An acute care physical therapy clinical practice database for outcomes research

An Improvement in Knee Disability does not Mean an Improvement in Functional Status in Geriatric Patients after Total Knee Arthroplasty

Purpose: We aimed to investigate the relationship between the change in knee disability and change in functional status from before bilateral total knee arthroplasty (TKA) to discharge in geriatric patients. Methods: We retrospectively analyzed the data of 88 patients who underwent bilateral TKA. Before surgery and at discharge, the knee disability and functinal status of the patients were assessed using the Hospital for Special Surgery (HSS) knee score and the Iowa Level of Assistance Scale (ILAS), respectively. The Spearman correlation test was used to assess the correlation between the change in the HSS knee score and the change in the ILAS score. Results: A statistically significant difference was found in the HSS knee score between before surgery and at discharge (p0.05). A moderate relationship was found between the change in the HSS knee score and the change in the ILAS score (r = –0.48, p

Dietetics in the digital age: The impact of an electronic medical record on a tertiary hospital dietetic department

AIM

The present study aimed to assess the impact of a hospital-wide electronic medical record (EMR) on the way dietitians collect routine data for their assessments and its impact on their clinical documentation and service provision.

METHODS

Data were collected retrospectively from the following sources: interdepartmental chart audit, the EMR itself (nutrition diagnosis), National Health Roundtable database (admissions requiring nutrition events) and the hospital-wide Pressure Injury Prevention Audits (height, weight and malnutrition screening).

RESULTS

There were improvements in medical record accessibility (76.4% pre vs 100% post, P < 0.001), awareness of medical alerts (82.5% unaware pre vs 34.5% unaware post) and legibility of documentation (53.8% pre vs 99.2% post, P < 0.001). Improvements in accessing medical charts under 1 minute also occurred (65.8% pre vs 99.2% post, P < 0.001). The percentage of nutrition diagnoses resolved during admission increased from 20.0% in February 2016 to 34.0% in August 2017. A 72.0% increase in admissions requiring nutrition interventions was found with 4075 admissions pre- and 7035 post-EMR implementation. Time spent per nutrition event reduced by 22.0% (118 minutes pre and 92 minutes post). Hospital audit data revealed mean height and weight collected increased from 79.3 ± 3.8% (n = 8 audits totalling 3041/3834 patients) to 86.0 ± 2.6% (n = 5 audits totalling, 2544/2958 patients) post-EMR with malnutrition screening completion increasing from 57.5% to 74.0%.

CONCLUSIONS

Findings indicate that EMR implementation has the potential to benefit the dietetic profession due to the potential to enhance the capacity and efficiency of dietetic departments.

Breaking Down Barriers to the Utilization of Standardized Tests and Outcome Measures in Acute Care Physical Therapist Practice: An Observational Longitudinal Study

BACKGROUND

Standardized tests and outcome measures (STOM) have not been consistently implemented as part of most physical therapists' practice. Incidence of STOM use among physical therapists at Beth Israel Deaconess Medical Center was similar to low levels cited nationally among acute care physical therapists. Targeted knowledge translation (KT) strategies have been suggested to promote the application of research evidence into clinical decision making.

PURPOSE

The purpose of this quality improvement (QI) effort was to implement a series of interventions aimed at increasing both use and interpretation of STOM by physical therapists practicing in acute care.

DESIGN

This study used an observational longitudinal design.

METHODS

A literature review identified current barriers and facilitators to the use of STOM by physical therapists. KT strategies were tailored to the practice setting in order to target barriers and promote facilitators to the use of STOM. Data were collected through retrospective chart review at baseline and then subsequently at 4 periods following the implementation of the QI project.

RESULTS

A statistically significant increase in both the use (primary outcome) and interpretation (secondary outcome) of STOM was observed following the implementation of KT strategies. The increase was sustained at all subsequent measurement periods.

LIMITATIONS

Limitations include the lack of a control group and the small number of setting- and diagnosis-specific STOM available for use by physical therapists practicing in acute care.

CONCLUSIONS

Implementation of KT strategies was associated with an increase in the frequency of use and interpretation of STOM. Similar QI efforts are feasible in any acute care physical therapy department and potentially other settings.

Turning Over the Hourglass

Richard K Shields, PT, PhD, has contributed to the physical therapy profession as a clinician, scientist, and academic leader (Fig. 1 ).

Dr Shields is professor and department executive officer of the Department of Physical Therapy and Rehabilitation Science at the University of Iowa. He completed a certificate in physical therapy from the Mayo Clinic, an MA degree in physical therapy, and a PhD in exercise science from the University of Iowa.

Dr Shields developed a fundamental interest in basic biological principles while at the Mayo Clinic. As a clinician, he provided acute inpatient care to individuals with spinal cord injury. This clinical experience prompted him to pursue a research career exploring the adaptive plasticity of the human neuromusculoskeletal systems. As a scientist and laboratory director, he developed a team of professionals who understand the entire disablement model, from molecular signaling to the psychosocial factors that impact health-related quality of life. His laboratory has been continuously funded by the National Institutes of Health since 2000 with more than \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}${\$}$\end{document} 15 million in total investigator-initiated support. He has published 110 scientific papers and presented more than 300 invited lectures.

A past president of the Foundation for Physical Therapy, Dr Shields is a Catherine Worthingham Fellow of the American Physical Therapy Association (APTA) and has been honored with APTA’s Marian Williams Research Award, the Charles Magistro Service Award, and the Maley Distinguished Research Award. He also received the University of Iowa's Distinguished Mentor Award, Collegiate Teaching Award, and the Regents Award for Faculty Excellence.

Dr Shields is a member of the National Advisory Board for Rehabilitation Research and serves as the liaison member on the Council to the National Institute for Child Health and Human Development.

Assessing functional recovery shortly after knee or hip arthroplasty: a comparison of the clinimetric properties of four tools

BACKGROUND

Following hip or knee arthroplasty, it is clinically warranted to get patients functional as quickly as possible. However, valid tools to assess function shortly after knee or hip arthroplasty are lacking. The objective was to compare the clinimetric properties of four instruments to assess function shortly after arthroplasty.

METHODS

One hundred eight patients undergoing hip or knee arthroplasty were assessed preoperatively, 1 and 2 days postoperatively, and 2 and 6 weeks postoperatively with the Timed Up and Go (TUG), Iowa Level of Assistance Scale (ILAS), Postoperative Quality of Recovery Scale (PQRS), and Readiness for Hospital Discharge Scale (RHDS). Descriptive data, floor and ceiling effects, responsiveness, interpretation and construct validity were determined.

RESULTS

Only the ILAS and RHDS support subscale demonstrated floor or ceiling effects. A large deterioration from preoperative to postoperative, followed by large improvements after surgery were seen in the TUG and ILAS scores. The RHDS personal status subscale and the PQRS pain and function dimensions demonstrated large improvements after surgery. Changes in the RHDS global scale and personal status subscale, PQRS pain dimension and TUG were significantly related to patient perceived improvement. Minimal important changes were obtained for the RHDS global (1.1/10) and personal status subscale (2.3/10), and the TUG (43.4 s at 6 weeks). For construct validity, the PQRS function dimension and RHDS were moderately related to the TUG or ILAS. The correlation between TUG and ILAS was high from preoperative to postoperative day 2, but substantially decreased at 2 and 6 weeks.

CONCLUSIONS

The TUG and RHDS personal status subscale demonstrated the best clinimetric properties to assess function in the first 6 weeks after hip or knee arthroplasty.

Predicting early clinical function after hip or knee arthroplasty

Objectives

Patient function after arthroplasty should ideally quickly improve. It is not known which peri-operative function assessments predict length of stay (LOS) and short-term functional recovery. The objective of this study was to identify peri-operative functions assessments predictive of hospital LOS and short-term function after hospital discharge in hip or knee arthroplasty patients.

Methods

In total, 108 patients were assessed peri-operatively with the timed-up-and-go (TUG), Iowa level of assistance scale, post-operative quality of recovery scale, readiness for hospital discharge scale, and the Western Ontario and McMaster Osteoarthritis Index (WOMAC). The older Americans resources and services activities of daily living (ADL) questionnaire (OARS) was used to assess function two weeks after discharge.

Results

Following multiple regressions, the pre- and post-operative day two TUG was significantly associated with LOS and OARS score, while the pre-operative WOMAC function subscale was associated with the OARS score. Pre-operatively, a cut-off TUG time of 11.7 seconds for LOS and 10.3 seconds for short-term recovery yielded the highest sensitivity and specificity, while a cut-off WOMAC function score of 48.5/100 yielded the highest sensitivity and specificity. Post-operatively, a cut-off day two TUG time of 31.5 seconds for LOS and 30.9 seconds for short-term function yielded the highest sensitivity and specificity.

Conclusions

The pre- and post-operative day two TUG can indicate hospital LOS and short-term functional capacities, while the pre-operative WOMAC function subscale can indicate short-term functional capacities.

Cite this article: Bone Joint Res 2015;4:145–151.

Descriptive data analysis examining how standardized assessments are used to guide post-acute discharge recommendations for rehabilitation services after stroke

BACKGROUND

Use of standardized assessments in acute rehabilitation is continuing to grow, a key objective being to assist clinicians in determining services needed postdischarge.

OBJECTIVE

The purpose of this study was to examine how standardized assessment scores from initial acute care physical therapist and occupational therapist evaluations contribute to discharge recommendations for poststroke rehabilitation services.

DESIGN

A descriptive analysis was conducted.

METHODS

A total of 2,738 records of patients admitted to an acute care hospital with a diagnosis of stroke or transient ischemic attack were identified. Participants received an initial physical therapist and occupational therapist evaluation with standardized assessments and a discharge recommendation of home with no services, home with services, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF). A K-means clustering algorithm determined if it was feasible to categorize participants into the 4 groups based on their assessment scores. These results were compared with the physical therapist and occupational therapist discharge recommendations to determine if assessment scores guided postacute care recommendations.

RESULTS

Participants could be separated into 4 clusters (A, B, C, and D) based on assessment scores. Cluster A was the least impaired, followed by clusters B, C, and D. In cluster A, 50% of the participants were recommended for discharge to home without services, whereas 1% were recommended for discharge to an SNF. Clusters B, C, and D each had a large proportion of individuals recommended for discharge to an IRF (74%-80%). There was a difference in percentage of recommendations across the clusters that was largely driven by the differences between cluster A and clusters B, C, and D.

LIMITATIONS

Additional unknown factors may have influenced the discharge recommendations.

CONCLUSIONS

Participants poststroke can be classified into meaningful groups based on assessment scores from their initial physical therapist and occupational therapist evaluations. These assessment scores, in part, guide poststroke acute care discharge recommendations.

Interrater Reliability of AM-PAC "6-Clicks" Basic Mobility and Daily Activity Short Forms

BACKGROUND

The interrater reliability of 2 new inpatient functional short-form measures, Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" basic mobility and daily activity scores, has yet to be established.

OBJECTIVE

The purpose of this study was to examine the interrater reliability of AM-PAC "6-Clicks" measures.

DESIGN

A prospective observational study was conducted.

METHODS

Four pairs of physical therapists rated basic mobility and 4 pairs of occupational therapists rated daily activity of patients in 1 of 4 hospital services. One therapist in a pair was the primary therapist directing the assessment while the other therapist observed. Each therapist was unaware of the other's AM-PAC "6-Clicks" scores. Reliability was assessed with intraclass correlation coefficients (ICCs), Bland-Altman plots, and weighted kappa.

RESULTS

The ICCs for the overall reliability of basic mobility and daily activity were .849 (95% confidence interval [CI]=.784, .895) and .783 (95% CI=.696, .847), respectively. The ICCs for the reliability of each pair of raters ranged from .581 (95% CI=.260, .789) to .960 (95% CI=.897, .983) for basic mobility and .316 (95% CI=-.061, .611) to .907 (95% CI=.801, .958) for daily activity. The weighted kappa values for item agreement ranged from .492 (95% CI=.382, .601) to .712 (95% CI=.607, .816) for basic mobility and .251 (95% CI=.057, .445) to .751 (95% CI=.653, .848) for daily activity. Mean differences between raters' scores were near zero.

LIMITATIONS

Raters were from one health system. Each pair of raters assessed different patients in different services.

CONCLUSIONS

The ICCs for AM-PAC "6-Clicks" total scores were very high. Levels of agreement varied across pairs of raters, from large to nearly perfect for physical therapists and from moderate to nearly perfect for occupational therapists. Levels of agreement for individual item scores ranged from small to very large.

Recovery Time of Independent Poststroke Abilities: Part I

The purposes of this study were to determine the time of the recovery of poststroke abilities and to identify prognostic indicators associated with recovery time among stroke patients undergoing a rehabilitation program. A sample of 421 stroke participants admitted to a rehabilitation center was recruited from medical records that were available from January 1987 to December 1992. The mean age was 61.8 years (range, 17-89 years). The relationship between the achievement of independent poststroke abilities and the potential covariates associated with recovery time was assessed through the analysis of survival data. Cox maximum-likelihood proportional hazard models were used for the analysis. Independent poststroke abilities included behavior, cognitive, perceptual, communication, visual, and motor status. The time from rehabilitation admission to complete independence was introduced to the model in relation to the covariates. The mean time of recovery of poststroke abilities ranged from 18.70 to 32.40 days from the rehabilitation admission. The survival analysis revealed that the time of recovery of the selected poststroke abilities was significantly influenced (p <.05) by one or several factors, among these were neuropsychological, physical, and life habits. With this precious information, stroke rehabilitation specialists may be able to reduce the length of time required to recover independent poststroke abilities by treating the specific neuropsychological, physical, and life habit characteristics identified in this study. A faster poststroke recovery will reduce the socioeconomic impact generated by stroke disability and will ensure a better quality of life to the stroke survivor.

Functional Assessment and Intervention by Nursing Assistants in Hospice and Palliative Care Inpatient Care Settings

This study assessed the impact of a nursing assistant-led functional intervention in an urban hospice. Thirty-three patients participated. A physical therapist trained 4 nursing assistants to assess 4 basic functional activities at admission and discharge and to provide daily activity training to intervention group participants. Control group participants were assessed at admission and discharge and received the usual standard of care. Both groups improved. The intervention group participants demonstrated significant improvement in the Timed up and Go test as well as their self-reported ability to achieve goals on the Patient-Specific Functional Scale. Control group participants made significant improvements in the ability to move from supine to sit in bed. These findings suggest that nursing assistants can provide activity-based assessment and intervention leading to improved function among patients in hospice.

Validity of the AM-PAC "6-Clicks" inpatient daily activity and basic mobility short forms

BACKGROUND

Standardized assessment of patients' activity limitations in acute care settings can provide valuable information. Existing measures have not been widely implemented.

OBJECTIVES

The aim of this study was to provide evidence for validity of scores on Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measures of basic mobility and daily activity in acute care.

DESIGN

A retrospective measurement study was conducted.

METHODS

The study used a database from one health system containing "6-Clicks" scores from first and last physical therapist and occupational therapist visits for 84,446 patients. Validity was analyzed by examining differences in "6-Clicks" scores across categories of patient characteristics; the ability of "6-Clicks" scores to predict patients' having more than one therapy visit; correlation of "6-Clicks" scores with Functional Independence Measure (FIM) scores; and internal responsiveness over the episode of care. Internal consistency reliability also was determined.

RESULTS

The "6-Clicks" scores differed across patients' age, preadmission living situation, and number of therapy visits. The areas under receiver operating characteristic curves derived using "6-Clicks" scores at the first visit to predict patients receiving more than one visit were 0.703 and 0.652 using basic mobility and daily activity scores, respectively. The "6-Clicks" scores at the final visit were correlated with scores on subscales of the FIM completed on admission to inpatient rehabilitation facilities (r=.65 and .69). Standardized response means were 1.06 and 0.95 and minimal detectable changes with 90% confidence level (MDC90) were 4.72 and 5.49 for basic mobility and daily activity scores, respectively. Internal consistency reliability of basic mobility and daily activity scores was .96 and .91, respectively.

LIMITATIONS

Using clinical databases for research purposes has limitations, including missing data, misclassifications, and selection bias. Rater reliability is not known.

CONCLUSIONS

This study provides evidence for the validity of "6-Clicks" scores for assessing patients' activity limitations in acute care settings.

Clinician adherence to a standardized assessment battery across settings and disciplines in a poststroke rehabilitation population

OBJECTIVES

(1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence.

DESIGN

Retrospective cohort study.

SETTING

Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists).

PARTICIPANTS

Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence ≥5% and if so, how long the increase lasted.

RESULTS

Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P≤.001), with PT having the highest adherence across all 3 disciplines (P<.004). Of the 25 events conducted across the 17-month period to improve adherence, 10 (40%) resulted in a ≥5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month.

CONCLUSIONS

Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time.

Issues affecting the delivery of physical therapy services for individuals with critical illness

Research supports the provision of physical therapy intervention and early mobilization in the management of patients with critical illness. However, the translation of care from that of well-controlled research protocols to routine practice can be challenging and warrants further study. Discussions in the critical care and physical therapy communities, as well as in the published literature, are investigating factors related to early mobilization such as transforming culture in the intensive care unit (ICU), encouraging interprofessional collaboration, coordinating sedation interruption with mobility sessions, and determining the rehabilitation modalities that will most significantly improve patient outcomes. Some variables, however, need to be investigated and addressed specifically by the physical therapy profession. They include assessing and increasing physical therapist competence managing patients with critical illness in both professional (entry-level) education programs and clinical settings, determining and providing an adequate number of physical therapists for a given ICU, evaluating methods of prioritization of patients in the acute care setting, and adding to the body of research to support specific functional outcome measures to be used with patients in the ICU. Additionally, because persistent weakness and functional limitations can exist long after the critical illness itself has resolved, there is a need for increased awareness and involvement of physical therapists in all settings of practice, including outpatient clinics. The purpose of this article is to explore the issues that the physical therapy profession needs to address as the rehabilitation management of the patient with critical illness evolves.

High intertester reliability of the cumulated ambulation score for the evaluation of basic mobility in patients with hip fracture

OBJECTIVE

To examine the intertester reliability of the three activities of the Cumulated Ambulation Score (CAS) and the total CAS, and to define limits for the smallest change in basic mobility that indicates a real change in patients with hip fracture.

DESIGN

An intertester reliability study.

SETTING

An acute 20-bed orthopaedic hip fracture unit.

SUBJECTS

Fifty consecutive patients with a median age of 83 (25-75% quartile, 68-86) years.

INTERVENTIONS

The CAS, which describes the patient's independency in three activities - (1) getting in and out of bed, (2) sit to stand from a chair, and (3) walking ability - was assessed by two independent physiotherapists at postoperative median day 3. Each activity was assessed on a three-point ordinal scale from 0 (not able to) to 2 (independent of human assistance). The cumulated score for each activity provides a total CAS from 0 to 6, with 6 indicating independent ambulation.

MAIN MEASURES

Reliability was evaluated using weighted kappa statistics, the standard error of measurement (SEM) and the smallest real difference (SRD).

RESULTS

The kappa coefficient, the SEM and the SRD in the three activities and the total CAS were >or=0.92, <or=0.20 and <or=0.55 CAS points, respectively.

CONCLUSIONS

The intertester reliability of the CAS is very high, and a change of more than 0.20 and 0.55 CAS points for the total CAS indicates a real change in basic mobility, at group level and for an individual patient, respectively.

Structured electronic physiotherapy records

BACKGROUND

With the introduction of the electronic health record, physiotherapists too are encouraged to store their patient records in a structured digital format. The typical nature of a physiotherapy treatment requires a specific record structure to be implemented, with special attention to user-friendliness and communication with other healthcare providers.

OBJECTIVE

The objective of this study was to establish a framework for the electronic physiotherapy record and to define a model for the interoperability with the other healthcare providers involved in the patients' care. Although we started from the Belgian context, we used a generic approach so that the results can easily be extrapolated to other countries. The framework we establish here defines not only the different building blocks of the electronic physiotherapy record, but also describes the structure and the content of the exchanged data elements.

METHODS

Through a combined effort by all involved parties, we elaborated an eight-level structure for the electronic physiotherapy record. Furthermore we designed a server-based model for the exchange of data between electronic record systems held by physicians and those held by physiotherapists. Two newly defined XML messages enable data interchange: the physiotherapy prescription and the physiotherapy report.

RESULTS

We succeeded in defining a solid, structural model for electronic physiotherapist record systems. Recent wide scale implementation of operational elements such as the electronic registry has proven to make the administrative work easier for the physiotherapist. Moreover, within the proposed framework all the necessary building blocks are present for further data exchange and communication with other healthcare parties in the future.

CONCLUSIONS

Although we completed the design of the structure and already implemented some new aspects of the electronic physiotherapy record, the real challenge lies in persuading the end-users to start using these electronic record systems. Via a quality label certification procedure, based on adequate criteria, the Ministry of Health tries to promote the use of electronic physiotherapy records. We must keep in mind that physiotherapists will show an interest in electronic record keeping, only if this will lead to a positive return for them.

Use of standardized outcome measures in physical therapist practice: perceptions and applications

BACKGROUND

Standardized instruments for measuring patients' activity limitations and participation restrictions have been advocated for use by rehabilitation professionals for many years. The available literature provides few recent reports of the use of these measures by physical therapists in the United States.

OBJECTIVE

The primary purpose of this study was to determine: (1) the extent of the use of standardized outcome measures and (2) perceptions regarding their benefits and barriers to their use. A secondary purpose was to examine factors associated with their use among physical therapists in clinical practice.

DESIGN

The study used an observational design.

METHODS

A survey questionnaire comprising items regarding the use and perceived benefits and barriers of standardized outcome measures was sent to 1,000 randomly selected members of the American Physical Therapy Association (APTA).

RESULTS

Forty-eight percent of participants used standardized outcome measures. The majority of participants (>90%) who used such measures believed that they enhanced communication with patients and helped direct the plan of care. The most frequently reported reasons for not using such measures included length of time for patients to complete them, length of time for clinicians to analyze the data, and difficulty for patients in completing them independently. Use of standardized outcome measures was related to specialty certification status, practice setting, and the age of the majority of patients treated.

LIMITATIONS

The limitations included an unvalidated survey for data collection and a sample limited to APTA members.

CONCLUSIONS

Despite more than a decade of development and testing of standardized outcome measures appropriate for various conditions and practice settings, physical therapists have some distance to go in implementing their use routinely in most clinical settings. Based on the perceived barriers, alterations in practice management strategies and the instruments themselves may be necessary to increase their use.

Implementing an integrated electronic outcomes and electronic health record process to create a foundation for clinical practice improvement

BACKGROUND AND PURPOSE

Improving clinical outcomes requires continuous measurement and interpretation in conjunction with treatment process and patient characteristics. The purposes of this study were: (1) to describe implementation and integration of electronic functional status outcomes into an electronic health record (EHR) for the promotion of clinical practice improvement processes and (2) to examine the effect of ongoing outcomes data collection in a large physical therapy service in relation to patient and clinic burden.

SUBJECTS

Data were examined from 21,523 adult patients (mean age=50.6 years, SD=16.3, range=18-99; 58.9% women, 41.1% men) referred for physical therapist management of neuromusculoskeletal disorders.

METHODS

Process and patient characteristic data were entered into the EHR.

OUTCOMES

data collected using computerized adaptive testing technology in 11 outpatient clinics were integrated into the EHR. The effect of data collection was assessed by measuring the participation rate, completion rate, and data entry time. Qualitative assessment of the implementation process was conducted.

RESULTS

After 1 year, the average participation rate per clinic was 79.8% (range=52.7%-100%), the average completion rate per clinic was 45.1% (range=19.3%-64.7%), and the average data entry time per patient (minutes:seconds) was 03:37 (SD=02:19). Maximum estimate of average administrative time per patient was 9.6% of overall episode time. Barriers to and facilitators of the implementation process were identified.

DISCUSSION AND CONCLUSION

The results indicate that routine collection of outcome data is realistic in a large public physical therapy service and can be successfully integrated with EHR data to produce a valuable clinical practice improvement platform for service evaluation and outcomes research. Participation and completion rate goals of 90% and 65%, respectively, appear to be feasible.

Circuit Class Therapy Versus Individual Physiotherapy Sessions During Inpatient Stroke Rehabilitation: A Controlled Trial

OBJECTIVE

To compare the effectiveness of circuit class therapy and individual physiotherapy (PT) sessions in improving walking ability and functional balance for people recovering from stroke.

DESIGN

Nonrandomized, single-blind controlled trial.

SETTING

Medical rehabilitation ward of a rehabilitation hospital.

PARTICIPANTS

Sixty-eight persons receiving inpatient rehabilitation after a stroke.

INTERVENTIONS

Subjects received group circuit class therapy or individual treatment sessions as the sole method of PT service delivery for the duration of their inpatient stay.

MAIN OUTCOME MEASURES

Five-meter walk test (5MWT), two-minute walk test (2MWT), and the Berg Balance Scale (BBS) measured 4 weeks after admission. Secondary outcome measures included the Iowa Level of Assistance Scale, Motor Assessment Scale upper-limb items, and patient satisfaction. Measures were taken on admission and 4 weeks later.

RESULTS

Subjects in both groups showed significant improvements between admission and week 4 in all primary outcome measures. There were no significant between group differences in the primary outcome measures at week 4 (5MWT mean difference, .07m/s; 2MWT mean difference, 1.8m; BBS mean difference, 3.9 points). A significantly higher proportion of subjects in the circuit class therapy group were able to walk independently at discharge (P=.01) and were satisfied with the amount of therapy received (P=.007).

CONCLUSIONS

Circuit class therapy appeared as effective as individual PT sessions for this sample of subjects receiving inpatient rehabilitation poststroke. Favorable results for circuit classes in terms of increased walking independence and patient satisfaction suggest this model of service delivery warrants further investigation.

Inter-rater reliability for function and strength measurements in the acute care hospital after elective hip and knee arthroplasty

OBJECTIVE

To determine the inter-rater reliability of function and strength measurements in patients undergoing elective hip and knee arthroplasty in an acute care setting.

METHOD

Forty-four patients underwent either total hip or knee arthroplasty. Patients were rated by 4 occupational therapists and 7 physical therapists on their performance of 5 functional tasks: lower extremity dressing, toilet transfer, supine-to-sit transfer, sit-to-stand transfer, and ambulation to 100 feet. Strength measurements of the quadriceps femoris muscle were measured quantitatively with a Microfet hand-held dynamometer. Data were analyzed to determine the interrater reliability using the Kappa statistic (K) for the functional tasks and the intra-class correlation coefficient (ICC) for the strength measurements.

RESULTS

A high level of inter-rater reliability was achieved for lower extremity dressing, toilet transfer, supine-to-sit transfer, sit-to-stand transfer, and ambulation to 100 feet, as evidenced by K values between 0.75 and 0.99. Reliability was also excellent for quantitative strength measurements using the dynamometer, with an ICC of 0.94.

CONCLUSION

This study demonstrated excellent interrater reliability with measurements of function and strength post-operatively after elective hip and knee arthroplasty. The practical implication is that by using a standardized measurement tool in the acute care setting, the treatment team can more reliably assess patients' progress, which may aid clinical decision making.

Reliability and validity of clinical outcome measurements of osteoarthritis of the hip and knee--a review of the literature

High reliability and validity of clinical rating schemes is crucial for their use as outcome measurements of treatment of hip and knee osteoarthritis. In this paper, we review the empirical evidence on the reliability and validity of commonly used clinical scores. Clinical scores and related reliability and validity studies were identified by systematic literature search. Scores were classified according to the type and joint. Reliability and validity studies were characterized according to design, population, number and qualification of observers, number of measurements, time interval between repeat measurements and results. Reliability and validity studies were reported for only 6 and 15 of the 45 identified clinical scores, respectively. Although comparisons are difficult due to differences in study design, relatively high reliability was reported for most measurements of pain, stiffness, and physical function, while results are less conclusive for clinical signs. Most validity studies focused on the correlation between various scores. Correlation was generally found to be high for overall numerical ratings, but scores often differed with respect to the interpretation of these ratings. Validity has been more comprehensively studied for Lequesne's scores, WOMAC, and ILAS, and these scores have shown satisfactory responsiveness to different treatment effects. Overall, knowledge on reliability and validity of clinical scores of hip and knee osteoarthritis is limited, underlining the need for further properly designed and conducted studies.

Treatment categories for low back pain: a methodological approach

Studies that evaluate effectiveness of physical therapy can be problematic because frequently several treatment techniques are used during an episode of care. Methods that categorize treatment techniques into discrete categories may be useful in studying treatment outcomes. The purpose of this study was to describe a method to create treatment categories used for patients with low back pain. We surveyed physical therapists in Virginia to identify frequently used treatments for patients with low back pain. One hundred fifty-five surveys were completed. Twenty-eight treatments, used frequently or very frequently by 50% or more of the respondents, were retained for analysis. Factor analysis was used to identify treatment categories. Seven categories were identified: McKenzie approach, manual therapy, exercise with equipment, active and stretching exercise, physical agents, aerobic exercise and walking, and ergonomic activities. Indices for the categories were created. Confirmatory factor analyses should be performed on a different sample to validate these findings.

Using computerized clinical nursing data bases for nursing research

Computerized clinical nursing data bases (CCNDBs) have significant potential as sources of data for research on the processes and outcomes of nursing care. The emergence of nurse-managed practice sites, in which patient care is driven predominantly by nurses' decisions, has prompted renewed interest in using data from these practices to answer questions that are important to nurses. The purpose of this article is to articulate strategies for using CCNDBs for nursing research. Recognition of the differences between clinical and research data bases is essential. The steps involved in obtaining and using computerized clinical data can be grouped into three phases: (1) locating and accessing CCNDBs, (2) assessing the content and quality of the data, and (3) extracting and analyzing the data. Processes involved in phase 1 include determining the research question, identifying eligible CCNDBs, negotiating access to the CCNDB, and ensuring the privacy and confidentiality of subjects. In phase 2 the processes include determining the content of the candidate CCNDBs, assessing the quality of the data in candidate CCNDBs, and determining the technical usability of data in candidate CCNDBs. Phase 3 involves mapping CCNDB data elements to research variables; determining data and record selection criteria; writing and implementing a query to select the desired records; designing a data base and record structure for research variables; performing analytic procedures on the research data; and reporting results of the research. Phases and procedures are discussed in detail in the article.