Practice Issues in the Acute Care Environment

WSHA 2016 Practice Issues in the Acute Care Environment James Barge, M.S., Theda Clark Hospital Janet Papenfuss, M.S., Mayo Clinic Health System, Franciscan Healthcare Kim Strege, M.S., Marshfield Clinic, Ministry St. Joseph s Hospital Kerry Winget, Au.D., Agnesian Healthcare James Barge, M.S., CCC/SLP Theda Clark Hospital Neenah, WI Chief responsibilities: Speech pathology services for level II trauma center, stroke center. Extracurricular: Associate Lecturer at University of Wisconsin Stevens Point on cognitive communication issues related to right hemisphere disorder, traumatic brain injury. Neenah, WI Theda Clark Hospital-Neenah Very proud father of a Speech Pathologist. Janet Papenfuss, M.S., CCC-SLP Supervisor of Speech Pathology Mayo Clinic Health System Franciscan Healthcare La Crosse, WI 23 years longevity, 6 year stint as Director of therapy services: PT, OT and SLP. Varied career experiences Lake County California school district Santa Rose Deaf and Hard of Hearing Center Private practice, Home care, long term acute, acute and rehab hospitals World ambassador for speech pathology services Haiti Cambodia 1

La Crosse, WI Mayo Clinic Health System Franciscan Healthcare Kim Strege, M.S., CCC/SLP Marshfield Clinic/Ministry Saint Joseph s Hospital Marshfield, WI Marshfield, WI - Population of approximately 20,000 - Ranked by Milwaukee Business Journal as 8 th Best Dream City in America - Ranked in the top 50 cities for: * education * freedom from stress categories - Home to: * the Rotary Winter Wonderland display * Wildwood Zoo Ministry Saint Joseph s Hospital & Ministry Saint Joseph s Children s Hospital AND... Marshfield Clinic Department of Speech Pathology Office Space where only a little work is actually done... 4 Speech Pathologists that serve patients primarily in the outpatient setting 4 Speech Pathologists that serve patients primarily in the inpatient setting 1 Clinical Fellow Speech Pathologist that works in the inpatient setting. (Not pictured) 1 Casual/On-Call Speech Pathologist for inpatient coverage. (Not pictured) 2 Speech Pathology Assistants 2

Kerry Winget, Au.D., CCC-SLP/A Agnesian Healthcare/ St. Agnes Hospital Fond du Lac, WI Responsibilities: Primary SLP for acute and inpatient rehab floors as well as VFSSs. Clinical interests: Dysphagia and dysarthria Eagerly awaiting full remodeling of our therapy area this summer. Fond du Lac, WI Agnesian Healthcare The original St. Agnes Hospital building was dedicated in 1896, the current building stands on that same site. Our staff of four SLPs provide speech services across the lifespan as well as serve the three hospitals within the system. Electronic Medical Records/ Electronic Health Records EMR records are shared within one healthcare organization EHR records are shared across multiple healthcare organizations Top 5 EMR/EHR vendors in the US 1. Epic 2. Cerner 3. Meditech 4. Other 5. McKesson EMR/EHRs Pros Consolidation of information Instant and portable availability Data trail Cons Technology and training requirements Compatibility Security and legality EMR/Point of Care Documentation Utilizing point of care documentation has been one way facilities are trying to improve therapist efficiency. Completed on the spot With patient vs. in the presence of the patient Reduces errors caused by delay in charting More appointment times for patient care 3

EMR/Point of Care Documentation Research indicates that therapists in a static workflow structure (i.e. outpatient therapy) show little gain in time by using mobile documentation, however gains evident when dynamic workflow is present (i.e. inpatient therapy.) Criticisms: focus becomes the computer (not the patient), increased use of machines rather than hands on therapy. EMR/Point of Care Documentation Majority of SLPs reported that they rarely complete charting using POC documentation with the patient present in acute care (ASHA, 2015) 3% 16% 49% 32% Never Rarely Usually Always EMR/Point of Care Documentation Order Turnaround General physician order turnaround is variable by hospital and differs between inpatient and outpatient orders Routine Order = within 24 hours (vs. within 5 days) Urgent Order = within 4 hours (vs. within 24 hrs) Stat Order = within 1 hr (vs. within 4 hrs) Therapy departments may have their own policies that supersede the generic expectation Order Turnaround The majority of surveyed SLPs reported their evaluations were completed within 24 hrs of initial order. (2016) 13% 77% 13% Same business day Within 24 hrs Within 48 hrs Diagnoses 2015 ASHA Health Care Survey results indicated majority of acute care patients have a dysphagia diagnosis. 6% 10% 7% 8% 14% 55% Dysphagia Aphasia Communication -TBI Motor Speech Communication -Dementia The dysphagia diagnosis was most predominant in the acute care facility vs. other facility types. 4

Treatment Despite the logic that more therapy is better current trends seem to indicate that patients are receiving less overall therapy treatment on acute care floors in either frequency of sessions or length of sessions despite fluctuating medical status. Difficulty timing therapy with testing/other needs Reduced endurance/tolerance/cooperation Staff availability Treatment 2011 NOMS Acute Care Data by Diagnosis Stroke (CVA & Occlusion TIA) Average Total Treatment = 2.6 hours Average Session Length = 16-30 minutes (60.4%) Frequency of sessions = 3 per week (26.1%) Brain Injury (Head Injury & Hemorrhage/Injury) Average Total Treatment = 2.7 hours Average Session Length = 16-30 minutes (66.5%) Frequency of sessions = 3 per week (30.5%) Respiratory Patients Average Total Treatment = 3.5 hours Average Sessions Length = 16-30 minutes (62%) Frequency of sessions = 3 per week (26.1%) Treatment The majority of surveyed SLPs reported treating their acute care patients for 16-30 minutes a session regardless of treatment focus. (2016) Swallowing Treatment 4% 6% 90% 30+ 16-30 1-15 Communication- Cognition Treatment 6% 76% 18% 30+ 16-30 1-15 Treatment The majority of surveyed SLPs reported treating their acute care patients 5 days a week. (2016) 17% 10% 40% 27% 6-7 days 5 days 3-4 days 1-3 days Caseload - Productivity 59% of 2015 ASHA general hospital respondents reported having a productivity requirement Mean expectation percentile of 80% Perceived importance of meeting expectation 1 (no importance) 0% 2 4% 3 22% 4 40% 5 (extremely important) 32% Caseload - Productivity Activities which therapists counted towards productivity Care coordination 13.8% Clinical team meetings 19.8% Documentation 20.7% Inservice/informal training 8.6% Other clinical prepping 6.9% None of the above 62.1% 5

Caseload Logistics/Productivity Staffing ASHA statistics indicate that the majority of working acute care SLPs are employed fulltime (62%) -SLPs working part-time 38% 57% of those SLPs are paid on a hourly basis -30% have annual salary -13% paid per visit Staffing/Weekend Coverage Weekend therapy coverage is becoming the standard rather than the exception. Research is showing that patients receiving 7 day a week therapy programs have shorter lengths of stay to achieve the same functional outcome levels as 5 day a week therapy. (2012) Size of hospital/community served SLP staff availability Weekend admission trends/numbers Specialty Services Primary Stroke Center Staffing/Weekend Coverage The majority of surveyed SLPs revealed majority of hospitals provided SLP services 7 days a week: (2016) 17% 17% 13% Saturday AND Sunday 53% Saturday OR Sunday On Call No Onsite or Call Staffing/Weekend Coverage SLP Screening Definition: Screens sort out apparently well people who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. (World Health Organization) Can be either dysphagia or communication focused. Triggered by observed deficit or decline in function. Some facilities have automatic screen triggers in EMR to alert therapy service (pathways or through nursing charting.) Improve timeliness of patient identification and onset of therapy services. 6

RN Dysphagia Screening Initiated in 2004 as a Stroke Get with the Guidelines Joint Commission Performance Standards, removed in 2010. Removed because there were no standards for what constituted a valid screening tool and no clinical trials had identified the optimal screening tool. RN Dysphagia Screening Popular Screening Tools Toronto Bedside Swallowing Screening Test Yale Swallow Protocol Standardized Swallowing Assessment Burke Dysphagia Screening Test Massey Bedside Swallow Screen Modified Mann Assessment of Swallowing Ability 3oz Water Swallow Test Acute Stroke Dysphagia Screen Gugging Swallow Screen Screening Test for Adult Neurological Dysphagia RN Dysphagia Screening The majority of surveyed SLPs revealed their facilities are using mostly facility made (homegrown) screening tools. (2016) Screening 17% 10% 10% 20% 43% Facility Made Yale Massey 3 Oz Water Test Others VFSS Referrals Which patients get referred for an acute care VFSS? New onset dysphagia Patients with diagnoses suspicious for silent aspiration Patients with recurrent pneumonia patterns Chronically dysphagic patients with new symptoms Which patients might not get referred for an acute care VFSS? Patients with chronic dysphagia tolerating current diet Patients unable to minimally participate Patients clinically unable to tolerate any oral bolus Patients whose plan of care would not be altered by the results (such as advanced directives.) VFSS Referrals How do patients get referred? Recommended by SLP following Clinical Swallow Eval Recommended by SLP following chart review or screen Directly by MD Hospital policy dictates referral procedure. Ordered by SLP Ordered by MD Ordered by SLP as protocol/pathway order. Proposed by SLP, then ordered by MD. Included as part of general SLP Eval orders 7

VFSS Barium VFSS Barium Regular Barium Product Works well enough That s what they order Less expensive 16% 4% 2016 Survey Varibar EZ HD ASHA recognized clarification of Joint Commission MM 4.1 All prescription or medication orders must be reviewed for appropriateness. Contrast media, including barium, is a medication. Only trained personnel can retrieve from storage. Quality control procedures to prevent retrieval errors. Barium use must be reviewed by pharmacy or medical staff. Varibar Standardized thickness levels Consistent test to test 80% EZ Paque ASHA reported members are adapting to these regulations Barium kept under lock and key Barium types, amounts given and lot numbers documented All containers of barium and food mixed with barium clearly labeled. Types of barium used are approved by hospital pharmacy board VFSS/Barium Water Protocols In patients with dysphagia, we are attempting to accomplish two goals: (a) restoration of nutrition and hydration and (b) prevention of adverse events. Frazier Rehabilitation Hospital developed their water protocol based on the following observations: People need water, and people with dysphagia will be more hydrated if they are allowed to drink water even if they aspirate it. People don't comply with thick liquid recommendations; people like water better than thick liquids. Water is safe to aspirate because it passes out of the alveoli without adverse events. Pro Arguments Compliance Quality of Life Hydration Safety Water Protocols Con Arguments Passive Undermines Thickening Risk Evidence Additional considerations in the acute setting: logistics of orders/policy/procedure, quality of oral care and staff training. Water Protocols The majority of surveyed SLPs revealed their facilities use of water protocols: (2016) 27% 40% 30% Yes No Sometimes 8

Water Protocols Discharge Transitioning 1 in 5 Medicare patients is readmitted to the hospital within 30 days. Discharge to a SNF is one of the strongest predictors of hospital readmission with 30 days. (2013) Readmissions can be classified into 3 groups: 1) Infection or complication from initial stay 2) Poor discharge education 3) Reoccurrence of the chronic condition Discharge Transitioning Seamless transition between healthcare facilities was frequently difficult because poor quality discharge information (wrong information, conflicting information, old information) was received, delaying appropriate care until medical details were clarified. Hospital provider direct contact information should be included; hospital operators were typically unable to find a knowledgeable nurse or therapist to clarify a patient s needs. (2013) Discharge Transitioning Challenges of quality transitioning for SLPs Easiest for patients going home Incorporate direct education, exercise/strategy teaching into our sessions. Moderate for patients discharging within facility Room and therapist may change but full access to EMR and ease of therapist communication. Hardest for patients discharging to outside facility Unexpected or early discharges mean discharge notes not finished, SLP notes not sent in packet, VFSS reports not included, therapists not available by phone. Discharge Transitioning The majority of surveyed SLPs reported discharge transitioning was completed by sending copies of SLP notes. (2016) Discharge Transitioning 7% 7% 6% Notes Telephone Call Fax 80% EMR Access 9

Questions, Comments, Additional Discussion Topics If only the SLPs could make the rules References (1) DiSotto-Monastero, Chen, Fisch, Donaghy, Gomez. Efficacy of 7 days per week inpatient admissions and rehabilitation therapy. Arch Phys Med Rehabil. 2012 Dec;93(12):2165-9. (2) Coyle. Water, Water Everywhere, But Why? Argument Against Free Water Protocols. SIG 13 Perspectives on Swallowing and Swallowing Disorders (Dysphagia), December 2011, Vol. 20, 109-115. (3) King, Gilmore-Bykovskyi, Roiland, Polnaszek, Bowers, Kind. The Consequences of Poor Communication during Hospital to Skilled Nursing Facility Transitions: A Qualitative Study. J Am Geriatr Soc. 2013 Jul; 61(7). (4) Schumann, McGuirk, McDonnell, Wilson. Assessing the Value of Mobile Pointof-Care Solutions for Three Clinical Workflows. Intel Whitepaper. 2008 (5) Reducing Hospital Readmissions. Center for Healthcare Quality and Payment Reform, 2013, Info@CHQPR.org (6) ASHA 2015 SLP Health Care Survey: Survey Summary Report. (7) ASHA NOMS: Adults in Healthcare Acute Hospital 2011 Summary Report. (8) ASHA Community website membership survey, 2016. (9) ASHA Use of Barium Sulfate Contrast During Videofluoroscopic Swallowing Studies, 2016. 10