Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review

Abstract

Importance: Practitioners need to be familiar with, and involved in, managing quality-related adverse events in postacute care.

Objective: To determine interventions within the scope of occupational therapy that address preventable adverse events in adult postacute inpatient and home health settings.

Data Sources: Articles published from January 1995 through 2019 identified through searches of MEDLINE, PsycINFO, CINAHL, OTseeker, and Cochrane databases.

Study Selection and Data Collection: Articles were collected, evaluated, and analyzed by two independent reviewers. They were assessed and synthesized with a goal of informing clinical practice.

Findings: Twenty-four articles were included in the review. Of the 10 Centers for Medicare & Medicaid Services preventable adverse events, 6 were addressed: diabetes management (n = 2), dysphagia (n = 5), infection control (n = 1), pressure ulcers (n = 6), falls (n = 5), and discharge management (n = 5). There was strong strength of evidence that exercise programs should, when appropriate, be implemented in both inpatient and home health settings to decrease the risk of falls. There was moderate strength of evidence that practitioners could consider implementing a facility wide evidence-based pressure ulcer program; providing multidisciplinary rehabilitation and swallow strengthening exercises for dysphagia; implementing a multidisciplinary, multicomponent falls program; and using a manualized depression intervention in home health to decrease hospital readmission.

Conclusions and Relevance: The review highlights the importance of preventable adverse events and of occupational therapy practitioners acknowledging and managing these events to enhance health outcomes and to control health care costs.

What This Article Adds: Many interventions typically performed by occupational therapy practitioners address preventable adverse events. The review highlights the importance of practitioners being aware of this category of impairment or injury.

This review highlights the importance of preventable adverse events and the importance of occupational therapy practitioners acknowledging and managing these events to enhance health outcomes and control health care costs.

Adverse events have been defined as those that occur as a result of error or failure to apply an accepted strategy for prevention (Agency for Healthcare Research and Quality [AHRQ], 2019). Interventions that can address preventable adverse events include falls prevention, infection management, pressure injury prevention, feeding and swallowing, medication management, and self-management of existing conditions (e.g., diabetes), among others. These types of interventions can have a positive influence on prevention of Office of the Inspector General (OIG) and Centers for Medicare & Medicaid Services (CMS) preventable adverse events, both during active patient care and for continued safety postdischarge. The purpose of this systematic review was to evaluate the current evidence for occupational therapy interventions that address preventable adverse events in postacute rehabilitation inpatient and home health settings. The focus of this review is inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), long-term care hospitals (LTCHs), and home health (HH) settings because these settings have been evaluated for adverse events by CMS and the OIG (American Occupational Therapy Association [AOTA], 2020; U.S. Department of Health and Human Services [HHS], 2014, 2016, 2018).

Background

The escalating cost of health care makes it necessary to focus on effective and efficient care. Many reimbursement plans now include shared responsibility among patients, provider, and payers for quality and effective care (Rosenbaum, 2011). The Patient Protection and Affordable Care Act (ACA; Pub. L. 111-148) laid the foundation for fundamental changes in health care quality and practice. These changes include a strong push to maximize meaningful outcomes for patients and increase accountability among health care facilities to minimize, if not completely eliminate, preventable adverse events.

The ACA includes a provision that requires facilities to demonstrate effective, comprehensive, data-driven plans for quality assurance and improvement (CMS et al., n.d.). CMS has developed specific quality indicators for IRF, SNF, and HH postacute rehabilitation settings. Some of these adverse event quality indicators have been labeled never events, adverse events that should not happen and will not be reimbursed for (Austin & Pronovost, 2015). In 2006, CMS addressed the concept of never events and began reducing or eliminating payments for such events so that more resources can be directed toward their prevention rather than toward paying more for them when they occur. All health care providers should understand preventable adverse events, quality indicators, and the consequences of not managing adverse events and consistently address them in their practice.

As team members, occupational therapy practitioners play an important role in helping to avoid preventable adverse events. Many interventions provided by occupational therapy practitioners, individually or in an interprofessional manner, address the prevention or management of preventable adverse events as defined by the OIG for postacute settings.

The purpose of this review was to critically evaluate and synthesize the current literature related to interventions within the scope of occupational therapy that address preventable adverse events. The findings of this review provide critical information for practitioners to address both the health and quality of life of patients and reduce the exorbitant costs of the U.S. health care system.

Method

Study Design

The systematic review was conducted according to the Cochrane Collaboration methodology (Higgins et al., 2019) and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic reviews (Moher et al., 2009). The review addressed the question “What is the evidence for occupational therapy interventions addressing preventable adverse events (Office of Evaluation and Inspections [OEI] safety performance measures) in adult, postacute inpatient and home health settings?”

Search Strategy

Search terms were determined by the medical librarian with input from outside experts in occupational therapy clinical care and quality improvement (QI) and through expert feedback and review of the current available literature (Supplemental Table A.1, available in the Supplemental Appendix online with this article at https://research.aota.org/ajot). The medical librarian who developed the search strategy also conducted the search. Medical subject headings and text words were used and were adapted as needed for each database. Only quantitative studies were included. Databases searched were CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, OTseeker, and PsycINFO. Reference lists of included studies were also hand searched, resulting in the additional inclusion of the PubMed database.

Inclusion Criteria

Studies meeting the following criteria were included: peer reviewed; publication date from 1995 to 2019; English language; intervention study; IRF, SNF, LTCH, or HH setting; interventions within the scope of occupational therapy (defined as not requiring a different degree or licensure) that addressed preventable adverse events; controlled trials; and pre–post interventions.

Participants

Participants in the reviewed studies were adults (age ≥18 yr) with any diagnosis receiving care in an IRF, LTCH, SNF, or HH setting.

Interventions

Interventions were included if they were within the scope of occupation therapy services (i.e., did not require a different degree or license) in the specified postacute settings and addressed prevention or management of preventable adverse events as defined by the OIG for postacute settings: improper use of medication and the potential for delirium, hypoglycemia, or dehydration to occur; falls occurring as a result of medication; falls; pressure ulcers; venous thromboembolism; deep vein thrombosis; diabetes management (exacerbation of preexisting disease); feeding tube problems; aspiration pneumonia or infection; catheter-associated urinary tract infection (CAUTI); wound care; and discharge management.

Levels of Evidence

We included evidence at Levels 1b to 3b (OCEBM [Oxford Centre for Evidence-Based Medicine] Levels of Evidence Working Group, 2011) if the inclusion criteria were met. These levels of evidence are defined as follows:

Level 1b: well-designed, appropriately powered individual randomized controlled trial (RCT)

Level 2b: individual prospective cohort study; small, lower quality RCT (e.g., <30 participants per group or pilot or feasibility studies); ecological studies; and two-group, nonrandomized studies

Level 3b: individual retrospective case-control study; one-group, nonrandomized pre–post study; and cohort studies.

Exclusion Criteria

Articles were excluded if they were published before 1995 or after 2019; non–English language; dissertations, conference proceedings, descriptive research, systematic reviews, study protocols, editorials, blogs, or commentary papers; descriptive projects; outside the scope of occupational therapy (requiring additional degrees or licensure); or participants were not adults or were not in a postacute rehabilitation setting included in this review (IRF, SNF, HH, LTCH). Excluded settings included nursing home settings in which residents were clearly living at the facility (>100 days or resident care). These facilities were excluded because they have not had a full review by CMS and the OIG in terms of preventable adverse events and do not fall under Medicare Part A. We also excluded systematic reviews from this review because the existing reviews did not use the same inclusion and exclusion parameters as our review. We deconstructed the systematic reviews that emerged in our search, and each separate article was hand searched and reviewed for the specific inclusion criteria for the current review. Appropriate individual articles were then included in the full review.

Data Extraction

The medical librarian conducted the search and removed duplicates; two reviewers (the authors) independently screened titles, abstracts, or both on the basis of the inclusion criteria. Differences between reviewers were resolved by discussion and, if necessary, consultation with a third party (an AOTA Evidence-Based Practice team member) until consensus was reached. The full text of the remaining studies was then obtained. A PRISMA flowchart summarizing the number of articles included and excluded at each stage of the review is provided in Figure 1. A screening tool was developed for both reviewers to independently review the full text of the articles on the basis of the inclusion criteria and then discuss their decisions. As previously described, differences were resolved by discussion and, if necessary, consultation with a third party, and reasons for excluding studies were documented. The 24 articles included in the final review were divided between the two authors, who extracted the data from their assigned articles and entered them into an evidence table. They then exchanged the evidence tables for a second review, and edits were completed upon discussion and consensus. Table A.2 in the Supplemental Appendix provides complete information on the studies included in the final review.

Figure 1.

PRISMA flow diagram for study selection.

Quality of the Evidence and Risk of Bias

Quality ratings were assigned by the two authors independently and revised once consensus was reached (Supplemental Tables A.3 and A.4). Risk of bias was evaluated depending on the study design (controlled trial or not). For studies that included a control group (randomized or nonrandomized), the Cochrane tool was used (Higgins et al., 2016). For noncontrolled trials, a tool developed by the (National Heart, Lung, and Blood Institute (2014) was used.

Overall Strength of Evidence

A qualitative analysis of the data was conducted. Data extracted from the studies were analyzed and summarized to answer the stated review question. Results were divided into thematic groups and analyzed in terms of strength of evidence using a formula based on the number of studies, level of evidence, quality, risk of bias, and significance of the findings for each theme or subtheme (U.S. Preventive Services Task Force, 2018). The ultimate strength of the findings was evaluated in the following way:

Strong: Two or more Level 1 studies. The available evidence usually includes consistent results from well-designed, well-conducted studies. The findings are strong, and they are unlikely to be strongly called into question by the results of future studies.

Moderate: At least 1 Level 1 high-quality study or multiple moderate-quality studies (i.e., Level 2a, 2b, 3a, or 3b). The available evidence is sufficient to determine the effects on health outcomes, but confidence in the estimate is constrained by such factors as the number, size, or quality of individual studies or inconsistency of findings across individual studies. As more information (other research findings) becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion related to the usefulness of the intervention.

Low: Small number of low-level studies, flaws in the studies, and so forth. The available evidence is insufficient to assess effects on health and other outcomes of relevance to occupational therapy. More information may allow estimation of effects on health and other outcomes of relevance to occupational therapy.

Results

Search Results

After removal of duplicates, 3,976 articles remained for screening. After review for inclusion criteria, 24 studies remained (see Figure 1 and Table A.2). Of the 10 CMS indicators included in the search, 6 were addressed in studies included in this review. The final articles were grouped into six themes related to these quality indicators (Table 1).

Table 1.

Overview of Review Results

Theme	Level of Evidence			Risk of Bias	Country
Theme	1b	2b	3b	Risk of Bias	Country
Diabetes management	1	1	0	Low	United States
Dysphagia	1	4	0	Moderate to low	Korea, Japan, China
Infection control	0	0	1	Low	United States
Pressure ulcer	1	2	3	Low	United States, Canada, France, Italy
Falls	4	0	1	Low	Australia, New Zealand, United States
Discharge management	1	2	2	Moderate to low	United States
Total	8	9	7

Table 2.

Types of Outcomes

Event	Outcome
Diabetes	Foot care knowledge, self-efficacy, self-care practices, medication management
Swallow or dysphagia	Functional evaluation, penetration and aspiration, video fluoroscopic swallowing study, movement of hyoid bone and/or suprahyoid muscles, dysphagia complications, presence of a tube feeding, mood, QOL, water swallow test
Infection	Urinary catheter use, CAUTI rates, UTI rates
PU	Incidence of PU, days to ulceration, peak interface pressure, glycemic control, QOL, falls
Falls	Number of falls, number of fractures, number of fallers, mobility evaluation, depression, hospital admissions, need for medical attention postfall, fall preventive measures, physical restraints, cost of program implementation and hospital costs, balance
Discharge	Readmission rates, acute hospitalization, days to hospitalization, QOL, depression, self-report on ADL and IADL function, physician and emergency department usage, satisfaction with services, symptom knowledge

Note. ADL = activities of daily living; CAUTI = catheter-associated urinary tract infection; IADL = instrumental activities of daily living; PU = pressure ulcer; QOL = quality of life; UTI = urinary tract infection.

Study Characteristics

Settings

All four rehabilitation postacute care (PAC) settings were represented. The number of studies conducted in each setting were as follows: IRF, n = 9; SNF, n = 5; LTCH, n = 2; and HH, n = 8.

Characteristics of Interventions

To address the topic of quality indicators for PAC, studies that met the inclusion criteria focused on interventions targeting both the person and the facility. QI programs included a facility- or systemwide evaluation related to one of the quality indicators, followed by the development or implementation of an existing evidence-based practice intervention (all Level 3b). The interventions typically involved addressing systems change (e.g., electronic medical records [EMRs]), provider education, and single or multiple patient interventions (see Table A.2). Eighteen studies focused on the individual (patient) level, and 6 QI projects focused on the facility level (infection, n = 1; pressure ulcer, n = 3; falls, n = 1; and discharge and transition, n = 1).

Types of Outcomes

The studies included numerous outcomes. The most common and important were incidence rates. Many of the others were secondary outcomes of interest (Table 2).

Risk of Bias Within Studies and Quality of Evidence

Overall risk of bias for each article is reported in Table A.2. A full evaluation of risk of bias is reported for each article in Supplemental Tables A.3 and A.4. Of the 24 articles reviewed, 21 had low risk of bias, and 3 had moderate risk of bias.

Synthesis of Results by Theme

Education for the Management of Diabetes-Related Problems

Two studies, 1 Level 1b (Dalton, 2012) and 1 Level 2b (Corbett, 2003), provided information about interventions for managing diabetes for adults in the HH setting. Both articles had low risk of bias. Dalton (2012) conducted a three-group (two intervention groups, one control group) RCT. One intervention was a multidisciplinary diabetes management program that included a standardized method of instruction and teaching tools used by all health care providers who provided care to patients with diabetes. The second intervention was a program to develop practitioners’ skills in three areas: glycemic control, foot care, and medication management. The control group included standard nurse education (two diabetes modules) for new employees. No statistically significant changes in level of self-care were found among the 363 HH patients in the three groups. Corbett (2003) conducted a RCT with foot care interventions that included brief individualized education during routine HH services. The control group received standard care, with no tailored foot care information. No statistically significant improvements related to the intervention were found (level of risk, knowledge of care, current practices).

These studies provide low strength of evidence for the use of educational materials (handouts or individual education) for HH patients with diabetes to improve self-care behaviors (foot care and glycemic control) because the interventions resulted in no significant improvements. Increased education alone did not improve diabetes self-management in the HH setting.

Interventions to Reduce Dysphagia

Strengthening exercises.

Three Level 2b studies (small RCTs; Kang et al., 2012; Park et al., 2016, 2018) implemented a variety of exercises to increase strength and performance for patients with dysphagia in an IRF setting.

Kang et al. (2012) implemented conventional swallow therapy, with additional bedside exercise training consisting of oral, pharyngeal, laryngeal, and respiratory exercises for the intervention group. The intervention group had statistically significant better swallowing function in the oral phase, decreased depression, and increased QOL. However, they showed no significant change in the incidence of dysphagia complications or use of feeding tubes. Park et al. (2018) tested a 30-min occupational therapy–supervised chin tuck against resistance (CTAR) exercise performed 5 days/wk for 4 wk while seated in a chair. The intervention group had statistically significant better improvements than the control group in the oral cavity, laryngeal elevation and epiglottic closure, residue in valleculae, and residue in pyriform sinuses. Park et al. (2016) tested expiratory muscle strength training (EMST), which involved forcible blowing as a means of generating high expiratory pressure against adjustable resistance. Using an EMST device, participants performed EMST with a 70% threshold value of maximal expiratory pressure, 5 days/wk for 4 wk. The intervention group had statistically significant differences in measured suprahyoid muscle activity, liquid penetration, and functional oral intake results than the control group.

These studies provide moderate strength of evidence for the use of strengthening exercises to decrease problems with dysphagia in the IRF population.

Multidisciplinary rehabilitation.

One Level 1b (Zheng et al., 2014) study tested the use of holistic, multidisciplinary rehabilitation for people with dysphagia in the IRF setting.

Zheng et al. (2014) developed a multidisciplinary rehabilitation team to offer physical, social, and psychological support to patients with dysphagia. The intervention included neurological testing and imaging, communication with patients and families to ease anxiety and depression, eating and swallowing rehabilitation, and training of the nursing staff who implemented oral and nonoral feeding. The intervention group had statistically significant better outcomes than the control group, who received usual care, with improvement in swallowing and number of participants with complete recovery.

As a result of the significant findings from this single strong RCT, there is moderate strength of evidence for the use of multidisciplinary rehabilitation to address the physical, social, and psychological need of patients with dysphagia in an IRF.

Kinesio^® Taping.

One Level 2b study (small RCT; Heo & Kim, 2015) implemented a Kinesio Taping (KT) intervention to address dysphagia in people poststroke receiving inpatient rehabilitation.

KT was applied to the external laryngeal muscles (digastric posterior bellies, mylohyoid, and geniohyoid), the sternocleidomastoid, and the upper trapezius. Participants were assessed by means of videofluoroscopic study during taping. The intervention group had statistically significant better vertical excursion of the hyoid bone and rotation of the epiglottis than the control group. They showed no significant improvement in the horizontal movement of the hyoid bone.

Because of the limited amount of research (1 Level 2b study), there is low strength of evidence that KT significantly improves swallowing function for people with dysphagia in an IRF poststroke.

Intervention to Reduce Catheter-Acquired Urinary Tract Infection

One Level 3b, single-cohort, pre–post QI study (Zurmehly, 2018) tested a provider education intervention to reduce nonessential urinary catheters and CAUTIs.

The intervention was a preexisting evidence-based urinary catheter protocol (assessment of need for catheter, connecting with EMRs) implemented across three units of a large LTCH. Providers were oriented to the new protocol through online educational modules. After implementation of the intervention, statistically significant improvements were found in reduction of the number of catheter days and incidence of CAUTI .

Because only 1 Level 3b study was found, there is low strength of evidence for a provider educational intervention to reduce the use of urinary catheters and CAUTIs in a LTCH setting.

Interventions to Prevent Pressure Ulcers or Manage Wound Care

Type of mattress.

One Level 1b study (Sauvage et al., 2017) implemented an intervention to assess the type of mattress used with residents of a SNF confined to bed.

A RCT evaluated an alternating-pressure air mattress (intervention group) compared with a viscoelastic foam mattress (control group). The researchers found that the intervention group had a statistically significant lower number of pressure ulcers than the control group.

This study provides moderate strength of evidence for significant improvement related to the intervention.

Multicomponent programs.

Three Level 3b QI projects evaluated the implementation of evidence-based multicomponent pressure ulcer prevention programs.

Hartung and Fell (2019) implemented a QI program that included standardized positioning plans developed from bedside interdisciplinary assessments and a revised algorithm for mattress selection in a large SNF. They found a statistically significant reduction in the incidence of pressure ulcers.

Tippet (2009) reported on a QI program in an SNF. The facility implemented evidence-based AHRQ guidelines to reduce the incidence of pressure ulcers. Implementation methods included an interdisciplinary leadership team, intensive training, evidence-based protocols, evaluation of support surfaces and wound– skin products, and process simplification. There was a statistically significant reduction in the incidence of pressure ulcers after the program’s implementation. In addition, there was a savings to the facility of more than $124,000 per year.

Young et al. (2015) implemented an evidence-based QI program, the Medline Pressure Ulcer Prevention Program (Young et al., 2012), in one LTCH. The program included caregiver education, provider training, new skin care products, and a standardized treatment algorithm. There was a statistically significant reduction in the incidence of pressure ulcers.

These 3 Level 3b QI projects provide moderate strength of evidence supporting implementation of a multifactorial, facility-wide, evidence-based pressure ulcer reduction program in both LTCH and SNF settings.

Wheelchair seat cushion.

One Level 2b pilot RCT (Geyer et al., 2001) implemented a seating cushion intervention for older adults (age >65 yr) in a SNF who use a wheelchair.

The intervention group received a pressure-reducing cushion, and the control group used a more traditional foam cushion. No more detail was provided about the two types of cushions. No difference was found between the groups in terms of the overall incidence of pressure ulcers. However, the pressure-reducing cushion was statistically significantly more effective in specifically preventing sitting-acquired pressure ulcers than the foam cushion.

With only 1 Level 2b study, there is low strength of evidence for a pressure-reducing wheelchair cushion for older adults who use wheelchairs in a SNF setting.

Wound management.

One Level 2b nonrandomized two-group study (Hodgins et al., 2014) tested a multicomponent intervention to improve wound healing.

The intervention included the use of a software program loaded with wound care information that was suitable for handheld devices. In addition, the intervention incorporated a standardized assessment tool (Cardiff Wound Impact Schedule; Price & Harding, 2004), electronic data entry, written treatment recommendations, and a supporting rationale prepared by nurses with expertise in diabetes. The implementation resulted in significantly more patients in the intervention group no longer receiving HH because their wound healed.

This Level 2b non-RCT study provided low strength of evidence for wound management in the HH setting.

Interventions to Reduce Falls

Exercise interventions.

Two Level 1b studies tested exercise programs to reduce the number of falls.

Haines et al. (2007) provided exercise sessions 3×/wk for 45 min in addition to usual IRF care (control) for patients who were recommended for a falls prevention exercise program. The intervention group had a statistically significant lower incidence of falls than the control group. Robertson et al. (2001) conducted home-based individually tailored exercise programs (strength, balance, walking) for HH clients age 75 yr or older. The intervention also included five home visits and telephone calls to increase motivation and discuss problems. The program was to be done >3×/wk for 30 min/session and included walking 2×/wk for 1 yr. Participants in the exercise group had statistically significantly fewer falls than those in the control group, but only among those age >80 yr.

These 2 Level 1b studies provide strong strength of evidence that exercise programs can reduce falls, particularly among those at high risk of falls.

Multifactorial interventions.

One Level 1b (Haines et al., 2004) and 1 Level 3b QI program (Webb-Henderson et al., 2009) tested the use of multifactorial falls prevention interventions.

Haines et al. (2004) implemented a targeted, multiple-intervention falls prevention program. It included a falls risk alert card with an information brochure (nursing), exercise program (physical therapy), education program (occupational therapy), and hip protectors (all disciplines) in an IRF setting. Participants in the intervention group had statistically significant fewer falls than those in the control group. Webb-Henderson et al. (2009) conducted a QI program in a HH setting. A multidisciplinary team including occupational therapy developed a multifactorial falls prevention program, which included a 12-item falls risk assessment, intervention strategies (educational materials and environmental adaptation), process and resource education for staff, and an e-learning module for annual education requirements for staff. A statistically significant reduction in falls occurred after the program’s implementation.

These studies provide moderate strength of evidence for a multicomponent, multidisciplinary falls prevention program in both the IRF and the HH settings.

Education program.

One Level 1b RCT (Haines et al., 2006) implemented an education program to reduce falls among patients in an IRF setting.

The education program was provided to IRF patients who were recommended for the intervention because of fall risk. The program consisted of 1:1 educational sessions (risk screening, types of falls, mechanisms of falls, preventive ideas, goal setting) with an occupational therapist. The intervention group had a statistically significant lower incidence of falls than the control group.

There is moderate strength of evidence for a 1:1 occupational therapy educational program for IRF patients at risk of falls.

Interventions to Support Discharge and Transitions and Reduce Hospital Readmissions

Depression management.

One Level 1b study (Bruce et al., 2016) tested a depression intervention to reduce hospital admissions among HH clients.

The Depression CAREPATH (CARE for PATients at Home; Bruce et al., 2011) intervention guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. There was statistically significant less admission or readmission to a hospital among the intervention group participants than the control group participants.

There is moderate strength of evidence for managing depression using the CAREPATH program to reduce admission into a hospital for HH patients.

Patient education.

Three studies, 2 Level 2b small RCTs (Delaney & Apostolidis, 2010; Feldman et al., 2004) and 1 Level 3b one-group pre–post study (Mathew & Thukha, 2018), tested patient education interventions to reduce hospital readmission for patients with heart failure (HF).

Delaney and Apostolidis (2010) tested eight structured education visits in the HH setting. The intervention used evidence-based protocols designed in previous trials to teach HF self-management and to prevent or reduce depression, as well as a telemonitoring system. They found no significant reduction in readmissions. Feldman et al. (2004) provided an evidence-based nursing protocol, patient self-care guide, and training to improve nurses’ teaching and support skills in a HH setting. They found no significant reduction in the hospitalization rate. However, the intervention group had statistically significant less HH care utilization, physician visits, emergency department use, and mortality. Mathew and Thukha (2018) provided three sessions of tailored patient-centered HF education on readmissions (a managing heart health booklet, a HF patient education video, group sessions, teach-back method) in the IRF setting. Each session lasted for 15 to 20 min. HF-related knowledge and self-care skills showed statistically significant improvements, and only 1 patient (of 26) in the intervention group was rehospitalized.

Because of inconsistent findings in these studies, there is low strength of evidence for patient education on HF and hospital readmission.

Project ReEngineered Discharge.

One Level 3b QI project (Berkowitz et al., 2013) evaluated the facility-level implementation of an evidence-based discharge program, Project ReEngineered Discharge (RED), to support discharge and reduce hospital readmissions.

Project RED is an evidence-based program to enhance discharge and reduce hospital readmission (Jack et al., 2012). Berkowitz et al. (2013) evaluated the success of implementing the program in a SNF. The program consisted of a comprehensive approach to transitions of care that included creating and teaching a personalized care plan to patients and their families, adapting facility processes to be more supportive, and ensuring a seamless transition to clinicians accepting care of the patient. Software facilitating these activities was integrated into the patient’s EMR at the SNF. Implementation of the Project RED program resulted in a significantly lower number of hospital readmissions within 30 days of discharge from the SNF facility.

This 1 Level 3b study provides low strength of evidence for implementation of Project RED in the SNF setting.

Risk of Harm or Adverse Events

None of the studies included in this review reported adverse events or harms related to the interventions evaluated.

Discussion

This systematic review provides evidence for interventions within the scope of occupational therapy to reduce or manage preventable adverse events in inpatient or HH PAC settings. Of the 10 indicators that CMS evaluates related to Medicare beneficiaries’ care in these settings, this review provided evidence for 6: pressure ulcers, diabetes management, dysphagia, infection, falls, and supported discharge. Some of the data reviewed resulted in low strength of evidence, which indicates a low level of certainty that the intervention is doing what it is supposed to in a significant way. Interventions with low strength of evidence cannot be recommended as evidence-based practice in the clinical setting. Typically, the reason for the low strength of evidence in this review was the limited number of high-quality studies. As always, evidence is only one tool in clinical decision making; if the evidence is insufficient, then decisions must be made on the basis of clinical experience and clients’ needs.

In this review, one intervention, an exercise program, resulted in strong strength of evidence and should be used by practitioners when appropriate (Haines et al., 2007; Robertson et al., 2001). Exercise should be implemented at least 3×/wk for 30 to 40 min for adults (particularly older adults) at risk for falls, in both the inpatient and the HH setting. It should include resistance, balance, and aerobic exercise. Both of these large RCTs also provided additional support to increase motivation for exercise and to manage problems that arise.

Several interventions provided moderate strength of evidence, highlighting interventions that practitioners should consider providing when appropriate. One is the facilitywide use of evidence-based multicomponent pressure ulcer reduction programs (Hartung & Fell, 2019; Tippet, 2009; Young et al., 2015). Although the interventions were different, the recommendation is to pick one evidence-based intervention and to implement it at the facility level, not just the individual level. The facility-level interventions often included components for the providers, the patients, and the EMRs.

For dysphagia, practitioners should consider a few interventions, such as holistic multidisciplinary care (Zheng et al., 2014) and a variety of strengthening exercises for swallowing (Kang et al., 2012; Park et al., 2016, 2018). For falls, practitioners should consider the use of a multidisciplinary, multicomponent falls program (Haines et al., 2004; Webb-Henderson et al., 2009) and an occupational therapy education program for the IRF setting (Haines et al., 2006). Finally, the use of a manualized depression intervention for HH patients should be considered to reduce admissions to hospitals (Bruce et al., 2016).

Six of the included articles were QI projects. They were conducted in the areas of infection, pressure ulcers, falls, and discharge. QI is a formal, systematic approach to the analysis of practice performance and efforts to improve performance (HHS, 2011). QI projects typically entail a plan to implement an evidence-based intervention or process throughout a facility or health care system. The process is intensive and long term and involves many steps and phases with the goal of participation and buy-in by all people in the facility. Steps typically include ground-up evaluation and prioritization of areas for improvement. Once the priorities are developed, current data are collected and analyzed to understand whether a problem currently exists. If there is a problem (i.e., falls, pressure ulcers), the new program is implemented and usually includes education; adapting environments, EMRs, or both; and a revised process of care. Once implemented, data are again collected to evaluate whether the intervention is addressing the problem. QI involves an ongoing, iterative cycle of evaluation and revision as needed (HHS, 2011). Given the topic of this review, we included QI projects, and they provided important information. Numerous sources providing information on conducting QI projects exist (e.g., AHRQ, 2020; Institute for Healthcare Improvement, 2018). Understanding how to develop and conduct a QI project is a valuable skill for occupational therapy practitioners to learn to improve health outcomes and to take a leadership role in their facility.

Adverse events fall under the umbrella of patient safety. Occupational therapy practitioners should also keep in mind the strong foundation of research related to addressing patient safety (Aspden et al., 2009; Berwick & Leape, 1999; Emanuel et al., 2008). The aviation industry and other high-risk fields have a long history of addressing preventable errors, and their techniques have been adapted to the medical field (Berwick & Leape, 1999). First, and most important, there needs to be a culture of safety that limits blame and instead focuses on making changes (Emanuel et al., 2008). Facilities should also emphasize teamwork (Emanuel et al., 2008). Similar to the occupational therapy process, in the field of patient safety there is an opportunity to change the person or behavior or, potentially, the environment, thereby managing behavior and decrease errors (Emanuel et al., 2008). This means addressing organization-level factors, work environment, task factors, provider factors, and patient factors (Emanuel et al., 2008). Addressing patient safety and preventable adverse events is crucial in all health care settings, including PAC rehabilitation. Interventions may target patients individually, or they may target the facility, and occupational therapy practitioners should be involved in both types. Interventions such as falls evaluations for patients, timely reduction of urinary catheter use, and supported discharge activities are very well supported to reduce falls, CAUTIs, and readmissions (Leland et al., 2015, 2019; Stevens & Lee, 2018). All occupational therapy practitioners need to be aware of these issues and take part in managing them in PAC settings.

Strengths and Weaknesses of the Systematic Review

The review was conducted with a high level of rigor and considered a broad range of interventions related to preventing or managing adverse events in PAC that are important for health care providers and facility quality evaluations. However, we did include Level 2b and 3b studies, which may dilute the findings. There was a general lack of multiple studies using similar interventions, so many findings were from 1 study and cannot be used to guide clinical decision making. As always, there is the chance that the review may have missed pertinent studies, and there is also the possibility of publication bias, with only studies with positive findings being published.

Implications for Occupational Therapy Practice and Research

Preventing adverse events in inpatient and HH PAC is crucial for health outcomes and for managing health care costs. Occupational therapy can address many preventable adverse event quality indicators, and practitioners should be aware of and focused on these problems. This review found several facility-level interventions through QI programs. This approach to addressing preventable adverse events is important. Typically, the interventions to prevent these events will be multidisciplinary and may include facility-level changes (i.e., algorithms, care process change, EMRs, training). Occupational therapy practitioners should take part in developing these QI programs because their skill in person-centered care, evaluating tasks and activities, and developing consensus are helpful to the success of such projects. In terms of research, there needs to be more. Interestingly, all the studies addressing dysphagia came from Asia (predominantly Korea). There were none from the United States. Similarly, for falls, only 1 study came from the United States; the rest were from Australia and New Zealand. Additional studies in the PAC setting as a whole are needed, particularly studies focusing on adverse events. More occupational therapy–specific intervention studies are needed that encompass interventions that address these preventable adverse events. Study methodology should include RCTs, but more QI-type projects would also be useful.

Conclusion

This review provides a high-level summary of effective interventions to prevent adverse events in inpatient and HH PAC. The majority were of moderate or low strength of evidence because many interventions were addressed by only 1 study. However, the review highlights the importance of preventable adverse events and the importance of occupational therapy practitioners acknowledging and managing them to enhance health outcomes and help manage health care costs.

Supplemental Material

Supplemental Information

Supplementary material for Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review

Supplementary material, sj-docx-1-aot-10.5014_ajot.2022.047589.docx for Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review by Elizabeth G. Hunter and Elizabeth Rhodus in The American Journal of Occupational Therapy

Footnotes

*

Indicates articles included in the systematic review.

Acknowledgment

The American Occupational Therapy Association supported the development and completion of this review. The review authors declare no conflict of interest.

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Supplementary Material

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0.07 MB

Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review

Abstract

Background

Method

Study Design

Search Strategy

Inclusion Criteria

Participants

Interventions

Levels of Evidence

Exclusion Criteria

Data Extraction

Quality of the Evidence and Risk of Bias

Overall Strength of Evidence

Results

Search Results

Study Characteristics

Settings

Characteristics of Interventions

Types of Outcomes

Risk of Bias Within Studies and Quality of Evidence

Synthesis of Results by Theme

Education for the Management of Diabetes-Related Problems

Interventions to Reduce Dysphagia

Strengthening exercises.

Multidisciplinary rehabilitation.

Kinesio® Taping.

Intervention to Reduce Catheter-Acquired Urinary Tract Infection

Interventions to Prevent Pressure Ulcers or Manage Wound Care

Type of mattress.

Multicomponent programs.

Wheelchair seat cushion.

Wound management.

Interventions to Reduce Falls

Exercise interventions.

Multifactorial interventions.

Education program.

Interventions to Support Discharge and Transitions and Reduce Hospital Readmissions

Depression management.

Patient education.

Project ReEngineered Discharge.

Risk of Harm or Adverse Events

Discussion

Strengths and Weaknesses of the Systematic Review

Implications for Occupational Therapy Practice and Research

Conclusion

Supplemental Material

Supplementary material for Interventions Within the Scope of Occupational Therapy to Address Preventable Adverse Events in Inpatient and Home Health Postacute Care Settings: A Systematic Review

Footnotes

*

Acknowledgment

References

Supplementary Material

Kinesio^® Taping.