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Toronto Rehab improves return to driving process for patients

Outpatient David Li in driving simulator
Outpatient David Li uses the STISIM Drive to practice his driving skills. (Photo: UHN)

Jennifer Walmsley came to Toronto Rehab after suffering a brain aneurysm. She could still talk and walk but had balance issues and weakness on her left side, and her short-term memory had been impacted.

It wasn't until she arrived at Toronto Rehab's Brain and Spinal Cord Rehabilitation Program that she first learned her driver's license had been suspended because of the aneurysm.

"I was distraught. I had lost so much," recalled Jennifer, who is now 62 and nearly 10 years post brain aneurysm.

"If I couldn't drive, my independence would be gone. I wouldn't be able to get groceries, or easily go see a friend. I'd have to depend on others. I desperately wanted to drive again."

In Ontario, if a patient is impaired from safely driving because of a stroke, brain injury or other medical condition such as seizures or a heart condition, legislation mandates that the physician must report the individual to the Ministry of Transportation (MTO). Following this report, the patient's licence will be suspended by the MTO until they are assured that the patient is medically fit to drive again.

In order to regain their driver's license, some patients may be required to undergo a functional assessment of their driving ability, including an on-road test, at a MTO-approved driving rehabilitation centre. These functional assessments cost the patient approximately $600 and are not covered by OHIP.

After a great deal of practice and support from her family and the Toronto Rehab staff, Jennifer tested to have her licence back and passed.

"It was impossible not to sweat during the test," said Jennifer. "I had to relearn so many things in order to drive again and getting back my driver's licence was a big milestone."

Licence suspension can be second trauma for patient

In Toronto Rehab's Brain and Spinal Cord Rehabilitation Program, nearly all of its inpatients and many of its outpatients have a suspended driver's licence due to their medical status. Many first learn about their licence suspension upon arrival to rehabilitation.

"For some people, losing their license is a second trauma," said Dr. Alex Lo, Physiatrist, Brain and Spinal Rehabilitation Program. "It comes at a time when they are already under significant stress."

Dr. Mark Bayley, Medical Director, Brain and Spinal Rehabilitation Program, adds, "patients will be confused because they have a perfect driving record and have difficulty accepting that their driving status is changed because of their health."

The need for a better return to driving process at Toronto Rehab

A year ago, the Program received a patient complaint about the return to driving process, which sparked the interprofessional team to examine the process across its multiple inpatient units and outpatient rehab programs. They found inconsistencies in terms of how and when patients were told about their licence being reported to the MTO; variation in the return to driving assessments administered by the occupational therapists (OT); and inadequate patient education on why this is happening, the role of their care team and the process involved to regain one's licence.

"The team also realized that patients often believe that physicians have the power to give them back their licence," said Dr. Bayley. "We needed specific education on the role of their doctors, therapists and the Ministry of Transportation."

The Program team undertook a quality improvement initiative using Lean process improvement methods to map out the patient experience from when they arrive to when they leave. It was determined there was significant variation in the quality of information and how the return to driving process was communicated across the Program.

Bringing the interprofessional team together ensured a formalized and coordinated approach moving forward. Now patients are told consistently upon arrival about their license being reported; it's charted in their patient record; they are provided with a new patient education brochure that was createdin partnership with Patient and Family Education to help guide the patient and their family through the process; and the occupational therapists provide consistent assessments to help determine readiness for the MTO driving test.

The new consistent approach is better preparing patients

"The assessments can sometimes put in context for the patient whether or not they are ready to take the test yet," explained Jacqualyn Davies, OT, Outpatient Neuro Day Hospital.

Jacqualyn and her colleagues take patients through a battery of assessments including, for example, a walking test, cognitive screens (tests for alternating attention spans), and a test to gauge reaction time. She also sometimes uses a driving simulator (called the STISIM Drive) that helps patients practice and provides the OTs an opportunity to observe driving skills.

David Li, who is 25 and suffered a traumatic brain injury after a fall in October 2016, is working with Jacqualyn to regain his licence. The driving simulator is part of his treatment.

David Li, outpatient, uses the STISIM Drive to practice his driving skills.(Video: UHN)
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"After my fall, I learned how to walk and hopefully one day I can regain my licence," said David, a computer science student at The University of Toronto. "I feel like it's probably necessary for them to test me again just in case something from the fall has modified some parts of my brain that I wouldn't notice."

The team has seen improvement in the return to driving process for patients. By providing the information sooner, they're lowering the patient's stress and giving them time to understand the process and plan transportation in the short term.

"Driving is an area where we're trying to protect individuals in society," said Dr. Bayley. "We also want to support our patients and their families the best we can by helping them regain a quality of life."

The physiatry resident physicians and occupational therapists who worked together to create the new return to driving process include: Brianna Bourne,  Andrea Calvet, Ida Cavaliere, Kelly Dosktrovsky, Jacqualyn Davies, Hamed Ghotbi, Robert Hastings, Debbie Hebert, Pamela Joseph, Geoff Law, Shannon Macdonald, Edith Ng, Chris Pita, and Susan Varughese.​

The new Return to Driving education material ​is available online and can be shared with patients across UHN.

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