Acute Rehabilitation Services Research Articles

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.

Prehabilitation for surgical patients: a systematic review protocol

Review question/objective The objectives of this review are to identify the impact of prehabilitation on postoperative outcomes. More specifically, the objectives are to identify: the impact of prehabilitation on post-operative functional status; the impact of prehabilitation on post-operative healthcare utilization (HCU) such as readmission, and/or utilization of acute rehabilitation service; the impact of prehabilitation on post-operative health-related quality of life (HRQL); and the impact of prehabilitation on post-operative pain. Inclusion criteria Types of participants This review will include studies that include adult patients (18 years and older) undergoing surgery in hospitals with the exception of day surgery patients. Types of intervention(s)/phenomena of interest This review will include any preoperative exercise interventions identified as a part of a prehabilitation program or preoperative exercises program in a study comparing it to ‘usual care’. Studies that compare the effectiveness of different prehabilitation programs such as home-based versus hospital-based prehabilitation, or aerobic exercise versus weight training will not be included in this review. Types of outcomes This review will explore the following post-operative outcomes: Primary outcomes: physical functional performance preferably measured by a validated tool such as the Timed Up and Go Test , 6-Minute Walk Test, Barthel Index, or Katz ADL. Secondary outcomes: healthcare utilization in terms of readmission, admission to acute rehabilitation; HRQL; and postoperative pain.

A Transdisciplinary Team Approach to Pain Management in Inpatient Health Care Settings

This paper will discuss the transition from multidisciplinary to interdisciplinary and transdisciplinary team approaches to pain management at New York University Langone Medical Center – Rusk Institute of Rehabilitation Medicine. A transdisciplinary team approach to pain management emphasizes mutual learning, training, and education, and the flexible exchange of discipline-specific roles. Clinicians are enabled to implement a unified, holistic, and integrated treatment plan with all members of the team responsible for the same patient-centered goals. The model promotes and empowers patient and family/support system goals within a cultural context. Topics of exploration include the descriptions of three team approaches to patient care, including their practical, philosophical, and historical basis, strengths and challenges, research support, and cultural diversity. Case vignettes will highlight the strengths and limitations of the transdisciplinary team approach to pain management throughout a broad and diverse continuum of care, including acute medical, palliative, and perioperative care and acute inpatient rehabilitation services.

Abstract TP400: Racial Differences in the Recovery from Ischemic Stroke after tPA.

Racial minorities are at a disadvantage with regards access to acute stroke therapies. We tested the hypothesis that differences between races would result in disparate recovery from ischemic stroke in patients who receive tPA. Data from the Nationwide Inpatient Sample (NIS) for the years 2001 through 2009 were analyzed. The data represents a 20% sample of all inpatient hospitalizations in the United States. Patients discharged with a diagnosis of Ischemic stroke were identified using ICD-9 codes. The code 99.10 was used to identify patients who received tPA. Patients with self reported races: white, black and hispanic who received tPA for ischemic stroke were included. Outcomes of hospitalization including death and discharge destination were assessed. Racial subgroups by age and gender were also analyzed. In the NIS, 15,279 patients received tPA for ischemic stroke between 2001 and 2009. This included 75.3% white, 12.8% black and 6.3% hispanic. In-hospital death rates were not significantly different: 12.8% for white, 10.9% for black and 6.9% for Hispanic; p=0.07. Death rates remained similar even after adjustments for age. In-hospital death was also analyzed in racial subgroups of men, women, young(≤45), middle age (46-70) and elderly(>70); and there was no difference between races. Discharge destination was used as a surrogate for recovery. Blacks and hispanics had about 25% greater odds of being discharged home. However, when adjusted for age, there was no true difference between the races. Considering a home discharge or discharge to a short term rehabilitation facility as a good outcome, blacks were at a significant disadvantage compared to whites; age adjusted OR 0.88(0.80-0.98). This disparity was noted among black men only, and not in black women. As a minority, Hispanic patients had similar rates of home or rehabilitation discharge as whites. In conclusion, in-hospital death rates and the likelihood of home discharge were similar among races. The mechanisms driving disparate access to acute rehabilitation services among black men are probably biological and social. Reasons for differential access to tPA should be explored and addressed, as minorities receiving tPA have similar survival potential and likelihood for home discharge.

Fall-related sub-acute and non-acute care and rehabilitation-related acute care: what is the impact?

BackgroundFalls are one of the leading causes of injury in older people. Rehabilitation services can assist individuals to improve mobility and function after sustaining a fall-related injury. However, the true...

Assessments in Australian stroke rehabilitation units: a systematic review of the post-stroke validity of the most frequently used

Purpose. In Australia, stroke is the leading cause of adult disability. For most stroke survivors, the recovery process is challenging, and in the first few weeks their recovery is supported with stroke rehabilitation services. Stroke clinicians are expected to apply an evidence-based approach to stroke rehabilitation and, in turn, use standardised and validated assessments to monitor stroke recovery. In 2008, the National Stroke Foundation conducted the first national audit of Australia's post acute stroke rehabilitation services and findings identified a vast array of assessments being used by clinicians. This study undertook a sub-analysis of the audit's assessment tools data with the aim of making clinically relevant recommendations concerning the validity of the most frequently selected assessments.Method. Data reduction ranked the most frequently selected assessments across a series of sub-categories. A serial systematic review of relevant literature using Medline and the Cumulative Index to Nursing and Allied Health Literature identified post-stroke validity ranking.Results. The study found that standardised and non-standardised assessments are currently in use in stroke rehabilitation. It recommends further research in the sub-categories of strength, visual acuity, dysphagia, continence and nutrition and found strengths in the sub-categories of balance and mobility, upper limb function and mood.Conclusions. This is the first study to map national usage of post-stroke assessments and review that usage against the evidence. It generates new knowledge concerning what assessments we currently use post stroke, what we should be using and makes some practical post stroke clinical recommendations.

Linking trauma registry injury data with national injury compensation data – opportunities for public health action in New Zealand

BackgroundTrauma registries can play a key role in quality assurance and planning of trauma care. This study aimed to explore the feasibility and utility of linking data from a trauma...

Effectiveness of Rehabilitation in Enhancing Community Integration After Acute Traumatic Brain Injury: A Systematic Review

We assessed evidence for post-acute traumatic brain injury (TBI) rehabilitation interventions used to enhance community integration (CI) relevant to occupational therapy. We conducted a systematic review of intervention studies on TBI rehabilitation from 1990 to 2007. We analyzed and summarized 10 studies that met the inclusion criteria. Of 10 studies, 7 found that post-acute TBI rehabilitation benefits CI; all effective studies involved occupational therapy or involved interventions occupational therapists can do. Many CI programs show positive results and should be studied more rigorously. Such promising programs should also be considered when decisions about post-acute TBI rehabilitation services for clients are being made. To further establish that post-acute TBI rehabilitation interventions improve CI, future studies should include intervention strategies based on injury severity, a control group, and longer term follow-up. The role of occupational therapy in these effective programs should be further explored.

A Descriptive Study on Vitamin D Levels in Individuals With Spinal Cord Injury in an Acute Inpatient Rehabilitation Setting

To determine the prevalence of inadequate or severely deficient levels of vitamin D in patients with spinal cord injury (SCI) admitted to an inpatient rehabilitation service and to describe any associations between patient demographics and injury characteristics and vitamin D levels. Retrospective case series. Academic inpatient SCI rehabilitation program. One hundred patients with SCI who were consecutively admitted to acute inpatient rehabilitation from January to December 2007. Data were retrospectively abstracted from the patient's medical chart. VitD-25(OH). The prevalence of VitD-25(OH) inadequacy or severe deficiency was 93% in this sample of patients with SCI. The mean VitD-25(OH) level was 16.29 +/- 7.73 ng/mL, with a range from 7.00 to 36.80 ng/mL. Twenty-one percent of the sample had VitD-25(OH) levels that were considered as severely deficient (< or =10 ng/mL). African-American subjects had statistically significant lower mean VitD-25(OH) levels compared with Caucasian subjects (12.96 versus 17.79 ng/mL; P = .003). Persons with an incomplete injury had significant lower mean VitD-25(OH) levels compared with complete injuries (14.64 versus 18.15 ng/mL; P = .023). Inadequate or severely deficient levels of VitD-25(OH) were highly prevalent in patients with SCI admitted to an acute inpatient rehabilitation service. Evaluation of serum VitD-25(OH) levels are recommended in patients with SCI because low levels may contribute to osteoporosis.

Incidence of and Risk Factors for Transferring Cancer Patients from Rehabilitation to Acute Care Units

The aim of this study was to examine the clinical factors associated with transfer from an acute inpatient rehabilitation service to an inpatient oncology service. Retrospective chart review in an inpatient rehabilitation unit within a tertiary cancer center. Participants included consecutive patients admitted to an acute inpatient rehabilitation unit (n = 98). The average age of these patients was 60 yrs old (range from 18 to 86). Main outcomes measures included the frequency of transfer and reason for transfer. Thirty-five percent (34/98) of patients were transferred back to the oncology service during acute rehabilitation, among them, 12% was for planned cancer treatment and 88% for worsening medical conditions. Age, sex, tumor diagnosis, presence of metastatic lesion, and most abnormal laboratory values at rehabilitation admission were not significant factors for transferring. Significant factors for transfers were low albumin (P = 0.04), elevated creatinine levels (P = 0.01), tube feeding (P = 0.03), and a Foley catheter (P = 0.02). Those patients who were transferred back to the oncology service were more likely to die during hospitalization (15%, 5/33) and less likely to be discharged to home (52%, 17/33) compared with patients who were not transferred (2% death, 1/62; 90% home, 56/62, P < 0.0001). Transferring back to the acute oncology service is 35% among patients undergoing acute cancer rehabilitation.

Cognitively Impaired Stroke Patients Do Benefit From Admission to an Acute Rehabilitation Unit

Rabadi MH, Rabadi FM, Edelstein L, Peterson M. Cognitively impaired stroke patients do benefit from admission to an acute rehabilitation unit. Objective To determine whether cognitively impaired stroke patients benefit (defined as having an improved level of functional independence and capable of being discharged home) from admission to an acute rehabilitation unit. Design Retrospective analysis of data from a historical cohort of patients with acute stroke within the last 4 weeks or less. Setting Acute stroke rehabilitation unit. Participants The study sample was divided into 4 distinct groups based on admission Mini-Mental State Examination (MMSE) scores: cognitively intact (MMSE score range, ≥25 points), mild cognitive impairment (MMSE score range, 21–24), moderate cognitive impairment (MMSE score range, 10–20), and severe cognitive impairment (MMSE score range, ≤9 points). Interventions Not applicable. Main Outcome Measures Primary outcome measures were: change in total FIM instrument score, cognitive FIM subscore, length of stay (LOS), FIM efficiency, and discharge disposition (home vs not-to-home). Results Based on the MMSE cut scores, there were 233 cognitively intact patients and 435 cognitively impaired (mild, n=139; moderate, n=165; severe, n=131) patients. The cognitively intact and the 3 cognitively impaired groups were similar in age, sex, and ethnicity. The data show that the 3 cognitively impaired groups of patients had delayed onset to acute rehabilitation admission and greater stroke severity and disability. The change in FIM total score and FIM efficiency was similar between the cognitively intact and the 3 cognitively impaired groups ( P=.058). There were, however, statistically significant changes in the FIM cognitive subscore favoring the cognitively impaired groups ( P<.001). Similarly, patients in the cognitively intact group had a shorter LOS ( P<.001) and more home discharges ( P<.001). Conclusions Our results suggest that despite severe neurologic impairment(s) and disability, cognitively impaired stroke patients make significant functional gains while undergoing rehabilitation and many can be discharged home. Based on these results, stroke patients with cognitive impairments benefit from rehabilitation and should be given the same access to acute rehabilitation services as stroke patients who are cognitively intact.

Poster 280: Elevated N-Telopeptide in Inpatients With Spinal Cord Injury Who Develop Acute Heterotrophic Ossification

Objective: To evaluate the relationship between urinary N-telopeptide with spinal cord injury (SCI) severity and the development of heterotopic ossification (HO). Design: Retrospective study. Setting: Acute Model Spinal Cord Injury System inpatient rehabilitation service. Participants: SCI patients admitted to acute rehabilitation. Interventions: Chart review was performed for 19 patients admitted between February 3, 2006, and December 27, 2006, with a diagnosis of acute SCI. Main Outcome Measures: American Spinal Injury Association classification of SCI, urine N-telopeptide, and blood creatinine testing was performed on admission, and clinically significant HO confirmed by triple-phase bone scans. Results: N-telopeptide and creatinine ratio was significantly higher in the HO group (311.52±193.53 vs 141.78±132.69, P=.04) and in those with complete injury (245.34±191.53 vs 105.47±61.98, P=.04). Conclusions: Based on preliminary data, N-telopeptide and creatinine ratio show some promise as a clinically useful indicator for HO in the acute phase of SCI. It may show utility as an index for early prevention of HO formation in SCI patients. N-telopeptide is also higher in the subjects with complete SCI, suggesting bone resorption is greater in this group.

The Hopkins Rehabilitation Engagement Rating Scale: Development and Psychometric Properties

Kortte KB, Falk LD, Castillo RC, Johnson-Greene D, Wegener ST. The Hopkins Rehabilitation Engagement Rating Scale: development and psychometric properties. Objective To conduct an initial investigation of the psychometric properties of the Hopkins Rehabilitation Engagement Rating Scale (HRERS), a 5-item, clinician-rated measure developed to quantify engagement in acute rehabilitation services. Design We used a cross-sectional design to conduct correlational and multivariate analyses to establish the measure’s internal consistency, interrater reliability, construct validity, and criterion validity. Setting Acute inpatient rehabilitation in 3 metropolitan hospitals. Participants A total of 206 subjects with spinal cord injury, ischemic or hemorrhagic stroke, amputation, or hip or knee replacement. Interventions Not applicable. Main Outcome Measures The HRERS, Positive and Negative Affect Schedule, Brief Symptom Inventory, Levine’s Denial of Illness Scale, Craig Handicap Assessment and Reporting Technique, and FIM instrument. Results The HRERS has good internal consistency (α=.91) and interrater reliability (intraclass correlation coefficient, .73) and represents a unidimensional construct. It correlated negatively with symptoms of depression ( r=−.24, P<.01), higher ratings of denial of illness ( r=−.30, P<.001), and self-rated negative affect ( r=−.23, P<.01), and correlated positively with self-rated positive affect ( r=.36, P<.001) and level of functioning 3 months postdischarge ( r=.22, P<.01). Conclusions The HRERS is a valid and reliable measure of rehabilitation engagement that relates to intermediate-term functional outcomes.

Occupational Categories and Return to Work After Traumatic Brain Injury: A Multicenter Study

Walker WC, Marwitz JH, Kreutzer JS, Hart T, Novack T. Occupational categories and return to work after traumatic brain injury: a multicenter study. Objective To further evaluate determinants of return to work (RTW) after traumatic brain injury (TBI), with focus on the relation between preinjury occupational category and RTW outcome. Design Prospective collaborative cohort study. Setting Seventeen National Institute on Disability and Rehabilitation Research–designated Traumatic Brain Injury Model Systems. Participants Consecutive sample of 1341 patients (age range, 18–62y) who were hospitalized with a TBI diagnosis, received both acute neurotrauma services and inpatient rehabilitation services, consented to participate, were employed before injury, and completed a 1-year follow-up assessment. Intervention An inpatient interdisciplinary brain injury rehabilitation program. Main Outcome Measure Competitive employment at 1 year postinjury. Results Participants were categorized into 1 of 3 groups depending on preinjury occupational title: professional/managerial (n=192), skilled (n=751), or manual labor (n=398). Chi-square analyses were computed to examine changes across occupation groups between preinjury occupation group and postinjury RTW. The rate of successful RTW was greatest for professional/managerial (56%), lower for skilled (40%), and lowest for manual labor (32%), yielding an odds ratio of 2.959 between the highest and lowest groups. Of those with successful RTW, most did so within the same occupational category grouping. A multiple logistic regression showed that preinjury occupation, education level, discharge FIM score, age, sex, marital status, and hospital length of stay each influenced RTW. Conclusions Prior research has shown that preinjury employment status (employed vs unemployed) greatly influences the odds of successful RTW after TBI. A related hypothesis, that occupational classification also influences RTW outcome, has been understudied and has yielded conflicting results. The current study shows convincingly that the type of occupation influences RTW outcome, with the best prospect for RTW among people with professional/managerial jobs. Occupational category should be examined in the future development of predictive models for RTW after TBI.

Early arm swelling after breast surgery: changes on both sides

Lymphedema is a common complication of treatment for breast cancer. However, little information is available describing changes in upper limb volumes in the early stages following surgery. Retrospective audit. Women who underwent unilateral mastectomy or axillary node removal for breast cancer at the Princess Alexandra Hospital, Brisbane, Australia. Circumferential measurements taken at 10 cm intervals from the ulnar styloid on each arm were converted to segmental volumes using the frustum approach. Pre-surgery baseline measures were taken by a physiotherapist at Preadmission Clinic at the Princess Alexandra Hospital. Follow-up measures were taken 6 weeks after surgery by Domiciliary Allied Health Acute Care and Rehabilitation Service physiotherapists in patients' homes. Limb segment volumes increased in the proximal upper limb segments at follow-up. The proportion of patients with a 10% or greater increase in volume in one or more segments of their upper limb were similar for ipsilateral (35%) and contralateral (32%) sides (to side of surgery), respectively. No significant interaction between time and arm (ipsilateral versus contralateral) was identified. These findings demonstrate that limb segment volume changes affect a greater proportion of patients during the first 6 weeks following surgery than previously recorded. They also indicate that flow of lymph from the side of surgery to the contralateral side may disperse lymph between sides during this early post-operative period. This has implications for how swelling is measured during this period and strategies to prevent onset of lymphedema.

A Follow-Up Study of Older Adults With Traumatic Brain Injury: Taking Into Account Decreasing Length of Stay

Frankel JE, Marwitz JH, Cifu DX, Kreutzer JS, Englander J, Rosenthal M. A follow-up study of older adults with traumatic brain injury: taking into account decreasing length of stay. Objective To examine age-related differences in rehabilitation outcomes following traumatic brain injury (TBI). Design Retrospective collaborative study. Setting Patients received acute neurotrauma and inpatient rehabilitation services at 1 of the 17 National Institute on Disability and Rehabilitation Research–designated Traumatic Brain Injury Model Systems (TBIMS) centers. Participants A sample of 273 older patients (≥55y) admitted for TBI were taken from the TBIMS National Database. Older patients were matched with subjects 44 years of age or younger, based on severity of injury (Glasgow Coma Scale score, length of coma, intracranial pressure elevations). Due to decreasing length of stay (LOS), only patients admitted from 1996 through 2002 were included. Intervention Inpatient interdisciplinary brain injury rehabilitation. Main Outcome Measures Acute care LOS, inpatient rehabilitation LOS, admission and discharge FIM instrument and Disability Rating Scale (DRS) scores, FIM and DRS efficiency, acute and rehabilitative charges, and discharge disposition. Results One-way analyses of variance demonstrated a statistically significant difference between older and younger patients with respect to LOS in rehabilitation but not for acute care. Total rehabilitative charges, and admission and discharge DRS and FIM scores also showed statistically significant differences between groups. Older patients progressed with significantly less efficiency on both the DRS and FIM scales. Significantly more charges were generated per unit for older patients to improve on the DRS scale, but not the FIM scale. Using chi-square analysis, a statistically significant difference in rate of discharge to home was identified between older (80.5%) and younger (94.4%) patients. Conclusions Results in this study are similar to those in earlier studies with smaller sample sizes. Major differences observed include significantly slower and more costly progress in inpatient rehabilitation for older patients with TBI, as well as a significantly lower rate of discharge to community for older patients. However, even with decreasing LOS in both settings, community discharge rate is still encouraging for older patients with TBI.

Acute Inpatient Rehabilitation of 55 Patients After Liver Transplantation

Acute rehabilitation for patients who have had liver transplants is often necessary to restore functional mobility, but no studies, except for case reports, have documented the complications, outcomes, or predictors of success of an acute inpatient rehabilitation program. Our objective was to examine each of these areas related to rehabilitation after liver transplantation. We performed a chart review of 55 patients who received a liver transplant and were treated on our acute rehabilitation service. We examined several factors, including age, reason for transplant, length of acute hospital stay, length of acute inpatient rehabilitation stay, FIMtrade mark scores, albumin levels, medical complications, and discharge disposition. Patients undergoing rehabilitation after liver transplantation required multiple medical interventions, including liver biopsy, ultrasound, blood transfusions, and dialysis. Several patients (15%) were transferred to the acute care hospital for medical problems. Both a low albumin and a long length of stay in the acute care hospital correlated with a longer stay in rehabilitation and less efficient rehabilitation. Longer rehabilitation stays correlated positively with FIM gain (P < 0.001, r = 0.534). Significant improvements in FIM scores (P < 0.001) during acute inpatient rehabilitation were noted in patients who were discharged to home. We also found that age, albumin level, and length of stay in the hospital did not predict discharge disposition. Patients who have had liver transplants can achieve significant functional gains in acute rehabilitation. Rehabilitation professionals should be aware of potential complications and factors that may affect the rehabilitation of this patient population.

The Case Manager??s Role in Optimizing Acute Rehabilitation Services

As patients move across the healthcare continuum at a faster pace, the role of the case manager within alternative care settings has become increasingly crucial in assuring that the care delivered demonstrates efficacy, efficiency, and high quality. This article explores the multidisciplinary role of the case manager in the acute rehabilitation setting and how effective case management interventions, such as coordination, collaboration, and advocacy among others, promote the delivery of comprehensive and cost-effective patient-centered care.