Nursing Manuscript
Functional Assessment and Intervention by Nursing Assistants in Hospice and Palliative Care Inpatient Care Settings: A Quality Improvement Pilot Study
American Journal of Hospice & Palliative Medicine® 1-8 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114555397 ajhpm.sagepub.com
Karen Mueller, PT, DPT, PhD1, Gillian Hamilton, MD, PhD2, Betheny Rodden, RN, BSN2, and Hendrick D. DeHeer, PhD1
Abstract This study assessed the impact of a nursing assistant-led functional intervention in an urban hospice. Thirty-three patients participated. A physical therapist trained 4 nursing assistants to assess 4 basic functional activities at admission and discharge and to provide daily activity training to intervention group participants. Control group participants were assessed at admission and discharge and received the usual standard of care. Both groups improved. The intervention group participants demonstrated significant improvement in the Timed up and Go test as well as their self-reported ability to achieve goals on the Patient-Specific Functional Scale. Control group participants made significant improvements in the ability to move from supine to sit in bed. These findings suggest that nursing assistants can provide activity-based assessment and intervention leading to improved function among patients in hospice. Keywords outcomes assessment, hospice and palliative care, physical therapists, nurses, patient care team, quality improvement
Background and Purpose Physical activity has been increasingly recognized as a valuable supportive intervention in patients with end-stage disease.1 A recent study of patients with advanced cancer receiving palliative care suggested that declining physical function, particularly the loss of walking ability, is associated with lower subjective scores of quality of life.2 Furthermore, while physical rehabilitation is not generally considered within the context of end-stage disease management in hospice, evidence suggests that patients with terminal disease rank optimization of function as a foremost concern, and many express the desire to participate in a physical activity program, particularly one involving walking.3-5 Despite this evidence, functional assessment and intervention in hospice and palliative care settings do not routinely occur.4,5 There appear to be several reasons for this, including lack of awareness (among hospice team members) about its potential benefits,3 lack of training in functional assessment among hospice team members,6 and lack of an international functional measure for use in palliative care.7 In the context of the interdisciplinary team, functional assessment and intervention are generally considered the domain of the physical therapist. At the current time, physical therapists are not considered members of the core hospice team under Medicare, the payment source for 84% of patients receiving hospice services in the United States in 2012.8
Moreover, a 2008 provision (418.72) of the Medicare Regulations and Conditions of Participation for Hospice Care requires that physical therapy services be made available and provided by an appropriate licensed personnel.9 These guidelines do not provide clear indications for referrals for physical therapist assessment, and recent evidence suggests that such referrals are dependent on nurses and their understanding of the physical therapist’s role.10 Accordingly, there is significant variability among the practice arrangements by which hospice and palliative care agencies secure physical therapist services. These include contractual agreements with physical therapists where patients are referred as ‘‘as-needed’’ basis, referrals to physical therapists practicing in home health agencies that occasionally receive hospice consults, and clinical practice in hospitals with hospice units. A study exploring physical therapy utilization in hospice and palliative care
1
Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ, USA 2 Department of physical therapy and athletic training, Hospice of the Valley, Phoenix, AZ, USA Corresponding Author: Karen Mueller, PT, DPT, PhD, Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ 86001, USA. Email: [email protected]
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2 facilities in the state of Michigan found that less than 5% of patients received physical therapy services in these settings.11 No data exist to determine the number of hospice agencies with full-time physical therapists on staff; however, anecdotal evidence suggests that there are few. Research exploring the impact of functional training in hospice and palliative care settings may thus be limited by the absence of consistent physical therapist involvement as a member of the hospice interdisciplinary team, along with barriers related to the lack of interdisciplinary awareness and training. However, given that 44.8% of US deaths occurred in hospice settings in 2012,8 continued research with patients at end of life is essential to optimize care for this growing population. In 2011, the Medical Director (author GH) of Hospice of the Valley (HOV), located in Phoenix, Arizona, contracted with a hospice physical therapist/educator (author KM) to explore the impact of functional assessment as part of a quality improvement measure for the organization. HOV was established in 1977, and it is one of the largest nonprofit hospices in the United States. The organization employs over 2000 staff members and 2500 volunteers who provide services to 18 000 patients per year. Hospice services are most often provided in patients’ homes. Patients may also be admitted to 1 of 16 inpatient palliative care units (PCUs) throughout the Phoenix area for short-term symptom management related to their hospice diagnosis. Each PCU has both a physician and a nursing director. The organization is staffed with a research department and has its own institutional review board.12 Nursing assistants are integral to patient care in all health care settings and are considered essential members of the hospice and palliative care team.13 Working under the supervision of either a registered nurse (RN) or a licensed practical/vocational nurse (LP/VN), nursing assistants interact closely with patients, providing direct personal care such as bathing, hygiene, dressing and toileting.13 Completion of a state-approved training program (typically around 120 hours) and a posteducational certification examination is required for nursing assistants who seek employment in any Medicare- or Medicaid-certified health care facility.14 In addition to practical skills involving patient care, nursing assistants are trained in several measurement skills including heart rate, blood pressure, and fluid intake. It is estimated that nursing assistants provide up to 90% of hands-on patient care in all settings in which they work.15 Because of the ongoing and intimate nature of their patient interactions, nursing assistants working in hospice and palliative care settings are often the first providers to observe the spiritual, psychosocial, and emotional issues that arise among patients facing end of life, yet their invaluable contributions are often unappreciated.13 Thus, in order to foster greater recognition of the critical role of nursing assistants in hospice and palliative care settings, educational initiatives have recently been developed to empower their involvement in the care of persons facing end of life. In 2002, the Hospice and Palliative Nurses Association established a process by which nursing assistants with 2000 hours of hospice and palliative care experience can acquire advanced recognition as a Certified Hospice and Palliative Nurse Assistant.13
The purpose of the current study was 2-fold; first, to explore the feasibility of training nursing assistants to conduct functional assessments and intervention with patients receiving inpatient palliative care services in the HOV network and second, to determine the impact of functional assessment and intervention on patient outcomes. This study was approved by the HOV Institutional Review Board on July 20, 2011.
Research Method Outcome Measures Given the frailty of the patients receiving services in the HOV network, it was imperative to select functional activities that were both meaningful and practical. Four specific activities were identified: (1) performing a supine ‘‘bridge’’ in bed (ie, extending hips and lower trunk off the support surface with knees flexed and feet on the support surface); Bridging was selected due to its utility in using a bed pan, self-positioning in bed, and lower body dressing; (2) moving from side-lying to sitting with legs over the edge of a bed; (3) moving to standing from sitting; and (4) walking a short distance (with or without an assistive device). Two objective outcome measures, the Timed Up and Go (TUG)16-20 and Modified Iowa Levels of Assistance Scale (MILAS)21-23, were used to assess these activities. In addition, patients’ subjective activity preferences and perceived levels of difficulty were assessed with the PatientSpecific Functional Scale (PSFS).24,25
Timed Up and Go The TUG measures the time a patient takes to assume standing from a seated position, walk 3 m at their safest optimal speed, and turn around and walk back to return to sitting. The TUG was developed for community-dwelling frail elderly adults aged between 60 and 90 years of age and has also been widely used for adults with mobility and cognitive deficits. In 1 study, the 10th to 90th percentiles for TUG performance were 6.0 to 11.2 seconds for community-dwelling women aged between 65 and 85 years.19 A score of 14 seconds or more is generally considered the cutoff for fall risk, and a score of 30 seconds or more is predictive of requiring an assistive device for ambulation and being dependent in activities of daily living (ADLs).19 The TUG has excellent interrater (intraclass correlation coefficient [ICC] ¼ 0.99) and intrarater reliability (ICC ¼ 0.99). The test score also correlates well with gait speed (r ¼ .55), scores on the Berg Balance Scale (r ¼ .72), and the Barthel Index (r ¼ .51).20
The Modified Iowa Levels of Assistance Scale The MILAS was developed to assess the function of patients with postoperative total hip replacement in the acute hospital setting.21,23 The assessment is comprised of 5 activities considered essential for safe discharge and optimal independent mobility in the home. These activities include moving from
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supine (via side-lying) to sitting at the edge of a bed, moving from sitting at the edge of a bed to supine, moving from sit to stand from a bed, walking 4 to 6 m, and ascending/descending 10 steps. For the purposes of this study, 2 activities (moving from supine to sitting in bed and moving from sit to stand in bed) were assessed. Each activity is graded on an ordinal scale from 0 to 6 for the level of assistance required. The MILAS rating scale provides clear operational definitions of each of the levels of assistance and has demonstrated high interrater reliability (K ¼ .79-.90).21-23
The Patient-Specific Functional Scale The PSFS24,25 is a generic outcome measure that quantifies functional limitations resulting from any illness or injury. The PSFS consists of an introductory statement that is read by the physical therapist or other health practitioners. Patients are then asked to identify up to 5 functional activities with which they are having difficulty performing (or are unable to perform) because of their medical problem. Each activity is then rated on a 10-point ordinal scale (from 0 being ‘‘unable to perform’’ to 10 being ‘‘able to perform with no difficulty’’). A total score is calculated by dividing the sum of the activity scores by the number of activities identified. A minimal detectable change (at a 90% confidence interval) is either a 2-point change in the total score or a 3-point change in a single activity score. The PSFS has demonstrated excellent test–retest reliability and sensitivity to change with an intraclass correlation coefficient of R ¼ .84 and a Pearson r ¼ .78, respectively.
Study Site and Patient Selection Participants were drawn from the population of consecutive patient admissions to 4 of 16 of the inpatient PCUs in the HOV network between October 1, 2011, and April 1, 2012. These 4 PCUs were initially identified as a representative sample by the HOV Medical Director (author GH) in consultation with the Director of Inpatient Services. The medical and nursing directors of each PCU were then contacted about their willingness to serve as a study site for the project and each consented to do so. All noncomatose participants over the age of 21 with an expected survival of 1 week (as determined by the medical staff of each PCU) were invited to participate. These inclusion criteria were intended to be as broad as possible while also providing sufficient time for both admission and discharge assessments. Written informed consent was obtained from each participant.
Training of Nursing Assistants The nurse investigator (author BR) invited 1 experienced nursing assistant from each of the 4 palliative units to undergo functional skills training for the study. Each of the 4 agreed to participate. The physical therapist investigator (author KM) provided a 1-hour training session to each nursing assistant
in the administration of TUG, MILAS, and PSFS. The nursing assistants were also instructed in the 4 basic functional interventions to be provided to the intervention group participants. These included (1) bridging from supine in bed, (2) assuming sitting from supine (via side-lying) in bed, (3) moving from sitting to standing, and (4) ambulation with physical support and/or an assistive device. In the course of the training, the 4 nursing assistants demonstrated the ability to administer each test and intervention effectively. The nursing assistants were instructed to use a gait belt for all upright activities. In addition, the nurse investigator (author BR) trained the nursing assistants in the process of acquiring informed consent from participants who met the inclusion criteria (as determined by the medical staff of each PCU). These personnel provided pre- and posttest functional skills assessment to patients in the 4 palliative care units utilized in the study. In addition, they provided the interventions twice each day and documented patient follow-up through the patient’s Medical Administration Record (MAR).
Experimental Design Two PCUs served as experimental sites. Each new admission was screened by the PCU Medical Director for likely survival beyond 1 week. Participants in these PCUs received a ‘‘pretest’’ functional assessment within 48 hours of admission and a ‘‘posttest’’ assessment within 72 hours of discharge. Immediately following the pretest assessment, the functional outcome scores and patient goals (from the PSFS) were conveyed electronically to the physical therapist consultant (author KM). The physical therapist then identified the appropriate functional interventions for each patient based on assessment results and returned these electronically to the PCU on the same day. The recommended interventions were placed in each patient’s MAR. The trained nursing assistants provided twice-daily opportunities for each of the patients to complete these activities and documented the results in the patients’ MAR. The 2 remaining PCUs served as control sites and were also screened by the Medical Director for expected survival beyond 1 week. Participants in these PCUs underwent ‘‘pretest’’ and ‘‘posttest’’ functional assessments in the manner described earlier. No interventions were provided to participants in these 2 PCUs who received the ‘‘usual standard of comfort care’’ (ie, patients initiated their own activities as desired with support as needed).
Statistical Analysis Demographic and numeric data were compiled electronically using a Windows Excel file. All analyses were conducted with SPSS version 19.0 (SPSS Inc, Chicago, Illinois). Frequencies and descriptive statistics were used to describe participant demographic characteristics and values on the 3 main outcomes (TUG, MILAS, and PSFS). To compare participants in the intervention and control groups at baseline, independent samples’ t tests and chi-square analyses were used. Paired samples’
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4 t tests (for within-group changes) and 1-way repeated measures’ Analyses of Variance (between groups) were conducted to compare changes from pretest to posttest of all major outcome variables. The a priori significance level was set at 0.05.
Results There were a total of 494 admissions to the 4 PCUs during the 6-month duration of the study (Intervention site 1 ¼ 102, Intervention site 2 ¼ 106, Control site 1 ¼ 143 and Control site 2 ¼ 143). Of these, 64 patients met the initial inclusion criteria. Among these, 4 refused consent, 3 consented but were too ill to complete the initial assessment, and 7 died before the initial assessment. The remaining 50 participants underwent initial screening; however, 10 were too ill to complete the posttest, and 7 were discharged before the posttest assessment could be completed. Thirty-three participants (18 in the intervention group and 15 in the control group) completed the study.
Demographics There were 14 females and 4 males (n ¼ 18) in the 2 experimental PCUs. In all, 9 women and 6 men (n ¼ 15) comprised the 2 control PCU participants. The average age of participants in the experimental and control groups was 82.5 years (range, 59-104 years) and 74.2 years (range, 31-92 years), respectively. There was no significant difference with respect to age between the 2 groups (P ¼ .173) The average time between pre- and posttest for the participants was 4.67 days in the intervention group and 6.33 days in the control group (range, 1-14 days; P ¼ .122). The hospice diagnoses of the 2 groups were similar. In both groups, cancer, congestive heart failure, and debility were the top 3 respective diagnoses. Other diagnoses included chronic obstructive pulmonary disease, neurodegenerative disease, AIDS, and dementia. Table 1 illustrates the hospice diagnoses of the patients in both groups.
Outcomes Patient Interventions The physical therapist investigator prescribed a minimum of 2 and a maximum of 3 functional activities to each of the intervention group participants based on the results of their admission assessment. Ambulation (with or without an assistive device) was the most common recommendation, prescribed for 16 (88.8%) of the 18 participants who were ambulatory at admission. Sit to stand was the next most utilized intervention and was recommended for 5 (27%) participants. Three (16%) participants received recommendations for bridging and assuming sitting from supine in bed. Patient adherence to the interventions was documented by the nursing assistants in the MAR. In the course of the 4.67day admission to discharge interval for the intervention group, each participant underwent at least 1 intervention session, and
Table 1. Hospice Diagnoses of Patients. Diagnosis Cancer Congestive heart failure Debility COPD Neurodegenerative AIDS Dementia
Intervention group (n ¼ 18)
Control group (n ¼ 15)
5 4 4 3 1 0 1
5 5 3 0 1 1 0
the overall average was 4.5 sessions (range, 1-23 sessions). There was only 1 documented refusal among intervention group participants.
Timed up and Go The initial TUG assessment participants in the intervention group demonstrated a significantly lower level of function compared to those in the control group (mean intervention pretest TUG ¼ 69.96 seconds; mean control pretest TUG ¼ 24.10 seconds, and P ¼ .02). At discharge, the 2 groups were no longer significantly different from each other (P ¼ .186). For within group change, the intervention group demonstrated a significant improvement in their TUG scores (P ¼ .046), represented by a mean decrease of 16.88 seconds from baseline to discharge. The control group participants also improved slightly, demonstrating a 4.6-second decrease between preandpost-TUG scores (P ¼ .186). In terms of change from baseline to discharge, the intervention group did not improve significantly more than the control group (P ¼ .177). Table 2 illustrates the admission, discharge, and change in TUG scores of the participants in both groups.
Modified Iowa Level of Assistance Scale The 2 functions of supine-to-sit and sit-to-stand were assessed using the 0 to 6 MILAS scoring rubric. A score of 0 pertains to complete independence without assistive devices, a score of 5 pertains to ‘‘failure to complete activity even with maximal assistance,’’ and a score of 6 corresponds to ‘‘not tested due to medical reasons or reasons of safety.’’ Both groups showed similar improvement in the supine-to-sit test, with the improvement being significant in the control group (P ¼ .032) and marginally significant among the intervention group (P ¼ .069). There were no significant differences between the 2 groups at baseline, discharge, or in terms of change from baseline to discharge. Table 3 illustrates the MILAS scores for supine to sit and sit to stand in the intervention and control groups.
The Patient-Specific Functional Scale Twenty-one (63%) participants in both groups identified walking as their most important activity. Ten (30%) participants in both groups identified the improvement in strength and endurance for sitting and transfers as their most important
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Table 2. Changes in Timed Up and Go (TUG) Following a Functional Intervention Among Hospice and Palliative Care Patients. Intervention group (n ¼ 18) TUG (seconds) BL Follow-up Change
P value withina
Control group (n ¼ 15)
P value within
P value betweenb
.046c
24.10 (14.19) 19.46 (12.49) 4.64
.186
.177
69.96 (64.83) 53.08 (53.59) 16.88
a
P values for within-group differences are based on paired samples’ t tests. P values for between-group differences are based on repeated measures’ analysis of variance (ANOVA). c P < .05. b
Table 3. Changes in MILAS Scores Following a Functional Intervention Among Hospice and Palliative Care Patients. Intervention group (n ¼ 18) P value withina Control group (n ¼ 15) P value within P value betweenb Supine to Sit Pre-test (mean, SD) Follow-up Change Stand from sit pretest (mean, SD) Follow-up Change
1.24 (1.52) 0.59 (0.62) 0.65 1.15 (1.35) 0.69 (1.49) 0.46
.069
.139
0.92 (1.04) 0.23 (0.60) .69 1.25 (1.48) 0.75 (0.68) .5
.032c
.933
.15
.921
Abbreviations: MILAS, Modified Iowa Levels of Assistance Scale; SD, standard deviation. a P values for within-group differences are based on paired samples’ t tests. b P values for between-group differences are based on repeated measures’ analysis of variance (ANOVA). c P < .05.
Table 4. Changes in Patient-Specific Functional Scale Following a Functional Intervention Among Hospice and Palliative Care Patients. Intervention group (n ¼ 18) P value withina Control group (n ¼ 15) P value within P value betweenb Functional Scale pre-test (Mean, SD) Follow-up Change
3.89 (2.91) 5.83 (2.90) 1.94
.008c
4.92 (2.64) 6.00 (3.72) 1.08
.167
.392
a
P values for within-group differences are based on paired samples’ t tests. P values for between-group differences are based on repeated measures’ analysis of variance (ANOVA). c P < .01. b
functional skills. Two participants were unable to identify a specific goal. From baseline to discharge, the intervention group demonstrated a significant improvement in the PSFS (pretest ¼ 3.89, posttest ¼ 5.83, change ¼ 1.94, P ¼ .008). This change approximates a perceived change in level of difficulty from ‘‘moderate’’ to ‘‘mild.’’ The PSFS scores of the control group also changed slightly, also reflecting a perceived change in the level of difficulty from ‘‘moderate’’ to ‘‘mild’’; however, the improvement from baseline to discharge within the control group was not statistically significant (pretest ¼ 4.92, posttest ¼ 6.00, change ¼ 1.08, P ¼ .167). The difference in change from pretest to posttest was not significantly different between the 2 groups (P ¼ .392). Table 4 illustrates the PSFS scores at admission and discharge for participants in both the groups.
Discussion This study demonstrates that patients in a hospice setting can achieve meaningful functional improvements as a result of
assessment and intervention by trained nursing assistants. Participants in the intervention group made significant improvements in their TUG scores as a result of an average of 4 daily practice sessions delivered by nursing assistants. This finding is of particular interest, given that the TUG scores of the intervention group were significantly worse than those of the control group at admission. In contrast to the other skills assessed in this study (bed mobility and sit to stand), walking with patients who have balance deficits requires more caregiver time in terms of direct supervision and assistance. This skill may have improved more in the intervention group due to the daily practice sessions offered to these participants. In 1 case, a 104-year-old member of the participant group who was nonambulatory at admission was able to ambulate with a walker and minimal assistance after a 22-day admission. It is possible that this patient would not have achieved such an outcome in the absence of daily practice opportunities. Walking function was the most commonly identified functional goal for 63% of all study participants; thus, the improvement in this skill in the intervention group has significant
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6 implications for the quality of life of these patients. Accordingly, the improvement in walking skills may have contributed directly to the significant improvement in the PSFS scores among intervention group participants. From baseline to discharge, the study found significant improvements among the control group participants on assuming sitting from supine compared with the intervention group participants. Although this control group did not receive daily practice opportunities in this skill, it is a function that may be easier for a patient to practice independently or with family members once it is evaluated. The ability to assume sitting from supine is a complex muscular activity that involves the use of the neck and trunk flexors which rotate the upper body from supine into side lying, and the lateral trunk and neck flexors to move from side lying into an upright position. In addition, rising to sitting from involves the use of upper extremity musculature in order to assist the trunk from horizontal to vertical. Due to the antigravity muscle activity involved in this skill, evidence suggests that it is more difficult than the maintenance of sitting balance.26 Furthermore, a study of 327 patients with stroke demonstrated that those who were able to rise from supine to sitting at admission were 6 times more likely to achieve independent ambulation and 9 times more likely to have favorable functional outcomes than those who were unable.27 One unexpected finding in this study was the significantly slower admission TUG scores of participants in the intervention group compared to those in the control group. The lack of between-group functional homogeneity was a major limitation of this study and has been identified as a potential barrier to outcomes research in the hospice population.28-31 Interestingly, despite this difference, the intervention group made a significant increase in their discharge TUG performance and was no longer significantly different from the control group at discharge. This finding suggests that the functional interventions were important in helping the slower intervention group to catch up to the faster control group. Recent evidence has determined walking speed to be the ‘‘sixth vital sign,’’ which is predictive of health status, hospitalization, and mortality.32 Specifically, TUG scores of greater than 32.6 seconds have been identified as the cutoff for fall risk in the frail elderly population.33 Furthermore, TUG scores of greater than 30 seconds are associated with dependency in transfers. At the current time, there is no Minimal Clinically Important Difference for the TUG. The intervention group improved their TUG score by 16.88 seconds, which represents a 25% change from their 69.96-second baseline. Although intervention group participants remained at risk of falls upon discharge, it is possible that this risk was nevertheless reduced. Further studies are needed to correlate TUG scores with fall rates among debilitated elderly persons such as those receiving hospice services. In addition to walking 10 feet, the TUG measures the ability to assume standing from sitting, turn around, and return to sitting from standing, each of which are important functional measures of strength and balance. However, because these
activities are included in the overall TUG score, the exact walking speed cannot be determined. Nevertheless, the TUG was deliberately utilized in this study for its value in assessing sit to stand and turning as well as walking ability. In contrast, the 10-m walk test is a pure assessment of walking speed. Thus, future studies of walking speed in the hospice population should involve use of this measure. Another unexpected study finding was that 73% of control group participants improved their TUG performance, even in the absence of opportunities for practice. The initial TUG assessment indicated that all but 3 participants in both groups were considered at high risk for falls (>14 seconds), and 15 participants were likely to be dependent with ADLs and in need of assistive devices (TUG > 30 seconds). At discharge, 7 of the 15 participants in both groups who were likely dependent with ADLs (TUG.30 seconds) improved to the point where they no longer fell into this category at posttest. These results suggest that assessment of standing and walking ability at hospice admission may have been, in itself, a motivating factor to patients who were already capable of this activity. The study findings showed that improvements were found in a short period of time (the average time between pre- and posttest was approximately 5 days). Participants in the intervention group were offered twice-daily opportunities for practice of functional skills and underwent an average of 4.5 sessions. Interestingly, there was only once documented refusal among participants in the intervention group, suggesting a high level of motivation. These findings illustrate the potential for significant functional improvement in patients with considerable debility who are motivated to exercise. Initiatives recognizing the contributions of nursing assistants in the hospice setting are of considerable importance given the frequency of their patient interaction. The nursing assistants in this study acknowledged gratitude for their participation and stated that they became more aware of the importance of encouraging functional activity when appropriate. The nursing assistants further noted that study participants were generally eager to engage in functional intervention training and that many increased their activity levels outside of scheduled treatment sessions. The nursing assistants also observed that increased functional activity improved the moods of study participants. Finally, 1 nursing assistant suggested that education on the value of functional activity should be included in the future orientation of all nursing assistants at HOV.
Limitations Although the results of this study are encouraging, they are limited by several factors reflecting the challenges of research with patients at end of life. These include a small sample size, wide variations among participant performance, and significant decline or death of participants before the discharge posttest. Both groups demonstrated large standard deviations in both pre- and posttest TUG scores; however, those of the intervention group were particularly large (64.83 and 53.59 seconds, respectively). Of the 14 intervention group participants who
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completed a pretest TUG, 9 had scores below 60 seconds (range, 20-43 seconds); however, 1 intervention participant had a pretest TUG score of 205 seconds and 4 had scores between 61 and 86 seconds. The inconsistency of these scores may have been due to variations in the extent of preadmission participant debility as well as the nature of their end-stage disease and related impairments. Although it may be advantageous to consider the hospice diagnosis when assigning patients to intervention or control groups, this may not be feasible, given the high mortality rate of this population as a whole. Finally, this study did not include a follow-up of study participants to assess the maintenance of improvements in the functional status after discharge. While postdischarge followup was not an initial consideration of this pilot project, future studies of this nature should include such assessment as a measure of value.
Conclusion This quality improvement pilot study was designed to assess the feasibility of training nursing assistants to deliver functional assessments and interventions to patients receiving hospice services, and the results suggest that such training was effective. Thus, in hospice settings without access to regular physical therapy services, nursing assistants can provide a valuable extension of such services with favorable patient results. The other purpose of this study was to assess the impact of daily intervention on improvement in patient functional outcomes. Given the considerable variability between the intervention and control groups, it was difficult to determine such an impact. Nonetheless, perhaps the most promising aspect of this study is that patients in both groups improved to some extent, leading to the possibility that functional assessment alone may have an encouraging impact on patients which fosters independent practice, particularly of essential skills such as assuming sitting from supine. Given the results of this study, future directions should include efforts to assure a level of functional homogeneity between intervention and control groups. In addition, use of the 10-m walk test will enable a clearer assessment of walking speed. Finally, larger groups of patients will assure significant power by which to determine clearer between group differences. Acknowledgment The authors would like to acknowledge Sarah Bird, Vice-President of Clinical Operations, Hospice of the Valley, Phoenix, AZ; Teresa Cooley, RN, Hospice of the Valley, Phoenix, AZ; Evelyn Mangan, CNA, Hospice of the Valley, Phoenix, AZ; Kacshya Wojnarowski, CNA, Hospice of the Valley, Phoenix, AZ; Karen Salvadore, LPN (was CNA at the time), Hospice of the Valley, Phoenix, AZ; and Scott Kolesar, RN (was CNA at the time), Hospice of the Valley, Phoenix, AZ.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by a grant from The Grayhawk Classic Residents’ Foundation at Vi at Grayhawk Scottsdale, AZ.
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8 14. Arizona State Board of Nursing. Certified Nursing Assistant Curriculum. Web site. https://www.azbn.gov/educationcnaprograms. Published January 27, 2006. Accessed September 18, 2014. 15. Hospice and Palliative Nurses Association. HPNA Position Statement: Value of Nursing Assistant in Palliative Care. Web site. https://www.hpna.org/pdf/PositionStatement_ValueOfNAs. pdf. Published January, 2013. Accessed September 18, 2014. 16. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the ‘‘get up and go test’’. Arch Phys Med Rehabil. 986;67(6): 387-389. 17. Podsiadlo D, Richardson S. The timed ‘‘Up & Go’’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-148. 18. Bischoff HA, Sta¨helin HB, Monsch AU, et al. Identifying a cut-off point for normal mobility: A comparison of the timed ’up and go’ test in community-dwelling and institutionalised elderly women. Age Ageing. 2003;32(3):315-320. 19. Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 2006;29(2): 64-68. 20. Ng SS, Hui-Chan CW. The timed up & go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil. 2005;86(8):1641-1647. 21. Shields RK, Leo KC, Miller B, Dostal WF, Barr R. An acute care physical therapy clinical practice database for outcomes research. Phys Ther. 1994;74(5):463-470. 22. Shields RK, Enloe LJ, Evans RE, Smith KB, Steckel SD. Reliability, validity, and responsiveness of functional tests in patients with total joint replacement. Phys Ther. 1995;75(3): 169-176. 23. Jesudason C, Stiller K. Are bed exercises necessary following hip arthroplasty? Aust J Physiother. 2002;48(2):73-81.
24. Physical Therapy Resources: The Patient Specific Functional Scale. Government of Western Australia. Transport Accident Commission. Web site. http://www.tac.vic.gov.au/files-move/ media/upload/patient-specific.pdf. Published 2005. Accessed July 16, 2013. 25. Chatman AB, Hyams SP, Neel JM, et al. The patient-specific functional scale: measurement properties in patients with knee dysfunction. Phys Ther. 1997;77(8):820. 26. Smith MT, Baer GD. Achievement of simple mobility milestones after stroke. Arch Phys Med Rehabil. 1999;80(4):442-447. 27. Wannatapan P, Kovindha A, Pirajev K, Kuptinirasaikul V. Relationship between the ability to change from a supine to sitting position at admission and mobility outcomes after stroke rehabilitation. J Med Assoc Thai. 2010;93(suppl 3):S21-S24. 28. Wohleber AM, McKitrick DS, Davis SE. Designing research with hospice and palliative care populations. Am J Hosp Palliat Med. 2012;29(5):335-345. 29. Kruse RL, Parker OD, Wittenberg-Lyles E, Demiris G. Conducting the ACTIVE randomized trial in hospice care: Keys to success. Clinical Trials. 2013;10(1):160-169. 30. Kutner J, Smith M, Mellis K, Felton S, Yamashita T, Corbin L. Methodological challenges in conducting a multi-site randomized clinical trial of massage therapy in hospice. J Palliat Med. 2010; 13(6)739-744. 31. Heitkemper MM, Bruner DW, Johnson JC, et al. National Institutes of Health statement-of-the-science conference statement in on improving end-of-life care. NIH Consensus State Sci. Statements. 2004;21(3):1-26. 32. Fritz S, Lusardi M. White paper: walking speed: the sixth ‘‘vital sign’’. Jour Ger Phys Ther. 2009;32(2):1-5. 33. Thomas JI, Lane JV. A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients. Arch Phys Med Rehabil. 2005;86(8):1636-1640.
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Functional Assessment and Intervention by Nursing Assistants in Hospice and Palliative Care Inpatient Care Settings: A Quality Improvement Pilot Study
American Journal of Hospice & Palliative Medicine® 1-8 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049909114555397 ajhpm.sagepub.com
Karen Mueller, PT, DPT, PhD1, Gillian Hamilton, MD, PhD2, Betheny Rodden, RN, BSN2, and Hendrick D. DeHeer, PhD1
Abstract This study assessed the impact of a nursing assistant-led functional intervention in an urban hospice. Thirty-three patients participated. A physical therapist trained 4 nursing assistants to assess 4 basic functional activities at admission and discharge and to provide daily activity training to intervention group participants. Control group participants were assessed at admission and discharge and received the usual standard of care. Both groups improved. The intervention group participants demonstrated significant improvement in the Timed up and Go test as well as their self-reported ability to achieve goals on the Patient-Specific Functional Scale. Control group participants made significant improvements in the ability to move from supine to sit in bed. These findings suggest that nursing assistants can provide activity-based assessment and intervention leading to improved function among patients in hospice. Keywords outcomes assessment, hospice and palliative care, physical therapists, nurses, patient care team, quality improvement
Background and Purpose Physical activity has been increasingly recognized as a valuable supportive intervention in patients with end-stage disease.1 A recent study of patients with advanced cancer receiving palliative care suggested that declining physical function, particularly the loss of walking ability, is associated with lower subjective scores of quality of life.2 Furthermore, while physical rehabilitation is not generally considered within the context of end-stage disease management in hospice, evidence suggests that patients with terminal disease rank optimization of function as a foremost concern, and many express the desire to participate in a physical activity program, particularly one involving walking.3-5 Despite this evidence, functional assessment and intervention in hospice and palliative care settings do not routinely occur.4,5 There appear to be several reasons for this, including lack of awareness (among hospice team members) about its potential benefits,3 lack of training in functional assessment among hospice team members,6 and lack of an international functional measure for use in palliative care.7 In the context of the interdisciplinary team, functional assessment and intervention are generally considered the domain of the physical therapist. At the current time, physical therapists are not considered members of the core hospice team under Medicare, the payment source for 84% of patients receiving hospice services in the United States in 2012.8
Moreover, a 2008 provision (418.72) of the Medicare Regulations and Conditions of Participation for Hospice Care requires that physical therapy services be made available and provided by an appropriate licensed personnel.9 These guidelines do not provide clear indications for referrals for physical therapist assessment, and recent evidence suggests that such referrals are dependent on nurses and their understanding of the physical therapist’s role.10 Accordingly, there is significant variability among the practice arrangements by which hospice and palliative care agencies secure physical therapist services. These include contractual agreements with physical therapists where patients are referred as ‘‘as-needed’’ basis, referrals to physical therapists practicing in home health agencies that occasionally receive hospice consults, and clinical practice in hospitals with hospice units. A study exploring physical therapy utilization in hospice and palliative care
1
Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ, USA 2 Department of physical therapy and athletic training, Hospice of the Valley, Phoenix, AZ, USA Corresponding Author: Karen Mueller, PT, DPT, PhD, Department of Physical Therapy, Northern Arizona University, Flagstaff, AZ 86001, USA. Email: [email protected]
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2 facilities in the state of Michigan found that less than 5% of patients received physical therapy services in these settings.11 No data exist to determine the number of hospice agencies with full-time physical therapists on staff; however, anecdotal evidence suggests that there are few. Research exploring the impact of functional training in hospice and palliative care settings may thus be limited by the absence of consistent physical therapist involvement as a member of the hospice interdisciplinary team, along with barriers related to the lack of interdisciplinary awareness and training. However, given that 44.8% of US deaths occurred in hospice settings in 2012,8 continued research with patients at end of life is essential to optimize care for this growing population. In 2011, the Medical Director (author GH) of Hospice of the Valley (HOV), located in Phoenix, Arizona, contracted with a hospice physical therapist/educator (author KM) to explore the impact of functional assessment as part of a quality improvement measure for the organization. HOV was established in 1977, and it is one of the largest nonprofit hospices in the United States. The organization employs over 2000 staff members and 2500 volunteers who provide services to 18 000 patients per year. Hospice services are most often provided in patients’ homes. Patients may also be admitted to 1 of 16 inpatient palliative care units (PCUs) throughout the Phoenix area for short-term symptom management related to their hospice diagnosis. Each PCU has both a physician and a nursing director. The organization is staffed with a research department and has its own institutional review board.12 Nursing assistants are integral to patient care in all health care settings and are considered essential members of the hospice and palliative care team.13 Working under the supervision of either a registered nurse (RN) or a licensed practical/vocational nurse (LP/VN), nursing assistants interact closely with patients, providing direct personal care such as bathing, hygiene, dressing and toileting.13 Completion of a state-approved training program (typically around 120 hours) and a posteducational certification examination is required for nursing assistants who seek employment in any Medicare- or Medicaid-certified health care facility.14 In addition to practical skills involving patient care, nursing assistants are trained in several measurement skills including heart rate, blood pressure, and fluid intake. It is estimated that nursing assistants provide up to 90% of hands-on patient care in all settings in which they work.15 Because of the ongoing and intimate nature of their patient interactions, nursing assistants working in hospice and palliative care settings are often the first providers to observe the spiritual, psychosocial, and emotional issues that arise among patients facing end of life, yet their invaluable contributions are often unappreciated.13 Thus, in order to foster greater recognition of the critical role of nursing assistants in hospice and palliative care settings, educational initiatives have recently been developed to empower their involvement in the care of persons facing end of life. In 2002, the Hospice and Palliative Nurses Association established a process by which nursing assistants with 2000 hours of hospice and palliative care experience can acquire advanced recognition as a Certified Hospice and Palliative Nurse Assistant.13
The purpose of the current study was 2-fold; first, to explore the feasibility of training nursing assistants to conduct functional assessments and intervention with patients receiving inpatient palliative care services in the HOV network and second, to determine the impact of functional assessment and intervention on patient outcomes. This study was approved by the HOV Institutional Review Board on July 20, 2011.
Research Method Outcome Measures Given the frailty of the patients receiving services in the HOV network, it was imperative to select functional activities that were both meaningful and practical. Four specific activities were identified: (1) performing a supine ‘‘bridge’’ in bed (ie, extending hips and lower trunk off the support surface with knees flexed and feet on the support surface); Bridging was selected due to its utility in using a bed pan, self-positioning in bed, and lower body dressing; (2) moving from side-lying to sitting with legs over the edge of a bed; (3) moving to standing from sitting; and (4) walking a short distance (with or without an assistive device). Two objective outcome measures, the Timed Up and Go (TUG)16-20 and Modified Iowa Levels of Assistance Scale (MILAS)21-23, were used to assess these activities. In addition, patients’ subjective activity preferences and perceived levels of difficulty were assessed with the PatientSpecific Functional Scale (PSFS).24,25
Timed Up and Go The TUG measures the time a patient takes to assume standing from a seated position, walk 3 m at their safest optimal speed, and turn around and walk back to return to sitting. The TUG was developed for community-dwelling frail elderly adults aged between 60 and 90 years of age and has also been widely used for adults with mobility and cognitive deficits. In 1 study, the 10th to 90th percentiles for TUG performance were 6.0 to 11.2 seconds for community-dwelling women aged between 65 and 85 years.19 A score of 14 seconds or more is generally considered the cutoff for fall risk, and a score of 30 seconds or more is predictive of requiring an assistive device for ambulation and being dependent in activities of daily living (ADLs).19 The TUG has excellent interrater (intraclass correlation coefficient [ICC] ¼ 0.99) and intrarater reliability (ICC ¼ 0.99). The test score also correlates well with gait speed (r ¼ .55), scores on the Berg Balance Scale (r ¼ .72), and the Barthel Index (r ¼ .51).20
The Modified Iowa Levels of Assistance Scale The MILAS was developed to assess the function of patients with postoperative total hip replacement in the acute hospital setting.21,23 The assessment is comprised of 5 activities considered essential for safe discharge and optimal independent mobility in the home. These activities include moving from
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supine (via side-lying) to sitting at the edge of a bed, moving from sitting at the edge of a bed to supine, moving from sit to stand from a bed, walking 4 to 6 m, and ascending/descending 10 steps. For the purposes of this study, 2 activities (moving from supine to sitting in bed and moving from sit to stand in bed) were assessed. Each activity is graded on an ordinal scale from 0 to 6 for the level of assistance required. The MILAS rating scale provides clear operational definitions of each of the levels of assistance and has demonstrated high interrater reliability (K ¼ .79-.90).21-23
The Patient-Specific Functional Scale The PSFS24,25 is a generic outcome measure that quantifies functional limitations resulting from any illness or injury. The PSFS consists of an introductory statement that is read by the physical therapist or other health practitioners. Patients are then asked to identify up to 5 functional activities with which they are having difficulty performing (or are unable to perform) because of their medical problem. Each activity is then rated on a 10-point ordinal scale (from 0 being ‘‘unable to perform’’ to 10 being ‘‘able to perform with no difficulty’’). A total score is calculated by dividing the sum of the activity scores by the number of activities identified. A minimal detectable change (at a 90% confidence interval) is either a 2-point change in the total score or a 3-point change in a single activity score. The PSFS has demonstrated excellent test–retest reliability and sensitivity to change with an intraclass correlation coefficient of R ¼ .84 and a Pearson r ¼ .78, respectively.
Study Site and Patient Selection Participants were drawn from the population of consecutive patient admissions to 4 of 16 of the inpatient PCUs in the HOV network between October 1, 2011, and April 1, 2012. These 4 PCUs were initially identified as a representative sample by the HOV Medical Director (author GH) in consultation with the Director of Inpatient Services. The medical and nursing directors of each PCU were then contacted about their willingness to serve as a study site for the project and each consented to do so. All noncomatose participants over the age of 21 with an expected survival of 1 week (as determined by the medical staff of each PCU) were invited to participate. These inclusion criteria were intended to be as broad as possible while also providing sufficient time for both admission and discharge assessments. Written informed consent was obtained from each participant.
Training of Nursing Assistants The nurse investigator (author BR) invited 1 experienced nursing assistant from each of the 4 palliative units to undergo functional skills training for the study. Each of the 4 agreed to participate. The physical therapist investigator (author KM) provided a 1-hour training session to each nursing assistant
in the administration of TUG, MILAS, and PSFS. The nursing assistants were also instructed in the 4 basic functional interventions to be provided to the intervention group participants. These included (1) bridging from supine in bed, (2) assuming sitting from supine (via side-lying) in bed, (3) moving from sitting to standing, and (4) ambulation with physical support and/or an assistive device. In the course of the training, the 4 nursing assistants demonstrated the ability to administer each test and intervention effectively. The nursing assistants were instructed to use a gait belt for all upright activities. In addition, the nurse investigator (author BR) trained the nursing assistants in the process of acquiring informed consent from participants who met the inclusion criteria (as determined by the medical staff of each PCU). These personnel provided pre- and posttest functional skills assessment to patients in the 4 palliative care units utilized in the study. In addition, they provided the interventions twice each day and documented patient follow-up through the patient’s Medical Administration Record (MAR).
Experimental Design Two PCUs served as experimental sites. Each new admission was screened by the PCU Medical Director for likely survival beyond 1 week. Participants in these PCUs received a ‘‘pretest’’ functional assessment within 48 hours of admission and a ‘‘posttest’’ assessment within 72 hours of discharge. Immediately following the pretest assessment, the functional outcome scores and patient goals (from the PSFS) were conveyed electronically to the physical therapist consultant (author KM). The physical therapist then identified the appropriate functional interventions for each patient based on assessment results and returned these electronically to the PCU on the same day. The recommended interventions were placed in each patient’s MAR. The trained nursing assistants provided twice-daily opportunities for each of the patients to complete these activities and documented the results in the patients’ MAR. The 2 remaining PCUs served as control sites and were also screened by the Medical Director for expected survival beyond 1 week. Participants in these PCUs underwent ‘‘pretest’’ and ‘‘posttest’’ functional assessments in the manner described earlier. No interventions were provided to participants in these 2 PCUs who received the ‘‘usual standard of comfort care’’ (ie, patients initiated their own activities as desired with support as needed).
Statistical Analysis Demographic and numeric data were compiled electronically using a Windows Excel file. All analyses were conducted with SPSS version 19.0 (SPSS Inc, Chicago, Illinois). Frequencies and descriptive statistics were used to describe participant demographic characteristics and values on the 3 main outcomes (TUG, MILAS, and PSFS). To compare participants in the intervention and control groups at baseline, independent samples’ t tests and chi-square analyses were used. Paired samples’
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4 t tests (for within-group changes) and 1-way repeated measures’ Analyses of Variance (between groups) were conducted to compare changes from pretest to posttest of all major outcome variables. The a priori significance level was set at 0.05.
Results There were a total of 494 admissions to the 4 PCUs during the 6-month duration of the study (Intervention site 1 ¼ 102, Intervention site 2 ¼ 106, Control site 1 ¼ 143 and Control site 2 ¼ 143). Of these, 64 patients met the initial inclusion criteria. Among these, 4 refused consent, 3 consented but were too ill to complete the initial assessment, and 7 died before the initial assessment. The remaining 50 participants underwent initial screening; however, 10 were too ill to complete the posttest, and 7 were discharged before the posttest assessment could be completed. Thirty-three participants (18 in the intervention group and 15 in the control group) completed the study.
Demographics There were 14 females and 4 males (n ¼ 18) in the 2 experimental PCUs. In all, 9 women and 6 men (n ¼ 15) comprised the 2 control PCU participants. The average age of participants in the experimental and control groups was 82.5 years (range, 59-104 years) and 74.2 years (range, 31-92 years), respectively. There was no significant difference with respect to age between the 2 groups (P ¼ .173) The average time between pre- and posttest for the participants was 4.67 days in the intervention group and 6.33 days in the control group (range, 1-14 days; P ¼ .122). The hospice diagnoses of the 2 groups were similar. In both groups, cancer, congestive heart failure, and debility were the top 3 respective diagnoses. Other diagnoses included chronic obstructive pulmonary disease, neurodegenerative disease, AIDS, and dementia. Table 1 illustrates the hospice diagnoses of the patients in both groups.
Outcomes Patient Interventions The physical therapist investigator prescribed a minimum of 2 and a maximum of 3 functional activities to each of the intervention group participants based on the results of their admission assessment. Ambulation (with or without an assistive device) was the most common recommendation, prescribed for 16 (88.8%) of the 18 participants who were ambulatory at admission. Sit to stand was the next most utilized intervention and was recommended for 5 (27%) participants. Three (16%) participants received recommendations for bridging and assuming sitting from supine in bed. Patient adherence to the interventions was documented by the nursing assistants in the MAR. In the course of the 4.67day admission to discharge interval for the intervention group, each participant underwent at least 1 intervention session, and
Table 1. Hospice Diagnoses of Patients. Diagnosis Cancer Congestive heart failure Debility COPD Neurodegenerative AIDS Dementia
Intervention group (n ¼ 18)
Control group (n ¼ 15)
5 4 4 3 1 0 1
5 5 3 0 1 1 0
the overall average was 4.5 sessions (range, 1-23 sessions). There was only 1 documented refusal among intervention group participants.
Timed up and Go The initial TUG assessment participants in the intervention group demonstrated a significantly lower level of function compared to those in the control group (mean intervention pretest TUG ¼ 69.96 seconds; mean control pretest TUG ¼ 24.10 seconds, and P ¼ .02). At discharge, the 2 groups were no longer significantly different from each other (P ¼ .186). For within group change, the intervention group demonstrated a significant improvement in their TUG scores (P ¼ .046), represented by a mean decrease of 16.88 seconds from baseline to discharge. The control group participants also improved slightly, demonstrating a 4.6-second decrease between preandpost-TUG scores (P ¼ .186). In terms of change from baseline to discharge, the intervention group did not improve significantly more than the control group (P ¼ .177). Table 2 illustrates the admission, discharge, and change in TUG scores of the participants in both groups.
Modified Iowa Level of Assistance Scale The 2 functions of supine-to-sit and sit-to-stand were assessed using the 0 to 6 MILAS scoring rubric. A score of 0 pertains to complete independence without assistive devices, a score of 5 pertains to ‘‘failure to complete activity even with maximal assistance,’’ and a score of 6 corresponds to ‘‘not tested due to medical reasons or reasons of safety.’’ Both groups showed similar improvement in the supine-to-sit test, with the improvement being significant in the control group (P ¼ .032) and marginally significant among the intervention group (P ¼ .069). There were no significant differences between the 2 groups at baseline, discharge, or in terms of change from baseline to discharge. Table 3 illustrates the MILAS scores for supine to sit and sit to stand in the intervention and control groups.
The Patient-Specific Functional Scale Twenty-one (63%) participants in both groups identified walking as their most important activity. Ten (30%) participants in both groups identified the improvement in strength and endurance for sitting and transfers as their most important
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Table 2. Changes in Timed Up and Go (TUG) Following a Functional Intervention Among Hospice and Palliative Care Patients. Intervention group (n ¼ 18) TUG (seconds) BL Follow-up Change
P value withina
Control group (n ¼ 15)
P value within
P value betweenb
.046c
24.10 (14.19) 19.46 (12.49) 4.64
.186
.177
69.96 (64.83) 53.08 (53.59) 16.88
a
P values for within-group differences are based on paired samples’ t tests. P values for between-group differences are based on repeated measures’ analysis of variance (ANOVA). c P < .05. b
Table 3. Changes in MILAS Scores Following a Functional Intervention Among Hospice and Palliative Care Patients. Intervention group (n ¼ 18) P value withina Control group (n ¼ 15) P value within P value betweenb Supine to Sit Pre-test (mean, SD) Follow-up Change Stand from sit pretest (mean, SD) Follow-up Change
1.24 (1.52) 0.59 (0.62) 0.65 1.15 (1.35) 0.69 (1.49) 0.46
.069
.139
0.92 (1.04) 0.23 (0.60) .69 1.25 (1.48) 0.75 (0.68) .5
.032c
.933
.15
.921
Abbreviations: MILAS, Modified Iowa Levels of Assistance Scale; SD, standard deviation. a P values for within-group differences are based on paired samples’ t tests. b P values for between-group differences are based on repeated measures’ analysis of variance (ANOVA). c P < .05.
Table 4. Changes in Patient-Specific Functional Scale Following a Functional Intervention Among Hospice and Palliative Care Patients. Intervention group (n ¼ 18) P value withina Control group (n ¼ 15) P value within P value betweenb Functional Scale pre-test (Mean, SD) Follow-up Change
3.89 (2.91) 5.83 (2.90) 1.94
.008c
4.92 (2.64) 6.00 (3.72) 1.08
.167
.392
a
P values for within-group differences are based on paired samples’ t tests. P values for between-group differences are based on repeated measures’ analysis of variance (ANOVA). c P < .01. b
functional skills. Two participants were unable to identify a specific goal. From baseline to discharge, the intervention group demonstrated a significant improvement in the PSFS (pretest ¼ 3.89, posttest ¼ 5.83, change ¼ 1.94, P ¼ .008). This change approximates a perceived change in level of difficulty from ‘‘moderate’’ to ‘‘mild.’’ The PSFS scores of the control group also changed slightly, also reflecting a perceived change in the level of difficulty from ‘‘moderate’’ to ‘‘mild’’; however, the improvement from baseline to discharge within the control group was not statistically significant (pretest ¼ 4.92, posttest ¼ 6.00, change ¼ 1.08, P ¼ .167). The difference in change from pretest to posttest was not significantly different between the 2 groups (P ¼ .392). Table 4 illustrates the PSFS scores at admission and discharge for participants in both the groups.
Discussion This study demonstrates that patients in a hospice setting can achieve meaningful functional improvements as a result of
assessment and intervention by trained nursing assistants. Participants in the intervention group made significant improvements in their TUG scores as a result of an average of 4 daily practice sessions delivered by nursing assistants. This finding is of particular interest, given that the TUG scores of the intervention group were significantly worse than those of the control group at admission. In contrast to the other skills assessed in this study (bed mobility and sit to stand), walking with patients who have balance deficits requires more caregiver time in terms of direct supervision and assistance. This skill may have improved more in the intervention group due to the daily practice sessions offered to these participants. In 1 case, a 104-year-old member of the participant group who was nonambulatory at admission was able to ambulate with a walker and minimal assistance after a 22-day admission. It is possible that this patient would not have achieved such an outcome in the absence of daily practice opportunities. Walking function was the most commonly identified functional goal for 63% of all study participants; thus, the improvement in this skill in the intervention group has significant
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6 implications for the quality of life of these patients. Accordingly, the improvement in walking skills may have contributed directly to the significant improvement in the PSFS scores among intervention group participants. From baseline to discharge, the study found significant improvements among the control group participants on assuming sitting from supine compared with the intervention group participants. Although this control group did not receive daily practice opportunities in this skill, it is a function that may be easier for a patient to practice independently or with family members once it is evaluated. The ability to assume sitting from supine is a complex muscular activity that involves the use of the neck and trunk flexors which rotate the upper body from supine into side lying, and the lateral trunk and neck flexors to move from side lying into an upright position. In addition, rising to sitting from involves the use of upper extremity musculature in order to assist the trunk from horizontal to vertical. Due to the antigravity muscle activity involved in this skill, evidence suggests that it is more difficult than the maintenance of sitting balance.26 Furthermore, a study of 327 patients with stroke demonstrated that those who were able to rise from supine to sitting at admission were 6 times more likely to achieve independent ambulation and 9 times more likely to have favorable functional outcomes than those who were unable.27 One unexpected finding in this study was the significantly slower admission TUG scores of participants in the intervention group compared to those in the control group. The lack of between-group functional homogeneity was a major limitation of this study and has been identified as a potential barrier to outcomes research in the hospice population.28-31 Interestingly, despite this difference, the intervention group made a significant increase in their discharge TUG performance and was no longer significantly different from the control group at discharge. This finding suggests that the functional interventions were important in helping the slower intervention group to catch up to the faster control group. Recent evidence has determined walking speed to be the ‘‘sixth vital sign,’’ which is predictive of health status, hospitalization, and mortality.32 Specifically, TUG scores of greater than 32.6 seconds have been identified as the cutoff for fall risk in the frail elderly population.33 Furthermore, TUG scores of greater than 30 seconds are associated with dependency in transfers. At the current time, there is no Minimal Clinically Important Difference for the TUG. The intervention group improved their TUG score by 16.88 seconds, which represents a 25% change from their 69.96-second baseline. Although intervention group participants remained at risk of falls upon discharge, it is possible that this risk was nevertheless reduced. Further studies are needed to correlate TUG scores with fall rates among debilitated elderly persons such as those receiving hospice services. In addition to walking 10 feet, the TUG measures the ability to assume standing from sitting, turn around, and return to sitting from standing, each of which are important functional measures of strength and balance. However, because these
activities are included in the overall TUG score, the exact walking speed cannot be determined. Nevertheless, the TUG was deliberately utilized in this study for its value in assessing sit to stand and turning as well as walking ability. In contrast, the 10-m walk test is a pure assessment of walking speed. Thus, future studies of walking speed in the hospice population should involve use of this measure. Another unexpected study finding was that 73% of control group participants improved their TUG performance, even in the absence of opportunities for practice. The initial TUG assessment indicated that all but 3 participants in both groups were considered at high risk for falls (>14 seconds), and 15 participants were likely to be dependent with ADLs and in need of assistive devices (TUG > 30 seconds). At discharge, 7 of the 15 participants in both groups who were likely dependent with ADLs (TUG.30 seconds) improved to the point where they no longer fell into this category at posttest. These results suggest that assessment of standing and walking ability at hospice admission may have been, in itself, a motivating factor to patients who were already capable of this activity. The study findings showed that improvements were found in a short period of time (the average time between pre- and posttest was approximately 5 days). Participants in the intervention group were offered twice-daily opportunities for practice of functional skills and underwent an average of 4.5 sessions. Interestingly, there was only once documented refusal among participants in the intervention group, suggesting a high level of motivation. These findings illustrate the potential for significant functional improvement in patients with considerable debility who are motivated to exercise. Initiatives recognizing the contributions of nursing assistants in the hospice setting are of considerable importance given the frequency of their patient interaction. The nursing assistants in this study acknowledged gratitude for their participation and stated that they became more aware of the importance of encouraging functional activity when appropriate. The nursing assistants further noted that study participants were generally eager to engage in functional intervention training and that many increased their activity levels outside of scheduled treatment sessions. The nursing assistants also observed that increased functional activity improved the moods of study participants. Finally, 1 nursing assistant suggested that education on the value of functional activity should be included in the future orientation of all nursing assistants at HOV.
Limitations Although the results of this study are encouraging, they are limited by several factors reflecting the challenges of research with patients at end of life. These include a small sample size, wide variations among participant performance, and significant decline or death of participants before the discharge posttest. Both groups demonstrated large standard deviations in both pre- and posttest TUG scores; however, those of the intervention group were particularly large (64.83 and 53.59 seconds, respectively). Of the 14 intervention group participants who
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completed a pretest TUG, 9 had scores below 60 seconds (range, 20-43 seconds); however, 1 intervention participant had a pretest TUG score of 205 seconds and 4 had scores between 61 and 86 seconds. The inconsistency of these scores may have been due to variations in the extent of preadmission participant debility as well as the nature of their end-stage disease and related impairments. Although it may be advantageous to consider the hospice diagnosis when assigning patients to intervention or control groups, this may not be feasible, given the high mortality rate of this population as a whole. Finally, this study did not include a follow-up of study participants to assess the maintenance of improvements in the functional status after discharge. While postdischarge followup was not an initial consideration of this pilot project, future studies of this nature should include such assessment as a measure of value.
Conclusion This quality improvement pilot study was designed to assess the feasibility of training nursing assistants to deliver functional assessments and interventions to patients receiving hospice services, and the results suggest that such training was effective. Thus, in hospice settings without access to regular physical therapy services, nursing assistants can provide a valuable extension of such services with favorable patient results. The other purpose of this study was to assess the impact of daily intervention on improvement in patient functional outcomes. Given the considerable variability between the intervention and control groups, it was difficult to determine such an impact. Nonetheless, perhaps the most promising aspect of this study is that patients in both groups improved to some extent, leading to the possibility that functional assessment alone may have an encouraging impact on patients which fosters independent practice, particularly of essential skills such as assuming sitting from supine. Given the results of this study, future directions should include efforts to assure a level of functional homogeneity between intervention and control groups. In addition, use of the 10-m walk test will enable a clearer assessment of walking speed. Finally, larger groups of patients will assure significant power by which to determine clearer between group differences. Acknowledgment The authors would like to acknowledge Sarah Bird, Vice-President of Clinical Operations, Hospice of the Valley, Phoenix, AZ; Teresa Cooley, RN, Hospice of the Valley, Phoenix, AZ; Evelyn Mangan, CNA, Hospice of the Valley, Phoenix, AZ; Kacshya Wojnarowski, CNA, Hospice of the Valley, Phoenix, AZ; Karen Salvadore, LPN (was CNA at the time), Hospice of the Valley, Phoenix, AZ; and Scott Kolesar, RN (was CNA at the time), Hospice of the Valley, Phoenix, AZ.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by a grant from The Grayhawk Classic Residents’ Foundation at Vi at Grayhawk Scottsdale, AZ.
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