Assessing function and performance RUG-ADL & AKPS Before You Start Make sure you have the assessment tool definitions or the PCOC Clinical Manual

FUNCTIONAL ASSESSMENT TOOLS There are 2 tools that assess the patient’s function and performance: Resource Utilisation Groups – Activities of Daily Living Australia-modified Karnofsky Performance Status The RUG-ADL measures motor function with activities of daily living- bed mobility, toileting, transfer and eating and the AKPS measures overall performance or ability to manage activities of daily living. Assessment focuses on the patient’s ability, capability and is useful as a prognostic measure. Together the 2 tools provide a clinical picture of the level of dependency and resources required and in the community setting can indicate carer burden. However, the assessments are not intended to measure or capture workload or time spent with the patient. pcoc.org.au

RUG-ADL AND AKPS IN SUMMARY Functional assessment using the RUG-ADL and AKPS Provides a clinical picture: Level of dependency Resources required Indicate carer burden (community setting) Functional assessment using the RUG-ADL and AKPS provides a clinical picture of the patient’s level of dependency, the resources required to provide care and in the community setting can indicate carer burden. Functional assessment may also assist with prognostication and discharge planning. Prognostication Assists in: Discharge planning pcoc.org.au

Resource Utilisation Group-Activities of Daily Living (RUG-ADL) The RUG-ADL is a 4-item scale measuring motor function with activities of daily living: Bed mobility Toileting Transfer Eating A patient's RUG-ADL score is an indication of the functional status and in most cases the amount of care and support required. The RUG-ADL score tells us the resources required to care for the patient. It may be used to determine level of home supports needed or suitability of aged care facility placement (low or high level care) or the staff levels required to care for the patient. It can be used in conjunction with other assessments used in discharge planning. The RUG-ADL score can be used in handover descriptions in order to summarise functional condition and can be useful “common language” in palliative care. This assessment is clinically useful in everyday practice and could be completed in conjunction with phase on a daily basis. Integration strategies may include writing the RUG-ADL and Phase score on handover/allocation sheets or whiteboard or documenting in nursing entries in the clinical record (patient progress notes). Further, these scores could be used in care planning/interdisciplinary meetings as together they provide a summary of the patient’s condition and clinical situation. Based on what the person does, not what they are capable of doing Inform us about the patient’s functional status, the assistance they require to carry out these activities and the resources needed for the patient’s care pcoc.org.au

HOW TO ASSESS RUG-ADL Determine the score for each of the 4 domains, and total the score: Total Score Total Score 4 18 Please refer to the full definition in the Clinical Manual: RUG-ADL definition. It is the total score that gives you a picture of the functional status and dependency. When communicating with other colleagues the total score is communicated rather than the individual score of each domain. The overall RUG-ADL scores may indicate the level of resources required to meet the care needs. For example the number of nursing staff for number of patients and their level of care. This assessment can be used to describe acuity and measure dependency.   RUG-ADL assessment changes may trigger Occupational Therapy assessment or increased equipment in the community or inpatient setting. For a community patient a high RUG-ADL (16-18) may trigger a referral to an inpatient palliative care unit or aged care assessment. = Person is Independent = Person requires full assistance of 2 people pcoc.org.au

PCOC Clinical Manual www.pcoc.org.au pcoc.org.au Please refer to the full definition in the Clinical Manual pcoc.org.au

Recommended Actions for Total Score ACTIONS FOR TOTAL RUG-ADL Total Score Range Recommended Actions for Total Score Total Score of 4-5 Independent - Monitor Total Score of 6-13 Requires assistance of one person. May be at risk of falls. Total Score of 14-17 Requires assistance of one person, plus equipment. Greater risk of falls and pressure areas. Total Score of 18 Requires two-person assist for all care. Greater risk of pressure areas. PCOC assessment and response protocol pcoc.org.au

CASE SCENARIO – RUG-ADL Raj is 63 years old and was diagnosed with MND 8 months ago. Raj lives at home with his wife. Use the information to assess Raj’s RUG-ADL score. Raj is able to turn over in bed independently but he requires help from his caregiver to transfer out of bed. He mobilises with a walking frame and is able to take care of his toileting needs. Raj is losing his swallow reflex and can only eat selected and specially prepared foods. Refer to the RUG-ADL definition found in the PCOC Clinical Manual pcoc.org.au

CASE SCENARIO – RUG-ADL Which total RUG-ADL score would you give Raj? 6 7 8 9 Answer is B Bed mobility = independent (1) Toileting = independent (1) Transfer = requires hands on assistance from one person (3) Eating = has a modified diet (2) The RUG-ADL describes the patient’s level of functional dependence. It is a four-item scale measuring motor function with activities of bed mobility, toileting, transfer and eating. Use RUG-ADL to align your nursing care with the patient’s physical needs, and as a consistent communication tool within and across services. pcoc.org.au

KEY MESSAGE: Accurate assessment of RUG-ADL is essential to avoid: Inappropriate resourcing to care for the patient Patient, family / carer and staff being put at risk of injury Patient being discharged home without appropriate equipment and / or assistance pcoc.org.au

AUSTRALIA-MODIFIED KARNOFSKY PERFORMANCE STATUS (AKPS) Assess performance in three dimensions: Self care Activity Work The Australia-modified Karnofsky Performance Status (AKPS) scale used in PCOC is applicable to both inpatient and community palliative care. It assesses performance and can be used to indicate prognosis and survival times. An AKPS assessment of 60 or below may trigger a family conference to discuss performance status and disease progression. Note: the original Karnofsky assessment has slightly different descriptors for scores 40, 30, 20, 10. pcoc.org.au

AUSTRALIA-MODIFIED KARNOFSKY PERFORMANCE STATUE (AKPS) 100 Normal with no complaints or evidence of disease 90 Able to carry on normal activity but with minor signs of illness present 80 Normal activity but requiring effort. Signs and symptoms of disease more prominent 70 Able to care for self, but unable to work or carry on other normal activities 60 Able to care for most needs, but requires occasional assistance 50 Considerable assistance and frequent medical care required 40 In bed more than 50% of the time 30 Almost completely bedfast 20 Totally bedfast requiring extensive nursing care by professionals and/or family 10 Comatose or barely rousable 0 Dead Resources: AKPS Definition The AKPS is a measure of the patients’ overall function or ability to manage their own activities of daily living. It is a single score between 0 and 100 assigned by a clinician based on observations of a patient's ability to perform common tasks. A score of 100 signifies normal physical abilities with no evidence of disease. Decreasing numbers indicate a reduced ability to perform activities of daily living. There are no half-way measures; 55, 44, 35 for example. pcoc.org.au

PCOC Clinical Manual www.pcoc.org.au pcoc.org.au Please refer to the full copy of this definition found in the clinical manual pcoc.org.au

CASE SCENARIO - AKPS Alan is a 65 year old man with pancreatic cancer. When you reviewed him last at home he was able to work part time in his own accounting business and described experiencing some minor symptoms. His Australia- modified Karnofsky Performance Status (AKPS) was 80. Today when you see him, he is now resting in bed for periods of time, unable to work and needs occasional assistance from his wife. You assess his AKPS as being 60. Refer to the Australia-modified Karnofsky Performance Status definition located in the PCOC Clinical Manual pcoc.org.au

CASE SCENARIO - AKPS What are the implications for care given Alan’s AKPS score of 60? Change in plan of care, recognise changes, appropriate referral, discuss at next team meeting No change in plan of care Change in plan of care, recognise changes and appropriate referral No change in plan of care, provide support for wife Answer is A As Alan’s AKPS decreases, it is important to consider appropriate referral to other services, such as physiotherapy, occupational therapy and/or social work may be required to optimise the opportunity for Alan to continue to function at home. pcoc.org.au

ACTIONS FOR AKPS Consider completing an advance care planning discussion with the patient and their substitute decision-makers 90, 80 or 70 Consider referral to allied health if patient has been in active work and is no longer able to work Discuss at team meeting 60 Consider discussion at multidisciplinary team meeting and review care plan Provide appropriate equipment as required 50 PCOC Assessment and Response Protocol pcoc.org.au

ACTIONS FOR AKPS Consider discussion at multidisciplinary team meeting and review care plan. Further supports may be required Consider pressure area care Provide appropriate equipment as required Consider impact of care on family caregiver-complete a caregiver assessment 40 or 30 Commence end of life care planning If death is likely in days, change to Terminal Phase 20 or 10 PCOC Assessment and Response Protocol pcoc.org.au

Strategies for education and training PCOC assessments are part of multidisciplinary orientation Staff have full definitions and lanyard cards PCOC is included in in-service style education programs Staff have access and use the PCOC Essentials online course All 5 assessment tools are routinely used to assess needs and this is supported by a local protocol Identified PCOC champions and leads Local Processes PCOC implementation, embedding and sustaining guide pcoc.org.au

Utilise AKPS and RUG-ADL Strategies for embedding AKPS & RUG-ADL To formulate care plans and frequency of review As an indicator of family/carer strain As a common language to communicate patient needs across the whole multidisciplinary team In planning for placement in Residential Aged Care To trigger referral to allied health and for medical review Utilise AKPS and RUG-ADL PCOC implementation, embedding and sustaining guide pcoc.org.au

KEY MESSAGE: The AKPS is a measure of the patient’s overall performance status or ability to perform their activities of daily living. Consider asking: “Have there been any changes today with the patient’s ability to attend to activities of daily living?” “Is the patient requiring more physical care today?” “How much time is the patient actually spending in bed?” pcoc.org.au

Definitions abbreviated Request lanyard cards www.pcoc.org.au Response to assessment scores pcoc.org.au

PCOC is a national palliative care project funded by the Australian Government Department of Health Thank You pcoc.org.au Prepared by Clapham S for the Palliative Care Outcomes Collaboration (2018) Australian Health Services Research Institute (AHSRI), University of Wollongong, NSW 2522 Australia. © PCOC 2018 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without permission from the Palliative Care Outcomes Collaboration (PCOC). Requests and enquiries concerning reproduction and rights should be addressed to: Manager, Palliative Care Outcomes Collaboration (PCOC) Australian Health Services Research Institute (AHSRI) Building 234 (iC Enterprise 1) Innovation Campus University of Wollongong NSW 2522 Phone: (02) 4221 5092 Fax: (02) 4221 4679 For further information please view the resources contained in the PCOC Clinical Manual, go to www.pcoc.org.au, or contact your PCOC Facilitator