Acute Inpatient Rehabilitation Setting Research Articles

Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

IntroductionPracticality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes.ObjectivesTo determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.Design and settingAssessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.ParticipantsThirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).InterventionLokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.Main outcome measuresNumber of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post).ResultsThe desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge – admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy “dose”.ConclusionsWith careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in study.

Feasibility, safety, and functional outcomes using the neurological controlled Hybrid Assistive Limb exoskeleton (HAL®) following acute incomplete and complete spinal cord injury – Results of 50 patients

Objective Recent studies reveal that Hybrid Assistive Limb (HAL®) locomotion training in paraplegic patients suffering from chronic spinal cord injury (SCI) induces improvements in functional and ambulatory mobility. The purpose of this study was to determine the safety, feasibility, and functional effectiveness of HAL® locomotion training in the initial rehabilitation of acute SCI patients. This clinical trial represents the first systematic intervention worldwide for acute SCI patients using a neurologically controlled exoskeleton. Design Single center, prospective study. Setting BG University Hospital Bergmannsheil, Bochum, Germany. Participants Fifty acute SCI patients (14 women, 36 men). Interventions All participants received a daily (5 times/week) HAL® exoskeleton supported training for 12 weeks (mean amount of training sessions 60.4 ± 30.08). Outcome Measures Functional outcome for overground walking was monitored using the 10-m-walk test (10 MWT) combined with the WISCI II score, 6-minute-walk test (6 MWT) and the timed-up and go test (TUG test). Treadmill-related parameters (speed, distance and walking time) and the Lower Extremity Motor Score (LEMS) were recorded separately. Results Significant improvements were observed for HAL®-associated (walking time, distance and speed) and for functional outcomes (10 MWT, 6 MWT and TUG-test). WISCI-II-Score and the LEMS increased significantly compared with the status prior to training. Conclusion HAL® locomotion training is feasible and safe in the rehabilitation of acute SCI patients. The HAL® exoskeleton enables the patient to perform effective treadmill training and leads to improvements in functional and ambulatory mobility. However, spontaneous recovery vs training-related effects remain unclear and findings should not be extrapolated beyond the acute in-patient rehabilitation setting. Trial registration: German Clinical Trials Register identifier: DRKS00010250..

Association of delirium and spatial neglect in patients with right-hemisphere stroke.

Delirium, an acute and fluctuating decline in cognitive functioning, increases mortality and length of hospital stays (LOS) and adversely affects functional outcomes. Previous studies suggested that the incidence of delirium may be increased in right-hemisphere strokes. Similarly, spatial neglect, a disabling deficit in unilateral spatial processing, is more common and more severe following a right-sided stroke. Spatial neglect has been established as a risk factor for delirium. It was hypothesized that functionally relevant spatial neglect and delirium are associated in patients with right-hemisphere stroke during acute inpatient rehabilitation. Data were examined from consecutive unilateral stroke patients evaluated with the 3-minute diagnostic interview for confusion assessment method (3D-CAM) and the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP). A retrospective, cohort study. Data collected in an acute inpatient rehabilitation facility. Six hundred twenty six patients with stroke were included. The measures were the relative risk of patients with right-hemisphere stroke having delirium when also positive for spatial neglect compared to patients with right-hemisphere stroke without spatial neglect, the incidence of 3D-CAM positive results by stroke hemisphere, and the effect of spatial neglect and delirium on functional outcomes for patients with right-brain stroke patients. There was a significantly higher risk of delirium in patients with right-hemisphere stroke with spatial neglect compared to patients with right-hemisphere stroke without spatial neglect. The rates of 3D-CAM positive results were not statistically different for left- compared to right-hemisphere strokes. Both delirium and spatial neglect had significant adverse effects on right-hemisphere stroke patients' functional independence. The results demonstrate an association between spatial neglect and delirium in patients with right hemisphere stroke in the acute inpatient rehabilitation setting. Because of the negative effect of these impairments on functional outcomes after stroke, prevention, early detection, and targeted treatments should be prioritized for these patients.

Post-acute Care Needs and Benefits of Inpatient Rehabilitation Care for the Oncology Patient.

This study aims to assess recent literature published on the post-acute care needs of cancer patients, specifically focusing on the acute inpatient rehabilitation setting. The neurologic cancer population appears to be the most studied oncologic population in acute inpatient rehabilitation studies within the past 5years. This finding is consistent with prior findings from the past several decades. Recent trends in inpatient cancer rehabilitation note a population with lower admission functional status and shorter lengths of stay compared to prior studies. Despite these findings, the percentage discharged to the community remains high. With new treatments yielding improved survival, cancer patients may live longer and risk accumulating more functional impairments. Physicians involved in their care must understand post-acute care needs and work in a multidisciplinary group to best determine post-acute disposition. This decision remains very individualized and should consider both oncologic and functional needs.

Addressing the Operational Challenges for Outpatient Stroke Rehabilitation.

The traditional model of rehabilitation services includes clear requirements for provision of services in the acute inpatient rehabilitation setting. However, there are fewer guidelines on the frequency and duration of rehabilitation services beyond the acute setting. Recent research has suggested that neurorehabilitation interventions that are provided frequently enough upon discharge from acute inpatient rehabilitation to facilitate repeated practice and feedback improve long-term stroke outcomes. However, it is challenging to provide high-frequency outpatient rehabilitation, as the logistics of scheduling and insurance limitations often do not allow it. The Sheikh Khalifa Stroke Institute at Johns Hopkins Medicine innovated a new model to provide the appropriate frequency of therapy for stroke rehabilitation in the outpatient setting. This article describes the restructured operational infrastructure for outpatient stroke rehabilitation to facilitate high-frequency transdisciplinary stroke rehabilitation in the real world, including the development of the outpatient postacute therapy programs and the identification of appropriate patients for each program, the development of scheduling matrices and treating teams to deliver the postacute therapy programs, the implementation of transdisciplinary neurorehabilitation, and the steps taken to empower patients to engage in rehabilitation at home and address barriers to accessing the programs. We assessed the effect of the operational restructuring on schedule utilization, no-show rates, and cancellation rates in the 3 mos before and after implementation of the program and show that it increased schedule utilization and reduced no-show rates and cancellation rates, suggesting that it may increase compliance with rehabilitation. It is possible to create the infrastructure needed to bridge the continuum of care for poststroke recovery and rehabilitation.

Sleep Quality in An Acute Inpatient Rehabilitation Setting: The Importance of Prior Sleep Disorders

<h3>Research Objectives</h3> To assess whether demographic and clinical factors might impact sleep quality during inpatient stay in a rehabilitation setting. <h3>Design</h3> In this prospective study, patients were assessed for their sleep quality at admission and discharge. <h3>Setting</h3> Patients admitted in the acute inpatient rehabilitation unit of Casa Colina Hospital and Centers for Healthcare (Pomona, California) were included in the study. <h3>Participants</h3> Thirty five patients participated to this study (age=61±16 years old; BMI=30±7kg/m2; 18 females, 18 Caucasians). <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> The Pittsburg Sleep Quality Index (PSQI) was administered as primary outcome. Demographic and clinical data were collected as covariates (i.e., age, BMI, gender, race, cause of hospitalization, pre-hospital setting and prior diagnosis of sleep disorders). The level of anxiety and depression were also assessed using Beck Anxiety Inventory (BAI) and Patient Health Questionnaire-9 (PHQ-9). <h3>Results</h3> The average length of hospitalization was 18±8 days. Cause of hospitalization included stroke (20%), spinal cord injury (28%), orthopedic (28%) and other diagnosis (23%). In this sample, 22% had a sleep disorder diagnosis (mostly sleep apnea) and 60% came from an acute care unit. ANOVAs with repeated measures were performed on the outcome measure (PSQI) controlling for BMI and age. Among the demographic and clinical variables considered, the presence of sleep disorders had an effect on changes in PSQI total scores. The PSQI decreased significantly in patients with prior diagnosis of sleep disorders. The pre-hospital setting trended toward statistical significance only for the group without sleep disorders. The initial level of anxiety or depression did not have an effect on the PSQI scores. However, changes in BAI and PHQ-9 total scores were related to changes in PSQI. Finally, our dataset did not reveal an effect of race or gender. <h3>Conclusions</h3> Prior sleep disorders diagnoses factors has an impact on sleep quality during hospitalization. These results identify high-risk patient characteristics that impact sleep hygiene which will be taken into consideration in developing an intervention for improving inpatient sleep hygiene. <h3>Author(s) Disclosures</h3> The authors have nothing to declare.

Increasing Compliance of Deep Vein Thrombosis Medical Prophylaxis in Acute Inpatient Rehabilitation Setting.

To improve medication reconciliation and decrease the rate of deep vein thrombosis (DVT) after the transfer of brain-injured neurologically impaired patients from an acute hospital setting to an inpatient rehabilitation facility, a performance improvement strategy was put in place. Such a strategy consisted of adding the proper DVT prophylaxis medication and dosage in the preadmission screen to prevent a delay in receiving the appropriate medication. This resulted in a dramatic reduction of inappropriately discontinued medications from 14.2% of patients to 5.78% over six months (p-value: 0.03). However, after the intervention, we surprisingly observed an increased rate of DVT from 6.2% to 10.11% (p-value: 0.03). This increase may be attributable to a larger number of venous duplex studies performed because of increased awareness of venous thromboembolism (VTE).

Factors Associated With Ventilator Weaning Success and Failure in People With Spinal Cord Injury in an Acute Inpatient Rehabilitation Setting: A Retrospective Study.

To evaluate baseline characteristics, describe pulmonary outcomes, and identify weaning predictors for people with acute traumatic spinal cord injury (SCI) who are dependent on mechanical ventilation at admission to acute inpatient rehabilitation (AIR). The retrospective study was conducted at an AIR facility in the United States. It included 91 adults with acute traumatic SCI from 2015 to 2019 who were dependent on mechanical ventilation. People who successfully weaned (85%) had fewer days from time of SCI to AIR admission (22 vs. 30, p = .04), higher vital capacity at admission to AIR (12 vs. 3 mL/kg predicted body weight [PBW]; p < .001), and lower (caudal) neurological injury level (p < .001) compared to those who failed weaning. The risk of pneumonia was higher in people who failed weaning compared to those who were weaned successfully (risk ratio, 5.5; 95% confidence interval [95% CI], 2.3-13). Receiver operating characteristics (ROC) curves suggest a vital capacity cutoff of 5.8 mL/kg PBW could predict weaning. The vital capacity of ≥ 5.8 mL/kg PBW is associated with 109 times higher odds (95% CI, 11-1041; p < .001) of weaning than vital capacity below that threshold. In this retrospective study, there was an increased risk of pneumonia in people with SCI who failed weaning at discharge from AIR. Vital capacity was a better predictor of weaning from mechanical ventilation compared to the neurological level of injury, with a cutoff of 5.8 mL/kg PBW predictive of weaning success. Further research is needed on this critical topic.

Benefits of Missing Value Analyses for Clinical Research using a Tele-Psychology Clinical Trial for Individuals with Spinal Cord Injury

<h3>Research Objectives</h3> Understand and account for missing data in a clinical research study. <h3>Design</h3> Randomized controlled clinical trial. <h3>Setting</h3> Santa Clara Valley Medical Center acute inpatient rehabilitation and general community setting. <h3>Participants</h3> Twenty-six individuals with spinal cord injury who presented with mild to moderate depression within 1-year post-injury. <h3>Interventions</h3> Cognitive Behavioral Therapy-based tele-psychology delivered via iPad FaceTime (10 sessions over 12 weeks). <h3>Main Outcome Measures</h3> Missing values across study variables, including demographics, Patient Health Questionnaire-9, Generalized Anxiety Disorder–7, and Satisfaction with Life Scale. <h3>Results</h3> The whole group Missing Value Analysis (MVA) revealed ∼17% of values were missing (125/754), 9/26 participants had at least one missing value, and 27/29 variables had at least one missing value. Out of 2^29 possible missing value patterns, only 10 were apparent and the most common missingness pattern was no missing data. Little's Missing Completely At Random (MCAR) test (ꭕ2[df=136, N=26]=134.2,p=.528) showed data were MCAR, with no relationship between missing data and any values in the dataset. Principal component analysis suggested four principal components that remained consistent after imputing missing data (mean substitution). Within-arm MVA showed data in both groups was MCAR (Group 1:ꭕ2[df=101, N=15]=63.2,p=.999;Group 2:ꭕ2[df=35, N=11]=10.8,p=1.00) with similar missingness patterns. <h3>Conclusions</h3> Missing data are an inevitable consequence of clinical research. Although often overlooked, MVA provides a mechanism to account for missing data in either the interpretations (e.g., skewed results) or analytics (e.g., imputing missing data). In this study, whole group and within arm MVA showed the data was MCAR and the data remained consistent after imputing missing values. MVA has the benefit of 1) quality control and assurance of data, 2) understanding and accounting for the missingness of data, and 3) reporting patterns in missing data to inform future studies. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest or financial ties to disclose.

Profiles of TBI Injury Severity as Predictors of Functional Outcomes and Well-being Outcomes

<h3>Research Objectives</h3> To identify profiles of traumatic brain injury (TBI) severity and relate profiles to functional and well-being outcomes. <h3>Design</h3> Longitudinal observational study with assessments during acute rehabilitation, discharge, and one year after injury. <h3>Setting</h3> Santa Clara Valley Medical Center (SCVMC) acute inpatient rehabilitation and general community setting. <h3>Participants</h3> Three hundred and seventy-nine individuals [76.8% male; mean(std) age=34.6(16.9) years] in the Traumatic Brain Injury Model Systems at SCVMC with head computed tomography (CT) data. <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> At discharge- length of stay, Functional Independence Measure (FIM), and Disability Rating Scale (DRS). One-year post-injury- Glasgow Outcome Scale (GOS), FIM, and Satisfaction with Life Scale (SWLS). <h3>Results</h3> Reults: Latent profile analysis (LPA) was used to identify subgroups with similar patterns across 12 indicators of injury severity, including duration of post-traumatic amnesia, Glasgow Coma Scale, time to follow commands, and head CT variables. LPA identified four latent classes: Class1 (least severe; N=75), Class2 (intermediate; N=124), Class3 (moderate; N=144), and Class4 (most severe; N=27). Younger age, lower education, rural residence, injury in motor vehicle accidents, and earlier injury years were associated with worse severity (ps <.05). Latent classes were related to outcomes. Compared to Class1, hospital stays were longer, FIM scores lower, and DRS scores larger at discharge among individuals in Class3 and Class4 (all ps < .01). One-year post-injury, GOS and FIM scores were significantly lower in Class3 and Class4 than Class1 (ps <.01). FIM scores were also lower among individuals in Class2, compared to Class1 (p=.015). SWLS scores were lower only among individuals in Class3 (p=.036); other comparisons relative to Class1 were not significant. <h3>Conclusions</h3> Meaningful profiles of TBI severity can be identified from acute injury characteristics and may suggest premorbid populations at risk for worse injuries, including younger individuals and those with lower education. Improving classification may help focus on those at elevated risk for severe injury and inform clinical management and prognosis. <h3>Author(s) Disclosures</h3> The authors have no conflicts of interest or financial ties to disclose.

Sleep Quality in an Acute Inpatient Rehabilitation Setting: The Importance of Prior Sleep Disorders

<h3>Research Objectives</h3> To assess whether demographic and clinical factors might impact sleep quality during inpatient stay in a rehabilitation setting. <h3>Design</h3> Patients were assessed for their sleep quality at admission and discharge. Demographic and clinical data were collected (i.e., age, Body Mass Index-BMI, gender, race, cause of hospitalization, pre-hospital setting and prior diagnosis of sleep disorders). The levels of anxiety and depression were also assessed. <h3>Setting</h3> acute inpatient rehabilitation unit of Casa Colina Hospital and Centers for Healthcare (Pomona, California). <h3>Participants</h3> Thirty five patients participated to this study (age=61±16 years old; BMI=30±7kg/m2; 18 females, 18 Caucasians). The average length of hospitalization was 18±8 days. Cause of hospitalization included stroke (20%), spinal cord injury (28%), orthopedic (28%) and other (23%). In this sample, 23% had prior sleep disorders (mostly, sleep apnea) and 60% came from an acute care unit. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> the Pittsburgh Sleep Quality Index (PSQI), the Beck Anxiety Inventory (BAI) and the Patient Health Questionnaire-9 (PHQ-9). <h3>Results</h3> ANOVAs with repeated measures were performed on the outcome measure (PSQI) controlling for BMI and age. Among the demographic and clinical variables considered, prior sleep disorders had a strong effect on changes in PSQI total scores [F(1,33)= 14.74, p < .001]. The PSQI decreased only in patients with prior diagnosis of sleep disorders [F(1,33)= 5.86, p < .05]. The pre-hospital setting trended toward significance for the group without sleep disorders [F(1,33)= 3.55, p=.07]. Changes in BAI [F(1,33)= 5.02, p < .05] and PHQ-9 [F(1,33)= 5.47, p < .05] total scores were related to changes in PSQI. Finally, our dataset did not reveal an effect of race or gender. <h3>Conclusions</h3> Sleep quality of patients with sleep disorders can deteriorate over inpatient stay and should be addressed in order to optimize recovery during rehabilitation. <h3>Author(s) Disclosures</h3> None.

Patient Sleep Quality in Acute Inpatient Rehabilitation.

Sleep is an important component of neurorehabilitation. This study evaluates sleep quality in the acute inpatient rehabilitation setting and is the first to compare sleep quality in acute rehabilitation versus the acute care hospital and home settings. To assess patient sleep quality in the acute inpatient rehabilitation setting. Cross-sectional survey study. Acute inpatient rehabilitation unit. Seventy-three patients admitted to the acute rehabilitation unit participated in the study. A validated sleep questionnaire was provided on admission regarding sleep at home and in the acute care hospital. The questionnaire was repeated on discharge from the acute rehabilitation unit regarding sleep during their rehabilitation admission. Visual analog scale of sleep depth, falling asleep, number of awakenings, percentage of time awake, and quality of sleep were obtained through use of the Richards-Campbell Sleep Questionnaire. These values were averaged to obtain "overall sleep perception." An additional question on environmental noise was added. Scores ranged from 0 for "worst sleep possible" to 100 for "best sleep possible." Patients reported significantly better sleep in all domains and overall in the acute rehabilitation unit compared to the acute care hospital, with the exception of percentage of time awake. Patients also reported significantly better sleep depth but worse noise in the acute rehabilitation unit when compared to home. Similarly, patients reported significantly better sleep in all domains and overall at home in comparison to the acute care hospital with the exception of percentage of time awake. Patient in the acute rehabilitation unit experience sleep quality that matches their experience at home and exceeds that in the hospital.

Comparing outcomes of mechanical ventilation with high vs. moderate tidal volumes in tracheostomized patients with spinal cord injury in acute inpatient rehabilitation setting: a retrospective cohort study.

Retrospective cohort study. The primary objective of this study was to evaluate safety and efficacy of higher tidal volumes (HVt) compared to moderate Vt (MVt) in people with spinal cord injury (SCI) admitted to acute inpatient rehabilitation (AIR) facility on mechanical ventilation via tracheostomy. AIR facility in the United States. Eighty-four adults with SCI were divided into MVt group if maximum Vt received in AIR was <15 ml/kg predicted body weight (PBW) and HVt group if maximum Vt was >15 ml/kg PBW. Primary outcomes were incidence of pneumonia and composite pulmonary adverse events (pneumonia, weaning failure, or acute care transfers due to respiratory complications). Secondary outcomes were AIR preweaning days defined as time from AIR admission to beginning of weaning, weaning days defined as days from start to end of weaning, and AIR ventilator days calculated as days on ventilator from AIR admission to discharge. MVt was utilized in 50 patients and HVt was utilized in 34 patients. The risk of pneumonia in HVt group was 4.3 times higher [95% confidence interval (CI): 1.5-12] compared to MVt group. Odds of pulmonary adverse events in HVt group was 5.4 times higher (CI: 1.8-17) compared to MVt group. There was no difference in preweaning days, weaning days, or AIR ventilator days between the two groups. Our data suggest that HVt is associated with increased risk of pneumonia and higher odds of pulmonary adverse events in tracheostomized patients with SCI which warrants further investigation.

An interview based approach to the anorectal portion of the International Standards of Neurological Classification of Spinal Cord Injury Exam (I-A-ISNCSCI): a pilot study.

Prospective, single-blinded study. To design and evaluate the use of an interview based version of the anorectal portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) exam in the acute inpatient rehabilitation (AIR) setting. AIR unit. Participants admitted to AIR underwent standard ISNCSCI exams (S-ISNCSCI) as part of routine inpatient care within 3 days of being administered an interview version of the anorectal portion of the ISNCSCI (I-A-ISNCSCI). Agreement between the anorectal portion of the S-ISNCSCI (S-A-ISNCSCI) and the I-A-ISNCSCI was evaluated. Forty of forty-five enrolled participants completed the assessments. Agreement between the I-A-ISNCSCI and S-A-ISNCSCI was substantial for anorectal sensation to light touch (k = 0.71, 95% CI 0.52-0.90, N = 36), pin prick (k = 0.68, 95% CI 0.48-0.87, N = 38), deep anal pressure (k = 0.77, 95% CI 0.53-1.00, N = 37), and completeness of injury based on combined sacral sensory criteria (k = 0.72, 95% CI 0.47-0.97, N = 40); and fair for voluntary anal contraction (k = 0.29, 95% CI -0.01 to 0.59, N = 36). Responses of "I don't know" were excluded from agreement analyses. This pilot study was a first step in developing interview based tools such as the I-A-ISNCSCI in an AIR setting providing convenient access to individuals with SCI and their direct feedback. The study design introduces potential recall bias and may not match true clinical situations such as remote follow-up of neurological changes for chronic patients. The use of interview based tools for assessing individuals with SCI remains worthy of further study.

Standardizing Geriatric Depression Screening in the Acute Inpatient Rehabilitation Setting

To determine the significance of depression screening within the geriatric acute inpatient rehabilitation population.

Impact of Successful Implementation of an Antimicrobial Stewardship Program in an Inpatient Rehabilitation Setting

BACKGROUND Antimicrobial stewardship in any setting is vital to organizational performance measures, as well as to meeting National Patient Safety Goals. Antimicrobial resistance causes about 23,000 deaths per year and about 250,000 cases of hospital-onset Clostridium difficile (C.diff) each year. This study was designed to determine if successful implementation of an antimicrobial stewardship program (ASP) would help in reducing the treatment of asymptomatic bacteriuria in the acute care inpatient rehabilitation setting to reduce overall antimicrobial use. METHODS This study was a confirmatory research process. We included all patients admitted to the inpatient rehabilitation facility during the study period from January 2017 through October 2018. Data was based on the National Healthcare Safety Network (NHSN) approved signs or symptoms. Education was provided to all clinical and medical staff. Data was collected monthly to determine what areas still needed attention until all aspects of the ASP were implemented successfully. RESULTS Initially, rates averaged around 79% of patients unnecessarily treated for asymptomatic bacteriuria. The study observed 2,591 patients admitted over a period of 22 months, during which we were able to reduce our erroneously treated asymptomatic patients to 0%. Medical staff are only utilizing NHSN definitions to treat patients if needed, staff are only looking for NHSN signs and symptoms to report to physicians, and overall days of therapy have been greatly reduced. CONCLUSIONS Implementation of an ASP reduces the overall use of antimicrobials with continued education and organizational support. Lower antimicrobial usage rates reduce the occurrence of hospital-onset C.diff infections and prevent long-term effects such as antimicrobial resistance. Facilities of all types may want to consider implementing ASP programs to reduce antimicrobial usage rates and to ensure patient safety. Antimicrobial stewardship in any setting is vital to organizational performance measures, as well as to meeting National Patient Safety Goals. Antimicrobial resistance causes about 23,000 deaths per year and about 250,000 cases of hospital-onset Clostridium difficile (C.diff) each year. This study was designed to determine if successful implementation of an antimicrobial stewardship program (ASP) would help in reducing the treatment of asymptomatic bacteriuria in the acute care inpatient rehabilitation setting to reduce overall antimicrobial use. This study was a confirmatory research process. We included all patients admitted to the inpatient rehabilitation facility during the study period from January 2017 through October 2018. Data was based on the National Healthcare Safety Network (NHSN) approved signs or symptoms. Education was provided to all clinical and medical staff. Data was collected monthly to determine what areas still needed attention until all aspects of the ASP were implemented successfully. Initially, rates averaged around 79% of patients unnecessarily treated for asymptomatic bacteriuria. The study observed 2,591 patients admitted over a period of 22 months, during which we were able to reduce our erroneously treated asymptomatic patients to 0%. Medical staff are only utilizing NHSN definitions to treat patients if needed, staff are only looking for NHSN signs and symptoms to report to physicians, and overall days of therapy have been greatly reduced. Implementation of an ASP reduces the overall use of antimicrobials with continued education and organizational support. Lower antimicrobial usage rates reduce the occurrence of hospital-onset C.diff infections and prevent long-term effects such as antimicrobial resistance. Facilities of all types may want to consider implementing ASP programs to reduce antimicrobial usage rates and to ensure patient safety.

Implementing an Opioid Risk Reduction Program in the Acute Comprehensive Inpatient Rehabilitation Setting

ObjectiveTo describe the implementation and evaluation of an interdisciplinary quality improvement (QI) project to increase prescription of take-home naloxone (THN) to reduce risks associated with opioids for patients admitted to an acute inpatient rehabilitation unit. DesignProspective cohort quality improvement project. SettingEighteen-bed acute comprehensive inpatient rehabilitation (ACIR) unit at a large academic institution. ParticipantsPatients admitted to ACIR between December 2015-November 2016 (N=788). InterventionsAn interdisciplinary QI model comprised of planning, education, implementation, and maintenance was used to implement a THN and opioid risk-reduction program involving provider and patient education. Analyses consisted of comparisons between baseline, early, and late phases of the project. Main Outcome Measures(1) The proportion of eligible patients who received a prescription for naloxone upon discharge from ACIR; (2) the proportion of patients originally admitted to ACIR on opioids that were weaned off upon discharge. ResultsThe adjusted odds of eligible patients being discharged from ACIR with a naloxone prescription during the late QI period were 7 (95% confidence interval [CI]: 3-21) times higher than during the early QI period (late QI period: 43%, 95% CI: 25%-63%; early QI period: 10%, 95% CI: 3%-28%; P<.001). For patients admitted on opioids, the adjusted odds of being weaned off opioids during the late QI period were 10 (95% CI: 4-25) times higher than during baseline (late QI period: 29%, 95% CI: 17%-45%; baseline: 4%, 95% CI: 1%-10%; P<.001). ConclusionsImplementation of a THN and opioid risk reduction QI project in an inpatient rehabilitation setting led to significantly more eligible patients receiving naloxone and more patients weaned off schedule II opioids.

Montreal Cognitive Assessment in Inpatient Stroke Rehabilitation: Diagnostic Accuracy and Optimal Cutoff Points

To determine the diagnostic accuracy, sensitivity, specificity, and optimal cutoff point of the Montreal Cognitive Assessment (MoCA) in individuals with mild stroke in an acute inpatient rehabilitation setting.

Acute Treatment of an Atypical Benign Paroxysmal Positional Vertigo Variant Postsevere Traumatic Brain Injury

Background and Purpose: The differential diagnosis and treatment of peripheral vestibular disorders in persons with traumatic brain injury presents a complex set of challenges. In the acute rehabilitation setting, orthopedic and medical restrictions, agitation, and/or the inability of the patient to verbalize current symptoms present barriers to many traditional means of assessment and intervention. The purpose of this article is to present a case report of 2 patients successfully treated in the acute inpatient rehabilitation setting postsevere traumatic brain injury with an atypical variant of horizontal canal benign paroxysmal positional vertigo in which both examination and intervention modifications were required in a novel context when applied to this patient population. Case Description: Two patients were consulted to have a vestibular rehabilitation examination performed given interdisciplinary reports of nystagmus and in 1 case significant emesis associated with bed mobility. Both patients presented as Rancho Los Amigos classification 3 to 4, were nonverbal, and presented with multiple comorbidities. Intervention: Both patients were treated for apogeotropic horizontal canal benign paroxysmal positional vertigo using a sequence of bedside canalith repositioning maneuvers safely and efficiently accommodating the clinical brain injury presentation. Outcomes: Both patients demonstrated complete remission of horizontal nystagmus and remission of associated emesis in the 1 case allowing for increased interdisciplinary rehabilitation participation. Discussion: This case report illustrates how application of recent scientific and clinical evidence may be applied within the early acute brain injury population. Vestibular rehabilitation may be an important component to acute neurological rehabilitation posttraumatic brain injury, even when the patient cannot actively verbalize symptoms. In these cases, the clinician must then use a collaborative approach as well as a clinical decision-making model on the basis of an understanding of the neurological underpinning of eye movements and nystagmus.

Survey of parental acceptance of massage therapy, energy therapy and acupuncture for their children in the acute pediatric inpatient rehabilitation setting

ObjectiveTo examine factors that influence parents' decision to accept or decline complementary therapies on an inpatient rehabilitation unit. Design/SettingParents of children aged 2–21 admitted for acute pediatric rehabilitation were provided a survey regarding their child's use of massage, energy therapy and acupuncture during admission. They were also asked about religious beliefs, education, perceived severity of injury and perceived response to the therapies. The study was conducted on the Inpatient Acute Pediatric Rehabilitation Unit at Kennedy Krieger Institute in Baltimore, Maryland, USA. ResultsOf those who completed the survey (n=38), 39% accepted massage services, 49% accepted energy therapy, and 16% accepted acupuncture for their child. Acceptance of massage services was significantly correlated with belonging to an organized religion (p<0.05). Participation in weekly religious services was associated with rejection of energy therapy (p<0.01). Prior parental experience with massage and acupuncture was associated with acceptance of these services for their child (p<0.01). Chronicity of condition and family education was not related to acceptance or rejection of services. Over 80% of parents felt massage and energy therapy helped the recovery process. In 63% of parents surveyed, acupuncture was felt to help the recovery process. ConclusionsPrior exposure to massage therapy and acupuncture was the most important factor in a parent accepting these services for their child. All three services were subjectively felt to have facilitated recovery. Future studies should assess subjective versus objective utility of these therapies in acute pediatric rehabilitation.