A Minute to Win It!! Striving Towards Rehabilitation Intensity in an Inpatient Stroke

Rehabilitation Program Mila Bishev Kalaa Chockalingam Stephanie Durocher Alison Lightbound Wendy Lopez Dr. Barathi Sreenivasan Gina Lam April 28, 2016

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Objectives

•  Implementation of the concept of Rehabilitation Intensity (RI) to inpatient stroke rehab at Sunnybrook – St. John’s Rehab.

•  How our team developed interprofessional collaborative quality improvements to increase therapy times, meet targets and individualize patient care plans.

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St. John’s Rehab

•  Opened in 1937 •  Inpatient and outpatient programs •  Central and Toronto Central LHINs •  One of Sunnybrook’s eight programs since 2012

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Patient Population •  Inpatient programs:

•  A1: Cardiac, Transplant, Amputee •  A2: Burn, Trauma, Complex Care •  A3: Stroke, Neurology, Oncology •  A4: MSK, Short Term Medical Rehab

•  Outpatient programs: •  All of the above populations except Cardiac •  Globally funded •  MVA •  WSIB

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Background Guidelines for Quality Based Procedures (QBPs) for Stroke Care have been outlined by:

•  Health Quality Ontario •  Ministry of Health and Long-Term Care •  Stroke Expert Advisory Panel •  Ontario Stroke Network •  Canadian Best Practice Recommendations for Stroke Care

Our task:

•  Applying these requirements in a rehab setting •  Providing and recording sufficient rehab intensity •  Providing rehab that “matters”

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Rehab Intensity

“The patient time spent in individual rehabilitation therapy

that is aimed at achieving therapy goals based on physical, functional, cognitive, perceptual and social means in order to maximize the

patients recovery” Ontario Stroke Reference Group, 2012

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Rehab Intensity

•  Key indicator for evaluating efficiency and effectiveness of stroke care

•  benchmark is 180 minutes of direct task-specific therapy per day by the interprofessional core therapies (OT, PT, and SLP)

•  At least 6 days per week

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Quality Improvement Initiative

Who was part of the process? Collaborative interprofessional team involves:

–  Clinical team •  Multiple focus working groups

–  Professional Practice / Education –  NRS Coordinator, Workload Coordinator and

Decision Support •  IT / Application Specialist

–  Management –  Partnerships with Toronto Stroke Networks

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Quality Improvement Initiative

What did we do? Identified gaps in meeting the QBP requirements:

•  Staffing ratios •  Treatment models •  Space and equipment resources •  Team communication processes •  Workload measurement system that supports

RI data collection and reporting

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Staffing Ratios

Revise staffing ratios 39 bed inpatient unit: •  21 stroke •  10 other neurology •  6 oncology •  2 flex beds

•  more clinicians see fewer patients for more time

Previous Revised

OT 1 : 10 1 : 6

PT 1 : 9 1 : 6

SLP 1 : 20 1 : 12

Therapist : Patient

** Made possible as a result of increased funding to the program

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Weekend Staffing

Increased weekend therapy •  Increased therapists to complete assessments to start

treatment earlier

Previous FTE

Revised FTE

OT 1 1

PT 1 2

OTA/PTA 3 3

SLP 0 1 (Sat only)

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Treatment Models

Increased 1:1 time between therapist and patient

Group therapy: •  Seen as still being beneficial •  Does not specifically fall under the rehab intensity definition of

individualized, direct, task-specific therapy

Previous Revised

Trending toward more group classes – to enable more patients to be seen in therapy

Therapy is primarily 1:1 Groups are viewed as supplementary

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Treatment Models Created a dual role for OTA/PTA: •  Creates more flexibility as assistants are not limited to a single

profession during a shift

•  OTA/PTA assist with dressing training in the mornings/walking program in afternoons → counts towards Rehab Intensity minutes

Previous Revised

Separate OTA and PTA staff Separate working shifts - dedicated

Dual role Able to work across different roles across a given shift

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Therapy Space Increased available therapy space

•  Additional therapy equipment purchased •  Provides more options for individualized treatments and quiet assessment/

treatment space •  Able to keep up volume of 15-17 treatments at the same time

Previous Revised •  One OT treatment room for

the unit •  One PT treatment room for

the unit •  2 SLP treatment rooms

In addition to the standard treatment rooms: •  Converted offices into additional

treatment rooms for OT, PT (including isolation treatment)

•  Additional SLP treatment room

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Stroke Cohort “All patients who require rehabilitation should be

referred to a specialist rehabilitation team in a geographically defined unit as soon as possible

after admission” QBP Clinical Handbook for Stroke, 2015

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Stroke Cohort •  Created a cohort of stroke beds on mixed unit •  Geographically defined co-location of stroke patients

Previous Revised •  Mixed unit •  Stroke cohort 12- 16 beds on one

side of the unit

Therapy Space

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Team Communication

•  Multiple structured interprofessional communication processes

•  Multiple venues for team communication •  Consistency of messages to patients and families •  360o view of patient shared •  Discharge planning initiated started day 2-3

Previous Revised •  No structured regular dialogue between

team members outside of rounds •  No discharge planning done proactively

until rounds •  MD/PT driven rounds •  One OT/Nurse to represent entire unit •  PT shifted in and out of rounds to present a

caseload

•  Sub-teams – informal, streamlined and regular communication on a daily basis

•  Stroke Huddles to be done day 2-3 •  IPC rounds : Shared rotating facilitation

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•  Sub-Teams

•  Consistency in patient care plans/patient goals with all team members

•  Daily communication more efficient between sub-team members

Previous Revised •  Mixed OT/PT/SLP/nursing •  Clinicians crossed over

•  Sub-teams of OT/PT/SLP/Nurse •  Each team presents their patients

in rounds

Team Communication

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Stroke Sub-teams

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Stroke Huddles •  Occurs on Day 2-3 within sub-team (OT/PT/SLP/nursing) •  Other members may be called to be present •  Early identification of stroke severity •  Early discharge planning •  Needed referrals •  Rehab Intensity Identification/Allocation

Team Communication

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Interprofessional Communication

“Stroke unit teams should conduct at least one formal interprofessional meeting per week at which they:

•  Identify patient concerns/goals •  Set rehabilitation goals •  Monitor patient progress •  Plan post discharge support

Discharge planning should be initiated as soon as possible after the patient is admitted to hospital.”

QBP Clinical Handbook for Stroke, 2015

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IPC Rounds

Restructured team rounds process: • Sub-teams take turns to enter rounds and present (walkie – talkie paging) • Facilitation: shared, collaborative, rotating role (all disciplines) • Discussion:

•  Week 1: full discussion of patient and Rehab Intensity Allocation •  Subsequent weeks: focused on goal achievement,

interprofessional problem solving to facilitate discharge planning, and changes in RI allocation

Team Communication

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Early D/C Planning

Day 2-3

Severity of stroke identified

Early discharge planning initiated

Admission NRS scores entered

Day 4-5 Collaboration with patient/

family Length of stay

discussed

RPG level determined

Day 5-7

Discharge Date (target)

Max LOS determined

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Striving towards Rehab Intensity with Individual Care Plans

Rehab Intensity

•  Dividing 180 mins across OT/PT/SLP

Patient A -  More cognitive issues -  80/40/60 minutes

Patient B -  More speech issues -  40/60/80 minutes

Stroke Huddles

IPC rounds

Caseload Boards

Weekly RI reports

Sub-Teams

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Snap shot of a patient’s day at our best…..

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RI = 235 mins

0800 hrs Nursing

0845 hrs ADL training 15-30 mins 0945 hrs

Medical Rounds

1000 hrs OT therapy

60 mins

1100 hrs SLP therapy

60 mins

1300 hrs PT therapy

60 mins

1400 hrs SLP therapy

30 mins

1500 hrs Walking program 10 mins

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Collecting RI

•  Modified workload measurement system to incorporate recording requirements for Rehab Intensity and for NRS

•  Includes categories for co-assessment and co-treatment (face to face with patient) –  Assessment or Therapeutic Intervention - Solo –  Assessment or Therapeutic Intervention - With therapist –  Assessment or Therapeutic Intervention - With assistant

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Workload Validation Reports

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Rehab Intensity Weekly Reports

May 30, 2016

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Rehab Intensity Weekly Reports

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Results

•  Success with RI collection •  Achieved by engaging in a collaborative initiative

across departments and roles to ensure a seamless integration of clinical and support processes

•  Value in creating an integrated workload system that captures Rehab Intensity, with no additional time requirement for clinicians to calculate

•  From 2010– 2015, therapy time for stroke patients increased by 54%

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0  

20  

40  

60  

80  

100  

120  

140  

F2010   F2011   F2012   F2013   F2014   F2015  Q1  

Minutes  

Fiscal  Year    

 Face  to  Face  Workload  minutes  per  pa5ent  per  day  for  OT,  PT  and  SLP  (includes  weekends)  

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Future Goals

•  Evaluate this initiative from the perspectives of data quality as well as the patient experience/engagement and staff satisfaction

•  Provide system leadership as we share experiences and successes with partner hospitals

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Sunnybrook- St. Johns’ Rehab A3 team

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Contact Us

Mila Bishev Patient Care Manager A-3 Neurology, Stroke and Oncology Programs St. John’s Rehab Sunnybrook Health Sciences Centre (phone) 416.226.6780 ext 7029 mila.bishev@sunnybrook.ca

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Questions