From the 2024 HVPA National Conference
Koura Sall DO (Temple University Hospital), John Ebeid MD, Shaan Desai MD , Abraham Ifrah MD, Richard Saporito MD, Jeffrey Anderson MD, Dharmini Shah Pandya MD, Claire Raab MD
Background:
Physical Therapy (PT) is a limited resource important in patients’ discharge planning and final disposition, especially those with mobility deficits. Nevertheless, there is a shortage of physical therapists, given the large consultation burden and inappropriate consultations. Inefficient utilization of PT can significantly impact patient outcomes and hospitalization costs. Studies showed that insufficient assessments of patient’s mobility by other providers, such as physicians and nurses, was a major contributor to inappropriate PT consults. Mobility scales such as the Johns Hopkins Highest Level of Mobility Scale (JH-HLM) have been studied and shown to improve patient mobility outcomes while reducing costs.
Objective:
To create a streamlined and objective assessment of patient mobility by physicians and nurses that would significantly reduce PT consultation burden and provide higher-value care for hospitalized patients by improving patient mobility.
Methods:
Internal medicine residents in a tertiary academic center were surveyed on practice patterns regarding patient mobility assessments, mobility aid utilization and PT consultation choices. A multidisciplinary team including PT managers, mobility aids, nursing managers, case management leadership, and information technology team collaborated to identify an optimal streamlined process of PT consultations. A clinical decision tree (CDT) within the hospital’s electronic medical record using the JH-HLM was designed to improve high value care of patients with mobility deficits. Residents were educated on the new process with bulletins and emails. After implementation of the CDT between February-March 2024, the number of PT and mobility aid consults were assessed. Additionally, SNF disposition to PT recommendation ratios in March 2023 and March 2024 were compared to assess for impact of CDT.
Results:
About twenty-six residents responded to the initial survey. Approximately 86% of residents reported knowing of a mobility aid program, 48% referred patients to mobility aids sometimes, and <1% reported using an objective measure to guide decisions on PT referrals. 4060 patients were evaluated by PT between January 2023 and December 2023, with a monthly average of 338 consults during that time. Approximately 42.86% of patients were recommended disposition to SNF, 3.28% were recommended high-intensity PT, 7.54% had no skilled PT needs, 3.23% were recommended outpatient PT, and 16.01% were recommended home PT. One month after CDT implementation (see Appendix A), approximately 51% of patients were recommended SNF placement, which resulted in 51% of these patients being discharged to SNF compared with 48% during the same month 1 year prior. The number of mobility aid evaluations increased from 19 in March 2023 to 118 in March 2024 following CDT implementation. Additionally, 84% of patients evaluated in March 2024 were discharged home compared to 58% a year earlier.
Conclusion:
The implementation of a CDT to standardize PT consultations provided modest improvements in patient mobility assessment and an increase in mobility aids referrals. More data is needed to see a firm reduction in PT consultations. Future efforts should be focused on continued education on new processes to physicians and nursing and expansion of CDT solutions to other hospital departments.
Clinical Implications:
The implementation of the CDT helped increase patients’ mobility assessment during their hospital stay leading to more home dispositions and potentially more mobile patients with less complications during their hospital stay. It would be interesting to investigate the effects on length of stay once more data is obtained.