Posted by on | Featured

Using Outcome Measures Remotely to Prevent hospital admissions & flatten the curve

Share on facebook
Share on twitter
Share on linkedin
Share on email
Ben Kenuk, PT, DPT

Ben Kenuk, PT, DPT

Physical therapists have long been an important player in preventing hospital admissions which, in the last few years, has become a key measure of our value. Today, COVID-19 has given rise to new challenges that are increasing the likelihood of re-hospitalization as well as limiting the effectiveness of traditional prevention strategies (Table 1). 

As hospitals continue to push for earlier discharge to prepare for an influx of COVID cases, patients are returning home with greater needs than ever for post-acute care but are not receiving the services required to keep them home safely due to the psychological effects of COVID-19. Home health physical therapists are being turned away at the door and some patients and caregivers are even declining medical equipment due to a fear of contamination. As a result, more and more patients are being re-hospitalized in critical condition, sparking a cycle that will certainly prolong and worsen the already devastating impact of COVID-19. 

Factors Increasing Readmissions due to COVID-19
  • Increased acuity/complexity of patients due to hospitals pushing for earlier discharge
  • Greater functional impairments and higher risk of falling due to refusal of rehab facility placement prior to returning home
  • Lack of necessary equipment to improve mobility/safety due to fear of contamination
  • Lack of post-acute follow-up due to refusal of home health services
Barriers to Preventing Readmissions due to COVID-19
  • Patients are refusing home health physical therapy due to fear of exposure
  • Home healthcare agencies are limiting number of therapy visits provided to minimize exposure and conserve personal protective equipment 
Table 1.

Since the psychological effects of COVID-19 will last long past the virus itself, it is critical that physical therapists step up and find new innovative ways to overcome these challenges in order to reduce hospital readmissions and ultimately minimize the impact of the virus in terms of both magnitude and duration. Otherwise, we jeopardize losing our position as a key stakeholder in healthcare, which is already being stress-tested by recent changes to reimbursement models.

Fortunately, advancements in research over the last decade have provided us with several outcome measures that allow us to accurately identify high-risk patients, establish measurable goals that are proven to prevent hospital admissions, and objectively monitor patient progress to ensure treatments are effective at achieving these goals. Three outcome measures in particular can easily and safely be administered remotely via Telehealth and/or by the patient’s family member. (A future article will cover appropriate outcome measures for patients who live alone.)

Gait Speed Test

The Gait Speed test is simple to perform, requires minimal equipment/space, and can independently predict an individual’s risk of being hospitalized. Individuals who walk ≤1.0 m/s and <0.83 m/s have a 17% and 43% greater risk of hospitalization within 1 year, respectively (Afilalo et al, 2018).

Instructions for caregiver:
  1. Measure and mark a 3 meter (9.8 ft) walkway.
  2. Have patient start standing 2 meters behind the first mark (allows time for acceleration).
  3. When you say “Go”, have patient walk at their comfortable pace at least 2 meters past the second mark (allows time for deceleration).
  4. Using a timer, measure the time from when their front foot crosses the first mark until their front foot crosses the second mark.
  5. Make sure to guard the patient closely for safety.
  6. If patient’s time to walk 3-meters is ≥3 sec (or ≤1.0 m/s), they may have a greater risk of hospitalization. Notify your physical therapist.
Goals to guide plan of care:

  1. Short-term goals:

    • Increase gait speed by 0.11 m/s ⇒ 22% lower odds of 1-yr hospitalization (Chan et al, 2016)

    • Increase gait speed by 0.2 m/s ⇒ 38% lower odds of 1-yr hospitalization (Studenski et al, 2003)

  2. Long-term goal:

    • Increase gait speed to >1.0 m/s ⇒ Up to 500% lower risk of hospitalization (Afilalo et al, 2018; Studenski et al, 2003;Cesaru et al, 2005; Montero-Odasso et al, 2005)

5 Time Sit-to-Stand Test (5xSTS)

The 5xSTS test measures how quickly an individual can stand-up and sit-down 5 times in a row. Scores on this test have been shown to independently predict hospitalization risk. Cesari et a (2009) found that scores ≥17 sec are associated with a 30% greater risk of hospitalization. Furthermore, if an individual is unable to complete the test or scores >60 sec, their odds of frailty increases 6-fold (Batista et al, 2012). A systematic review from this year evaluated 15 studies involving 10,245 patients and found that frailty was associated with 2.3x greater risk of hospital readmission (Xu et al, 2020).

Instructions for caregiver:
  1. Have patient sit in a standard chair with arms crossed over chest.
  2. Instruct patient to stand-up without using their arms. If they are unable to stand without using their arms, stop the test now and notify your PT. Patient may have a 6x greater risk of frailty and 2.3x greater risk of hospitalization.
  3. If the can stand without using arms, using a stop watch, measure how long it takes them to stand up and sit-down 5 times in a row as quickly and safely as they can. Make sure to guard patient closely for safety.
  4. Start timer at command “Go.” Stop timer when buttocks touch seat after 5th stand.
  5. Write down the score and notify the patient’s PT.
Goals to guide plan of care:
  1. Short-term goals:
    • Improve 5xSTS score by 2.5 seconds ⇒ minimal change in score required to experience a noticeable improvement in function (Duncan et al, 2011; Meretta et al, 2006)
  2. Long-term goal:
    • Improve 5xSTS score to <17 sec ⇒ lower risk of hospitalization (Cesari et al, 2009)

6-Minute Walk Test (6MWT)

The 6MWT measures the total distance an individual is able to walk in 6 minutes. This test is typically completed using a 50-100 ft walkway but can be modified for household distances as necessary. Individuals who walk ≤360 and ≤240 meters in the 6-minutes have a 44% and 73% greater risk of hospitalization within 9 months, respectively (Ferreira et al, 2019).

Instructions for caregivers:
  1. Measure and mark a clear walking path (should be at least 3 meters [9.8 ft]).
  2. Have patient start standing at one end. When you say “Go”, have patient walk back and forth for 6 minutes. The patient can stop to rest but don’t stop the timer. Keep track of how many laps are completed to calculate their total distance walked.
  3. Make sure to guard closely and have a chair nearby for safety.
  4. Final score is the total distance walked in the 6 minutes. 
  5. Individuals who walk ≤240 meters (or ≤787 ft) in 6 min may be at a higher risk for hospitalization. Notify the physical therapist.
Goals to guide plan of care:
  1. Short-term goals:
    • Increase distance by 5% ⇒ 6% lower odds of 1-yr hospitalization per each 5% increase from baseline score (Ruhl et al, 2017)
  2. Long-term goal:
    • Increase distance to >360 meters ⇒ Lower risk of hospitalization in the next 9 months (Ferreira et al, 2019)
  •  

SUMMARY

COVID-19 has given rise to new challenges that are increasing the likelihood of re-hospitalization as well as limiting the effectiveness of traditional prevention strategies. It is critical that physical therapists step up and find new ways to overcome these challenges in order to reduce hospital readmissions and ultimately minimize the impact of the virus. To do this, physical therapists can use outcome measures remotely, via Telehealth, to identify high-risk patients and set treatment goals that are proven to reduce the risk of hospitalization. 
 
To improve the efficiency and effectiveness of using outcome measures during the pandemic, we are offering full access to the MOBILE MEASURES app FREE for 3 months. Please email ben@mobilemeasures.org to receive access to this offer. 
 

REFERENCES

  1. Duncan RP, Leddy AL, et al. Five times sit-to-stand test performance in parkinson’s disease. Arch Phys Med Rehabil. 2011;92(9):1431-1436.
  2. Meretta B, Whitney S, Marchetti G, et al. The five times sit to stand test: responsiveness to change and concurrent validity in adults undergoing vestibular rehabilitation. Journal of Vestibular Research. 2006;16:233‐243.
  3. Xu W, Cai Y, Liu H, Fan L, Wu C. Frailty as a predictor of all-cause mortality and readmission in older patients with acute coronary syndrome : A systematic review and meta-analysis [published online ahead of print, 2020 Apr 27]. Wien Klin Wochenschr. 2020;10.1007/s00508-020-01650-9. doi:10.1007/s00508-020-01650-9
  4. Afilalo J, Sharma A, Zhang S, et al. Gait Speed and 1-Year Mortality Following Cardiac Surgery: A Landmark Analysis From the Society of Thoracic Surgeons Adult Cardiac Surgery Database. J Am Heart Assoc. 2018;7:e010139.
  5. Montero-Odasso M, Schapira M, Soriano E, et al. Gait velocity as a single predictor of adverse events in healthy seniors aged 75 years and older. Journals of Gerontology. 2005;A60(10): 1304-1309.
  6. Cesari M, Kritchevsky SB, Newman AB, et al. Added value of physical performance measures in predicting adverse health-related events: results from the health, aging, and body composition study. Journal of the American Geriatrics Society. 2009;57(2):251-259.
  7. Batista FS, Gomes GA, Neri AL, et al. Relationship between lower-limb muscle strength and frailty among elderly people. Sao Paulo Med J. 2012;130(2):102-108.
  8. Ferreira JP, Metra M, Anker SD, et al. Clinical correlates and outcome associated with changes in 6-minute walking distance in patients with heart failure: findings from the BIOSTAT-CHF study. European Journal of Heart Failure. 2019.
  9. Chan KS, Friedman LA, Dinglas VD, et al. Evaluating physical outcomes in ARDS survivors: validity, responsiveness & minimal important difference of 4-meter gait speed test. Critical Care Medicine. 2016;44(5):859-868.
  10. Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51(3):314-322.
  11. Cesari M, Kritchevsky SB, Penninx BWHJ, et al. Prognostic value of usual gait speed in well-functioning older people. Results from the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2005; 53:1675-1680.
  12. Ruhl AP, Huang M, Colantuoni E, et al. Healthcare Resource Use and Costs in Long-Term Survivors of Acute Respiratory Distress Syndrome/ A 5-Year Longitudinal Cohort Study. Crit Care Med. 2017;45(2)/196–204. doi/10.1097/CCM.0000000000002088.
Comments are closed.