INCREASING THE INTENSITY OF REHABILITATION FOR PATIENTS ON A SUB-ACUTE INPATIENT STROKE REHABILITATION UNIT:

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1 INCREASING THE INTENSITY OF REHABILITATION FOR PATIENTS ON A SUB-ACUTE INPATIENT STROKE REHABILITATION UNIT: Seeking Efficiencies in Scheduling of Rehabilitation Esmé French frenche@tbh.net September 26, 2017 INTRODUCTION ~ TIME IS FUNCTION Background Canadian Stroke Best Practice Recommendation: Adequate intensity of therapy essential to obtain maximum benefit ( Hebert et al., ) Higher intensity therapy associated with better outcomes & reduced length of stay ( J e t t e, W a rren & W irtalla, ) Patients receiving 3-3½ hours of therapy per day fared better than those receiving less ( W a n g e t a l., ) In Ontario, collection of rehab intensity data (time a patient spends in individual, goal-directed rehabilitation therapy) has been mandatory since April, 2015 It is a provincially recommended performance indicator of appropriate stroke rehabilitation 1

2 THE PROBLEM Current rehab intensity time in Ontario falls short of the recommendations It is approximately 1/3 of recommended time in the Quality-Based Procedures: Clinical Handbook for Stroke (Health Quality Ontario & Ontario Ministry of Health and Long-Term Care, 2016) Stroke patients should receive, via an individualized treatment plan, at least 3 hours of direct task-specific therapy per day by the interprofessional stroke team for at least 6 days per week AT FIRST GLANCE: MEASURING REHABILITATION INTENSIT Y IN ONTARIO ( ) BETH LINKEWICH, RUTH HALL, RYAN METCALFE 2

3 AT FIRST GLANCE: MEASURING REHABILITATION INTENSIT Y IN ONTARIO ( ) BETH LINKEWICH, RUTH HALL, RYAN METCALFE REHAB INTENSIT Y PROJECT TEAM Setting & Population 25 bed sub-acute inpatient neurology rehabilitation unit with patients with stroke/abi & their family/caregivers as available Project Team: Regional Stroke Rehabilitation Specialist, Unit Manager, National Rehabilitation Reporting System (NRS) Coordinator, frontline OT, PT, SLP and Rehab Assistant, former patient & family 3

4 STAFF & PATIENT ENGAGEMENT Sought staff feedback as to possible reasons why we are not achieving the 180 minutes/day of stroke rehabilitation intensity Chart paper left up in common room for 2 weeks Examples Process: Time for scheduling and updating boards Staff: Ideally more Rehab Assistant involvement in morning care Clients: Not ready for treatment Environment: much time spent clearing space in gym Policies: Rehab staff not fully replaced for absences REHAB INTENSIT Y PROJECT TEAM AIM: Maximize outcomes for patients with stroke on the inpatient rehabilitation unit GOAL: In 1 year, the amount of daily rehabilitation time that patients receive will increase by 50%, from 60 to 90 minutes. OUR QUESTION: What changes to scheduling processes contribute to increased rehabilitation time received by patients with stroke on an inpatient rehabilitation unit? 4

5 LITERATURE REVIEW - 8 ARTICLES Key Findings Technology used to support scheduling processes Designated non-clinical staff used to schedule patients rather than therapists Scheduling system must be flexible to accommodate regular changes and address individual patient characteristics and needs Access to the schedule by multiple users such as staff, patients, families and volunteers was necessary User-friendly, large, electronic visual displays were recommended Daily printouts for posting in individual patient rooms were suggested References on last slide LIT REVIEW SUMMARY Overall level of evidence was low: 1 non-randomized retrospective study, 3 quality improvement projects 4 reports from the decision support and IT sector Summary A number of efficiencies can be gained by improving upon the current state (therapists manually scheduling own patients) All studies reviewed supported the need for a local quality improvement initiative to seek scheduling efficiencies ( V e s t r i e t. a l., ; Da v id, ; Polla r d, a & b; Ruston B e r ge, ; B e ggs e t a l., ; W o o d e t. a l., ; H ua n g e t. a l., ; & Schimmelpfeng e t a l., ) 5

6 QUALIT Y IMPROVEMENT INITIATIVES Model for Improvement Approach Plan-Do-Study-Act cycles Small Tests of Change Non-clinical staff member for scheduling Electronic, centralized schedule Modified patient daily therapy schedule OT and Assistant routinely scheduled for a.m. care routine DATA COLLECTION/ANALYSIS Outcome Measure primary: rehab time; secondary: LOS, FIM efficiency Process Measure e.g. staff time spent scheduling, patient readiness for therapy, Balancing Measures e.g. patient, family/care-partner, and staff satisfaction Team will also monitor & respond to unintended consequences, and additional factors that may influence rehab time during the project e.g. staffing vacancy; competing priorities etc 6

7 WHERE WE RE AT Rehab intensity has been steadily improving since April 2015 Data quality continues to be stressed, weekly/monthly checks Outcomes reported quarterly to front line staff KEY REFERENCES D a v i d, R. ( ). A f i x e d s c h e d u l i n g s y s t e m f o r r e h a b i l i t a t i o n i n p a t i e n t s. C l i n i c a l M a n a g e m e n t I n P h y s i c a l T h e r a p y, 7 ( 6 ), H e b e r t, D., L i n d s a y, M. P., M c I n t y r e, A., K i r t o n, A., R u m n e y, P. G., B a g g, S., T e a s e l l, R. ( ). C a n a d i a n s t r o k e b e s t p r a c t i c e r e c o m m e n d a t i o n s : S t r o k e r e h a b i l i t a t i o n p r a c t i c e g u i d e l i n e s, u p d a t e I n t e r n a t i o n a l J o u r n a l o f S t r o k e, 1 1 ( 4 ), d o i : / H u a n g, Y., Z h e n g, J., & C h i e n, C. ( ). D e c i s i o n s u p p o r t s y s t e m f o r r e h a b i l i t a t i o n s c h e d u l i n g t o e n h a n c e t h e s e r v i c e q u a l i t y a n d t h e e f f e c t i v e n e s s o f h o s p i t a l r e s o u r c e m a n a g e m e n t. J o u r n a l o f t h e C h i n e s e I n s t i t u t e o f I n d u s t r i a l E n g i n e e r s, 2 9 ( 5 ), J e t t e, D. U., W a r r e n, R. L., & W i r t a l l a, C. ( ). T h e r e l a t i o n s h i p b e t w e e n t h e r a p y i n t e n s i t y a n d o u t c o m e s o f r e h a b i l i t a t i o n i n s k i l l e d n u r s i n g f a c i l i t i e s. A r c h i v e s o f P h y s i c a l M e d i c i n e & R e h a b i l i t a t i o n, 8 6 ( 3 ), H e a l t h Q u a l i t y O n t a r i o, M i n i s t r y o f H e a l t h a n d L o n g - T e r m C a r e. ( ). Q u a l i t y - b a s e d p r o c e d u r e s : c l i n i c a l h a n d b o o k f o r s t r o k e ( a c u t e a n d p o s t a c u t e ). T o r o n t o, O N : H e a l t h Q u a l i t y O n t a r i o. R e t r i e v e d f r o m h t t p : / / w w w. h q o n t a r i o. c a / e v i d e n c e / e v i d e n c e - p r o c e s s / e p i s o d e s - o f - c a r e # c o m m u n i t y - s t r o k e P o l l a r d, C. ( a ). E l e c t r o n i c s c h e d u l i n g : M a k i n g t h e m i n u t e s c o u n t. I n t e r n a t i o n a l J o u r n a l o f S t r o k e, 1 1 ( 2 S ), 7 7. P o l l a r d, C. ( b ) K n o w l e d g e e x c h a n g e i d e a : T h e u s e o f e l e c t r o n i c s c h e d u l i n g t o m a x i m i z e r e h a b i n t e n s i t y. R e t r i e v e d f r o m O n t a r i o S t r o k e N e t w o r k w e b s i t e : h t t p : / / o n t a r i o s t r o k e n e t w o r k. c a / s t r o k e - q b p - r e s o u r c e - c e n t r e / w p - c o n t e n t / u p l o a d s / s i t e s / 2 / / 0 1 / R e ha b - I n t e n s i t y - S u c c e s s - S t o r y - f r o m - H o t e l - D i e u - S h a v e r - a n d - R e h a b i l i t a t i o n - C e n t r e _ J a n u a r y p d f R u s t o n B e r g e, J. ( ). K n o w l e d g e e x c h a n g e i d e a : E l e c t r o n i c s c h e d u l i n g b o a r d. R e t r i e v e d f r o m O n t a r i o S t r o k e N e t w o r k w e b s i t e : h t t p : / / o n t a r i o s t r o k e n e t w o r k. c a / s t r o k e - q b p - r e s o u r c e - c e n t r e / w p - c o n t e n t / u p l o a d s / s i t e s / 2 / / 0 1 / R e h a b - I n t e n s i t y - S u c c e s s - S t o r y - f r o m - G r e y - B r u c e - H e a l t h - S e r v i c e s _ J a n p d f S c h i m m e l p f e n g, K., H e l b e r, S., & K a s p e r, S. ( ). D e c i s i o n s u p p o r t f o r r e h a b i l i t a t i o n h o s p i t a l s c h e d u l i n g. O R S p e c t r u m, 3 4 ( 2 ), V e s t r i, A., P i z z i g h e l l o, S., P i c c o l i, S., & M a r t i n u z z i, A. ( ). B e n e f i t s o f c e n t r a l i z e d s c h e d u l i n g i n a p o s t a c u t e r e s i d e n t i a l r e h a b i l i t a t i o n p r o g r a m f o r p e o p l e w i t h a c q u i r e d b r a i n l e s i o n s : A p i l o t s t u d y. Ar c h i v e s o f P h y s i c a l M e d i c i n e a n d R e h a b i l i t a t i o n, d o i : h t t p : / / d x. d o i. o r g / / j. a p m r W a n g, H., C a m i c i a, M., T e r d i m a n, J., M a n n a v a, M., S i d n e y, S., & S a n d e l, M. ( ). D a i l y T r e a t m e n t t i m e a n d f u n c t i o n a l g a i n s o f s t r o k e p a t i e n t s d u r i n g i n p a t i e n t r e h a b i l i t a t i o n. A m e r i c a n A c a d e m y o f P h y s i c a l M e d i c i n e a n d R e h a b i l i t a t i o n, 5, W o o d, R. M., G r i f f i t h s, J. D., W i l l i a m s, J. E., & B r o u w e r s, J. ( ). O p t i m i z i n g r e s o u r c e m a n a g e m e n t i n n e u r o r e h a b i l i t a t i o n. N e u r o R e h a b i l i t a t i o n, 3 5,