mobility outcomes at 2 small hospitals in the mid north coast of nsw stephen downs jodie marquez...

Mobility Outcomes At 2 Small Hospitals in the Mid North Coast of NSW

Stephen DownsJodie Marquez

Pauline Chiarelli

Research Questions• Change in balance

• Relationship between diagnosis and change in balance

• Accuracy of physiotherapist’s estimates of change

• Relationship between balance and discharge destination

Mid North Coast NSW

Exclusions: • <16 years old• Orthopedically unable to FWB on both legs• Medically unfit to test balance testing• Unable to understand balance testing instructions• Unable to provide informed consent• Expected to have a very short length of stay.

Ethics: Approved by the North Coast Area Health Service and the University of Newcastle Human Research Ethics Committees

• Baseline and Discharge Balance Score

• Physiotherapist’s Estimate of Change

• Clinically Significant conditions

• Discharge Destination

• Number of Physio interventions

Recorded

Clinically Significant Conditions

• Condition affects mobilityOr

• Condition was reason for admission

Carer availability also noted

Berg Balance Scale (BBS)• 14 parts each 0-4

(possible total 56 higher score is better)

• Reliable– Berg, et al 1989; Liaw et al (2008)

• Minimal detectable change (95%) 4.6-6.3 – Donoghue et al (2009)

• Predicts Falls – Hall et al (2001)

173 Potential participants

131 Met Criteria30 Declined

101 Enrolled

42 didn’t meet criteria

12 Lost

89 Completed Study

42 Patients did not meet the inclusion criteria:

• 2 were acutely unwell• 2 were end stage palliative care• 15 were not fully weight bearing• 9 were too confused to follow

instructions• 14 were expected to be discharged after

such a short time that the baseline and discharge measures could not be reasonably expected to change

173 Potential participants

131 Met Criteria30 Declined

101 Enrolled

42 didn’t meet criteria

12 Lost

89 Completed Study

12 were lost from the study

• 1 became acutely unwell and was transferred to an acute care hospital

• 1 was too acutely unwell on the day of discharge to allow BBS testing

• 7 were lost to follow up• 1 had too short a length of stay• 3 withdrew

0

5

10

15

20

25

Age distribution of participants (mean = 80.95)

Conditions• 40 Fall • 33 Dementia• 33

Cardiac/Resp/ Vascular

• 24 Infection • 20

Musculoskeletal • 20 Delirium• 19 Other

Neurological• 13 Depression

• 13 Stroke• 9 Joint

Replacement• 9 # Proximal

Femur • 6 Palliative Care• 1 # Pelvis

None of these conditions predicted how much the BBS would change or accuracy of physiotherapist’s estimate

Pre Admission Status

D/C to Communi

ty

D/C to

Hostel

D/C to Nursing Home

Community (81)

64 (79%) 4 (5%)

13 (16%)

Hostel (5) 0 2(40%)

3(60%)

Nursing Home (3)

0 0 3(100%)

Mean Change in BBSBaseline

Mean (sd)Discharge Mean (sd)

Mean change in BBS (sd)

22.38(5.86)

30.85 (15.10)

8.47(10.37)

95% CI 6.32-10.63

The change was significant at p<0.001 but the 2 hospitals did not have significantly different changes in BBS (p=0.45)

Describing physiotherapy intervention (average intervention rate 3.65 per

week)

05

101520253035404550

0 20 40 60 80 100

Number of days under physiotherapy care

Occ

asio

ns

of

ph

ysio

ther

apy

serv

ice

Accuracy of initial physiotherapist prediction of discharge BBS (n=83)

On average physio estimates were underestimates

Average error

1.73(sd 9.4)

95% CI -0.29 - 3.08

6.99(sd 6.49)

Probability of discharge to nursing home compared to Baseline BBS

• Observed

—— Predicted

……. 95% confidence limit

Probability of discharge to nursing home compared to Final BBS

• Observed

—— Predicted

……. 95% confidence limit

-20

020

40

Ch

an

ge

in B

BS

0 20 40 60Days under physiotherapy care

Fitted values

Days Under Care / Change in BBS

What Does This Study Add?

• Relationship between BBS and D/C destination

• Number of physio interventions• How BBS changes• Prevalence of various conditions• Physios provide useful estimates

of change

Limitations

• Generalisability• No follow up• Causality not shown• Not enough power to predict

changes from diagnosis

So What?• We have an ageing population• BBS-Nursing home connection• Variable change – wait before placing

• Physio predictions of change useful