Kelly Tanner

Introduction: The global goal of pediatric rehabilitation services is to increase the ability of children to participate in meaningful life activities. Services that do not include a participation-centered goal are unlikely to achieve this impact. In this study, a participation component was operationally defined as a reference to a person or place outside the therapy context, regardless of the practice setting or discipline. The aim was to increase the use of participation-level goals among patients seen across all departments in the Division of Clinical Therapies from 50% to 80% by December 31, 2022, and sustain this level for 6 months. Methods: We implemented Plan-Do-Study-Act cycles in accordance with the Model for Improvement endorsed by the Institute for Healthcare Improvement. We tailored interventions for 6 participating departments. Strategies included audit and feedback, targeted communication with teams, and the use of champions. Then, we sampled charts across departments. We analyzed data using a statistical process control chart with a baseline mean of 32.5% and a target of 80%. Results: The goal of 80% of charts containing a rehabilitation goal with a participation-level component was achieved after 24 months of interventions, reaching a new centerline of 82% and sustaining this level for 6 months. Conclusions: We implemented patient goals with a participation component across multiple rehabilitation departments within a large division of a major pediatric hospital, using quality improvement methodology. Departments benefited from general strategies (eg, reminders) and tailored interventions (eg, targeted communication) to achieve and maintain 80% compliance.

Importance: Clinicians and researchers can leverage clinical documentation of therapy services for quality improvement and research purposes. However, documentation is often institution specific and may not adequately capture the dose of therapy delivered, thus limiting collaboration. Objective: To implement documentation of pediatric occupational and physical therapy dose from one institution to another institution. Dose documentation includes the frequency, intensity, time, and type of interventions delivered (FITT Epic® Flowsheet) at each session. Design: Prospective time-series quality improvement study. Setting: Two large urban pediatric hospitals. Participants: Occupational and physical therapy staff members. Intervention: Staff training and feedback loops utilizing existing groups. Outcomes and Measures: The process measure (number of available staff trained and using the FITT Epic Flowsheet over time) and the outcome measure (percentage of FITT Epic Flowsheets used for treatment visits each month) were analyzed using a statistical process control chart. The balancing measure (percentage of notes closed before 7 p.m. on the same day as the encounter) was analyzed using mean per month across three time periods. Results: Fifty-seven staff members (68%) attended formal training. On average, clinicians documented 90% of sessions using the FITT Epic Flowsheet after implementation. There was no change observed in the balancing measure. Conclusions and Relevance: Documentation of dose was spread from one institution to another. Shared documentation will facilitate future collaboration for quality improvement and research purposes. Occupational therapy practitioners and leaders should consider implementing documentation with common dose elements. Plain-Language Summary: Occupational therapy documentation is often institution specific and may not adequately capture the dose of therapy (frequency, intensity, time) or types of interventions that were delivered, thus limiting opportunities for collaboration between institutions. This article adds to the literature on administrative supports for clinical and quality improvement research by illustrating a specific example of how documentation of dose can be shared from one institution to another. The data show that clinicians at one institution started using a new style of documentation using the FITT Epic® Flowsheet and shared discrete dose elements with another institution, creating new opportunities for collaboration. Shared documentation can facilitate future collaboration for quality improvement and research purposes.

Importance: Parent coaching (PC) is a best practice for young children with, or at high risk for, cerebral palsy (CP). Occupational therapy practitioners in outpatient settings encounter barriers to implementing PC. Objective: To increase the documented use of PC in outpatient occupational therapy visits for children younger than age 2 yr with, or at high risk for, CP from 0% to 80%. Design: Multicenter quality improvement (QI) initiative with a time-series design. Setting: Three pediatric tertiary-care institutions, each with multiple outpatient occupational therapy clinics. Participants: Practitioners in the outpatient clinics and patients <2 yr old with, or at high risk for, cerebral palsy. Intervention: Plan–do–study–act cycles included interventions packaged as a toolkit: education sessions, quick references, electronic medical record (EMR) supports, and site-specific strategies. Outcomes and Measures: The primary outcome measure was the use of PC in outpatient sessions. Process measures included pre- and posteducation practitioner knowledge scores and an EMR checklist. Balancing measures (ensuring that changes do not cause problems in other areas) of parent satisfaction/experience and practitioner productivity were measured pre- and postintervention. Results: The primary outcome measure goal (80% documented use of PC in sessions) was attained in the seventh month of the study, sustained for 4 mo, and settled at 79.1% for the remaining 6 mo. Practitioner knowledge scores increased from 83.1% to 87.9% after initial education sessions, t[56] = 3.289, p = .001. Parent satisfaction/experience and practitioner productivity scores did not change. Conclusions and Relevance: QI methodology can support PC implementation in pediatric outpatient practice. What This Article Adds: This multisite QI initiative shows that outpatient occupational therapy practitioners can implement PC as a best practice with the use of a toolkit. Results suggest that education alone does not result in changes to practitioner behavior and that QI methods can help when implementing best practices in a clinical setting.

The COVID-19 pandemic necessitated rapid adoption of telehealth for outpatient pediatric occupational therapy practice. The dose of therapy may have varied across diagnostic and geographical groups despite efforts to ensure access for all patients. The objective of the study was to describe the visit length of outpatient pediatric occupational therapy practice for three diagnostic groups at one institution both during and prior to the COVID-19 pandemic. Retrospective review of electronic health records for two time periods using both practitioner-entered and telecommunications data. Data were analyzed using descriptive statistics and generalized linear mixed model. Prior to the pandemic, average treatment length did not vary by primary diagnosis. During the pandemic, average visit length varied by primary diagnosis, with feeding disorder (FD) visits significantly shorter than cerebral palsy (CP) and autism spectrum disorder (ASD) visits. During the pandemic, visit length was associated with rurality for the whole sample and for patients with ASD and CP, but not FD. Patients with FD may have been seen for shorter durations during telehealth visits. The technology gap may affect services for patients living in rural communities.

Objective: Telerehabilitation has long been recognized as a promising means of providing pediatric services; however, significant barriers such as cost, payor reimbursement, and access prevented widespread use. The advent of the COVID-19 pandemic necessitated rapid adoption of telerehabilitation into clinical practice to provide access to care while maintaining social distancing. The purpose of this study is to present clinical data on the feasibility and acceptability of speech-language pathology, developmental occupational and physical therapies, and sports and orthopedic therapies telerehabilitation delivered in a pediatric hospital setting. Methods: Telerehabilitation services were rapidly implemented in three stages: building the foundation, implementing, and refining this service delivery model. Paper patient satisfaction surveys were administered as part of ongoing quality improvement efforts throughout 2019 and were adapted for online administration in 2020 for telerehabilitation patients. Outpatient visit counts by type (in-person, phone, and video) were extracted from the electronic medical record using data warehousing techniques. Results: Historical patient satisfaction rates from 2019 indicated high patient satisfaction (98.97% positive responses); these results were maintained for telerehabilitation visits (97.73%), indicating that families found telerehabilitation services acceptable. Patient volume returned to 73.5% of pre-pandemic volume after the implementation of telerehabilitation services. Conclusions: Pediatric telerehabilitation is feasible to provide in clinical settings, and the services are acceptable to patient families. Future work is needed to evaluate the impact of telerehabilitation services on patient care and applications for ongoing use of this delivery model.

Importance: Occupational therapy practitioners need updated information about which interventions may improve motor skills for young children. Objective: To identify the effectiveness of occupational therapy interventions to promote motor development and prevent delay for children ages 0–5 yr. Data Sources: Six databases (CINAHL, MEDLINE, PsycINFO, ERIC, Cochrane, and OTseeker) were searched for articles published from January 2010 to March 2017. Study Selection and Data Collection: The search yielded 4,488 articles that were reviewed for inclusion. Fifty-six studies were entered into both evidence and risk-of-bias tables. Included studies used Level I–III designs, were within occupational therapy’s scope of practice, included participants with a mean age younger than 6 yr, and addressed motor skills. Findings: Three intervention themes emerged: early intervention for children younger than age 3 yr, interventions for preschool children ages 3–5 yr, and interventions for children with or at risk for cerebral palsy. Conclusions and Relevance: Occupational therapy practitioners should consider use of interventions with moderate or strong evidence as described in this review. Limitations include high risk of bias and limited evidence for several interventions. What This Article Adds: This article provides occupational therapy practitioners with updated information on evidence-based practices for children age 5 and younger who have motor delays.

Treatment options are limited for children and adolescents with severe obesity. One alternative treatment is the protein-sparing modified fast (PSMF), a low-carbohydrate, high-protein diet that can result in substantial weight loss. The aim of the study is to evaluate the adherence and efficacy of a revised PSMF (rPSMF) for severe obesity in a pediatric tertiary care weight-management program. The rPSMF with 1200–1800 calories, 40–60 g of carbohydrate/day and 1.2–1.5 g protein/kg of ideal bodyweight was implemented over 12 months. Twenty-one participants enrolled in the study. Mean age 16.2 ± 1.4 years, females (76.2%) and mean weight at baseline was 119 ± 19.9 kg. Regardless of adherence to the rPSMF, the mean weight change at 1 month was −3.7 ± 3.5 kg, (range −13.5 kg to 0.9 kg); at 3 months was −5.5 ± 5.1 kg, (range −19.3 kg to 1.8 kg) and at 6 months was −4.7 ± 6.6 kg, (range −18.3 kg to 8.6 kg). At 12 months, the mean weight change was −1.3 ± 10.6 kg (range −17.7 kg to 14.8 kg). Parent and child-reported physical and psychosocial quality of life (HRQOL) improved. Despite limited adherence, the rPSMF diet resulted in clinically significant weight loss and improved HRQOL for children and adolescents with severe obesity.