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QI Project Physical Therapy and Patient Discharge

QI Project Physical Therapy and Patient Discharge. Stephanie Cauble, Michelle Griffith, Natasha Magnuson, Jessica Moss, Bridget Ory, and Robert Valet April 26, 2007 Internal Medicine Residents Ambulatory Rotation. The Patient.

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QI Project Physical Therapy and Patient Discharge

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  1. QI ProjectPhysical Therapy and Patient Discharge Stephanie Cauble, Michelle Griffith, Natasha Magnuson, Jessica Moss, Bridget Ory, and Robert Valet April 26, 2007 Internal Medicine Residents Ambulatory Rotation

  2. The Patient • 47 year old female with poorly controlled diabetes admitted with a foot ulcer to the plastic surgery service on 2/12 • Debrided on day 4 • Dermal substitute placed on day 8 • Tx MICU on day9 • Course was complicated by ARF, N/V and delirium

  3. Physical Therapy • Plastics mandated that she be “No weight bearing” • PT was consulted on admission, but no note appeared in the chart. • PT re-consulted with transfer to Morgan • However, she had recurrent N/V and often wasn’t feeling well enough for PT • Unclear how often she was receiving PT as no notes in electronic chart, but assumption was she was being seen by PT • Ultimately, discharged was complicated and delayed.

  4. Web Link for Resources: www.ihi.org/ihi/sitemap.aspx

  5. Benson RT, Drew JC, Galland RB. A waiting list to go home: an analysis of delayed discharges from surgical beds. Ann R Coll Surg Engl. 2006 Nov;88(7):650-2. • Nine of 75 patients (12%) had discharge delays • They occupied 35% of the total 'bed-days' of the group • Median in-patient stay of 41 days compared with 2 days for the other patients

  6. Graf, Carla. Functional Decline in Hospitalized Older Adults: It's often a consequence of hospitalization, but it doesn't have to be. American Journal of Nursing. 2006 Jan:106(1):58-67. • Hospitalization in older adults leads to a "cascade to dependency" • Nearly one-third of hospitalized patients 70 years old and older showed a decline in ADLs upon discharge • Routine walking schedules, activities to prevent sensory deprivation, and timely hospital discharge can help prevent functional decline.

  7. Barriers to discharge and appropriate patient care • Poor lines of communication between medical staff and PT staff • Misconceived notion that PT was following pt when they were not • Unable to refer initially because no PT note in chart, this delayed referral and delayed finding out that insurance denied request.

  8. FISHBONE DIAGRAM: FOR THE OBVIOUS REASON

  9. Resident Education • Goals • Increase housestaff knowledge of services provided by PT/OT • Improve housestaff skills for communicating effectively with PT/OT • Serve patients more effectively • Enhance the interdisciplinary team • Increase efficiency of discharge planning

  10. Gaps in Resident Knowledge • Content Knowledge • Indications of PT and/or OT needs in a patient • Equipment for patient discharge • Acceptance criteria for care facilities/services • “skilled” needs criteria • Procedural Knowledge • Do you want evaluation for placement, treatment, or both? • Effective ways to communicate with PT/OT

  11. Learning Opportunities • PGY-1s visit PT/OT at the VA during ambulatory rotation • Could include placement criteria with educational materials • Inpatient monthly orientation • Add inpatient rehab services pager to our resource card • Cover hints for ordering PT/OT consult • Review key placement criteria

  12. Helpful Hints • Entering consult: include anticipated length of stay or timeframe for discharge, placement eval vs. treatment concern in comments • PT/OT brief notes may currently appear in paper chart well in advance of StarPanel- check it • Keeping in touch: the magic pager 835-1147 or through charge nurse

  13. Not just urban legend... • Inpatient rehab e.g. Stallworth • pt must tolerate 3 hours of therapy • Medicare patients may be allowed 10 days to work up to that if PT/OT thinks it's reasonable • Skilled Nursing Facility • OT needs alone won't qualify; PT needed • other skilled needs: IV abx, new feeding tubes, stage III or IV ulcer • 3 days in hospital required

  14. Placement Requirements (con’t) • Assisted Living Facility • Patient is paying out of pocket • Independence with transfers (and sometimes ADLs) required • Intermediate Care • Nursing home without skilled intervention • Medicaid coverage requires a 30 day hospital stay • Equipment • Central supply vs. outside vendors

  15. Current Order Options PT eval and treatment a) How often: PRN b) When to start: Routine c) For how long: 30 days d) Comments PT, OT and ST evaluation and treatment 3 click boxes for PT, OT and ST with similar default

  16. Request vs. Consult • Request • Implies a simple task that does not require full evaluation • Ex: Equipment requests • Consult • Requires evaluation, expert recommendations and treatment and consequently, more time • Ex: Discharge recommendations, inpatient treatment, recommendations for appropriate equipment and therapy for home

  17. Improvement in current order system • Separate requests and consults • Multiple choice options or free text instead of defaults. 3. Specify whether treatment and/or placement recommendations are needed by team 4. Include space for teams’ preferences, patient’s schedule limitations Ex. Dialysis MWF mornings

  18. Sample PT Request Order: Assistance Device request 1. Podus boot 2. Walker a) Needed by - ASAP - Prior to discharge b) Comments

  19. Sample Consult Order: Physical Therapy Consult a) Diagnosis requiring rehab b) Activity level • Treatment • Anticipated discharge date • How often therapy needed • Comments: include goals • Placement recommendations • Comments: Include indications and limitations.

  20. After consult placed. . .PT notes • Notes from PT/OT appear in StarPanel, but. . . --First note appears in paper chart • Problem: Would like to have all notes in one place, ideally all would be in StarPanel • When should we expect first note in StarPanel after consult placed? What if consult is placed on the weekend?

  21. What isn’t on the daily note? • Equipment needed (walker, boot, bedside commode) • Activity restrictions (actually in the note, but could be more prominent) • Clearance needed (orthopedic, wound care) • Anticipated length of treatment

  22. Where is the patient going?—dispo plans • In KPS case, notes from 3/1/07-3/7/07 from SW, medical team, and physical therapy all outline slightly different goals for discharge • Discharge recommendations from PT are of extreme importance in facilitating discharge; could these be moved to the top of the note?

  23. Recommendations for change • Activity limitations included and flagged if inappropriate • Equipment needed • Clearance needed • Include (template) explanation of the numerical scoring system • Contact number for questions

  24. Stay tuned! • Collaboration between OT /PT and the residents has resulted in some improvements already implemented, especially to the charting process. • Education of residents will be included in orientation.

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