Project Description
The emergency room is a department often characterized by its large diversity of clients, medical conditions, treatments and interprofessional teams. Assessing a large array of individuals from all backgrounds, over 136 million people visit the emergency department each year (Chown & Soley, 2016). Encountering not only those with physical impairments, but also those with mental ailments as well, emergency departments provide 24-hour care for serious accidents, medical and surgical emergencies frequently impacting daily occupational performance (James et al., 2016). However, with one study showing over 50% of older adults to have left an accident and emergency department unable to perform basic activities of daily living, the role of occupational therapy in the ED has recently been highlighted (Hendriksen & Harrison, 2001). Not only assisting with safe discharge, but also with assistive technology, home assessment, and both cognitive and physical functioning, skilled occupational therapy services have been found to both increase quality of care, while decreasing hospital re-admissions and demands placed on emergency primary care (Rogers et al., 2016; Hendriksen & Harrison, 2001). In fact, according to health policy researchers, occupational therapy is the only spending category that reduces hospital re-admissions, with the profession providing a “unique immediate focus on patients’ functional and social needs, which can be an important driver to readmissions if left unaddressed” (Rogers et al., 2016). With 20% of Medicare patients found to be readmitted within 30 days of discharge, and 75% of re-admissions considered preventable, investments in occupational therapy can “improve care quality without significantly increasing hospital spending,” and may potentially save the Centers of Medicare and Medicaid Services approximately $12 billion annually (Roger et al., 2016; Chown & Soley, 2016). To facilitate in this development, this capstone project aims to determine if the inclusion of occupational therapy in the ED has the potential to decrease hospital re-admission rates.
Needs Assessments
- According to Hendriksen & Harrison (2001), approximately “50% of older adults with limb, rib, and back trauma found to have left an accident or emergency department unable to perform basic activities of daily living”.
- Functional impairment has been shown to be a huge predictor of an increased risk of 30-day all-cause hospital readmissions (Arbaje et al., 2008; DePalma et al., 2013; Greysen et al., 2015).
- Health policy researchers found occupational therapy to be the only spending category that reduces hospital re-admissions, according to research, Occupational Therapy places a unique and immediate focus on patients’ functional and social needs, which can be important drivers to readmission if left unaddressed (Rogers et al., 2016).
- Research also demonstrates 41% of patients to believe discharge instructions to be too short, and 20% of patients not feeling as if they can ask questions during guidance, occupational therapist can ensure a transfer of discharge knowledge by facilitating teach back tell back, and demonstration and reverse demonstration strategies before discharge, further reduce readmissions and demands placed of emergency primary care (Makinen et al., 2019).
- 20% of Medicare patients are historically readmitted within 30 days of discharge, and 75% of re-admissions are considered preventable (Chown& Soley, 2016).
- Reducing these preventable readmissions can save the Centers of Medicare and Medicaid Services approximately $12 billion annually Chown & Soley, 2016).
- The homeless population is one of the most frequently re-admitted populations, costing hospitals both a lot of resources and money, and are often discharged back to the streets without appropriate discharge planning that meets functional capacities (Lloyd et al., 2017; Miyawaki et al., 2020; Singh et al., 2015) .
Literature Review
- Occupational therapy is the only hospital spending category found to reduce hospital re-admissions rates (Rogers er al., 2016). In addition, OT is the most cost-effective service shown to increase care quality within the hospital setting (Rogers et al., 2016; Chown & Soley, 2016; Cusick et al., 2009; Lloyd et al., 2017; Singh et al., 2015).
- A study by Chown and Soley (2016) found that common diagnoses treated by occupational therapy practitioners in the ER include; cranial bleeds, strokes, concussions, altered mental status, hypotension, ambulatory dysfunction, upper extremity injuries, and weakness and fatigue.
- Research highlights the role of OT in the emergency department and interventions beneficial within this department (Cusick et al., 2009).
- Bastable et al (2019) found that ED discharge handouts are often written at a 12th-grade reading level or above and many patients are unable to read and understand the discharge instructions.
- Found to potentially also provide relief to emergency room overcrowding, OT provides multiple benefits to the emergency department (James, 2017).
- According to research, OT services are available in emergency departments abroad, however, are not universally offered in emergency departments in the United States (Veillette, Demers & Dutil, 2007; Cusick, Johnson & Bissett, 2009; Spang & Homlqvist, 2015).
Area of Focus
Research | Program and Policy Development | Advocacy
Primary Project Site
Parkview Hospital Randallia
Parkview hospital Randallia emergency department provided the opportunity to participate as a member of the emergency interprofessional team to assess ADL/IADLs and mobility concerns in emergency department patients.
Mission
To enhance awareness of the benefits of Occupational Therapy services within the emergency department, and to serve and promote occupational participation in emergency room patients, decreasing hospital re-admissions.
Project Leader
About Gena
My name is Gena Gonzalez and I am an occupational therapy student aiming to expand OT services in the emergency department to decrease hospital readmissions for my Capstone project. Originally from Houston, Texas, I am completing my doctoral degree in Occupational Therapy at Huntington University in Fort Wayne, IN. My passion lies in acute care and mental health, with my previous rotation being in Parkview Randallia’s inpatient acute setting. With experience in BridgeWay's psychiatric unit and in the ICU, I look forward to enhancing patient care quality.
Project Mentors
Expert Mentors: Kristy Ponder, OTR/L: Acute care occupational therapist with 20 years experience in the acute setting with a specialty in mental health. Gabrielle Nix, OTR/L: Supervisor of Rehab services at Parkview Hospital Randallia. Faculty Mentor: Jill Linder, DHSc, OTR, CBIS, CSRS: Outpatient OT at Parkview Hospital with a speciality in orthopedic and neurological impairments.
Project Outcomes
This study has a total of 9 deliverables below:
Deliverable #1: OT based job scope review
Deliverable #2: Five assessments and five interventions applicable to emergency department patients
Deliverable #3: Document expanding on 3 occupation-based assessments with descriptions on applicability to the ED.
Deliverable #4: Two PowerPoint presentations
Deliverable #5: Pre/Post-test on presentation content
Deliverable #6: OT profile applicable to ED patients
Deliverable #7: Two additional questions in OT profile applicable to ER patients
Deliverable #8: Finalized manuscript of Research
Deliverable #9: Methods for research
Development of Clinical Practice
- Conducted acute occupational therapy evaluations on ED patients under direct OTR/L supervision
- Provided assistive device and durable medical equipment recommendations prior to ED discharge
- Recommended discharge planning and placement sites prior to ED discharge
- Evaluated and treated patients with various condition and symptoms including: Back pain, limb pain, rib pain, falls, short of breath, fatigue, dizziness
- Collaborated interprofessionally with ED physicians, ED nurses, case management, and social workers to improve care quality
- Recommended therapy services post ED discharge including: Home Health Care, Outpatient Therapy, Fall prevention clinic
- Collaborated with patients and family members on treatments and post discharge recommendations to facility in safe discharge
Research
Evaluated occupational therapy's contribution in the emergency department in reducing readmission rates. Evaluated readmission rates of 100 patients who have received skilled OT services in the emergency department and compared rates with 100 patients who did not receive OT services in the emergency department prior to ED discharge to determine significance. Final research manuscript located above in deliverable 6.
Education
- Highlighted scope of practice and educated both ED staff and inpatient therapy staff on OTs contribution to the emergency department, as evidenced by 2 presentations and a completed pre/post tests with 10 questions.
Advocacy
- Advocated for OT evaluations in the emergency department from physicians and physician assistants
- Created and posted fliers detailing OT's contributions and patient indications for OT evaluations
- Advocated for continued therapy recommendations prior to ED discharge
- Advocated for AD and DME prior to ED discharge
- Advocated for skilled nursing facility placement/admission for severe ED patients to reduce readmission risks
Future Directions
After 5 years, I aim for OT services to become more common in emergency departments around the United States. By advocating, educating and providing present and future OTs with resources that I have accumulated during my capstone project, I aim to continue advocating for OT services in emergency departments in my home town of Houston, Texas post graduation. After graduation, I aim to get an acute care job and branch into the emergency department.
Contact Information
gonzalezg1@huntington.edu or gena.gonzalezotd@gmail.com
References
AmericanOccupationalTherapyAssociation.org. (n.d.). https://www.aota.org/Conference-Events/OTMonth/what-is-OT.aspx.
American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Supp. 2). https://doi.org/10.5014/ajot.2020.74s2001
Arbaje, A. I., Wolff, J. L., Yu,Qilu, Powe, N. R., Anderson, G. F., & Boult, C. (2008). Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling medicare beneficiaries. Gerontologist, 48(4), 495–504. https://doi.org/10.1093/geront/48.4.495
Burke, J. F., Skolarus, L. E., Adelman, E. E., Reeves, M. J., & Brown, D. L. (2014). Influence of hospital-level practices on readmission after ischemic stroke. Neurology, 82(24), 2196–2204. https://doi.org/10.1212/WNL.0000000000000514
Cassarino, M., Robinson, K., Quinn, R., Naddy, B., O’Regan, A., Ryan, D., Boland, F., Ward, M. E., McNamara, R., O’Connor, M., McCarthy, G., & Galvin, R. (2019). Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: A systematic review. PloS One, 14(7), e0220709. https://doi.org/10.1371/journal.pone.0220709
Chown, G., Soley, T., Moczydlowski, S., & Smoyer, A. (2016). A phenomenological study on the perception of occupational therapists practicing in the emergency department. Open Journal of Occupational Therapy (OJOT), 4(1), 1–15. https://doi.org/10.15453/2168-6408.1126
Cusick, A., Johnson, L., & Bissett, M. (2009). Occupational therapy in emergency departments: Australian practice. Journal of Evaluation in Clinical Practice, 15(2), 257–265. https://doi.org/10.1111/j.1365-2753.2008.00991.x
DePalma, G., Xu, H., Covinsky, K. E., Craig, B. A., Stallard, E., Thomas, J., III., & Sands, L. P. (2013). Hospital readmission among older adults who return home with unmet need for ADL disability. Gerontologist, 53(3), 454–461. http://doi.org/10.1093/geront/gns103
Greysen, S. R., Stijacic Cenzer, I., Auerbach, A. D., & Covinsky, K. E. (2015). Functional impairment and hospital readmission in Medicare seniors. JAMA Internal Medicine, 175(4), 559–565. https://doi.org/10.1001/jamainternmed.2014.7756
Hendriksen, H., & Harrison, R. A. (2001). Occupational therapy in accident and Emergency departments: a randomized controlled trial. Journal of Advanced Nursing (Wiley-Blackwell), 36(6), 727–732. https://doi.org/10.1046/j.1365-2648.2001.02038.x
James, K. (2017). Emergency departments and occupational therapy: Integration, Unscheduled Care and Over-crowding. International Journal of Integrated Care (IJIC), 17, 1–2. https://doi.org/10.5334/ijic.3705
James, K., Jones, D., Kempenaar, L., Preston, J., & Kerr, S. (2016). Occupational therapy and emergency departments: A critical review of the literature. The British Journal of Occupational Therapy, 79(8), 459–466. https://doi.org/10.1177/0308022616629168
Lloyd, C., Hilder, J., & Williams, P. L. (2017). Emergency department presentations of people who are homeless: The role of occupational therapy. The British Journal of Occupational Therapy, 80(9), 533–538. https://doi.org/10.1177/0308022617706679
Mäkinen, M., Castrén, M., Huttunen, K., Sundell, S., Kaartinen, J., Ben-Meir, M., & Renholm, M. (2019). Assessing the discharge instructing in the emergency department: Patient perspective. International Emergency Nursing, 43, 40–44. https://doi.org/10.1016/j.ienj.2018.07.005
Miyawaki, A., Hasegawa, K., Figueroa, J. F., & Tsugawa, Y. (2020). Hospital readmission and emergency department revisits of homeless patients treated at homeless-serving hospitals in the usa: Observational study. JGIM: Journal of General Internal Medicine, 35(9), 2560–2568. https://doi.org/10.1007/s11606-020-06029-0
Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 1–19. https://doi.org/10.1177/1077558716666981
Singh, S., Lin, Y.-L., Nattinger, A. B., Kuo, Y.-F., & Goodwin, J. S. (2015). Variation in readmission rates by emergency departments and emergency department providers caring for patients after discharge. Journal of Hospital Medicine, 10(11), 705–710. https://doi-org.elibrary.huntington.edu/10.1002/jhm.2407
Spang, L. & Homlqvist, K. (2015). Occupational therapy practice in emergency care: Occupational therapists’ perspectives. Scandinavian Journal of Occupational Therapy, 22(5), 345-354. http://dx.doi.org/10.3109/11038128.2015.1033455
Veillette, N., Demers, L. & Dutil, E. (2007). Description de la pratique des ergothérapeutes du Québec en salle d'urgence. Canadian Journal of Occupational Therapy, 74(4), 348-358. http://dx.doi.org/10.2182/cjot.07.006
Credits:
Created with an image by Ruben Pinto - "Emergency department entrance"