Want to Predict Hospital Length of Stay?

If you want to accurately assess when a patient is ready for discharge following arthroplasty, you have a choice—the physical therapist’s scoring or the nurse’s scoring—of the same test! A new study from Rothman Orthopaedic Institute in Philadelphia compared postop progress scoring by nurses and physical therapists (PTs) and found that there is a difference.

Their study, “Activity Measure for Post-acute Care Mobility Scoring System: Comparison of Nursing and Physical Therapy Evaluation for Primary Hip and Knee Arthroplasty Patients,” was published in the September 13, 2022, edition of the Journal of the American Academy of Orthopaedic Surgeons.

The primary reason for the study, explained co-author Ryan Sutton M.D. was, “We are always looking for opportunities to improve postoperative efficiency at our institution.”

Dr. Sutton, an orthopedic resident at Rothman, explained that “The Activity Measure for Post-acute Care (AM-PAC) ‘6 click’ scoring system is a metric used by nursing staff and physical therapy staff at our institution to evaluate patient’s postoperative progress in regard to patient mobility and is a tool used to aid in discharge disposition decision making.”

“The scoring system has been validated for physical therapist use in the literature but has not been readily studied for use by nursing staff. We wanted to see if using nursing staff scores could potentially substitute for physical therapist scores and aid in predicting postoperative discharge disposition.”

According to the American Physical Therapy Association, the six domains include: bed mobility, sit to stand; stand to sit, supine to sit, seated transfers, ambulation, and ascending stairs.

The team reviewed all primary total joint arthroplasties (TJAs) at Rothman from 2019 to 2021, for a total of 1,119 patients. Each patient had postoperative Activity Measure for Post-acute Care evaluation performed by nursing and physical therapy within 24 hours of surgery. Inter-rater reliability between therapy and nursing scores was analyzed.

How different were nurse scores from PT scores, using the same test?

Agreement testing between PT and nursing scores was weak for all six AM-PAC components (Spearman correlation of 0.437). There was a clear difference in scoring, depending on who conducted the test.

However, nursing scores were typically conducted earlier than therapist scores (204.0 ± 249.9 minutes versus 523.5 ± 449.4 minutes.

“Agreement testing for nursing and therapist scores in the 24-hour postoperative period were weak,” said Dr. Sutton to OTW. “However, higher nursing and therapist scores were significant predictors of less than two-day hospitalization and home discharge disposition. As a result, nursing scores could help aid in the decision making but should not be used as a substitute for therapist scores at this time.”

“While we expected the scoring system to be a predictor of postoperative discharge disposition, we did not expect poor inter-rater reliability. This could reflect different times that the scores were being taken by staff in the postoperative period and unified training on use of the scoring system by both nursing and therapist staff.”