Reasons for Extending Length of Stay in Inpatient Spinal Cord Rehabilitation

Transcription

1 Reasons for Extending Length of Stay in Inpatient Spinal Cord Rehabilitation September 5, 2012 Heather Flett MSc, BScPT, BA Advanced Practice Leader- Spinal Cord Rehab Toronto Rehab UHN, University of Toronto, Department of Physical Therapy

2 Co-Investigators Jennifer Yee 1, MScN, BScN Kristina Guy 1,2, MSc, BScPT Natalie Cournoyea 1, MA, BScN Joanne Zee 1, BScPT Dr. Anthony Burns 1,3, MD, MSc 1. Toronto Rehab University Health Network 2. University of Toronto, Department of Physical Therapy 3. University of Toronto, Faculty of Medicine

3 Background Improving patient flow & access is a priority across health care jurisdictions Significant focus on acute LOS (New, 2012) Early admission to rehab is important prognostic indicator of functional outcome (Scivoletto, 2005) Pressure to rehab LOS yet little focus on 2 nd bottleneck in the system Discharge from inpatient rehab (New, 2012)

4 Rationale Toronto Rehab: 57-bed free-standing dedicated SCI rehab program with 3 distinct clinical teams Historically, functional outcomes (FIM) had met or exceeded benchmarks however LOS exceeded national average In 2010, quality improvement efficiency exercise initiated focusing on LOS while maintaining clinical outcomes (Burns, 2012) Simultaneously focused on identifying key barriers to discharge from inpatient rehab

5 Objective: To examine the reasons that length of stay (LOS) were extended in an inpatient spinal cord injury rehabilitation (SCR) program

6 Methods Benchmarking of SCR LOS conducted Can. Institute for Health Information National Rehab Reporting System (NRS) NRS categorizes Spinal Cord Dysfunction into Rehab Patient Groups (RPG) based on: 1) Etiology - traumatic, non-traumatic 2) Admission motor FIM * score 3) Age Target LOS set for RPGs based on national average Tentative discharge date calculator created *FIM instrument, data set & impairment codes referenced herein are property of Uniform Data System for Medical Rehabilitation, a division of University Buff(UB) Foundation Activities Inc.

7 Tentative D/C date Calculator Admission Motor FIM Age (yrs) Traumatic N/A 125 Non- Traumatic < > N/A N/A < > N/A N/A 23 Target LOS

8 D/C Decision & Tracking Tools Formalized d/c criteria developed D/C criteria and team consultation used to identify common reasons for extending LOS Patient Census Tool implemented to record target LOS and to systematically track when LOS extended and reasons for LOS extension

9 Reasons for Extending LOS 1. Requires inpatient specialized SCI rehab 2. Community services unavailable or insufficient 3. D/C living environment : a) Waitlist for institutional or attendant care b) Home modifications 4. Equipment not yet prescribed due to : a) Pt. status changing b) D/C address not determined c) Pt. &/or family readiness 5. Prescribed equipment not ready due to: a) Funding not secured b) Vendor/supplier delays 6. Service interruptions 7. Logistics

10 RESULTS

11 Study Cohort April 4, 2011 through June 26, 2012 Mean age = 51.3 years Admissions n (%) Average LOS Non-traumatic 162 (60%) 55 days* Traumatic 108 (40%) 83 days Total days *p=

12 % pts whose LOS exceeded target 60% 50% 40% * p-value = % 20% 10% 43% n=116 50% n=81 32% n=35 0% Entire Cohort ( n = 270) Non-Traumatic (n = 162) Traumatic (n = 108) Note: 3 days = met LOS target

13 Incidence of multiple reasons for LOS extension 30% % patients with 2 reasons for LOS extension 25% 20% 15% 10% 5% 18% (n=49) 19% (n=31) 17% (n=18) 0% Entire Cohort ( n = 270) Non-Traumatic (n = 162) Traumatic (n = 108)

14 Frequency of Reasons for LOS Extensions 70 Discharge Barriers Requires inpatient resources 8 Lack of Community Services Discharge Living Environment Equipment Availability Service Interruptions Logistics

15 Discharge Barriers Equipment Availability (n = 57) n=8 Not prescribed - Changing pt status n=16 Not prescribed - D/C address pending n=15 Not prescribed- Pt/family readiness n=7 Prescribed - Funding unavailable n=11 Prescribed - Vendor delays

16 Discharge Barriers Discharge Environment (n = 36) n=12 Waiting for institutional placement n= 24 Home modifications

17 % patients Reasons for Extension: Non-trauma vs Trauma Entire Cohort * p= D/C Environment Equipment Non-traumatic Traumatic

18 Discussion Non-traumatic patients more frequently required LOS extension due to need for further inpatient rehab Non-traumatic patients have been found to have shorter LOS (Al-Jadid, 2010, McKinley, 2001), however may actually need longer LOS to achieve same outcomes (Craven, 2011) Although lack of institutional & supportive housing was previously thought to be most significant d/c barrier, delays for equipment & home modification were more frequent in this cohort. Several factors contributed to delays in equipment prescription and provision

19 Future Directions Refinement of LOS targets Categorize reasons into intrinsic (intraorganizational) & extrinsic (extraorganizational) factors (New, 2012) Develop strategies to address intrinsic factors within our control Examine opportunities for health-system advocacy to address extra-organizational factors

20 Conclusions Objectively setting targets and monitoring LOS while examining the underlying reasons for extending LOS has provided insight into patient needs and barriers to discharge Provides the foundation for further initiatives to improve patient flow and experience across the continuum

21 Acknowledgements We would like to acknowledge the staff of the Toronto Rehab Spinal Cord Program for their support and commitment to this initiative

22 Volumes Days Volumes and Average LOS (ALOS) FY: 256 Q4: Q1-3: FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 0 Volumes ALOS Source: NRS

23 FIM Change (Avg) Program FIM Change Source: NRS