Abstract
Introduction
Approximately one-third of older patients leave hospital with a new functional impairment. Tracking rehabilitation progress following acute illness could improve recognition and understanding of hospital-acquired disability. However, traditional mobility and functional scores include measures that are not part of routine rehabilitation therapy, adding a time burden for staff to report. Capturing data already recorded in routine electronic records could provide an efficient patient tracking measure of rehabilitation success.
Methods
A scoping literature review appraised existing scores of mobility and functional status. Analysis of 15 admissions through the Royal Infirmary of Edinburgh identified mobility and functional domains which were reliably recorded in free text electronic health records. A pilot score was drafted, comprising admission and discharge scores (0-30 points), medical progress (0-10), physiotherapy and occupational therapy tracking (0-30). Higher scores indicate greater functional independence. Expert feedback was obtained through focus group discussion with physiotherapists and occupational therapists. The approach was tested in a fresh set of six case studies. Two independent scorers applied the scoring schema and agreement was assessed using Cohen’s weighted-kappa coefficient.
Results
The selected electronic health records contained 438 medical, 352 nursing and 183 therapist entries. Existing measures such as the Barthel Index were not recorded for any patient. Focus group discussion identified value in the overall approach and informed item-weighting. The pilot functional score allowed visualisation of rehabilitation trajectories over the course of each admission. Excellent inter-rater reliability was demonstrated for the medical (Cohen’s Kappa 0.99, 95% confidence interval [CI] 0.96–1.00) and physiotherapy (Kappa 0.96, 95% CI 0.93–0.99) components.
Conclusions
A functional tracking score generated from routine health records proved feasible and reproducible in this pilot. Future development should assess validity, reliability and prognostic power in larger populations, exploring automation using natural language processing. Development of graphic visualisations may aid communication within multidisciplinary teams.
Comments
Thanks. Will be interesting to see how this develops.
Thank you so much for your comment.
Other uses for the tool
This is really exciting - it could be used as an early warning system on (doctor light) step-down wards to identify two groups of patients we often struggle with: those who are deteriorating medically over a day or two but whose nursing obs haven’t changed (yet), or changing functionally over weeks (which might mean their discharge plans were no longer safe, or that their prognosis was poorer than first estimated).
Thank you!
Thank you so much for your comment. I totally agree with your suggestions for further uses of this tool. We look forward to seeing how we can use the score.
Pilot of Routine Electronic tracking of functional status in Hos
Very useful study. Did you see deterioration in scores for those who scored high on first assessment and than lower in later? Just like "Discharged from Physio" comments often seen in inpatient even in frail older or post rehabilitation periods on the wards.
Thank you for your comment. Now that we have demonstrated the use of the tool in case studies, we hope to apply to a much larger cohort to look for trends like this. We might expect higher initial scores followed by decline in patients who are discharged with hospital-acquired disability.
Very interesting study - which mobility and functional domains were reliably documented and used in this analysis? And - you mention Barthel Index not systematically recorded - did you look for any other validated measures of function? (Final question!!) - was there any suggestion on introducing a standardised proforma eg in PT or OT assessments from which data could be more easily coded and extracted?
Thank you so much for your comment. The scores are composed of a number of mobility and functional domains including sit-to-stand, distance mobilised, independence with ADLs etc. In the case note analysis, we looked for all the validated measures of function/mobility that were studied in our literature review (including the Elderly Mobility Score, Barthel Index, TUG etc). I have included more information about this in the video presentation. The PT and OT assessments already followed a helpfully consistent format- one of our aims was to avoid large changes to their routine practice and documentation. However, a conversation about further standardisation would certainly be important.