Do You Have Discharge Criteria?
Have you ever thought about or developed discharge criteria for your practice? You may think to yourself at this point, that this could be a waste of time or an exercise in futility. You may think, “Why would I need discharge criteria? I will just release the patient when the pain is gone.”
Well, what if:
1). the patient never fully is able to resolve pain
2). the patient is able to resolve pain but has poor function (ADL tolerance, sports & recreational activity tolerance, range of motion, balance, stability, etc.).
Do you recommend more treatment? Do you refer? Do you discharge? If you discharge do you risk a relapse? Have you done your due diligence to ensure an outstanding outcome?
In this day and age, there are some additional points to consider that could affect your practice. Are you inadvertently sabotaging your practice’s marketability (marketing via your outcomes) by not having specific discharge criteria? Do you incur additional liability by not having benchmarks for successful treatment, failure of trial of care, referral or discharge? Are you affecting your practice’s bottom line by prematurely discharging patients from care?
There is a real credible threat to your patient’s health in addition to your practice’s health. With rising premiums, deductibles, copayments and increased out of pocket expenses, I’ve seen more patients in the past several years than in years prior to self-discharge when the pain is gone with poor function and an increased chance for relapse. Inadvertently, these patients may be sabotaging their outcome. Personally, I think it’s up to us as providers having sworn the Hippocratic Oath to pause for a second in the patient’s best interest and have an honest discussion centered on discharge criteria. I feel that having specific discharge criteria and having an honest and open discussion on the 1st visit, re-exam and on discharge date sets the stage for a better chance at what the patient and doctor all want and that is an outstanding outcome.
That being said, have you thought about specific criteria for your practice? Below, I lay out the criteria for low back pain that I use in my practice. Feel free to use or modify at your discretion. Please note that we implement the criteria once the case has been accepted in the office, red flags have been ruled out, after a discussion/consultation with the patient and implementing a trial of care.
Low Back Pain Discharge Criteria
1). Pain Resolved > 75% as self rated pre vs. post VAS scales
2). Improvement in primary outcome assessment (Oswestry Low Back Scale) > 75% percent
3). Improvement in secondary outcome assessment (Patient Specific Functional Scale) > 75%
4). Able to repeat and reproduce his/her home exercise program and home care instructions upon pop quiz before discharge
5). Full and symmetrical range of motion (for the patient not a book # value)
6). Single leg stance time to age-matched and gender-matched peers example: > 35 seconds for adult males under 55 years old
7). Extensor Endurance > 30 seconds
8). Flexor Endurance > 30 seconds or within 80% of extensor endurance
9). Side Bridge > 30 seconds without major asymmetries (No more than 5 seconds of difference)
10). SFMA: At a minimum no dysfunctional painful patterns with the problem specific patterns of Multisegmental Flexion, Multisegmental Extension, Multisegmental Rotation, Single Leg Balance, Squat.
FMS score > 12 with no zeros and no test involving the problem area with a score below 2
Please note that these criteria represent “evidence-informed” medicine rather than truly evidence-based medicine. Additionally, note that these criteria were developed for our clinic use using the available research and in combination with our own clinical experience.
This is an ongoing process that is evolving with research. In recent years, I have experimented with the notion of adding a scoring system of 0-2 with:
1). 0 representing that we have not shown improvement from baseline to re-evaluation in the criteria
2). 1 indicating that there has been improvement in the criteria
3). 2 indicating that we have reached or exceeded the criteria.
The maximum possible score would, therefore, be 20. The criteria for discharge would be > 70% or 14/20. At present, this is not research supported; however, I think it would make for an excellent study. In this day and age are you practicing “best care medicine” without discharge criteria?
For additional information to assist you with creating your own low back pain discharge criteria, please visit www.clinicalcompass.com, select Resources, the find “Clinical Practice Guideline: Chiropractic Care for Low Back Pain.”
About The Author
Dr. Pappas is a chiropractic physician, certified athletic trainer and certified strength and conditioning specialist. Dr. Pappas blends the best of physical medicine with the best of integrated medicine to help patients and athletes of all shapes and sizes. He utilizes tools such as chiropractic manipulation, soft tissue work (IASTM, Graston, myofascial release, neural mobilization and joint mobilization), biomedical acupuncture, functional movement based assessment, the McKenzie Method, strength training and conditioning, kinesiology taping, customized nutrition and specialty laboratory testing (blood, saliva, urine, and stool) when needed. Dr. Pappas’ clinical focus is sports medicine, conservative orthopedics, rehabilitation, and integrated medicine. His sports medicine interests are endurance athletes, overhead athletes (pitchers, throwers, volleyball players and tennis players), contact sports athletes (football, rugby, lacrosse, field hockey, soccer, and basketball) and Crossfit athletes.
He has worked with athletes at all levels from professional to amateur. He reads and interprets the medical literature daily to stay abreast of cutting edge advances in his field. The doctor is currently a sports medicine volunteer for Andrew High School in Tinley Park, IL. He is an avid runner and aspiring triathlete having completed 5 marathons, 5 half marathons and numerous 5 and 10k races. The doctor is also active in the local, suburban Chicago running scene. He has goals of qualifying and competing in the Boston and New York Marathons, the Ironman in Kona, Hawaii, and climbing Mt. Kilimanjaro in Kenya, Africa. He recently completed the Pikes Peak Ascent, a half marathon to the 14,115-foot summit of Pikes Peak. One day he hopes to serve his country as a team chiropractor for the United States Olympic teams and serve as a team chiropractor for one of the professional teams in Chicago. His mantra is “Why Put Off Feeling Good?” He can be reached by email at email@example.com.