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

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
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
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Opened in 1937
Inpatient and outpatient programs
Central and Toronto Central LHINs
One of Sunnybrook’s eight programs since 2012
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
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
•  more clinicians see fewer patients for more time
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Weekend Staffing
Increased weekend therapy
Previous
FTE
Revised
FTE
OT
1
1
PT
1
2
OTA/PTA
3
3
SLP
0
1 (Sat only)
•  Increased therapists to complete assessments to start
treatment earlier
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Treatment Models
Increased 1:1 time between therapist and patient
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
Group therapy:
•  Seen as still being beneficial
•  Does not specifically fall under the rehab intensity definition of
individualized, direct, task-specific therapy
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Treatment Models
Created a dual role for OTA/PTA:
Previous
Revised
Separate OTA and PTA staff
Dual role
Separate working shifts dedicated
Able to work across different roles
across a given shift
•  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
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Therapy Space
Increased available therapy space
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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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
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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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Therapy Space
Stroke Cohort
•  Created a cohort of stroke beds on mixed unit
Previous
Revised
•  Mixed unit
•  Stroke cohort 12- 16 beds on one
side of the unit
•  Geographically defined co-location of stroke patients
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Team Communication
•  Multiple structured interprofessional communication
processes
Previous
Revised
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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
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Sub-teams – informal, streamlined and regular
communication on a daily basis
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Stroke Huddles to be done day 2-3
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IPC rounds : Shared rotating facilitation
Multiple venues for team communication
Consistency of messages to patients and families
360o view of patient shared
Discharge planning initiated started day 2-3
Team Communication
•  Sub-Teams
Previous
Revised
•  Mixed OT/PT/SLP/nursing
•  Clinicians crossed over
•  Sub-teams of OT/PT/SLP/Nurse
•  Each team presents their patients
in rounds
•  Consistency in patient care plans/patient goals with all team
members
•  Daily communication more efficient between sub-team members
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Stroke Sub-teams
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Team Communication
Stroke Huddles
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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
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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Team Communication
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
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Early D/C Planning
Day 2-3
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Day 4-5
Day 5-7
Severity of stroke
identified
Early discharge
planning initiated
Collaboration
with patient/
family
Length of stay
discussed
Discharge Date
(target)
Admission NRS
scores entered
RPG level
determined
Max LOS
determined
Striving towards Rehab Intensity
with Individual Care Plans
Stroke
Huddles
•  Dividing 180 mins across
OT/PT/SLP
Patient A
-  More cognitive issues
-  80/40/60 minutes
SubTeams
Rehab
Intensity
Patient B
-  More speech issues
-  40/60/80 minutes
Weekly RI
reports
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IPC
rounds
Caseload
Boards
Snap shot of a patient’s day at our
best…..
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0800 hrs
Nursing
1500 hrs
Walking
program
10 mins
0845 hrs
ADL training
15-30 mins
0945 hrs
Medical
Rounds
RI = 235 mins
1000 hrs
OT therapy
60 mins
1400 hrs
SLP therapy
30 mins
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1300 hrs
PT therapy
60 mins
1100 hrs
SLP therapy
60 mins
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
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May 30, 2016
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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Face to Face Workload minutes per pa5ent per day for OT, PT and SLP (includes weekends) 140 120 Minutes 100 80 60 40 20 0 F2010 F2011 F2012 F2013 Fiscal Year 34
F2014 F2015 Q1 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
[email protected]
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Questions
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