1. Physical Therapy and Patient Discharge
Case
Scenario
Problem
Statement
Current
Situation
A
percentage
of
hospital
discharge
delays
are
due
to
the
delay
in
physical
therapy
recommendations.
Workflow
Patient is a 74 year-­‐old female with a past medical history of type 2
diabetes, COPD, and HTN, who was admitted for community-­‐acquired
pneumonia. She was initially hypoxic on room air, requiring 2-­‐4L
oxygen via nasal cannula. She was treated with IV ceftriaxone and
azithromycin, and improved over the course of 72 hours.
Social Hx: Patient lives at home in Canton, MI with her husband. She is
independent in all ADLs. She quit smoking 20 years ago, but previously
had a 30 pack-­‐year smoking history.
On morning of anticipated discharge, patient mentions that she feels
unsteady on her feet after spending 3 days in bed.
Physical
therapy
consulted
STAT
following
morning
rounds
at
10:30am.
Physical
therapy
evaluates
patient
at
3:00pm
and
they
place
a
note
at
3:45pm,
recommended
SAR
placement
Case
management
sends
out
patient’s
information
to
surrounding
facilities,
but
it
is
too
late
in
the
day
for
patient
to
be
placed
Patient
discharged
to
SAR
the
following
day
John Le1, Daniel Dunlap2, Mark Foster2, Jessica Parsh2, Megan Shetty2, Ruo Zhu2
1University of Michigan School of Dentistry, Ann Arbor, MI
2University of Michigan Health System, Department of Internal Medicine, Ann Arbor, MI
Created
a
survey
for
case
managers
Scope
of
Problem
“…there is often a delay because updated PT and OT notes are needed to submit for insurance authorization;; It takes a lot
of time between getting an order for the PT and OT;; then having to get them to see the patient AND write a note that can be
submitted to the insurance company.”
“Having PT assigned to treatment team earlier would be helpful to communicate care needs, notes posted in a timely
fashion”
-­ Reviewed charts of all patients admitted to the Newburgh
and four General Medicine Services from Monday, June 8
to Friday, June 12, 2015.
-­ Evaluated for: 1) admission and discharge dates, 2)
whether PT consult was placed, 3) when the PT consult
was placed (time, date, day of week), 4) whether the PT
consult was placed with the admission orders, 5) when the
PT note was filed, and 6) PT recommendations for
discharge
• 67/96 patients (70%) had a Physical Therapy consult
placed
• 4/67 consults (6%) were STAT or discharge pending;; the
rest were routine
• 44/67 consults (66%) were placed on admission – often
before the patient was ever seen
• Average completion time for routine PT consult: 32 hours
• Average completion time for STAT PT consults: 7-­10 hours
Home,
11
Needed
placement2
3
Other,
5
Did
not
need
evaluation,
4
Home
with
assist,
24
Order
placed
on
admission,
44
Order
placed
late,
23
Timing
of
PT
orders PT
recommendations
27:50:00
24:22:14
22:52:16 23:33:45
38:39:18
66:00:00
37:39:10
0:00:00
12:00:00
24:00:00
36:00:00
48:00:00
60:00:00
72:00:00
84:00:00
Sun Mon Tue Wed Thu Fri Sat
Day
of
week
consult
placed
Time
to
complete
PT
consult
(hrs)
Methods
Results
Goals
for
Improvement
• Decrease the number of inappropriate reasons for physical therapy consults by 50% in 3 months
• PT pocket card
• MiChart PT order set changes
• Decrease the number of unnecessary consults by 50% in 3 months
• Dot phrase for disposition section: “.DISPO”
• Avoid an increase in the incidence of “STAT” consults
• Dot phrase for disposition section
• For routine consults, decrease the time from original consult to note with physical therapy recommendations to less than 24
hours (time should not increase by our interventions)
• MiChart PT order set changes
Acknowledgements
• Faculty Mentor: David Stewart, MD
• Jill Quarles from Physical Therapy
• Case management: Cathie Dixon, Jean Kledzik, Carolyn
Boyle