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It’s all in the incentives

An incentive is something that motivates an individual to perform an action.

And, that something could be anything. Meet the omnipresent influencer of behavior. Frequently, incentive is understood to be associated with some form of monetary compensation for specific behavior. But, incentives are not merely monetary. And, they exhibit influence. Yes. Always. 100% of the time. In any environment, any scenario, any interaction, and every decision including clinical encounters. Incentives can be viewed as any tangible or intangible reinforcement, and thus influencer, of behavior. Theses “rewards” range from monetary to personal, concrete to cognitive-emotional. And interestingly, incentives still affect behavior even when individuals consciously identify and recognize their presence. They are social, contextual, or even cultural. And, they impact decisions and performance.

Incentives are present in a variety of forms and contexts. Most generally, incentives can be assessed via a variety of binary comparisons including: Explicit verses Implicit, Reward verses Punishment, Short verses Long Term, and Immediate verses Delayed. Yet, the content of incentives range from monetary to verbal, and in contexts of private and public. The environment, including people, specific location, and context of the situation, in conjunction with broader constructs such as expectation and culture also matter.

Physician’s prescribing habits are affected by pharmaceutical marketing. Prescribing is affected by the gifts, no matter how menial, of pharmaceutical companies. This effect is observed even if physicians believe the gifts have no bearing on their prescription decisions. The data and incentives lead the Office of the Inspector General to research gifts and payments that promote prescription drugs. In this instance, physicians are Prescribing Under the Influence:

This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, “Oh, what’s this cute little stuffed bear?” Either way, the doctor stops and spends a moment.
In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: “We’ve got such and such on the hospital’s formulary now.” Or “The new form of this drug can be given once a day instead of four times a day. The patients will love it.” It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.

Self-referral, or referral for profit, is associated with increased utilization of lab tests, imaging, and physical therapy. A meta-analysis revealed a 2.48 combined relative increased frequency of referral in refer for profit scenarios. In most cases, I truly believe physicians are not sitting in front of patients actively scheming on how to justify an imaging procedure, lab test, or referral to physical therapy in order to maximize profit. On the whole, I don’t assume the physicians in these scenarios are unethical and overtly over prescribing. But, the incentive is present, and thus behavior is altered. The evidence shows that self-referral invariably leads to higher utilization and higher costs.

What are specific incentives within the profession of physical therapy? What should be modified? Everyday outcome measures are handed to patients, clinical measurements made, and assessments written. What are patients and incentivized to say and do? Or, believe? Administrators, managers, and clinic directors in hospitals and private clinics present data to their staff. Specific metrics are identified and goals are constructed.

Recognizing the development of interaction between personal and environmental (including social, societal, cultural) influences on behavior illustrates the complexity of how, when, and why we behave in certain ways. In healthcare, the layers of systems and hierarchy of influence is complicated. Our decisions and behavior are not nearly as rationale, nor conscious, as they feel to us personally. The interplay of personal, inter-personal, and environmental influences coupled with tangible or perceived rewards influences how people act. In conjunction with individual motivation, incentives, both seen and unseen, are determinants of who will thrive in certain educational and clinical contexts. One such example is the difference between extrinsic and intrinsic motivation. What people do is just as complex as why people think they do it. And, there is a disconnect, a blind spot, between our perception of bias in ourselves verses others.

Unfortunately, incentives have unintended consequences. The cobra effect is an illustration that “incentives don’t always work out the way we expect them to.” Beyond identifying a target metric and outcome, it’s imperative to identify the actual behaviors that are desired. Sometimes a change in a specific measurement (productivity, patient report outcomes, etc) do not necessarily reflect the desired behavior changes. In particular, research investigating payment incentives and subsequent clinician behavior within healthcare illustrate tangible manifestations of “unintended consequences.”

How is the outpatient therapist incentivized if measured and assessed primarily via patient report questionnaires? How are we changing behavior in the acute care therapist by assessing them based on the number of “units” they “bill?” What about the outpatient therapist who receives a bonus based upon units billed? What if changes in the metrics we are utilizing don’t truly illustrate significant change, don’t result in the best care, and don’t reinforce ideal behavior? A health services research article on medicare payment comments:

While some payment methods may lead to excessive utilization, other payment methods may put too much pressure on cost containment and potentially lead to underprovision of resident care (Coburn et al. 1993; Cohen and Spector 1996; Murtaugh et al. 1988)

In addition to tracking specific measures, ideal behaviors need to be identified. To account for unintended consequences broadly identify various behaviors likely to lead to the measured goals. Sometimes behaviors that are actually not desired can cause significant desirable change in target measures. Undesirable action for desired outcome. So, what behaviors can cause a change in the metric? And, what contributes to encouraging such behaviors? But, also, what incentivizes behaviors that change the metric, but may also cause unintended consequences?

If a clinic, hospital, profession, or health care system seeks to fundamentally alter care delivery robust assessment of the current incentives within healthcare, including conflicts of interest is mandatory. Then change the incentives to affect and encourage ideal clinician behavior. A successful approach likely involves a combination of incentivizing important outcomes as well as specific behaviors. Changing the single data point does not necessarily reflect the desired overall change in other measurements or behavior. The depth of affect of incentives in conjunction with unintended consequences illustrate the difficulty in controlling change. A seemingly brilliant idea such as “pay for performance” or outcomes based payment is fatally flawed without a conscientious focus on the many potential behaviors that may result in the specific outcome. Might it even be chaos?

What are the incentives? Identify the answers and then target behaviors requiring alteration. Shift behaviors towards ideal processes. Ideal behaviors will likely have positive unintended consequences. A myopic focus on only the desired numeric change will produce a myriad of potentially paths to “success.” Some of these paths were never the intended action of success. And in fact, may be the opposite of the incentive’s initial philosophical goal.

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Physical Therapists in the ICU: ACTION for #ICUrehab #AcutePT

If immobility is pathology, then movement is medicine. But, now that the rationale is present, how is action initiated? Understanding the current literature in regards to mobility and physical therapists in the intensive care unit illustrates the need and the potential for physical therapists. This potential leads to the vision. Yet, rationale and vision do not guarantee action, nor results.

Every patient requires an individualized assessment and interaction to determine the best plan of care, outcomes tracking, and goals. So, does each individual ICU. Evaluation of current practice and culture, barriers to mobility and physical therapy, and a plan to achieve specific goals. Data and outcomes tracking can provide insight into progress.

Research surveying various professions elucidates commonly reported barriers to mobility and physical therapist involvement in the ICU. Yet, many of the identified barriers appear more perception than the reality. Fears based upon “what if?” scenarios. What if the patient falls? What if a line becomes dislodged? What if they decompensate? What’s the worst possible event? Illness severity, safety, and line dislodgment are commonly report. These fears are contrary to the literature on safety and feasibility. Does this indicate these concerns are likely unwarranted?

Barriers: Perception and Reality

Perception is reality. The multi-disciplinary environment of critical care, including the a culture of a specific unit, requires analysis to ensure specific perceptions are identified. Barriers should be overcome with education, discussion, training, and graded exposure. Individual practitioner’s perceptions, fears, and concerns contribute to professional interactions, unit culture, and ultimately patient care. Fear based barriers include illness severity, illness acuity, safety, feasibility, and perceived lack of benefit. Other reported challenges include lack of consults, staffing, knowledge, time, expertise, experience, cost, equipment, and unit culture. All unit specific and individually identified barriers must not only be acknowledge, but adequately addressed. Reported concerns are not to be discounted.

Perceptions

  • Illness Severity
  • Illness Acuity
  • “Too Sick”
  • Unsafe
  • Not Feasible
  • Lack of Need
  • Lack of Benefit

Logistics

  • Time
  • Equipment
  • Lack of Consults
  • Lack of Priority
  • Staffing

Culture, Practice Patterns, & Professional

  • Knowledge of Individuals & Various Professions
  • Experience & Expertise
  • Sedation
  • Current Mobility
  • Current Physical Therapist Presence & Practice

Now, this of of course is not an exhaustive list. A unit may contain unique barriers and perceptions outside of this list. Focused meetings, targeted surveys, and small group discussions can assist in illuminating the beliefs of individuals and the overall culture of a unit. A physical therapist lead quality improvement project to promote early mobility in the intensive care unit utilized a survey of nurses and respiratory therapists to identify current perceptions.

1. Do you think physical therapy should evaluate/screen all intensive care unit/cardiovascular intensive care unit patients?
2. Do you feel comfortable getting patients into neuro chairs without physical therapy?
3. Do you feel comfortable using the mechanical lifts without physical therapy?
4. Do you get patients out of bed/ambulate without physical therapy if they are able?
5. Do you think patients should be getting up on ventilators?
6. What are the barriers to mobilizing patients on ventilators?
7. What are the harmful effects of physical therapy working with patients in the intensive care unit?
8. What can physical therapy do to improve communication with the RNs, MDs, respiratory therapists, patients, families, etc.? Please be specific.
9. What can physical therapy do to improve patient care? Please be specific.

The survey questions revealed many of the barriers listed above. Interestingly, all respondents agreed that every patient in the ICU should be evaluated by a physical therapist.

As much, as soon, as often as we can?

The concept of mobility and rehabilitation during intensive care appears quite important and profound. Therefore, it’s quite obvious that every patient should be out of bed and ambulating at least three times per day. Well, not exactly. Although being in the ICU in the presence of lines, tubes, and life support equipment should not automatically preclude individuals from movement and therapy participation, each patient will present and perform quite differently.

So, what are the specific interventions? How does a physical therapist decide what to do? And, when? What about dosage, intensity, frequency, and duration? Similar to other patient populations (such as individuals with back pain), critical illness is far from homogenous. Even a very specific ICU type contains a range of diagnoses and individuals. Treatment content, duration, intensity, and frequency should likely vary. Further, given the acuity of illness and the medical complexity of patients, close monitoring of many variables is necessary. The specifics of these particular concepts remain complicated and dependent on many variables. At times it appears there are more questions than answers.

Generally, the goal is to decrease sedation, bed rest, and confusion while increasing wakefulness, movement, and engagement. There are nearly infinite options available to accomplish such goals. An approach of “as much, as soon, and as often as possible” simplifies the conceptualization of treatment. But, such an approach is always performed within the specific confines and constraints of the system, staffing, experience, and culture of the current clinical situation.

Response Dependent Progression

An individualized, response dependent approach facilitates proper monitoring from moment to moment and session to session. Decision making requires integration of information from multiple sources to reach an overall assessment that determines progression, pause, or regression. Such a system hopefully decreases the likelihood of grossly “over treating” or “under treating” a specific patient at each specific encounter. The variable nature of medical stability, presentation, and physiologic status of critical ill patients may result in robust, swift changes in vital signs, physiology, and even patient performance. A patient’s specific clinical scenario including diagnoses, physiologic state (labs, medications, vital signs), and current medical goals warrants the a priori construction of individualized safety parameters regarding upper and lower limit values for vital signs.

Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.
Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.

The research to date suggests that in order to achieve maximum effect physical therapy should be performed in the ICU, while patients are intubated, 5-7 days a week, and in conjunction with or following sedation interruption. Initiate a progressive approach focused on achieving functional milestones such as sitting, standing, marching, transferring out of bed, and ambulating as quickly, but as safely as possible. Exercise testing, prescription, and progression is feasible, effective, and possibly predictive. Although, given the duration of bed is associated with weakness and long term physical impairment suggests functional mobility should likely not be neglected.

Measuring, Assessing, & Planning

An assessment of current and historic practice can include average unit census, average number of physical therapy consults, percent of the unit with consults, and number of patients actually seen per day. Average time from admit to first physical therapy encounter in conjunction with average duration and frequency of treatment provide general insights into current physical therapy practice.

Next, by assessing unit specific data in relation to current practice, predictions for future staffing, equipment, and training can be constructed. Such a model can be further specified based upon targets for the number of patients (or percentage of the unit) to be treated each day, and at what frequency. In addition, the current number (or percentage of) patients who are likely to benefit from, or be appropriate to participate in, physical therapy can illustrate a disconnect between current practice and ideal practice. Identifying a lack of consult standards may shed light on variability in consult numbers, timing, and frequency. Standardized criteria for consults, mobility, or physical therapist involvement provide assistance in decision making. But, each individual patient requires analysis within the framework of guidelines, not decisions mandated by them.

The current demand (consults), physical therapy practice, and provider perceptions are utilized to model need, illustrate the lack of physical therapist involvement, and potentially quantify a current lack of resources to provide appropriate timing, frequency, and duration of therapy. If feasible, informal or formal investigations into factors associated with physical therapy consultation provide further understanding into current practice regarding physical therapy consultation and practice. A disconnect between the research literature and current unit culture, including various professions practice patterns, highlights the need for transdisciplinary practice change and potential quality improvement.

Financial Modeling

Johns Hopkins constructed a financial model allowing prediction of staffing, costs, and potential financial outcomes. By utilizing the number of yearly admits, current ICU & hospital length of stay (for a specific targeted ICU), and direct variable costs of care a very accurate model of staffing, start up costs, and potential cost savings scenarios can be assessed. Varying possible length of stay reduction outcomes allows for a sensitive, yet conservative prediction of cost savings in multiple potential situations. Modeling various outcomes allows for the presentation of worst case, likely, and best case end points. Utilizing actual data from their own quality improvement project and data from the literature they conclude

A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

Measurement and Outcomes Tracking

The potential data and outcomes depend on data availability, program goals, ICU type, patient population as well as any specific research questions. Outcomes can be analyzed at the patient, unit, and hospital level.

Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs
Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs

At the patient level there are a variety of impairment, patient report, and patient performance measures, many of which have been specifically investigated for utilization in the intensive care unit.

Impairment based, patient report, and patient performance measures.

Quality Improvement Project Design

Designing and implementing a quality improvement project with a focus on research methodology improves the accuracy of measured results. Such an approach eases discussions with hospital administrators regarding need, costs, and program appraisal. Appropriate planing, background research, and project construction prior to implementation allows for more specific analysis.

Background, Construction, & Education

  • Assess current PT practice, unit culture, clinician perspectives
  • Compare current practice to ideal practice, current program models, and feasible quality projects
  • Construct project goals
  • Model staffing, training, equipment, and program requirements
  • Identify, acknowledge, and address current barriers
  • Identify champions from each discipline: PT, RN, MD, RT
  • Interdisciplinary Meetings & Education: RT, RN, MD, RT
  • Acknowledge, educate, address concerns
  • Join Critical Care Quality Meetings or Committee
  • Identify Lead PT for ICU(s)
  • Assign ICU Unit Based Physical Therapist(s)
  • Identify educational needs of PT and rehab department
  • Identify educational needs of other disciplines
  • Perform education and follow up meetings

Data

  • Identify target data and outcomes tracking
  • Obtain facility specific data for financial modeling
  • Build data tracking sheets & data bases (if needed)
  • Leverage electronic medical record (if able)
  • Train clinicians on documentation and “data entry”
  • “Go live” with documentation and data collection
  • Establish a post documentation training pre-project implementation baseline

Implementation

  • “Go Live”
  • Sustain & Maintain Program via Updates and Meetings
  • Evolve care based on observation, feedback, and data analysis
  • Assess & Analyze Program and Data Collected

The elegance of a quality improvement approach is the potential for an ever evolving feedback loop of assessment, planning, implementation, and analysis. At specified intervals, repeat the process based on current results, identified issues, and current research.

Facility Specific Questions and Issues

1. What if current practice illustrates a lack of consults, infrequent consults, or poor timing of consults (i.e. too late in hospital course)?

Create specific consult criteria. Educate nursing staff and physicians. Provide checklist.

2. What if there is no dedicated physical therapist in ICU?

Quality improvement project focused on unit based physical therapist and increased overall patient mobility.

3. What if patients are too sedated?

Assess RN sedation guidelines and practices. Pair therapy with sedation vacations & awakening trials. Meet with MD’s, RN’s, and RT’s. Work with RN educator to facilitate RN lead project regarding sedation.

4. What if there is a lack of patient mobility outside of therapy sessions?

Nursing staff education. Nurse targeted progressive mobility guideline.

5. How to prioritize if unable to address every consult and patient on caseload in the ICU(s)?

Focus on duration of bed rest, individuals requiring mechanical ventilation, especially those requiring greater than 3 days of mechanical ventilation. Assess last time mobilized and last therapy session.

Quality and Assessment

Obviously, analyzing and interpreting clinically generated data is difficult. Given the complexity of the daily clinical environment and lack of rigor available in a controlled research trial, data can often be inaccurate or even misleading if not understood properly. Utilizing a quality improvement model within the context of critical care is an evolving method for program design and interpretation, but

The results of many quality improvement (QI) projects are gaining wide-spread attention. Policy-makers, hospital leaders and clinicians make important decisions based on the assumption that QI project results are accurate. However, compared with clinical research, QI projects are typically conducted with substantially fewer resources, potentially impacting data quality…Data quality control is essential to ensure the integrity of results from QI projects.

Resources exist for appropriate design, training, data collection, implementation, sustainability, assessment, analysis, interpretation, and translation of quality improvement designs and data.

1. The SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration
2. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team
3. Improving the quality of quality improvement projects
4. Improving data quality control in quality improvement projects
5. How to use an article about quality improvement
6. Rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model
7. ICU early physical rehabilitation programs: financial modeling of cost savings
8. Translating research into clinical practice: the role of quality improvement in providing rehabilitation for people with critical illness
9. Quality Improvement Guide

A variety of complex issues affect potential physical therapy and mobility in the intensive care unit. But, it is possible. Change is a process, not an event. One patient, one provider, one day at a time.

 

 

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Physical Therapists in the ICU: Rationale for #ICUrehab

For 3 weeks I was held in a room, I was tied to the bed if I tried to get away. I couldn’t talk; I couldn’t eat; I was not allowed to sleep;
Groups of people would enter the room and look at me and talk about me and I was sometimes undressed in front a small audience.
I was shot full of drugs.
I was too weak to move.
I could not see my body, but it had been cut nearly in half.
Insects crawled on the walls and ceilings…

Sound like prison or torture? Well, it’s not. The quote is from Nancy Andrews, a survivor of critical illness who developed delirium . And, an articulate spokeswomen regarding ICU sequelae, specifically delirium, from a survivors perspective.

Now, to be fair, I am already bias. I treat primarily in ICU’s (medical, cardiac, and step down units). I also treated in the treatment arm of a randomized control trial of early, intensive physical therapy for individuals requiring mechanical ventilation for greater than 4 days. The treatment group received physical therapy 7 days a week for at least 30-60 minutes. And, I participate in research surrounding ICU physical therapy. Oh, I am also a physical therapist. So, don’t take my word for it…

But, the curse of bed rest needs to end.  In 1966 “The Dallas Bed Rest Study” put five 20 year old males to bed for three weeks. Investigators conducted pre and post testing followed by exercise training and long term follow ups (30 and 40 years). The acute effects of the bed rest and long term outcomes are staggering. Net proportional decline in VO(2 max) over 40 years was comparable to that experienced after 3 weeks of strict bed rest (27% vs. 26%). Additionally, 40% of age related decline in maximal oxygen uptake could be attributed to physical inactivity specifically. Three weeks of bed rest at 20 years of age resulted in a more profound impact on physical work capacity than 30 years of aging.

Unfortunately, each day of bed rest in the ICU may predict a 3 to 11% strength decline up to 2 years later. During a 2 year investigation, the length of bed rest was consistently associated with measures of weakness at all time points. The presence of weakness correlated to decreased physical function and quality of life.

The Legacy of Critical Illness

So, why are we talking about this? It has been well established that individuals who survive critical illness requiring mechanical ventilation specifically acute respiratory distress syndrome exhibit muscle weakness, persistent physical disability, and impaired reports regarding quality of life (via the SF-36) after hospital discharge. After 5 years, with an impressive 86% follow up rate, only 75% returned to work and subjects utilized 4 times the healthcare costs (86% follow up rate).

Sequelae of the ICU

The phenomena of ICU-Acquired Weakness (ICU-AW) and it’s specific subsets critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) have been characterized. Following merely 18 hours of mechanical ventilation structural and functional changes in the diaphragm muscular are present. Those who require prolonged mechanical ventilation are worse off still. Some exhibit global electrophyisologic abnormalities consistent with neuropathy and myopathy in conjunction with weakness 5 years post ICU discharge. Many complain of persistent weakness, disability, and a prolonged recovery period.

Dr. Margaret Herridge, MD, MPH comments:

This is a huge public health catastrophe when we’re saving people’s lives but they’re ending up with severe disability. It’s a very important message for patients, families and primary care physicians because I think patients assume they should be well, so they feel bad that they aren’t.

Sadly, the sequelae of critical illness extend beyond physiologic abnormalities of nerves and muscles, weakness, and physical function. Survivors display significant neuro-cognitive problems. At one year follow up of 821 medical and surgical ICU patients more than 50% displayed memory and attention deficits. The presence of post-traumatic stress and post-traumatic stress syndrome are now well recognized. At 1, 2, and 5 years post ICU discharge reports of depression and anxiety persist in nearly 50% of some studied cohorts. Survivors suffer not merely from physiologic and physical impairments, but significant and quite limiting neuro-cognitive deficits in conjunction with psychological difficulties.

What happened to me in the hospital?   Yes, my life was saved, and I am grateful for that, but life AFTER the ICU was extraordinarily difficult, not only physically but also mentally. -Nancy Andrews

Factors associated with long term physical impairments include duration of bed rest, age, ICU length of stay, and potentially the dosage corticosteroids.  Amount and duration of sedation, development of delirium, and delusional memories are associated with long term neurocognitive impairments.

And, unfortunately it doesn’t end with the patient. Family members and caregivers of ICU patients exhibit mental health difficulties including anxiety, depression, PTSD, and complicated grief following the intensive care experience. Recently, Post Intensive Care Syndrome (PICS) was constructed to assist in recognition and classification of survivors’ as well as family members’ post ICU impairments. The goal, of course, is to improve outcomes following critical illness.

Physical Therapy IN the ICU?

The focus surrounding early mobilization of critically ill, mechanically ventilated patients as well as physical therapists involvement in the ICU continues to grow. Although by no means complete, the research suggests that early mobilization and physical therapy is safe, feasible, and appears beneficial. Findings illustrate potential effects and associations at a physiologic, patient performance, functional, medical outcomes, and health care services level.

The bottom line is having a patient, who for at least a part of the day, can be awake from drug affect, and interact with the environment in a purposeful way is the key foundation to the idea. – John P. Kress, MD

Associations and effects of early mobility programs and/or physical therapist treatment include:

Increased

Decreased

What are WE (physical therapists) doing?

Does clinical practice reflect this strong premise suggesting safety, feasibility, and rationale for physical therapists in the ICU? A survey of physical therapists belonging to the acute care section of the American Physical Therapy Association from 2007 suggests physical therapists are more likely to be routinely involved in the ICU with neurologic and trauma related diagnoses as oppose to medical diagnoses. Follow up survey data from 2012 suggests a lower likelihood of mobility as perceived complexity (either medically or logistically) increases.

Now, given the limitations of survey data, firm conclusions on WHY are not possible. But, it appears that as medical complexity increases, the less likely physical therapists are to be involved. The more “medical” the diagnoses, the less likely physical therapists are to be involved. Is this secondary to perceived risk? Lack of perceived benefit? Lack of knowledge in long term outcomes, safety, and feasibility? The ICU equipment? Staffing?

What is the basis of physical therapist decision making regarding patients in the intensive care unit? Are therapists making treatment decisions based on the presence of machines, the logistics, and the fears of worst case outcomes? In proper risk analysis, it is imperative to also assess the risk of not intervening. The long term sequelae of critical illness illustrate the potential risks of a critical illness and ICU course left to “natural history.”

Road Blocks & Speed Bumps

Regardless of the evidence, rationale, safety, and feasibility barriers do exist. These barriers likely exist within and between individual clinicians, specific professions, various departments, different units, and the entirety of each specific hospital. But, barriers also involve the interactions of these individuals and professions at all levels of the hospital. The staffing, patient prioritization, training, knowledge, and historic practice patterns are all important variables requiring considerations. Many factors and individuals result in the overall, but dynamic culture of a unit and/or hospital. In order to facilitate change, an eventual transformation of ICU culture is required.

What do PATIENTS think?

I was never told by anyone what to expect – ICU Survivor

A current randomized control trial entitled Do it Now (Diagnosis and Treatment of Neuromuscular Weakness) is investigating early, intensive physical therapy (7 days a week, 30-60 minutes) and standard physical therapy (3 days a week, 15-20 minutes) in patients requiring mechanical ventilation for greater than 4 days. Part of the study is a survey investigating patient and proxy perceptions of physical therapy. To date no robust investigations of patient, family, and proxy perceptions of early, intensive physical therapy exist. The literature on long term outcomes in conjunction with individual patient stories illustrate the shattering trauma of the ICU:

It’s been two years and I’m still trying to sort out what was real and what wasn’t. I still think about it several times a week and continue to ask questions of my family. I have a compelling need to know what happened to me… – ICU Survivor

Interestingly, regardless of which arm of the above study, patient’s  and proxy’s reported physical therapy as highly necessary and beneficial. Although difficult and requiring significant exertion, both patient groups were satisfied with the experience. Neither group would have requested less therapy sessions. And, in fact, both groups requested slightly more. Maybe engagement in a therapeutic process can decrease some of the trauma of the ICU experience? In a brief video, Dale Needham, MD of Johns Hopkins routinely observes that patients agree:

Patient’s overwhelming tell us is that they like the early physical medicine and rehabilitation, they like being awake. They certainly like getting out of bed and moving. It shows them that there is hope, it shows them there is a life beyond the intensive care unit. And, a life for them to get back to. It gives them goals for improvement, It shows them that they can get better.

Nancy Andrews comments from a patient’s perspective:

I can share advice based on my experience. Reach out to people. Talk about what you remember. Draw, play games, listen to music, dance, DO PHYSICAL THERAPY, Reconstruct what happened and sort it out. Talk to your doctor. Ask for help.

Summary

1. Immobility is PATHOLOGY
2. Critical Illness  is a neuromuscular, cognitive, psychological INSULT
3. Long Term Functional Outcomes are POOR
4. Mechanisms of physical therapy and mobility are likely multi-factorial
5. Physical Therapist practice in the ICU is evolving, but varied
6. Patients & Family’s understand benefit of physical therapy
7. Patient’s & Family’s desire physical therapy

Dale Needham, MD summarizes the issue

We must stop making excuses about why a patient can’t do rehabilitation today—he has a CT scan or she’s getting dialysis. We need to highly prioritize rehabilitation, which we now see as just as—if not more—important than many other tests and treatments we offer our patients in intensive care.

Change is possible. The rationale is present, it is time for action.

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Data Quality: Garbage In = Garbage Out

Measuring and objectifying observations and phenomena. Numbers. Data. These are the cornerstones of analytics. The presentation and appearance of (apparent) objectivity. Whether in research, health care policy, economics, business, or clinical practice, data is important.

The data doesn’t lie.

But, sometimes the people that interpret it do. Not that they mean to. It’s not done on purpose (except when it is). So, yeah, unfortunately, the numbers can lie. And, they will lie to you if you are not conscientious about assessing them more deeply.

“What gets measured, gets managed.” Peter Drucker

Data Quality

Questions of why this works, or, maybe, more importantly, “does this work as proposed? Does the explanatory model make sense?” are not inherently built into the evidence based approach. Yet, these questions are vital to integrating and understanding outcomes research, while evolving our theoretical models. Such a task mandates metacognition and critical thinking. Failure to critical assess the quality, and potential meaning, of data, will result in improper conclusions.

The evidence hierarchy is sorted by rigor not necessarily relevance –EBP and Deep Models

But, the questions and issues surrounding data quality and interpretation transcend assessing the literature within the context of the evidence based hierarchy. Much like the research literature, the data collected, analyzed, and utilized everyday warrants critical appraisal. It all requires assessment; data encountered inside and outside the clinic, data utilized for decision making and understanding. The concepts of scientific inquiry should be wielded routinely, including assessment of quality, source, and limitations of the numbers. Only then, can proper interpretation and subsequent decision making occur.

Is it accurate?
Is it representative?
Where did the numbers originate?
What do the numbers actually represent?
What conclusions can or can not be concluded from a data set?

The evidence based practice hierarchy is concerned mainly with questions of “what works?” and “what is effective and efficacious?” These are necessary, important, big questions. But, the term “evidence” as utilized by most clinicians and researchers is focused mainly on randomized clinical trials, systematic reviews, and meta analyses of randomized control trials. Outcomes based research. This is a necessary and obvious step forward from purely observational, experienced driven clinical practice and education. Despite the obvious importance of experience (or more accurately deliberate practice) in clinical decision making, analysis based on experience or clinical observation only is prone to errors such as confirmation bias and convenience. Clinical observation alone is limited in it’s ability to ascertain phenomena such as a natural history and regression to the mean. And thus, this issue is related not only to data quality, but proper data interpretation. Understanding data quality assists in assessing “what works”, but also in tackling the complex question of “why does it appear to work?” Both questions are inherent to, and reliant upon, the quality of data.

Numbers, Data, and Objectivity

In attempting to objectively measure the world, has the potential accuracy and quality of data been forgotten? Overlooked even? A number seductively presents the appearance of objectivity and accuracy, but does not guarantee it. Big Data provides an excellent example of data quantity with relatively overlooked quality. Astounding data-sets through avenues such as social media and search engines afford researchers and large companies the opportunity to analyze data-sets that would literally explode your lab top. For example, in 2008-2009, based on web search data Google Flu Trends more accurately and quickly predicted and modeled flu outbreaks than the Centers for Disease Control (CDC). Well, until 2012-2013 when it wasn’t so accurate, over estimating peak trends. In big data are we making a mistake? Tim Harford explores the scientific and statistical problems still present (even when the size of a data set requires it to be stored in a warehouse): 

But a theory-free analysis of mere correlations is inevitably fragile. If you have no idea what is behind a correlation, you have no idea what might cause that correlation to break down. One explanation of the Flu Trends failure is that the news was full of scary stories about flu in December 2012 and that these stories provoked internet searches by people who were healthy. Another possible explanation is that Google’s own search algorithm moved the goalposts when it began automatically suggesting diagnoses when people entered medical symptoms…

Statisticians have spent the past 200 years figuring out what traps lie in wait when we try to understand the world through data. The data are bigger, faster and cheaper these days – but we must not pretend that the traps have all been made safe. They have not…

But big data do not solve the problem that has obsessed statisticians and scientists for centuries: the problem of insight, of inferring what is going on, and figuring out how we might intervene to change a system for the better.

Measurement Matters

Now, just because it can be measured, does not mean it should be measured. Measurement alters behavior. And, the change is not always as envisioned or desired. As soon as a goal is set to alter a metric, incentives apply. This concept transcends clinical care. It applies to business, management, and clinician behavior. Enter the cobra effect.

The cobra effect occurs when an attempted solution to a problem actually makes the problem worse. This is an instance of unintended consequence(s).

So, is the goal to change that specific metric only?  Or, is the actual goal to encourage specific behaviors that appear to directly affect, or are correlated with, that metric. Regardless of the goal, care must be taken in defining success. This requires a clear definition of what is measured and why. Again, deep analysis of data quality and interpretation are necessary to properly interpret results of process changes. Due to the appearance of objectivity in the presentation of numbers, it is easy to make inaccurate or far reaching conclusions. This is especially true when care is not taken to assess all the components of the data:

What does the data actually represent?
Who or what measured it? Who or what entered it?
How was it initially assessed and subsequently interpreted?
What other data needs to be considered or measured?

Now, even with reliable and accurate data input, inaccuracy can occur. The wrong conclusions can be “output” because of the misinterpretation regarding what the data is representing or signifying. Wrong numbers = wrong analysis = wrong conclusion = wrong interpretation = misguided application.

Steer away from subjectivity

The complexity of even the simplest data sets is astounding. Ever present are questions such as: Is the data valid? Does the data represent the assumed construct or principle? What potential bias is involved? Is it reliable between people; between subsequent measurements? Is it actually measuring what we think it’s measuring? Can it answer the questions we are posing? Measured and presented data is rarely as simple as a concrete number.

The attempted objectification and simplification of subjective, individualized, complex phenomena such as happiness, satisfaction, engagement, or pain may be tragically flawed. Commonly, over reaching conclusions are based on assumptions of accurate and/or complete representation. The data presented is merely a measurement, a number produced via the tool chosen.

A tool misused produces data that’s unusable

That tool may, or may not, accurately convey the construct it was initially designed to represent. In the case of patient report questionnaires, the individual filling out the tool will always be biased; influenced by the environment, their expectations of what should be conveyed, influences from others (explicit and implicit), as well as complex incentives depending on their needs, goals, and expectations. Further, most data encountered on daily basis, including clinical outcome measures (whether patient performance or patient report), is not collected in controlled environments with explicit processes. Bias will always affect reporting and recording. Questions of the accuracy, reliability, and validity apply not only to the tool, but also to the person recording the measurement. It quickly becomes complicated. The Modified Oswestry Disability Index never seems so messy when presented as a straight forward percentage.

Compare the stark contrast between how an outcome measure is collected within a research trial vs. everyday clinical practice. In order to minimize both error and affects of bias, outcomes in a trial are collected by a blinded assessor. A standardized set of directions is utilized, with a pre-defined process for administration and measurement. But, even in more controlled, direct data collection environments, what is being measured and what that actually illustrates, is not straight forward. Representation is not always linear. Even in randomized, tightly controlled, double blind studies bias and flaws are present. This does not inherently make the data useless. Leaps of logic need to be recognized.

If data is sloppy enough it is beyond useless. It’s harmful.

Why? Because, unreliable, variable data that is not truly measuring or representing the phenomena one assumes will ultimately lead to inaccurate conclusions. Regardless if the data is positive, negative, or neutral it is misleading.

How? Because, the data itself can not be representative of what we think it is measuring, purely by the the fact that the data itself is unreliable, overly variable, and “sloppy.” Further, if the assumption is made that a measure represents a certain construct, but it actually does not, it has no validity. Without reliability, validity is unobtainable. Without validity, reliability is misleading.

Data Quantity vs. Data Quality

So, should the focus remain on quality or quantity in data? Both. Is more data always better? Well, that depends on the quality. But, what is quality data? Quality is a relative term. Collecting, analyzing, or using data is only part of the equation. Once collected, questioning validity, reliability, representativity, and relevance is necessary. In the cases when data has already been collected and potentially presented, it’s time for some serious skeptical inquiry. Understanding what data actually represents and illustrates assists in proper critical appraisal. Proper critical appraisal allows proper interpretation. Proper interpretation is the foundation for  effective utilization. Less controlled data collection environments do not necessarily produce unusable data, and in fact can be quite useful in the realm of health services and care delivery models. Yet, the conclusions drawn on effects, mechanisms, and efficacy need to be tempered. Focus on understanding exactly what a data set can and can not illustrate given the data collection environment and design and metrics.

Unreliable and invalid data in, wrong conclusions out. Always. Any accurate representation will be by chance alone. But, in these instances, the probability of attaining an accurate representation will often be less than chance. Limits are always present, and can not be avoided, but understanding the limits of the data assists in drawing conclusions that are the least wrong. While the data itself is important, what is done with the data, and why, is almost more important. And, these principles apply whether you are assessing your clinics “outcomes” or tracking disease outbreaks with big data. Focus on improving the quality and accuracy of data collection on the front end. Train those measuring, collecting, and entering data. Improve analysis and inquiry on the back end. In addition to asking “where’s the data?” we should be asking “where did that data come from?” and, “what does it actually illustrate?”

Be skeptical. Garbage in = garbage out.

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Precision in Language

Language is obviously important as words are the basis of explicit communication. As is such, specificity in language and word definitions is vital to interaction. But also, specificity in meaning is required for accurate scientific research. Thus, terms are often operationally defined in studies. It is an attempt to clearly communicate how the researchers are defining, utilizing, and investigating a construct. Hopefully, ensuring appropriate interpretation and application of results while bundling theoretical constructs through explicit definitions.

I’m no expert in linguistics, philosophy, or even language, but I think this is an important professional topic. Now, admittedly, physical therapists deal with complex physiologic systems and phenomena. Some concepts can elude specific definitions physiologically and linguistically. Pain is a perfect example.

The lived pain experience is an emergent, individually experienced phenomena dependent on a myriad of interacting physiologic, psychologic, environmental, social, cultural, and linguistic components. It’s not merely resultant from nociception nor tissue damage or even injury. Yet, the presence of such complex systems and phenomena should not preclude striving for specificity of language. Vagueness does not help us. Investigating form, meaning, and context of language assists in research, education, and patient interaction. Luckily, the International Association for the Study of Pain created a taxonomy, and is attempting to more robustly define terms related to the painful experience. The list includes hyperalgesia, hyperesthesia, noxious stimulus, peripheral sensitization, central sensitization, and neuropathic pain among others. Some terms, such as allodynia (“pain due to a stimulus that normally does not provoke pain”), are considered “clinical terms” and purposefully absent of proposed mechanisms. Other terms, such as nociceptive stimulus (“an actually or potentially tissue-damaging event transduced and encoded by nociceptors”), are mechanistically more specific.

As a more concrete, basic science example, what would result if 100 physical therapists & 100 physicists  were charged to define strength, power, acceleration, stability and balance? How many definitions? How much similarity would they display?

@Jerry_DurhamPT has a hypothesis…

101definitions

101 definitions.

One, exact definition (and likely a formula) from the 100 physicists. And, likely 100 separate, but similar, definitions from 100 physical therapists. These words have explicit definitions and equations within the realm of physics (classical mechanics). As Erik Meira asserts robust, specific definitions are absolutely necessary for science:

I’m not trying to get metaphysical here but we must define our terms in order to be scientific…Poorly defined statements are inherently not scientific. Just because it’s published does not make it science.

Specificity and discipline in language is a necessary first step. It is required for accurate discussion and collaboration within research, clinical practice, and between professionals. This includes other professions (and not just healthcare). But, unfortunately, appropriately defining and subsequently understanding definitions does not account for, nor address, how other healthcare professionals, disciplines, patients, and society perceive certain words. What are their definitions? As an example, lets explore the word “prevention.”

Prevention: the action of stopping something from happening

Within healthcare and physical therapy, true prevention by definition, is kind of a misnomer. But, the health care system, patients, and consumers utilize the term prevention differently. Usually, the concept of “prevention” is actually used to mean “risk reduction.” Thus, the “functional definition” within the context of healthcare and patient interaction is slightly altered. What is actually meant by ACL injury prevention is reducing the likelihood of an ACL tear. Epidemiology provides some insight…

In epidemiology, the absolute risk reduction, risk difference or excess risk is the change in risk of a given activity or treatment in relation to a control activity or treatment. It is the inverse of the number needed to treat. -Wikipedia

In epidemiology, the relative risk reduction is a measure calculated by dividing the absolute risk reduction by the control event rate.

The relative risk reduction can be more useful than the absolute risk reduction in determining an appropriate treatment plan, because it accounts not only for the effectiveness of a proposed treatment, but also for the relative likelihood of an incident (positive or negative) occurring in the absence of treatment. -Wikipedia

Currently, there are no singular interventions to fully prevent the occurrence of most diseases and injuries in normal life situations. In being alive, there is always risk.

So what to do? If other disciplines such as mathematics, physics, or psychology have defined a certain term or construct, I propose it necessary to understand and utilize that definition accurately in professional discourse. The terms above, which originate from classical mechanics, immediately come to mind. We should challenge and operationally alter definitions from other fields only if strong data and logic warrant modification. Further, in research, discussion, and education the most specific, accurate definitions should be sought after. If unknown, questions should arise, discussion should ensue, and operational definitions provided. Science requires precision in language: exact terms. Lastly, the patient and consumer’s definition of certain words needs to be ascertained. Where feasible, more appropriate explanations should be provided to improve public and professional understanding of terminology. Communication is strained, and collaboration limited, if we are essentially “speaking different languages.”

A physical therapist does not need to be an engineer, but understanding the language of mechanics allows for true discussion between fields. It opens the door for increased collaboration.

A physical therapist does not need to be a psychologist, but knowledge of psychological constructs allows for evolved ways of conceptualizing and treating patients. It lends itself to improved research and clinical practice.

A physical therapist does not need to be a linguist, but explicitly defining words is necessary. It helps us understand form, meaning, and context.

collaborate

We need specificity and discipline in our language. Combining our expertise with the language and concepts from other disciplines fosters the ability to more robustly communicate and subsequently collaborate. This allows us to identify the grey, and step into uncertainty. For then we can truly start to explore the chaos, slowly illuminating specificity. Vagueness, after all, is beyond the limits of logic and reason.

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Metacognition, Critical Thinking, and Science Based Practice #DPTstudent

Metacognition can be considered a synonym for reflection in applied learning theory. However, metacognition is a very complex phenomenon. It refers to the cognitive control and monitoring of all sorts of cognitive processes like perception, action, memory, reasoning or emoting.

A recent #DPTstudent  tweet chat dealt with the concept of metacognition broadly (list of links), but more specifically discussed the need for critical thinking in education and clinical practice. Most agreed on the dire need for critical thinking skills. But, many #DPTstudents felt they had no conceptual construct on how to develop, assess, and continually evolve thinking skills in a formal, structured manner. Many tweeted they had never been exposed to the concept of metacognition nor the specifics of critical thinking. Although, most stated that “critical thinking” and “clinical decision making” were commonly referenced.

What’s more important than improving mental skill sets?

Thinking is the foundation of conscious analysis. Yet, even with a keen focus on assessing and improving our thinking capacities, unconscious processes influence not only how and why we think, but what decisions we make, both in and out of the clinic. We are humans. Humans with bias minds. Brains that, by default, rationalize not think rationally…

Everyone thinks; it is our nature to do so. But much of our thinking, left to itself, is biased, distorted, partial, uninformed or down-right prejudiced. Yet the quality of our life and that of what we produce, make, or build depends precisely on the quality of our thought. Shoddy thinking is costly, both in money and in quality of life. Excellence in thought, however, must be systematically cultivated. – Via CriticalThinking.org

Need a Model

Mary Derrick observed previously in her post that the words critical thinking and clinical decision making are often referenced without much deeper discussion as to what these two concepts entail or how to develop them. Students agree that critical thinking and sound clinical decision making are stressed in their pre-professional education. But, all levels of education appear to grossly lack formalized courses and structured approaches. The words are presented, but rarely systematically defined. The actual skills rarely practiced and subsequently refined. Students thus lack not only exposure and didactic knowledge of metacognition, critical thinking, and decision making, but also lack experience evolving these mental skills.

Critical_Thinking_Wheel_DJacobs
Critical Thinking Wheel via Diane Jacobs @dfjPT 

Need to teach how to think

Alan Besselink argued a scientific inquiry model to patient care is, from his view, “the one approach.”

There is, in fact, one approach that provides a foundation for ALL treatment approaches: sound, science-based clinical reasoning and principles of assessment, combined with some sound logic and critical thinking.

One approach to all patients requires an ability to gather relevant information given the context of the patient scenario. This occurs via the clinician’s ability to ask the appropriate questions utilizing appropriate communication strategies. Sound critical thinking requires the clinician to hold their own reasoning processes to scrutiny in an attempt to minimize confirmation bias if at all possible. It also requires the clinician to have a firm regard for the nature of “normal” and the statistical variations that occur while adapting to the demands of life on planet earth.

Philosophically, I agree. It appears the question “what works?” has been over emphasized at the potential sacrifice of questions such as “how does this work?”  “why do we this?” and “why do we think this?”

Unfortunately, the construct of evidence based practice assumes the user applying the EBP model is well versed in not only research appraisal, but critical thinking. The structure of evidence based practice overly relies on outcomes studies. It lacks a built in process for integration of other sources of knowledge as well as the applicable question of “does this work as theoretical proposed?” The evidence hierarchy is structured and concerned with efficacy and effectiveness only. Many will be quick to point out that from a scientific rigor standpoint the evidence hierarchy is structured as such, because other forms of inquiry (basic physiology, animal models, case reports, case series, cohort studies, etc) can not truly answer questions “what works?” without significant bias. Robust conclusions on causation can not be made via less controlled experiments. And this, of course, is true. In terms of assessing effectiveness and efficacy in isolation, the evidence hierarchy is appropriately structured.

But, the evidence hierarchy does not consider knowledge from other fields nor basic science, and thus by structure explicitly ignores plausibility in both theory and practice. To be fair, plausibility does not necessarily support efficacy nor effectiveness. So, it is  still imperative, and absolutely necessary, to learn the methodology of clinical science. Understanding how the design of investigations affects the questions they can truly answer precedes appropriate assessment and conclusion. Limits to the conclusions that can be drawn are thus explicitly addressed.

Need the Why

Because of the focus on evidence based practice, which inherently (overly?) values randomized control trials and outcomes studies over basic science knowledge and prior plausibility, students continue to learn interventions and techniques while routinely asking “what works?” Questions of “how did I decide what works?” “why do I think this works” and “what else could explain this effect?” also need to be commonly addressed in the classroom, clinic, and research. Such questions require formalized critical thought processes and skills.

These questions are especially applicable to the profession of physical therapy as many of the interventions have questionable, or at least variable, theoretical mechanistic basis in conjunction with broad ranging explanatory models. This is true regardless of effectiveness or efficacy. In fact, it is a separate issue. Physical therapy practice is prone to the observation of effect followed by a theoretical construct (story) that attempts to explain the effect. A focus on outcomes based research perpetuates these theoretical constructs even if the plausibility of the explanatory model is unlikely. In short, while our interventions may work, on the whole we are not quite sure why. @JasonSilvernail‘s post EBP, Deep Models, and Scientific Reasoning is a must read on this topic.

The profession suffers from confirmation bias in regards to the constructs guiding the understanding of intervention effects. In addition, most, if not all, interventions physical therapists utilize will have a variety of non-specific effects. These two issues alone highlight the need for critical thought in order to ensure that our theoretical models, guiding constructs, and clinical processes evolve appropriately. And, further, to facilitate appropriate interpretation of outcomes studies.

It is not “what works?” vs. “why does this work?” Instead, a focus on integrating outcomes studies into the knowledge and research of why and how certain interventions may yield results is needed. This requires broadening our “evidence” lens to include physiology, neuroscience, and psychology as foundational constructs in education and clinical care. Further, research agendas focused on mechanistic based investigations are important to evolving our explanatory models. Education, research, and ultimately clinical care require both approaches. Interpretation, integration, and application of research findings, be they outcomes or mechanistic, necessitates robust cognitive skills. But, do we formally teach these concepts? Do we formally practice the mental skills?

So, now what?

There appears to be an obvious need, and obvious value, to learning how to think. But, that is just the start. The necessity of learning to think about thinking is required to improve the specific skill of critical thinking. The understanding and application of evidence based practice needs more robust analysis. Growth of critical thinking, metacognition, and an evolution of evidenced based to science based practice produces the foundation for strong clinical decision making. The call for evidence based medicine to evolve to science based medicine focuses on ensuring clinicians interpret outcomes studies more completely. It appears to put strong emphasis on increased critical thinking and knowledge integration.

Does Evidence Based Medicine undervalue basic science and over value Randomized Control Trials?

A difference between Sackett’s definition [Evidence Based Practice] and ours [Science Based Medicine] is that by “current best evidence” Sackett means the results of RCTs…A related issue is the definition of “science.” In common use the word has at least three, distinct meanings:

1. The scientific pursuit, including the collective institutions and individuals who “do” science;

2. The scientific method;

3. The body of knowledge that has emerged from that pursuit and method (I’ve called this “established knowledge”; Dr. Gorski has called it “settled science”).

I will argue that when EBM practitioners use the word “science,” they are overwhelmingly referring to a small subset of the second definition: RCTs conceived and interpreted by frequentist statistics. We at SBM use “science” to mean both definitions 2 and 3, as the phrase “cumulative scientific knowledge from all relevant disciplines” should make clear (by jennifer). That is the important distinction between SBM and EBM. “Settled science” refutes many highly implausible medical claims—that’s why they can be judged highly implausible. EBM, as we’ve shown and will show again here, mostly fails to acknowledge this fact.

 

What to do?

1. Learn how humans think by default: Biased
2. Learn the common tricks and shortcuts our minds make and take
3. Understand logical fallacies, cognitive biases, and the mechanics of disagreement
4. Meta-cognate: Think about your own thinking with new knowledge
5. Find a mentor or partner to critique your thought processes: Prove yourself wrong
6. Critique thought processes, lines of reasoning, and arguments formally and informally
7. Debate and discuss using a formalized structure
8. Think, reflect, question, and assess
9. Discuss & Disagree
10. Repeat

Science Based Practice…

1. Foundations in basic science: chemistry, physics, physiology, mathematics
2. Prior plausibility: “grand claims require grand evidence”
3. Research from other relevant disciplines from physics to psychology
4. Mechanics of science: research design and statistics
5. Evidence Based (outcomes) Hierarchy

Questions lead, naturally, to more questions. Inquiry breads more inquiry. Disagreement forms the foundation of debate. And thus, Eric Robertson advocates for embracing ignorance

Ignorance is not an end point. It’s not a static state. Ignorance isn’t permanent. Instead it’s the tool that enables one to learn. Ignorance is the spark that ignites scholarly inquiry.

Ignorance: the secret weapon of the expert.

Growth is rarely comfortable, but it’s necessary. And, that’s a lot to think about….

Resources

A Practical Guide to Critical Thinking
CriticalThinking.org
Logical Fallacies
Critical Thinking Structure
List of Fallacies
List of Cognitive Biases
Science Based Medicine
Clinical Decision Making Research (via Scott Morrison)
Clinical Decision Making Model
Thinking about Thinking: Metacognition Stanford University School of Education
Occam’s Razor
The PT Podcast: Science Series
Understanding Science via Tony Ingram of BBoyScience
I don’t get paid enough to think this hard by @RogerKerry1 (his blog is fantastic)

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The Ultimate Log ‘N Blog for PT app!

Screen Shot of ProtoGeoI wish I had this newly released app last week during CSM 2013! Moves by Protogeo Oy, brings a sweet new movement tracker to the field of personal data monitoring. With no need to purchase a new device, charge it, or risk losing it, Moves is a smart phone app that uses a combination of your phone’s accelerometer and some server-based processing to determine what you are doing and when. Cycling? Got it. Running? Got it. Driving to the next trailhead? Got it covered. (I wouldn’t swim with your phone…but…)

I’d like to see a social component developed on this, but you can share screenshots or summaries of your feats with friends easily enough. This may just be the app every DPT Student needs to track their miles for the Log N’ Blog for PT fundraiser. And, it’s FREE! Enjoy!

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#AcutePT helps ICU save $818,000 per year!

In a recent post So, you think you can walk? I outlined some of the evidence, rationale, logic, and decision making involved in acute care physical therapist practice. I discussed the important of conceptualizing and studying physical therapists impact “beyond function.”

An article from UPI.com entitled Providing Physical Therapy in ICU Helpful highlights exactly this concept. The study discussed will be published around March in Critical Care Medicine. An e-published ahead of print version is already available: ICU Physical Rehabilitation Programs: Financial Modeling of Cost Savings. The benefits of technology allow us to begin preliminary discussion and analysis!

The authors modeled cost savings utilizing best-case and most conservative estimates of length of stay reductions, upfront costs, and other factors based on  existing published data and their specific quality improvement project. The quality improvement project undertaken at Johns Hopkins University within the medical ICU included full time, dedicated physical therapists and occupational therapists in the medical ICU. The vision:

A multidisciplinary team focused on reducing heavy sedation and increasing MICU staffing to include full-time physical and occupational therapists with new consultation guidelines.

In total, the early rehabilitation program cost the hospital approximately $358,00 more per year than the previous standard of care. So, what did the results say? Within 1 year, ICU length of stay decreased by an average of 23% while medical ICU admissions increased by over 20%. An $818,000 per year net savings after accounting for start up costs (approximately $358,000) was observed. Conclusions:

A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.

The “actual experience” investigation is actually published in Archives of Physical Medicine and Rehabilitation: Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project. The study lead, Dr. Dale Needham, MD, PhD, passionately advocates for the importance and necessity of physical therapists and early mobility within ICU’s for individuals with critical illness. Independently, the results of that quality improvement study are also profound:

Results: Compared with before the quality improvement project, benzodiazepine use decreased markedly (proportion of MICU days that patients received benzodiazepines [50% vs 25%, P=.002]), with lower median daily sedative doses (47 vs 15 mg midazolam equivalents [P=.09] and 71 vs 24 mg morphine equivalents [P=.01]). Patients had improved sedation and delirium status (MICU days alert [30% vs 67%, P<.001] and not delirious [21% vs 53%, P=.003]). There were a greater median number of rehabilitation treatments per patient (1 vs 7, P<.001) with a higher level of functional mobility (treatments involving sitting or greater mobility, 56% vs 78%, P=.03). Hospital administrative data demonstrated that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year.

Conclusions: Using a quality improvement process, intensive care unit delirium, physical rehabilitation, and functional mobility were markedly improved and associated with decreased length of stay.

  • Early mobility in acute care. It’s important.
  • The physical therapist in acute care. A vital part of the care team.
  • Looking beyond function to conceptualize and understand the impact of the physical therapist? Necessary.
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So, you think you can walk? #AcutePT

All you do is walk people! Are you going to walk Mrs. Smith? Are you getting Mr. Johnson up? You don’t have to think in acute care!

In my opinion, the role of the physical therapist in acute care hospitals has some of the most profound & robust reasoning and logic. In addition, clinical research evidence continues to illustrate the positive benefit of physical therapists within acute hospitals for individuals who have had total joint replacements to the most critically ill individuals in intensive care units. The Physical Therapy Journal special issue on Rehabilitation for People with Critical Illness inspired me to discuss acute care practice in more depth. Despite the complex, fast paced environment and short lengths of stay, physical therapists continue demonstrate value in regards to patient outcomes, hospital throughput and flow, and risk reduction. The acute care environment is bursting with opportunity for physical therapists to enact meaningful change through innovative practice models and health care changing research.

Yet, the above are common statements and questions the acute care physical therapist must routinely face. Unfortunately, the skills, knowledge, role, and contribution of the acute physical therapist is misunderstood not just by other healthcare professionals within and outside the hospital environment. Equally as important, is the misunderstanding of physical therapist colleagues who practice in other settings.

In the editorial Acute Care Physical Therapist Practice: It’s Come a Long Way physical therapy journal editor Dr. Rebecca Craik, PT, PhD, FAPTA comments:

“Should Physical Therapists Practice in Acute Care Settings?” That was the 2007 topic for the Rothstein Debate, an annual event held at APTA’s conference and exhibition and established to honor PTJ’s esteemed Emeritus Editor in Chief Jules M. Rothstein (1945–2005).

 Dianne Jewell, PT, PhD, FAPTA, was moderator. Anthony Delitto, PT, PhD, FAPTA, and Charles Magistro, PT, FAPTA, argued for and against the need for physical therapists in the acute care setting. On one side, the physical therapist was characterized as a sophisticated decision maker with a breadth of knowledge that spanned medicine and physiology; on the other side, the physical therapist was characterized as just another clinical staffer who “dragged” patients down the hall.

The session was filled to capacity with approximately 300 people; the tension was palpable, the debaters articulate—but tempers were kept in check. The debate was declared a draw. I still recall my surprise that day at learning about the paucity of research on acute care practice:

1. The clinical decision-making process touted as complex by the “pro” team had not been described in the literature.

2. Responsive outcome measures had not been agreed upon.

3. Clinical trials had not been conducted to compare different interventions in that setting.

4. Cost-effectiveness had not been examined.

Today, in my opinion, I feel asking whether physical therapists belong in acute care shows a gross misunderstanding for the history and future of the physical therapy profession generally and the role of the acute care practioner specifically. Where is the recognition and assessment of the logic, rationale, and research behind acute care practice? My hope is that this debate topic was purposefully chosen to expose physical therapists to the acute care practice environment. Dr. Craik contends it inspired action. Acute care research and investigations since that debate have grown tremendously in both number and quality.

What are the physical therapist’s roles in acute care?

The obvious role of the physical therapist is to examine and evaluate a patient within the International Classification of Functioning, Disability, and Health (ICF Framework) to determine current and future need for rehabilitation, appropriate discharge location, equipment needs, and current functional level. Specific impairments of body structures and function, activity limitations, and participation limitations can be identified. Physical therapists can then also prescribe mobility and movement recommendations which I like to term “movement medicine.” This conceptualization of acute care practice, while accurate, is overly simplistic. For many, this is where their understanding and conceptualization of #acutePT ends.  In fact, it only represents a minute fraction of the effect and role of PT.

Beyond Function…

The profound effect that physical therapists can have in the acute care environment extends far beyond function and mobility. When analyzing the acute care practice environment from the outside many often ask if specific physical therapy interventions are effective from a functional, patient outcomes standpoint. While valid, this narrow scope does not fully encompass acute care practice.

The role and effect of the physical therapist’s presence, input, and treatment (generally and intervention content specifically) needs to be analyzed from multiple perspectives. Various metrics need to be assessed. Outcomes from multiple levels of the care and delivery process from the individual patient to the specific unit to the hospital to the entirety of the healthcare system need to be analyzed. This includes not only function and functional improvement, but current and future costs of an episode of care. No doubt, patient performance and function including future functional status and time to accomplishment of functional milestones are vitally important. But, length of stay, readmission rate, proper/safe discharge location, and reduction of medical complications are all important outcomes to patients, hospitals, and the healthcare system.

Physical therapist’s presence, guidance, and treatment can actually reduce the risk of adverse medical events including pneumonia, blood clots, readmissions, and longer lengths of stay. They may have an impact on hospital costs, future medical costs, overall healthcare costs and morbidity. These are important outcomes metrics. Taking a function only approach to acute care physical therapist practice and research may be detrimental. For example, a study may show that the functional outcome of a patient population treated by a physical therapist resulted in minimal improvements in function at hospital discharge. But, what if the same study illustrated that the treatment drastically lowered the incidence of pneumonia. Is that an outcome of interest to patients, physicians, hospitals, and health care administrators? A retrospective study illustrated physical therapists make accurate and appropriate discharge recommendations. More interestingly, when actual discharge location did not match the therapist recommendation the odds of readmission were 2.9 times higher than when the actual discharge matched therapist recommendation.

Physical therapists act not only as treating clinicians, but valued consultants (or a consulting service) in the acute care hospital. In a qualitative study of acute care practice the authors discuss acute care physical therapist practice in the evolving healthcare and hospital environment

According to the Centers for Disease Control and Prevention’s National Center for Health Statistics, the number of hospital days of care for patients of all ages was 226 million in 1970 compared with only 166 million in 2006. Similarly, the average length of stay was 7.8 days in 1970 and 4.8 days in 2006. Today’s hospital environment is one where patients are admitted for procedures, invasive medical management, and surgical interventions while longer-term healing, recovery, and rehabilitation occur elsewhere.

As a result, questions have been raised regarding the relevance of physical therapist intervention and management, commonly associated with the more lengthy rehabilitation phase of care, being delivered in such a fast-paced setting. The responses of the physical therapists interviewed in the study by Masley and colleagues suggest something else is occurring. The themes of this article and previous studies regarding the role of the physical therapist seem to demonstrate that physical therapists have evolved to becoming valued professional consultants who provide a unique, essential perspective, rendering them integral contributors to the acute care team. Today’s physical therapists specialize in evaluating and managing the patient’s functional mobility needs and, within that scope, serve as both consultants and effective transitional care providers.

Communication and Advocacy

Inter-professional communication is an ongoing necessity within the acute care hospital. Physical therapists are routinely interfacing with nurses, physicians, case managers, social workers, and other hospital staff. Acute care physical therapists are positioned to find and fight for allies outside the physical therapy profession. Emergency medicine and critical care physicians are recognizing the skills, expertise, and contribution of physical therapists. From coast to coast, they are advocating for physical therapists within and outside hospital walls resulting in development of innovative clinical programs and lines of research. Physical therapists are routinely a part of trans-disciplinary programs to improve patient care and outcomes. Through their physical location within a hospital setting, acute care physical therapists can leverage knowledge, skills, and expertise to promote and advocate for the entire profession of physical therapy.

Where’s the evidence?!?!

Recently, on twitter, a #DPTstudent tweeted that acute care had the least amount of supporting research. One of the reasons for this perception, I believe, is that much of the evidence supporting physical therapist practice in acute care is published in non-physical therapy specific journals such as Critical Care Medicine, Chest, and the Archives of Physical Medicine & Rehab. For example, Critical Care Medicine published an entire supplemental issue on Intensive Care Unit-Acquired Weakness (ICU-AW). But, the Journal of Acute Care Physical Therapy and Cardiopulmonary Physical Therapy Journal are still fantastic resources (by jennifer). As I outline in the Leveraging Technology Series post Selection of Content, we must read outside of the physical therapy specific literature. So far, I have discussed some of the rationale, which is vital, but what has research illustrated?

Total Joint Replacement
A study investigated the effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients illustrating that “Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed.” A study published way back in 1993 illustrated that receiving weekend treatment by a physical therapist correlated with decreased length of stay following joint arthroplasty.

Emergency Department
I have written before about the emergence of physical therapists in the emergency department. Preliminary data illustrates potentially improved patient satisfaction with care and shorter wait times when physical therapists are present in the ED. In addition, physicians practicing in emergency medicine have recognized the expertise and contribution of physical therapists in a variety of conditions including painful problems, musculoskeletal conditions, dizziness, and overall mobility/safety/discharge determination. An article in PTJ discussed the development of this novice practice venue.

Intensive Care Units
“Intensive Care Units cater to patients with the most serious injuries and illnesses, most of which are life-threatening and need constant, close monitoring and support from specialist equipment and medication in order to maintain normal bodily functions.”

Early mobility and physical therapy has been shown to be not only safe, but feasible in the individuals who require mechanical ventilation. A randomized control trial investigating early physical therapy and occupational therapy in critically ill mechanically ventilated patients concluded that not only was early physical therapy treatment safe and well tolerated early on in a critical illness course, but resulted in better short term functional outcomes and less delirium. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project  demonstrated with “hospital administrative data…that across all MICU patients, there was a decrease in intensive care unit and hospital length of stay by 2.1 (95% confidence interval: 0.4-3.8) and 3.1 (0.3-5.9) days, respectively, and a 20% increase in MICU admissions compared with the same period in the prior year” And earlier this year, a systematic review on early mobility in the intensive care unit was published.

Response Dependent Progression

Back to some of the original questions. Well, so what? All you are doing is helping people get up and walk around. Can’t a nurse assistant do that? In a study of mobilization level in a surgical intensive care unit it was found that physical therapists mobilize their patients to a higher level than nurses.  And, sometimes sitting ain’t easy. What appears simple procedurally often involves complex knowledge and decision making. A gentle manual technique may require a complex reasoning process and constant assessment of patient response. Similarly, in acute care the decision to sit up, stand, transfer, or ambulate requires the integration of physical therapy specific principles with knowledge of medical conditions, medical management, pharmacology, and pathophysiology. Mobility and therapy progression (within and between session) is based upon the principle of response dependent progression which necessitates integrating the previous knowledge with the patient’s current presentation/functional status while constantly monitoring physiologic status (vital signs), patient performance, and patient feedback (fatigue, shortness of breath, and other symptoms). The acute care physical therapist must assess and integrate complex information from various sources. Much of this information is dynamic in nature requiring constant integration and re-assessment…

So, you think you can walk?

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If You’re Going, You Might As Well Get There

[list][/list]Sometimes, it’s pure and simple logic that prevails as the best solution to something. This was the case in an important new study published ahead of print in Spine. You may have seen the presser released by APTA, AAOMPT on the matter. They’re exuberant, and they should be. Well, mostly.

The study, published by Drs. Julie Fritz, John Childs, Rob Wainner, and Tim Flynn, examined a payor database and looked at over 32,000 data sets of patients with low back pain with the purpose of describing physical therapy utilization in primary care settings. Further, they looked at both associated healthcare costs and the question of whether the physical therapy care being provided was either adherent with practice guidelines for an active treatment or non-adherent. Treatments were classified as non-adherent when they included things like ultrasound that are not proven interventions for patients with low back pain. While not a perfect practice, the researchers used billing codes as their determination factor for treatment adherence.

The findings of this study are fascinating to me. Albeit, many public health studies that look at low back pain and care patterns and/or costs are fascinating to me, so I’ll let you be the judge.

The key findings of the study were:

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    • For patients receiving physical therapy, early referral (within 14 days) was associated with less overall healthcare utilization, which included lower use of surgery, fewer doctor visits, less injections, and less advanced imaging that those with delayed referral (14-90 days).
    • For patients receiving adherent care, overall health utilization was also lower, but to a lesser degree that that seen with the early referral group.

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Graph demonstrating health utilization costs related to low back pain. Series 1 is costs for patients in early referral (gray) vs. delayed (orange). Series 2 shows costs for adherent care (gray) vs. non-adherent care (orange).

 

As you can see by the graph above, significant savings were realized by early referral to physical therapy and by adherent physical therapy care. Logic sure does shine forth here. If you’re going to go somewhere, well you might as well just get there. Significantly, the finding in this study is important because it runs counter to the suggestions by many LBP practice guidelines that suggest primary care physicians delay referral to other services as many patients are likely to improve anyway. Overall trends to reduce the medicalization of LBP are important, but this study reflects a trend whereby physicians are referring about half of patients to physical therapy within 14 days anyway. It turns out, this may end up being an evidence-supported practice.

Not all was rosy, however. Here are some other findings that were important:

Overall patient data sets and 7% utilization for patients with low back pain.

 

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    • Overall utilization for physical therapy for patients with low back pain in this data set was only 7%.
    • Overall healthcare costs were higher for patients receiving physical therapy. This might reflect increased severity, co-morbidities, etc, we just don’t know.
    • Only 21% of the physical therapy care provided was able to be classified as adherent. This could reflect an imperfect measuring tool, but I suspect there’s a problem here.
    • Wide geographic variability persists in the management of LBP, including physical therapy utilization and adherence to guidelines.

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This study is full of many other gems. It’s gated at Spine, so apologies for not including a full text link. The good new: Spine is a huge journal and this will be seen. As with many studies, this leaves more questions to ask. Such as, what factors make the patients who are referred early have lower subsequent utilization. The authors hypothesize it may have to do with the concept of self-efficacy. I like it.

I like it so much, in fact, that I’m involed in a related study with some of the authors to examine a similar question in a Department of Defense database. I’m eager to see what we find.

This study was jointly funded by grants from the Orthopaedic and Private Practice sections of the APTA, AAOMPT, and a faculty research grant from Texas State University.