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
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
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)
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
Objective: To examine the reasons that length of stay (LOS) were extended in an inpatient spinal cord injury rehabilitation (SCR) program
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.
Tentative D/C date Calculator Admission Motor FIM Age (yrs) Traumatic 12-16 N/A 125 Non- Traumatic 17-41 <30 92 17-41 >31 83 42-84 N/A 44 12-28 N/A 76 29-54 <50 63 29-54 >51 46 55-72 N/A 29 73-84 N/A 23 Target LOS
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
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
RESULTS
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 270 66 days *p=0.00001
% pts whose LOS exceeded target 60% 50% 40% * p-value = 0.0057 30% 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
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)
Frequency of Reasons for LOS Extensions 70 Discharge Barriers 60 50 63 57 40 30 36 20 10 0 Requires inpatient resources 8 Lack of Community Services Discharge Living Environment Equipment Availability 13 12 Service Interruptions Logistics
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
Discharge Barriers Discharge Environment (n = 36) n=12 Waiting for institutional placement n= 24 Home modifications
% patients Reasons for Extension: Non-trauma vs Trauma 35 30 Entire Cohort 25 20 15 * p=0.0032 D/C Environment Equipment Non-traumatic Traumatic 10 5 0
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
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
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
Acknowledgements We would like to acknowledge the staff of the Toronto Rehab Spinal Cord Program for their support and commitment to this initiative
Volumes Days Volumes and Average LOS (ALOS) 300 90 250 81 84 70 FY: 256 Q4: 64 68 80 70 200 60 150 100 226 232 246 Q1-3: 192 50 40 30 50 20 10 0 FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 0 Volumes ALOS Source: NRS
FIM Change (Avg) Program FIM Change 32 31 31.3 31.1 30 29 28 27 26 27.2 26.1 25 24 23 2008-2009 2009-2010 2010-2011 2011-2012 Source: NRS