Background: Disposition planning is a vital part of clinical care in the hospital setting and requires a collaborative multidisciplinary approach. Physical therapy (PT) assessments are often a key part of this process but due to staffing shortages and high acuity – both of which were exacerbated by the COVID pandemic – therapists at a large safety net academic hospital were overworked and spread thin. Unnecessary PT consultations were a frequently proposed area for improvement from our therapists because these consults wasted time, resources, and manpower. In addition to decreased staff satisfaction, unnecessary PT assessments contribute to delays in care, delays in discharges, and poor patient experience. The Activity Measure for Post-Acute Care (AM-PAC) 6 Clicks Assessment is a validated tool that has been shown to predict post-hospitalization disposition and can also be used to determine who would benefit from an inpatient PT assessment. Though the physical therapists had been using the AM-PAC 6 Clicks in practice and documentation, physicians, who receive little to no training regarding mobility assessments, were wholly unaware of its utility.
Methods: A team of physical therapists and physicians looked at the consultation process and performed a retrospective analysis of the inpatient PT consultation data which demonstrated that about 9% of all consults across all clinical services (N = 16, 625) were unnecessary. Unnecessary PT consults were defined as a total AM-PAC mobility score of less than 11 (very limited function) or greater than 20 (little to no functional deficits). Of the total number of consults found to be unnecessary, roughly 50% of these consults came from the hospital medicine service. Thus, a physician assessment of mobility using an AM-PAC 6 Clicks questionnaire built into the electronic health record, was rolled out to hospital medicine in the spring of 2022. The AM-PAC form has built in decision support and states that PT assessments are unlikely to be necessary if the total score on the form is less than 11 or greater than 20. If scores fall outside the recommended range, justification for the consultation must be explained. Physical therapy consults became conditional on the AM-PAC questionnaire being completed by the hospital medicine teams.
Results: Following the implementation of the physician completed AM-PAC 6 Clicks form, there was a significant decrease in the percent of unnecessary consults from the hospital medicine teams(monthly average of 11.3% pre-intervention to 7.8% post-intervention), as well as a decrease in the percent of total unnecessary consults across all services that were attributed to the hospital medicine teams (from 50.4% pre-intervention to 37.1% post-intervention). Time from order to PT consultation did not show significant change, but the data was heavily impacted by acute staffing shortages during the pandemic.
Conclusions: This project demonstrates how a simple process change can reduce time wasted in clinical care and can be successful without depending on additional staffing. The physician assessment of mobility through the AM-PAC questionnaire has led to a decrease in the number of unnecessary consults and there has been a positive trend to reducing turn around times from consult request to PT assessment. The added benefit of this intervention has been the shared understanding about patient mobility among the hospital medicine physicians and therapists.
