JHQ 305: Interventions to Reduce Inappropriate Physical Therapy Consultation in the Inpatient Setting: A Quality Improvement Initiative-JHQ 305 Article

JHQ 305 Article

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This quality improvement initiative addressed overuse of inpatient physical therapy (PT) consults at a 700-bed academic hospital, where 23.9% of PT consultations were deemed inappropriate based on an AM-PAC “6-Clicks” basic mobility score of 23–24 (scores indicating minimal/no functional impairment and little expected benefit from inpatient PT). Overutilization was considered costly and contributed to delays in care and discharge planning, potentially worsening hospital-associated disability for patients who truly needed rehabilitation services.<br /><br />Using a Six Sigma framework, an interdisciplinary team (nursing, PT, physicians, and informatics) analyzed April 2020–November 2021 data and conducted “Voice of the Customer” interviews plus workflow process mapping. Root causes included provider unfamiliarity with AM-PAC, limited provider assessment/visibility of patient mobility, and diffusion of responsibility when various team members suggested PT consults.<br /><br />Two interventions were implemented stepwise: (1) a revised electronic health record (EHR) PT consult order that displayed the nurse-entered AM-PAC score and provided clinical decision support advising discontinuation of PT orders when AM-PAC >22 and suggesting alternatives (e.g., nursing-assisted ambulation), supported by targeted education; and (2) a nursing role change allowing bedside nurses—who perform AM-PAC and assess function daily—to place PT consult orders (with provider cosign), first piloted on one unit then spread hospital-wide.<br /><br />The primary outcome was monthly percentage of inappropriate PT consults. Post-intervention, inappropriate consults dropped from 23.9% to sustained below 10%. Statistical process control and segmented regression showed the nursing ordering responsibility change produced a significant immediate reduction (p=0.0019), while the isolated EHR change did not show a significant effect during its brief two-month standalone period. Limitations included AM-PAC-based misclassification for non-mobility indications and difficulty separating the independent effects of the two interventions.

Keywords

inpatient physical therapy overuse

PT consult appropriateness

AM-PAC 6-Clicks basic mobility

electronic health record clinical decision support

Six Sigma quality improvement

nursing-led PT consult ordering

interdisciplinary workflow process mapping

hospital discharge delays

statistical process control segmented regression

academic hospital rehabilitation utilization