QI ProjectPhysical Therapy and

Patient Discharge

Stephanie Cauble, Michelle Griffith, Natasha Magnuson, Jessica Moss, Bridget Ory,

and Robert Valet

April 26, 2007Internal Medicine Residents

Ambulatory Rotation

The Patient

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

Physical TherapyPlastics 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 MorganHowever, she had recurrent N/V and often wasn’t feeling well enough for PTUnclear how often she was receiving PT as no notes in electronic chart, but assumption was she was being seen by PTUltimately, discharged was complicated and delayed.

What are we trying to accomplish?AIM

What are we trying to accomplish?AIM

How will we know that a change is an improvement?Data

(Tools: Surveys, Run Charts)

How will we know that a change is an improvement?Data

(Tools: Surveys, Run Charts)

What changes can we make that will result in an improvement?Process Analysis

(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)Decide on changes

What changes can we make that will result in an improvement?Process Analysis

(Tools: Flowchart, Cause & Effect Diagram, Pareto Chart, etc.)Decide on changes

IMPROVEMENT MODEL

Planthe

Improvement

Studythe

Results

Dothe

Improvement

Act

Act to keep changeor Abandon and try

another change

PDSA Cycle—Small rapid cycles of changeLangley, Nolan, et al. 1996

P

A D

SWeb Link for Resources: www.ihi.org/ihi/sitemap.aspx

What are we trying to accomplish?

Aim:

To increase the efficiency of discharging patients when physical therapy is needed.

What are we trying to accomplish?

Aim:

To increase the efficiency of discharging patients when physical therapy is needed.

How will we know that a change is an improvement?

Record delays in discharge that could have been prevented

How will we know that a change is an improvement?

Record delays in discharge that could have been prevented

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

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.

What changes can we make that will result in an improvement?

Process Analysis

What changes can we make that will result in an improvement?

Process Analysis

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.

FISHBONE DIAGRAM: FOR THE OBVIOUS REASON

Delays in Pt.Discharge

TESTS/PROCEDURES

PLACEMENT

Awaiting inpt hospice

Social work, PT, facility

NH placement (2)

Case mgrs/SWs ‘spread too thin’

Slow Stallworth evals (2)

Pt RESISTANCE

Pt resistance (2)

PHYSICAL THERAPY

PT recs don’t match attending idea of when patient can go home

PT without enough staff to see patients

quickly

Waiting on PT recs (2)

MEDS FOR D/C

Patient doesn’t have access to meds – requires car

Need help filling scripts

PICC line placed

Waiting on procedures

Waiting for labs to be drawn/

tests to be done

Waiting on lab results

Abnormal labs

Pts w/no ability to care for themselves, but no ‘skilled nursing’ needs to facilitate placement

FAMILIES

Families with multiple questions despite AM

No family member available to take home/care for

Extended family shows up day of d/c

Pt/family questions

Pt education/meds

RESIDENTTEACHING

Conferences (4)

Post-call rounds, notes, orders

Long rounding attendings

Bedside rounds (pt interrupts presentation)

MISC

Arranging home

health (2)

Home Health coordi- nating IV abx

Computer, phone availability 7N, 8N

New admissions/team size

Waiting for consult recommendations (3)

Arranging F/U for pt

INSURANCE

Insurance (waiting for approval or

will not cover) (2)

Insurance issues w/securing adequate follow-up

Different case mgrs/SWs have different levels of success

accessing resources

Patient transportation (4)

Pt ‘doesn’t feel comfortable,’

although medically stable

Discharge DelaysMedicine Residents

3.2007

Pt admitted

Will patient need

placement?

Write in admission

orders

If it is Friday or weekend, this

may not happen until

Monday

Did PT see patient

?

Note in chart or call from PT that note will

be written

PT has very long notes and

sometimes difficult to find recommendati

ons

PT may write note that

patient not available when

they came.

Patient needs PT while in

hospital

What happens then?

Recommendation made in

chart

How often patient will be

seen is not clear to MDs

Social Worker communicates

with PT for placement

Patient ready or discharge

Documentation ready for placement

?

MD or SW calls PT to see

patient

They have Bobbie’s

number and he responds very

quickly.

No anticipated LOS for triage before consult(Psych consult

has good model)

Can patient get a boot or

something simple without a full consult?

Does PT consult differ for medicine patients vs

Orthopedics?

What is difference

between OT and PT for

equipment?

Thursday, April 12, 2007

Page 1

Medicine Patients and PT and OT ConsultsInternal Medicine Residents 3/07

Issues/Questions

Call central OT/PT line and

leave message.

Don’t know if they got

message.

PT has very long notes and

sometimes difficult to find recommendati

ons

No anticipated LOS for triage before consult(Psych consult

has good model)

Can patient get a boot or

something simple without a full consult?

Pt admittedMD Writes order

for consult Did PT see

patient?

Failed attempt: PT may write

note and identify why patient not seen. PT’s note will be viewable

in StarPanel.

Recommendation made in chart

(being redesigned)

Patient ready or

discharge

Documentation ready for placement

?

MD or SW calls PT to see

patient

They have Bobby’s

number and he responds very quickly.

No anticipated LOS for triage before consult(Psych consult

has good model)

Can patient get a boot or

something simple without a

full consult?Probably not

Does PT consult differ for medicine

patients vs Orthopedics? Yes,

Ortho often has plan for OT/PT in

order set.

What is difference

between OT and PT for

equipment? They will provide brief education.

Thursday, April 12, 2007

Page 2

Medicine Patients and PT/OT ConsultsDebra Gibbs (Director) and Bobby Knight (PT) 3/07

Issues/Questions from MDs

N N

Call central OT/PT line and leave message. Don’t know if

they got message. Pager: 835-1147 or ask med recept on floor to page (they know

which PT covers)

Nsg assessment (includes

screening for potential OT/PT

or placement issues)

Positive screen triggers request

for OT/PT consult from MD (not consistently

done)

PT will do consult and write

frequency in note based on

impact on discharge, pts

functional level, rehab potential and ability to

tolerate rehab intervention.

Goal is to complete consult within 24 hours

of consult receipt.

MD reviews consult notes

and recommendation

s

Care of plan decided upon

with PT or OT issues addressed

PT will attempt to see patient

again same day, but rarely have time same day.

PT will leave note in chart or

call if they do not have time to

write note immediately.

Y

PT has very long notes and sometimes difficult to find

recommendationsThis is being redesigned.

Some confusion about activity orders: Bed rest means

absolutely no getting up. Up with assistance means

someone must help the patient get up.

Some PT consults also need clearance from Ortho. Medicine pts have a lot more issues bec of co-

morbidities.

Patients seen at VUMC who we plan on

sending to a Rehab Hospital (Nash Rehab

or Stallworth) must have OT/PT consults.

“Requests for recommendations”

are made for discharge. Consults

and request for treatments means

pts needs treatment in the hospital.

Notes from OT/PT

Patient discharged

Note: insurance requirements may vary from

needing note on the day of

discharge to within last 2

days.

Y

PT and OT typically document at the end of

the AM and PM, so notes for a daily treatment may

not be immeidately available.

What changes can we make that will result in an improvement?

Changes

What changes can we make that will result in an improvement?

Changes

Resident Education

GoalsIncrease 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

Gaps in Resident Knowledge

Content KnowledgeIndications of PT and/or OT needs in a patient

Equipment for patient discharge

Acceptance criteria for care facilities/services

“skilled” needs criteria

Procedural KnowledgeDo you want evaluation for placement, treatment, or both?

Effective ways to communicate with PT/OT

Learning Opportunities

PGY-1s visit PT/OT at the VA during ambulatory rotation

Could include placement criteria with educational materials

Inpatient monthly orientationAdd inpatient rehab services pager to our resource card

Cover hints for ordering PT/OT consult

Review key placement criteria

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

Not just urban legend...

Inpatient rehab e.g. Stallworthpt 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 FacilityOT 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

Placement Requirements (con’t)

Assisted Living FacilityPatient 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

EquipmentCentral supply vs. outside vendors

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

Request vs. Consult

RequestImplies a simple task that does not require full evaluation Ex: Equipment requests

ConsultRequires evaluation, expert recommendations and treatment and consequently, more timeEx: Discharge recommendations, inpatient treatment, recommendations for appropriate equipment and therapy for home

Improvement in current order system

1. Separate requests and consults2. 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

Sample PT Request

Order: Assistance Device request

1. Podus boot

2. Walker

a) Needed by

- ASAP

- Prior to discharge

b) Comments

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.

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 StarPanelWhen should we expect first note in StarPanel after consult placed? What if consult is placed on the weekend?

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

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?

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

PDSA CYCLEPDSA CYCLE

Planthe

Improvement

Studythe

Results

Dothe

Improvement

Act

Act to keep changeor Abandon and try

another change

PDSA Cycle—Small rapid cycles of changeLangley, Nolan, et al. 1996

P

A D

S

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.