We consider all the different senses that the person uses and see which one elicits the highest responses, which then guides your treatment plan.

“The SMART assessment gives the individual the best opportunity to show their level of awareness, and then as clinicians we know that we have given them the best chance if we have optimised everything. If you follow the process and do the assessment thoroughly, you can be confident that you won't have missed anything.”

Kirsty Allison, OT at Elysium’s specialist neurorehab centre The Bridge in Middlesbrough, has recently qualified as a SMART Assessor and explains how the SMART assessments feed into a more detailed treatment plan for patients.

Kirsty says: “The SMART Assessment provides an indicative diagnosis of what level of consciousness and awareness the person actually has, which can then feed into a more comprehensive treatment plan. It’s very thorough. For example, the first section of the assessment looks at any pre-existing problems, like positional issues, sleep wake issues, and it gives you some baseline ideas of what you can do to support the individual in your care. It also identifies any strengths they've got, so you can optimise those and build that into therapy. By addressing those issues and strengths first, it creates an important, standardised baseline which you can then work from.”

Who can deliver SMART?

The SMART assessment must be applied by a SMART assessor who has completed specialist training and adheres to the SMART standards of practice and guidelines. However, a particular strength of the SMART is that the whole MDT and family members can input into the assessment so that a comprehensive understanding of an individual can be gained.

Elinor Jordan-Bennett is Senior OT at Adderley Green Care Centre in Stoke-on-Trent, a specialist neuro-rehab centre which has been designed specifically to support the needs of individuals who have complex care and rehabilitation needs. For Elinor, bringing together the various experience, expertise and interactions of the whole team is what makes the difference.

Elinor explains: “PDOC is a very complex area to work in and there can often be confusion between what is a reflexive response like a cough, and the varying interpretations of a smile which could be reflexive or intentional. The SMART assessment brings clarity around responses and provides the care team, families and also commissioners a better understanding of what that person's abilities are.

“So far I’ve completed five assessments, currently commencing my sixth and it has involved a whole team of people across the MDT. This has included Therapy Assistants, Care Staff, Psychology, Activity staff, Speech and Language Therapists, Physiotherapists, Nurses, and even bringing in the non-clinical team members such as our domestic team. For example, I’ve spoken with members of our cleaning team to see if they have observed any responses when they are interacting with the individual whilst cleaning the individual’s room. It’s a very thorough process and through it we get a very accurate picture of a person’s response levels.” our service. The sensory assessment itself goes through different sensory modalities and looks at responses to each of those.

How does the SMART assessment benefit families?

When a relative is in PDOC it is a particularly confusing and distressing time for families.

Not only must they come to terms with what has happened to their loved one, but also they need to adjust to navigating an uncertain future, waiting for signs or responses from their relative in PDOC. Pauline Matthews, Lead OT at the Bridge in Middlesbrough, is currently working towards becoming a SMART assessor, and she explains how having an independently verified set of guidelines removes some of that uncertainty for families because the SMART assessment places all responses on a diagnostic spectrum and identifies the quality of those responses.

Pauline explains: “It’s incredibly useful to have an independent set of guidelines to work from.

"We think about what principles have we learnt during the assessment and how can we ensure they are optimised in day-to-day experience for our residents.

"We’ve made a sensory room and a sensory terrace as well, where we’ve incorporated tactile areas, lighting, and a solar powered water feature. It’s all wheelchair accessible and also accessible from postural chairs so if you have somebody who is in PDOC and requires postural support they can also use it.”

What are the benefits of SMART for MDTs?

It gives us definitive answers to exactly what that person is able to do and where to pitch our intervention. As clinicians we feed into the assessment, but the family members can also contribute and so it builds a detailed overview of response levels. It can then give indications about the prognosis of the individual and what inventions might be beneficial in the future.

“So, in terms of when we work with families, it’s not just us saying this is what we’re seeing, this is from an independently verified and produced assessment. It helps put their experience with their loved one into context and they have a better understanding of what is happening and what outcomes there may be. Anybody who has a SMART assessment should be reviewed yearly, so the families are updated about their relative’s status and any natural recovery that the person in PDOC is having.”

How the SMART creates a holistic assessment environment

For Kirsty Allison, OT at the Bridge in Middlesbrough, she’s noticed how using the SMART assessments has not only improved the family experience but environments across the service have also been optimised.

Kirsty says: “Since completing the training we’ve become more mindful of how we involve families and their experience of supporting their loved one. It can be very confusing, so I’ve developed an information pack for families about what they can expect at different levels of consciousness.

“We try to provide information and educate families about what they might see and its meaning.

"For example, they can see their relative saying words and appearing to be following them round the bed, so they question how they can be in a prolonged disorder of consciousness?”

Kirsty goes on to explain how the assessment has inspired innovation across the service.

“In the same way, we’re more mindful now of how we can optimise sensory experience across

Susan Field, Director at The Dean explains how the comprehensive nature of the assessment enables her MDT to work together with clarity. Susan says: “The assessment is very detailed, so not only does it confirm consciousness levels but it clarifies any future rehabilitation goals which guide and shape the way our team work together. The clarity that we obtain from the SMART assessment is hugely beneficial for our MDT and influences the whole care pathway.

“From the different interventions and therapies that we can use, to how we help family members with psychological support, are all guided in some way by the results from the assessment. Should individuals become unwell, get admitted to hospital or need end of life care then our decisions are influenced by the outcome of the assessment.”

How do commissioners respond to the SMART assessment work?

Elinor Jordan-Bennett, Senior OT at Adderley Green Care Centre in Stoke-on-Trent, explains the benefit for commissioners and patients.

Elinor says: “When individuals come to us from an acute hospital, they’ve typically had baseline assessments completed, for example, the Wessex Head Injury Matrix and Coma Recovery Scale. These are two of the three recommended assessments by the Royal College of Physicians 2020 PDOC guidelines.

"These provide a good initial understanding of what treatment pathway an individual needs but the SMART assessment goes into much more depth due to the structured guidelines.

“SMART provides essential information both for the care team and commissioners, because ultimately the treatment plan that comes out of the SMART assessment is very comprehensive and personalised.

"We also have regular review meetings for the individuals in our care and the SMART feeds into all of those.”

For more information on SMART assessments, the RHN (Royal Hospital for Neuro-Disability) has produced a comprehensive guide here

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