3/19/2018

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Clinical Reasoning and Proof of Value in Acute Care Physical

Therapy Practice Michael Bang PT, OCS

Ryan Elliott PT, OCS, FAAOMPT Cristen Clark PT, OCS, FAAOMPT

Michael Ross PT, DHSc, OCS

Objectives (Part 1)

• Encourage • Continue using the Fundamentals of Practice

• Chart Review • History • Examination • Continuum of Care

• Challenge • Synthesize and Act on Exam Findings • Enhance Clinical Reasoning • Know & Articulate your VALUE

Objectives: Acute Care PT (Part 2)

• Describe the current state of clinical practice

• Analyze the clinical impact of PT intervention in the acute space

• Describe redesign of acute care PT within a major medical system

• Highlight acute care PT value through clinical reasoning • Case Vignettes

Why US??

• Senior Faculty: Manual Therapy Fellowship • 8-12 hours/week of Acute Care Practice

• Clinical Reasoning>>OMT technique • Emphasize patient care across the continuum • “Be a great PT”

• Fellowship graduates: • Academia • Acute care supervisors • Pediatrics • Fellowship Coordinators • Embedded into special operations in the military

A Battle is Being Waged

• Early Mobility • YES, and we are SO much more than mobility

• Multidisciplinary Collaboration

• System Change is Required • How?

• Extreme variation in practice

Acute Care PT is a Career

• Acute care PT has often been ill-defined & under-studied • Limited data:

• Outcomes? • Efficiencies?

• Staffing?

• Acute care PT positions are historically difficult to recruit/retain

• Acute is a “stepping stone” to other PT positions • Pay your dues…

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What we’re not…

• Assist with RASS

• CAM-ICU

• PEEP

• Spontaneous breathing trials

Value in PT

• Kaiser Permanente: REDESIGN Northern California Rehab Services

• How do we show Value in Acute Care PT? • Literature Review

• Clinician Engagement

• Academy of Acute Care’s 2015 Core Competencies

Value in Physical Therapy…

• Research emphasis has been dominated by outpatient orthopedics

• Timing of PT intervention matters • Cost of LBP management are exploding • Patient education is imperative early in the episode of care • Practice paradigms vary widely

• Ramifications of Reduced Fear/Anxiety

• Improved Patient Outcomes

• Reduced Downstream Healthcare Utilization

Grandpa Elliott: circa 2002

• After his 2nd PT session in the hospital

• “Oh, so you’re like a dog-walker for humans”…

Current Role

• Discharge Disposition…

What do we have to offer…

• Rehabilitation Excellence • FUNDAMENTALS

• Chart Review • History • Physical Exam

• Differential Diagnosis

• Champions of Mobility • PT/RN partnership • Multidisciplinary Mobility Training

• Continuum of Care/Discharge Disposition

• Clinical Reasoning

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RISK/BENEFIT…

• Mobility

• Empowers patients

• Reduces delirium & HAP

• Promotes functional independence • (+) predictor of returning home

• Shorter LOS

• Has almost no negative side effects

• In contrast…

• Immobility makes every organ system worse

• Skin breakdown

• Weakness & loss of muscle mass depression

• Poor circulation/risk of DVT

• Glucose intolerance

• Weak cough & respiratory muscles

• Constipation

Recovery…Happily Ever After?

• FIM score after 7 days of Vent: • Independent risk factor for 1 year mortality rate

• Severe disability at 1 and 5 years after Critical Illness

• PICS

• ARDS

• ICU-AW

• Sepsis

• Kyle Ridgeway…2/23 • Outcomes after Critical Care

Hospital Readmission Studies Hospital Associated Deconditioning (HAD)

• 68% of patients discharged from postacute care settings are below PLOF

• Functional mobility? • >85% of time lying in bed

• Hospitalized adults 61 times more likely to have ADL limitation compared to non-hospitalized adults

Post Hospital Syndrome (PHS) • Older adults with poor physical function have 3x the odds

of readmission compared to medically complex patients that have high physical function

• Falvey et al, 2016

Importance of Mobility

• 10 year study of 22,289 participants • 15% readmission rate within 30 days

• 16.9% with no functional impairment • 18.8% with ≥1 ADL difficulty

• 18.4% with dependence in 1–2 ADLs

• 25.7% with dependence in ≥3 ADLs

Greyson et al. Functional Impairment and Hospital Readmission in Medicare Seniors (2015)

Why is Patient Mobility SO Important?

• 449 participants >70 years old • Patients fully independent in ADLs 2 weeks prior to hospitalization

• Dependence in >1 ADL at discharge • Dependence=needing assistance from another person for that task

• 1 year prospective study regarding recovery, dependence & mortality • 27% still had dependence in ADLs

• 37% mortality rate

• Barnes et al. Prediction of Recovery, Dependence or Death in Elders Who Become Disabled During Hospitalization, 2012

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SUMMARY

• This is not adhesive capsulitis…

• Disability s/p hospitalization is not “self limiting”

“Don’t people already know this?” Jenna Elliott, non-PT, wife, harsh critic

You may know…

• This conference defines selection bias

• What is the standard of care across this country?

• Do your colleagues know? • Every patient?

• Disclosure: • Proof of value never stops—and shouldn’t

• Kaiser Permanente: Engaged in mobility and clinical reasoning culture shift • Imperfectly

Kaiser Permanente Northern California: Rehabilitation Redesign • Quality Patient Care

• Sustainable Practice

• Consistent Patient Care Experience

To Know our Value is Important… To Show Value is Imperative • How do we define our practice?

• Rehabilitative vs Consultative?

• Reimbursement-driven care

• How do we demonstrate this value to senior hospital leadership? • What is the optimal frequency and duration of care in the acute space?

Engagement: Regional Decision-Makers

• Previously: Limited/No PT representation

• Regional Director of Rehabilitation Services

• Clinician Directors

• Average PT is concerned over the state of practice • What do we DO about it?

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Clinician-Led Redesign

• >200 senior clinicians collaborated on current state and barriers:

• Appropriateness: Consults on patients not yet assessed by nursing • Timing: Consults late in the patient’s hospitalization • Re-certifications • Rehabilitation: marginalized due to new consult volume • Perception: Discharge dispositioners, not rehabilitation experts

• We’re better than being dog-walkers for humans…

Barriers to Showing Value

• What do you do? • Practice definition

• Mobility was in the eye of the beholder • Too important to be practitioner-dependent

• How does PT get consulted in acute care? • By whom?

• Based upon what criterion?

Words Matter…Define Terms & Value

• Regional Mobility Protocol • Mobility was measured by ambulation • We were not accounting for our most vulnerable patients

• Defining Terms: • Mobility belongs to everyone • Rehabilitation is lead by PT

• Stop ostracizing our colleagues • Skilled vs Unskilled Care…?!?!

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The Current View of ICU Mobility

Exclusions Criteria • Patients discharged before noon • PLOF I or II • Patients on comfort care

• Patients listed as “brain dead” on problem list

• Patients with documented NMW <=1

14 – 67% % of ICU patients excluded

REGIONAL MOBILITY PROTOCOL

• Mobility is more than ambulation

• Clarify Criterion for a PT consultation • RN performs initial mobility assessment

• A gap between PLOF and Current level of function= PT ordered

• Clearly identify mobility activities for nursing to attempt

• Graded progression of nursing mobility assessment

Bed Mobility

Sitting

Standing/Transfer Walking <50ft

Walking >=50ft

Regional Mobility Protocol

Ac

tiv

itie

s

to A

tte

mp

t

• Active ROM: able to repetitively

move extremities on command

(extend, flex, etc)

• Active rolling/turning

• Active participation in bed

mobility during nursing care

• Sit at edge of bed, with feet on

solid surface.

• Scoot self laterally along the

edge of the bed with or without

assistance

• Cardiac chair as an acceptable

alterative for patients who lack

strength, alertness, or trunk

stability to sit at edge of bed

• Active transfer to chair/commode

• Stand at the edge of bed

• March in place/Side step at the

edge of bed

• Ambulate away from bed

with assistance of care

provider, and assistive

devices as needed

• Ambulate away from bed

with assistance of care

provider, and assistive

devices as needed

Cri

teri

a fo

r

Pro

gre

ss

ive

Mo

bil

ity

• Able to feel arms

and legs

• Able to lift extremities

against gravity

• Able to sit at edge of

bed

• Lift legs against gravity

and hold for 5 seconds

• Sit balanced without

the use of arms or

assistance

• Able to move from

sitting to stand

• Able to complete 3-5

steps of marching in place

• Able to take one step

forward and one step

backwards with no loss of

balance and no knee

buckling

• Able to tolerate

ambulating with no lo

ss of balance and no

knee buckling

(in-room distances)

• Able to walk in the

halls

Is patient progressing toward PLOF – defined 2 weeks prior to admission?

*Plan for mobility needs to be individualized for the patient and discussed daily during MDR. This protocol is not meant to substitute for good clinical judgment — If there is a reason the

patient should not be mobilized according to the ordered protocol, a discussion with the primary physician is warranted.

1 Complete Pre-Hospital Level of Function (PLOF) Assessment and Patient Pre-Mobility Screen*

2 Assess patient progression across mobility levels toward PLOF

PT Document in doc flowsheet highest mobility level achieved, at least twice daily 3

Address and reassess upon admission and at every shift if patient does not pass initial pre-mobility screen

If “NO” and a gap exists between PLOF and current function, consider a Physical Therapy Consultation

In the presence of a “NO” response, mobility can still be progressed unless deemed unsafe to proceed

If “YES,” proceed to next assessment level

Yes No Yes No Yes No Yes No Yes No

*No MD contraindications to begin mobility, patient is able to follow simple commands or cues, pain has been adequately addressed

Yes No If the patient does not meet criteria for progressive mobility

& a gap exists between current function & PLOF, consider

a Physical Therapy Consultation.

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PT/Nursing Partnership

• NURSING PARTNERS: Do the right thing for the patient • FUNDAMENTALS OF ASSESSMENT & TREATMENT

• It will be measured

• It will be credited

• Early PT engagement • FUNDAMENTALS

• PT provides Mobility Recommendations

• Clear Visibility across disciplines

• PT responsible for setting frequency/duration of rehabilitative care

PT LEADERSHIP IN EARLY MOBILITY

OPENED DOORS

• PT leadership in multidisciplinary mobility programs

• Improved transparency of documentation between disciplines

• Improved collaboration regarding hospital based falls

• Improved Workplace Safety

• Improvement in the continuum of care • Fall prevention classes • Outpatient PT follow-up • HHPT and SNF communication

Back to Grandpa Elliott…

• Is “walking a patient” skilled?

• Do we treat based upon diagnosis?

• Are our PTs bored?

• A Reminder • CLINICAL REASONING WITHIN ACUTE CARE

• Preaching to the choir…cream of the crop

Are we overpaid discharge dispositioners?

• Our jobs our on the line…

• Patients suffer in our absence…

• Clinical Reasoning is one of our differentiators

• We collect data, but do we ACT upon it? • Perform the FUNDAMENTALS of the PT evaluation

• The synthesis and application of facts into action

• COMMUNICATE these findings across disciplines

Academy of Acute Care Section: Core Competencies • “Acute care practice encompasses the knowledge and skills suitable

to thoroughly examine and appropriately intervene with patients in medically compromised situations encountered in any acute care hospital environment across the lifespan, from children to adults”.

• A great honor to have patients entrust their care to us in their most vulnerable state.

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IS THIS PATIENT APPRORIATE FOR PT INTERVENTION? • Bill Bouissonnault:

• TREAT • Do we assess mere function, or assist with the differential?

• Are we treating a diagnosis?

• Are we treating the right diagnosis?

• TREAT AND REFER • Do we assist with the why, not just the what?

• REFER • Sometimes most difficult to collaborate in the acute setting

• We all can too often assess/treat the “admitting diagnosis”

Continuum of Care

• Patient education regarding mobility and safety • Best motivators in acute care

• Family education

• Patient advocacy

• Interdisciplinary Communication • Years of RELATIONSHIP development

Clinical Reasoning in Acute Care: Case Discussions

• Highlighting: • Fundamentals of Clinical Practice

• Clinical Reasoning

• Differential Diagnosis

• Treatment

• Continuum of Care

58 y/o female s/p R THA • Algorithm or Assessment…

Chart Review

• Right Hemiplegia x 1 year

• Expressive aphasia

• Chronic low back pain

• Anemia

• Alcohol dependence • Drinks 1/5 vodka per day

• Moderate Tobacco User

• Colitis

• L ankle ORIF • Daily norco: (1-2 10 mg/day)

• Methadone: 3-4 tabs/4 times/day

PRE/POST OPERATIVE RADIOGRAPHS: (Anterior THA)

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HISTORY

• 1 year ago admitted for Left CVA • Right hemiparesis and expressive aphasia

• Discharged to SNF

• HHPT: ambulatory household distances supervised with quad cane

• Mod A for transfers & bed mobility

• Outpatient Chart Review

• 58 year old female referred to outpatient PT • R sided weakness/deconditioning

• R knee pain s/p fall • Non-ambulatory since the fall

Patient Profile

Past History: 7 months prior… • Son witnessed patient trip and fall

• Impact to her right knee

• Complaints of right knee pain and inability to ambulate

• Per ED physician:

• Mild swelling R knee

• Mild tenderness medial aspect of knee.

• No laxity on stress but tenderness with ROM and stress of MCL.

• Ordered right knee x-rays: (-), assessment: knee sprain • Patient not safe ambulating due to CVA

• Issued knee brace and wheelchair

• DC: Home

PRIMARY CARE VISITS: 4x in 4.5 months

• Knee sleeve, APAP and PT

• SUMMARY: • Worsening pain

• Difficult exam due to aphasia • Patient still non-ambulatory

• Physical Exam: • No joint tenderness, deformity or swelling

• No muscular tenderness

• Full ROM without pain, no crepitus

PT Visit #1: 7 months s/p fall

• Objective:

• Observation: WC dependent

• Dependent transfer to treatment table

• Unable to bear weight on R LE

• Knee AROM: 10-100—limited by pain

• Hip PROM: severely limited in all planes with guarding & pain • Internal rotation or flexion reproduced primary pain

• Tearful and high level of pain

• Assessment: advised MD regarding further work up of hip

• Plan: referred back to PCP for further workup

Acute Care: which mindset will we choose?

• “Simple” post-operative dx

• “Algorithm” of care

• “Boring protocol”

• Functional Assessment

• Discharge Disposition

• Holistic patient care

• Expressive aphasia

• Non-elective THA

• No assumptions

• ASK WHY?

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Ramifications of Standard Care

• Patient initially refused PT intervention

• Discharge destination and quality of life at risk • Patient was at “PLOF”

• Patient Care Coordinator: Board & Care discharge for custodial care

• Wheelchair bound 7 months for a reason!

PT IMPACT: Acute Care Rehabilitation

• Fear of all mobility

• High levels of pain

• Initially refused PT intervention

• Patient education regarding rehab potential

• Pain Science Education

• Family education

• Patient Advocacy regarding COC • Discussions with DC planners

• HBS

• SNF coordinator

Outcome

• Seen by Acute PT daily x 6 days • Reiteration of goals • Progressive rehab • HOPE!

• SNF x 7 days • Max A bed mobility • Mod A stand/pivot transfers • “Non Ambulatory at baseline”

• HHPT: 2 months x 15 visits • Renewed hope • Modified Independent Bed Mob/Transfers • Gait: 100 feet with SBA and Quad Cane

Importance of Your Role

• Worldwide, approximately 1.5 million people sustain Hip Fractures/year • Increase incidence to 2.6 million by 2025

• 4.5 million by 2050 • (Sterling R. S. (2011). Gender and race/ethnicity differences in hip fracture incidence, morbidity, mortality, and function. Clinical Orthopaedics and Related Research® , 469 (7), 1913 – 1918)

• One year mortality rate in patients >65: 8-36% • (Michaëlsson K. Nordström P. Nordström A. Garmo H. Byberg L. Pedersen N. L. Melhus H. (2014). Impact of hip fracture on mortality: A cohort study in hip fracture discordant identical twins. Journal of Bone an d Mineral

Research , 29 (2), 424 – 431)

SUMMARY: REMEMBER THE FUNDAMENTALS

• Chart Review: Why the non-elective THA?

• Why a hip fracture?

• History: PLOF—why did the patient decline?

• Detailed chart review

• Examine your patient

• Coordination of Care:

• Patient education/encouragement

• Patient advocacy

• Multidisciplinary engagement

DIZZINESS

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Dizziness in the Emergency Department • 15 million people develop dizziness every year

• ED visits for dizziness are on the rise:

• Annual ED visits from 1995 to 2011:

• All visits: increased by 44%

• Dizziness visits: increased by 97%

• From 2 million to 3.9 million • 3.5% of all ED visits

(Kattah ’09, Newman-Toker ’08 & ‘16, Cheung ’10, Saber Tehrani ‘13)

Dizziness in the Emergency Department

• Cost estimate for ED visits: ~$4 billion

• Total health care related costs: estimated > $10 billion

(Kattah ’09, Newman-Toker ’08 & ‘16, Cheung ’10, Saber Tehrani ‘13)

Dizziness in the Emergency Department

Compared to patients without dizziness in the ED, dizzy patients:

• Undergo more testing

• Undergo more imaging

• Have higher ED lengths of stay

• Are more likely to be admitted

(Newman-Toker ’08, Dallara ‘94, Kerber ‘10)

Acute Vestibular Syndrome (AVS) in the ED

• PERSISTENT DIZZINESS

• NAUSEA/VOMITING

• GAIT INSTABILITY

• NYSTAGMUS

• HEAD MOTION INTOLERANCE

Acute Vestibular Syndrome (AVS) in the ED MOST LIKELY DIFFERENTIAL:

• Vestibular Neuritis or Labyrinthitis • Very commonly misdiagnosed

• Stroke

• Posterior fossa (cerebellum or brainstem) • 96% of these strokes are ischemic

• When a stroke is the cause of dizziness, there is almost always other associated symptoms

• Other: Multiple Sclerosis, vertebral dissection, thiamine deficiency, autoimmune,

infections, metabolic conditions, etc.

(Hall ’16; Kerber ‘09, Tarnutzer ’11, Kerber ’12)

Dizziness in the Emergency Department:

• Posterior circulation strokes can mimic peripheral causes of dizziness

• In strokes with primary symptom of dizziness: • 3% are missed • 5% of those with an untreated TIA suffer a stroke within 48 hours

• Proper diagnosis is crucial • Prompt treatment lowers CVA risk after TIA by ~80%

• Neuroimaging is on the rise…

(Casani ’13)

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Neuroimaging • CT scans to rule out stroke:

• Increased from 10% in 1995 to ~40% in 2011

• Ineffective at ruling out stroke

• 16% sensitivity for all patients with dizziness • <1% sensitivity for dizziness in patients lacking clear neurological signs

• Cost of CT for dizziness in ED in 2013: $360 million

• Contributes to misdiagnosis and false sense of security

• Not without risk

Neuroimaging • MRI with Diffusion Weighted Imaging (DWI):

• Miss 10-20% of strokes presenting with AVS in the first 48 hours

• Take longer and cost 4x as much as CT scans

• Cost estimates in 2013: $110 million

• Used in 1-2% of dizzy patients

Neuroimaging • Increase in neuroimaging:

• Has led to an increase in length of stay • Has NOT led to a greater diagnostic yield of CNS diagnosis

• Suggestions:

• Stop unnecessary CT scans • Increase MRI in APPROPRIATE patients (6% of all dizzy visits)

• This would save ~half a billion dollars/year • Improve diagnostic accuracy in CNS patients • Reduce hospital admissions in benign peripheral inner ear disorders

• Focus on what is more accurate…history and physical examination

(Newman-Toker ’16)

CHALLENGE ACCEPTED?

• We should be called on each one of these dizzy patients

• Value? • Reliance on costly false negative imaging

• Merely performing gross functional assessment

Physical Therapy Role

• History and physical exam are more accurate than imaging

• Assist with determining peripheral vs central issue

• Assist with treatment and discharge plan

• Perform appropriate maneuver if BPPV

• Early mobilization

Physical Therapy Role

Fundamentals of Practice

• THOROUGH CHART REVIEW:

• Patient’s evolving condition over time

• Understand stroke risk factors

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Physical Therapy Role

Fundamentals of Practice

• HISTORY:

• Symptom quality: inconsistent

• Timing and triggers: more useful

Physical Therapy Role

Fundamentals of Practice

• BEDSIDE EXAMINATION:

• “HINTS”…

“HINTS” exam

100% sensitive and 96% specific for stroke

“A benign HINTS examination result at the bedside “rules out” stroke better than a negative MRI with DWI in the first 24 to 48 hours after symptom onset with acceptable specificity (96%)”

• MRI sensitivity < 48 hours after symptom onset = 83% • CT sensitivity = 16%

“HINTS” Head Impulse- Nystagmus- Test of Skew

1. HEAD IMPULSE TEST ->You WANT the HIT to be ABNORMAL on one side, indicating a PERIPHERAL cause of vertigo ->If HIT is positive or negative BILATERALLY, indicates a CENTRAL cause of vertigo

2. NYSTAGMUS: -> You WANT the nystagmus to beat in ONLY ONE direction, indicating a PERIPHERAL problem -> If the direction changes, is purely torsional, or vertical, indicates a CENTRAL problem 3. TEST OF SKEW (skew deviation): ->You want PERFECT vertical alignment of the eyes, indicating there is no central problem

KATTAH, 2009

HINTS

• If any of these 3 tests are worrisome:

• Presume stroke

• Recommend admission

HINTS • Also add HINTS ”plus”

• Targeted neurologic examination: • Limb ataxia

• Dysarthria

• Diplopia

• Ptosis

• Anisocoria

• Facial sensory loss (pain/temperature)

• Gait and truncal ataxia: • Able or unable to sit up/ walk without assistance

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Case Example

• 67 year old female • NICU nurse Kaiser Oakland, lives alone, enjoys traveling, no regular exercise routine

• Past medical history: • HTN (currently untreated)

• Diverticulosis

• Hypothyroidism

• Adjustment disorder w/ depressed mood

• Vitamin D deficiency

• Medications: vitamin D3

Case Example

• 9 days after patient returned from vacation in Europe, she developed cough, congestion, bilateral ear fullness.

• Within 1 week of symptoms, developed dizziness, nausea/vomiting, headache, and imbalance. Called EMS, brought to ED by ambulance.

Case Example

• In ED, negative workup including: • CT of head and sinus

• Chest x-ray

• EKG

• NIHSS total: 0

• Given posterior CVA risk (age and untreated HTN), physician ordered: • Brain MRI w/ DWI

• Placed patient on observation

• PT evaluation

Bedside PT Examination

• CERVICAL AROM: wnl, guarded, increases subjective dizziness each direction

• MODIFIED VBI: (-)

• GAZE STABILITY ASSESSMENT • SPONTANEOUS NYSTAGMUS: right beating

• GAZE EVOKED NYSTAGMUS: direction fixed right beating nystagmus

• Saccades and Smooth Pursuit testing: intact

• HEAD IMPULSE TEST: (+) left

• SKEW DEVIATION: (-)

• Gait: moderate veering without walker

Evidence for Early Vestibular Rehabilitation in Neuritis

• Improved postural stability (Strupp ‘98)

• Less perception of disability and handicap (Banious ‘00)

• Dizziness and unsteadiness while walking are significantly decreased (Bjerlemo ‘06)

• Reduced duration of symptoms and need for medications (Venosa ‘07)

• Reduced perception of handicap, decreased symptom, and better performance (Teggi ’09)

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Case Example

• Patient education

• Gait training (80 ft w/ SBA and FWW)

• Recommendation: ambulate frequently throughout the day w/ FWW

• Discussed and demonstrated VOR stabilization exercise as soon as tolerable

• Recommendation: outpatient PT

• Physician and patient decline prednisone suggestion from PT

CASE EXAMPLE

• Patient with high anxiety

• Seen 3 days later in outpatient physical therapy

• Remains in acute stage as expected

CASE EXAMPLE

• Attempted to progress VOR and VSR

• Patient education: • decrease vigor of HEP

• reduce anxiety regarding condition

• Seen for 4 sessions: • Once/week for 2 weeks

• Once every 2 weeks for the next 2 weeks

• All symptoms resolved within 2 months

SUMMARY: OUR VALUE

• Dizziness is an extremely common symptom

• Causes are numerous

• Diagnosis is difficult

• Resource overutilization and misdiagnoses are common

• History and physical exam are more accurate than imaging

OUR ROLE:

Identify benign inner ear conditions:

• Discharge planning for home

• Early mobilization and treatment

• Fast-track to outpatient

• Reduce healthcare costs

Identify serious signs and symptoms:

• Save lives

• Reduce healthcare costs

References

Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418–1428.

Hines AL, Barrett ML, Jiang HJ, Steiner CA. Conditions with the Largest Number of Adult Hospital Readmissions by Payer, 2011. HCUP Statistical Brief #172. Rockville: Healthcare Research and Quality; 2014

Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693–703.

Falvey JR, Magione KK, Stevens-Lapsley. Rethinking Hospital-Associated Deconditioning: Proposed Paradigm Shift. Phys Ther. 2015;95(9):1307-1315.

Shih SL, Gerrard P, Goldstein R, et al. Functional status outperforms comorbidities in predicting acute care readmissions in medically complex patients. J Gen Intern Med. 2015;30:1688–1695.

Shih GL, Gerrard P, Goldstein R, et al. Functional Status Outperforms Comorbidities as a Predictor of 30-Day Acute Care Readmissions in the Inpatient Rehabilitation Population. 2016;10(17):921-926.

Falvey JR, Burke RE, Malone D et al. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016;96(8):1125-1134.

Greyson SR, Cenzer IS, Auerbach AD, Covinsky KE. Functional Impairment and Hospital Readmission in Medicare Seniors. JAMAInternMed.2015;175(4):559-565

Barnes DE, Mehta KM, Boscardin WJ, Fortinsky RH, Palmer RM, Kirby KA, Landefeld, CS. Prediction of Recovery, Dependence or Death in Elders Who Become Disabled During Hospitalization. J Gen Intern Med 28(2):261–8.

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References • Casani, et al: Cerebellar infarctions mimicking acute peripheral vertigo: how to avoid misdiagnosis? Otolaryngol Head Neck Surg; 2013; 32:

pp. 1518-1521.

• Cheung CS: Predictors of important neurological causes of dizziness among patients presenting to the emergency department. Emerg Med J 2010; 27: pp. 517-521.

• Dallara J, Lee C, McIntosh L, Sloane PD, Morris D. ED length-of-stay and illness severity in dizzy and chest-pain patients. Am J Emerg Med. 1994; 12:421–4.Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008; 7:951–64.

• Edlow, J, Newman-Toker: A new diagnostic approach to the adult patient with acute dizziness. Journal of Emerg Med; 2017: pp 1-35.

• Hall CD, Herdman SJ, Whitney SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: Journal of Neurologic Physical Therapy. 2016;40(2):124-155.

• Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009; 40:3504–10.Kerber KA, Meurer WJ, West BT, Fendrick AM. Dizziness presentations in U.S. emergency departments, 1995-2004. Acad Emerg Med. 2008; 15:744–50.Kerber, 09

• Kerber KA, Schweigler L, West BT, Fendrick AM, Morgenstern LB. Value of computed tomography scans in ED dizziness visits: analysis from a nationally-representative sample. Am J Emerg Med. 2010; 28:1030–6.Kerber ’12

• Newman-Toker DE. Charted records of dizzy patients suggest emergency physicians emphasize symptom quality in diagnostic assessment. Ann Emerg Med. 2007; 50:204–5.

• Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008; 70:2378–85.Newman-Toker ‘13

• Newman-Toker: Missed stroke in acute vertigo a time for action, not debate. Ann Neurol 2016; 79: pp. 27-31.

• Saber Tehrani: Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med 2013. 20: pp. 689-696.

• Tarnutzer AT, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Acute vestibular syndrome: does my patient have a stroke? A systematic and critical review of bedside diagnostic predictors. CMAJ. 2011; in press.

Medical Screening and Referral In Older

Adults

Michael D. Ross, PT, DHSc, OCS

Daemen College

Amherst, NY

mross@daemen.edu

Thank you!

• Academy of Acute Care Physical Therapy

• To all of you for attending!

• Michael Bang, PT

For your patients……

Do you Treat, Treat and Refer, or

Refer Only?

Differential diagnosis

….is the comparison of symptoms of similar diseases and medical diagnostics

(laboratory and test procedures performed) so that a correct assessment of

the patient/client’s actual problem can be made

Hypothetico-deductive reasoning model to facilitate diagnosis

Goodman and Snyder, 2013

Fundamental Principles of Evidence-Based

Practice

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. BMJ. 1996;312: 71-72.

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Patient’s Values and Expectations

respect for the patient’s values, preferences, and expressed needs

coordinated and integrated care

clear, high-quality information and education for the patient/family

physical comfort, including pain management

emotional support and alleviation of fear and anxiety

involvement of family members and friends, as appropriate

continuity, including through care-site transitions

access to care

N Engl J Med 366;9, March 1, 2012

Michael J. Barry, and Susan Edgman-Levitan

Manary et al, N Engl J Med Dec 26, 2012

Core Competencies

The Lancet 2016 388, 1545-1602DOI: (10.1016/S0140-6736(16)31678-6)

Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license Terms and Conditions

Leading ten causes of global age-specific

years lived with disability in 2015

The Lancet 2016 388, 1545-1602DOI: (10.1016/S0140-6736(16)31678-6)

Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license Terms and Conditions

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Case Discussion

53 year-old woman

2 wks s/p lumbar spinal fusion revision

surgery

– 6 surgeries over 3 years

CC: LBP, B shoulder (L>R), L upper

extremity, and upper back/neck pain

– B LE pain as well

PMHx: CAD, depression and suicidal

ideations

– 18 pack-year smoking history

Meds: Neurontin, Percocet, Soma, and

Xanax

Physical Exam

Pulse: 82 beats per minute

Blood pressure: 160/100 mmHg

Respiration rate: 22 breaths per minute

Moderate assist to transfer from a supine to

sitting position and from a seated to standing

position

Moderate assistance to ambulate 9-m with a

walker

SOB, lightheadedness, and fatigue with

activity

Physical Exam

Moderate assist to transfer from a supine to

sitting position and from a seated to standing

position

Moderate assistance to ambulate 9-m with a

walker

SOB, lightheadedness, and fatigue with

activity

NEXT STEP?

Treatment

Due to concern over a progressively worsening cardiac

condition, the PT immediately consulted the cardiologist, who

agreed to see the patient the next day

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Outcome

Cardiac catheterization revealed 75% blockage of her left

anterior descending coronary artery, 50% blockage of her left

circumflex artery and 99% blockage of her right coronary

artery

Outcome

Cardiac catheterization revealed 75% blockage of her left

anterior descending coronary artery, 50% blockage of her left

circumflex artery and 99% blockage of her right coronary

artery

Outcome

The patient was subsequently treated with coronary artery

bypass grafting (CABG)

Ten days following her CABG, cardiac rehabilitation was

started in her home with the same PT

Outcome

CC: post-surgical chest pain and low back soreness, which

was now greatly improved

Independent with transfers and ADLs

Ambulated 300-m with a SPC without LE pain

No longer complained of SOB or lightheadedness

Outcome

No longer taking her Percocet, Soma, or Xanax

Started on Lipitor and continued with the use of Neurontin

She was treated by the home health physical therapist for 8

weeks and then discharged to an advanced cardiac

rehabilitation program at a community hospital

Concerns

Multiple lumbar surgeries

History of cardiac disease

– Elev BP, SOB, dizziness, lightheadedness

– Meds (beta blocker, diuretic)

Pain pattern presentation (?)

Prevention (?)

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MI presentation and chest pain (n = 434,877) (Canto JG et al, JAMA, 2000)

33% of pts with MI did not have chest pain on presentation to

hospital

Woman, pts with DM, elderly

Longer delay before hospital presentation

Less likely to have an MI diagnosed and receive primary treatment

Higher mortality rate (23% vs 9%)

MI Presentation in Women Core Competencies

Case Discussion

80 y/o woman

Admitted to inpatient svc for pain control and

further evaluation

Fall prior evening at home which resulted in

severe LBP and difficulty walking

ED: neg CT scans of hips/ L-spine/brain

PT consulted to assess gait/transfer

capabilities/DC options

Case Discussion

Alert and oriented to name, location, date

Lives alone

– Daughter lives 5-min away

Daughter and patient note balance and gait

difficulties over the last couple of months

SPC for ambulation was recommended

Participated in a daily walking program up until

2 months ago

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Case Discussion

Meds: Norvasc, Diovan, Actonel, Pravachol

Goal is to get back home

Tests & Measures

Pulse: 76 beats per minute

Blood pressure: 135/88 mmHg

Respiration rate: 17 breaths per minute

Fair upper and lower extremity strength – Weakness more pronounced weakness in the UEs and on the R

Poor to fair bed mobility and transfer capabilities – Able to transfer from bed to chair with a use of a walker

– Mod assist due to pain/weakness

Tests & Measures

Fair upper and lower extremity strength – Weakness more pronounced weakness in the UEs and on the R

Fair bed mobility and transfer capabilities – Able to transfer from bed to chair with a use of a walker

– Mod assist due to pain/weakness

What’s the next step?

Tests & Measures

General hyperreflexia was noted – hyperactive deep tendon reflexes

– Hoffman reflex and Babinski sign are present

Patient also reported bilateral hand numbness and tingling/decreased fine motor skills prior to admission

Positive Hoffman’s Reflex Babinski Sign

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Hoffman and Babinski sign: clinical significance

A Hoffman and Babinski sign generally indicates cord involvement in the

cervical spine or intracranial pathology

Advanced diagnostic imaging is indicated—especially prior to mechanical

intervention

(Cook et al, 2007)

Patient Disposition

Examination findings were discussed with the patient’s physician

Magnetic resonance imaging of the brain and cervical spine were ordered to assess for a cerebrovascular accident and cervical myelopathy

T2 Weighted MRI – Sagittal View

C3 C3

T2 sagittal MR image reveals marked narrowing of the spinal canal at C3/C4 to C4/5 (arrows) secondary to posterior disc protrusions, degenerative osteophyte formation, and buckling of ligamentum flavuum. A small area of myelomalacia is also present within cord is present at the C5 level.

C3

Patient Disposition

The patient was subsequently referred to neurosurgery for evaluation

It was determined that the patient was a surgical candidate

The patient subsequently underwent surgical decompression laminoplasty from C3 to C6

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Outcome

At two months following surgery, the patient ambulated with an age-appropriate gait pattern with a SPC

Demonstrated a 5/5 lower extremity and 4+/5 upper extremity strength with manual muscle testing

At one year following surgery, the patient was living independently and had returned to her daily walking program

Description of Compressive Cervical Myelopathy

Spinal cord compression caused by narrowing of the cervical spinal canal

Cord Compression Signs

– Paresthesia

– Weakness

– Ataxia

– Babinski

– Clonus

– Hoffman’s

– Romberg

Description of CSM

In cases of progressive CSM, improved outcomes are reported if surgical

treatment is initiated earlier in the course of the disorder

– Therefore, early diagnosis is critical for optimal condition management and patient

outcomes

Because the early signs of CSM are often subtle and overshadowed by other

medical conditions, the diagnosis can be missed

Central Neurologic Exam

Examining for upper motor neuron or long tract signs – Subjective Exam

N/T

Balance

– Neuro Exam

Strength, sensation, DTRs

– Pathologic Reflexes

Hoffman’s Test

Babinski’s test

Clonus

Balance assessment: Gait, Tandem walking, Romberg

Chronic Anterior Cervical Cord Compression (Bohlman et al, 1979; Ono et al, 1977)

Histological alterations in the cord

– demyelination of the lateral columns

– ascending necrosis and degeneration of the dorsal columns

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Cervical Cord - Functional Review

Dorsal Columns

Corticospinal Tract

Spinothalamic Tract

Take home messages

Differential diagnosis in patients with a history of falls

– Early recognition of signs and symptoms of progressive CSM

– Appropriate referrals for diagnostic imaging and surgical evaluation when indicated

Physical therapists have a unique skill set in the acute care setting:

– maximize outcomes, with a particular emphasis on determining the appropriate

frequency and intensity of therapeutic interventions, optimizing physical function, and

reducing readmission rates

Thank you!