What do these stories illustrate about ER/ALC issue?

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1 What do these stories illustrate about ER/ALC issue? Maximizing the Impact of Rehab on Provincial Priority Issues Mark Bayley, MD, FRCPC Medical Director, Neuro Rehabilitation Program, Toronto Rehab and Chair, Stroke Evaluation Advisory Committee, Ontario Stroke Network

2 Objectives : 1. To Review some of the strategies to enhance flow through the rehab system 2. Review some of the Stroke Reference group proposals to the ER/ALC Rehab task group

3 Goals: To promote earlier access to stroke rehabilitation To Intensify inpatient stroke rehabilitation to treat more complex patients more efficiently Increase access to outpatient rehabilitation to reduce use of inpatient rehabilitation for mild stroke

4 Issue-Early assessment Lack of early rehabilitation intervention Lack of Common assessments between Acute and rehab Wait until rehab ready to start referral processes not pulling patients out of acute care Discharge planning starts late

5 Specialized Stroke care at Regional Stroke Centers vs Other Acute Facilities Time to Referral 40 LOS Mean AlphaFIM 10 0 RSC Other Acute Facilities

6 Recommendation-Improve Communication and Early referral 1. Create system of stroke Units with access to rehab professionals 2. Common Language for E.g. Alpha FIM, Charleston Comorbidities Daily Active List of patients from ER, ICU and Acute Care ward E-Referral, Shared Information Systems and Electronic Patient Record where possible

7 Action Items to Accelerate Best Practices and Impact ALC Early Access: Mobilization within 24 hours of admission Alpha FIM completed on Day 3 Alpha FIM score > 80 = outpt rehabilitation Alpha FIM score 40-80= inpatient rehabilitation Alpha FIM score 40-60=? Inpatient rehabilitation Alpha FIM score <40= options for restorative/ongoing assessment Onset to Rehab: Ischemic strokes= Day 5 Hemorrhagic strokes= Day 7 Rehabilitation has same priority level as acute care for access to LTC

8 Recommendation- Increase capacity to manage medically complex earlier Appropriate Staffing Levels Increase Rehab nursing ratio i.e. nurse:patient ratio on all shifts, but particularly on evenings and nights to comparable acute care to meet acuity of patient needs

9 Barrier- Diagnostic testing Completion of relevant secondary prevention workup e.g. carotid dopplers, angiograms, echocardiograms, EEG, MRI, CT etc ) If diagnostics not completed in acute care, not timely access to tools, access to acute diagnostics such as stat bloodwork, ECG, x-rays 24-7

10 Barrier- Repatriation of Unstable patients Evidence suggests that earlier transfer to rehab results in an a small increase in transfers back to acute care e.g. in the event a patient is not medically stable,

11 Repatriation of Unstable patients Philosophy of shared patient care Reciprocal Arrangements -Negotiate pre-arranged transfer agreements Develop capacity to rapidly swap patients Inform EMS of these relationships

12 Action Items to Accelerate Best Practices and Impact ALC Intensification: 7 day a week admission process 7 day a week service Minimum 3 hours direct therapy per day Appropriate Settings: Acute and Rehabilitation Stroke Units Ambulatory and Community Rehabilitation

13 Case 3 - Prompt Access to Community Rehab or Outpatients To reduce ALC and inappropriate use of inpatient rehab expand outpt. rehab for milder ABI and stroke impairments Proposal: Keep Outpatient departments in hospitals only to support discharge of inpatients

14 Prompt Access to Community Rehab or Outpatients To reduce ALC and inappropriate use of inpatient rehab expand outpt. rehab for milder ABI and stroke impairments Proposal: Keep Outpatient departments in hospitals only to support discharge of inpatients Outpatient clinics are more efficient

15 Goal- Earlier Onset of Rehabilitation Recommendation 1. Early Communication 2. Enhance nursing skill mix and ratio 3. Completion of diagnostics 4. Intensify rehab to reduce LOS 5. Outpatient rehab Cost 1. 1x$- Coordination 2. $$$$ or Trade ALC days - rehab 3. 1x$-Coordination 4. $$ or decrease occupancy 5. $ cheap compared to inpt

16 Conclusion- Save money by following Best practice! Consider system of Regional/District Stroke specialized units Earlier onset of Rehabilitation to reduce ALC days Intensify Therapy and Nursing skill sets at Rehab centers while reducing LOS in Rehab Increase access to diagnostics etc 7 days per week

17 Acknowledgements Toronto West Stroke Network of Ontario Stroke System DR. R. Teasell and Evidence Based review of Stroke Rehab and Brain injury teams GTA rehab Network

18 Thanks Questions?

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