Acute Rehabilitation Services Research Articles

Personalised exercise rehabilitation in cancer survivorship: the percs triage and referral system study protocol

BackgroundTo effectively embed exercise rehabilitation in cancer survivorship care, a co-ordinated system of acute and community exercise rehabilitation services, forming a stepped model of care, is recommended. Patients can be directed to the exercise rehabilitation service which best meets their needs through a system of assessment, triage and referral. Triage and referral systems are not yet widely applied in cancer survivorship practice and need to be evaluated in real-world contexts. The PERCS (Personalised Exercise Rehabilitation in Cancer Survivorship) study aims to evaluate the real-world application of an exercise rehabilitation triage and referral system in cancer survivors treated during the COVID-19 pandemic. Secondary aims are to evaluate change in physical and psychosocial outcomes, and to qualitatively evaluate the impact of the system and patient experiences, at three months after application of the triage and referral system.MethodsThis study will assess the implementation of an exercise rehabilitation triage and referral system within the context of a physiotherapy-led cancer rehabilitation clinic for cancer survivors who received cancer treatment during the COVID-19 pandemic. The PERCS triage and referral system supports decision making in exercise rehabilitation referral by recommending one of three pathways: independent exercise; fitness professional referral; or health professional referral. Up to 100 adult cancer survivors treated during the COVID-19 pandemic who have completed treatment and have no signs of active disease will be recruited. We will assess participants’ physical and psychosocial wellbeing and evaluate whether medical clearance for exercise is needed. Participants will then be triaged to a referral pathway and an exercise recommendation will be collaboratively decided. Reassessment will be after 12 weeks. Primary outcomes are implementation-related, guided by the RE-AIM framework. Secondary outcomes include physical function, psychosocial wellbeing and exercise levels. Qualitative analysis of semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR) will provide insights on implementation and system impact.DiscussionThe PERCS study will investigate the real-world application of a cancer rehabilitation triage and referral system. This will provide proof of concept evidence for this triage approach and important insights on the implementation of a triage system in a specialist cancer centre.Trial registrationThis study is registered on ClinicalTrials.gov, registration number: NCT05615285, date registered: 21st October 2022.

Post–Acute Care Rehabilitation Services and Outcomes in Skilled Nursing Facilities Before and During the COVID-19 Pandemic

This cohort study evaluates changes in rehabilitation services provided by skilled nursing facilities during the COVID-19 pandemic.

Urinary Dysfunction: Frequency, Risk factors, and Interventions in patients with Cancer during Acute Inpatient Rehabilitation.

Introduction: Urinary dysfunction has a strong impact clinically, socially, and economically. Although the development of acute urinary dysfunction in hospitalized patients with cancer is common in clinical practice, its occurrence and management strategies are scant in the literature. It has been reported as one of the more common medical complications in patients with cancer undergoing acute inpatient rehabilitation. This study assessed the frequency of and risk factors for acute urinary dysfunction among these patients and identified the interventions used for management. Methods: This is a retrospective study of consecutive patients admitted to a National Cancer Institute Comprehensive Cancer Center's acute inpatient rehabilitation service from 9/1/2020 through 3/15/2021. We excluded patients that were readmissions during the study time frame. We collected patients' demographic, clinical, and functional data. We defined acute urinary dysfunction as the development of any new urinary symptom(s) or diagnosis, which involved additional work-up and/or management after admission to the acute inpatient rehabilitation service. Results: Of the 176 total patients included in this study, 47 (27%; 95% confidence interval [CI], 20-34) patients had acute urinary dysfunction. The most frequent diagnoses were urinary tract infection (32%) and neurogenic bladder (26%). The most common tests were urine cultures (32%) and urinalyses (30%). The most commonly prescribed medications were antibiotics (32%) and alpha-1 blockers (15%). Other most frequent interventions included timed voiding (34%) and intermittent catheterization with bladder scans (28%). Acute urinary dysfunction was associated with an increased length of stay on the inpatient rehabilitation service (odds ratio [OR], 1.13; 95% CI, 1.06-1.20; P<.001), surgery during the index admission (OR, 2.50; 95% CI, 1.21-5.16; P=.014), and fecal incontinence (OR, 6.41; 95% CI, 1.83-22.44; P=.004). Conclusion: Acute urinary dysfunction was noted to be a substantial problem in this cohort. This is an overlooked dimension of inpatient cancer rehabilitation that deserves more attention. Patients at risk for acute urinary dysfunction may benefit from close monitoring for medical management and rehabilitation interventions to maximize functional independence with bladder care. More research regarding acute urinary dysfunction types and management approaches in post-acute care settings for patients with cancer is justified.

Social Determinants Of Health And Onset Of Rehabilitation Services Among Individuals With Traumatic Brain Injury

<h3>Research Objectives</h3> Early onset of rehabilitation services is associated with functional outcomes at discharge. However, the impact of social determinants of health (SDoH) on early access to acute care rehabilitation services in not well understood. We sought to examine the influence of community-level SDoH on early access to rehabilitation services among individuals with TBI. <h3>Design</h3> In a secondary analysis of de-identified electronic health record (EHR) data, multinomial logistic regression models were computed to calculate odds ratios and 95% confidence intervals for the likelihood of early onset of rehabilitation services. <h3>Setting</h3> 14 regional acute care hospitals. <h3>Participants</h3> 5,812 adults with TBI. <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> Community-level SDoH (i.e., Median income; Education attainment; Residence location). Onset of rehabilitation services in days (i.e., No Services; Early; Minimally delayed; Delayed). <h3>Results</h3> Multinomial logistic regression models showed that patients living in locations with a median income between $47,500 and $61,069 (vs. median income ≤$47,500) were more likely to receive no OT (OR=1.704, p < .05) and PT services (OR=1.619, p < .05; vs. receiving delayed services). Compared to patients with severe TBI, those with mild or moderate were more likely to receive early access to OT (OR=3.188, p < .05) and PT services (OR=2.793, p < .05; vs. receiving delayed services). Patients with greater comorbidity burden were less likely to have early access to OT (OR=.876, p < .05) and PT services (OR=.870, p < .05; vs. receiving delayed services). Other indicators of community-level SDoH were not associated with onset of rehabilitation services. <h3>Conclusions</h3> Further research is needed to determine whether our SDoH variables were too diffuse to capture individual experiences and impacts on care, or whether community-level education and income, and rurality truly do not influence time to therapy for patients hospitalized with TBI. Other, individual-level variables, such as age, comorbidity burden, and TBI severity, demonstrated clear relationships with therapy onset. These findings may help therapists evaluate and standardize equitable access to timely rehabilitation services. <h3>Author(s) Disclosures</h3> None.

COVID-19 in Acute Inpatient Rehabilitation (CARE): Factors Affecting Recovering Patient Outcomes

Retrospective chart review which included patients admitted to an acute inpatient rehabilitation service at a single center from April 2020 to July 2021. Rehabilitation outcomes assessed included discharge disposition, functional efficiency, change in self-care and mobility, and length of stay (LOS).

Nutrition Management in Patients With Traumatic Brain Injury: A Narrative Review.

Traumatic brain injury (TBI) is a major cause of long-term physical and psychological disability and death. In patients with TBI, undernutrition is associated with an increased mortality rate, more infectious complications, and worse neurologic outcomes. Therefore, timely and effective nutritional therapy is particularly crucial in the management of TBI to improve patients' prognoses. This narrative review summarizes the issues encountered in clinical practice for patients with neurotrauma who receive acute and post-acute in-patient rehabilitation services, and it comprehensively incorporates a wide range of studies, including recent clinical practice guidelines (CPGs), with the aim of better understanding the current evidence for optimal nutritional therapy focused on TBI patients. Recent CPGs were reviewed for 6 topics: 1) hypermetabolism and variation in energy expenditure in patients with TBI, 2) delayed gastric emptying and intolerance to enteral nutrition, 3) decision-making on the route and timing of access in patients with TBI who are unable to maintain volitional intake (enteral nutrition versus parenteral nutrition), 4) decision-making on the enteral formula (standard or immune-modulating formulas), 5) glycemic control, and 6) protein support. We also identified areas that need further research in the future.

Clinical profile, aetiology, short-term outcome and predictors of poor outcome of neonatal seizures among out-born neonates admitted to a neonatal unit in Paediatric emergency of a tertiary care hospital in North India: A prospective observational study.

Neonatal seizures are common manifestations of several neurological or systemic disorders and associated with high morbidity, mortality and poor short- and long-term developmental outcomes. It is important to determine the aetiology and factors that determine the poor outcome, more so in a newly developed setting. The early detection of predictors of poor outcome will help in planning acute management, counselling, follow-up and rehabilitation services. In this prospective observational study, we looked at the clinical profile, aetiology, short-term outcomes and predictors of poor outcome of neonatal seizures among out-born neonates. The common causes were hypoxic ischaemic encephalopathy, sepsis and metabolic disturbances. One-third of neonates had poor outcome. Abnormal neurological and cardiorespiratory examination at admission; low oxygen saturation, glucose and pH; and hypoxic ischemic encephalopathy-III were predictors of poor outcome.

Phase-Adapted Rehabilitation for Acute Coronavirus Disease-19 Patients and Patient With Long-term Sequelae of Coronavirus Disease-19.

Since the beginning of the COVID-19 pandemic in early 2020, many papers have highlighted the need for the rehabilitation of patients with SARS-CoV-2 infection. Most papers refer to the need for respiratory rehabilitation in the acute phase; however, the fact that the infection also affects other organ systems has to be considered in rehabilitation interventions. Long-term symptoms in many cases severely limit activity and participation and alter quality of life, leading to rehabilitation needs. This article proposes a phase-adapted model of linking the acute, postacute, and long-term symptoms of COVID-19 with the well-established matrix of acute, postacute, and long-term rehabilitation services. A review of currently available recommendations for phase-adapted rehabilitation strategies, including the relevance of prehabilitation within this context, is provided.

Length of Hospital Stay for Hip Fracture and 30-Day Mortality in People With Alzheimer's Disease: A Cohort Study in Finland.

BackgroundPersons with Alzheimer’s disease (AD) are at higher risk of hip fractures (HFs) than general older population and have worse prognosis after HF. Hospital stays after HF have shortened along time. We investigated the association between length of hospital stay after HF and mortality after discharge among persons with AD.MethodThe MEDALZ cohort includes all Finnish community dwellers who received clinically verified AD diagnosis in 2005–2011 (N = 70 718). Patients who experienced first HF after AD diagnosis in 2005‒2015 (n = 6999) were selected. Length of hospital stay for HF was measured as a sum of the consecutive days spent in hospital after HF until discharge. Outcome was defined as death within 30 days after hospital discharge.ResultsMean of overall length of hospital stay after a HF decreased from 52.6 (SD 62.9) days in 2005 to 19.6 (SD 23.1) days in 2015. Shortest treatment decile (1‒4 days) had the highest risk of death within 30 days after discharge (adjusted hazard ratio [aHR] 2.76; 95% confidence interval [CI] 1.66–4.60) in addition to second (5‒6 days; aHR 2.52; 95% CI 1.50–4.23) and third (7‒10 days; aHR 2.22; 95% CI 1.34–3.69) deciles when compared to the sixth decile of length of stays (21‒26 days).ConclusionsAmong persons with AD, shorter length of hospital stay after HF was associated with an increased risk of death after discharge. After acute HF treatment, inpatient rehabilitation or proper care and services in home need to be organized to older persons with AD.

Exploring post acute rehabilitation service use and outcomes for working age stroke survivors (≤65 years) in Australia, UK and South East Asia: data from the international AVERT trial

ObjectivesInformation about younger people of working age (≤65 years), their post stroke outcomes and rehabilitation pathways can highlight areas for further research and service change. This paper describes: (1) baseline...

Variation in Hospital-Based Rehabilitation Services Among Patients With Ischemic Stroke in the United States.

Little is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke. The objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke. This was a retrospective, cohort design. The sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes. Among 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes. The findings are limited to patients with ischemic stroke. Only 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Epidemiology of Traumatic Spinal Cord Injury in Ireland, 2010–2015

Background: The International Spinal Cord Society and World Health Organisation recommend the collection of epidemiological data on traumatic spinal cord injury (TSCI). A 1-year prospective study is ongoing in Ireland. While the results of this study are awaited, it was concluded from a feasibility exercise that a complete retrospective dataset, 2010–2015, could be obtained and would be useful for service planning. Methods: All patients with TSCI discharged from the national SCI acute and rehabilitation centres were included. Data was collected on gender, age, aetiology, level of injury, American Spinal Injuries Association impairment scale, length of rehabilitation admission and discharge destination. Population denominators were national census figures 2006 and 2011, rolled forward. Results: The incidence of TSCI remained constant throughout the study period, 11.5–13.3 per million per year. The mean age of injury onset was 48.9 (SD 19.8) years. Males accounted for 71.5%. The most common injury level/AIS was incomplete tetraplegia, accounting for 43.2% of all TSCI. Leading aetiology was falls, accounting for 53.3% of injuries. Patients with incomplete tetraplegia were older than those with all other injuries (p < 0.001). Conclusions: The epidemiological trends identified are similar to those prevalent elsewhere in the developed world. More incomplete tetraplegia among an older patient population necessitates a review of how acute care and rehabilitation services are delivered.

Neurocognitive Engagement Therapy

Background and Purpose: Physical rehabilitation therapists are recognizing increasing numbers of older clients presenting with cognitive impairment in the post–acute setting. Therapists working with these patients often feel ill-prepared to address the special challenges of this population and often experience difficulty fully engaging the client in therapy. Decreased engagement in a therapy plan of care may lead to worse functional outcomes and increased debility. The purpose of this study was to examine the efficacy of neurocognitive engagement therapy (NET), a new model for rehabilitation, through a randomized clinical trial. Neurocognitive engagement therapy utilizes evidence-based best practices in dementia care as well as task-specific practice to increase engagement and therapeutic gains among individuals with cognitive impairment in the post–acute setting. Methods: Eighty-five subacute rehabilitation patients participated in the study, with 43 in the active group who received care based on the NET model and 42 in the control group who received traditional post–acute rehabilitation services. The groups were randomly assigned by location of the post–acute admission. The Pittsburgh Rehabilitation Participation Scale was used to measure patient engagement in physical, occupational, and speech therapy. The Modified Barthel Index was used to assess change in overall function. Results and Discussion: Results revealed that Active group participants demonstrated higher mean engagement ratings across all 3 NET therapy types (Ps ≤ .05), with the same mean number of sessions. A Group-by-Time ANOVA revealed a significant interaction effect (P = .05) for pre-/postfunctional gains on the Barthel, indicating more functional gains in the Active group. After accounting for individual differences in engagement, hierarchical multiple linear regression modeling demonstrated that engagement mediated the effects on functional improvement. That is, active patients appeared to have greater functional gains because they had higher engagement. Conclusion: The results suggest that NET is efficacious for cognitively impaired patients. Patients who received NET were more engaged in the process of therapy and had greater functional gains than those who were cognitively impaired and received traditional rehabilitation.

Integrated Care Pathway for Patients with Spinal Cord Injury in Ireland

Introduction: Trauma and rehabilitation networks in Ireland are largely underdeveloped and there is significant variance in patient pathway within and across acute hospital services, specialist rehabilitation services and post-acute regional or community based rehabilitation services. Currently, in the absence of established clinical pathways across existing acute and rehabilitation services, patient pathway is convoluted. For patients with the most complex and severest injuries access to complex specialist rehabilitation services is compromised and outcomes such as discharge to community is poor. The vision for this project was to develop an all systems approach to support the patient journey for patients with Spinal Cord Injury from acute hospitals, post-acute rehabilitation services, disability services and long term care. Short description of practice change implemented: The National Clinical Programme for Rehabilitation Medicine has developed a care pathway in collaboration with all key stakeholders which describe the ideal patient journey for all those with a spinal cord injury, including those who are ventilator dependent. This is the first time such a pathway has been developed and will promote a patient centred approach to the management of this cohort of patients while also giving clear parameters against which patient journey can be measured going forward. Currently there is a cohort of patients in Ireland with high level spinal cord injury including some who remain in need of chronic ventilation who are unable to be served through within existing services. These patients are experiencing prolonged stays in acute hospital and some are unable to access complex specialist rehabilitation services. Implementation of the pathway will see patients who are ventilator dependent being able to access specialist rehabilitation services in Ireland for the first time and will also see the possibility of a discharge home realised for many. Aim and theory of change: The reduction in unnecessary variation in the care pathway of patients with spinal cord injury was felt to be achievable through the development of an ICP in collaboration with all key stakeholders. Targeted population and stakeholders: The ICP for patients with spinal cord injuries spans numerous service delivery sites, as such, collaboration with a wide number of stakeholders including acute hospitals, critical care, rehabilitation services, disability and community services, patients and patient support groups was necessary. Timeline: This project was identified as an area needing development in the 2016 workplan of the Rehabilitation Medicine Programme. Highlights: The project is small in numbers but significant in terms of process changes. It requires services working together across organisational boundaries in a way that is not often seen within the Irish healthcare system. Implementation will see patients with complex disability being able to access services in Ireland which they previously would have had to travel oversees to access. Comments on sustainability: The Principles supporting the care pathway are reflective of evidence based practice. The extensive consultation process undertaken by the programme has supported multi-agency collaboration and buy-in which will sustain this new way of working. The parameters set out in the patient pathway will afford us the opportunity to objectively measure patient journey and identify unnecessary variation in a way previously not possible. Comments on transferability: While this pathway is for spinal cord injury, the underpinning principles should be consistent for all with a need for specialist rehabilitation service and thus applicable across other diagnostic groups. Conclusions: The high level objectives for the project are: Process Improvements: - Improved access to both the National Spinal Unit (NSIU) and NRH for all patients requiring the tertiary level services they provide - Allow access to post acute specialist rehabilitation services at the NRH, particularly for those who are ventilator dependent Quality: - Reduce the number of patients being discharged back to acute hospital setting post rehabilitation services - Improve patient experience Discussions: Quality care is care which is patient centred. To be truly patient centred, a move away from individual service priorities is required with a focus on aligning priorities to support the patient journey. Lessons learned: The patient voice should be central to all health care planning

Rehabilitation Services Provision and Payment.

Persons with spinal cord injury (SCI) experience disability and have significant need for rehabilitation. To deliver appropriate rehabilitation, interventions and programs suitable services must exist. A prerequisite for system improvement is a description of rehabilitation services. The aim of this paper was to develop a rehabilitation service framework for SCI. Additionally, principles and models of payment of rehabilitation services will be discussed. Health-related rehabilitation services should be available along the continuum of care and implemented at all levels of health care. The three most important types of services are acute, postacute, and long-term rehabilitation services. Health-related rehabilitation services for patients with SCI must be able to provide high-quality equipment and a well-trained, highly specialized and multiprofessional team of rehabilitation workers. The principles of payment for SCI rehabilitation services vary according to the organization of health care systems, which primarily depends on the sources of money (eg, from national health care systems, other health insurances, or out of pocket). Funding systems and payment criteria may influence service provision and justice in service delivery. It is important to analyze the provision of rehabilitation services and the related funding system using uniform assessment and evaluation tools.

Reduced Functional and Quality of Life Outcomes Associated With Delays in Evaluation for Acute Rehabilitation Services

To assess the impact of delays in evaluation for rehabilitation services on disability and health-related quality of life (HRQoL) after ischemic stroke and transient ischemic attack (TIA).

Exploring Health Care Providers’ Perceptions of the Needs of Stroke Carers: Informing Development of an Optimal Health Program

Background: Health care provider experiences of the carer have been researched, but little is written about how these can inform development of support programs. Objectives: This study aimed to (1) explore health care provider perceptions of stroke carer roles and support needs and (2) examine carer needs across the stroke care trajectory to assist with development of an Optimal Health Program (OHP) to support carers. This study is part of a staged program of research that will evaluate and refine the OHP. Methods: Four dual-moderated semi-structured focus groups of stroke health care providers across acute, subacute, and community rehabilitation services were conducted. Facilitators used a semi-structured focus group schedule to guide discussion. Sessions were recorded, transcribed, and analyzed using thematic and content analysis. Results: Three key themes emerged: transition, information, and impact of stroke. A number of subthemes highlighted the distinct roles of health care providers and carers. Specific elements of the OHP were identified as having the potential to advance support for carers across the stroke care trajectory. Discussion: Findings support the integration of an OHP for carers within existing stroke care services in Australian public hospital and community settings. Conclusion: This study suggests how health care provider experiences could inform a self-management OHP to assist carers in navigating stroke services and to address their health-related concerns.

Abstract NS17: One Hospital's Experience in Establishing a Stroke Peer Visitor Program

Background and Purpose: Literature suggests that despite being overwhelmed during the acute phase of stroke, patients and families want and are accepting of the support a peer visitor can provide. While patients undergoing acute rehabilitation services in our organization were exposed to a stroke peer visitor network, there was no equivalent peer program for in-patient stroke survivors. Therefore, the purpose was to design, develop and implement a stroke peer visitor program for hospital in-patients. Methods: Using the ShareGivers ™ Peer Visiting program resources as a guide, an in-patient stroke peer visiting program was designed and implemented. Recruitment and training of stroke survivor peer mentors was followed by individualized on-site orientation and program implementation. Evaluations of the program were ongoing. Results: Through 23 weeks of program implementation, six stroke peer visitors contributed 111 hours making 61 patient visits. Stroke peer visitors contributed an average of 5 hours per week. Stroke in-patients welcomed the visits from the peer visitors. Feedback was positive from nursing staff, patients/families and the peer visitors. Common responses were, “I love it when the stroke volunteers are here”, “so helpful to hear from someone who’s been there”, “the patient/family had so many questions”, “had a great visit”. Conclusions: Participant feedback suggests peer visits in the acute phase of stroke recovery are important, beneficial and inspirational. Desire for growth of the program is reflected in requests for annual orientation, adding more peer volunteers, partnering new with experienced volunteers during training and introducing area hospitals to a central peer visiting training concept. Implication for future nursing research includes quantifying the benefits of peer visitation for stroke survivors and their families while in the acute phase of stroke recovery.

Introduction and Overview

Often referred to as the ‘silent epidemic’, traumatic and other forms of acquired brain injury are now considered to represent a significant and growing public health problem worldwide. Beyond the direct impacts of acquired brain injury on injured persons, this disability likewise impacts families. While medical personnel and acute rehabilitation services deliver an incredible array of high quality and sophisticated techniques to treat acute injuries, a concomitant service delivery system to support the needs of families is lacking. This is especially unfortunate given the extensive array of instrumental and affective forms of care families provide to their injured family members, often resulting in high levels of caregiver burden, depression and anxiety.

Implementation of Acute Stroke Rehabilitation Services in Our Hospital －Comparison Between the Years 2010 and 2000－

We retrospectively compared the stroke rehabilitation services in our hospital in 2010 with those in 2000. The severity of strokes in 2010 was worse than that in 2000. The period between the onset of stroke and beginning of physical therapy was shortened from 11.3 days to 4.0 days, and the period between prescription and beginning of physical therapy was shortened from 1.1 days to 0.2 days. We consider that two reasons for these changes were that requests to the department of rehabilitation came at earlier stages in the development of symptoms and that we could shift chronic rehabilitation services to acute rehabilitation services due to an increase in the number of physical therapists. Introducing the electronic medical record system might also have been efficient for these changes.