Regional Stroke Strategy

1. Regional Stroke Strategy Outcome Measures Forum June 11, 2009 p

2. Organizing Group • Deb Willems • Eileen Britt • Sheila Cook • Linda Dykes • Chris Edwards • Paula Gilmore • Mary Solomon • Gina Tomaszewski • Laurie Zimmer

3. Objectives • Develop a common understanding of measurement terms and what each means to clinical practice. • Discuss: o When each outcome measure could be used o The benefits of using a core set of outcome measures across the continuum of care o Potential challenges to using consistent outcome measures and ideas to overcome the barriers. • Take key messages about outcome measures back to your organization and support follow-up activities (depending on your organization’s readiness levels).

4. Where today fits in the scheme of things • What’s come before: • Consensus Panel • Briefly mention 21 tools – more later • What’s happening in other regions

5. Southwestern Ontario Stroke Strategy Region Designated Rehabilitation Beds by Stroke District Owen Sound Rehab beds = 16 Stratford Rehab beds = 15 Woodstock future Rehab beds = 22 Sarnia Rehab beds = 27 London Rehab beds = 118 Windsor Rehab beds = 50 St. Thomas Rehab beds = 10 Chatham Rehab beds = 23 Calculation for Stroke usage = # stroke admissions x ALOS(+SI) for stroke/ 365 days x 90% occupancy

6. Where today fits in the scheme of things Canadian Best Practices in Stroke Rehabilitation Outcomes: Report of the Expert Panel • Prioritize a set of outcome measures that could be used to evaluate the outcomes of stroke rehabilitation in Canada • Use the International Classification of Functioning to identify measure for the domains of body structure and function, activity and participation • Recommend measures for clinical use based on reliability, validity, responsiveness, proven application with stroke and ease of use See all domains/measures in full document in your binder

7. Tools of the Trade:Core Set for Occupational and Physical Therapists

8. Today’s Focus is on: • Perception • Pain • Arm and Leg Function • Mobility • ADLs Because: • Manageable number of measures/domains to cover • Domains primarily applicable to OT and PT, RN and IDT • Cognition measure recommendations changing (and should include SLP)

9. What’s happening in other Regions? Central South (Hamilton) • Forum in February 2008 • Clinicians piloted 11 tools “The greatest benefit is in choosing outcome measures that cross the continuum of care…then as a therapist, I know a bit about the patient before I even see them”

10. What’s happening in other Regions? West GTA (Mississauga) • Forum in February 2009 • Gained common understanding of tools and benefits of using standardized measures “I can see that use of standardized outcome measures will provide consistency within and between organizations…and will commit to using assessments pre and post treatment” All other regions across the province working on implementation

11. After today… • Following the workshop: • Key Messages • Opportunity to try them • Support available • Outcome Measures II • Follow-Up • Create a community of practice • people connect with each other to share their expertise and learn from other members’ experiences

12. Measurement QuizIf you were describing, to an 86 year old person, how much they could safely lift would you say: • 10 pounds • 5 kg • A bag of potatoes this big • Press: # • Sheila 1025 - 1045

13. Correct Response • 3. A bag of potatoes this big

14. Key Points • Translate Data to Meaningful information

15. Select up to 3 answersThe chance of you being struck by lightning is: • 1/5000 • 1/700,000 • Higher if you take part in outdoor activities • Higher if you take shelterunder a tree • Press: # * # * # Send

16. Correct Response • It depends. • How much detail do you require for the situation?

17. Key points • Translate Data to Meaningful information. • Context is important. • Start with the end in mind.

18. Correct answers The chance of you being struck by lightening is: 1. 1/5000 in your lifetime (80 yrs) 2. 1/700,000 in a year in you live in North America 3. Higher if you’re a golfer or angler 4. Higher if you stand under a tall tree

19. Select 1 answer 82 degrees F = x degrees C • 26.7 • 28.9 • 30.2 • I know there’s a formula, but I can’t remember it • I don’t have a clue • If I needed to know this, I’d use an online conversion tool • Press: #

20. Correct answer • 2 = 28.9 • 82 - 30 X 5/9

21. Key points • Translate Data to Meaningful Information. • Context and level of detail for the situation are important. • Start with the end in mind. • Tend to use measures we are most comfortable with. Can be confusing to others. • Lots of resources readily available to help us - we don’t have to keep everything in our heads.

22. Select 1 answer Your care team has a patient who weighs 95 kg (209 lbs). This means each of her legs probably weighs: • I don’t need to know this information, it is not importantto me • It is not important to me, but it may be important to others on the team • 13.57 kg or 29.9 lbs • 8.7 kg or 19.1 lbs • Press: # * # Send

23. Correct answer • Leg weight = total body weight/7 • 95/7 = 13.57 kg or 29.9 lbs

24. Key points • Translate Data to Meaningful Information. • Context and level of detail for the situation are important. • Start with the end in mind. • Tend to use measures we are most comfortable with. • Lots of resources readily available to help us. • So much information is available must select what is most important. Also consider what is valuable to others.

25. Pick 3 answers Which of the following best describes “validity”: • Test • Consistency • Accuracy • Precision • Press: # * # * # Send

26. Correct answers 1. Test 3. Accuracy 4. Precision

27. Select 1 answer Someone weighs 200 lbs. He gets on a scale 5 times and each time the display reads 150: • The scale is valid,but not reliable. • The scale is reliable,but not valid. • The scale is neithervalid nor reliable. • Press: #

28. Correct answer • 2: Reliable but not valid

29. Definitions • Validity - success at measuring what we set out to measure • Reliability - extent to which a measuring procedure gives the same results on repeated trials

30. Select all that apply A screening tool: • Identifies patients or populations who are at risk • Identifies when a more in-depth assessment is needed • Identifies if a patient has a specific condition or deficit (e.g. depression) • Measures change over time • Press: ?? * ?? * ?? * ?? Send

31. Correct answer • Identifies patients or populations who are at risk • Identifies when a more in-depth assessment is needed

32. Select 1 answer Which of the following are screening tools: • Line Bisection • Pain Rating Scale • Berg Balance • Chedoke McMaster Stroke Assessment • Press: #

33. Correct answer • 1. Line Bisection

34. Select 3 answers What type of tool is the FIM: • Screening • Assessment/Classification • Outcome measure • Population tool • Press: # * # * # Send

35. Correct answer • 2. Assessment/Classification • 3. Outcome measure • 4. Population tool

36. Select 1 answer Which is not a benefit of outcome measures: • Measure change over time • Patients find them motivational • Help set goals • Help with transitions to next setting • Identify risk safety issues • Contribute to service planning • Many require special training • Press: #

37. Correct answer • 7. Many require special training

38. Definitions Screening tool: A test or testing carried out routinely in order to identify, as early as possible, those at high risk of a particular problem or feature. RNAO Best Practice Guidelines indicate that screening tools can augment, but not replace a comprehensive assessment. Its primary purpose may be to identify the need for referral to a specialized discipline for further assessment/intervention. A common example of a screening tool is the Modified Mini-Mental State Examination used for cognitive screening. Assessment: the detailed identification of specific impairments in body function, structure or system (including psychological). Classification Tool:categorize clients into homogeneous subgroups based on level of impairment. This classification is useful for the purposes of predicting outcomes, guiding intervention, and to categorize clients for the purposes of research. It also provides a common language for communication e.g. American Spinal Injury Association (ASIA) Impairment Scale Evaluative Measure: Measures of change (or lack of change) in the well-being of a defined population. Improvement in an outcome measure reflects the health status of the resident, whereas a process measure reflects the care delivery to the resident. Improvement in an outcome measure has a direct effect on mortality and morbidity. Process or System Measure: provides information about program or team effectiveness; may be clinical (e.g. FIM) or not (wait times).Is a measure that enables providers and programs to document results of care delivery, providing a common language for comparison of outcomes across programs.

39. Stroke Rehabilitation Outcome Measures Robert Teasell MD FRCPC Professor and Chair-Chief Department of Physical Medicine and Rehabilitation Schulich School of Medicine Lawson Health Research Institute June 11, 2009

40. Measuring the Outcomes of Stroke Rehabilitation Results of a Canadian Stroke Strategy/Heart and Stroke Foundation National Consensus Panel Rationale • Stroke Rehabilitation can be enhanced by use of standardized outcomes

41. Why Bother? • Consistency (individualism saved for shopping or picking paint colors) • Use Best Measure with known psychometric properties • Communication Across the Continuum (avoid Tower of Babel) • Maximizes Resources (assessments cost $) • Allows Comparisons (can identify strengths and weaknesses) • Allows Better System Evaluation • Promotes Better Care

42. Consensus Panel Principles for selection • Tried to select measures that worked across the continuum • Can be interprofessional administration • Can be administered in reasonable time at beginning and end of Rehabilitation • Minimize cost of training • Ideally available in English and French.

43. Korner-Bitensky et al. traced > 5500 randomly sampled clinicians • Interviewed 1733 stroke clinicians (OT, PT, SLP) in 10 provinces • Working in:acute in-patientin-patient rehabcommunity practice

44. Study Participants OT n=651 PT n=650 SLP n=432 Gender • 574 females, 76 males Age • 40 years (22-to-72) Stroke Experience • 50% > 10 years • 29% > 4-10 years • 15% = 1-3 years • 5% < 1 year Gender • 598 females, 53 males Age • 37 years (22-to–64) Stroke Experience • 39% > 10 years • 33% = 4-10 years • 23% = 1-3 years • 5% < 1 year Gender • 407 females, 25 males Age • 38 years (24-to-64) Stroke Experience • 44% > 10 years • 37% > 4-10 years • 16% = 1-3 years • 4% < 1 year

45. What measures are Canadian Clinicians using? • Nicol Korner Bitensky et al surveyed about 1800 rehabilitation clinicians in Canada by telephone • Asked to answer scenarios concerning typical stroke patients • Asked about what measures they used

46. Number Using 1 - Berg Balance Scale 2 – Sensation 3 – Chedoke-McMaster 4 – transfers 5 – ROM 6- tone 7- gait assessment

49. Number Using 1 - ADL 2 – OSOT 3 – MVPT 4 – transfers 5 – physical/functional Assessment 6- Mini-Mental State Exam 7- sensation