CQI Poster Fair
June 12, 2008
Posters
Evidence Supported Approach to Treatment of
Post-Operative Lumbar Fusion Patients
Spine Focus Team 2007/2008
Team Members: Darrel Lee, Jimmy Gilmore, Flavio Silva, Tabitha Napier, Teresa Pritchett, Cory Hustad, Melinda Chandler, and Eric Williams
Purpose:
Results:
Develop protocol guidelines for post-op lumbar
fusion patients that can be followed along the
continuum of care while patient is at VOI in both
Acute Care, Outpatient Departments, or outside
providers.
Questions:
1.
Are VOI clinicians providing effective and
consistent rehabilitation programs for
Lumbar fusion patients? Are the outcomes
being tracked?
Patient Educational Materials Developed Included:
 Lumbar Fusion Patient Guide (Figure A)
 Lumbar Fusion Protocol for Clinicians (Figure B)
 Phase 1-3 exercise sheets
 Instructions for using LSO Brace
 Activity Chart
 Bed mobility and transfer skills information
sheet
 Pre Op and early post op needs and goals.
 Appropriate use of (SF-36 and Oswestry
questionnaire)
(A)
2.
Recommendations and Plan:
(B)
Are referring physicians comfortable with
post-operative rehabilitation programs
currently in place?
Lumbar Fusion Patient Guide
Methodology:
• Collected Orthopaedic Surgeons’ basic postoperative restrictions guidelines.
• Identified materials needed to be included in a
Lumbar Fusion Patient Guide Folder.
• Established the rehabilitation protocol based on
our research and surgeon’s recommendations.
• Currently, we are reviewing outcome measures to
determine the difference between VOI-PT postoperative outcomes vs. the outcomes of patients
who do no post-op PT or complete rehabilitation
with another PT provider.
Protocol: Lumbar Fusion
What is a Lumbar Fusion?
How the spine works
The Lumbar Fusion surgery
The risk of surgery
• Exercise and educational handouts will lead to
improved patient compliance by facilitating self-efficacy
and confidence. These materials, as well as the
Lumbar Fusion Protocol will be available on the VOI
share drive and hard copy placed in all protocol
manuals.
• Provide in-services to all Vanderbilt clinicians
regarding the Lumbar Spine Fusion Protocol (in- and
out-patient).
Pre-operative Education

Preparing for Lumbar Fusion Surgery
Medical clearance
Dental clearance
Blood donation
Staying healthy
Reviewing insurance and financial planning
Preoperative hospital visit
Medications before surgery
Preparing your home

In-Hospital Care
Preparing for your hospital admission
What happens after surgery
Medical care
Physical therapy

Returning Home
Discharge from the hospital
Back Brace
Home care
Medications after surgery
Incision
What to watch for
Physical therapy
Increasing your activity
Practicing infection prevention
• Lumbar Spine Fusion Folders will be distributed to
patients by the VOI Surgeon or clinician leading to more
consistent, safe and efficient practice among VOI
clinicians.
Patients will participate in a pre-operative class to educate and prepare them for what to
expect during surgery and post-operative recovery process
Patients will be given a folder with information including:
o Surgical Procedure
o Pre-operative and Phase 1 post-operative exercises
o Post-surgical Instruction
o Post-surgical LSO Instructions
o Transfer Training
Post-surgical Acute Physical Therapy Education
Physical Therapists will review the contents of the folder again. The following items will
be reviewed with each patient and must be demonstrated by each patient (check off)
before discharge:
o ADL education (precautions given by physician)
1. Use of brace/corset when indicated.
2. Ten pound lifting restrictions
3. Home walking program and Home Exercise Program (HEP) compliance
4. Proper Body Mechanics and Posture for all ADLs
o Education on transfers
 Sit-Stand
 Log Roll
o Posture education (use of lumbar roll)
 Sleeping
 Sitting
 Standing/Walking
• Monitor and record future outcome measures using
SF-36 and Oswestry at follow-up physician
appointments. Data collected will determine the
difference our protocol has made on patient’s recovery
following lumbar spinal surgery compared to those who
either do not receive physical therapy or who go to other
facilities for their care.
Sensory Processing and Children with Hearing Loss
Lead Investigator: Vicki Scala, MS, OTR/L
Co-Investigators: Heather Kavanaugh, OTD, OTR/L; Elizabeth Murillo, MS, OTR/L;
Tamala Bradham, PhD, and Geneine Snell, MA, CCC-SLP
Interpretation of Sensory Profile Scores
Auditory Processing
Visual Processing
3.5
2.5
2
1.5
1
3.5
Sensory Profile Score Rating
Sensory Profile Score Rating
Sensory Profile Score Rating
Procedure/Methodology:
Vestibular Processing
3.5
3
0.5
3
2.5
2
1.5
1
0.5
3
2.5
2
1.5
1
0.5
0
0
1
2
3
4
5
6
7
8
0
1
9
2
3
4
Touch Processing
7
8
9
1
2.5
2
1.5
1
0.5
4
5
6
7
8
2.5
2
1.5
1
0.5
9
2
3
4
Subject
Modulation Related to Endurance/Tone
5
6
7
8
1
0.5
0.5
2
3
4
5
2.5
2
1.5
1
0.5
6
7
8
9
2
3
4
5
6
7
8
1.5
1
0.5
5
2
3
4
6
7
8
2
1.5
1
0.5
2
3
4
5
6
Sensory Profile Score Rating
3
2.5
2
1.5
1
0.5
0
1
0.5
7
8
9
1
2
3
4
Subject
6
7
8
9
5
Subject
3
2.5
2
1.5
1
0.5
0
5
9
1.5
3.5
4
8
2
Items Indicating Thresholds for Response
3.5
3
7
2.5
0
1
Behavioral Outcomes of Sensory Processing
2
9
3
Subject
1
6
Emotional and Social Responses
2.5
9
5
3.5
Subject
Sensory Profile Score Rating
4
8
0.5
0
3
7
1
Subject
3
0
9
2
1
Sensory Profile Score Rating
Sensory Profile Score Rating
2
8
1.5
9
3.5
2.5
7
2.5
Modulation of Visual Input Affecting Emotional Responses
3
6
3
Subject
3.5
5
0
1
Modulation of Sensory Affecting Emotional Responses
2
4
3.5
Subject
1
3
Modulation of Movement Affecting Activity Level
0
1
2
Subject
3
0
Recommendations/Plan
1
1
Sensory Profile Score Rating
Sensory Profile Score Rating
1.5
9
1.5
9
3.5
2
8
2
Modulation Related to Body Position/Movement.
2.5
7
1
2
3
4
• Initial data analysis (descriptive)
indicates trends for sensory
processing disturbances with those
children who experienced the
greatest medical complications,
not necessarily related to their
hearing loss.
2.5
Subject
3
6
0
1
3.5
5
3
0
3
4
3.5
3
0
2
3
Oral-Sensory Processing
Sensory Profile Score Rating
3
1
2
Subject
3.5
Sensory Profile Score Rating
Sensory Profile Score Rating
6
Multisensory Processing
3.5
Sensory Profile Score Rating
5
Subject
Subject
Sensory Profile Score Rating
IRB approval was first obtained
for this study. Parents of
children ages 2-7 years who
were enrolled in the Mama Lere
Hearing School at Vanderbilt
completed the Sensory Profile or
the Infant/Toddler Sensory
Profile and returned it for
analysis. Medical background
information for each
participating student was
collected for inclusion in data
analysis regarding age of onset
of hearing loss, cause of hearing
loss, correction for hearing loss,
other diagnoses the child may
have and current medications.
• Only 1/3 of the surveys distributed
were returned (9 usable forms); all
were for children 3-6 years.
• To allow for greater clarity when reporting the
descriptive data, scores from the Sensory Profile
were assigned the following ratings:
• “Definite Difference” (>2 s.d. from the mean) = 1
• “Probable Difference” (1-2 s.d. from the mean) = 2
• “Typical” (within 1 s.d. from the mean)=3
Research Question:
Are there trends in
responses to sensory
events in the environment
that are attributable to
children with hearing loss?
Summary of Results
5
Subject
6
7
8
9
6
Due to the small return rate for the
surveys, the study team determined
that the IRB proposal would be
resubmitted with an extension of the
time for data collection to include this
upcoming school year (2008/09). This
will also provide a longer period to
educate parents as to the importance
of the study so that increased
participation may be garnered. Full
data analysis (correlational and
descriptive) will be completed when
additional data is available for greater
statistical significance.
Process
♥
♥
♥
♥
♥
♥
Assessment of the current materials
Review of literature and current practice
Contact leading cardiac facilities
Compare learned information to current practice
Update orientation packet and competency form
Create education handout
Cardiac Focus Group
Andrea Renzella, OTR/L
and Elena Schiro, PT
2007/2008
Questions
♥ Are the current cardiac orientation and
competency forms for the acute rehabilitation
department current?
♥ What type of education handouts are needed
for these patients?
New Orientation Packet
Summary of Results
♥ Orientation handout updated appropriately
♥ All precautions needed for cardiac surgery
service were updated
♥ i.e., Sternal precautions, pacemaker
precautions
♥ Competency form was created for the
cardiac service
♥ Table complied of information provided by
leading cardiac facilities that were contacted
♥ Physical and Occupational Therapy
provided at leading cardiac facilities was
similar to VUMC
♥ Patient education handout was created
New Education Handout
Assessment
We found that the orientation and competency
forms were not current. Therefore, all orientation
materials and competency forms were updated
and a patient handout was created. By
completing the above tasks, all new employees
and all existing employees will be educated on
the appropriate protocols, precautions, and
competencies needed to effectively provide
treatment to cardiac surgery patients.
Recommendations
We recommend that this new orientation packet
and competency form be checked yearly to
ensure they continue to be current. This will
ensure that all new employees are oriented
appropriately. Also, when new protocols or
precautions are made, an inservice should be
provided to existing employees.
Rehabilitation Management of Zone II Flexor Tendon Injuries
Skip Brown, OTR, CHT
Peggy Haase, OTR, CHT
Joanna Hearington, RN
Research question:
What is the current evidenced based
treatment/rehabilitation protocol for postoperative management of zone II flexor
tendon repairs without fracture?
Flexor Tendon Zones of the Hand
•Zone 1 - distal to FDS
insertion
•Zone 2 - “No Man’s Land”
•Zone 3 - proximal palm
•Zone 4 - carpal tunnel
•Zone 5 - proximal to CT
Evidenced Based Research
•Reviewed 22 articles from 2001-2007
•Level 1 & 2 evidence – 6 articles
•Levels 3, 4 & 5 – 16 articles
•Also reviewed key currently used
protocols: Indiana Hand Center,
Modified Duran, Kleinert controlled
motion and early active motion
protocols
Project Outcomes
•Patient education handout to be
given at discharge from surgery
center
•Patient education handout for initial
post-op visit with therapist – includes
precautions, splint wearing schedule,
wound care, edema and pain control
•Phased rehabilitation protocol
•Phased exercise program with
handouts
Dana Moulton, OTR, CHT
Lisa Perrone, OTR, CHT
Pam Harrell, OTR, CHT Facilitator
Flexor Digital Anatomy
Types of Sutures
Dorsal Blocking Splint
•Wrist - 20degrees flexion
•MP’s - 70-90 degrees flexion
•IP’s - full extension
Hand Therapy Rehabilitation Protocol
Phase I: Weeks 1-6
-Dorsal blocking splint full time
-PROM of digits in splint
-Wound care, scar massage, edema control
-AROM of noninvolved joints
-Place and hold finger flexion with MD approval
-Wrist/finger tenodesis with MD approval
Phase II: Weeks 6-12
-AROM of fingers and wrist; may begin as soon as
4 week if tendon is adhering
-D/C splint
-Continue scar massage and edema control
-Evaluate strength and initiate strengthening
-Initiate composite wrist and finger extension
-Add modalities and mobilization splinting as
needed
Phase III: Weeks 8-12
-Continue strengthening and mobilization as
needed
-Continue scar management, edema control and
modalities as needed
Phase IV: Week 12 and beyond
-Return to full hand use without restrictions
including work and sports
Head & Neck Cancer Rehabilitation Oncology: Expansion of a Model
Cancer Focus Group Member: Andrea Antone, PT
Facilitator/Mentor: Ann Marie Flores, PT, PhD, MS, MA; Co-Facilitator: Kelly Floyd, MS, OTR/L
Purpose: Adaptation of an existing rehabilitation
services delivery model to the head & neck cancer
patient population at VUMC.
Objectives/Goals
• Determine benchmarks of care, patient satisfaction and
perceived educational needs for head & neck cancer
patient rehabilitation
• Creation of post-operative rehabilitation services
protocols for head & neck cancer surgical procedures
Methods
Objective/Goal #1: Determine benchmarks of care,
patient satisfaction and perceived educational needs
for head & neck cancer patient rehabilitation
• Literature review
• Interviews of internal and external experts in rehabilitation
and surgery
• Survey of satisfaction & educational needs for head &
neck cancer survivors
Objective/Goal #1: Determine benchmarks of care, patient
satisfaction and perceived educational needs for head &
neck cancer patient rehabilitation
Table 1: Levels of evidence for literature review
Topic
Level of
Citation
Evidence*
Cancer
1
Institute of Medicine. From cancer patient to cancer survivor: lost in transition. 2006. National Academies Press.Washington, DC.
Survivorship &
Rehabilitation
Exercise &
Therapeutic
Exercise
1
2
3
4
Post-operative
precautions &
Lymphedema Risk
Reduction
1
2
3
4
Post-operative
precautions
Scar Management
& Mobility
5
4
1
5
Tissue Fibrosis
3
Trismus & TMJ
hypomobility
1
2
3
4
American College of Sports Medicine. The recommended quantity and quality of exercise for developing and maintaining cardio respiratory and muscular fitness in healthy adults. Med Sci Sports
Exer 1990; 22: 265-274.
Courneya KS, Mackey JR, Jones LW. Coping with cancer: Can exercise help? Phys Sportsmed 2000; 28:49-73.
Demark-Wahnefried W, Aziz NM, Rowland JH, Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol. 2005 Aug 20; 23(24):
5814-30
Doyle C, Kushi LH, Byers T, Courneya KS, Demark-Wahnefried W, Grant B, McTiernan A, Rock CL, Thompson C, Gansler T, Andrews KS; The 2006 Nutrition, Physical Activity and Cancer
Survivorship Advisory Committee; American Cancer Society. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. Cancer J
Clin. 2006 Nov-Dec; 56(6): 323-53.
Neiman DC, Courneya KS. Immunological conditions. In ACSM’s resource manual for guidelines for exercise testing and prescription (5th edition) guidelines. Kaminsky LA, Bonzheim KA,
Garber CE, Glass SC, Hamm LF, Kohl HW, Mikesky A [eds]. 2005; pp.528-542.
Markes, M. Brockow, T. Resch, KL. Exercise for women receiving adjuvant therapy for breast cancer. [Systematic Review] Cochrane Breast Cancer Group Cochrane Database of Systematic
Reviews. 1, 2008.
Sola, I. Thompson, E. Subirana, M. Lopez, C. Pascual, A. Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. [Systematic Review] Cochrane Lung
Cancer Group Cochrane Database of Systematic Reviews. 1, 2008.
McQuade KJ, Dawson J, Smidt GL. Scapulothoracic muscle fatigue associated with alterations in scapulohumeral rhythm kinematics during maximum resistive shoulder elevation. J Orthop
Sports Phys Ther. 1998 Aug; 28(2): 74-80.
Remmler D, Byers R, Scheetz J, Shell B, White G, Zimmerman S, Goepfert H.A prospective study of shoulder disability resulting from radical and modified neck dissections. Head Neck Surg.
1986 Mar-Apr;8(4): 280-6.
Vos JD, Burkey BB. Functional outcomes after free flap reconstruction of the upper aerodigestive tract. Curr Opin Otolaryngol Head Neck Surg. 2004 Aug; 12(4): 305-10.
Cappiello J, Piazza C, Giudice M, De Maria G, Nicolai P. Shoulder disability after different selective neck dissections (levels II-IV versus levels II-V): a comparative study. Laryngoscope. 2005
Feb; 115(2): 259-63.
Miyata K, Kitamura H. Accessory nerve damages and impaired shoulder movements after neck dissections. Am J Otolaryngol. 1997 May-Jun; 18(3): 197-201.
Sobol S, Jensen C, Sawyer W 2nd, Costiloe P, Thong N. Objective comparison of physical dysfunction after neck dissection. Am J Surg. 1985 Oct; 150(4): 503-9
Krause HR. Shoulder-arm-syndrome after radical neck dissection: its relation with the innervation of the trapezius muscle. Int J Oral Maxillofac Surg. 1992 Oct; 21(5): 276-9.
Nahum AM, Mullally W, Marmor L. A syndrome resulting from radical neck dissection. Arch Otolaryngol 1961; 74:424–428.
Nussenbaum B, Liu JH, Sinard RJ.Systematic management of chyle fistula: the Southwestern experience and review of the literature.Otolaryngol Head Neck Surg. 2000 Jan;122(1):31-8.
Patten C, Hillel AD. The 11th nerve syndrome. Accessory nerve palsy or adhesive capsulitis? Arch Otolaryngol Head Neck Surg. 1993 Feb; 119(2): 215-20.
Salerno G, Cavaliere M, Foglia A, Pellicoro DP, Mottola G, Nardone M, Galli V.The 11th nerve syndrome in functional neck dissection.Laryngoscope. 2002 Jul; 112(7 Pt 1): 1299-307.
Wiater JM, Bigliani LU. Spinal accessory nerve injury. Clin Orthop Relat Res. 1999 Nov;(368): 5-16.
Salerno G, Cavaliere M, Foglia A, Pellicoro DP, Mottola G, Nardone M, Galli V.The 11th nerve syndrome in functional neck dissection.Laryngoscope. 2002 Jul; 112(7 Pt 1): 1299-307.
Williams J, Toews D, Prince M.Survey of the use of suction drains in head and neck surgery and analysis of their biomechanical properties.J Otolaryngol. 2003 Feb; 32(1): 16-22.
Patten C, Hillel AD. The 11th nerve syndrome. Accessory nerve palsy or adhesive capsulitis? Arch Otolaryngol Head Neck Surg. 1993 Feb; 119(2): 215-20.
Guldiken Y, Orhan KS, Demirel T, et al. Assessment of shoulder impairment after functional neck dissection: Long term results. Auris Nasus Larynx 32 (2005) 387–391.
Van Wilgen CP, Dijkstra PU, van der Laan BF, Plukker JT, Roodenburg JL. Shoulder and neck morbidity in quality of life after surgery for head and neck cancer. Head Neck. 2004 Oct; 26(10):
839-44.
Hillel AD, Kroll H, Dorman J, Medieros J.Radical neck dissection: a subjective and objective evaluation of postoperative disability. J Otolaryngol. 1989 Feb; 18(1): 53-61.
Salerno G, Cavaliere M, Foglia A, Pellicoro DP, Mottola G, Nardone M, Galli V.The 11th nerve syndrome in functional neck dissection. Laryngoscope. 2002 Jul; 112(7 Pt 1): 1299-307.
Patten C, Hillel AD. The 11th nerve syndrome. Accessory nerve palsy or adhesive capsulitis? Arch Otolaryngol Head Neck Surg. 1993 Feb; 119(2): 215-20.
Cohen SM, Burkey BB, Netterville JL. Surgical management of parapharyngeal space masses. Head Neck. 2005 Aug; 27(8): 669-75.
Coleman SC, Burkey BB, Day TA, Resser JR, Netterville JL, Dauer E, Sutinis E. Increasing use of the scapula osteocutaneous free flap. Laryngoscope. 2000 Sep; 110(9): 1419-24.
Shaheen KW. Jackson-Pratt drains: patient discharge instructions. Plast Surg Nurs. 1998 Spring; 18(1): 50.
Piazza C, Cappiello J, Nicolai P. Sternoclavicular joint hypertrophy following neck dissection and upper trapezius myocutaneous flap transposition. Otolaryngol Head Neck Surg 2002; 126:193–
194.
Siddiquee BH, Amin SA, Sharif A. Comparative study of radical neck dissection vs. modified radical neck dissection in metastatic neck gland.Mymensingh Med J. 2007 Jan;16(1):25-8.
Mustoe TA, Cooter RD, Gold MH, Hobbs FD, Ramelet AA, Shakespeare PG, Stella M, Teot L, Wood FM, Ziegler UE; International Advisory Panel on Scar Management.International clinical
recommendations on scar management. Plast Reconstr Surg. 2002 Aug; 110(2): 560-71.
Edwards, J. Scar Management. Nursing Standard. 2003 Sept; 17(520); pp. 39-42.
Lennox AJ, Shafer JP, Hatcher M, Beil J, Funder SJ. Pilot study of impedance-controlled microcurrent therapy for managing radiation-induced fibrosis in head-and-neck cancer patients. Int J
Radiat Oncol Biol Phys. 2002 Sep 1;54(1):23-34.
Dijkstra PU, Kalka WWI, Roodenburg JLN. Trismus in head and neck oncology: a systematic review. Oral Oncology (2004) 40 879–889; Aust J Physiother. 2006; 52 (3): 211-6.
Grandi G, Silva ML, Streit C, Wagner JCB. A mobilization regimen to prevent mandibular hypomobility in irradiated patients:An analysis and comparison of two techniques. Med Oral Patol Oral
Cir Bucal 2007;12:E105-9.
Dijkstra PU, Sterken MW, Pater R., Spijkervet FKL, Roodenburg JLN. Exercise therapy for trismus in head and neck cancer. Oral Oncology (2007) 43, 389– 394.
Cohen EG, Deschler DG, Walsh K, Hayden RE. Early use of a mechanical stretching device to improve mandibular mobility after composite resection: a pilot study. Arch Phys Med Rehabil. 2005
Jul; 86(7): 1416-9.
Objective/Goal #2: Creation of post-operative rehabilitation
services protocols for head & neck cancer surgical
procedures
• Literature review
• Interviews of internal and external experts in rehabilitation an d
surgery – identification of procedures, post-operative
precautions, special considerations
Objective/Goal #2: Creation of post-operative
rehabilitation services protocols for head & neck
cancer surgical procedures
ACTIVITY
0-2/3 Wks Post-op
Lifting
Duke Univ.
Hospital –
Rehabilitation
Services
UNC Rehabilitation
Services
U. of Iowa –
Rehabilitation
Services
VUMC (ENT
surgical &
nursing staff)
No
Isometric neck , jaw,
shoulder & wrist
muscle tightening
(tightening the
muscles with no
movement)
Immediate PostOperative
Precautions for
Exercise
Common specific post-operative precautions*
Inpatient: Yes - Once
transferred to step-down unit
Passive neck , jaw,
shoulder & wrist
movements (no
weights)
No
No
Fibular Free Flap: NWB (1-6 wks) – WBAT (immediately or progression per
physician) on donor LE; use of boot x 3 wks.; ankle ROM
Yes –physician
preferences
Inpatient & Outpatient: No
Neck Dissection: no – gentle cervical AROM by phsician preference; AROM
only after drains removed
Inpatient: Yes –included in
surgical pathway
Pectoralis Flap: ROM donor UE as tolerated or begin POD 3 - 4 or by
physician preference
Outpatient: Yes - postoperative referral as part of
pathway
Scapular Free Flap: ROM donor UE POD 3-4
Item
%
Were you satisfied with the explanation of the exercises?
YES
NO
100
0
YES
NO
100
0
Were all your questions answered?
Will you follow the exercise program?
Not likely at all
Not likely
Likely
Very Likely
Are the exercises easy to make a part of your daily routine?
YES
NO
Prior to surgery, how important did you think exercise would be for your
recovery?
Not important at all
somewhat important
Important
Very important
After surgery, how important do you think exercise will be for your recovery?
Not important at all
Somewhat important
Important
Very important
How easy are the exercise handouts to understand?
Not easy at all
Somewhat easy
Easy
Very easy
Missing
0
8
8
83
92
0
8
17
33
17
33
0
8
25
67
0
8
33
50
8
Table 4: Summary of Open-Ended Responses to “Is there anything else you
would like to let us know to help improve Rehabilitation Oncology Programming?”
Illustrative Quotations
““PT person very pleasant, well informed, & easy to
communicate with. Great service here at Vandy”
“Great attitude from everyone on staff . . .”
“Your professionalism exceptional.”
Information and
Suggestions for
Improvement
When physician says it is okay
YES
YES
YES
YES
YES
Yes – use splint if
given one
Yes
Yes – use splint if
you have been given
one & move in painfree range
YES
YES – wrist extension as
splinted (this can vary between
neutral & wrist extension)
Dr. Burkey’s patients – begin
this 1 week AFTER surgery
Active neck, jaw,
shoulder & wrist
movements (no
weights)
YES – use splint if you have
one & move into extension as
splinted
Dr. Burkey’s patients – begin
this 1 week AFTER surgery
Dr. Sinard’s patients – begin
this 2 weeks AFTER surgery
Active neck, jaw,
shoulder & wrist
movements with
weight
NO
Summary
Table 3: Head & Neck Education Satisfaction Survey: Percent of Responses (n = 12)
Theme
Professionalism, attitude
& communication
YES
Dr. Sinard’s patients – begin
this 2 weeks AFTER surgery
For radial forearm flap:
Outpatient: No
Inpatient & Outpatient: No
Yes –use splint if you
have been given one
& lift as tolerated & in
pain-free range
NO
For radial forearm flap:
Radial Forearm Free Flap: donor site immobilized &/or NWB
No
6 + Wks Postop
FOR RADIAL FOREARM FREE FLAP
Driving
Table 2: Results of Telephone Interviews of Expert Panel
EBM
Timing of Rehabilitation
Site
protocols
Services for Inpatient &
for H&N
Outpatient
3-5 Wks Post-op
“Everyone has been very helpful.”
“Offer ‘We kicked cancer’s ass’ to people,
especially those who cannot afford them.”
“My B.S. is in health & physical education but it is
easy for me to understand. But anyone [can
understand it] if they try.”
• Existing post-operative head & neck surgery protocols are
largely physician preferences.
• EBM literature review shows no standard agreement for
H&N cancer rehabilitation except for effects of exercise
after treatment
• Preliminary patient satisfaction survey
• Pleased with the quality of post-operative education
• Need for pre-operative education to increase
understanding of the importance of post-operative
exercise.
• Post-operative rehabilitation services protocols revised for:
• evidence-based
• consistent information for therapists & patients.
Next Steps
• Continue patient satisfaction surveys for inpatient
and outpatient settings
• Participate in development & administration of pre
operative education for head & neck cancer patients.
• Update EBM literature review
• Continue interviews of external experts in
rehabilitation & surgery
A Rehabilitation Oncology Program for Recipients of Stem Cell Transplantation (SCT):
A Year in Review
Cancer Focus Group Members: Scott Hawes, PT, NCS; Emily Sutinis, PT
Facilitator/Mentor: Ann Marie Flores, PT, PhD, MS, MA; Co-Facilitator: Kelly Floyd, MS, OTR/L
Results
Purpose
To evaluate the Rehabilitation Oncology
Program for the Stem Cell Patient
Population 2007.
Figure1: Attendance at patient/caregiver
pre-SCT class
39%
Discussion/Conclusions
Figure 2: Utilization of the pre-transplant
baseline assessment
Patient only
Patient & Caregiver
Objectives
Did not receive
pre-transplant
60%
61%
Figure 3: Percent using high dose steroids
in SCT
Did not recieve high
dose steroids
79%
The majority of SCT patients are being referred to
PT after steroid initiation in a timely manner (mean = 8.7
days) for both inpatients & outpatients.
•
The percentage of SCT recipients attending the returns
education class appears inadequate for optimal PT
learning. In addition, the pre-transplant assessment is not
being utilized consistently. Decreased attendance in both
are most likely attributed to busy and overlapping
schedules just prior to transplant.
•
"Walk Nashville" Restorative Program continues to be in
need of participation and encouragement by nursing staff.
93%
Figure 5: Timeliness of post-steroid
Rehabilitation Oncology referrals
Figure 6: Orientation to "Walk Nashville"
Restorative Program
7%
12%
No Referral
44%
56%
Oriented
Not Oriented
81%
Table 1: Levels of physical activity* for those
participating in “Walk Nashville” Restorative
Program adjusted for length of stay†
Mean
(s.d.)
Methods
• *Tracked 11N patient activity levels during
acute hospitalization
•
Did not receive
Rehabilitation
Oncology Services
Late Referral
• *Tracked attendance of the SCT
patient/caregiver class
An overwhelming majority of SCT recipients receive high
dose steroids. Thus, steroid myopathy is a risk for this
population. In agreement with literature, a large
percentage of SCT allograft candidates (30-60%) are at
risk of developing steroid myopathy (30-60%). Since 80%
of our SCT patients with allografts are placed on high
dose steroids, it is likely that we may see a larger
percentage develop steroid myopathy, as compared to
the literature.
Received
Rehabilitation
Oncology Services
Received high dose
steroids
Timely Referral
• Chart reviews were conducted on all 2007
SCT recipients
•
7%
1) Evaluate attendance at the patient/caregiver
education class & utilization of the PT pretransplant baseline assessment
3) Determine administrative efficacy of "Walk
Nashville" restorative program & activity
patterns of the allograft SCT recipients while
hospitalized
Different components of the SCT program are being
utilized.
Figure 4: Utilization of Rehabilitation
Oncology services post-steroid
administration
21%
2) Determine timing of Rehabilitation Oncology
referrals after high-dose steroid initiation
Received pretransplant
assessment
40%
•
Next Steps
Average laps
walked
10.05
(n=12)
-8.47
•
Increase attendance to the caregiver class and pretransplant Rehabilitation Oncology evaluation.
Average
Mins.
Bicycled
3.32
•
Improve administration of and participation in "Walk
Nashville" with multidisciplinary team leadership.
(n = 13)
-5.93
•
Continue tracking physical activity and physical function
of SCT candidates & recipients.
* “Other” exercise not included as only 1 inpatient
reported “other” activity
†Average length of stay = 16.33 days (s.d. = 10.45)
Rehabilitation Annual Competency
Program

Developed By: The Pediatric Rehabilitation Staff
Purpose: To ensure VCH rehab staff provide safe, effective, comprehensive and
appropriate care in the best manner possible
Determined Four Areas
of Focus for Annual
Competency:
 Safety
 Evaluation, Treatment,
and Discharge Planning
 Documentation
 Customer Satisfaction
Additional
Competencies
Developed for these
Specialty Areas:






General Outpatient
General Inpatient
NICU
Early Intervention
Serial Casting
Orthopedics
Competency Monitoring Tools:
 Licensure – current TN license
 Veritas – incident reporting system to monitor falls, line management,
modality safety, infection control, equipment use. Reports monitored monthly
 Chart Audits – 5 per year performed by level III clinicians on randomly
selected discipline or area specific charts
 Manager Observations – 2x per year focusing on AIDET, patient safety,
infection control, and evaluation/treatment planning
 Vandy Safe – annual on-line training for universal precautions, fall
prevention, patient contact, standards of conduct, HIPAA, conflict of interest
 Web In-services – Age specific competencies
 CPR – required to be up-to-date
 Patient Satisfaction Surveys (PRC Data) with scores reported quarterly
- Chart Audits
- Manager Observations
- Web In-services
Eval, Tx, D/C
Planning
- Licensure
- Veritas
- Vandy Safe
- CPR
Safety
Recommendations and Plan:
 Develop an Orientation Competency Program for New Staff
 Utilize Outcome Measures to allow for further assessment of
clinical competency within the department and for national
comparison.
 Implementation planned for July 2008
- Patient
Satisfaction
Customer
Surveys
Satisfaction - Manager
Observations
Documentation
- Chart Audits
General Pediatric Rehab Outpatient Competencies
Developed by the Pediatric Rehabilitation Staff
Purpose: To measure, document and support competency in
safety; evaluation, treatment and discharge planning;
documentation and customer satisfaction
Professional
Development
Group discussions and
review of new
treatment strategies,
research or case studies
in the evaluation and
treatment of children
*case studies
*journal reviews
*inservice
Frequency: 6 times per
year
Attendance
requirement: 50%
Chart Audits
Review and assess the tests,
interventions, and educational
information selected and
performed by the therapist
*1/5 chart audits per year will be
completed by a select outpatient
peer who will discuss problem
solving and reasoning for
treatment of choice
Equipment Competency
Review
To ensure staff, working with
equipment, understand how to
set-up, adjust, and use the
equipment and any precautions
related to its use in order to
ensure patient safety
Equipment including:
*Lite Gait Walkable
*Game Cycle/Bike
*Standers/Assistive Devices
*Climbing wall
*Functional Electrical Stimulation
General Inpatient Annual Competency Program
Developed By: Sarah Wilson, OT, Amber Yampolsky, PT

Purpose: To ensure VCH rehab staff provide safe, effective, comprehensive and
appropriate care in the general inpatient setting
Determined Three Additional Areas of Focus for Inpatient
Annual Competency:
 Case Studies
Purpose: through group discussions, education, and review of documentation
of commonly treated patients, all team members will review and improve skills
needed for varying diagnoses. Evaluations and treatment plans of specific case
studies of patients recently or currently being treated by the pediatric rehab
inpatient team will be examined.
Timeline: 6x/year – every other month
Attendance Requirements: 50%
 Journal Club
Purpose: to have group discussions and education regarding current
information and evidence in the literature regarding PT/OT evaluation and
treatment of pediatric patients in the acute care setting.
Timeline: 6x/year – every other month
Attendance Requirements: 50%
 Equipment Competency Review
Purpose: to ensure that staff working with equipment understand how to work
the equipment and any precautions related to its use in order to ensure patient
safety and prevent injuries.
Equipment Competency Check-Off : Staff will complete the review and
checklist will be kept in employee file for review at Annual Performance
Review. The review will be done in a group format with a leader reviewing and
demonstrating equipment use.
Area Specific General Inpatient Annual Competency Plan
YEAR:
EMPLOYEE NAME:
Core Competency
Monitoring/Training
Tools
Completion Date
Date
Safety: Equipment
Use
Documentation, Evaluation
And Treatment Planning
Date
Equipment Competency
Check-off - Annually
Case Studies - 6 offered/year,
must attend 50%
Dates: 1.
2.
3.
4.
5.
6.
Journal Club - 6 offered/year,
must attend 50%
Dates: 1.
2.
3.
4.
5.
6.
Annual Equipment Competency Check-Off
Pediatric Rehab Acute Care
____ 1. Hoyer Lift
____ 2. Neurochair
____ 3. Treadmill
____ 4. Stationary Bike
____ 5. Nintendo Wii
____ 6. UE ergometer
____ 7. Splint Pans
____ 8. Hydrocollator
____ 9. Electric Knife
____ 10. Heat Gun
____ 11. Cast Saw
____ 12. Tumbleform
____ 13. CPM – continuous passive motion machine
Employee Name: __________ Date: _______
Employee Signature: _____________________
Instructor: _____________________________
Recommendations and Plan:
 Develop an Inpatient Orientation
Competency Program for New Staff
 Investigate and implement the use of outcome
measures
 Implementation planned for July 2008
Outpatient Orthopedic Competencies
Peds Rehab
Developed by – Mandy D’Amour-PT, Tom Robertson-OT, Donna Trotter-PT
Professional Development
Purpose: To review and implement current
evidenced based practice for the orthopedic patient.
Details: Therapist will complete two Ortho specific
journal article reviews annually that will be
incorporated into a bibliography log. Therapist will
also attend one orthopedic specific in-service or
continuing education course per year. Participate
in departmental group discussion.
Equipment
Purpose: To review equipment use,
adjustments, contraindications
Modalities
Purpose: To ensure proper and safe
modality usage, set-up and implementation.
Details: Therapist will complete a written
modality test and use check-off annually by
peer in orthopedic specialty.
Special Test, Assessments
Purpose: To assess appropriate use, administration
and interpretation of special test.
Details: Peer member observation will be
completed 2 x per year.
Please take handout to view competency check-off
Serial Casting
Suzanne Satterfield, OTR
Jenny Robison, PT, ATP
Ellen Argo, PT


Purpose: To develop competencies for new and current occupation al and
physical therapists for serial casting for restoration of soft t issue
extensibility in children with neuromotor impairment.
Assessing competency:




Mentor program
Mentor observation of casting
Written assessment
Quarterly journal club
Early Intervention Competencies
Pediatric Rehab
Developed by: Caryn Givens- PT, Jodi O’Hara-OT, Jennifer Pearson-OT, Marci Poirier-PT
Demonstrate Knowledge of
Paperwork/Process for TEIS
•
•
Purpose: To understand TEIS process for
information flow and communication between
service providers
Details: Packet of TEIS information given to
therapists annually including – Role in Early
Intervention, WPN instructions, Justification for
Change, IFSP process, AT purchase procedures,
etc
TEIS In-service
•
•
Purpose: to learn local, state, and federal laws
governing Early Intervention services
Details: TEIS representative will provide annual inservice and information packet to therapists or as
needed if rules change throughout the year
Monthly Accounting/Denial Report
•
•
Purpose: To determine if the therapist is
completing all required paperwork in TEIDS
system and if communication has occurred with
the team.
Details: A monthly report will be run by accounting
and reviewed by office manager for
problems/trends to be identified.
Early Intervention Observation Audits
•
•
Purpose: To demonstrate the knowledge of family
centered services to meet TEIS contract requirements
Details: Observation audits will be performed 2x/year to
identify inclusion of family in treatment session and
HEP/goal setting.
*****************************************************************
Early Intervention Observation Form
Therapist Name: ______________________________
Date:________________________
Patient Initials:________________
Reviewer Name:_______________________________
Answer these questions as they relate to early intervention evaluation observed:
1.
Does the therapist identify and explain the value of preferred activities and
routines?
Yes
No
2.
Does the therapist learn about the child’s preference and family expectations?
Yes
No
3.
Does the therapist identify outcomes appropriate for the child’s family routine?
Yes
4.
No
Does the therapist specify strategies and sequences she/he will use to achieve
maximum results?
Yes
No
Therapist Signature:_________________________________ Date:_______________
Reviewers Signature:________________________________ Date:________________
Neonatal Intensive Care Annual
Competency Program
Developed By: Jennifer LaRocca, Deborah Powers, Judi Smerilson

Purpose: To ensure NICU rehab staff provide safe, effective, comprehensive and
appropriate care in the best manner possible
Determined Four Areas
of Focus for Annual
Competency:
 Safety
 Evaluation, Treatment,
and Discharge Planning
 Documentation
 Continuing Education
Additional
Competencies
Developed for this
Specialty Area:
 Infant Handling Skills
 Infant Massage
 NICU Specific
Standardized Testing
 Developmental Care
 Positioning
Competency Monitoring Tools:
 Licensure – current TN license
 Veritas – incident reporting system to monitor falls, line management,
modality safety, infection control, equipment use. Reports monitored monthly
 Chart Audits – 2 per year performed by specialized NICU clinicians
 Team Member Observations – 2x per year focusing on AIDET, patient
safety, infection control, and evaluation/treatment planning
 Vandy Safe – annual on-line training for universal precautions, fall
prevention, patient contact, standards of conduct, HIPAA, conflict of interest
 Journal Article Reviews/Case Studies– 2 per year on NICU specific topics
 Continuing Education – Will attend 1 NICU specific continuing education
course or inservice per year
 CPR – required to be up-to-date
-Developmental Care
-Infant Massage
-Handling Skills
Eval, Tx, D/C
Planning
- Licensure
- Veritas
- Vandy Safe
- CPR
Safety
- Journal
Articles
Continuing - Case Studies
Education - Inservices
- NICU course
Recommendations and Plan:
 Develop an Orientation Competency Program for New Staff
 Utilize Outcome Measures to allow for further assessment of
clinical competency within the department and for national
comparison.
 Implementation planned for July 2008
-
Documentation
- Chart Audits
-Team Member Observations