Physiatry Serves an Important Role in the Acute Care of Patients: Disability Prevention!

TY - JOUR

T1 - Physiatry Serves an Important Role in the Acute Care of Patients

T2 - Disability Prevention!

AU - Prather, Heidi

N1 - Funding Information: Heidi Prather DO ⁎ pratherh@wudosis.wustl.edu Section, Physical Medicine and Rehabilitation, Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Ave, Campus Box 8233, St Louis, MO 63110 ⁎ ⁎ Disclosure: 8A, 2010 Scott F. Nadler, DO, research grant from the Foundation of PM&R ; 8A, 2010-2011 ICTS JIT Core Usage Funding RFA Research Design and Biostatistics Group; 9A, secretary on NASS board of directors, PM&R senior editor, Spineline editor ⁎ Address correspondence to: H.P. As one of PM&R 's senior editors, I was asked to write an Invited Perspective regarding something I know regarding the future and physical medicine and rehabilitation. This was a daunting assignment because the longer I am in practice, the less I know. So, I am left to write about something I do. I am the section chief of a small group, which includes 5 faculty physiatrists and a fellow or 2, that resides in an orthopedic department in a tertiary medical center of a highly ranked medical school. Visualize goldfish in the Pacific Ocean and that would be us. We consider ourselves as ambassadors for the field of physical medicine and rehabilitation and attempt to provide exceptional health care for patients with impairments and disabilities related to the musculoskeletal system. Because we are a small group immersed in a large university setting, it has become apparent to me that physiatrists have rightly championed and dedicated themselves to serving the disabled patient population in ways many other specialties cannot. Meaning, some specialties are just not “armed” with what it takes to manage chronic long-term medical conditions. Disability often occurs in the chronic setting of health care and is often associated with chronic long-term problems and the need for true “management” over time. Physiatrists are “naturals” at truly managing patient care problems over time. As a result, we find that a physiatry referral is not commonly the first specialty considered by referring physicians or patients in the acute setting. It is not uncommon for me to introduce myself to a patient for the first time and the response I get is, “Thanks for seeing me. You are doctor number 9. Please figure this out.” Then I am handed a stack of medical records that is complete with a table of contents. So why was I not doctor number 1 in this referral pattern? Are we not good at performing or developing a (1) history that focuses on mechanism of injury, activities, and functional responsibilities before injury; (2) specific physical examination driven by the results of the history; (3) plan for appropriate diagnostic testing; (4) treatment plan that reflects mechanism of injury, symptom management based on history, examination, and, when necessary, diagnostic testing; and (5) treatment plan that does not end until the goal of return to maximal function has been addressed or realized? Because we know chronic care and we know impairment and disability at the end point of the spectrum, are we not well suited to assess and manage patients at the beginning of the spectrum? If we can position ourselves at the acute end of health care delivery, then we can contribute to the prevention of disability. The research for this perspective editorial included interviewing physiatrists who have long been involved in the acute and subacute care in providing services to patients with potential or known prognostic indicators of long-term disability. Michelle Gittler, MD, medical director of the Spinal Cord Program at Schwab Rehabilitation Hospital and clinical associate professor of surgery, orthopedic surgery and rehabilitation at the University of Chicago, has developed a service in which the physiatry service evaluates patients with spinal cord injury in the acute setting. “In general, when we are asked to see a patient with a new diagnosis of spinal cord injury, we are the physicians assigning a neurologic level of injury and determining completeness of injury. We iterate the problem list and often write orders to treat neuropathic pain, neurogenic bladder and bowel, and establish a care plan to prevent secondary complications,” related Gittler. But the rehabilitation model extends beyond patient care. “We discuss prognosis with families (and staff) and begin navigating this catastrophic time with the patient.” In addition to assisting in the management of patients with a recognized spinal cord injury in the acute setting, Gittler and her colleagues are often consulted in the acute care setting when a diagnosis is uncertain. “Additionally, we are often the service diagnosing new spinal cord injuries that have gone unrecognized.” Appropriate diagnosis leads to appropriate treatment, which can change a patient's entire course of care. A similar message was given by John Cianca, MD, of the Human Performance Center where he also serves as a clinical associate professor of physical medicine and rehabilitation at Baylor College of Medicine. His practice is dedicated to sports and musculoskeletal injuries. “Seeing sports injuries acutely allows me to ascertain the mechanism of injury or the underlying mechanics (in the case of an overuse injury) before compensatory bad habits develop. This makes the overall treatment path clear and more efficient.” Sometimes health care systems can work against the practitioner trying to allow access to patients. Cianca believes that educating the patient initially is the key to long-term success. When asked how he manages this, Cianca offered, “I allow myself enough time with patients to educate them on the mechanism of injury or training errors so that they may be less likely to continue with bad technique or faulty thinking.“ Ultimately this can result in a reduction of repeated “urgent needs.” Kerry Maher, MD, medical director of admitting for Brooks Rehabilitation Hospital, Jacksonville, Florida, describes the importance of physiatrists being involved in the acute phase of the care of trauma patients. Maher's service performs 8-10 intensive care unit consults per week for trauma patients at Shands Jacksonville Medical Center, a level I trauma center affiliated with the University of Florida. “Our early involvement in the care of trauma patients assists in making sure patients' needs are being met in the intensive care unit and prevention from the adverse effects of immobilization. Success with implementation in the acute care setting facilitates discharge planning or transfer to a rehabilitation service.” Maher relates that this service has slowly grown over time, with a lot of her efforts spent integrating with the trauma medical community, which now also includes a trauma psychology service. The case mix index held by Brooks is 1.47 points, a number higher than the national average of 1.28. Despite this, when Maher's service is consulted, patients are transferred from the acute care hospital to a rehabilitation setting 3.5 days sooner than the national average. Brooks has implemented this service regionally in Florida. According to Richard D. Zorowitz, MD, associate professor of physical medicine and rehabilitation, The Johns Hopkins University School of Medicine chairman, Department of Physical Medicine and Rehabilitation Johns Hopkins Bayview Medical Center, physiatry input in the acute setting for stroke patients is essential in their transition from “patient” to “stroke survivor.” Zorowitz relates, “At Johns Hopkins Bayview Medical Center, the neurology and neurosurgery teams hold multidisciplinary rounds with the therapists, physiatrist, social work, case management, and nutritionist daily. We discuss each patient and decide which disciplines need to see the patient. Once seen, the team provides input to determine not only how to triage a patient to postacute care but also to determine any strategies or interventions needed to facilitate the transition of that patient. Following rounds, I, as the physiatrist, meet with the therapists to determine if there are any issues in determining the triage of a patient. In this way, the acute rehabilitation team maintains a unified front in providing guidance to the acute care teams. By using the same principles of interdisciplinary teamwork as we do in the inpatient rehabilitation facility, we can provide higher-quality care to our patients on a timely basis, pertinent information to the acute care teams that assists in the care and triage of the patient, and decrease length of stay by addressing issues that might delay discharge. The added value to the patient is better care, fewer complications, and a more effective discharge that decreases the risk of re-admission to the acute care hospital.” So, what I learned from those I interviewed was a reflection of what was going on at my own university. This is where I get back to what I do. I was recently charged with developing a spine center at our outpatient facility in a local suburb of St Louis, Missouri. I am proud to work with world-renowned spinal deformity and cervical spine surgeons. Surgeries worthy of Discovery Channel documentaries take place at this university on a daily basis. So, why would my chairman come to me? Well, he wanted to facilitate the development of junior faculty and provide services in the community in addition to what we were already doing in the tertiary university setting. Although I was not looking for another responsibility but trying to keep the glass half full, my response was “Let's develop a multidisciplinary spine center geared toward acute and subacute disorders. Let's see if we can be a part of prevention of long-term disability.” In a weak moment, he signed off on this lofty idea. So, with my new charge, I set off to find another group doing this well so that I could adapt other's experiences and apply them to our center. To my surprise, I struggled to find this exact model dedicated to acute care. There are many exceptional spine centers with many physiatrists actively involved in providing care. Many were struggling to balance access to care and triaging patients to appropriate providers. All were providing end-of-spectrum interventions and procedures for people with spinal disorders with significant structural disorders, instability, or pain impairment unresponsive to previously tried treatment. These services are necessary and, when applied to the appropriate patient with the appropriate diagnosis, facilitate recovery and allow for the return to function. But many patients either do not need or are not candidates for such interventions. What about preventing the need for these interventions when possible? Did I not find what I was looking for because we are procedure driven and reimbursed for what we do to patients and not how we help and enable patients to live in good health? Have we lost sight that “treatment” is not always “doing something” to someone and that “education “is really treatment? Further, are we resigned to the fact that spine pain is something that comes and goes over time and the “intervention” is not needed until it has become severe or chronic? But, do we wait for the patient with diabetes to get consistent blood glucose levels of 400 mg/dL before intervention? Does intervention for a patient with diabetes always involve “doing” something to the patient? My answer to the latter was no. This idea of providing access for patients in the acute and subacute setting sent me back to do some research. I found some support of the concept in an article by Anderson and Aday [ 1 ] published in Medical Care , “Access to Medical Care in the U.S.: Realized and Potential.” They summarized measuring access in the following: “Access has been defined as 1) availability of health facilities and personnel, 2) various costs of using facilities and personnel, 3) actual use of health services, and 4) the use of health services relative to some measure of apparent need of the population for these services (ie, physician visits relative to symptoms perceived, disability experienced, or judged severity of conditions) [ 1 ].” Further the researchers stated, “we subscribe to the view that access itself is best measured through observations of people's behavior, that is, their actual use of health services and that the equity of the access is most appropriately judged by examining their actual utilization relative to some measures of the illness they experience [ 1 ].” Exactly. Offer the access to appropriately triaged patients, see who will take advantage of the services provided and follow their outcome. What a great idea. The article was published in 1978 while I was in junior high school. So this idea was not so new. In my stubbornness, I resolved that we should still pursue the concept, and I had to get on it as I had chairman-imposed deadline and the architect was sitting in the next room … . There were several recurrent frustrations that we experienced at our university practice on a regular basis that I wanted the small spine center to try to overcome: 1 Access to care for patients. We commonly have long wait times for scheduling patient appointments. This is in part because of the large volume of patients in a rural region and in part that we accept all government forms of payment and other providers in the community do not. When a patient waits to see me, I believe that I have become a part of his or her problem. To counter this, we decided to develop a scheduling system so that the physiatrist could have ensured open appointments to allow patients with acute and subacute problems to schedule an appointment within 48 hours of calling the spine center. 2 Access for patients with acute and subacute disorders. Members of the center developed a triage system geared to ensure that patients are evaluated by the appropriate provider. We developed a 4-question triage questionnaire for nonmedically trained schedulers to ask patients. Appropriate patients with pain for 3 months or less are scheduled to see a physiatrist for the initial evaluation. Every patient is asked the “red flag” questions to assess for a progressive neurologic injury. If the patient reports a “red flag,” then he or she is triaged to see a physiatrist or surgeon the same day. 3 Consistent subgrouping of patients to provide consistent care and tracking of outcomes. The etiologies for spine pain are varied and not well understood. In the acute setting, imaging is not always necessary. As a result, use of only structural diagnoses has many shortcomings. To counter this, we subgroup patients based on the motion they experience pain in and its distribution. If a structural diagnosis is known, then this is included. We use the 14 subgroupings to identify the educational materials that the individual needs. Further, this subgrouping drives therapeutic recommendations. 4 Capture patient psychosocial needs early. The psychosocial components and needs that a patient has at the time that he or she is experiencing pain are wide and variable. Identifying them early can enhance recovery. Frustrated by tools that are long or require another individual to look at a spreadsheet to score, I set out to find a tool that was virtual. We use the STarT back screening tool to assess the factors [ 2-4 ]. The tool uses 9 questions, which total to 9 points to assess anxiety, depression, catastrophication, and fear avoidance. Based on their score, patients are grouped into 1 of 3 groups: low, medium, and high risk. Researchers at the University of Kiehl developed and validated the tool and found that patients in the low-risk group do well with education and a few treatment intervention sessions, such as physical therapy. The medium-risk group requires more services and intervention but can improve and even move to the low-risk group. Patients in the high-risk group will require more time and interventions by health care providers. Despite this, high-risk patients often do not move to a lower-risk subgroup. Further, if more intensive services are given to the low-risk group, their outcomes do not improve. Using this tool has helped shape awareness and the need for behavioral management before meeting the patient. It has helped us identify patients who might really do well with education and a few physical therapy visits and those who will likely require more intensive services. It is a virtual tool and easy to use because it requires that I only need to know how to count to nine. Most days I can handle that. 5 Consistent individualized patient education. Often I have thought that my “educational piece” was a photocopied sheet of basic information that I struggled to get in every patient's hand before leaving my office. To counter this, a nurse manager dedicated to the spine center reviews an educational pamphlet developed by nurses, physicians, and physical therapists at the center. Based on the patient's subgrouping determined by pain provocative activities and distribution of pain, the nurse reviews 3 activities to avoid and 3 activities to try to relieve symptoms. The nurse reviews all of the medications, referrals, and needs for scheduling. The intent is for the patient to leave the center armed with education that provides information about what the patient should and should not do and a plan of care. It is also one more chance for the patient to have questions answered. 6 Easy access for patient follow-up. We have consistently struggled to provide timely follow-up. To counter this, a certified nurse practitioner dedicated to the spine center plays a vital role in seeing patients within 4 weeks of their initial visit. The purpose of this visit is to ensure that the patient is making adequate progress and that treatment goals have been met. If the patient is not progressing, then the next steps are taken, including further diagnostic testing or intervention. Follow-up outcome measures are taken at this time as well. If a patient fails to show up for his or her return appointment, then the nurse manager calls the patient to assess progress and obtain the outcome measures. 7 Track outcomes to determine treatment effectiveness. Getting consistent outcome measures takes time, energy, and patience. However, outcome measures can demonstrate effectiveness of treatment and provide a guideline for improvement. In addition to the STarT back screening tool, we are collecting a modified Oswestry disability impairment questionnaire and a numeric pain score. Although not comprehensive, this combination gives us feedback on the patient's perceived pain level, impairment, and psychosocial needs. So how have we been doing so far? In the past 6 months, we have evaluated 452 new patients and 241 return patients. The most common patient diagnostic subgrouping categories include flexion provoked low back pain with leg pain and low back pain without a specific direction of provocation and leg pain. Advanced imaging, such as magnetic resonance imaging, computed tomography, or nuclear bone scan, was ordered in 24% of patients. Two-thirds of patients attended physical therapy, and 14% received a spine injection. Twenty patients (4.4%) were referred for a surgical consult, and 5 underwent surgery. Three of the 5 surgeries were not for a spine disorder and included shoulder and hip trauma. The mean numeric pain score at the time of the initial visit improved from 5.02 to 3.0, and the mean modified Oswestry disability impairment improved from 25.2 to 18.5 to the time of follow-up 4-6 weeks after the initial visit. Most impressively, at the initial visit, the patients' average score on the STarT back screening test grouped them in the medium-risk group. On return, the average patient scored in the low-risk group. Something must be happening with education because now the average patient in our center is in a risk group that is supposed to use fewer health care resources! None of this has been vetted from a research standpoint, but we are in the process of doing that now and we will eventually see some “real numbers.” The burden is definitely associated with tracking the outcomes of all the patients at the spine center, and I have been back to my administrators asking them to spend money on a better tracking mechanism. We will all soon be expected to report our outcomes to third-party payers. This will be tough but likely the evidence will be on our side that physiatry care in the acute setting is beneficial. Physiatrists are well suited to lead collaborative groups of providers involved in evaluating and treating patients with acute and subacute disorders. We know chronic disability well and, therefore, are passionate and well suited to work to prevent it. My perspective is that, if physiatrists continue to insert themselves into the care of patients in the acute setting, then I will not be known solely as “doctor number 9.” Maybe some day I will be paged for a “stat physiatry consult to the emergency room.” I promise I will run! For some patients, we can stomp out disability before it happens.

PY - 2012/7

Y1 - 2012/7

UR - http://www.scopus.com/inward/record.url?scp=84863872218&partnerID=8YFLogxK

U2 - 10.1016/j.pmrj.2012.05.009

DO - 10.1016/j.pmrj.2012.05.009

M3 - Article

C2 - 22814727

AN - SCOPUS:84863872218

SN - 1934-1482

VL - 4

SP - 469

EP - 472

JO - PM and R

JF - PM and R

IS - 7

ER -