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Standard Outcome Measures
Problems
• Rehab recommendations sometimes questioned due to assessments’ high degree of subjectivity
• If legitimate need for update, same provider not always available
• Condition changes between admission and discharge
Goals
• Concrete, objective evidence for decision making
• Clarity regarding functional status
• Modify discharge disposition based on repeat of measure, or project discharge plan based on score
Standardized Measures
• Objectify decision making
• Reproducible
• Pinpoint specific limitations- CTSIB
• Estimate Fall Risk• Independence = 0% Risk?
Acute rehab vs. SNF
• If we demonstrate objectively that a patient is appropriate for acute-level rehab, more patients who need that service should be accepted
• Tests to predict activity tolerance?• Most are higher level i.e. assess COPD impact
• Room for improvement
On the fence
• If we aren’t completely sure about discharge disposition• Cases where patients have some support
• Deficits unclear
• Possibility of significant change in condition during acute stay
• Cases where patients refuse STR; quantify fall risk
Frequent Flyers
• If patients return, we can repeat test instruments to quickly compare function/ assess changes
• Case managers can refer to rehab evaluations from prior admit to determine discharge plan early on
Balance/ Fall Risk
• Berg Balance Scale
• Tinetti
• Timed Up and Go (TUG)
• Five Times Sit to Stand (LE strength)
• Four-Step Square Test
Gait
• 2 min walk test
• 10 meter walk test
• Gait Speed
• Functional Gait Analysis
• Dynamic Gait Index
• Measuring distance
Functional Status
• Acute Care Index of Function
• Function in Sitting Test
• Activity Measure for Post Acute Care (AMPAC)
• Barthel Index
• FIM
Cognition
• Mini Mental State Exam
• MoCA
• _____________
ACIF
• All items are already part of acute assessment
• No threshold score
• Good reliability
• Subscales for • Mental Status
• Bed Mobility
• Transfers
• Ambulation (gait or wheelchair)
AMPAC- Short Form
• 6 items, already part of assessment
• “How much difficulty does the pt have…”• Sit <> Stand
• Unable
• A Lot
• A Little
• None
• “How much help does the pt need…”• Walking in hospital room
• Total
• A Lot
• A Little
• None
AMPAC Metrics
• 24 = highest functioning, 6 = lowest
• 20.1 = Home
• 17.9 = Home with home care
• 14 = SNF
• 13.6 = IRF
• 11.5 = LTAC
• Also used for G-Codes/ CMS Modifier
Berg
• Extensively studied for prediction of fall risk
• Many items are already part of assessment
• Short Berg“The 7-item BBS-3P measure has sound psychometric
properties and practical utility for use with people who have had a stroke. The 7-item BBS-3P, therefore, is suggested for use in people with stroke in both clinical and research settings.”
Short Berg
• Reaching Forward
• Eyes Closed Standing Unsupported
• Tandem Stance
• Unilateral Stance
• Turning to Look
• Object Retrieved from Floor
• Stepping Reciprocally to a Stair
Chiu et al.
Timed Up and Go
• 13.5 sec
• 30 sec
Functional Reach
• For “Frail Elderly”• < 18.5 cm indicates fall risk
• For “Community-Dwelling Elderly”• < 7” means
• Unable to leave neighborhood without help
• Limited in mobility Skills
• Most restricted in ADLs
Four Step Square Test
• Quick test; < 5 min
• Simulates negotiation of environmental obstacles
• For geriatric population: > 15 sec = at risk for multiple falls
• Useful for patients resistant to STR
5x Sit to Stand
• > 15 sec = risk of recurrent falls
Psychometric Properties
• Populations tested
• Standard Error of Measurement
• Minimal Detectable Change
• Minimal Clinically Important Difference
• Cut-off Scores
• Norms
Psychometric Properties
• Test-retest reliability
• Intrarater, Interrater reliability
• Criterion Validity
• Professional Association Recommendations
• All on rehabmeasures.org
Improvising
• Measured parameters for gait• Time to walk x distance
• Distance walked in x seconds
• Cadence: i.e. 8 steps in 10 seconds
• For balance• Inches shifted from midline
• Maintain sitting at midline x 30 sec with CTG
• Perturbations tolerated
• Romberg
Some Standards
• Shumway-Cook: Community Distance = 150’
• Gait Speed: < 0.57 m/s associated with falls/ predictor of disability ( slower than 32 ft. in 10 sec.)
• Change in Gait Speed: Decline > 0.15 m/sec/year is predictive of falls (Quach et al. MOBILIZE study)
ICU
• Determine when patients appropriate for mobilization
• FSS-ICU
• PFTI-s
Time
• Some tests are time-consuming• Some have shorter versions• We can still use parts as objective measures
• We should identify opportunities where using them will:• Improve patient care• Save time compared to alternatives• Facilitate better communication with team, family• Help determine if both disciplines should consult
on a patient
Resources
• Rehabmeasures.org• Also has specificity/ sensitivity, validity data
• APTA.org
• Ptnow.org
• Acutept.org