Swing Bed care is inpatient sub-acute rehabilitation performed at Critical Access Hospitals. Currently there is no standard system in use to measure functional outcomes for these patients. In 2013, we determined the need to be able to quantify our patients’ functional improvements from admission to discharge. After some research, we implemented the Barthel Index in order to quantify our patients’ functional improvements.
We chose to score each swing bed patient upon admission and discharge. The Barthel Index allowed us to look at 10 specific self-care activities of daily living. These included: Feeding • Bathing • Grooming • Dressing • Bowels • Bladder • Toilet Use • Transfers (bed to chair and back) • Mobility (on level surfaces) • Stairs
We collected data from June 2013 until December 2015. We divided our Swing bed diagnoses into three categories:
1. Orthopedic (common diagnoses: partial/total joint replacements, hip fractures, Open Reduction Internal Fixation, amputation and ankle fractures)
2. Neurological (common diagnoses: Cerebrovascular Accident and Upper Motor Neuron Disease)
3. Deconditioned (common diagnoses: congestive heart failure exacerbation, chronic obstructive pulmonary disease exacerbation, dementia, wound care, and cancer)
We implemented weekly Physical Therapy/Occupational Therapy re-evaluations, and assigned designated Physical therapist assistants to the unit, as well as trained our Physical Therapy staff in utilizing Standardized Functional Assessment tools, such as the Timed Up and Go, and Gait velocity.
Through this innovative program, our patients gained measurable improvements!
• Improved clinical outcomes, reduced cost to system by avoiding skilled nursing home placement: 18% increase for Orthopedic patients who returned to prior level of residence from 2014-2015
• Improved clinical outcomes and quality of care: 13% improvement in the Barthel Index from Admission to Discharge from 2014-2015 for all three categories
• Improved interdisciplinary teamwork: Using the Barthel Index provides a Multidisciplinary overlap of care with each Swing Bed patient
• Improved patient safety and potential decrease in re-admissions: Using the Barthel classification in family meetings assists to objectively quantify how much additional care will be required for the patient to return home to ensure the safest discharge plan
By implementing the Barthel Index at admission and discharge with our Swing Bed population, we had marked objective, quantifiable data with improvement in functional independence. This had a direct positive effect on safe discharges. With delegating certain domains of the Barthel Index to the specialized discipline, we created a stronger Multi-disciplinary approach to each of the Swing Bed patients. These functional domains are discussed at our weekly Interdisciplinary Care Plan meetings, which improved teamwork and patient outcomes. Utilizing the Barthel Classification system has significantly enhanced education of our family and patients to ensure a safe discharge, ideally, to their prior level of residence. This system significantly decreases patient harm with ensuring enough care will be provided when returning home.
In 2016, we presented the Swing Bed Improvement project as a statewide initiative to other New York Critical Access hospitals. Out of 18 of them, 8 agreed to use this Barthel Index tool and administer it on Swing Bed admission and discharge. We were able to benchmark and collect data with the 8 who participated over the past year. We have received many accolades for implementing this tool and improving patient outcomes. It is our goal to implement it nationwide.
And the patient impact: more patients are discharged to their prior level of residence, we have improved clinical quality and decreased the need for skilled nursing facility care.
In 2016, we had an 80.2% return to home rate overall. In the sub-category of Orthopedic patients, we had a 89.3% return to home rate.
One example of the difference we are making is the story of John P. John P. was an LVAD patient at Ellenville Regional Hospital and went through the Swing Bed program. He shared with us that in all his life, our hospital is the best he has been to. He was treated exceptionally well, the food was delicious and if he didn’t like something, the nurse would get him something else. Treatment and service by the nurses was also at a very high level; they were always there for him. He also raves about the therapy work. Even after discharge, when he runs into those that gave him therapy here, he shares with them how they are the best and what a great experience it was. Before his surgery, he would just lie in bed from a weak heart and other healthcare professionals didn’t think he would make it. But then he came to Ellenville Regional Hospital, and our treatment speaks for itself. He was released July 28th, 2017, and let us know that while he uses a walker, he feels like he could get up and run. He learned a great exercise program while at Ellenville Regional hospital, and he is improving each day with his exercises at home.
What's next for our Swing Bed Program?
We are also improving the outcomes for our inpatients through our Swing Bed Outcomes Improvement Project, which has been developed to be able to quantify our Sub-Acute Rehab (Swing Bed) patient’s functional outcomes from admission to discharge. A measurement tool was created utilizing the Barthel Index of Activities of Daily Living. This project involved multiple disciplines: Nursing, Physical Therapy & Occupational Therapy. The goals of the project are to improve the functional independence of swing bed patients; maximize the monthly percentage of swing patients who return home or to their prior level of residence; improve the communication among the rehabilitation team and increase efficiency in working together, and to educate patients families and caregivers to ensure that a safe discharge is established. This project is now becoming a state-wide model, and is in the process of going national.
The Barthel Index helps our Swing Bed population. Won't you invest in us to continue such remarkable projects?