Clinical pathway across tertiary and community care after an interventional cardiology procedure

Outcome indicators for stroke: application of an algorithm treatment across the continuum of postacute rehabilitation services

OBJECTIVE

To determine the feasibility and utility of applying a case-mix adjusted algorithm for treatment across the continuum of stroke rehabilitation.

DESIGN

Implementation of a clinical algorithm developed through national expert panels to standardize rehabilitation assessment and treatment of veterans with stroke. Stroke patients were stratified into initial severity groups using FIM instrument-Function Related Groups (FIM-FRG) classifications and were followed up from first rehabilitation referral to completion of all active restorative functional goals. FIM-FRG assignments were used to establish case-mix adjusted outcome indicators for the continuum of rehabilitation services.

SETTING

Rehabilitation services in medical and surgical units, intermediate care units, inpatient rehabilitation bed units, and outpatient settings in 10 participating Veterans Affairs (VA) medical centers.

PATIENTS

Stroke patients (n = 421) who received rehabilitation in the 10 participating VA centers.

MAIN OUTCOME MEASURES

Patients' functional gains, length of treatment (LOT), functional status at discharge, LOT efficiency, costs, cost efficiency, and disposition location.

RESULTS

Two hundred twenty-three patients began rehabilitation while in acute medical or surgical units, 171 in inpatient rehabilitation units, 24 in intermediate care, and the remainder while in other settings. With cases compiled across all settings, average total rehabilitation costs for patients in the lowest FRG class (most severe disabilities) were more than twice those for patients assigned to the highest FRG class (least severe disabilities). FIM gains were greatest in the subset of younger stroke patients with the most severe disabilities.

CONCLUSIONS

Implementing a standard algorithm of rehabilitation care that includes outcome indicators adjusted to patients' disability severity is feasible. The algorithm's utility is evident because it encompasses rehabilitation care provided across the full continuum, promotes access to care by advocating assessment of all stroke patients, encourages early initiation of treatment, and promotes a smooth transition though various levels of care while encouraging cost containment.

Application of the Omaha System in acute care

Although effective as a standardized language for documentation in community and public health settings, the Omaha System has not been evaluated in acute care settings. The purpose of this study was to evaluate the utility of the Omaha System to code the terms used by nurses when documenting hospital care. The nursing documentation in 30 hospital records was content analyzed for signs and symptoms, patient problems, and nursing interventions, then coded into the categories of the Omaha System. Degree of match was evaluated using concept match scores, and utility was determined using empirical, operational, and pragmatic criteria. Study findings suggest several strengths (i.e., high reliability, coded 97% of the problems, easy to use) and some limitations (lack of mutual exclusivity among terms, lack of semantic clarity, the need for three new problems). This study has important implications in demonstrating the utility of the Omaha System for possible expansion into acute care to standardize communication between the hospital setting and home care.