Using Nursing Assessments of Mobility and Activity to Prioritize Patients Most Likely to Need Rehabilitation Services.

OBJECTIVE: To identify nursing assessments of mobility and activity associated with lower-value rehabilitation services. DESIGN: Retrospective cohort analysis of admissions from December 2016 to September 2019 SETTING: Medicine, neurology, and surgery units (n=47) at a tertiary hospital. PARTICIPANTS: We included patients with a length of stay ≥7 days on units that routinely assessed patient function (n=18,065 patients). INTERVENTIONS: Not applicable. MAIN OUTCOME: We examined the utility of nursing assessments of function to identify patients who received lower-value rehabilitation consults, defined as those who received ≤1 therapy visit. MEASURES: Patient function was assessed using 2 Activity Measure for Post-Acute Care (AM-PAC or "6 clicks") inpatient short forms: (1) basic mobility (eg, bed mobility, walking) and (2) daily activity (eg, grooming, toileting). RESULTS: Using an AM-PAC cutoff value of ≥23 correctly identified 92.5% and 98.7% of lower-value physical therapy and occupational therapy visits, respectively. In our cohort, using a cutoff value of ≥23 on the AM-PAC would have eliminated 3482 (36%) of lower-value physical therapy consults and 4076 (34%) of lower-value occupational therapy consults. CONCLUSIONS: Nursing assessment, using AM-PAC scores, can be used to help identify lower-value rehabilitation consults, which can then be reallocated to patients with greater rehabilitation needs. Based on our results, an AM-PAC cutoff value of ≥23 can be used as a guide to help prioritize patients with greater rehabilitation needs.

The Johns Hopkins Activity and Mobility Promotion Program: A Framework to Increase Activity and Mobility Among Hospitalized Patients.

BACKGROUND: Greater mobility and activity among hospitalized patients has been linked to key outcomes, including decreased length of stay, increased odds of home discharge, and fewer hospital-acquired morbidities. Systematic approaches to increasing patient mobility and activity are needed to improve patient outcomes during and following hospitalization. PROBLEM: While studies have found the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program improves patient mobility and associated outcomes, program details and implementation methods are not published. APPROACH: JH-AMP is a systematic approach that includes 8 steps, described in this article: (1) organizational prioritization; (2) systematic measurement and daily mobility goal; (3) barrier mitigation; (4) local interdisciplinary roles; (5) sustainable education and training; (6) workflow integration; (7) data feedback; and (8) promotion and awareness. CONCLUSIONS: Hospitals and health care systems can use this information to guide implementation of JH-AMP at their institutions.

Activities of Daily Living Assessment Early in Hospitalization Is Associated With Key Outcomes.

IMPORTANCE: Assessing patients' activities of daily living (ADLs) function early in hospitalization may help identify patients at risk for poor outcomes. OBJECTIVE: To investigate the association between patients' ADL function at hospital admission and length of stay, inpatient falls, hospital-acquired pressure injuries, and discharge disposition. DESIGN: Retrospective cohort study using scores collected on the Activity Measure for Post-Acute Care Inpatient Activity Short Form (AM-PAC IASF) in routine care at admission. SETTING: Two inpatient units at the Johns Hopkins Hospital. PARTICIPANTS: Hospitalized patients with various diagnoses, including neurosurgical, stroke, and general neurology (N = 1,899). RESULTS: People with lower AM-PAC scores (every 10-point difference) had increased odds (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.4-1.8) of being in the highest length-of-stay quartile (≥8 days), having an injurious fall (OR = 1.7; 95% CI = 1.3-2.2), acquiring a pressure injury (OR = 2.7; 95% CI = 1.5-5.3), and being discharged to a postacute care facility (OR = 3.02; 95% CI = 2.1-2.7). CONCLUSIONS AND RELEVANCE: Greater functional impairments in ADLs, measured with the AM-PACS IASF, were significantly associated with worse outcomes. AM-PAC IASF scores may be useful in identifying patients with ADL deficits and targeting occupational therapy services for patients who are at higher risk for negative outcomes. What This Article Adds: Early assessment of ADL function in routine care of hospitalized patients may aid in treatment and care plan decisions, particularly for inpatients who may be at higher risk for adverse outcomes.

Using Systematic Functional Measurements in the Acute Hospital Setting to Combat the Immobility Harm.

Hospitalized patients often experience unnecessary immobility and inactivity leading to direct harms and poor outcomes. Despite growing evidence that early and regular mobility and activity are safe and helpful for patients in the hospital, there remains substantial room for improvement in clinical practice. Key to improvement is establishing an interdisciplinary approach to measurement and communication using a common language of function. Here we provide a framework for systematic functional measurement in the hospital. We also provide 3 specific examples of how this framework has been used to improve care: (1) targeting specialized rehabilitation providers to the patients most likely to need their services, (2) generating a daily mobility goal for all patients, and (3) identifying patients early who are likely to require postacute care.

Precision Rehabilitation: Optimizing Function, Adding Value to Health Care.

Precision medicine efforts are underway in many medical disciplines; however, the power of precision rehabilitation has not yet been explored. Precision medicine aims to deliver the right intervention, at the right time, in the right setting, for the right person, ultimately bolstering the value of the care that we provide. To date, precision medicine efforts have rarely focused on function at the level of a person, but precision rehabilitation is poised to change this and bring the focus on function to the broader precision medicine enterprise. To do this, subgroups of individuals must be identified based on their level of function via precise measurement of their abilities in the physical, cognitive, and psychosocial domains. Adoption of electronic health records, advances in data storage and analytics, and improved measurement technology make this shift possible. Here we detail critical components of the precision rehabilitation framework, including (1) the synergistic use of various study designs, (2) the need for standardized functional measurements, (3) the importance of precise and longitudinal measures of function, (4) the utility of comprehensive databases, (5) the importance of predictive analyses, and (6) the need for system and team science. Precision rehabilitation has the potential to revolutionize clinical care, optimize function for all individuals, and magnify the value of rehabilitation in health care; however, to reap the benefits of precision rehabilitation, the rehabilitation community must actively pursue this shift.

Increasing patient mobility through an individualized goal-centered hospital mobility program: A quasi-experimental quality improvement project.

BACKGROUND: Hospital-acquired functional decline due to decreased mobility has negative impacts on patient outcomes. Current nurse-directed mobility programs lack a standardized approach to set achievable mobility goals. PURPOSE: We aimed to describe implementation and outcomes from a nurse-directed patient mobility program. METHOD: The quality improvement mobility program on the project unit was compared to a similar control unit providing usual care. The Johns Hopkins Mobility Goal Calculator was created to guide a daily patient mobility goal based on the level of mobility impairment. FINDINGS: On the project unit, patient mobility increased from 5.2 to 5.8 on the Johns Hopkins Highest Level of Mobility score, mobility goal attainment went from 54.2% to 64.2%, and patients exceeding the goal went from 23.3% to 33.5%. All results were significantly higher than the control unit. DISCUSSION: An individualized, nurse-directed, patient mobility program using daily mobility goals is a successful strategy to improve daily patient mobility in the hospital.

Development and Implementation of a New Model of Care for Patients With Stroke, Acute Hospital Rehabilitation Intensive SErvices: Leveraging a Multidisciplinary Rehabilitation Team.

ABSTRACT: The optimal timing and intensity of early rehabilitation remain uncertain. The literature has stated that too early high-intensity mobility within 24 hours can result in poor outcomes as compared with the 24- to 48-hour poststroke (Stroke 2012;43:2389-94. Stroke 2004;35:1005-9). However, few studies have shown that mobilizing patients a few times per day can have positive results (Stroke 2004;35:1005-9. Cerebrovasc Dis 2010;29:352-60). In addition to mobility impairments, many patients after stroke have dysphagia, aphasia, and cognitive-linguistic deficits. To date, there is limited literature on early rehabilitation in these areas. Here, we describe a program of enhanced rehabilitation in the acute care hospital. In this enhanced model of care, our team delivers up to six sessions of therapy per day focused on the patient's deficits. A patient can receive up to two sessions of each discipline daily to include physical therapy, occupational therapy, and speech language pathology. The model emphasizes team collaboration between therapy disciplines, physiatry, nursing, and neurology accomplished through a daily therapy schedule, rehabilitation huddle, and direct communication before and after therapy sessions. With this model, we aim to enhance coordination of care resulting in improved patient satisfaction and, ultimately, recovery.

Feasibility of an Enhanced Therapy Model of Care for Hospitalized Stroke Patients.

INTRODUCTION: The aim of this study was to determine the safety and feasibility of an enhanced therapy model for hospitalized stroke patients. METHODS: This was a quasi-experimental cohort study of acute stroke patients from a single hospital. In the intervention group, all hospitalized patients on the acute stroke service were seen by at least two therapy disciplines daily in addition to routine stroke care. The comparison group consisted of all patients admitted to the same stroke service 1 year before who received the standard of care. The primary endpoint was the number of completed therapy sessions. Exploratory endpoints compared the length of hospital stay, hospital readmission rates, and degree of disability measured by the 90-day modified Rankin Scale score. RESULTS: A total of 1110 records were analyzed with 553 subjects in the intervention group and 557 in the control group. The intervention group received a significantly higher number of therapy sessions. There was no significant difference in length of hospital stay. However, 30-day readmission rates were lower, and the percentage of patients who achieved a good functional outcome on the modified Rankin Scale was higher during the intervention period. CONCLUSION: Increasing exposure to intensive multidisciplinary therapy comparable with that of acute inpatient rehabilitation in the hospital setting is feasible and may reduce both readmission rates and disability.

Development and Implementation of a Standard Assessment Battery Across the Continuum of Care for Patients After Stroke.

ABSTRACT: Stroke rehabilitation occurs across the continuum of care starting in the acute hospital and through the inpatient and outpatient settings. Rehabilitation aims to minimize impairments and maximize function in individuals after stroke. Because patients often undergo rehabilitation for extended periods, longitudinal assessment of impairment, activity, and participation can facilitate the evaluation of patients' progress toward recovery, as well as communication and decision making to guide clinical practice regarding the intervention(s) to be used and may also be leveraged for clinical research. However, the clinical implementation of a standard assessment battery that spans the continuum of care for patients after stroke is challenging because of operational and time constraints. Here, we describe the development and implementation of a standard assessment battery across the continuum of care by physical therapists, occupational therapists, and speech-language pathologists at the Sheikh Khalifa Stroke Institute. We specifically describe our experience in (1) identifying the core team to lead the process, (2) selecting the measures for the standard assessment battery, and the timeframe for administration, and (3) implementing the standard assessment battery in routine clinical practice.

A Learning Health System Infrastructure for Precision Rehabilitation After Stroke.

ABSTRACT: Functional recovery and the response to rehabilitation interventions after stroke are highly variable. Understanding this variability will promote precision rehabilitation for stroke, allowing us to deliver targeted interventions to the right person at the right time. Capitalizing on large, heterogeneous data sets, such as those generated through clinical care and housed within the electronic health record, can lead to understanding of poststroke variability. However, accessing data from the electronic health record can be challenging because of data quality, privacy concerns, and the resources required for data extraction. Therefore, creating infrastructure that overcomes these challenges and contributes to a learning health system is needed to achieve precision rehabilitation after stroke. We describe the creation of a Precision Rehabilitation Data Repository that facilitates access to systematically collected data from the electronic health record as part of a learning health system to drive precision rehabilitation. Specifically, we describe the process of (1) standardizing the documentation of functional assessments, (2) obtaining regulatory approval, (3) defining the patient cohort, and (4) extracting data for the Precision Rehabilitation Data Repository. The development of similar infrastructures at other institutions can help generate large, heterogeneous data sets to drive poststroke care toward precision rehabilitation, thereby maximizing poststroke function within an efficient healthcare system.

Implementation of a Framework for Telerehabilitation in Clinical Care Across the Continuum During COVID-19 and Beyond.

ABSTRACT: The COVID-19 pandemic has propelled an unprecedented global implementation of telemedicine and telerehabilitation as well as its integration into the healthcare system. Here, we describe the clinical implementation of the A3E framework for the deployment of telerehabilitation in the inpatient and outpatient rehabilitation continuum by addressing accessibility, adaptability, accountability, and engagement during the COVID-19 pandemic. By using an organized, coordinated, and stratified approach, we increased our telerehabilitation practice from 0 to more than 39,000 visits since the pandemic began. Learning from both the successes and challenges can help address the need to increase access to rehabilitation services even beyond the COVID-19 pandemic.

Key Data Elements for Longitudinal Tracking of Physical Function: A Modified Delphi Consensus Study.

OBJECTIVE: Physical function is associated with important outcomes, yet there is often a lack of continuity in routine assessment. The purpose of this study was to determine data elements and instruments for longitudinal measurement of physical function in routine care among patients transitioning from acute care hospital setting to home with home health care. METHODS: A 4-round modified Delphi process was conducted with 13 participants with expertise in physical therapy, health care administration, health services research, physiatry/medicine, and health informatics. Three anonymous rounds identified important and feasible data elements. A fourth in-person round finalized the recommended list of individual data elements. Next, 2 focus groups independently provided additional perspectives from other stakeholders. RESULTS: Response rates were 100% for online rounds 1, 3, and 4 and 92% for round 2. In round 1, 9 domains were identified: physical function, participation, adverse events, behavioral/emotional health, social support, cognition, complexity of illness/disease burden, health care utilization, and demographics. Following the fourth round, 27 individual data elements were recommended. Of these, 20 (74%) are "administrative" and available from most hospital electronic medical records. Additional focus groups confirmed these selections and provided input on standardizing collection methods. A website has been developed to share these results and invite other health care systems to participate in future data sharing of these identified data elements. CONCLUSION: A modified Delphi consensus process was used to identify critical data elements to track changes in patient physical function in routine care as they transition from acute hospital to home with home health. IMPACT: Expert consensus on comprehensive and feasible measurement of physical function in routine care provides health care professionals and institutions with guidance in establishing discrete medical records data that can improve patient care, discharge decisions, and future research.

The physical therapist informatician as an enabler of capacity in a data-driven environment: an administrative case report.

Background and purpose: Many professions including nursing and medicine have developed subspecialties in the field of clinical informatics to assist in the management of patient outcomes. This report describes the development of a physical therapist-informatician (PT-I) that occurred concurrently with the introduction of an electronic health record (EHR). Case description: A physical therapist supervisor participated in professional development to become a full-time PT-I within the Department of Physical Medicine and Rehabilitation (DPMR) of an academic medical center. Cycles of needs assessment and gap analysis produced a nimble process that evolved to meet a shifting environment and to incorporate lessons learned. Outcomes: The development of a full-time PT-I enabled the DPMR to become the stewards of mobility data across the enterprise. The benefits that accrued, as a result, included enhanced success of EHR adoption, decreased revenue loss, and actionable, meaningful data use. Discussion: Having a PT-I facilitate the adoption of informatics into DPMR culture enabled participation in enterprise-level EHR optimization. Standardized data from the EHR was used to improve the performance of clinicians throughout the hospital. The field of physical therapy could benefit from a targeted use of informatics to articulate the EHR workflow and data needs.

Prediction of Disposition Within 48 Hours of Hospital Admission Using Patient Mobility Scores.

Delayed hospital discharges for patients needing rehabilitation in a postacute setting can exacerbate hospital-acquired mobility loss, prolong functional recovery, and increase costs. Systematic measurement of patient mobility by nurses early during hospitalization has the potential to help identify which patients are likely to be discharged to a postacute care facility versus home. To test the predictive ability of this approach, a machine learning classification tree method was applied retrospectively to a diverse sample of hospitalized patients (N = 761) using training and validation sets. Compared with patients discharged to home, patients discharged to a postacute facility were older (median, 64 vs 56 years old) and had lower mobility scores at hospital admission (median, 32 vs 41). The final decision tree accurately classified the discharge location for 73% (95% CI, 67%-78%) of patients. This study emphasizes the value of systematically measuring mobility in the hospital and provides a simple decision tree to facilitate early discharge planning.

Study protocol for targeted interventions to prevent chronic low back pain in high-risk patients: A multi-site pragmatic cluster randomized controlled trial (TARGET Trial).

BACKGROUND: Low back pain (LBP) is one of the most prevalent and potentially disabling conditions for which people seek health care. Patients, providers, and payers agree that greater effort is needed to prevent acute LBP from transitioning to chronic LBP. METHODS AND STUDY DESIGN: The TARGET (Targeted Interventions to Prevent Chronic Low Back Pain in High-Risk Patients) Trial is a primary care-based, multisite, cluster randomized, pragmatic trial comparing guideline-based care (GBC) to GBC + referral to Psychologically Informed Physical Therapy (PIPT) for patients presenting with acute LBP and identified as high risk for persistent disabling symptoms. Study sites include primary care clinics within each of five geographical regions in the United States, with clinics randomized to either GBC or GBC + PIPT. Acute LBP patients at all clinics are risk stratified (high, medium, low) using the STarT Back Tool. The primary outcomes are the presence of chronic LBP and LBP-related functional disability determined by the Oswestry Disability Index at 6 months. Secondary outcomes are LBP-related processes of health care and utilization of services over 12 months, determined through electronic medical records. Study enrollment began in May 2016 and concluded in June 2018. The trial was powered to include at least 1860 high-risk patients in the randomized controlled trial cohort. A prospective observational cohort of approximately 6900 low and medium-risk acute LBP patients was enrolled concurrently. DISCUSSION: The TARGET pragmatic trial aims to establish the effectiveness of the stratified approach to acute LBP intervention targeting high-risk patients with GBC and PIPT. TRIAL REGISTRATION: ClinicalTrials.govNCT02647658 Registered Jan. 6, 2016.

Classroom attention in children with type 1 diabetes mellitus: the effect of stabilizing serum glucose.

OBJECTIVE: To determine whether stabilizing serum glucose, via introduction of an insulin pump, improves classroom attention among children with type-1 diabetes mellitus. STUDY DESIGN: Four boys having type-1 diabetes mellitus with unstable serum glucose were observed in their classroom for 10 baseline days. An insulin pump was placed and serum glucose stabilized, and they were then observed again for 10 days. A modified multiple baseline design was used to determine if improved on-task and off-task behavior was associated with better glycemic control. Rating scales and a laboratory measure of attention, measures of secondary interest, were also administered before and after pump introduction, and potential improvement in individuals' scores was evaluated. RESULTS: All boys had apparent improvement in on-task and off-task behavior as observed in their classrooms. Improvements were substantial, averaging 20% in on-task behavior and 34% in off-task behavior. However, no changes were detected on rating scales or laboratory measures. CONCLUSION: This study offers preliminary evidence that stabilizing serum glucose improves classroom attention, although the effect was detected only by observation of classroom behavior using highly structured techniques. Consequently, use of direct observation techniques may be important in studying the effects of chronic illness on classroom functioning.