Allied Health Consults

Legacy project deactivated in TMP study.

This project is still active as defined below, and does not stop as Overstay starts at a site.

Please do not discuss this project 
with other staff except collectors 
at your sites.  
This project will observe staff 
behaviour and we are concerned about a 
Hawthorne effect. 

Purpose

To determine "how many" allied health consults patients are getting, in part to determine the effect of the Overstay Predictor Project on this variable.

We want to collect whether a consult was requested, not what sort of delays happen. That is something we know we need to consider, but it is not part of this temporary collection. We assume that most patients get allied health consults but we need numbers to back up the assumption.

Project Dates

• all medicine wards at: (HSC, STB, GRA, VIC)
• Start:
  • HSC Nov 5, 2012
  • STB Nov 6, 2012 (stopped for 2 weeks, Nov 22-Dec6 because of misunderstanding with start of overstay)
  • VIC Nov 7, 2012
  • GRA Dec 7, 2012

• End:

1. GRA, STB -Stop June 4.13 (no worry if stop date is not exactly on this day. Close enough).
2. VIC - Stop June 30.13
3. HSC - Stop September 31.13

Collection Instructions

Generate a tmp entry for the first/initial consult request (completed or not) for any of the four allied health disciplines when a patient is:

- in the ER immediately PRIOR TO being admitted only to a ward that we are collecting data on.

- after being admitted to or before being discharged from only a ward we are collecting data on.

- do not add a consult if they are transferred from the ICU and continue to have allied health support initiated in the ICU.

• Project:AlliedHC
• Item (as appropriate):

1. Home Care
2. Physio
3. OT
4. Social work

Template:Discussion would it be worthwhile to track Aboriginal Services +/or Geri-Rehab consults as well? I will discuss this with the steering committee. Geri Rehab may be useful.LHathout

• no other fields need to be filled, i.e. no times etc.
• if there are no consults there is nothing to do for this project, i.e. there is no "no consults" entry

Admission from other ward (either collected or not)

If a patient is admitted from another ward where we collect then:

• if arrives with consult, then don't collect for that same consult
• if a new consult is generated, then do collect

• At the HSC I have found that when pts are transferred around the med units staff may reconsult physio D/T the fact that each unit has their own physio person and wants physio to continue,(not all the time) but when this does happen I collect as a new consult.--

PStein 13:45, 2013 January 7 (EST)*** OK I am getting confused I want clarification please.

1. Question One if a pt comes from a ward we are collecting from to another ward we are collecting from (ie S4 to N5) the initial consults were done on S4 ie PT /OT/HC but are continued on N5 (without a new consult form) we were not to enter it on N5 Correct??? YESLHathout
2. Question Two We are now seeing new consult being filled out for example S4 had PT/OT filled out transfered to N5 new forms filled out for PT/OT now we enter these in on S5 Correct? If it is a continuation or transfer of services no.LHathout
3. Question 3 Pts coming from ICU have PT/OT/SW consults we don't follow them in ICU or enter them in ICU laptop then they are transferred to S4 these services are still seeing the pt on the ward do we enter them in our ward laptops even if no new consult was filled out? Do not enter a consult for services started in the ICU See AboveLHathout
4. Question 4 we have pts coming from surgical wards we are not collecting on PT/OT/ SW have been following them they are still following them on the wards when they are transferred to a collecting ward. They have no new consult filled out do we collect on these pts?? I know if new consults are filled out we do collect. Now I don't know if consults are being reconsulted just verbally or not due to we were not to discuss this with the allied health team. On our forms at the Vic anyone can fill them out drs nurses ect no signature is needed so it would be tough to figure out who filled it out and if it was a self referral.

All good questions. The intention of the project is to know if Medicine consulted allied health in relation to discharge planning. If a patient come from the ICU PT may continue working to get the patient back to a basic functional baseline on the unit. Which PT provides care (ICU or unit)? How do we know care is transferred? How is this distinguishable from a new self generated PT consult working in preparation for discharge. I don't know if PT differentiates between this type of work (in hospital required PT care such as chest physio versus doing a stair assessment in preparation for discharge). I know that there seems to be inconsistent documentation practices as to how Allied Health consults are handled when a patient moves units. I will ask Linda Pooley what is the normal documentation practice for patients transferred between units and programs.LHathout

Linda Pooley Regional Physiotherapy Manager of Acute Care, and HSC site director said: We have automatic referral in the ICU’s so at times we have an order or consult and at times we have initiated it based on our automatic referral. When the patient moves to the ward the therapist passes the information (cardex) to the ward therapist who will follow the patient. It is our responsibility to ensure there is continuity of care.Within 48 hours we would either get an order from the physician to continue physio or we can write team initiated referral in the chart and continue to see the patient if we feel it is appropriate.There should not be any inappropriate discontinuation of therapy.

We do not have self consults we have team initiated consults where any member of the team can ask for our involvement and we assess the appropriateness of this request. We document this in the right side of the order sheet. Other sites will have other processes. Each site has different processes re the automatic patients seen or for team initiated, interdisciplinary consults etc.

Care Map generated consults

If a consult is generated because a patient is put on a care map (e.g. ACS caremap), 'do code those allied health consults, because if a consult is generated, it will affect Allied Health workload and availability.

EMIP

Include EMIP patients in this project, because if a consult is generated, it will affect Allied Health workload and availability.

Problems with collection instructions?

Can you think of a scenario in which the instructions above are not clear and comprehensive? I am not concerned for the moment whether they are "right" or "wrong", just if they would leave you confused how to code, or if you think you might interpret them different from another collector. Ttenbergen 10:58, 2012 November 5 (EST)

• Yes there was. The initial instruction was misinterpreted. Was not clear if first consult of any of the four allied health consults, or the first consult for each of the four allied health consults: Deb. Dec 17.12
• One problem lately has been changes made almost daily. ie. we were told to stop collecting allied health on May 31st and then to restart again. Then we were told to stop June 4th and then the next day to restart again. When instructions are constantly changing it is likely that people will not know what to do anymore. There are probably some data collectors who have stopped having read the instructions a few days ago and missed the update. Please make up your mind before posting instructions. Thanks, --LKolesar 14:15, 2013 June 5 (EDT)
  • I absolutely agree, Laura, and I for one will try to do better with this. Ttenbergen 15:43, 2013 June 5 (EDT)
    • Lets not get too critical of things that are not perfect. This is not a frequent occurance. There were no deaths because of this.Trish Ostryzniuk 16:20, 2013 June 6 (EDT)

Self referrals

• I have encountered several pts where the Home Care nurse has self referred; in other words, a consult was not generated by the ward but was done by the HC dept themselves. Yes include them as consults. Home care check patients against their database and if they already receive home care the automatically follow them to determine if there is a need to modify their care plan.LHathout
  • our home care nurse at the VIC will often self-refer in emerg because the patient is known to the system and will need services on return home. Yes I include this referral in the study.Jkublick Dec 12,2012
• at the Grace it is easy to establish as the HC Coordinator writes self referral on a consult sheet and then puts the sheet in the chart

I have asked Marie Anne Lynch and Donna Romaniuk to determine the value of differentiating between referrals and self referrals. They think their is value to identifying these as self referrals Regarding consult requests Marie Anne says that the practice is usually a written consult and who initiated the consult. Although there are times in rounds it may be stated to another to see. But that should be included in the note from the person" Data collectors, can you clarify if you usually can identify when a consult is self generated? LHathout 16:12, 2013 January 8 (EST)Template:Discussion If it is possible to distinguish between self consults and Medicine generated consults I will ask Tina to include this option in the temp fields.LHathout

Data use and analysis

The data will be analyzed as part of the Overstay project. Tina is involved with that and can provide it directly.

The plan for this data is to give a broad picture of consultation practices before and after the Overstay project. The data will be grouped and counted for comparison. We are not planning to use this data to get any detailed information on individual patients. We may use the data to trigger a chart review in special cases.

We are aware that the consult practices at the sites are complex, and our project is not aiming to get a full picture. Specifically, we need to simplify what we are investigating so we end up with data we can compare across patients, wards and hospitals.

Considerations when analyzing this data

• At the Vic we have been double coding the allied health consults: for example if a pt is transferred from one ward to another the allied health tmp. entry has been re-entered on those pt's. in their new location because the allied health will follow the pts on the new unit. As of today Dec 6th when a pt moves from one unit to another unit the allied health tmp area will be left blank unless a new consult has been filed. Julie, the pts admitted to N5, S5, or S4 will have their first consult generated there (if they came from emerg) When those pts are transferred to S3 (or to N5/S5 from S4) they are still followed by allied health but I'll leave the allied health tmp entry blank.

Collector observations and comments that might help interpretation of this data

Why we didn't add dates to the collection

I have removed comments relating to this from the discussion below The tmp entries in CCMDB.mdb could accommodate date and time, but we decide 'not to collect this for the following reasons:

• We will primarily use this data in the form of counts, and there it would not help.
• If we wanted to add dates we would have to set rules around how to collect them in special cases (e.g. unknown, before admission, several consults, etc); this would make the collection more complicated, and it would mean that there would be too few of each case to combine them with any meaning.
• The dates might give an idea about what went wrong in a specific case, but if we wanted that level of detail there would need to be a chart review anyway, so having it in the database would add no value.
• also, see #Data use and analysis

Why don't we collect where a consult was generated, or by whom?

I have removed comments relating to this from the discussion below Consultes could be generated before patients arrive on the ward, and various parties can generate them. We decided not to collect this because it would complicate both the collection rules and aggregation of the data.

• also, see #Data use and analysis

Why collect only these four types of allied health consults?

They are the ones that will be directly affected by project Overstay.

Miscellaneous

I will treat these as comments only, unless you put a {{discussion}} tag and a question I could address. At the Vic, non-teaching medicine spends much of its time on discharge planning. PT and OT are often consulted in emerg and patients are usually assessed in emerg. If a patient does not pass the function assessment, the patient will be admitted to a ward. The patients here are sometimes admitted for failure to cope in the community. They are followed up on the ward usually the next day or when the patient's medical condition improves enough for the patient to participate. I notice that a patient may be medically stable but not able to perform ADL (activities of daily living)due to deconditioning. Discharge will be delayed till the patient has plateaued or gained a prior level of ADL functioning. This is the first significant delay in patient discharge that I see and holds up discharge planning for weeks. It can take weeks or more for the patient to regain strength. PT and OT work together and will consult each other on the patient's progress. Once PT feels that the patient is mobilizing well, OT will complete their assessment and determine the type of supported needed in the home if home is the goal. Home Care (HC) becomes involved once the patient has plateaued and makes the needed arrangements. The home care process seems fast and efficient in my opinion; usually a matter of 2-3 days approx. this is of course when the patient is returning to a prior living arrangement. When a patient fails to meet the criteria to return home or needs supportive housing a second delay begins. Paneling is the third time consuming process and waiting for placement seems to take months. These are the three main delays I see here at the Vic on my non-teaching units. What do others see happening? Jkublick Nov 1, 2012.

• Decided to include consults in ER immediately prior to ward admission. Ttenbergen 15:59, 2012 November 1 (EDT)
  • I agree with Judy. Just to let you know consults to physio and or occupational health can be filled out by a nurse /doctor /or allied health care service. Many patients who come to our wards are already receiving homecare which is cancelled and then has to be reviewed again to see if they require more treatments /adls at home. Do you want 1st timer to homecare services ? I have found out some services (Home care) are being delayed because information is not being relayed to them ie from ER They are not faxing the information to Home care and they are unaware that the pt needs follow up on the ward, until someone asks them what is happening? This just happened last week The pt wasnt seen for 7 days.
    • • I agree with all comments made. Maybe we could capture if consults were made in ER or on Ward.--FLindell 09:44, 2012 November 5 (EST)--FLindell 09:44, 2012 November 5 (EST)