much for coming to our lecture today. Today we're going to focus on how to build cancer rehabilitation medicine programs, and we will all discuss pearls and pitfalls of program development. Joining me will be Dr. Haas and Dr. Zhao. What we'll be doing today is Dr. Zhao will present SPRINT, and this is a program that's created at Seattle Children's, and she's with the University of Washington. Dr. Haas, who was a fellow over at Cincinnati Children's, and now at Shirley Reinability Lab, will discuss the bone marrow transplant program that was at Cincinnati Children's. And then lastly, I will discuss ICANN Rehab, which is a program that was created by myself at Children's Health, and I'm through University of Texas Southwestern. Hi everyone. I appreciate everyone being patient with my pre-recorded sessions, as I have a three-week-old newborn at home. Without further ado, I would love to introduce Dr. Zhao, who will be presenting on SPRINT at Seattle Children's. Good morning, everyone. I am going to share my slides. Bear with me. Okay. Well, thank you so much for having me. I'm so happy to be here. Again, my name is Elaine Zhao. I am a pediatric physiatrist at Seattle Children's Hospital. I did my residency at University of Washington, my fellowship at Seattle Children's, and now I'm attending at Seattle Children's, so I've been here for quite a while. So part of my role is being the consult director at Seattle Children's Hospital for those who are hospitalized. I also have clinics. In addition to my general clinic, I have some specialized clinics, and one of them is neuro-oncology. Cancer rehab is very much near and dear to my heart. Today we're going to talk about a program that we developed at Seattle Children's called SPRINT. I have no conflict of interest. At Seattle Children's, we are a tertiary care regional hospital. We serve what we call the region, so that includes Washington, Wyoming, Alaska, Montana, and Idaho. It's a relatively large hospital. Our cancer care unit and bone marrow transplant unit combined have 48 beds, and there's definitely more coming as the hospital is building another gigantic building that will have many more beds. Our inpatient rehab unit has 12 beds, and that's part of the hospital. So again, as the consult person at Seattle Children's, we get consulted on kids who are in the hospital for various reasons, and one of the most common questions is they have had something happen and a functional decline, and are they inpatient rehab candidates to receive more intensive therapies? What I have found over the years is that as I'm assessing these patients' readiness for inpatient rehab, the ones who are on cancer care bone marrow transplant units tend to be so much more medically complicated, or there's reasons for them to stay on the cancer care unit, and so that readiness for rehab just seems to be far away, yet many of these kids really are at a place where they can still participate in more intensive therapies, and so we brainstormed and thought of ways that we can bring the intensive therapy to them while they're receiving their cancer care on the cancer care unit, and so we developed a program called SPRINT. Actually, one of our former fellows came up with this name, Short-Term Pediatric Rehab Intensive Therapy, and so who's a candidate for SPRINT? So far right now, we only have SPRINT for the inpatient hemonc and bone marrow transplant units, and that's due to really staffing issues, staffing shortage, and it's for kids who are in the hospital on the cancer care unit who have experienced significant change in their functional status or they have had difficulties doing their daily activities, and these are usually families or patients that we recognize would benefit from more structure in their days and from the milieu of having a rehab team supporting them. Our first SPRINT patient was a teenager whose, you know, parents had full-time jobs, and it was difficult for them to be at the bedside, and we recognized that she had a lot of potential, but it was really difficult to sort of motivate her to be out of bed, and so, you know, kids like her, we recognize that would really benefit from having a more structured day and more scheduled therapies, and so these are people that we tend to sort of think SPRINT for. Excuse me. So again, these are kids who have had a functional change, yet they're not inpatient rehab candidates. They otherwise would be considered for inpatient rehab if it wasn't for ongoing therapies that we can safely administer on the rehab unit, they have ongoing active medical issues that require more close monitoring, or they just would benefit from a little bit of flexibility in their daily therapy schedules, and therefore, we think maybe they might be less tolerant of the inpatient rehab schedule, which tends to be a little bit more sort of rigid, and these are also kids who require at least two of the major therapy disciplines, PT, OT, or speech, and they're able to participate in at least two hours of therapies daily, and so as we think about who is a candidate for SPRINT, there are other considerations, like, you know, what are the goals that we are hoping to achieve with more intensive therapies is not just, you know, trying to improve their independence, although I think, you know, lots of it is that, but certainly those who are on the palliative path would also benefit from more intensive therapies in terms of caregiver training, making sure, you know, the family has the right equipment, has the right training to care for their child as they eventually exit from the hospital, so they maintain their quality of life, and we also think about the medical stability and the timing of these kids, because sometimes you know, if there's like a major surgery or procedure coming up in a week, that might not be the right time to start SPRINT. Right now, SPRINT is a two-week program, Monday through Friday, two to three hours a day, depending on, you know, how many therapy disciplines they need. They, again, stay on their cancer care unit or bone marrow transplant unit, and the expectation is that these are kids that are anticipated to be hospitalized for at least two weeks while they're receiving daily intensive therapies, and we communicate these questions with, to our cancer care colleagues. Right now, we can only accommodate two patients at a time, and again, this is due to staffing. It's our cancer care therapists who are, you know, taking extra time out of their daily, you know, workload to, you know, set aside and allow these kids to participate in SPRINT, and so, you know, having, you know, five consecutive or simultaneous patients participate at a time, it would be, you know, really time-consuming for them, so right now, we can only accommodate two simultaneous SPRINT patients at a time, and who is all involved? Well, it's really a big team, of course, the rehab team, the consult physicians, PT, OT, and speech. The primary team, the cancer care and bone marrow transplant teams, are very much involved. Usually, the physicians or the MPs are following along. The bedside nurse has a very active role in getting the patients ready for therapies, administering the meds, you know, before therapies are starting, or, you know, around the therapy times, unhooking their G-tube, for example, during therapies, and certainly psychology is very much involved, and we also incorporate other sort of therapy disciplines, like child live music therapy, and sometimes pain service, like acupuncture, that anything to really help enhance the progress and the quality of our program. So, before SPRINT starts, we have a pre-SPRINT meeting, where it's the rehab physicians, the bedside nurse, the he-monk attending or resident, all the therapists, the family, as well as the patients, and we meet inside the patient's room, and we all gather and basically go over, you know, what's going to happen in SPRINT. We go over some expectations. There's, you know, expectations for participation in therapies, but also participation in activities outside of therapies, and how the patient and the families themselves can sort of enhance the experience for themselves. We talk about schedule, the therapy schedules that are, again, scheduled around, you know, medication time. We want to make sure, you know, the patient's not receiving Ativan and Benadryl right before therapies start, and again, you know, can G-tube or certain lines be unhooked, so they can be sort of a little bit freer during therapy times. We talk about sleep-wake cycle. What time do you wake up? You know, what time do you go to bed? Because my secret hope is that with a more structured day, their sleep-wake cycle would also improve, and, you know, part of the schedule is also incorporating other services like school, acupuncture, art, music therapy, and we talk about functional goals. What are your goals that you want to achieve in the next two weeks? We certainly, you know, have our therapists sort of chime in on what they want to work on during the two weeks of SPRINT, but we absolutely also ask the patients themselves and the parents, you know, what would you like to achieve in the two-week time that you're participating in SPRINT, and usually they're pretty well-aligned with the therapist's goals as well, and then we also talk about sort of homework. What can the kids do? What can the parents do with the kids outside of therapy sessions so that when there are no therapies, you're continuing the functional progress, and so we are wonderful assistant, rehab assistant, made these signs that has a little trophy with SPRINT on it that is hung on the door, and so anybody who walks by, says therapy in session, knows that, oh, therapy is in session, they're participating in SPRINT, and if it's not important, please come back later, and it's worked fairly well in that I think the feedback is most of the therapy sessions are fairly uninterrupted, but of course, you know, sometimes, sometimes it just happens, and on the right is sort of a sample daily schedule of what a SPRINT schedule might look like, and after the two weeks are up, we do a post-SPRINT meeting and basically kind of a wrap of reviewing how they have done, and some sort of long-term goals, like, you know, SPRINT is over, they're going to continue to receive therapies, maybe at lower frequencies, and what are some of the longer-term goals, and can we keep up with this schedule even though, you know, SPRINT is technically over, can you keep up with the outside of therapy activities, so that we're not losing momentum, so that they continue to make functional gains, and if the patient is nearing discharge, we also talk about discharge planning and outpatient follow-up, and then we present them with this, you know, sparkly, it's not sparkly, but it's colorful certificate, and it's amazing how excited people are over this certificate. We all sign it, the therapists and I sign it, sometimes we laminate it and post it on the wall, and the kids just love it, you know. So when we first developed SPRINTS, right off the bat, we wanted to know, you know, down the road, how are we going to measure our success, and so we decided on a couple outcome measures, that we would administer pre- and post-SPRINT, so at the beginning of SPRINT, at the end of SPRINT. One of them is a very short questionnaire that I just sort of came up with, addressing some of the more subjective measures of sadness, nervousness, pain, and fatigue. It's really, really brief, sometimes to a fault, because recognize that, you know, with the meeting and the other functional measure that I will talk about, there's a lot of questions thrown at them, and so the idea is, can we do, can we administer a short questionnaire, just to get a general gist of some of the more subjective measures, and so the questionnaire consists really only of four questions. There's the parent part, and the child part. For the parents, I asked them, in the last seven days, has your child felt sad, and the answer choices are never, rarely, sometimes, always, often, always, if they felt nervous or worried, and got tired, or had pain, and then if the child is able and willing, and they're over seven years old, we ask similar questions about themselves, and we do this, again, before and after SPRINT. And then, in terms of the functional outcome measures, we use the PD, which is the Pediatric Evaluation of Disability Inventory, and it's got several sections. It's got three major sections, the functional skills section, assistance, caregiving assistance section, and sort of modification section, and in its entirety, it really takes a long time to administer from beginning to end, so what we adopted was just the one part of the PD, which is the caregiver assistance section, and we purposely picked PD because this particular section is somewhat similar to the WIFM that the inpatient folks administer, but with WIFM, the therapists really need to undergo special training to administer, whereas PD, you can read the, not pamphlet, but the book, and learn how to do it without special training. And within the PD, there are three domains. There's self-care and many subsections. There's mobility, and there's a social function domain, and so we kind of divided the domains so that PT would administer the mobility domain, the OT would administer the self-care domain, and if speech therapy is involved, they would administer the social function domain, and I'll tell you, most of the kids do receive PT and OT. Actually, not very many actually receive speech therapy, and so we published our outcome, and this just came out in March of 2021. We'll go over what we found. So from January 1st of 2017 through October of 2018, we had 18 patients participate in sprints. Their age range really widely varied from two-year-olds to almost 18-year-old. The median was around five years of age. Most of them had leukemia, lymphoma, six of them had some sort of CNS tumor, one sarcoma, and two had SCID, and half of, well, a little more than half of them were receiving chemotherapy through their hospitalization during their hospitalization during sprint, and the reasons why they were sprint candidates were, well, all of them were deconditioned, and these labels were, these diagnoses were sort of drawn from notes or what people put in as the diagnosis at the time of their hospitalization, and so all of them were labeled as deconditioned. 44% of them were labeled to have peripheral neuropathy or neuropathic pain. I suspect this is probably higher, a lot higher than 44%, but that's just what was listed in the notes, and then, excuse me, some of them had, excuse me, tetraplegia, paraplegia, hemiplegia, and, excuse me, three of them had ataxia. So what we found was that there was a statistical significant change in the PD caregiver assistance compared to comparing their pre- and post-sprint function, specifically in their self-care and mobility domains, so these were significant. Under the social function domain, only the functional expression task achieved significant change. Otherwise, you know, the rest of them didn't. We also looked, within the study, we also looked at, you know, if there were barriers to therapy, what were they? And again, these were elicited from the actual therapy notes, and because our therapists are very good at documenting, you know, what's going on and some of the more subjective and descriptive things that happen during therapies. Most of them, if they could not participate in therapy sessions that day or they had to cut the therapy session short, most of them are due to the patient's symptoms. A small percentage of them, 22% of them, were due to things related to patient care, like they needed meds or, you know, they needed to adjust their lines or they need to go to the bathroom, and 7% of them had an unexpected transfer to ICU, or they discharged a little bit sooner than we expected, and so they didn't quite get to finish Sprint. Part of the challenge is, as the attending and the resident on the Himong team sort of switch, sometimes that communication of, well, you know, we are going to finish Sprint on this day, some of that message kind of didn't get through, and so some of these patients got discharged prior to the completion of Sprint. There were no adverse events related to Sprint participation, and adverse events were defined as things like, you know, did they have a fall, did they have a fracture, did they miss some sort of procedure, major procedure, or medication because they were, you know, participating in therapies that resulted in adverse outcome, so nothing like that happened, which is good. And on the questionnaire, 11 patients, I'm sorry, 11 parents answered them and four patients answered them, and there was no significance between the pre- and post-Sprint questionnaire responses. They were kind of all over the place. So, as we reflect on our program, you know, we are a few years in, excuse me. And for the most part, we have received really positive feedback from families. And, you know, a lot of them even request for, you know, longer therapies, longer sprint duration. But we also wanted to know how about the providers and the nurses, how do they feel about it? So we actually also sent out a survey asking the providers and nurses how they sort of regard sprint. And overall, overwhelmingly, we received really positive responses. And most people actually do want to know more about sprint. And I feel like as the program has kind of gone along throughout the years, you know, people are starting to know what sprint is. Sometimes we get consult specific to sprint because the cancer care providers are also recognizing that, all right, these kids have had a functional decline. Medically, they're not ready to go anywhere. Let's ask about sprint. So it's really great that we hear a lot of and see a lot of excitement around our program. Certainly there's a lot of room for improvement. Again, we can only accommodate two simultaneous patients at a time to participate in sprint because of limited therapist availability. And certainly, you know, the two-week mark was set just so that we can have a stop somewhere. With our first one, we didn't set a stopping point and it did kind of go on forever. And so we felt like it's not the most efficient way of going about things. And so we kind of arbitrarily set two weeks as the duration of sprint. And we've actually had patients that go through sprint twice. And certainly therapies continue after sprint is over anyway. But, you know, for those who could benefit from more intensive therapies, it would be great that we can extend the duration of sprint for those. And, you know, one thing I always wonder is, you know, how does sprint affect other things in the acute hospitalization? Does it affect their length of stay? Does it change their medical course? Does it somehow, you know, help with other aspects of their medical issues? And so these are the things that we don't know yet, maybe for future studies. So next step, you know, we are actually looking at our functional outcome measure because there are newer versions of PD. The PD-CAT is a computer version. The original PD is really only validated for kids from zero to seven, whereas the PD-CAT is validated, you know, for older kids through, I think, 20. And there's also shorter versions, so the PD-CAT is a shorter version. I think the obstacle we're coming up against is something about licensing and how, you know, how do we share the program amongst many different therapists? And so there's just some sort of technical things that we're trying to figure out there. And I've always felt like the questionnaire that we came up with is just too short. It's not long enough to really assess many of the important subjective measures that these patients feel. And the balance is always, I don't want to overwhelm them with tons of questions after they, you know, the therapists go through the PD with them. And so I think we're looking at other more validated measures. PQL is one of them that we're looking at. And can we expand the model of SPRINT to other units? Certainly there are many other kits and other services that would also benefit from this model of rehab. And so we're looking at the feasibility of that as well. So that's it. Thank you so much for listening. And I'm going to stop sharing. Awesome, thank you so much. Next up we have Dr. Haas, who's going to talk about the program at Cincinnati Children's. And he's actually currently in attending at Northwestern. All right. Thanks so much, Dr. Traviano. As she mentioned, I am a recent graduate of the Pediatric Rehab Medicine Program at Cincinnati Children's. I'm currently now in attending at Northwestern based out of Shirley Ryan, but also see patients at Lurie Children's Hospital, mostly through the Division of Hematology, Oncology, Neuro-oncology and Stem Cell Transplant. And it's really because of my interest in oncology, especially stem cell transplant patients that I wanted to take opportunity to present about the bone marrow transplant rehab program. So jumping in, just want to kind of go over what I will be covering. So want to initially define the rehabilitation needs for pediatric patients undergoing bone marrow transplant, look a little bit more locally at the landscape for bone marrow transplant program at Cincinnati Children's, then outline the components of what's called the Modified Rehabilitation Program, which is in part specific for bone marrow transplant patients, and then address some of the common pitfalls and barriers. So looking broadly at bone marrow transplant in general, there's been lots of evidence and support in the literature for rehabilitation across the bone marrow transplant process. That includes notable contributions from our physiatry colleagues, including Dr. Terry Gillis, whose 2001 article on cancer really advocates for physiatrists and other rehab team members to become acquainted with the unique needs and challenges of the bone marrow transplantation population in order to design and modify treatment programs effectively and safely. She and colleagues outlined how patients undergoing bone marrow transplant have specific impairments to a wide variety of factors, including their primary disease and any prior treatment, the actual induction process, and then multiple complications from graft versus host to treatment effects from steroids and then prolonged immobility and those effects. Additionally, Dr. Gillis and her colleague underscored how there's such physiologic frailty or fragility in these patients and that requires lots of anticipatory management to prevent and minimize disability. This fragility is underscored in a variety of studies, including one from 2013 in archives by Dr. Jack Fu that found that among adult patients, 21 years and older with bone marrow transplant who were admitted to acute inpatient rehab, about 41% of those admissions required transfer back to acute care services with a sizable portion of those not returning to inpatient rehab due to death. Additionally, the need for rehab across the bone marrow process has been supported by others with a clear emphasis on impairment-driven rehabilitation, especially in the post bone marrow transplant period. This diagram from a 2019 white paper on the role of physical therapy in hematopoietic stem cell transplant or bone marrow transplant, which included contributions from Dr. Sean Smith, outlines the aspects for which physical therapy in particular is beneficial through the course of bone marrow transplant from the initial assessments pre-transplant as well as identifying any sort of deficiencies, especially musculoskeletal, all the way through kind of post-transplant and looking at improving overall fitness and identifying complications and then more specifically during transplant to aid recovery. We look a little bit more closely at pediatric levels. There's the majority of the studies and guidelines are really coming out of the adult populations. However, there's growing evidence for the role of rehabilitation and therapy services for pediatric populations. In 2014, the Division of Occupational and Physical Therapy at Cincinnati Children's compiled a best evidence statement regarding physical therapy in hematopoietic stem cell transplant process to improve specifically quality of life for children, adolescent and young adults ages six to 2016. The best evidence statement is accessible online in its entirety. However, I've included some of the highlights here which map really closely to that diagram from Dr. Smith's white paper and primarily looking at kind of pre-transplant evaluations coming up with individual recommendations as well as family education in terms of what to anticipate and the importance of physical activity in the overall process and then kind of additional low to moderate intensity throughout the hospitalization and then coming up with plans on discharge. These are the recommendations that have been in place at Cincinnati Children's for several years prior to the development and implementation of the specialized modified rehabilitation program that I will describe shortly. But first I wanna talk a little bit more about the bone marrow transplant program at Cincinnati Children's, which was founded back in 1986 and since then has had over 200, sorry, 2,200 stem cell transplants or bone marrow transplants and currently averages about 100 per year making it one of the largest programs in the country. Additionally, with the national and international reputation of Cincinnati Children's Cancer and Blood Disease Institute, many of these patients frequently include those with refractory or relapsed malignancies, very rare immunodeficiencies and very severe bone marrow failure syndromes making the overall kind of acuity of the bone marrow transplant population at Cincinnati a little bit higher than some around the country. One particularly interesting aspect of patient flow through the hospital for patients with bone marrow transplant is that anyone who's undergone a bone marrow transplant that is admitted will be on the bone marrow transplant service unless they require ICU level or ventilator care, in which cases the bone marrow transplant service is most often a daily consultant. And then with the backdrop of the best evidence coming out of the physical and occupational therapy division standard practice, any patient admitted to the bone marrow transplant service has physical and occupational therapy consults per protocol and these therapists are dedicated to the bone marrow transplant unit, includes several therapists who are board certified clinical specialists in oncology physical therapy and it is up to their kind of treating discretion in terms of the frequency at which they will engage with patients. So that's kind of the backdrop for the introduction or kind of creation of the Modified Rehabilitation Program. So looking specifically at that kind of why this came about, specifically the inpatient rehab unit at Cincinnati Children's is not capable of handling ventilator dependent patients and due to the high medical complexity of bone marrow transplant patients, as well as the kind of patient flow issue of patients admitted to Cincinnati Children's being bone marrow transplant primary, there was a need to service patients that fit these two different categories. So the result was a Modified Rehabilitation Program that was designed exclusively for bone marrow transplant and then ventilator dependent patients who are typically on the transitional care unit. More recently, the reason why there's an asterisk there is more recently there've been some oncology patients, both pre bone marrow transplant and those who are not needing bone marrow transplant who are admitted to the Modified Rehabilitation Program. However, these patients are typically evaluated on a case by case basis with preference for more traditional admission to inpatient rehab service through the appropriate insurance authorization. So this means that patients in the Modified Rehab Program remain admitted to acute care, which also means that when they start the program, the therapists are not doing additional evaluations and WEFM scores are not tracked for them. Overall, there's a capacity for up to four patients and part of this is just due to staffing of the rehab therapists who cover both the rehab units, 12 beds, as well as four overflow for a total of 16 that get the rehab level therapy services. This also means that there's full involvement of the rehab team. So similar to the Sprint Program, there's lots of people that come in involved. Obviously, there's PM&R daily through the week following. It's specifically rehab physical and occupational therapists, speech therapists if needed. It's not the same therapists who are following them through bone marrow transplant. Additionally, there's things like recreation therapy, child life, which is throughout the whole hospital. There are some duplicative services like social work. So the rehab specific social worker and case manager assist along with the bone marrow transplant counterparts to help overall. The reason why nursing is kind of down here in the corner is that most often rehab nursing is not utilized unless there's more specific care that would be needed, such as neurogenic bowel or autonomic dysreflexia teaching, which is very rare. But for the most part, the rest of the entire rehab team is involved. So talking a little bit about initial kind of barriers and pitfalls to the program, I think it's important to talk first about kind of overall referrals. So as I mentioned before, the backdrop of having this best evidence statement through the division and on that committee was actually the head of bone marrow transplant, Dr. Stella Davies, who's very knowledgeable about the importance of physical therapy, occupational therapy. She can list off a whole bunch of ADLs off the top of her head. She's very much a big proponent, but I think we need to kind of step back and realize that as physiatrists, we get a lot of training in identifying who are appropriate candidates for intensive rehab level therapy services and just have an understanding of kind of when patients are appropriate. As a fact that this program doesn't require insurance authorization, oftentimes rehab medicine is viewed as kind of the gatekeepers. And so bone marrow transplant physicians may be strongly pushing and advocating for their patient to get services when either the patient is too medically active or fragile with poor activity tolerance and a high likelihood of needing to go to the unit or too high functioning to justify admission, traditionally to an inpatient rehab facility. Additionally, very often when referrals are made, the primary bone marrow service team has not had discussions with their dedicated therapists regarding the patient's rehab potential. I believe this is mostly due in part to their training and clinical practice. And obviously we know as physiatrists that we have daily conversations with our allied health colleagues and understand their expertise in coming up with individualized programming and providing recommendations. And so lots of times it's making sure that even though the bone marrow transplant team is asking for involvement, really making sure that the patient is appropriate. So next level is really kind of determining and managing expectations. So right off the bat, we need to make sure we have buy-in from family as well as nursing. Part of this is because the nurses are dedicated to bone marrow transplant, so they're not as familiar with rehab patients and the overall schedules and expectations. As the program has evolved, we're kind of getting a little bit more familiarity, but still need to make sure that nurses are kind of aware of what the expectations are. And then kind of more importantly, I think from family's perspective, they know that three hours of therapy is gonna be involved, but they may not have an understanding of exactly what that means. In addition to that, kind of like Dr. Cao outlined with the SPRINT program, we need to have a discussion with the medical team for bone marrow transplant about timing of upcoming procedures, things that would take away a significant amount of time from rehab, as well as just medication administration, TPN, tube beads, time that they'd be hooked up to a pump that would just overall complicate their care. In addition, compared to their floor-based therapies, the rehab therapies are on a pretty inflexible schedule, especially if the census is pretty high for rehab. So involves just making sure that the teams know kind of what the schedule is gonna be so that family or nursing can make sure that the patient is dressed and ready to go and has all their care needs completed before their therapy so that they're not spending time completing that outside of any sort of therapeutic intervention. Additionally, I'll mention that in the past there's been some ethical concerns raised mostly by the acute care therapists about utilizing rehab-level services and having twice-daily therapies for patients that are still admitted to acute care service. And that's, again, kind of managing expectations and making sure that the Division of Occupational and Physical Therapy is aware of the program's existence and the reason for why we're doing it. Next, kind of wanna talk a little bit more about physical limitations within the building. So this is kind of a schematic aerial view of at least as of this summer what a lot of the hospital looks like. There's a new critical care tower located back here behind location B, where actually most of bone marrow transplant will be now. But previously, at least when I was there as a fellow, the A building was where bone marrow transplant was located. And so they are actually located on the fifth floor of the A building on 5 South. So they have an entire unit. This is adjacent to other oncology services on the fifth floor of the A building. Patients who are traditionally admitted to the rehab service, either from outside hospitals or other units, are on the fourth floor, still in the A building, but fourth kind of center. And that is also where the therapy gyms that are dedicated for rehab patients are located. There's additional rehab space available or kind of overflow treatment rooms, especially individual treatment rooms on the seventh floor. But this means that patients who are on bone marrow transplant, but getting those Toy Staley therapies, need to physically move floors, which they have to access patient elevators, there's risk of exposures, and just that additional transit time can cut down on the already precious therapy time, since there may be delays in kind of their overall care. Looking at kind of by the numbers, the program officially launched the beginning of my first year fellowship in October, 2019. So now we have two full years of data. So overall, there's been approximately 43 patients admitted to the combined program that includes bone marrow transplant, that ventilator dependent unit, and then some of the oncology patients. Specifically over the last two years, there's been 15 for bone marrow transplant alone. And then we've seen a year over year increase in both bone marrow transplant, as well as the total program. And this is compared to over this, the last fiscal year that ended in June, 2021, a total of 136 admissions to the rehab unit. And currently there's not specific outcomes that we've looked at. That's kind of an internal process that we're working on now. But I'd say overall, there's been improvements with the team's understanding and kind of awareness of our involvement, as well as appreciation for improvement in the patient's quality of life and overall medical complexity. And I think there's a big push within the institution to look more specifically at kind of how the interventions can affect the overall resource utilization, lengths of stay, complexity, need to go back to the unit, and those sorts of outcomes. So that's kind of where things end for me now. So I will turn it back over to Dr. Traviano. All right, thank you so much. We'll go ahead and begin my pre-recorded session. Hi everyone, I'm super excited today to discuss a program I created called Integrative Cancer Rehabilitation, or ICANN Rehab. My only disclosure is I recently received a research service package grant for Team Me with Indy Anderson. And so the objectives we're gonna discuss today, I divided into several different aspects to talk about how this program was developed and how you can in fact create your own program. And so I'm gonna go over how to discuss and define a clinical landscape locally and nationally. And I actually wanted to talk about how COVID affected the program that I created. I also wanna talk about how we identify stakeholders and how this can really provide great opportunity for networking, as well as creating goal setting from the stakeholders to incorporate within your program. I will outline after I found all of these different aspects, I will outline then how I created Integrative Cancer Rehabilitation Program, or ICANN Rehab, and then talk about how I implemented that program. And then lastly, I'll address the pearls and pitfalls of ICANN Rehab and lessons learned. And so first we'll talk about how we define our clinical landscape. And so when we're thinking about this, there are some national considerations to occur to reconsider. So we have cancer rehabilitation is deemed as necessary. However, defining rehabilitation is often nonspecific and not well-defined. And these are some of the major national institutions that actually deem cancer rehabilitation necessary. Now, when we're thinking about this on a national and a local scale, we have to recognize that pediatric cancer rehabilitation programs are not common, and this can make cultural integration in a system a little bit more challenging. Not a lot of people understand what PM&R does and how helpful we can be in terms of cancer rehabilitation. And I think when you are addressing or beginning a program, it's really important to understand how a system culturally understands what PM&R does and what rehabilitation services generally do. And then assessing how open the system is to change and to accept the services of PM&R and rehabilitation. And then it's also really important, the same with oncology, where they have a particular roadmap for all patients in terms of radiation and chemotherapy treatments. I think it's really important to help define what the current rehabilitation roadmap is and is what happens with patients when they need therapies or they need equipment needs or any sort of storming management or dystonia, things like that. What exactly happens from that rehabilitation roadmap standpoint? And so this is a really fantastic graph that was, it's actually in the cancer rehabilitation textbook. And I think it's really important to consider these differences when you are establishing your program. So one is, is your program academic-based where it's larger, there may be disease-specific oncologists, maybe many tumor boards, and maybe affiliated with a major cancer center or promotion based on academic production, or is your program based on community? So is it serving the community itself? Are there oncologists that maybe not be as specified, but they see multiple tumor types? Do we have, no, maybe it's not as many tumor boards. Do we have greater financial pressure to see patients? And maybe we don't have cancer centers that have a rehab requirement. So I think this is really important to consider when you're building your program. And so right now what I'm going to do is I'm going to explore the clinical opportunities that are available. And I've divided this into five different areas, outpatient clinics, inpatient consult services, tumor boards, rehabilitation services, and research opportunities. And so we're going to go through that together. And so in terms of outpatient clinics, we have to figure out exactly what multidisciplinary clinics with oncology are possible for PM&R to be involved in and or what is available in your area. I also think it's important in just in terms of your department and division to figure out the scheduling needs, clinic availability, is there, you know, what is the bandwidth and staff and department support for creating a cancer rehabilitation service and kind of evaluating what those needs are and what barriers may be to promoting your program. Secondly, we can talk about inpatient consults and services. So what does oncology look like? Is it, do we have very specific oncologists that do maybe just BMT, SCT rounds? Or have they divided it into multiple services on the acute side? And how about PM&R? Is there just a general consult service? Is there a consult service? Have there, you know, are there specific consult services within PM&R? And what is the availability and bandwidth of PM&R? Also just understanding your inpatient rehabilitation setup. So obviously you'll know and understand what the basic setup is like. And I have some of those different parameters to consider. But also think about what about the oncology patients that go through your inpatient center? So how many oncology patients are admitted? What is the cultural relationship between intake coordination oncology teams? How is the local admission criteria? And so, for example, some centers, you can coordinate radiation at a specific time for patients and then there is a possibility that they can go to inpatient rehab, whereas other places may not have that flexibility with their radiation schedule. And so it's not possible to have a child be in inpatient rehabilitation despite their need functionally. Third, let's talk about tumor boards. So sometimes there are multiple different types. There's multiple different numbers of them, different frequencies, and, you know, trying to understand where that meeting leadership is and who's in charge of these particular boards and then understanding who is present at these meetings. So is rehab ever been present? Is it present? Are there PTOT speech therapists there? Maybe not. What about leadership? Really important to understand that opportunity. Now, in terms of rehabilitation services, again, we know that we need to assess that rehabilitation roadmap. And so part of that is determining what available programs are there in your current institution. Do oncology patients go through this? If not, are we missing an opportunity to be able to really hone in on what these patients need? Where are your outpatient and inpatient services and locations? How about what is the equipment availability and the therapist training for particular equipment, such as locomount, robotic suits, et cetera? How about what kinds of specialists are there for therapists? Are there some that specialize in lymphedema, maybe pain? Are there some that are interested in cancer or other specific needs? And is there in general, from a therapy side and a rehabilitation services side, an interest in availability of bandwidth for growth and expansion? All of these things really important to consider. And lastly, research opportunities. There is so much opportunity within pediatric oncology rehabilitation. And so going into it and figure out what is the established research culture? What are the opportunities in all departments, not just PM&R, but also oncology? Is it possible for us to say piggyback off of oncology research and add in some functional metrics? And what functional metrics are being used and why are they being used and for what patient population are they being used for? I would like to bring up some of the issues that I had in developing this program during early COVID. And so I had just started creating this program maybe in spring, early summer into my fellowship and beginning of being in attending. And so there was some opportunity in terms of, this was before a lot of virtual burnout. There was a lot of increased availability for virtual meetings and a lot of clinics were canceled at that time. And there was also increased time for program creation. And then some of the challenges that I had is we really, we didn't know what COVID was going to be like. And so there was very, we had no idea what the trajectory was going to be like in terms of affecting patients and or clinics and or roles as providers. And I feel like there were also very limited providers and clinics. So for instance, I know that they were only allowed to have three providers in certain multidisciplinary clinics and PM&R didn't make the cut. And so it wasn't until recently that PM&R was added back into that multidisciplinary clinic. And again, that was just a barrier that we had with COVID. And of course, the biggest thing that I found was I didn't have FaceTime. I mean, I was able to Zoom, sure, with a lot of providers and things like that, but there's something missing when you don't have that in-person connection. You can't really curbside them when you need to, and you can't really say, hey, what's up? I've got this patient when you're at meetings or tumor boards. And so what I have here, I'm not going to go through all of these, but this is more for your reference later. When we kind of combine all the clinical landscape considerations, so local considerations, outpatient clinics, inpatient consult services, tumor boards, rehab services, and research, those things that I'd gone over, this is a summary of what I found in terms of how this was incorporated into ICANN Rehab. And so you can see here, as far as local considerations, we're an academic center for outpatient clinics. Yes, there were some outpatient clinics, but PM&R was not fully into all of them. Yes, we had a general consult service, but we didn't have a specific rehab service, and we did have interest from specific therapists locally to do more oncology and cancer rehab. There are four tumor boards. We had the opportunity for building more infrastructure within the rehabilitation services, and there was some limitation to having some oncology patients due to really the complexity of their coordination of care. It was a really big barrier. And then, of course, research was not well established in the children's health aspect, but again, there was a huge opportunity through the oncology department where they had a lot more grant funding and research coordinators. So we talked about clinical landscape and how to define that for your program and how this was incorporated into ICANN Rehab. So next, we're going to talk about how to identify stakeholders in terms of networking opportunities and how to apply their goals and your goals together to define your program. And so when you're thinking about building a program, here are all the potential stakeholders that you should look into in terms of building your program. Perils I figured out. So of course, we want to make sure there's a lot of PM&R leadership support for program building. You have that time and you have the opportunity for PM&R presence in multidisciplinary clinics. I always had a basic outline of the program when I was presenting to my stakeholders, but I was always changing and modifying it in between stakeholder meetings just to make sure that the goals were updated for every stakeholder. And I basically went in thinking that no one knows what PM&R does. And I think that was beneficial because I found myself defining what PM&R does and then there were lots of questions about, wait, you guys do that? I had no idea. I'm going to refer a blankety blank patient to you. So it just opened up the opportunity for referrals and more discussion in terms of education. Of course, we were all sharing our goals and I was always very open to say, hey guys, I want your opinion as a part of this. I want this program to be as much as yours as it is mine. And I want us to all be communicating. And so I always emphasize the importance of making sure we were all on the same page. And then I always gave best contact information and referral information if that was possible. And then I always felt like I was kind of following the breadcrumbs with different stakeholders. So I would find that I would talk to one stakeholder and they would say, hey, you should talk with blank person. I think they'd be really interested in your program. And so that was how I was able to spread the network and get more shareful stakeholders for the program. And I shared all the stakeholders at each meeting so everyone understood how much we were networking and who was on board. And again, it's really important to have your program be super flexible and dynamic because things are gonna change and you want it to change and modify to the specific needs of the culture of your program and for patients. And so again, I'm not gonna go over all of these specific goals that were identified for every group, but this is here and available for you guys. So when you guys look into starting your own program, this may be some of the things that may be further explored with the different services. And so the one thing I do wanna bring up is I know for the program I was creating, I know I wanted to increase rehab presence across the continuum of care. I wanted to improve therapy access. I was interested in holding rehab specific conferences weekly with a therapist so we could improve our communication for patient care. I knew I wanted to improve research presence and I wanted to merge oncology and pument or functional outcomes. I knew I wanted to create a protocol for goals, interventions, plan of care and assessments. And I was interested in creating a specific cancer rehab consult service as well as an outpatient cancer rehab clinic. And then I was interested in categorizing patients based on a DIH and DEETS model of care to streamline services and protocols. And I'll get into that a little bit later. But again, here are some of the protocols and goals of each service and what they needed. So for instance, oncology wanted just better recommendations and more integration to multidisciplinary clinics. Neuropsychology wanted more research partnerships. Psychology wanted more physician support for difficult cases and medications, so on and so forth. So next I'm going to outline the ICANN Rehab Program and what this actually is. Now that we've gathered our clinical landscape, we now have identified our stakeholders in their goals and we've shared my goals. And now we have a lot of really cool things to work with in terms of defining and creating the program. So what is ICANN Rehab? So Integrated Cancer Rehabilitation or ICANN Rehab, this is a clinical infrastructure created to increase rehabilitation presence for children across the continuum of care in order to improve functional outcomes and clinical practices. And so similar to what I said before in terms of divvying up this clinical landscape, I divided this program into four aspects, outpatient services, inpatient services, conferences, and programs and protocols. And so again, some of these program goals will be improved functional outcomes. I want to improve access to rehabilitation resources and services, and I wanted to streamline multidisciplinary approach. And so this is actually a very inspiring study that I read in terms of how to categorize patients based on domain across their continuum of care when they are getting oncological treatment. And so there's this really beautiful graph in chapter 88 of the Cancer Rehabilitation Principles and Practices book. Thank you to those who created this graph. That was kind of an aha moment for me in terms of creating domains and kind of helping categorize patients based on what their needs were, and on top of that, determining the types of rehab they'll need based on the DEETS model. So we have preventative, restorative, supportive, and palliative rehabilitation. And so here is where I further delineated some of these domains, and some of this is pretty intrinsic and makes sense in terms of definition. And I've outlined some of the goals for each patient that is within each type of cancer domain. And so for instance, for cancer treatment, we have address impairment-driven concerns as a goal, or maybe for end of life, we'll be doing palliative rehabilitation, so on and so forth. Again, this is here for your reference, so you guys can refer to these later. And so I also created a mind map in terms of the program structure and the four aspects, and every single clinic and each service that we are providing in terms of cancer rehabilitation. Again, this is something I would always share with stakeholders, and then I would be flexible in changing this for each meeting. And so again, I talked about this earlier. So I really wanted to have what I call ICANN Rehab Rounds, where I imagine it being a weekly 30-minute conference. And this was a time when it's the PaymentR team and therapist team, and we're chatting about how to stratify these oncology patients, figure out what program or protocol is needed in terms of therapy. Do they need IPR? Do they need outpatients, home health, et cetera? Sometimes there were a lot of concerns that therapists wanted to address, like, hey, you know, I've got this patient. They've got a lot of gait instability and weakness. Hey, can you please check them out? Or what do you think is going on with this? Or hey, I've got this kid that I'm seeing that PaymentR isn't referred for. I think we need to put in a referral for this patient. And I generally was like, yeah, totally. I'm happy to see that patient. I would also discuss the oncology roadmap for a lot of these patients, since that was often not fully disclosed for a lot of the therapists, and or there was a tumor board that needed to be attended to to determine what their roadmap was, to determine if they need to go to inpatient rehab or so on and so forth. This was primarily for acute patients, but there's also opportunity for outpatient setting as well. And again, at first, this has been PaymentR, therapists, therapy team leads, and inpatient rehabilitation intake coordinators, but it can be open to all types of multidisciplinary teams. And so the last part is research and protocol development. And so I created PT, OT, and speech task forces where each of the assessments and goals interventions are all age-based, discipline-based, and location-based. And so we went back and forth on figuring out if we needed to be super specific in terms of the type of cancer or general, and we decided to be general at first, just so it wasn't overcomplicated. And so phase one has been assessment gathering. And so our goal one day is to have an EMR integration, either with, we have Epic, so Slice or Dicer, or be able to automatically upload into RedCap. And that's something that I'm currently working with the IT department right now on. Phase two has been point of care episodes and episodes of care. And phase three has been what are specific goals and interventions? And something that I've been doing just with every consult or outpatient functional metric, or outpatient patient, is I've been gathering functional metrics. And so I've been gathering Lansky's, Karnofsky's, and ECOGS. And then if a patient has chronic GDHD, I'm also adding a PROM and an NIH joint fascia score. So now that we've talked about ICANN Rehab and how this was created, now I'm going to talk about how I actually implemented this program back in, I think it was last September. So I needed to get patients, right? So I found that the quickest way I could get patients was from the acute consult side and then having inpatient rehabilitation follow-ups outpatient. And then slowly I got more referrals from outpatient clinics once other team members were able to figure out, oh my gosh, she does this or Kaminar does that. That's awesome. And so we were able to see more patients eventually as the year went on. I was able to streamline ease of access as well as a referral system. So what I did is I was available via TigerText, email, pager, and EMR chat. And then I was able to discuss with outpatient schedulers exactly what cancer rehab is. They were having issues where they would call a patient for follow-up and the patient would be like, wait, what, what is Kaminar? So that was something that I was going to help kind of figure out more on the outpatient, like on the inpatient side to explain more of what Kaminar does. And then I was able to kind of coordinate that with schedulers. I was initially present at all the tumor boards, but we'll get into a little bit more about that in more detail later on. I had a quick elevator spiel about the program and what Kaminar does for all the multidisciplinary teams and oncologists just to improve networking and to help patients and other providers understand what Kaminar is and what we do and how the ICANN rehab can be helpful. And so because I had a lack of face time initially for early COVID, the moment I became an attending and like could, you know, I had my license came in and everything else and I was able to start seeing patients. I increased the face time as much as possible. I was at all the boards. I rounded with the oncology providers. I made sure that I was rounding at the same time so that we could do a lot of curbside and chat about different patients. And I was also going to the provider touchdown spaces just to introduce myself and say hi. I was sharing my program with the division and the departments of oncology and Kaminar, which was helpful with marketing. And then I also created a referral checklist for, hey, this is how or why you can refer patients to Kaminar. And I had things like, you know, gait instability or weakness or CIP and things like that. And again, I can't emphasize this enough, be flexible of your program will change and you want it to change because you want it to meet the needs of the culture. So what is going on with ICANN rehab right now? So I am really thankful and grateful that it is still going strong. I have an ICANN rehab acute consult service. Our census is between eight to 15 patients. We are auto-consulted for all BMT, SCT patients now. And then culturally we have done pretty well with the transition of having a general pager to a cancer consult pager and having the different services understand that. I have an outpatient weekly half-day cancer rehab clinic. We are, Kaminar is back in the neuro-oncology clinic. And then I have a really great relationship and referrals back and forth between the oncology services and all their multidisciplinary clinics. And these are kind of the ranges that I see. I've had to kind of min-max how I do tumor boards really due to bandwidth and there's kind of a variable utility. So I found that with MSK tumor boards that our opinion and a need for rehabilitation input is something that is asked for during the clinic, during the rounds and same with neuro-oncology. That's something that's needed and asked for especially the coordination to inpatient rehab or home health services or outpatient therapies. ICANN rehab rounds has actually changed from weekly to bi-monthly. And really this is because not a lot changes. And so that's because a lot of our patient census is a lot of BMT, SCT cases. And so not a lot changes from week to week. And honestly, the therapists have told me that now that they can text me or email me really quickly that they have a lot more support without need for a lot of meeting. And there's also that aspect of Zoom fatigue that I think has affected a lot of us in COVID. I'm starting an educational series that's aimed specifically for therapists but open to other providers. The protocol for the task forces is in final stages of completion. It should be finished within the month. And then I've actually found that I've incorporated other interests into patient populations. And so not only am I doing a lot of the mindfulness and meditation for a lot of patients, but I've started doing a lot of osteopathic and manipulative medicine, especially muscle energy for patients that have chronic GDHD. And I've actually started noticing some improvements in their PROM scores. And this is a young program. I mean, it's been about 13 months since I've implemented this and there's plenty of room for growth and modification. And so lastly, I wanna address the pearls and pitfalls of ICANN Rehab and things that I have learned. And so just know that patients will be lost to follow-up and just know that you're gonna explain what PMR is and what we do all the time. And so it's a really great study by Chevelle who found the five themes. And I have found all five of these themes. Like the patients feel like they're too busy. Rehab is not necessary. There's some process they're waiting for to reach completion to begin rehab, whether it's chemo, radiation, or diagnosis. Rehabilitation is not beneficial. Participation is burdensome. Oncology is highly individualized. So while my categorizing based on domains is theoretically a cool idea, it's not really practical in real life. So it's nice to kind of think about that in the back of our minds in terms of the kinds of rehab that a patient will need, but it's not super functional. Like for instance, cancer diagnosis, it's sometimes just non-existent in patients or like a day long or hours long. Communication and coordination is key. I feel like that is paramount when it comes to oncology or cancer rehabilitation. There is so much opportunity for research, and I feel like I had some lost opportunity for doing a systemic review when it came to assessment gathering for protocols and the task forces, but it's not too late. I'm also looking into creating a scoping versus narrative review, and then when you're gathering assessments, you have to consider, is this worth the therapist's time? Is this worth money fiscally, and can we get more out of AMPAC or PROMIS measures? So I was saying earlier that utility of tumor boards can be variable, and that's going to depend on your institution and culture. Again, I had the lost opportunity for FaceTime and better networking due to COVID. I would say, as far as culturally, navigate the pros and cons of having a cancer rehabilitation-specific consult service. I really like it. It's something that cancer or rehab is a little different from general rehab, and I feel like it's worth it, but you may find at your institution it's not worth separating those. If your institution has remote patient monitoring, I think this is a huge opportunity for research, but we have limited bandwidth currently, and it's in its early stages of development. And like I've done, as far as providing unique skill sets, put in your own skill sets to find your program. Again, remain flexible. I said that a bunch of times. It's super important. And then, of course, most of all, have fun and be proud of all the hard work that you've put in. I have to have a huge, huge shout-out, and I'm super, super grateful to a lot of the people that were influencing in this creation of program development. So I couldn't have done it without a lot of the mentorship that has been provided to me, and I'm really grateful for a lot of the leadership that provided me the opportunity to have the bandwidth and the creative ability to just build this program. And shout-out to Mike, who is a cancer rehab here at UT Southwestern, and he's let me borrow his book and allows me to ask a bunch of random questions about cancer rehab. So I'm really grateful for having him. And then therapists, I'm super grateful for all the therapists that are on the PTOT task forces as far as creating the protocol and development that has been needed. So here are some of my references. And please shout-out. I geek out on program development and cancer rehab. So if you have some ideas for your program or you want to just network, and I would love to talk with you about the different opportunities that are available at your program and how we can connect. Thank you so much. All right, everyone. We are now going to switch gears and go into the Q&A aspect of our talk today. And so we have one question. We have a shout-out of gratitude to Dr. Sal for the presentation. And the one question is, I was wondering if you see any downsides of sprint rehab versus having patients on the rehab unit in terms of rehab outcomes? Downside of sprints. Okay. So sprint versus inpatient rehab. Yeah. I tell people that sprint really doesn't replace inpatient rehab because I think they're different in many ways in that, at least in sprint, the cancer care team seems to be sort of much more involved. But the services available to sprint is also less compared to inpatient rehab. And that's probably a difference at our facility. Like, for example, TR, Therapeutic Recreation, is not available to us. Our psychologists in sprint is the cancer care psychologist, whereas on the inpatient rehab, it's a rehab psychologist where they address sort of slightly different things. And actually, the biggest difference is actually the nurses. Your cancer care nurses are great, but when it comes to neurogenic bowel, neurogenic bladder, skin, sort of those rehabby things, the rehab nurses are really sort of skilled at those things. And so for people who are participating in sprint, we try to fill in those gaps, especially with nursing knowledge and training. But sometimes those gaps are, you know, we know that they are there. And so I like to think that sprint does not replace inpatient rehab because it really doesn't. And in fact, we have had patients participate in sprint because they're medically not ready for inpatient rehab, but they have ongoing functional needs to benefit from intensive therapies. So then they transition to inpatient rehab afterward. So I don't know how it compares in terms of outcomes. That's something I thought about doing, but, you know, we were using PD as our functional outcome measure for sprint, whereas on the inpatient side, it's WEFM. And so it's just different enough to not allow those sort of statistical analyses to occur. But that's a good question. Yeah. Awesome. Thank you. Other questions? We have one that just came in. Oh, just thank you for the answer. Makes sense. All right. Next question we have is what is some of the most challenging aspects of building the program? I'm happy to take that one first, and then we can have Dr. Haas and then Dr. Sal answer. So again, I feel like the most challenging piece for me was actually coming up with the idea of making sure that we remain flexible and kind of following the first, who are the first stakeholders that I could talk to and approach? So I feel like once I was able to get my goals ready and set and then do a lot of research on my end to determine what was most important and what I was hoping for in a program, I feel like that to me, for me, that was the hardest part was the very, very, very beginning. But once you have this sort of idea, a basic outline, you have like a handful of people that you know you want to talk to, even five or so. Then after that, I feel like, oh, my gosh, everything started making more sense. And then I was starting to follow the breadcrumbs, like I was saying earlier. And then I was able to really spread out the network. And then I was able to really tailor the program to what the culture needed. So really, I think it's the very, very, very beginning. Then at first, the second aspect, I feel like I was a little concerned about, but it ended up being totally fine, was implementing the program itself. You can talk the talk, but until you walk the walk, it really, there was like that gap that I was concerned about. But honestly, I found that once I had planned everything during the time of COVID for a few months, and then once I'd become an attending, I was like, oh, man, I am totally ready to implement this program. And so it ended up being a little bit easier than I thought it was going to be. But I can definitely see it being more challenging if beforehand a person is not super planned and everything is very theoretical. So I would say very, very beginning. And then second is that implementation of the program. Dr. Haas, you take it away. Yeah. So I, at least for the bone marrow transplant program at Cincinnati, I obviously was not involved in the pre-planning. It was more of like the early implementation. And I think really at least what I saw was, and I'm kind of seeing now here as an attending at a different institution, it's really just kind of making sure that there's clear expectations about what the program is and what it isn't. I think, like you mentioned, flexibility is important in terms of evolving over time and seeing how to kind of iteratively improve, but also kind of making sure that the initial concept that you have is kind of, you know, you're striving for it and you're not kind of bending because you want to please people, making sure that you're kind of demonstrating the overall worth. And I think another thing, you know, I again, wasn't intimately involved in the design, but at least something that I'm taking away is being kind of very mindful of how to show the benefits and kind of, you know, it's a lot of resources involved in terms of your time, therapist times, and just kind of overall collaboration. And I think in my heart that it's definitely improving outcomes. And I think if we can show it, then it should be more widespread, there'll be more kind of utility for cancer rehab doctors, you know, across the spectrum. And so I think that there'll be a big push and then, you know, hopefully we're able to have interventions early, then, you know, we may not have to have some of the pretty kind of more severe kind of functional deficits arise as a result of treatments. So for me, I think in the very beginning, the enthusiasm was there. I think everybody recognizes that there is a very special population that just, you know, needs more intensive therapies, even while they're receiving acute care. And the question is how to deliver that. I think the biggest challenge we were dealing with was how to balance the therapist's workload so that they can still do this, you know, offer this intensive therapy without taking away their services from other patients, and really not, you know, burning out our lovely therapist. And striking that balance, you know, took a little bit of time. Like I said, our first patient did Sprint Forever. She did great, but it went on for weeks, and we're like, okay, we need to cut it off somewhere. But that in and of itself also presented as, you know, a potential barrier, like could some of these kids, you know, benefit from longer? So it's sort of this ongoing, you know, review of, you know, are we doing the right thing? How can we tweak it? And, you know, it was kind of a fact of, if you build it, they'll come. And certainly we, I feel like we have received more and more referrals from the cancer care unit since we developed the program. And actually other people, like other departments have, you know, heard of Sprint as well, and even have specifically asked, like, is there Sprint in the community? Is there Sprint for my, you know, cardiac transplant, you know, transplant patient, that sort of thing. And so it's nice, but then, you know, we want to offer these services. And again, it comes down to, do we have the bandwidth? Do we have, is this a feasible thing? And we're also recognizing that we're building a strong inpatient program. And when it comes to outpatient, I think that's where we're also facing a gap. I'm in neuro-oncology clinic, which is a multidisciplinary clinic, but for those who have leukemia and lymphoma and whatnot, I don't think there's as much of a sort of built-in rehab presence there. I know some of them do get seen in a general rehab clinic, but it just feels a little bit less structured, less, you know, I don't know how consistently they're being followed. And so I think part of the challenge is how do we continue to offer these services, you know, throughout their childhood, not just on the inpatient side. And as much enthusiasm I have, you know, I know my time is also sort of limited in that I would love to see more of these patients in outpatient, but I don't have the time and certainly, you know, my colleagues are also, you know, quite full. And so feasibility, I think is a big challenge. Awesome. Thank you guys. Another question that we have is how are your programs received in the hospital systems? And so actually I'll have Dr. Cao answer that first and Dr. Haas and then myself. How is it received by others? How is it received in the hospital? Yeah, yeah. So as I commented in my slides, it's been received really quite well. Again, people know it by name and sometimes they know it by name, but they're not quite sure what that means, but at least they know it by name. And I find that it actually provides some comfort, maybe that's not the right word, to some of the cancer care providers, because they know that their patients are receiving sort of this, you know, intensive therapy where it's packaged and there are people, you know, directly addressing their functional needs. And so it definitely feels more structured and more intentional. And so I think in and of itself, it offers sort of a better package for these patients. And yeah, I think people still want to know about it for those who don't know about it. In general, there's just good enthusiasm. Again, sometimes we do disappoint them because there are therapists, you know, we consulted on specific patients. Hey, are they sprint candidates? And we say they're not, not because they don't have the functional goals, but because they're already doing pretty well with sort of your regular way of delivering consult therapies. And I've found that when we say no, and we explain why, and we explain that they're still receiving therapies and they're still making functional gain, there's some disappointment on the team's part. So yeah, I'm trying, I'm still trying to figure out how to sort of address some of that disappointment. And yeah, it's just, it's introduced an interesting dilemma that I didn't think would occur. But yeah, so far it's been well received. Yeah. Yeah. I think similarly, you know, there's a big push and we've definitely had conversations similar to that where the team will ask us. And then when we say like, oh, they're actually doing so well, like I think they'll be fine with just, you know, their, their standard floor-based therapies. And they're like, oh, really? And they just, I think that the unit really wishes that they could have dedicated twice daily therapies for as many, you know, as many hours of therapy as there are therapists to give. And like I mentioned in the slides, there's been a push from the other oncology services, kind of those who are not needing bone marrow transplants to have that level of therapy. And, you know, I think it's, again, it's an individualized regimen and whether that's best for the patient or whether kind of traditional route of coming to inpatient units is better. But yeah, I think overall I wouldn't say that there's additional units. I mean, we definitely have gotten consults from cardiac rehab and pulmonary transplant and asking for additional services that are similar, which I think would be an interesting patient population or would be patient populations that could benefit and may, you know, maybe expanding into that would be helpful. But yeah, I think there's been lots of support overall from the institution. Yeah, similar to everyone here. It's once people understand what we do and how we're helpful, everyone wants more rehab. Everyone wants PM&R everywhere. And so for right now, you know, I feel very grateful and lucky that the program has been very well received and that I'm pretty psyched to be auto consulted for a lot of these different patient populations. And I'm over the moon that even the oncologist himself, even before I started working on this program, they said, we need rehab. So please like do whatever needs to be done to make sure this is more implemented within our services. So it was, I just been very, I've been very psyched for the whole process, honestly, and been very happy that really it's been very well received and even by patients as well. Another question, which a lot of us pretty much, we talked about a little bit in our presentations, but what are some of the next steps in building and or implementing your program? And I think Dr. Haas has some really excellent points and ideas on this. And so I'd love him to go first and then I can talk and then I can have Dr. Sal go last. Yeah. So, you know, I think I'm in an interesting position of switching institutions and not only switching institutions, but also kind of bridging multiple institutions where I'm at, where I'm at a post-acute kind of inpatient rehab facility, as well as a children's hospital. And that presents a lot of difficulties just in terms of resources and, you know, care continuums. But at least from the post-acute side, I kind of happened to walk into an already developing pathway. I'm just going to pull up some slides for that, but this is, you know, it's primarily for inpatient, but also going to be working through the day rehab to outpatient transition of identifying kind of similar to Dr. Shamiano, identifying where patients are in their rehab course. Not that you can't kind of transition between or different aspects of the overall rehab needs are, you know, siloed between restorative or supportive or palliative, but that the therapists kind of know what those words mean and kind of, kind of flesh out a little bit more about what they're working on. And more specifically, they have a whole battery of different pediatric specific metrics that they're looking at. So basically for all inpatients, if there's appropriate diagnoses that would justify these outcome measures, the therapists are kind of already working towards getting all that data. And it's been great to know kind of coming in the door that there's all this data that's going to be kind of compiled. And this is just starting out basically now I have an admission today with a patient with ATRT. So all of her data is going to be pulled as soon as the therapists work on it. And yeah, I think that's been huge. I think the other is really just kind of, you know, I'm glad that Dr. Traviano has kind of gone through this process very recently and I can kind of pick her brain or borrow her ideas for developing those kind of new relationships with the teams over at at Lurie Children's. But, you know, I think the biggest thing that I've took away from all of it is just kind of FaceTime explaining your role. Don't worry about having to repeat yourself again and again, and just kind of show your worth. And, you know, if it's ultimately benefiting the patients, then that's really what matters. Awesome. Yeah. I feel like the biggest piece that I'm working on right now is the protocol development and similarly to what you're doing. So I saw the little graph that you have, like, I recognize a lot of those because those are some of the ones that we're also incorporating into our protocol development. I feel like just that one little piece is what we're missing in terms of implementing our program for all of our cancer patients. And so once that protocol is developed, then we'll be able to really have a lot of data to back up what we're doing and showing how much better we're doing in terms of improving functional outcomes. And the second thing is we have a program that's sort of similar to Sprint and the BMT SCT program, but it's not for cancer. It's for children. It's called Leaps and Bounds. And so it's for children who are, they, who are like basically almost inpatient rehab, but not quite for various reasons. And so either we need to tune them up to get ready for inpatient rehab, or, or maybe they just need this short stint of, you know, a couple weeks of, of, of kind of like a two hour, two hour, very specifically scheduled therapies a day for five days a week. And, and then like, maybe they don't even need inpatient rehab there, you know, after that. So I actually am hoping to create, to do, to create sort of a Sprint-ish integration into Leaps and Bounds plus Sprint-ish. So that way we can make it cancer specific and not just kind of like all the kids specific. So yay, Dr. Sao for being an inspiration. Will you please tell us that Sprint-ish would be awesome. Right? Like that will be the acronym that I use and I'll come up with something that's like an ISH. I'll figure something out. Sprint-ish. We'll work on your name. Exactly. That's great. So, so that's something that, that we're currently working on now. Oh, and I guess for Sprint, I know I talked a little bit about what are our next steps. We're definitely re-evaluating our functional outcome measures, as well as some of the subjective measures, exploring PD-CAT and PSQL. And actually we're also looking at how, again, how to bridge the services between inpatient and outpatient and make sure we kind of close the gaps there. There was some ambition to incorporate a Sprint as part of everybody's bone marrow transplant journey. And of course the, the feasibility around that and also the inpatient versus outpatient services provided for that program.

integrated cancer rehabilitation program

oncology culture

consult services

resources

key stakeholders

tumor boards

inpatient rehab services

outpatient rehab services

research opportunities

collaboration

goal setting

communication

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