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Expedite Discharge & Prevent Hospital Readmissions: Evidence-Based Strategies for COVID Therapy Teams

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As I reflect on my first few weeks as a member of the “COVID Therapy Team” at the Hospital of the University of Pennsylvania, I am able to recognize how important our role is in addressing the problems that patients and healthcare systems are currently facing (and are likely to face) during and after the pandemic. In the acute care setting, physical therapists have a direct impact on expediting discharge and preventing hospital readmissions. Although this is no different from our usual role, the effectiveness and efficiency by which we accomplish these goals is much more significant in the midst of a pandemic. 
In the last few weeks, several guidelines have been published outlining recommendations to assist the physical therapy workforce in managing patients with COVID-19. These guidelines highlight the importance of minimizing unnecessary exposure to the virus as well as minimizing unnecessary use of personal protective equipment (PPE).  It is recommended that physical therapists should not enter isolation rooms just to screen referrals, but rather exhaust all indirect options prior to evaluating and treating at bedside.
Lacking from the recommendations, however, are specific strategies to expedite discharge and prevent hospital readmissions while minimizing exposure/PPE use after it is confirmed that the patient is in fact appropriate for physical therapy services. 
In my (biased) opinion, the best way to do this is to utilize outcome measures early and throughout the patient’s episode of care. By doing this, we can establish specific goals that have been proven to expedite discharge and prevent hospital readmissions as well as objectively monitor our patient’s progress to ensure the interventions we provide are effective at meeting those goals.
Although there have not yet been any studies published on outcome measures specifically for patient’s with COVID-19, we can extrapolate the research that is available on similar populations to assist with our decision making. 

Useful Outcome Measures for Patients with COVID-19

1) Short Physical Performance Battery (SPPB)

The SPPB is a composite of 3 physical performance tests: standing balance, gait speed, and repeated chair stands. The SPPB is a feasible and safe method to evaluate the functional status of patients with acute respiratory distress syndrome (ARDS) and acutely ill geriatric patients admitted to the hospital. Furthermore, research has has shown that the SPPB can accurately predict hospital length of stay (LOS), risk of hospital readmission, and overall functional prognosis. From this, physical therapists can establish short- and long-term goals for their patients to guide their plan of care.

Evidence-Based Goal Setting

  • Increase SPPB score by 1 point.

    • Volpato et al (2008) found that per each 1 point increase was associated with a 0.5-day reduction in hospital LOS.
    • Volpato et al (2011) found that per each 1 increase was associated with a 14% lower odds of hospital readmission.

  • Increase SPPB score to at least ≥7 out of 12 points.

    • Gandotra et al (2019) found that in patients with ARDS, those with intermediate physical function (SPPB 7-9) at discharge showed rapid improvement to high physical function (SPPB 10-12) by 2 months, which was sustained at 6 months.
    • Volpato et al (2011) found that in hospitalized older adults, those with scores >7/12 at discharge were less likely to experience worsening ADL (activities of daily living) function in the next month.


Try it out free on the Mobile Measures app!



2) Gait Speed Test

Gait speed, a component of the SPPB, has been studied independently in patients with ARDS and can provide important prognostic information for this population. From this research, physical therapists can create evidence-based short- and long-term goals to guide their plan of care for patients with COVID-19 in order to expedite discharge and recovery and prevent hospital readmissions.

Evidence-Based Goal Setting

  • Increase gait speed by 0.11 m/s score by 1 point.

    • Chan et al (2016) found that in patients with ARDS, per each 0.11 m/s faster was associated with:
      • 56% lower odds of future mortality
      • 22% lower odds of hospital readmission
      • 34% higher odds of returning to normal activity
      • Higher self-reported physical function and health-related quality of life

  • Increase gait speed by 0.03-0.06 m/s

    • Chan et al (2018) found an increase in gait speed of 0.3-0.6 m/s is the minimum required for patients with ARDS to experience a noticeable improvement in function.

  • Increase gait speed to ≥1.0 m/s

    • Files et al (2018) found that in critically ill patients, per each 0.1 m/s slower than 1.0 m/s was associated with 13% and 18% greater odds of 30-day and 1 year mortality, respectively, after hospital discharge. 
    • Persons who walk >1.1 m/s are expected to have the energy capacity needed to perform household maintenance, whereas those walking <0.67 m/s are likely to be limited in the energy needed for self-care (Studenski, 2009)

3) 6-Minute Walk Test (6MWT)

The 6MWT is a valid measure of functional capacity for patients surviving ARDS. Changes in 6MWT distance have been shown to accurately predict risk of hospital readmission, functional prognosis, and even costs of follow-up care following hospitalization for ARDS. This information is critical for patients and healthcare systems given the financial impact of COVID-19.

Evidence-Based Goal Setting

  • Increase 6MWT distance by 5% from baseline. 

    • Rhul et al (2017) found that in patients with ARDS, each 5% increase was associated with:
      • 6% lower odds of hospital readmission
      • 7% lower follow-up care costs

  • Increase 6MWT distance by 30 meters.

    • Chan et al, 2015 found that in patients with ARDS, each 30 meter increase was associated with:
      •  16% lower odds of mortality
      • 9% lower odds of hospital readmission
      • 12% higher odds of returning to normal activity

4) Functional Status Score for the Intensive Care Unit (FSS-ICU)

The FSS-ICU is a reliable, valid, and responsive functional assessment designed specifically for patients in the ICU. The FSS-ICU includes 5 functional tasks (rolling, transfer from supine-to-sit, sitting at the edge of bed, transfer from sit-to-stand, and walking). Each task is scored from 0 (not able to perform) to 7 (complete independence) with a total FSS-ICU score range of 0 to 35.  The FSS-ICU has been shown to significantly predict duration of post-ICU hospital LOS, discharge location, and functional recovery (6,8).

Evidence-Based Goal Setting

  • Increase FSS-ICU score by 1 point.

    • Huang et al (2016) found that for a 1 point increase,
      • post-ICU hospital LOS decreased by 0.27 days, and
      • odds of discharge straight to home increased by 11%.

  • Increase FSS-ICU score to at least ≥16 out of 35 points.

    • Thomas et al (2016) found that, in patients with ICU acquired weakness, higher FSS-ICU scores independently predicted the chance of regaining independent sit-to-stand function.

SUMMARY

The ability of COVID Therapy Teams to expedite discharge and prevent hospital readmissions is critical to the success of our healthcare system during the current pandemic. To do this in a way that minimizes unnecessary exposure to the virus and unnecessary use of PPE, we must utilize outcome measures early and throughout every patient’s episode of care. The Short Physical Performance Battery, Gait Speed Test, and 6-Minute Walk Test are three outcome measures that may be useful for COVID Therapy Teams to achieve these goals.
 
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 to anyone who is working with COVID-19 patients. Please email ben@mobilemeasures.org to receive access to this offer. 
 

REFERENCES

  1. Chan KS, Aronson Friedman L, Dinglas VD, et al. Evaluating Physical Outcomes in Acute Respiratory Distress Syndrome Survivors: Validity, Responsiveness, and Minimal Important Difference of 4-Meter Gait Speed Test. Crit Care Med. 2016;44(5):859–868. doi:10.1097/CCM.0000000000001760
  2. Chan KS, Mourtzakis M, Aronson Friedman L, et al. Evaluating Muscle Mass in Survivors of Acute Respiratory Distress Syndrome: A 1-Year Multicenter Longitudinal Study. Crit Care Med. 2018;46(8):1238–1246. doi:10.1097/CCM.0000000000003183
  3. Chan KS, Pfoh ER, Denehy L, et al. Construct validity and minimal important difference of 6-minute walk distance in survivors of acute respiratory failure. Chest. 2015;147(5):1316–1326. doi:10.1378/chest.14-1808
  4. Files DC, Neiberg R, Rushing J, et al. Influence of Prehospital Function and Strength on Outcomes of Critically Ill Older Adults. J Am Geriatr Soc. 2018;66(3)/525–531. doi/10.1111/jgs.15255
  5. Gandotra S, Lovato J, Case D, et al. Physical Function Trajectories in Survivors of Acute Respiratory Failure. Ann Am Thorac Soc. 2019;16(4):471–477. doi:10.1513/AnnalsATS.201806-375OC
  6. Huang M, Chan KS, Zanni JM, et al. Functional Status Score for the ICU: An International Clinimetric Analysis of Validity, Responsiveness, and Minimal Important Difference. Crit Care Med. 2016;44(12):e1155–e1164. doi:10.1097/CCM.0000000000001949
  7. 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.
  8. Thomas S, Burridge JH, Pohl M, Oehmichen F, Mehrholz J. Recovery of sit-to-stand function in patients with intensive-care-unit-acquired muscle weakness: results from the General Weakness Syndrome Therapy cohort study. J Rehabil Med. 2016;48(9):793–8. doi: 10.2340/16501977-2135.
  9. Volpato S, Cavalieri M, Guerra G, et al. Performance-based functional assessment in older hospitalized patients: feasibility and clinical correlates. J Gerontol A Biol Sci Med Sci. 2008;63(12):1393-1398.
  10. Volpato S, Cavalieri M, Sioulis F, et al. Predictive value of the short physical performance battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci. 2011;66(1):89-96.
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