10/13/2017. The K2A Cycle. Focused Intensive Repetitive Step Training (FIRST)

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1 Walking the Walk: Translation of Scientific Findings into Clinical Practice September 14 and 15, 2017 State of the Science Chicago, IL T. George Hornby PT, PhD Jennifer Moore PT, DHSc, NCS The K2A Cycle Case Example: ation of a Gait Assessment Battery in an Inpatient Stroke Rehabilitation Program Focused Intensive Repetitive Step Training (FIRST) 1. Examine current interventions provided to patients during sub-acute rehabilitation and their relation to patient outcomes (years 1 & 2) 2. high intensity stepping program (years 3, 4, 5) Can a research-based intervention be implemented into inpatient stroke rehabilitation? Does this intervention result in better outcomes than conventional therapy? 1

2 Study Description MARY FREE BED REHABILITATION HOSPITAL Grand Rapids, MI Private non-profit hospital 103 acute rehab beds, 48 skilled nursing rehab beds 342 stroke admissions in PTs on Stroke unit PATIENT INCLUSION CRITERIA Inpatient with stroke dx < 2 months post stroke 18yrs old No lower-extremity amputation or weight bearing precautions Patient or family/poa able to provide informed consent FIRST Project: Phase 1 Are patients with stroke who are admitted to inpatient rehabilitation: 1) Assessed with a standard gait and balance assessment battery to determine ambulatory prognosis? 2) Treated with a gait training intervention that maximizes stepping practice? 3) ed with an outcome measurement battery? Identification: Survey Swinkels et al, 2011 of measures in practice (n=8): diagnosis (62.5%), prognosis(87.5%), monitor change (100%) Frequency of use (n=8): 40% of patients (37.5%), 60% of patients (12.5%), 80% of patients (37.5%), 100% of patients (12.5%) Generally positive perception of measures Berg and 6 MWT were in routine use 2

3 Select : Measurement Recommendations Current guidelines/recommendations related to Stroke Rehabilitation walking & balance related measures: Berg Balance Scale 10 meter walk test 6 minute walk test Highly recommended measures (APTA StrokEDGE, Stroke Rehabilitation Clinical Practice Guideline, 2016) d in previous studies that tested high intensity, variable gait training (daily stepping) Assess Recommendations for FIRST Measures Standardization procedures Assessment timing Assessment documentation of SEMs, MDCs, Fall risk related to stroke Assess Barriers and : Surveys and Discussions FACILITATORS BARRIERS Organizational and social: Vision & Stakeholder involvement Organizational Readiness Individual: Clinicians knew expectations Research assistant support Articulated needs for adoption Financial: Funding to support implementation & skills Difference in practice beliefs Prioritizing assessments Low functioning patients not typically assessed Environment and resources No [barriers].just need the motivation Assess 3

4 Adherence FIRST KT Barrier KT Intervention & skills Current practice & culture Environmental resources Education sessions: Consultations, structured meetings, and problem-solving Train core and weekend PT staff Cheat sheet developed for SEMs, MDC s, goal writing Scripts / training related to communication with patients Leadership support (clear expectations) Audit and feedback Reporting at team conference Specific day for all PTs to perform outcome measures Research assistant helps with data collection, timing, putting equipment out for easy access and reminders Minimized therapist documentation burden: developed data collection forms covering entire LOS, assistant scans into EMR : Audit Results 100% 80% 60% Adherence Goal 40% 20% 0% Months Post ation Terminated feedback : Summary Impact on clinicians Positive perceptions of use of assessments in practice Adherence rates: consistently > 85% after 6 months Impact on patients Patients enjoyed testing and were motivated by the feedback General outcomes of conventional care High number of steps/day (median 2300 steps) Lower stepping dose/response relationship (r=.3) Organizational outcomes Generally positive experience ing assessments throughout the system of care 4

5 Demographics MFB (Median, IQR) or N (%) RIC (Median, IQR) or N (%) age 66 (59-75; 119) 64 (55-75; 201) gender: male/female 71/48 114/87 lesion location: right 55 (46%) 74 (39%) left 47 (39%) 88 (44%) bilateral 17(14%) 32 (17%) lesion type: ischemic 90 (76%) 142 (71%) hemorrhagic/unknown 29 (24%) 59 (29%) duration post-stroke (days) 5 (4-8; 119) 13 (8-25; 201) Charlson Comorbidity Index 1 (0-2; 119) 1 (0-3; 201) Baseline Characteristics MFB RIC Baseline Assessments Median (IQR) Median (IQR) Paretic leg strength 3.7 ( ; 119) 1 (0-3; 177) 6 min walk test (m) 81(12-200) 15 (3.0-67) 6 min level of assistance 4 (1-5) 3 (2-4) Berg Balance Scale 18 (5-34) 5 (4-22) FIM-Bed mobility 4 (3-4) 2 (1-3) FIM-Toilet transfers 4 (3-4) 2 (1-3) FIM-Walk 2 (1-4) 1 (1-2) Results MFB - Admission Discharge N (%) FIM-Bed mobility 4 (3-4) 5 (4-6) 119 (100) FIM-Toilet transfers 4 (3-4) 5 (4-6) 119 (100) FIM-Walk 2 (1-4) 5 (4-6) 119 (100) RIC - Admission Discharge N (%) FIM-Bed mobility 2 (1-3) 5 (3-5) 201 (100) FIM-Toilet transfers 2 (1-3) 4 (3-5) 201 (100) FIM-Walk 1 (1-2) 4 (3-5) 201 (100) 5

6 Results MFB - Admission Discharge N (%) 6 min walk test (m) 81(12-200) 243 ( ) 114 (96) 6 min level of assistance 4 (1-5) 5 (5-6) 115 (97) Berg Balance Scale 18 (5-34) 43(33-50) 115 (97) RIC - Admission Discharge N (%) 6 min walk test (m) 15 (3.0-67) 146 (44-281) 166 (83) 6 min level of assistance 3 (2-4) 5 (4-5) 166 (83) Berg Balance Scale 5 (4-22) 34 (13-46) 173 (86) Results Daily stepping MFB (baseline): median 2300 steps per day RIC (post-implementation): median 1512 steps per day Results Daily stepping MFB (baseline): median 2300 steps per day RIC (post-implementation): median 1512 steps per day 6

7 Results - Stepping and Initial LoA Admit LOA Total A Max A Mod A Min A CGA or better MFB Median steps/day ( ) ( ) ( ) ( ) ( ) RIC Median steps/day ( ) ( ) ( ) ( ) ( ) Mod I N/A N/A 6 MWT and Steps/Day Results: Predictors Primary predictors for D 6MWT: RIC: D6MWT = 5.91 steps/ paretic strength MFB: D6MWT = 0.79 admission 6MWT Primary predictors for D BBS day 0.68 admission 6MWT 1.6 age steps/1000 day 39 gender + steps/1000 RIC:DBBS = 6.0 day 0.72 admission BBS [cortical] 0.10[duration] + 16 MFB: DBBS = 2.2 Charlson comorbidity index 5.8 [gender] 29 7

8 Leadership: Organizational goals/vision Integrate into routine clinical practices/processes Standardized testing day (phased out the RA) Weekly reporting in team conference Journal club / education inservices Modification of EMR in process Integrated into new hire orientation on the floor Acknowledgements Locomotor Recovery Laboratory Principal Investigator: T. George Hornby PT, PhD Staff Patrick Hennessy MPT, NCS Jane Woodward, DPT, NCS Mark Connolly, BS Chris Henderson PT, PhD Carey Holleran PT, DHS, NCS Funding Agency: Department of Health and Human Services, National Institute on Disability, grant number (H122B and H133B140012) Administrators/Physicians Elliot Roth, MD Richard Harvey, MD Linda Lovell, BS Larissa Swan, OT Mary Free Bed Rehabilitation Hospital John Butzer, MD Roberta Virva, PT Lauren Lenca, PT Wes Selby 24 8