Inpatient Rehab Research Articles

"Home" Alone.

"Home" Alone Andrea Hope Rubin and Monica L. Gerrek This narrative is a collaboration between Andrea Rubin, burn survivor, and Monica Gerrek, burn unit ethicist. Monica begins by describing Andrea's injuries and hospitalization. Monica On October 11, 2014, Andrea Hope Rubin was in a freak car accident. Though she was rescued from the burning car, she suffered a 58% total body surface area burn with third degree burns to her chest, arms, back, legs, head, and face. Andrea was left without a nose or ears, barely any lips or eyelids, and she lost partial vision in her right eye. She also suffered fourth degree burns on her lower right arm, which was quickly amputated just below the elbow. Andrea's scalp was so badly burned that her hair will never grow back and, to this day, she continues to seek treatment for the wounds on her head. Andrea spent approximately 12 weeks in the burn intensive care unit. She was intubated and sedated for about half of that time. After being discharged from the burn unit, she spent roughly eight weeks in a rehabilitation unit, which was located in the hospital. Because of this set up, Andrea was easily able to receive continuing treatment from the burn team and other providers. During this time, she was told repeatedly that she would be going to acute rehab for eight weeks upon discharge. Though Andrea was not looking forward to this, she was committed to ensuring the best possible recovery for herself and doing the necessary work to achieve independence. Needless to say, Andrea was elated when she was told she was too advanced with respect to occupational therapy to go to acute rehab and would be going home instead. No one had expected Andrea to recover so quickly. She had received a lot of praise during her time in inpatient rehab because of her diligence and dedication to regaining her physical abilities. Andrea knew she had worked hard and was proud of herself for being an overachiever. After hearing the news, Andrea quickly started making phone calls to family and friends to share her excitement with them. Her elation over her new discharge plans quickly turned to tremendous fear, however, when her family and friends panicked at the news. Andrea Everyone who asked about my going home asked about "acute care." I had to convince them that I was going home home, and I couldn't believe no one was happy that I was coming home five months after my accident. I was just so happy to go home that I figured surely insurance or someone will care for me. I didn't think beyond it. I was just so excited to get out of the institutionalized environment. Then I saw everyone around me panic and they started [End Page 210] talking about putting me in a nursing home and I didn't know who was going to pay for that. I got frightened. Monica Conversations with family and friends made Andrea realize that she couldn't actually take care of herself. She could barely feed herself or brush her teeth, let alone cook, shower, dress, or drive herself to the numerous doctors' appointments she would have upon discharge. When Andrea expressed her concerns to her providers and asked them to reconsider, they told her that it wasn't up to them—that according to her insurance company she was not eligible for acute rehab given she had met the standards for discharge to home. Andrea was incredulous. She couldn't believe anyone expected her to go home and manage activities of daily living or instrumental activities of daily living on her own. Andrea There was nothing that bridged the gap for care—from hospital to home. My family was so freaked out. What are we going to do with her? Who's going to do what and where and when and how? My family was so stressed out . . . I need rides, I need to get places, there was constant care. The exit strategy was non-existent. Monica In addition, Andrea didn't have a home to go home to. Prior to the accident, she had been living with a...

1875. La Crosse Virus Neuroinvasive Disease in Children: A Contemporary Review and Evaluation for Predictors of Disease Severity

BackgroundLa Crosse Virus (LACV) is the most common neuroinvasive arboviral disease in children. Contemporary data on clinical presentation, management, outcomes, and predictors of disease severity are lacking.MethodsA retrospective analysis was performed of children (0–18 years) admitted to Nationwide Children’s Hospital from January 2009 to December 2018 diagnosed with LACV neuroinvasive disease (LACV-ND). LACV-ND diagnosis was defined as a compatible clinical illness and serum serologic detection of LACV in the absence of other infectious etiologies. Demographic, clinical, laboratory, electroencephalography (EEG), radiologic, and outcome data were recorded. Severe disease was defined as the presence of clinical or electroencephalographic status epilepticus, SIADH, PICU admission, mechanical ventilation (MV), parenteral/tube feeding, inpatient rehab, or intracranial pressure monitoring. Single variable and multivariate analyses were performed to determine factors predictive of disease severity.ResultsOf the 140 patients, 76 (54%) males with a median age of 8 years [10 months-16 years], were identified with LACV-ND. Symptoms at presentation, laboratory abnormalities, EEG, radiography, and outcomes are shown in Table 1. Fifty-seven (41%) patients met criteria for severe disease, notably for PICU admission (n = 41), status epilepticus (n = 35), MV (n = 13), and inpatient rehab (11). No in-patient deaths were observed. Exploratory analysis revealed that patients with severe disease were often younger at presentation, had higher rates of altered mental status (AMS), and seizures. Elevated serum white blood cell counts (WBC) and polymorphonuclear cell (PMN) predominance in serum and cerebrospinal fluid (CSF) were observed more frequently in severe disease. Multivariate analysis revealed presentation with seizures (OR 4.7 [95% CI 1.7–12.6], P = 0.001), elevated serum WBC (OR 1.7 [95% CI 1.2–2.5], P = 0.004), and a higher CSF PMN% (OR 1.03 [95% CI 1.01–1.06, P = 0.003) to be independent predictors of severe disease.ConclusionAt presentation, patients with severe disease tended to be younger, have greater rates of neurologic symptoms, and leukocytosis with PMN predominance in blood and CSF. These clinical and laboratory findings may serve as useful biomarkers to predict disease severity. Disclosures All Authors: No reported Disclosures.

2005 Dieulafoy’s Lesion and Granulomatosis With Polyangitis

INTRODUCTION: Commonly located in the proximal stomach, Dieulafoy’s lesions are a result of small vessel dilation that can result in GI hemorrhages. Granulomatosis with polyangiitis, a systemic small-vessel vasculitis, usually involves the respiratory tract, kidneys, skin, and joints. Although GI symptoms are uncommon, previous cases have shown an association between Dieulafoy’s lesions and other systemic vasculitides, including Buerger’s disease and HSP. This case suggests a possible link between Dieulafoy’s lesion and granulomatosis with polyangiitis. CASE DESCRIPTION/METHODS: A 69-year-old white female with history of nasal vestibulitis, sinusitis, and otitis media presented with generalized weakness and sharp, bilateral chest pain with associated shortness of breath and tachycardia. CTA was negative for pulmonary embolism. Labs revealed normal procalcitonin and lactic acid but elevated ESR, CRP, D-dimer, and WBC. Due to her high oxygen requirement, patient underwent a bronchoscopy that revealed multiple lung nodules. Biopsies revealed caseating granulomatous inflammation. Further workup confirmed the diagnosis of granulomatosis with polyangiitis, and she was started on Rituxan and solumedrol. Her condition was improving until she had acute onset of hematemesis, dropping her hemoglobin by 5 g/dL. She underwent an EGD that revealed hiatal hernia with erosions, a Dieulafoy vessel in the gastric body of the lesser curvature, and a large clot that obscured nearly two-thirds of the stomach. Once hemodynamically stable, EGD was repeated and revealed several small satellite ulcers around a large 1 cm ulcer with visible vessel in the greater curvature that was then cauterized and clipped. Hemoglobin remained stable for the remainder of the hospital course. Biopsies were negative for H. pylori. She was discharged to inpatient rehab, where she continued to receive Protonix, Rituxan, prednisone, Xopenex, and Pulmicort. DISCUSSION: Several case reports linking Dieulafoy’s lesions with vasculitides have been reported in recent times. In the case above, this abnormal lesion was found in a patient with active granulomatosis with polyangitis, a diagnosis primarily known to affect the respiratory and renal system. The presence of a Dieulafoy’s lesion can be life-threatening, as in this case. EGD is an important tool for diagnosis and treatment of these lesions in the upper GI tract. Awareness of this potential association can help physicians anticipate and prevent fatal outcomes while inducing remission of this disease.

CYTOMEGALOVIRUS PNEUMONITIS IN A CRITICALLY ILL PATIENT WITH RHEUMATOID ARTHRITIS ON IMMUNOTHERAPY

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Cytomegalovirus (CMV) pneumonitis is an uncommon diagnosis typically seen in patients with immunosuppression. It can range in pathology from minimal interstitial pneumonitis to diffuse alveolar damage. It is associated with high morbidity and mortality in HIV patients and transplant recipients but is rare in patients with autoimmune diseases on immunotherapy. CASE PRESENTATION: A 52 year old female with previous history of rheumatoid arthritis on methotrexate and infliximab for over 1 year was transferred from outside hospital to the ICU after progressive dyspnea and tachypnea with high fever for two weeks that had not been improving on antibiotics. She was intubated for pending respiratory failure and had an urgent bronchoscopy with lavage. Sample from BAL showed histoplasmosis and amphotericin B with broad antibiotics and steroid burst was started. Her course was complicated over the first week of her stay by shock requiring pressor support, AKI, transaminitis, anemia, thrombocytopenia, and difficulty weaning from the ventilator. She was diagnosed with disseminated histoplasmosis. Other labwork for infectious and autoimmune workup at this time had been negative, including histo antigen, blastomyces, toxoplasma, HIV, hepatitis panel, ANA, and ANCA panel. Extubation was attempted on day 12 of her stay but she required reintubation the following day. Ampho B was switched to itraconazole at this time but patient still did not significantly improve after several more days. A surgical lung biopsy revealed CMV with diffuse alveolar damage in addition to histoplasmosis and the patient developed a pneumothorax. Viral load PCR for CMV was 99500 IU/ml. Ganciclovir was started. Her course would be complicated further by A-Fib with RVR and neutropenia, but over the next several weeks her oxygenation and overall clinical condition would slowly improve. She was transferred to LTACH after a 2 month long ICU stay. She was eventually extubated at LTACH and is currently doing well at home following an inpatient rehab stay. DISCUSSION: This patient developed multiple organ failure during her ICU stay and only began to clinically improve following diagnosis and treatment of her CMV infection. She did not respond well to broad spectrum antibiotics or antifungal initially. BAL has poor sensitivity and specificity for CMV and more aggressive diagnostic workup is sometimes indicated. There are no current guidelines for either antiviral prophylaxis or duration of therapy for CMV in setting of autoimmune disorder on immunotherapy. CONCLUSIONS: We strongly suggest that in patients on immunosuppressive therapy with acute respiratory failure who fail to respond to treatment with a recognized pathogen, other pathologies should be considered. Reference #1: Papazian L et al. Cytomegalovirus reactivation in ICU patients. Intensive Care Med. Jan;42(1):28-37. 2016 Reference #2: Travi G et al. Cytomegalovirus pneumonia in hematopoietic stem cell recipients. J Intensive Care Med. Jul-Aug;29(4):200-12. 2014 Reference #3: Lee KY et al. Predictors of Mortality in autoimmune disease patients with concurrent cytomegalovirus infections detected by quantitative real-time PCR. PLoS One. Jul 25;12(7). 2017 DISCLOSURES: No relevant relationships by Clifford Hecht, source=Web Response

145 An Audit on Hip Fracture Rehabilitation Using a Community Integrated Care Programme

Abstract Background Teiripe sa Bhaile (TsaB) is an integrated rehabilitation programme that provides Early Supported Discharge (ESD) to patients following hip fractures. It involves weekly multidisciplinary domiciliary visits to patients under the guidance of a community geriatrician. ESD in hip fractures has been proven to be safe, more effective at improving functional recovery than inpatient rehab with a reduced average length of stay (LOS) (Chudyk 2009) and better outcomes in mobility and quality of life. (Langeland 2019) Methods A retrospective chart review was carried out on patients enrolled in TsaB since July 2018. The Chartered Society of Physiotherapy for Hip Fracture Rehabilitation state that following discharge from hospital, rehabilitation should commence within 72 hours and all patients should receive two hours of rehabilitation per week until they have reached their goals. An appropriate outcome measure is recommended to measure progress against each rehab goal. The Functional Independence Measure (FIM) which looks at their level of assistance with Activities of Daily Living, was recorded pre and post completion of the programme. Results Fifteen patients completed TsaB over 3 to 8 week period. The male to female ratio was 3:1. The average age was 80.75 years. The average LOS in hospital post hip fracture was 54 days. The average LOS in hospital with TsaB was 14.8 days. This equates to 4 bed days saved per week. Each patient was seen within 72 hours of referral and received on average 3 hours per week of rehabilitation until their rehabilitation goals were achieved. Average improvement in FIM was 36.35 (>20 is clinically significant). The average Rockwood frailty scale pre-rehabilitation was 5.6 (mild to moderately frail). This improved to 3.14 (managing symptoms) on discharge. No patients were readmitted within the 30 days post discharge from hospital. Conclusion TsaB is a home based integrated rehabilitation programme that enables patients to receive rehab in their homes and reduces the likelihood of complications such as hospital acquired infections and deconditioning.

07 Rehabilitation in Patients with Dementia Following Hip Fracture

Abstract Background Hip fractures are an increasing phenomenon in the older population. Receiving post-operative rehabilitation is associated with better outcomes and a higher likelihood of returning to preexisting level of functioning. Best rehabilitation practices for people with dementia have not been established. Methods All patients >/= 60 years old with a hip fracture admitted under the orthopaedic team between March 2016-February 2018 were reviewed. Those with a diagnosis of dementia were extracted from the database. Clinical Frailty Scale (CFS), Zuckermann Functional Recovery Score (FRS) and New Mobility Score (NMS) were documented at baseline and at one year. Outcomes assessed included 1 year mortality, decline FRS/NMS, change in CFS and nursing home (NH) admission rates. Results 465 patients’ hip fractures were recorded: 175 patients had dementia. 67 patients were dead at 1-year post fracture (38.285% mortality rate). Of the 108 patients with dementia who were living at 1-year; 30.5% (n=33) received offsite rehab. 58.4% (n=63) received routine in-patient rehab. 12 lost to follow-up. Of the 33 patients that received off-site rehab the mean FRS at baseline was 66 and decreased to 45.56 at 1 year (30.9% reduction). The mean CFS at baseline was 5.1, increasing to 6 at 1-year (17% increase). Mean NMS was 5.7 decreasing to 3.7 at 1-year. In those patients with dementia that did not receive off site rehab (n=63); baseline mean FRS was 38 reducing to 30 at 1 year (26.6 % reduction). Mean CFS was 6.25- increasing to 6.47 at 1 year. 41% of patients admitted from home who did not receive off-site rehab were discharged to NH. Of the group discharged to off-site rehab: at 1 year 33% were in a NH and 72% remained at home. Conclusion Both groups demonstrated decline in function. Those that received off-site rehab had higher premorbid functioning/mobility and reduced frailty. There was a reduced NH admission rate at 1-year in the group that received off-site rehab.

Highlighting the Roles of Anemia and Aspirin in Predicting Ninety-Day Readmission Following Aseptic Revision Total Joint Arthroplasty

BackgroundRevision total joint arthroplasties (TJAs) are associated with an increased rate of complications. To date, it is unclear what drives readmission after aseptic revision arthroplasty and what measures can be taken to possibly avoid them. The purpose of this study is to (1) determine the reasons for readmission after aseptic revision TJA and (2) identify patient-specific or postoperative risk factors through a multivariate analysis. MethodsA retrospective study examined 1503 cases of aseptic revision TJA between 2009 and 2016 at an urban tertiary care hospital. Eighty-seven cases (5.8%) of readmission within 90 days of index surgery were identified. Bivariate and multivariate analyses were performed to assess independent risk factors for readmission. ResultsThe reasons for readmission were infection (38%), wound complications (22%), and dislocation/instability of the prosthetic joint (13%). Only preoperative anemia was associated with an increased odds ratio (OR) of readmission (OR 1.82, 95% confidence interval [CI] 1.126-2.970, P = .015), whereas postoperative venous thromboembolism prophylaxis with aspirin (OR 0.58, 90% CI 0.340-0.974, P = .039) and discharge to an inpatient rehab facility (OR 0.22, 95% CI 0.051-0.950, P = .042) were associated with significantly lower odds of readmission. ConclusionBased on this single institutional study, addressing preoperative anemia and considering the implementation of aspirin for venous thromboembolism prophylaxis may be 2 targets to potentially reduce readmission after aseptic revision TJA.

Indicators for Nonroutine Discharge Following Cervical Deformity-Corrective Surgery: Radiographic, Surgical, and Patient-Related Factors.

Nonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost-of-care. Given the rising prevalence of cervical deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge. To identify factors associated with nonroutine discharge after CD-corrective surgery using a statistical learning algorithm. A retrospective review of patients ≥18 yr with discharge and baseline (BL) radiographic data. Conditional inference decision trees identified factors associated with nonroutine discharge and cut-off points at which factors were significantly associated with discharge status. A conditional variable importance table used nonreplacement sampling set of 10 000 conditional inference trees to identify influential patient/surgical factors. The binary logistic regression indicated odds of nonroutine discharge for patients with influential factors at significant cut-off points. Of 138 patients (61 yr, 63% female) undergoing surgery for CD (8±5 levels; 49% posterior approach, 16% anterior, and 35% combined), 29% experienced nonroutine discharge. BL cervical/upper-cervical malalignment showed the strongest relationship with nonroutine discharge: C1 slope ≥ 14°, C2 slope ≥ 57°, TS-CL ≥ 57°. Patient-related factors associated with nonroutine discharge included BL gait impairment, age ≥ 59 yr and apex of CD primary driver ≥ C7. The only surgical factor associated with nonroutine discharge was fusion ≥ 8 levels. There was no relationship between nonhome discharge and reoperation within 6 mo or 1 yr (both P>.05) of index procedure. Despite no differences in BL EQ-5D (P=.946), nonroutine discharge patients had inferior 1-yr postoperative EQ-5D scores (P=.044). Severe preoperative cervical malalignment was strongly associated with nonroutine discharge following CD-corrective surgery. Age, deformity driver, and ≥ 8 level fusions were also associated with nonroutine discharge and should be taken into account to improve patient counseling and health care resource allocation.

Cervical Spine Surgery: Improved Surgical Outcomes Using Enhanced Recovery After Surgery (ERAS) Pathways

Abstract INTRODUCTION Enhanced recover after surgery (ERAS) programs have been utilized by surgeons across the globe, but its implementation in cervical spine surgery (CSS) has been limited. ERAS programs have been associated with beneficial patient outcomes, shorter hospital stays, and quicker recovery periods. We developed a cervical spine care pathway which was applied to all outpatients undergoing surgery. In principle the CSS pathway should minimize complications, reduce the length of stay, and improve the outcomes of cervical spine surgery patients. METHODS The pathway was divided into 3 phases preoperative, perioperative and postoperative. We looked at LOS, mortality, complications, and 30-d readmissions. One year of data was collected and compared to national published data. Outcome measurements and demographics were retrieved from the electronic health record (EHR) of each patient by a blinded independent reviewer. All surgeries were performed by a single surgeon at a single institution. RESULTS There were 144 cervical cases that were included in this study. Out of the 144 total patients, 43 had a single-level procedure, while 101 had a multi-level procedure. Patients who followed the Cervical Spinal Pathways were found to have significantly reduced LOS, mortality, complications, and readmission rates compared to national averages. LOS was significantly affected by preoperative activity level and postoperative complications. Patients who were not ambulatory preoperative had a longer length of stay while inpatient rehab placement was arranged. CONCLUSION CSS pathways should be used in spinal surgeries to improve post-surgical outcomes. Individual items within the ERAS pathway need to be studied independently to determine the significance of each factor on surgical outcomes.

A Single-Institution's Experience With the CMS Noncervical Spine Fusion Bundle Payments

Abstract INTRODUCTION To reign in escalating healthcare costs, multiple cost-containment methodologies have been proposed. CMS has recently initiated bundle payments for certain DRGs during a 90 d global period. These include DRG codes 459 and 460: spinal fusion except cervical with and without major complications or comorbidity, respectively. METHODS The investigators reviewed patients who have been included in the CMS dataset for the aforementioned CMS trial. The data were utilized to analyze our performance in both quality and estimated cost metrics. Data not included in the CMS dataset were obtained via a retrospective chart review. RESULTS A total of 29 patients were included (25 with DRG 460 and 4 with DRG 459). Currently, there are no complete episodes, and final net episode payments are not known. Mean age was 68.9 (SD 9.7) yr. There were 17 males and 12 females. A total of 25 cases were elective and 4 were traumatic. Average length of stay (LOS) was 6 d (2-16 d) with a mean estimated cost of $30,631 (SD $6332). Six patients went to an inpatient rehab for a mean of 14 d (6-21 d) at a mean estimated cost of $28,089 (SD $7372). Two patients went to a skilled nursing facility for 8 and 23 d at a mean estimated cost of $21,906 (5091 and 38,721). Only 1 traumatic case went to rehab/SNF (25%) compared to 7 elective cases (32%). The estimated net episode payment (ENEP) for discharge to home was $36,726 versus that for discharge to facility of $73,100. CONCLUSION From these preliminary data, we conclude that being discharged to Rehab/SNF approximately doubled the ENEP. Of interest, being admitted as a trauma did not increase the risk of being discharged to Rehab/SNF. As patient data mature, we will be able to analyze the cost and expense relationship to obtain a variance to target in our population.

Drivers of Variability in 90-Day Cost for Elective Laminectomy and Fusion for Lumbar Degenerative Disease

Considerable variability exists in the cost of surgery following spine surgery for common degenerative spine diseases. This variation in the cost of surgery can affect the payment bundling during the postoperative 90 d. To determine the drivers of variability in total 90-d cost for laminectomy and fusion surgery. A total of 752 patients who underwent elective laminectomy and fusion for degenerative lumbar conditions and were enrolled into a prospective longitudinal registry were included in the study. Total cost during the 90-d global period was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multivariable regression models were built for total 90-d cost. The mean 90-d direct cost was $29 295 (range, $28 612-$29 973). Based on our regression tree analysis, the following variables were found to drive the 90-d cost: age, BMI, gender, diagnosis, postop imaging, number of operated levels, ASA grade, hypertension, arthritis, preop and postop opioid use, length of hospital stay, duration of surgery, 90-d readmission, outpatient physical/occupational therapy, inpatient rehab, postop healthcare visits, postop nonopioid pain medication use nonsteroidal antiinflammatory drug (NSAIDs), and muscle relaxant use. The R2 for tree model was 0.64. Utilizing prospectively collected data, we demonstrate that considerable variation exists in total 90-d cost, nearly 70% of which can be explained by those factors included in our modeling. Risk-adjusted payment schemes can be crafted utilizing the significant drivers presented here. Focused interventions to target some of the modifiable factors have potential to reduce cost and increase the value of care.

Abstract WP180: Association Between Medicare Reform and Access to Rehabilitation in Ischemic Stroke Patients

Introduction: In 2010, the Centers for Medicare and Medicaid Services (CMS) implemented the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) Rule, requiring IRF patients to tolerate 3 hours of daily therapy (PT &OT/SLP). If unable, rehab at a skilled nursing facility (SNF) is recommended, contrasting the 2016 AHA Stroke Rehabilitation Guidelines for optimal recovery. Hypothesis: Stroke patients are more likely to receive rehab at a SNF compared to an IRF after implementation of the CMS 2010 IRF PPS Rule. Methods: We calculated the proportion of stroke patients discharged to IRF vs home and SNF vs home using prospectively collected registry data from Get with the Guidelines - Stroke, for a cohort of ischemic (85.7%) and hemorrhagic (14.3%) stroke patients between 2008 and 2015 (n=1,962,933). Univariate analyses compared stroke severity by NIHSS, sociodemographic/clinical characteristics and in hospital rehabilitation assessments. Multivariable regression modeling assessed the association between CMS 2010 IRF PPS Rule and age, teaching versus non-teaching hospital and US geographic region. Results: Post CMS 2010 IRF PPS Rule, 1 out of 15 ischemic stroke patients had lower IRF rehab odds (OR 0.94; 95%CI 0.92-0.95; P<0.0001); 1 out of 9 ischemic stroke patients had higher SNF rehab odds (OR 1.12, 95% CI 1.10-1.14; P<0.0001). Multivariable regression - ischemic stroke: Across all ages, in the South, Northeast and at teaching hospitals, the odds of IRF rehab decreased and the odds of SNF rehab increased after implementation of CMS 2010 IRF PPS Rule (Fig 1 & 2). Conclusions: Ischemic stroke patients, with similar clinical histories & stroke severity, had decreased odds of inpatient rehabilitation facility rehab and increased odds of skilled nursing facility rehab after implementation of the CMS 2010 IRF PPS Rule. Additional studies analyzing the effects of low intensity SNF rehab versus IRF rehab on return home and long-term disability are needed.

Alcohol and Drug Abuse Resource Utilization in the ICU

Alcohol and drug abuse continue to be major causes of morbidity and mortality and have significant social and economic ramifications. Studies have shown that for every $1 spent on substance use disorder treatment, $4 are saved on healthcare costs. Characterizing the healthcare resource utilization of these patients may shed light on the burden of disease and opportunities for intervention. A retrospective chart review of all patients admitted to the ICU between July 1, 2017 and December 31, 2017 was completed. Variables regarding demographic and clinical characteristics as well as healthcare resource utilization were collected. Of 737 admissions to the ICU, 158 (21%) were due to acute or chronic complications of alcohol or drug abuse. Even though alcohol and drug users were significantly younger (average age 50 years) than the general ICU cohort (average age 66 years), resource utilization was similar between these patients. The median length of stay in the ICU was similar. The number of patients transferred to in-patient rehab was low (8%), and all of those were due to comorbid psychiatric illness. The total hospital charges for the alcohol and drug abuse cohort was over 7 million dollars for the 6 months observed. A significant number of patients had at least one ER visit (49%) during the previous year, and most of these had numerous visits. ICU resource utilization by patients with acute and chronic sequelae of drug or alcohol abuse disorders continues to be high. These patients utilize resources at rates similar to an older group with other disease processes. Patients are unlikely to receive intervention for their disorder unless they have a comorbid psychiatric illness. Patients admitted to the ICU with alcohol or drug-related illness were frequently seen in the ER or were admitted to the hospital in the year prior to ICU admission, providing opportunities for intervention.

An Interdisciplinary Approach to Early Mobilization of the Super Bariatric Patient in Acute Inpatient Rehab

An Interdisciplinary Approach to Early Mobilization of the Super Bariatric Patient in Acute Inpatient Rehab

Using the Brief-BESTest paired with a novel algorithm to provide targeted balance interventions for people with subacute stroke: a feasibility study

ABSTRACTBackground: Balance is a common mobility limitation following stroke, but determination of the most effective balance-related plan of care can be difficult due to multiple balance impairments that vary between individuals. The Brief-BESTest is a validated outcome measure for balance based on six systems of postural control. It may also be a useful tool to guide clinicians in their balance plan of care design.Objective: The objective of this study was to determine the feasibility of a quantitative balance plan of care for patients with subacute stroke, using a novel algorithm that utilizes the scoring design of the Brief-BESTest. The authors hypothesized that this plan of care could create targeted balance interventions among this population.Methods: Eligible patients with subacute stroke at an inpatient rehab facility completed the Brief-BESTest within 1 week of admission. The subjects participated in specific interventions based on test section scores during their rehab stay.Results: Five subjects completed testing and participated in targeted balance interventions, addressing three to five systems of postural control. Subjects demonstrated improved Brief-BESTest overall scores by 2, 1, 7, 4, and 6 points from admission to discharge. Improvements in section scores were primarily seen in the systems of postural control identified by the algorithm. All subjects improved in Functional Independence Measure (FIM™)30 scores for locomotion (walking and stairs) by 5, 6, 7, 6, and 9 points, respectively. All subjects were discharged to the community.Conclusion: Our observational study found this method of assessment and intervention to be feasible in the subacute stroke population and was associated with improved balance scores and improved functional mobility. Further study is warranted to determine effectiveness and efficiency.

A MEG source reconstruction workflow

Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model.Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013.In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period.Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Implementation of Daily Goals on a Pediatric Inpatient Rehab Unit to Improve Family Satisfaction/Involvement

Implementation of Daily Goals on a Pediatric Inpatient Rehab Unit to Improve Family Satisfaction/Involvement

Poster 150: Reintegrating Patients into the Dining Room: An Inpatient Rehab Quality Improvement Project

PM&RVolume 10, Issue 9S1 p. S51-S51 Poster 150: Reintegrating Patients into the Dining Room: An Inpatient Rehab Quality Improvement Project Kathryn S. Zakrzewski DO, Kathryn S. Zakrzewski DO Virginia Commonwealth University Health, Richmond, VA, United StatesSearch for more papers by this authorWilliam E. Carter MD, William E. Carter MDSearch for more papers by this author Kathryn S. Zakrzewski DO, Kathryn S. Zakrzewski DO Virginia Commonwealth University Health, Richmond, VA, United StatesSearch for more papers by this authorWilliam E. Carter MD, William E. Carter MDSearch for more papers by this author First published: 26 September 2018 https://doi.org/10.1016/j.pmrj.2018.08.162Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume10, Issue9S12018 AAPM&R Annual Assembly AbstractsSeptember 2018Pages S51-S51 RelatedInformation

Friday, September 28, 2018 10:30 AM–12:00 PM abstracts: complications of cervical spine surgery: 156. Indicators for nonroutine discharge following cervical deformity-corrective surgery: radiographic, surgical, and patient-related predictors

BACKGROUND CONTEXT Recent studies suggest nonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost of care. Given the rising prevalence of cervical-deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge in surgical CD patients. PURPOSE Identify predictors of nonroutine discharge after CD-corrective surgery using a statistical learning algorithm. STUDY DESIGN/SETTING Retrospective review of prospective, multicenter CD database. PATIENT SAMPLE Surgical CD patients (C2–C7 Cobb>10°, CL>10°, cSVA>4cm, or CBVA>25°). OUTCOME MEASURES Discharge location, health-related quality of life (HRQL) outcomes. METHODS Included: patients>18 years with discharge and baseline (BL) radiographic data. Nonroutine discharge was defined: inpatient rehab or skilled nursing facility (SNF). Conditional Inference Decision Trees identified factors predictive of nonroutine discharge, and cut-off points at which factors have a global effect. A Conditional Variable Importance Table used nonreplacement sampling set of 3,000 Conditional Inference trees to identify top influential factors from procedural and patient-related data. Binary logistic regression indicated effect size of the top 18 influential variables at each variable's respective significant cut-off point. Means comparison testing assessed the relationship between nonroutine discharge and reop/HRQL outcomes. RESULTS Included: 138 patients (61±10 years, 63%F) undergoing CD-corrective surgery (8.2±4.6 levels; 49% posterior-only approach, 16% anterior-only, 35% combined). A total of 29% of patients experienced nonroutine discharge (21% inpatient rehab, 8% SNF). BL cervical and upper-cervical malalignment was the strongest predictor of nonroutine discharge: [1] C1 slope>14° (OR:8.35 [95% CI:3.07–22.71]), [3] C2 slope>57° (OR:6.95 [2.64–18.33]), [4] TS-CL>57° (OR:5.89 [2.19–15.85]), [14] C0 slope>-0.66° (OR:4.15 [1.86–9.26]), [15] cSVA>40mm (OR:4.63 [1.97–10.87]), [18] McGregor's slope>1.9° (OR:4.08 [1.68–9.91]). Patient-related predictors of nonroutine discharge were [2] BL gait impairment (OR:5.29 [2.25–12.42]), [8] age>59 years (OR:4.25 [1.63–11.05]), [10] apex of CD primary driver>C7 (OR:3.90 [1.78–8.56]), and [13] admission to surgical ICU (OR:5.35 [1.93–14.82]). While experiencing two or more complications was predictive of nonroutine discharge (OR:4.16 [1.87–9.22]), the only specific complications predictive of nonroutine discharge were EBL>900cc (OR:3.56 [1.65–7.67]) and presence of any neurological complication (OR:2.76 [1.78–8.35]). The only surgical predictor of nonhome discharge was [12] fusion>8 levels (OR:4.03 [1.81–8.98]). Length of stay>6 days was also predictive of nonroutine discharge (OR:3.99 [1.79–8.91]). There was no relationship between nonroutine discharge and reop within 3 months (P=.249), 6 months (P=.793), or 1-year (P=.814) of index procedure. Despite no differences in BL EQ-5D (P=.946), nonroutine patients had inferior 1-year postop EQ-5D scores (nonroutine: 0.75, home: 0.79, P=.044). CONCLUSIONS In a population of 138 operative CD patients, severe preoperative cervical malalignment was a strong predictor of nonroutine discharge. Age, driver of cervical deformity, and long fusions (>8 level) were also predictive of nonroutine discharge, and should be taken into account to better evaluate resource requirements following surgery and improve patient counseling.

A Retrospective Review of Patients With Acute Stroke With and Without Palliative Care Consultations.

Despite advances in stroke care, patients continue to incur significant disability, are at risk for future events, and are inconsistently comanaged with palliative care (PC) specialty teams. The purpose of this study was to review patients with stroke admitted to our institution, comparing patients with and without PC consultation. We retrospectively reviewed medical record data of all patients with stroke admitted to our neurosciences ICU (NICU) in July 2014 to June 2015 with and without PC consultation. Review focused on stroke type, patient demographics, median days to discharge and death, and posthospitalization discharge. Of 463 patients admitted to the NICU with a stroke diagnosis, 27% (125/463) had (PC) consultation. A higher percentage of the patients with PC consult presented with hemorrhagic stroke than those without PC consult (38% vs 21%, P < .001). Patients with PC consult had longer median days to discharge and death ( P < .001) and a higher percentage of mortality (32% vs 11%). Of the 301 patients without PC consult who discharged (89.1%), 36.5% discharged to inpatient rehab while 10% discharged to a skilled nursing facility. In comparison, of the patients with PC consultation who discharged alive (41.1%), 15.7% discharged to inpatient rehab whereas 39% discharged to skilled nursing ( P < .001). The uncertainty of which patients with stroke benefit most from specialty PC is highlighted in that although sicker patients are referred to PC, a substantial portion (41%) of these patients discharge alive, of which 39.2% discharged to skilled nursing. Future research should focus on which patients with stroke would benefit from specialty PC.