OVERCOMING OBSTACLES TO ACUTE CARE REHABILITATION RESEARCH
Handout – 9 pages
2015 Combined Sections Meeting
February 4 – 7, 2015 – Indianapolis, Indiana
Slides will be available following the conference
SPEAKERS
Steven Fisher, PT, PhD
Associate Professor
Department of Physical Therapy
University of Texas Galveston Medical Branch
301 University Boulevard
Galveston, TX 77555-1144
Phone: (409) 772-9492
stfisher@utmb.edu
Patricia J Ohtake, PT, PhD
Associate Professor
Department of Rehabilitation Science
515 Kimball Tower
University at Buffalo
Buffalo, NY 14214
Phone: (716) 829-6732
ohtake@buffalo.edu
Diane Jette, PT, MS, DSc, FAPTA
Associate Chair and Professor
Department of Physical Therapy
MGH Institute of Health Professions
36 First Avenue
Charlestown Navy Yard
Boston, MA 02129
Phone: (617) 724-4844
djette@mghihp.edu
Barbara K. Smith, PhD, PT
Research Committee Chair
Acute Care Section APTA
Research Assistant Professor
Department of Physical Therapy
University of Florida
P.O. Box 100154
Gainesville, FL 32610-0154
Phone: (352) 294-5315
bksmith@PHHP.UFL.EDU
Dianne Jewell, PT, DPT, PhD, CCS, FAACVPR
Founder and CEO, The Rehab Intel Network
Program Director, Arcadia University
PT Health Policy Certificate Program
450 S. Easton Road
Glenside, PA
dvjewell@gmail.com
Carmen Kirkness, PT, PhD
Assistant Professor, College of Medicine
Assistant Director,
Health Outcomes Research Center
University of Illinois at Peoria
One Illini Drive
Peoria, IL 61615
Phone: (309) 671-8438
csk@uic.edu
Mary Stilphen, PT, DPT
Senior Director, Department of Rehabilitation
and Sports Therapy
Cleveland Clinic
9500 Euclid Avenue
Cleveland, Ohio 44195
Rehabilitation
Phone: (216) 444-8610
stilphm@ccf.org
COURSE DESCRIPTION AND OBJECTIVES
Acute care physical therapists and clinics are ideally positioned to generate evidence about the
value of physical therapy. The Revised Research Agenda for Physical Therapy was released in
2011 to direct and prioritize issues and lines of research in physical therapy. The Agenda
includes areas of basic and clinical science, epidemiological, work force, and health services
research that are germane to acute care physical therapy practice. While there is a growing
recognition of the value of rehabilitation interventions in acute care settings, there is also an
increased demand for controlled studies of therapies on patient-centered (physiological function,
mobility, and disability) as well as health services-related (e.g. cost, utilization) outcomes.
Despite the high need for systematic studies of therapeutic interventions in acute care, the
systems and environment of a hospital setting provide challenges to designing and
implementing relevant yet feasible studies. This session will examine current challenges
associated with the conduct of rehabilitation research in the acute care setting and suggest
potential methods for clinical therapists and administrators to address these obstacles.
Particular focus will be placed upon obtaining institutional approvals, employing partnerships
between academic and clinical settings to yield a rigorous study design and navigate hospital
systems barriers, utilizing valid, standardized outcome measures, and building research
mentors and networks.
After this session, participants will be able to:
1. Evaluate the state of rehabilitation research in acute care physical therapy.
2. Describe the challenges associated with the following issues in acute care rehabilitation
research and identify potential resolutions:
a.
b.
c.
d.
e.
Obtaining Institutional Permissions
Selecting a study design to maximize the generalizability of the collected data
Navigating Hospital Systems, Processes, and Pressures
Utilizing systematic outcome measures
Building a research network
Schedule
11:00 – 11:05
Introduction
Moderator: Dianne Jewell, DPT, PhD, CCS, FAACVPR
11:05 – 11:15
Current State of Rehabilitation Research in Acute Care
Patricia Ohtake, PT, PhD
11:15 – 11:30
Obtaining Institutional Permissions
Steven Fisher, PT, PhD
Facilitated discussion
11:30 – 11:35
11:35 – 11:50
11:50 – 11:55
11:55 – 12:10
12:10 – 12:15
Systematically Employing Robust Outcome Measures
Carmen Kirkness, PT, PhD
Facilitated discussion
Using Academic Partnerships to Strengthen Research Output
Diane Jette, PT, MS, DSc, FAPTA
Facilitated discussion
12:15 – 12:30
12:30 – 12:35
12:35 – 12:50
12:50 – 12:55
12:55 – 1:00
Managing Hospital Systems, Processes, and Pressures
Mary Stilphen, PT, DPT
Facilitated discussion
Locating Mentors and Networking Support
Barbara Smith, PT, PhD
Facilitated discussion
Closing Remarks
Moderator: Dianne Jewell, DPT, PhD, CCS, FAACVPR
Current State of Rehabilitation Research
Patricia Ohtake, PT, PhD
1. The environment is ripe for research, but the challenges are many
2. Case presentation: how a great idea in the clinic turned into a research agenda
a. It starts with an intriguing question
b. Identify a partner and a champion – obtain permissions, design, overcome
obstacles
c. Select suitable outcome measures
d. Develop and foster research relationships
Obtaining Institutional Permissions
Steven Fisher, PT, PhD
1. Classifying your project
a. In the acute setting that classification typically begins with identifying whether
the project you have in mind relates to:
i. Scientific questions – Research
ii. Institutional change – Quality Improvement (QI) project
iii. Formal description practice – Case Report
2. Differentiating between human subject research,1 QI projects, and clinical case
reports, in the acute setting.
3. Considerations in obtaining institutional permissions based on your project:
a. Research
i. dealing with the Institutional Review Board (IRB)
1. Different classes of human subject research
2. Working with a Faculty sponsor
ii. Registering your study
iii. Obtaining informed consent from a hospitalized patient
b. QI project
i. When QI is research
ii. Are there intentions to use the information other than for local
improvement of patient care?
iii. Role of the IRB
c. Case Report
i. Standard of care vs. an intervention
ii. Institutional and Federal Guidelines regarding permissions for case
reports
iii. Scientific journal requirements regarding permissions for case reports
iv. HIPAA
(1) U.S.Department of Health and Human Services, Office for Human Research Protections. Protection
of Human Subjects Title 45 Code of Federal Regulations. 46. 1-15-2009. Ref Type: Report.
Optimizing Health Systems Resources for Clinical Care and Research
Carmen Kirkness, PT, PhD
1. Research starts with the physical therapist provider
a. What are the data being collected for---what do you want to be able to
accomplish? Can the data serve multiple purposes and, if so, how?
b. Electronic database vs paper
i. Choice of EHR
ii. Involvement in set up of EHR
1. Flowsheet or not?
a. Case example Flow sheet vs Non flow sheet
iii. Opportunities for discrete data vs. narrative
iv. Examples of clinical benefit but not research benefit; example of
research benefit but not clinical
c. Daily documentation
i. Builds a base for state of the current science from which interventions
can be evaluated
ii. Useful data include interventions, intensities of interventions, duration
of visits, number of visits
iii. Accuracy (missing data)
iv. Outcomes documented
1. Example: pain poorly documented, walking distance well
documented
v. Development/selection of specific tools that may be helpful for acute
care
1. AMPAC 6 clicks, others?
2. Tools with evidence for reliability and validity
3. Minimal training requirements
4. Measurement protocols that are easy to follow and not too time
consuming
5. Measures that make sense to clinicians
Using Academic Partnerships to Strengthen Research Output
Diane Jette, PT, DSc, FAPTA
1. Matching a clinician with researcher
a. Working together to understand what types of questions can or cannot be
answered with the data
b. Starting with a research question developing a protocol
c. IRBs
d. Data use agreement
e. Who’s study is it?
f. Authorship
g. Responsibilities
i. Clinical value vs research value
h. Expectations
i.
Case Examplesi. University collaborations with Community Hospitals
2. Types of studies most often feasible with clinical data
a. Observational, comparative effectiveness
Managing Hospital Systems Processes and Pressures
Mary Stilphen, PT, DPT
1. Research Structure in Hospital Setting
a. Research Champion
b. Physician Champion
c. Management Champion
2. Hospital System
a. Permission
b. Design
c. Navigate institutional help
d. Data sets
e. Examples
3. Hospital System Challenges
a. Financing
b. Payment
c. Organizational Pressure
4. Acute Care Research Cleveland Clinic
a. Liver Transplant
b. 6 Clicks
c. PT during blood transfusion
d. Collection of data
Sample references of collaborative studies in acute care settings
1. Jette DU, Brown R, Collette N, Friant W, Graves L. Physical Therapists’ Management of Patients
in the Acute Care Setting: An Observational Study. Phys Ther. 2009:1-24.
2. Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending
discharge placement from the acute care setting. Phys Ther. 2003;83:224-236.
3. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. AM-PAC ‘6-Clicks’
functional assessment scores predict acute hospital discharge destination. Phys Ther. 2014;
94:1252-1261.
4. Jette DU, Stilphen M, Ranganathan VK, Passek SD, Frost FS, Jette AM. Validity of the AM-PAC
“6-Clicks” Inpatient Daily Activity and Basic Mobility Short Forms. Phys Ther. 2014;94(3):379-391.
5. Masley PM, Havrilko C-L, Mahnensmith MR, Aubert M, Jette DU. Physical Therapist Practice in
the Acute Care Setting: A Qualitative Study. Physical Therapy. 2011;91(6):906-922.
Locating Mentors and Networking Support
Barbara Smith, PT, PhD
1. Identify types of support available
a. Teams
b. Champions
c. Networks
d. Mentors
2. Determine your goal (s)
a. Short and intermediate impact projects
b. Longer term career and research planning
3. Teams and Champions – draw on “local talent”
a. Institutional resources
b. Establish pilot data and plant a seed, justify or change facility procedures
and care
4. Networks
a. Local and/or cast a broader net
b. Sharing and constructive resources of ideas and resources, pooling time
and talent, dividing labor on larger projects
5. Mentors
a. Implies deeper investment in mentor-protégé relationship
b. Promotes deeper learning, personal growth can result in professional
strength, reciprocal learning
c. Requires strategies to deepen learning and establish expectations
d. Involves most significant commitment of time
6. Resources for Mentored Research in Acute Care PT
a. Academic and alumni groups
b. Professional associations
c. National Institutes of Health
Selected Resources
1. DeCastro F, Sambuco D, Ubel P, Stewart A, Reshma J. Mentor networks in academic medicine:
moving beyond a dyadic conception of mentoring for junior faculty researchers. Acad Med. 2013
Apr;88(4):488-96. doi: 10.1097/ACM.0b013e318285d302.
2. Ezzat AM, Maly MR. Building Passion Develops Meaningful Mentoring Relationships among
Canadian Physiotherapists. Physiother Can. 2012 Winter;64(1):77-85. doi: 10.3138/ptc.2011-07.
Epub 2012 Jan 31.
3. Gopee N, ed. Mentoring and supervision in healthcare. 2nd edition. 2011. Sage, Thousand Oaks, CA.
304 pages.
4. http://sourcebook.od.nih.gov/ethic-conduct/TrainingMentoringGuide_7.3.02.pdf
5. http://www.apta.org/CareerManagement/Mentoring/
6. Ragsdale JR, Vaughn LM, Klein M. Characterizing the adequacy, effectiveness, and barriers related
to research mentorship among junior pediatric hospitalists and general pediatricians at a large
academic institution. Hosp Pediatr. 2014 Mar;4(2):93-8. doi: 10.1542/hpeds.2013-0075.
7. Schwartz AL. Commentary: physician-scientist attrition: stemming the tide through national networks
for training and development. Acad Med. 2011 Sep;86(9):1071-2. doi:
10.1097/ACM.0b013e318224fd75.