Table 5. Adherence to audited indictors (n = 114) at three audit time points and difference (Chi square) between time points.

Explicit audit indicators linked to model of care and/or clinical practice guideline recommendations	Adherence to audit criteria			Differences in adherence measured between time points
	0–2 months (n = 8)	13–15 months; post intervention (n = 8)	18–19 months; follow-up (n = 20)	13–15 months minus 0–2 months		18–19 months minus 13–15 months
	n	n	N	p value (Fischer exact statistic)	Cramer’s V	p value (Fischer exact statistic)	Cramer’s V
Behavioural support plan
1: Patient behavioural support plan is known to the family and informal carers [Model of care recommendation]	3	1	5	*	*	1.0	.289
2: An admission screen of behavioural support requirements has taken place [26]	3	8	19	.026	.674‡	1.0	.122
3: Patient behavioural support plan is in place [26]	2	3	12	.196	.600‡	*	*
4: The implementation of strategies documented in the patient behavioural support plan occurs [26]	2	3	12	.429	.548‡	*	*
5: Patient behavioural support plan is known to staff [26]	7	8	18	*	*	*	*
6: Antecedent behaviours are known to staff [26]	2	1	10	1.0	.333†	.154	.452†
Care plan
1: Family are able to identify primary rehabilitation goals consistent with documented goals from interdisciplinary family meeting [Model of care recommendation]	3	4	8	.444	.478†	.516	.333†
2: Patient centred goals are displayed appropriately in the patient's room [Model of care recommendation]	1	7	12	.010	.732†	.214	.266
3: Patient is able to identify primary rehabilitation goals consistent with documented goals from interdisciplinary family meeting [Model of care recommendation]	4	6	5	1.0	.076	.569	.262
4: Up-to-date treatment plan is in place [26]	5	6	17	1.0	.135	.606	.118
5: Documented goals guide and inform therapy and treatment [43]	2	8	14	.007	.775‡	.141	.330†
6: Staff are able to identify primary rehabilitation goals consistent with documented goals from interdisciplinary family meeting [Model of care recommendation]	7	8	13	1.0	.258	.142	.365†
Continuity of care
1: Engagement with visitors is evident throughout a clear welcoming process [Model of care recommendation]	1	6	13	*	*	*	*
2: A patient centred care approach is used on the unit throughout the entire patient journey [10,25,27,40,42,43,44]	2	8	18	.015	.730‡	.577	.175
3: Continuity of care is in place for nursing [Model of care recommendation]	0	8	14	.0001§	1.0‡	.141	.330†
4: Continuity of care is in place for allied health [Model of care recommendation]	1	8	16	*	*	.295	.258
5: Continuity of care is in place for medicine [Model of care recommendation]	1	8	20	*	*	*	*
6: Patient/ family/informal caregivers are involved in the care planning meeting on the unit. [10,27,42,43]	1	7	18	.005	.854‡	1.0	.121
7: Escalation of patient issues or concerns has been documented appropriately [Model of care recommendation]	1	6	13	*	*	*	*
8: Engagement with family/informal caregiver is evident throughout every stage of recovery. [medical notes] [11,27]	5	8	20	.200	.480†	*	*
9: Engagement with family/informal caregiver is evident throughout every stage of recovery. [family report] [11, 27]	2	5	10	.021	.732‡	.559	.236
Discharge planning
1: Interdisciplinary and patient (and family) directed discharge plan development is in place [25,40,43,44]	5	6	7	1.0	.174	.165	.370†
2: Training of family/ informal caregivers occurs prior to discharge: including safe use of equipment and management of the patient to ensure patient & caregiver safety in the home environment [medical notes] [25, 43] (a minimum of 4 weeks)	1	2	0	*	*	*	*
3: Assessment of discharge destination environment and available support occurs prior to discharge [25, 43] (a minimum of 4 weeks)	0	5	4	.167	1.0‡	.455	.430†
4: All required equipment and adaptations are provided prior to discharge [25]	*	1	0	*	*	1.0	1.0‡
5: Training of family/ informal caregivers occurs prior to discharge: including safe use of equipment and management of the patient to ensure patient & caregiver safety in the home environment [family report] [25, 43] (a minimum of 4 weeks prior)	1	1	1	*	*	*	*
6: Educating patients and family/informal caregivers about relevant formal and informal resources and how to access these resources including voluntary services and groups occurs prior to discharge [26, 43]	0	1	1	1.0	.333†	1.0	.577‡
7: Minimum of two weeks (before discharge) are spent in the transitional living space [26]	3	3	1	*	*	1.0	.250
Equipment use
1: Instructions for the patient’s individualised equipment use is in place [43]	7	8	14	1.0	.258	1.0	.156
2: If prescribed, ceiling track hoist is used for every transfer within the past week [Model of care recommendation]	1	4	3	.333	.632‡	1.0	.378†
3: All staff are aware of the patient’s individualised equipment needs [medical notes] [Model of care recommendation]	7	6	20	1.0	.277	.259	.331†
4: All staff are aware of the patient’s individualised equipment needs [ask staff] [Model of care recommendation]	7	8	20	*	*	*	*
Patient/family education [11]
1: Ward orientation	3	7	16	.119	.516‡	1.0	.020
2: Diet/nutrition	2	0	1	.487	.337†	1.0	.141
3: Psychosocial changes after ABI	1	7	15	.010	.750‡	1.0	.101
4: Wounds/lines/drains/airways	0	2	2	1.0	.316†	.547	.234
5: Tracheostomy care	*	1	1	*	*	*	*
6: Goal setting and rehabilitation importance	3	8	16	.026	.674‡	.532	.229
7: Discharge planning	1	7	11	.010	.750‡	.201	.287
8: Patient/family centred care	2	8	17	.007	.775‡	.567	.184
9: Diagnosis/illness/injury	1	6	16	.041	.630‡	.616	.108
10: Medical procedures/treatments	1	1	7	1.0	1.0‡	.364	.243
11: Safety	1	8	10	.001	.882‡	.026	.459†
12: Activity/mobility	0	7	8	.001	.882‡	.043	.417†
13: Self-care ADLs within the ward	1	7	6	.010	.750‡	.030	.500‡
14: Pain management	0	3	1	.200	.480†	.091	.395†
15: Medication management	0	0	5	*	*	.280	.309†
16: Equipment use	1	8	9	.001	.882‡	.115	.410†
Goal setting
1: Patient has commenced goals setting within 48 hours of admission [11]	8	8	14	*	*	.277	.287
2: Goal-based planning meeting has taken place [11, 26] (within 2 weeks of admission)	0	8	13	.0001§	1.0‡	.142	.365†
Medical management
1: Family / caregivers trained in the medical management plans for paretic upper limbs during transfers, hypersensitivity, and neurogenic pain are in place [26]	1	4	2	.143	.730‡	*	*
2: Benzodiazepines and Neuroleptic antipsychotics use minimised [10]	4	6	14	.608	.189	1.0	.030
3: Medication for Executive Dysfunction follows recommended guidelines [26]	*	*	0	*	*	*	*
4: Medication for management of memory is in place [26]	*	*	0	*	*	*	*
5: Stimulants are prescribed for management of memory as appropriate [26]	*	*	0	*	*	*	*
6: Medication for Arousal and Attention is prescribed appropriately [26,40]	2	2	0	*	*	*	*
7: Pain management plans are regularly reviewed [26]	7	8	19	*	*	*	*
8: Medical management plans for paretic upper limbs during transfers, hypersensitivity, and neurogenic pain are in place [26]	2	4	6	.429	.471†	1.0	.239
9: Appropriate medication management of agitation/ aggression is in place [26,40]	3	3	4	*	*	.500	.378†
10: Appropriate medication management of spasticity is in place [10,40,43]	0	3	5	.100	1.0‡	*	*
11: Appropriate medication management of mood and seizures is in place [26]	1	3	18	.400	.612‡	*	*
Medical records
1: All invasive procedures are documented in accordance with hospital policies [Hospital policy]	1	8	20	.001	.882‡	*	*
2: Records only contain accurate statements of fact or clinical judgement [41]	7	8	20	1.0	.258	*	*
3: Records only contain abbreviations which are accepted and commonly known [Hospital policy]	4	8	20	.077	.577‡	*	*
Minimally conscious care
1: Patients in a Coma, Vegetative and Minimal Conscious State are screened using a consistent assessment of recovery [40]	*	1	1	*	*	*	*
2: The Coma Recovery Scale -Revised has been administered consistently [40]	*	1	1	*	*0	*	*
3: Multisensory stimulation for patient in a coma or vegetative state is not carried out as an intervention [40]	*	1	1	*	*	*	*
Safety
1: During the past week, the patient was sitting out of bed on morning of observation before 8am [Model of care recommendation]	0	4	13	.467	.408†	.359	.265
2: Safe diet strategies are in place [Model of care recommendation]	7	8	19	1.0	.258	*	*
3: Safe diet strategies are followed [Model of care recommendation]	7	8	19	1.0	.258	*	*
4: During the past week, the patient was sitting out of bed for all meals [Model of care recommendation]	2	4	14	1.0	.333†	.576	.167
5: All patients are screened for their fall risk as soon as practicable after admission [hospital policy]	*	8	20	*	*	*	*
6: All patients are screened for their pressure injury/sore risk as soon as practicable after admission [hospital policy]	*	8	20	*	*	*	*
7: All staff working with patients can identify safe transferring strategies [43]	8	8	20	*	*	*	*
Personal care regime
1: Maximum privacy during use of the toilet at all times [Model of care recommendation]	*	4	10	*	*	*	*
2: All patients will have showers at a regular time each day consistent with their pre-injury showering time [Model of care recommendation] [medical notes]	0	4	10	.200	1.0‡	*	*
3: Patient personal care regimes are documented to ensure consistency between staff & with the aim of maximising independence [Model of care recommendation]	6	6	15	*	*	1.0	.000
4: All patients have a personalised toileting regime in place, at a regular time each day [Model of care recommendation]	1	0	2	1.0	.189	1.0	.222
5: All patients will have showers at a regular time each day consistent with their pre-injury showering time [Model of care recommendation] [ask patient]	1	5	14	.103	.577‡	.557	.195
Post traumatic amnesia management
1: The Westmead PTA Scale (WPTAS) is commenced within 24 hours of emerging from coma and used to assess all patients following closed TBI [45]	2	2	1	*	*	*	*
2: The Orientation Log (O-Log) is commenced within 24 hours of emerging from coma for all other neurological patients (open TBI, stroke, hypoxic brain injury) [45]	*	*	1	*	*	1.0	1.0‡
3: The WPTAS /O-Log is administered by a consistent member of appropriately trained staff. (Clinical guidelines) [45]	1	4	8	.333	.632‡	.516	.333†
4: The WPTAS/O-Log is administered at a consistent time each day [Model of care recommendation]	0	4	10	.067	1.0‡	1.0	.218
5: Patients in PTA receive goal-oriented and procedural therapy (no new learning) [45]	4	5	4	*	*	1.0	.333†
Roles and responsibilities
1: Roles and responsibilities for the implementation of the patient’s care are in place for family/caregivers and have been discussed with family [Model of care recommendation]	0	5	8	.008	1.0‡	.261	.358†
2: Roles and responsibilities for the implementation of the patient’s care are followed by the family/informal caregivers [Model of care recommendation]	4	5	9	*	*	.542	.255
3: Patient and/or their families/ informal caregivers are involved in the provision of patient care [Model of care recommendation]	5	6	11	*	*	1.0	.171
4: Roles and responsibilities for the implementation of the patient’s care are in place for family/informal caregivers [Model of care recommendation]	0	7	12	.001	.882‡	.214	.266
5: Roles and responsibilities for the implementation of the patient’s care are followed by the family/informal caregivers [Model of care recommendation]	0	7	12	.0001§	1.0‡	.273	.303†
6: Patient and/or their families/ informal caregivers are involved in the provision of patient care as much as they wish [26]	5	8	19	.200	.480†	1.0	.122
Therapy
1: All appropriate patients are screened by a speech and language therapist within 48 hours of admission [26]	7	8	18	*	*	.577	.175
2: Seating plans are communicated with the family/informal caregivers [Model of care recommendation]	1	4	5	*	*	*	*
3: A therapy timetable is in place for each patient [Model of care recommendation]	7	8	18	1.0	.258	1.0	.127
4: Therapy is provided in the appropriate context for the individual [Model of care recommendation]	1	8	20	.200	.667‡	*	*
5: Learning and memory aids are in place in patient's room [Model of care recommendation]	5	8	19	.200	.419†	1.0	.122
6: Management of motor function and control is in place and follows evidenced based guidelines [10,11,25,26]	0	7	14	.001	.882‡	1.0	.000
7: Therapy is provided in the appropriate context for the individual [26, 42]	1	8	20	.003	.861‡	*	*
8: Leisure and recreation activities are included in the patient's weekly program [26, 42]	4	2	10	.608	.258	.236	.254
9: Seating needs are assessed within the required timeframe [Model of care recommendation]	4	8	20	.077	.535‡	*	*
10: Seating plans are followed by all staff. [Model of care recommendation]	1	7	12	.010	.837‡	*	*
11: Patients with a visual impairment have been assessed as per guidelines [10,11,25,26,40,43,44]	0	4	6	.167	.632‡	1.0	.000
12: Patients received a minimum of 4 hours of therapy per day at least 5 days a week in the past week [Model of care recommendation]	0	2	3	.467	.378†	1.0	.098
13: There is documented evidence that patients have received therapy from at least 3 different professions during the past week [Model of care recommendation]	6	8	19	.467	.378†	1.0	.122
14: Effective treatment approaches for rehabilitation are in place and embedded in daily life activities [10]	4	7	10	.282	.405†	.190	.330†
15: Learning and memory aids are in place and documented [42, 45]	3	7	20	.070	.632‡	*	*
16: If ‘15’ Is Yes: Patient is trained in the use of one, single external aid to compensate for memory impairments [Model of care recommendation]	2	6	18	.103	.537‡	1.0	.150
17: Errorless learning approach / scripts are documented [Model of care recommendation]	0	2	8	.091	.632‡	1.0	.060
18: Interventions addressing poor executive functioning are in place [45]	1	1	0	.250	.655‡	.167	1.0‡
19: Repetition of computer based tasks are not carried out unless additional cognitive rehabilitation strategies are used [45]	3	2	7	*	*	*	*
20: Staff are aware of seating plan [Model of care recommendation]	4	7	19	.192	.461†	*	*
Ward round
1: Documented evidence of that the weekly ward round includes ANUM and the patient nurse in addition to RMO/Resident and rehabilitation physician [41]	2	0	0	.467	.378†	*	*
2: Documented evidence of the weekly ward round records nursing dependency data [Model of care recommendation]	*	*	1	*	*	1.0	.122
3: Documented evidence that ward rounds are taken to each patient (inclusive of therapy spaces) [Model of care recommendation]	0	8	20	.0001§	1.0‡	*	*
4: Documented evidence that weekly ward rounds include discussion of: basic care needs, specialised nursing needs, dependency on nursing time for common tasks, and influences on dependency [41]	*	*	1	*	*	1.0	.122

* = Unable to compute as some items responses are ‘not applicable’

† = medium effect size[41]

‡ = large effect size[41]

§ statistically significant at the Bonferroni adjusted p-value 0.000217