jueves, 2 de agosto de 2012

Proposal of a multidisciplinary team approach

Over recent years several international1-3 have proposed a multidisciplinary approach to tinnitus management.
Clinicians and researchers have suggested adopting a multidisciplinary team model for tinnitus management and treatment, similar to the model for chronic pain services.1-2,6

An holistic approach is adopted by an American tinnitus treatment programme with the goal of enabling patients to manage the multiple consequences of tinnitus, including psychosocial (depression, concentration difficulty, inability to participate in work and leisure); and physical (sleep deprivation and muscle tension) consequences of tinnitus’.2

It is argued that tinnitus involves multiple systems and therefore treatment is provided by a multidisciplinary team.2

The recommendation that tinnitus patients are best served by a multidisciplinary team approach, has gained support among several international authors in recent years as the methods for enhancing care and treatment options for patients are explored1,3,4,6 although the idea was first proposed over twenty years ago.15-16 It is suggested that a multidisciplinary team approach to tinnitus treatment and management in the UK only
exists in a few centres of excellence.1,4
It has been argued that tinnitus research has been hindered by the need for interprofessional communication and partnership, resulting in an insufficient understanding of tinnitus as a whole.1

A significant collaborative approach by audiology, clinical psychology and otololaryngology1 addressed this discrepancy, by producing a clear, multidisciplinary approach which recommends an amalgamation between neurophysiological and psychological models of tinnitus.

However practical obstacles to a multidisciplinary team approach to tinnitus treatment are raised including; ensuring appropriate staffing levels, blend of skills and professional experience.1

Services for adults with tinnitus: a good practice guide—A comprehensive document produced by the UK Department of Health, NHS Guidelines, ‘Provision of Services for Adults with Tinnitus: A Good Practice Guide’4 provides an outline structure and pathway for tinnitus service provision.

The guide proposes a network or ‘matrix of services’ which gives tinnitus patients a greater access to services and a greater choice of treatment options.

The two part guide firstly offers a vision, context and principles for the organisation and delivery of services; and secondly a good practice pathway for the majority of adults with tinnitus which suggests an effective
way to deliver care and also outlines practical details of the vision for tinnitus services.4

The guideline for a public health model proposes that adults with tinnitus should receive a free, local, high quality, efficient responsive services, with minimal waiting times.4 Within the NHS, the pathway to appropriate tinnitus management is not always as efficient and effective, often characterised by long waiting times for services4,6 It is argued that clear referral pathways are required for patients whose clinical needs fall outside the skills of specific team,1,6 for example, patients with neurological symptoms or extreme distress should be referred to a specialist centre or service.4,6

A stepped care approach to tinnitus treatment was proposed by the good tinnitus guide.
Four separate levels of service provision have been identified for tinnitus  management, depending upon the patient’s clinical presentation.

The initial service provider is often the primary care service, or general practitioner.
Patients with for example, bilateral tinnitus with suspected hearing loss, or persistent mild tinnitus, may be referred to local audiology services for management by qualified audiologists.
Referral to a specialist centres or supra-specialist centre, includes a broader multidisciplinary team.
The specialist and supra-specialist centres include a range of healthcare professionals;
  • consultant audiovestibular physicians (AVP), 
  • Ear Nose and Throat (ENT) surgeons (or otolaryngologist), 
  • audiological scientists, 
  • audiologists,
  •  hearing therapists, 
  • clinical psychologist, 
  • nurse, 
  • administrators and 
  • clerical staff, withaccess to other specialities. 

Competent assessment and appropriate triage has been cited,4 8,9,16 as an essential starting point, critical for early identification of any underlying medical conditions requiring prompt and appropriate management of tinnitus.2-4,8,

Within the stepped care approach, it is proposed that multidisciplinary teams operating within the specialist and supra-specialist centres maintain the team integration by4:
  • regular team meetings to discuss patient pathways, 
  • discuss referral criteria and audit of outcomes;
  • that professional roles are expanded or redesigned with retraining provided;
  • all professional staff be competent in counselling and psychological support skills17; 
  • clinical psychologist be skilled in CBT; and provide appropriate supervision for staff offering psychological treatment or counselling.4 
  • It is therefore important to understand how the tinnitus team works together and why working in a well functioning team has advantages for patients and staff.5

Table 1: Advantages for effective teams (from Onyett BPS Report)

1. Improve quality of care (reduce time in hospital, better accessibility, enhanced user satisfaction, better acceptance of interventions and improved health outcomes) through achievement of co-ordinated and collaborative inputs from different disciplines
2. Link and integrate information for e.g. life of a client based upon long term relationships with
different team members.
3. Speedily develop and deliver services cost effectively while retaining high quality
4. Enable organisations to learn (and retain learning) more effectively, in groups rather than one
individual’s own knowledge
5. Time saving activities performed concurrently rather than sequentially
6. Innovation promoted by cross-fertilisation of ideas
7. Collegiality, friendship and emotional support from team increases staff satisfaction and
professional stimulation

Working in teams—One international multidisciplinary approach to tinnitus management outlines the professionals and treatments offered within a given team or service3 but does not describe how the team operates or functions.
The working relationships between the team members as a whole can also form an influential outcome on the overall service.
A recent report on the ways in which psychologists work in teams in the UK5 provides an understanding of how multi-professional teams operate and how effectiveness can be maximised.

A fundamental aspect of the working in teams report is that the report is relevant for any team member wanting to use psychological principles at work.5

The working in teams report therefore supports the tinnitus guidelines recommending that all staff working in teams with tinnitus patients should be competent in counselling and psychological support skills.

Several advantages are identified for well planned and well designed effective teams, as summarised by the working in teams report 19 listed in Table 1: Advantages for effective teams.

Several of the advantages listed have also been described within a specialist audiovestibular medicine service.6
A tinnitus multidisciplinary team—In May 2006 the British Tinnitus Association in conjunction with North Trent Region, Department of Audiovestibular Medicine, hosted a study day for professionals working with adults with tinnitus, using an interactive demonstration of multidisciplinary team work.

A key part of the demonstration was designed to reveal the holistic approach to assessment, planning and treatment or interventions, by illuminating the team communication processes using role plays with actors as tinnitus patients and individual members of the multidisciplinary team.18

The result was to offer delegates a unique insight into the performance, dynamics and patient benefits of a multidisciplinary tinnitus team in a specialist centre.

The initial medical assessment and rationale for tinnitus assessment by the Consultant Physician in Audiovestibular Medicine has been described in detail16 and provides the key starting point for all patients referred to the service.

Multi-disciplinary team working in a specialist centre with complex tinnitus patients has identified the difficulties of engaging psychologically distressed patients in tinnitus treatment.6

Psychologically distressed tinnitus patients may take up considerable time and resources in unproductive treatment or therapy, when their psychological needs are unidentified or not adequately addressed.

Alternatively patients may drop out of treatment, which then presents general practitioners with the challenges of managing potentially complex patients.

 A case example of a skilled multidisciplinary team approach provided for a psychologically distressed patient with a complex tinnitus and balance presentation explained the benefits of a multidisciplinary team approach.6

A referral to clinical psychology for assessment identified untreated post traumatic stress disorder (PTSD).

A coordinated treatment plan, including concurrent psychological therapy, audiology and physiotherapy was provided.
The result was a reduction in the patient’s psychological distress and successful management of

The efficient and effective use of rehabilitation resources reduced the time and frequency of appointments with audiology and physiotherapy, as the patient’s psychological needs were met.

Furthermore, the successful outcome improved each of the therapist’s sense of efficacy with a complex patient.6
Several features of the recommended tinnitus teams in specialist and supra-specialist tinnitus centres4, are also documented in other reports of team working, including:

  • having a diverse multidisciplinary team,1, 2,3 monthly tinnitus team meetings and additional therapists team meetings; 
  • whole person approach of physical and psychosocial needs;1,2,6 
  • joint and parallel collaborative working; research and audit; in-service training, for example, suicide prevention training6; 
  • case discussions;
  • location of team members in the same department; 
  • understanding of professional roles and skills17; 
  • respectful and positive working relationships 1,6,7 
  • and the tinnitus education group.2,4,16

Summary of factors associated with an effective team working BPS summary—

In summary the working in teams report argue that there are several factors are
associated with effective team working5 as shown in
Table 2 Factors associated with effective team working below:

Table 2: Factors associated with effective team working (Onyett BPS)
1. Clear and achievable objectives
2. Differentiated, diverse and clear roles
3. A need for members to work together to achieve shared objectives
4. The necessary authority, autonomy and resources to achieve these objectives
5. Capacity for effective dialogue this means effective processes for decision making, being able to engage in constructive conflict and if complex decision making is involved, the team needs to be small enough (no larger than eight or nine people)
6. Expectations of excellence
7. Opportunities to review what the team is trying to achieve, how it is going about it and what needs to change
8. Effective leadership

A multidisciplinary team approach is one part of a bigger network or matrix of service provision in the treatment of tinnitus, which can have significant benefits for patients and the teams in providing a service for tinnitus patients.4

Understanding the appropriate use of services and networks enables accurate referral, assessment and provision of healthcare in tinnitus management.
The tinnitus good practice guide4 suggests different levels of tinnitus service provision, according to clinical need, not all of which is provided within a multidisciplinary team.
The suggestion that tinnitus patients are best treated clinically by being offered management in a multidisciplinary team is partially supported, in specific instances.

Appropriate patient referrals to specialist centres, suggests that designing clear, effective, efficient, holistic multidisciplinary teams5 will benefit tinnitus patients and the staff working with them.

A framework for best practice offered by a multidisciplinary team has been demonstrated to provide a number of benefits.

Whether this model can be adapted or employed in healthcare settings outside the UK NHS, is certainly an area for further debate, particularly if there are insufficient resources available or small services existin large geographical areas without a local specialist centre.

Healthcare providers might want to explore ways in which the provision of tinnitus management could
incorporate a multidisciplinary team approach.

Perhaps a national centre of excellence could be considered as a starting point, given the evidence that a multidisciplinary team approach has advantages for particularly complex and distressed patients in specific instances.

Author information: Georgina Shakes Clinical Psychologist, Practice 92 Mt Eden
Ltd, 54 Mt Eden Road, Auckland
Correspondence: Dr Georgina Shakes Consultant Clinical Psychologist, Practice 92
Mt Eden Ltd, 54 Mt Eden Road, Auckland 1024 PO Box 8050 Symonds Street 1150
Auckland, New Zealand. Email: prac92@ihug.co.nz
1. Andersson G, Baguley D, McKenna L, McFerran DJ. Tinnitus: a multidisciplinary approach.
London: Whurr Publishers Ltd 2005.
2. Newman CW, Sandridge SA. Incorporating group and individual sessions into a tinnitus
management clinic. In: Tyler R, ed. Tinnitus treatment: clinical protocols. New York: Thieme
Medical Publishers, Inc. 2005:187-97.
3. Van de Heyning P, Meeus O, Blaivie C, Vermeire K, Boudewyns A, De Ridder D.Tinnitus: a
multidisciplinary clinical approach. B-ENT. 2007;3 Suppl 7:3-10.
4. Dept of Health. Provision of Services for Adults with Tinnitus: A Good Practice Guide. NHS
5. Onyett, S. Summary Report: New Ways of Working for Applied Psychologists in Health and
Social Care – Working Psychologically in Teams. The British Psychological Society 2007.
6. Shakes G. Clinical psychology service to North Trent Medical Audiology (NTMA): A
changing service. Unpublished report 2005.
7. Tyler RS. Neurophysiological models, psychological models, and treatments for tinnitus. . In:
Tyler RS, ed. Tinnitus treatment: Clinical protocols. New York: Thieme Medical Publishers,
Inc. 2006:1-22.
8. Sanchez TG. What to Expect from Your Physician and Healthcare Professionals In: Tyler RS,
ed. The Consumer Handbook on Tinnitus. Sedona: Auricle ink Publishers. 2008:183-197.
9. Kileny PR. Causes of Tinnitus. In: Tyler RS, ed. The Consumer Handbook on Tinnitus.
Sedona: Auricle ink Publishers. 2008:15-29.
10. Welch D, Dawes PJ. Personality and perception of tinnitus. Ear Hear. 2008;29(5):684-92.
11. Davis A & Rafaie A. E. Epidemiology of tinnitus. In: Tyler RS, ed. Tinnitus Handbook. San
Diego: Singular Publishing Group. 2000: 1-23.
12. Fagelson, M. Overview: The Consumer Handbook on Tinnitus. In: Tyler RS, ed. The
Consumer Handbook on Tinnitus. Sedona: Auricle ink Publishers. 2008:1-14.
13. McKenna L, Andersson G. Changing Reactions. In: Tyler RS, ed. The Consumer Handbook
on Tinnitus. Sedona: Auricle ink Publishers. 2008: 63-79.
14. Stephens SD, Hallam RS, Jakes SC. Tinnitus: a management model. Clin Otol Allied Sci.
15. Coles RR, Hallam RS. Tinnitus and its management. Br Med Bull. 1987;43(4):983-98.
16. Tungland OP. Tinnitus suffering: some medical aspects', Audiol Med. 2004; 2:1,18-25.
17. Searchfield G, Magnusson J, Shakes G, Biesinger E, Kong O, (Personal communication on
forthcoming chapter) Counselling and Psycho-education for tinnitus management. 2009.
18. Shakes G. Personal communication. Dept of Audiovestibular Medicine Sheffield. 2006.

Fuente: NZMJ 19 March 2010, Vol 123 No 1311; ISSN 1175 8716 Page 167 of 167
URL: http://www.nzma.org.nz/journal/123-1311/4040/ ©NZMA

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