OVERCOMING OBSTACLES TO ACUTE CARE REHABILITATION RESEARCH Handout – 9 pages

2015 Combined Sections Meeting February 4 – 7, 2015 – Indianapolis, Indiana

Slides will be available following the conference

SPEAKERS Steven Fisher, PT, PhD Associate Professor Department of Physical Therapy University of Texas Galveston Medical Branch 301 University Boulevard Galveston, TX 77555-1144 Phone: (409) 772-9492 stfisher@utmb.edu Diane Jette, PT, MS, DSc, FAPTA Associate Chair and Professor Department of Physical Therapy MGH Institute of Health Professions 36 First Avenue Charlestown Navy Yard Boston, MA 02129 Phone: (617) 724-4844 djette@mghihp.edu Dianne Jewell, PT, DPT, PhD, CCS, FAACVPR Founder and CEO, The Rehab Intel Network Program Director, Arcadia University PT Health Policy Certificate Program 450 S. Easton Road Glenside, PA dvjewell@gmail.com Carmen Kirkness, PT, PhD Assistant Professor, College of Medicine Assistant Director, Health Outcomes Research Center University of Illinois at Peoria One Illini Drive Peoria, IL 61615 Phone: (309) 671-8438 csk@uic.edu

Patricia J Ohtake, PT, PhD Associate Professor Department of Rehabilitation Science 515 Kimball Tower University at Buffalo Buffalo, NY 14214 Phone: (716) 829-6732 ohtake@buffalo.edu Barbara K. Smith, PhD, PT Research Committee Chair Acute Care Section APTA Research Assistant Professor Department of Physical Therapy University of Florida P.O. Box 100154 Gainesville, FL 32610-0154 Phone: (352) 294-5315 bksmith@PHHP.UFL.EDU Mary Stilphen, PT, DPT Senior Director, Department of Rehabilitation and Sports Therapy Cleveland Clinic 9500 Euclid Avenue Cleveland, Ohio 44195 Rehabilitation Phone: (216) 444-8610 stilphm@ccf.org

COURSE DESCRIPTION AND OBJECTIVES Acute care physical therapists and clinics are ideally positioned to generate evidence about the value of physical therapy. The Revised Research Agenda for Physical Therapy was released in 2011 to direct and prioritize issues and lines of research in physical therapy. The Agenda includes areas of basic and clinical science, epidemiological, work force, and health services research that are germane to acute care physical therapy practice. While there is a growing recognition of the value of rehabilitation interventions in acute care settings, there is also an increased demand for controlled studies of therapies on patient-centered (physiological function, mobility, and disability) as well as health services-related (e.g. cost, utilization) outcomes. Despite the high need for systematic studies of therapeutic interventions in acute care, the systems and environment of a hospital setting provide challenges to designing and implementing relevant yet feasible studies. This session will examine current challenges associated with the conduct of rehabilitation research in the acute care setting and suggest potential methods for clinical therapists and administrators to address these obstacles. Particular focus will be placed upon obtaining institutional approvals, employing partnerships between academic and clinical settings to yield a rigorous study design and navigate hospital systems barriers, utilizing valid, standardized outcome measures, and building research mentors and networks. After this session, participants will be able to:

1. Evaluate the state of rehabilitation research in acute care physical therapy.

2. Describe the challenges associated with the following issues in acute care rehabilitation research and identify potential resolutions:

a. Obtaining Institutional Permissions b. Selecting a study design to maximize the generalizability of the collected data c. Navigating Hospital Systems, Processes, and Pressures d. Utilizing systematic outcome measures e. Building a research network

Schedule 11:00 – 11:05 Introduction

Moderator: Dianne Jewell, DPT, PhD, CCS, FAACVPR

11:05 – 11:15 Current State of Rehabilitation Research in Acute Care Patricia Ohtake, PT, PhD

11:15 – 11:30 Obtaining Institutional Permissions Steven Fisher, PT, PhD

11:30 – 11:35 Facilitated discussion

11:35 – 11:50 Systematically Employing Robust Outcome Measures Carmen Kirkness, PT, PhD

11:50 – 11:55 Facilitated discussion

11:55 – 12:10 Using Academic Partnerships to Strengthen Research Output Diane Jette, PT, MS, DSc, FAPTA

12:10 – 12:15 Facilitated discussion

12:15 – 12:30 Managing Hospital Systems, Processes, and Pressures Mary Stilphen, PT, DPT

12:30 – 12:35 Facilitated discussion

12:35 – 12:50 Locating Mentors and Networking Support Barbara Smith, PT, PhD

12:50 – 12:55 Facilitated discussion

12:55 – 1:00 Closing Remarks Moderator: Dianne Jewell, DPT, PhD, CCS, FAACVPR

Current State of Rehabilitation Research Patricia Ohtake, PT, PhD

1. The environment is ripe for research, but the challenges are many

2. Case presentation: how a great idea in the clinic turned into a research agenda

a. It starts with an intriguing question

b. Identify a partner and a champion – obtain permissions, design, overcome

obstacles

c. Select suitable outcome measures

d. Develop and foster research relationships

Obtaining Institutional Permissions Steven Fisher, PT, PhD 1. Classifying your project

a. In the acute setting that classification typically begins with identifying whether the project you have in mind relates to:

i. Scientific questions – Research ii. Institutional change – Quality Improvement (QI) project iii. Formal description practice – Case Report

2. Differentiating between human subject research,1 QI projects, and clinical case

reports, in the acute setting. 3. Considerations in obtaining institutional permissions based on your project:

a. Research i. dealing with the Institutional Review Board (IRB)

1. Different classes of human subject research 2. Working with a Faculty sponsor

ii. Registering your study iii. Obtaining informed consent from a hospitalized patient

b. QI project i. When QI is research ii. Are there intentions to use the information other than for local

improvement of patient care? iii. Role of the IRB

c. Case Report

i. Standard of care vs. an intervention ii. Institutional and Federal Guidelines regarding permissions for case

reports iii. Scientific journal requirements regarding permissions for case reports iv. HIPAA

(1) U.S.Department of Health and Human Services, Office for Human Research Protections. Protection

of Human Subjects Title 45 Code of Federal Regulations. 46. 1-15-2009. Ref Type: Report.

Optimizing Health Systems Resources for Clinical Care and Research Carmen Kirkness, PT, PhD 1. Research starts with the physical therapist provider

a. What are the data being collected for---what do you want to be able to

accomplish? Can the data serve multiple purposes and, if so, how?

b. Electronic database vs paper

i. Choice of EHR

ii. Involvement in set up of EHR

1. Flowsheet or not?

a. Case example Flow sheet vs Non flow sheet

iii. Opportunities for discrete data vs. narrative

iv. Examples of clinical benefit but not research benefit; example of

research benefit but not clinical

c. Daily documentation

i. Builds a base for state of the current science from which interventions

can be evaluated

ii. Useful data include interventions, intensities of interventions, duration

of visits, number of visits

iii. Accuracy (missing data)

iv. Outcomes documented

1. Example: pain poorly documented, walking distance well

documented

v. Development/selection of specific tools that may be helpful for acute

care

1. AMPAC 6 clicks, others?

2. Tools with evidence for reliability and validity

3. Minimal training requirements

4. Measurement protocols that are easy to follow and not too time

consuming

5. Measures that make sense to clinicians

Using Academic Partnerships to Strengthen Research Output Diane Jette, PT, DSc, FAPTA 1. Matching a clinician with researcher

a. Working together to understand what types of questions can or cannot be

answered with the data

b. Starting with a research question developing a protocol

c. IRBs

d. Data use agreement

e. Who’s study is it?

f. Authorship

g. Responsibilities

i. Clinical value vs research value

h. Expectations

i. Case Examples-

i. University collaborations with Community Hospitals

2. Types of studies most often feasible with clinical data

a. Observational, comparative effectiveness

Managing Hospital Systems Processes and Pressures Mary Stilphen, PT, DPT 1. Research Structure in Hospital Setting

a. Research Champion

b. Physician Champion

c. Management Champion

2. Hospital System

a. Permission

b. Design

c. Navigate institutional help

d. Data sets

e. Examples

3. Hospital System Challenges

a. Financing

b. Payment

c. Organizational Pressure

4. Acute Care Research Cleveland Clinic

a. Liver Transplant

b. 6 Clicks

c. PT during blood transfusion

d. Collection of data

Sample references of collaborative studies in acute care settings

1. Jette DU, Brown R, Collette N, Friant W, Graves L. Physical Therapists’ Management of Patients in the Acute Care Setting: An Observational Study. Phys Ther. 2009:1-24.

2. Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003;83:224-236.

3. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. AM-PAC ‘6-Clicks’ functional assessment scores predict acute hospital discharge destination. Phys Ther. 2014; 94:1252-1261.

4. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. Validity of the AM-PAC “6-Clicks” Inpatient Daily Activity and Basic Mobility Short Forms. Phys Ther. 2014;94(3):379-391.

5. Masley PM, Havrilko C-L, Mahnensmith MR, Aubert M, Jette DU. Physical Therapist Practice in the Acute Care Setting: A Qualitative Study. Physical Therapy. 2011;91(6):906-922.

Locating Mentors and Networking Support Barbara Smith, PT, PhD

1. Identify types of support available

a. Teams

b. Champions

c. Networks

d. Mentors

2. Determine your goal (s)

a. Short and intermediate impact projects

b. Longer term career and research planning

3. Teams and Champions – draw on “local talent”

a. Institutional resources

b. Establish pilot data and plant a seed, justify or change facility procedures and care

4. Networks

a. Local and/or cast a broader net

b. Sharing and constructive resources of ideas and resources, pooling time and talent, dividing labor on larger projects

5. Mentors

a. Implies deeper investment in mentor-protégé relationship

b. Promotes deeper learning, personal growth can result in professional strength, reciprocal learning

c. Requires strategies to deepen learning and establish expectations

d. Involves most significant commitment of time

6. Resources for Mentored Research in Acute Care PT

a. Academic and alumni groups

b. Professional associations

c. National Institutes of Health

Selected Resources

1. DeCastro F, Sambuco D, Ubel P, Stewart A, Reshma J. Mentor networks in academic medicine: moving beyond a dyadic conception of mentoring for junior faculty researchers. Acad Med. 2013 Apr;88(4):488-96. doi: 10.1097/ACM.0b013e318285d302.

2. Ezzat AM, Maly MR. Building Passion Develops Meaningful Mentoring Relationships among Canadian Physiotherapists. Physiother Can. 2012 Winter;64(1):77-85. doi: 10.3138/ptc.2011-07. Epub 2012 Jan 31.

3. Gopee N, ed. Mentoring and supervision in healthcare. 2nd edition. 2011. Sage, Thousand Oaks, CA. 304 pages.

4. http://sourcebook.od.nih.gov/ethic-conduct/TrainingMentoringGuide_7.3.02.pdf

5. http://www.apta.org/CareerManagement/Mentoring/

6. Ragsdale JR, Vaughn LM, Klein M. Characterizing the adequacy, effectiveness, and barriers related to research mentorship among junior pediatric hospitalists and general pediatricians at a large academic institution. Hosp Pediatr. 2014 Mar;4(2):93-8. doi: 10.1542/hpeds.2013-0075.

7. Schwartz AL. Commentary: physician-scientist attrition: stemming the tide through national networks for training and development. Acad Med. 2011 Sep;86(9):1071-2. doi: 10.1097/ACM.0b013e318224fd75.