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  • Study of Hospital Uncovers 'Alarming' Omission of PT Recommendations From Discharge Orders

    Researchers analyzing data from "a large academic hospital with a chronic stroke center" have found that physical therapist (PT) recommendations for patients transitioning to subacute care facilities are being omitted from discharge orders at rates of 54%-100%, depending on the type of PT recommendation. Authors contend that not only do the omissions create the potential for gaps in care, but that related Medicare readmission data suggest that the omissions may be associated with increased 30-day hospital readmission rates.

    In the study, e-published ahead of print in the Archives of Physical Medicine and Rehabilitation (abstract only available for free), researchers compared individual patient files containing PT recommendations with the contents of final discharge orders for 613 patients with a primary diagnosis of stroke (302) or hip, pelvis, or femur fracture (315). All patients were adults, and all were discharged to subacute care facilities between 2006 and 2008.

    Authors of the study focused on PT recommendations around patient safety (including falls risk), assistance required for mobility, and use of assistive devices, and limited their analysis to only those PT recommendations entered into the patient's record within 48 hours of discharge. Next, they compared the rate at which these recommendations were included in final discharge orders.

    What they found wasn't encouraging. Out of 611 discharge orders, only 3 contained all PT recommendations. PT recommendations were completely omitted in 53% of the orders, and partially omitted in 47%.

    When it came to which kinds of recommendations were omitted (completely or in part), researchers found that recommendations for assistance required for mobility were removed in nearly 100% of the orders, while recommendations on the use of assistive devices were omitted at a 77% rate, and recommendations around patient safety were taken out of 54% of the orders.

    Researchers were also able to track readmission rates for the 266 patients who were Medicare beneficiaries. When they compared the beneficiaries whose orders kept the PT recommendations with those whose orders omitted them, they found higher 30-day readmission rates among the group with omissions—26% versus 18%.

    Authors of the study write that while there has been anecdotal evidence that PT recommendations were being omitted from discharges orders, theirs is the first study "to quantify the alarming frequency at which such omissions occur."

    "Given the importance of PT recommendations to patient outcomes, especially within the early post-hospital period, the frequency at which this information was omitted in this study is concerning," authors write. "Furthermore, early exploratory analyses in this study suggest that omissions may be associated with worse 30-day post-hospital outcomes."

    Study authors acknowledge several limitations to the research, not the least of which is the fact that analysis was limited to a single academic hospital. They also acknowledge that it is possible that PT recommendations were communicated "through some other means," such as during a nursing hand-off, email, or patient chart.

    The researchers also acknowledge that while it may be true that patients in subacute care facilities receive onsite treatment from a PT at some point, the omission of the hospital PT's recommendations creates a potentially dangerous communication gap.

    "While the majority of patients … ultimately receive a PT consultation at the facility … there is often a delay between when the patient arrives, when the consultation occurs, and when the physical activity plan of care is enacted," authors write. "The consequences of these delays are potentially catastrophic for high-risk patients whose rehabilitative gains made in the inpatient setting may be interrupted or poorly maintained due to inappropriate activity levels or safety precautions in the sub-acute care facility."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

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