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