Inpatient Rehabilitation Facility Research Articles

Abstract WP63: The Effect Of Inpatient Rehabilitation Facility Treatment On 90 Day Outcomes: A Shift Analysis Of Modified Rankin Scale Score In Ischemic Stroke Patients

Introduction: Several AHA Guidelines recommend inpatient rehabilitation facility (IRF) care to enhance post-stroke recovery. We evaluated the IRF treatment effect on modified Rankin scale (mRS) score change at 90 days in ischemic stroke (IS) patients. Methods: Using prospectively collected data from Get With the Guidelines-Stroke, the Uniformed Data System for Medical Rehabilitation registry and the electronic medical record, we identified IS patients with discharge disposition of home or IRF between 1/1/2018-12/31/2020. Sociodemographics, clinical variables and IS treatment rates were summarized. IRF outcomes, including length of stay (LOS), improvement in mobility and self-care scores and discharge disposition were compared in thrombectomy vs no thrombectomy groups. mRS at IRF discharge was calculated with a Cronbach interrater score of 0.88; shift analyses of mRS at hospital discharge and 90 days were completed for IS patients in the Home and IRF care groups. Results: Among 738 patients, 499 went home, 239 went to IRF. IRF patients were more likely to have Medicare insurance (49.2 vs 28.9%), undergo thrombectomy (16.3 vs 4.6%) have increased LOS (12.7 vs 4.8 days) and stroke severity (mean NIHSS 7.8 vs 4.8; mean mRS 3.1 vs 1.7) compared to Home (Table 1). At IRF, 39 patients previously underwent thrombectomy, 200 did not. Both groups had a IRF LOS >14 days and considerable recovery in the self-care and mobility domains (Table 2). Shift analysis of mRS at hospital discharge compared to 90 days yielded significant improvements in mRS of 0-2 and lower mortality in the IRF group compared to home group (Figure). Conclusion: In ischemic stroke patients with higher disease severity, IRF treatment is a catalyst for improved functional recovery.

Abstract TP70: Preliminary Associations Between Quality Indicators, Motor Status, And Self-efficacy In Early Stroke Rehabilitation

Introduction: Recent changes in reimbursement policies for inpatient rehabilitation facility (IRF) providers prompted the adoption of Quality Indicators (QI) on the IRF Patient Assessment Instrument leading to the discontinuation of the Functional Independence Measure (FIM). Given that the FIM has shown associations with motor assessments and self-efficacy measures during early stroke recovery, the purpose of this study was to confirm if similar associations exist with QI. Methods: Participants with acute ischemic and hemorrhagic stroke completed a battery of assessments at the time of IRF admission and discharge: Total QI (summation of self-care and mobility items), Upper Extremity Fugl-Meyer (UEFM), Action Research Arm Test (ARAT), and Stroke Self-Efficacy Questionnaire (SSEQ). We determined associations between QI and these measures by computing correlation coefficients with an alpha value=.01 denoting significance following a Bonferroni correction. Results: Fourteen individuals (7 females, age=65.9±9.0 years, 8.1±3.5 days post-stroke) with moderate-severe motor deficit completed study procedures. Table 1 summarizes admission and discharge scores and associations with QI. Conclusions: Significant associations between motor assessments and QI from this ongoing study parallel similar associations involving the FIM. The implementation of QI in IRFs necessitates additional work to validate our findings and to determine psychometric properties of QI to enhance clinical research in stroke rehabilitation.

Abstract WMP42: Trajectory Of Global Disability During First 90 Days Poststroke: Foundational Data For Early Rehabilitation Intervention Trials

Background: Novel recovery interventions may be particularly beneficial started 3-10d poststroke, when patients become eligible for intensive inpatient rehabilitation and biologic neuroplasticity is at its peak. To design recovery clinical trials in this population, it is important to characterize the evolution of global disability through 3mo of conventional care. Methods: Among all ischemic stroke (IS) and intracranial hemorrhage (ICH) patients enrolled in an NIH multicenter acute treatment trial (FAST-MAG), we analyzed disability course among patients discharged to acute inpatient rehabilitation facilities (IRFs) 2-9 days poststroke. Results: Among 1426 IS and ICH patients, 255 (17.9%) were discharged to IRFs, including 12.8% within 2-9d and 5.1% beyond 9d. Among IS patients, rate of 2-9d discharge to IRFs was 13.0% (135/1041), age 71.1 (±12.4), 42% female, NIHSS on first hospital arrival 10.3 (±6.8), and global disability on day 4 mRS=3 in 15.9% and mRS=4 in 43.8%. Among ICH patients, rate of 2-9d discharge to IRFs was 12.2% (47/385), age 62.4 (±11.7), 32.9% female, NIHSS on first hospital arrival 11.5 (±5.7), and global disability on day 4 mRS=3 in 12.2% and mRS=4 in 45.1%. Among Day 4 mRS 3-4 patients, mRS improvement by 90d among ICH and IS patients was 83.0% vs 72.6%, p = 0.17. Mean mRS change for ICH and IS was -1.5 (±1.1) vs -1.3 (±1.4) (Figure). Final 90D mRS among ICH and IS patients was mean 2.2 (±1.1) vs 2.4 (±1.5). Conclusion: In this broad acute stroke patient cohort, 1 in 8 patients were transferred to inpatient rehabilitation within 2-9d days poststroke. Intracranial hemorrhage patients had nominally greater improvement on the mRS by 90d than ischemic stroke patients. This course delineation provides a roadmap for future rehabilitation intervention studies.

Abstract WP77: Racial Disparities Of Post-stroke Hospital Discharge

Objective: Early post-acute care for stroke survivors affect their morbidity, mortality, and long term disability and quality of lives. This study aimed to understand the utilization of post-acute services among different racial/ethnicity population. Methods: We examined the discharge destinations amongst patients admitted directly from the emergency department for ischemic stroke and transient ischemic attack (TIA) in 2017-2018 using the National Inpatient Sample, a 20% stratified sample of all discharges from U.S. community hospitals. Results: This study included 1,000,645 live ischemic stroke/TIA discharges with good racial/ethnicity representations (Table). Compared to their White counterpart, Hispanic patients were more likely to be discharged to home without home health care (49.1% vs 42.1%, OR 1.33, 95% CI 1.27-1.38), as well as Native Americans (47.5%, OR 1.24, 95% CI 1.06-1.46). Conversely, Hispanics are less likely to be discharged to inpatient rehabilitation or skilled nursing facilities than White (29.1% vs 36.5%, OR 0.71, 95% CI 0.68-0.74), as well as Native Americans (32.7%, OR 0.85, 95% CI 0.72-0.99). Facility discharge rates were comparable among Black and White (OR 0.99, 95% CI 0.97-1.03). Conclusion: Hispanics and Native Americans are more likely to be discharged to home without home health care and less likely to be discharged to facilities after stroke. Further study are need to understand the attributes of the discharge disparities after stroke hospitalization.

Abstract WP118: Characteristics And Short-term Outcomes Of Delirium After Acute Ischemic Stroke

Background: Delirium after acute ischemic stroke is a common clinical occurrence, associated with longer hospital admissions, worse functional outcomes, and increased mortality. We aim in a prospective study to assess the characteristics and risk factors for delirium after acute ischemic stroke (AIS) in a US population. Methods: Between September 2019 and June 2021, patients diagnosed with AIS within 48 hrs of stroke onset were prospectively evaluated for delirium using the Confusion Assessment Method (CAM)-ICU daily for the first eight days of their hospital stay. Patients with severe stroke and expected mortality within the first month at the time of admission or with severe aphasia unable to follow commands were excluded. Data regarding demographics, co-morbidities, hospital stay, stroke metrics, lab work, and medications were analyzed. Results: Over 12 non-consecutive months (due to pandemic interruptions), we evaluated 213 patients, of which 179 could be assessed with the CAM-ICU. Delirium was present in 89 (49.7%), occurring within the first 24 hours of admission in 33.6% and for longer than one day in 32.0%. There were no statistically significant differences in age, gender, race, co-morbidities, or TOAST etiology among patients with and without delirium (Table 1). Patients with delirium had higher NIHSS and were more likely to receive tPA. Patients with delirium were more likely to be discharged to inpatient rehabilitation facilities than home (p=0.05). Only patients with delirium had unexpected mortality after admission, but this statistic failed to show significance. Conclusion: In a cohort of AIS patients without significant expected mortality on admission, the incidence of delirium is high. Our study confirms prior results demonstrating higher inpatient mortality, longer hospital admissions among patients with delirium, and more delirium in patients receiving tPA.

Abstract TMP57: Acute Ischemic Stroke Patients Receiving Reperfusion Therapy Do Not Have Worse 90-day Outcomes After Delirium.

Background: Post-stroke delirium (PSD) is associated with increased mortality and worse long-term functional outcomes. Patients who receive reperfusion therapies in the hospital are frequently kept from regular sleep-wake cycles the first 24 hrs after treatment, and this disruption could lead to an increase in PSD. In this study, we evaluate the effect of PSD on immediate and long-term outcomes in AIS patients receiving reperfusion therapies. Methods: Between September 2019 and June 2021, pts diagnosed with AIS within 48 hrs of stroke onset were prospectively evaluated for PSD using the Confusion Assessment Method (CAM)-ICU daily for the first eight days of their hospital stay. Patients with severe stroke and expected mortality within the first month at the time of admission or with severe aphasia unable to follow commands were excluded. Reperfusion therapies were defined as any IV thrombolytic, IA thrombolytic, or mechanical thrombectomy (MT). The primary outcome was considered a 90-day mRS score of 0-2. Results: Of 179 patients assessed with the CAM-ICU, 89 (49.7%) had PSD. We identified 94 patients that had undergone one or both reperfusion therapies; 52 (55.3%) had delirium. Patients who received tPa had a higher risk for delirium (42 vs 29, p = 0.04), but no difference was observed with MT (Table 1). Patients with PSD had a longer hospital length of stay and a higher median admission NIHSS. Patients with delirium who received tPA were more likely to be discharged to inpatient rehabilitation facilities than home (p-value 0.004, OR 10.1 95%CI 2.1,48). No significant difference was found in 90-day modified ranking scale (mRS) scores of 0-2 in those with or without PSD. Conclusion: AIS patients with PSD after reperfusion therapy had no significant difference in 90-day good outcomes despite having longer hospital admissions and being less likely to be discharged home. Further evaluation into how reperfusion therapies convey protection to patients is necessary.

Depressive Symptomatology and Functional Status Among Stroke Survivors: A Network Analysis

ObjectiveTo (1) characterize poststroke depressive symptom network and identify the symptoms most central to depression and (2) examine the symptoms that bridge depression and functional status. DesignSecondary data analysis of the Stroke Recovery in Underserved Population database. Networks were estimated using regularized partial correlation models. Topology, network stability and accuracy, node centrality and predictability, and bridge statistics were investigated. SettingEleven inpatient rehabilitation facilities across 9 states of the United States. ParticipantsPatients with stroke (N=1215) who received inpatient rehabilitation. InterventionsNot applicable. Main Outcome MeasuresThe Center for Epidemiologic Studies Depression Scale and FIM were administered at discharge from inpatient rehabilitation. ResultsDepressive symptoms were positively intercorrelated within the network, with stronger connections between symptoms within the same domain. “Sadness” (expected influence=1.94), “blues” (expected influence=1.14), and “depressed” (expected influence=0.97) were the most central depressive symptoms, whereas “talked less than normal” (bridge expected influence=−1.66) emerged as the bridge symptom between depression and functional status. Appetite (R2=0.23) and sleep disturbance (R2=0.28) were among the least predictable symptoms, whose variance was less likely explained by other symptoms in the network. ConclusionsFindings illustrate the potential of network analysis for discerning the complexity of poststroke depressive symptomology and its interplay with functional status, uncovering priority treatment targets and promoting more precise clinical practice. This study contributes to the need for expansion in the understanding of poststroke psychopathology and challenges clinicians to use targeted intervention strategies to address depression in stroke rehabilitation.

Gait and Balance Outcome Measures Are Responsive in Severely Impaired Individuals Undergoing Inpatient Stroke Rehabilitation

ObjectiveTo investigate whether gait and balance outcome measures in patients with severe gait and balance impairments at admission to inpatient rehabilitation provided additional and meaningful information beyond customary measures. Specifically, this study investigated whether individuals who obtained low scores at admission exhibited improvements that exceeded the established minimal detectable change during inpatient rehabilitation. We also investigated whether gait outcomes would capture changes in function not identified by customary measures. DesignSecondary analysis of a knowledge translation project aimed at increasing the systematic collection of these outcome measures in a poststroke cohort. SettingSubacute inpatient rehabilitation facility. ParticipantsIndividuals<2 months poststroke (N=157) with 34-43 with severe deficits including Berg Balance Scale≤5, 10-meter walk test=0 m/s, or 6-minute walk test=0 m. InterventionNot applicable. Main outcome measuresBerg Balance Scale, 10-meter walk test, 6-minute walk test. ResultsAfter 1 week of rehabilitation, 41%-53% of severely impaired individuals had changes above minimal detectable changes in gait and balance outcomes, which increased to 68%-84% at discharge. Across the entire cohort, FIM locomotion scores failed to identify changes in gait function for 35% of participants after 1 week of rehabilitation. ConclusionsRoutine assessment of gait and balance outcome measures in patients with severe deficits early poststroke may be beneficial. These measures were responsive after 1 week of rehabilitation and detected changes not captured by customary measures. Routine use of a standardized gait and balance assessments may provide clinicians with important information to guide clinical decision making.

Association of improvement in functional capacity after rehabilitation with long-term survival in heart failure

BackgroundThe prognostic value of change in six-minute walking distance (6MWD) after treatment to predict mortality in heart failure (HF) remains a controversial issue. We assessed the prognostic value of rehabilitation-induced improvement in 6MWD in predicting mortality in patients with HF. MethodsWe studied 2257 patients admitted to six inpatient rehabilitation facilities after a hospitalization for HF (N. 912) or because of worsening functional capacity and/or deteriorating clinical status (N. 1345). A six-minute walking test was performed at admission and discharge. The primary outcome was 3-year all-cause mortality after discharge from cardiac rehabilitation. We used multivariable Cox proportional hazard modeling to assess the association of increase in 6MWD with 3-year mortality, adjusting for established predictors of mortality. Results6MWD significantly increased by 61 m (p < .001) from admission to discharge and 969 patients (42.9%) achieved an increase in 6MWD >50 m. After full adjustment, an increase in 6MWD >50 m was associated with a 22% decreased risk for 3-year mortality (HR 0.78 [95% CI 0.68–0.91]; p = .002). When modeled as a continuous variable, improvement in 6MWD remained independently associated with decreased risk for 3-year mortality (HR per each 50 m increase: 0.92 [95% CI 0.88–0.96]). ConclusionsRehabilitation–induced improvement in 6MWD was associated with a significantly reduced risk for 3-year mortality. Our data also suggest that an improvement in 6MWD of more than 50 m could represent a clinically meaningful endpoint of cardiac rehabilitation for patients with heart failure.

Retrospective trends in length of stay and bowel management at discharge from inpatient rehabilitation among individuals with spinal cord injury.

Retrospective observational cohort study. To describe the trend in length of stay (LOS) and its association with the rate of individuals needing total assistance with bowel management upon discharge from inpatient spinal cord injury (SCI) rehabilitation facilities. Participants enrolled in the National Spinal Cord Injury Model Systems (NSCIMS) database. The NSCIMS database was used to obtain bowel management characteristics from individuals (n = 15,975) aged 15 years or older discharged from inpatient rehabilitation facilities between 1988 and 2016 with known demographic factors and LOS. Levels of bowel management were defined from the functional independence measure (FIM) based on the level of assistance required to complete a bowel program. To control for changes in participant population and injury characteristics over the study period, the inverse probability of treatment weight (IPTW) technique was used. Linear and logistic regressions and the Spearman correlation coefficient were used for statistical analyses. The LOS significantly decreased more than ¾ of a day on average each year from 1988 (LOS: 83.16 days) to 2016 (LOS: 50.53 days). Concurrently, the odds of needing total assistance in bowel management at discharge increased 4.1% each year. The correlation between these trends was moderate (-0.63). Association analyses yielded that a 1-day decrease in average LOS was associated with a 0.53% increase in those needing total assistance for bowel management at discharge. Over the years, as inpatient rehabilitation LOS decreased, rates of those needing total assistance for bowel management at discharge increased.

African Americans and Women Have Lower Functional Gains During Acute Inpatient Rehabilitation After Hemorrhagic Stroke.

Intracerebral hemorrhage can lead to significant long-term disability. While research in stroke rehabilitation has focused primarily on ischemic strokes, identifying factors that impact recovery in patients with intracerebral hemorrhage is necessary. Our purpose is to identify factors, including racial and sex disparities, associated with functional outcomes in intracerebral hemorrhage patients after inpatient rehabilitation. This was a retrospective analysis of consecutive patients with intracerebral hemorrhage admitted to an inpatient rehabilitation facility at an academic tertiary facility in the Southeastern United States from 2016 to 2019. Clinical characteristics, demographics, admission, and discharge Functional Independence Measure scores were collected. We evaluated 59 patients (54.4 ± 14.1 yrs, 39% females, 48.2% African American) with a median intracerebral hemorrhage volume of 13.4 (4.2-33.0) and a mean (SD) Functional Independence Measure efficiency of 1.8 ± 1.3. In multiple regression, being female was negatively associated with Functional Independence Measure efficiency (β = -1.13, P = 0.0037) when adjusting for race and intracerebral hemorrhage score. The Functional Independence Measure efficiency was lower in African Americans (β = -0.97, P = 0.0119) when adjusting for sex and intracerebral hemorrhage volume. The results of our study indicate that Functional Independence Measure efficiency was worse for African Americans and female patients with intracerebral hemorrhage. Future research should consider these racial and sex disparities and focus on providing targeted rehabilitation therapy.

Psychometric properties of the Center for Epidemiologic Studies Depression (CES-D) scale in stroke survivors

ABSTRACT Purpose This study aimed to evaluate the psychometric properties of the Center for Epidemiologic Studies Depression (CES-D) scale in adults with stroke. Methods A secondary analysis of the Stroke Recovery in Underserved Populations Cohort Study. The CES-D was administrated to 828 stroke patients at discharge from inpatient rehabilitation facilities and at 3- and 12-month follow-ups. Data were analyzed using classical test theory (CTT) and Rasch measurement model. Results Confirmatory factor analyses of the CES-D items showed excellent fit of a four-factor model (CFI = 0.98; TLI = 0.98; RMSEA = 0.05). CTT analyses revealed satisfactory reliability and validity. Rasch analyses also supported the unidimensionality of each factor (subscale). Wright maps indicated a floor effect and item gaps. A few items displayed differential item functioning: 3 items (1 depressed affect and 2 somatic symptoms) across gender, 1 item (depressed affect) across time of assessment and all # somatic symptom items across time of assessment. Conclusion The four-factor structure of the CES-D was confirmed and its psychometric properties were validated, supporting the use of four subscales to characterize depressive symptomatology in adults with stroke. Supplementary assessments are needed for evaluating and comparing somatic symptoms over time. A refinement of the CES-D was recommended to better differentiate stroke survivors with subtle depressive symptoms.

Acute Inpatient Rehabilitation Improves Function Independent of Comorbidities in Medically Complex Patients

Objectives(1) To evaluate the benefits of acute inpatient rehabilitation for a medically complex patient population and (2) to assess the effect of comorbid conditions on rehabilitation outcomes. DesignRetrospective cohort study. SettingFreestanding inpatient rehabilitation facility. ParticipantsA total of 270 medically complex adult patients including those with cardiac, pulmonary, and orthopedic conditions, with mean age of 73.6 years; 52.6% were female and 47.4% were male (N=270). InterventionsNot applicable. Main Outcome MeasuresFunctional Independence Measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), home discharge rate, and readmission to acute care (RTAC). ResultsAmong 270 medically complex patients, mean total FIM gain, mean RLOS, and mean FIM efficiency with SD were 26.0±13.6 points, 12.6±5.9 days, and 2.3±1.6, respectively. A total of 71.9% of patients were discharged to home, 12.2% for RTAC, and 15.9% to a skilled nursing facility (SNF). Hypertension (HTN) was the only comorbidity significantly associated with FIM gain (53.7% [total FIM gain ≥27] vs 67.2% [total FIM gain <27]; P=.024) and FIM efficiency (53.3% [FIM efficiency ≥2.12] vs 67.4% [FIM efficiency <2.12]; P=.025), independent of age, body mass index, sex, race, ethnicity, insurance type, and Charlson Comorbidity Index. The 5 most common reasons for RTAC were cardiac, pulmonary, acute blood loss anemia, infection, and neurologic conditions. ConclusionsAmong 270 medically complex patients, 71.9% were discharged to home, 15.9% to an SNF, and 12.2% for RTAC with a mean RLOS 12.6 days, mean total FIM gain of 26 points, and mean FIM efficiency of 2.3, which were all better than those of all admissions at our facility in 2018. Furthermore, RLOS, total FIM gain and FIM efficiency in this study were all better than their corresponding eRehabData weighted national benchmarks (RLOS, 15.82 days; FIM gain, 25.57; FIM efficiency, 2.13) for a total of 202,520 discharges in 2018. These findings support acute inpatient rehabilitation for this patient population. With the exception of HTN, no medical comorbidities or demographic variables were associated with rehabilitation outcomes.

Centering race/ethnicity: Differences in traumatic brain injury inpatient rehabilitation outcomes.

Persons of color have a higher incidence of traumatic brain injury (TBI) and experience disparities in the quality and quantity of interventions received, discharge disposition, functional outcomes, and mortality rate post TBI. To examine racial/ethnic differences in rehabilitation outcomes for patients with TBI. Multiyear (2005-2016) and retrospective cohort using secondary data analysis from inpatient rehabilitation facilities (IRFs) across the United States. eRehabData participating IRFs throughout the United States. Forty-one thousand eight hundred forty-seven adults with a diagnosis of TBI, admitted to U.S. eRehabData participating IRFs. Not applicable. Inpatient rehabilitation functional outcomes and discharge disposition. Participants were 41,847 non-Hispanic Whites (NHWs), Hispanics, non-Hispanic Asians (NHAs), and non-Hispanic Blacks (NHBs) aged 18-107 years. NHWs were used as the reference group. NHBs had the longest length of stay (17.65 ± 14.96). At admission, NHB, Hispanic, and NHA races/ethnicities were significantly associated with 1-3 point lower motor, cognitive, and total Functional Independence Measure (FIM) scores. NHB race was significantly associated with less than 1-point lower cognitive, motor, and total efficiency FIM scores. At discharge, NHB race was significantly associated with 1-2 point lower motor, cognitive, and total FIM scores; Hispanics and NHA race were associated with less than 1-point lower cognitive FIM scores. Compared to NHWs, Hispanic ethnicity was associated with greater odds of a discharge to home (odds ratio=1.16, 95% confidence interval=1.06-1.27). Contrary to established literature on functionality differences 1 year post TBI, the current study found racial/ethnic differences in functional outcomes during inpatient rehabilitation. These findings suggest a need for cultural competence/sensitivity in the care of racial/ethnic persons and centering potential contributing factors for racial/ethnic differences in TBI rehabilitation outcomes.

Predicting home discharge after inpatient rehabilitation of stroke patients with aphasia

ABSTRACT The early identification of the discharge setting from Inpatient Rehabilitation Facilities is a primary goal in stroke-related research because of its clinical and socio-economic relevance. Several features have been identified as significant predictors of the discharge setting. Within cognitive deficits, aphasia is known to be a common and disabling condition that could influence rehabilitation outcome. However, it is often set as an exclusion criterion in stroke research. This study aims to investigate the predictive power of clinical variables, in particular specific language disturbances and nonlinguistic cognitive deficits, for discharge setting in post-acute stroke patients with aphasia after intensive multidisciplinary rehabilitation. In a sample of 158 patients, demographic, motor, language, and nonverbal cognitive data were retrospectively considered for the prediction of the discharge to home vs. another institutional setting. Univariate analysis identified relevant differences between groups and the significant variables were included in a logistic regression model. The results showed that better functional motor status, absence of dysphagia and unimpaired nonlinguistic cognitive profile independently predict the discharge to home. In particular, nonverbal cognitive functioning seemed to be specifically relevant within the aphasic population. The findings could be helpful for setting up the rehabilitation priorities and an adequate discharge arrangement.

Examining the accuracy of the AM-PAC “6-clicks” at predicting discharge disposition in traumatic brain injury

ABSTRACT Objective To assess the accuracy of the AM-PAC “6-Clicks” in predicting discharge dispositions among severely injured patients with an acute traumatic brain injury (TBI). Methods We performed a retrospective review of patients with a TBI who presented to our trauma center from 2016 through 2018 and received a “6-Clicks” assessment. Outcomes were hospital length of stay (LOS) and discharge disposition: home, inpatient rehabilitation facility (IRF), subacute location (SL), or death/hospice. Subgroup analyses evaluated patients with concomitant mobility-limiting injuries (CM-LI). Results There were 432 patients with a TBI; 42.6% (n = 184) had CM-LI. CM-LI patients had lower “6-Clicks” scores compared to patients with an isolated TBI (9 vs 14, p < .0001) and a longer hospital LOS (16.5 d vs 9 d, p < .0001). Increasing “6-Clicks” scores were associated with a home discharge (OR 1.21, 95% CI 1.15–1.28, p < .0001) while decreasing scores were predictive of an IRF or SL discharge or death/hospice. Increasing scores correlated with decreasing hospital LOS for the cohort (β − 8.93, 95% CI −10.24 – −7.62, p < .0001). Conclusion Among patients with an acute TBI, increasing “6 Clicks” scores were associated with a shorter hospital LOS and greater likelihood of home discharge. Decreasing mobility scores correlated with discharge to an IRF, SL, and death/hospice.

Trends and Disparities in Inpatient Rehabilitation of Adolescents: The Effect of Demographics, Injury Characteristics, and Facility Type.

Intensive rehabilitation of adolescents occurs in general and pediatric inpatient rehabilitation facilities (IRFs), but differences in admission and outcomes by facility type have not been thoroughly investigated, particularly among persons with spinal cord injury (SCI). To investigate factors related to admission to pediatric or adult IRFs among adolescents and compare the rehabilitation outcomes between facility types. Using a single-center retrospective cohort study design, demographic information, medical data, and rehabilitation outcomes were obtained by chart review of patients aged 15 to 18 years who received a rehabilitation medicine consultation at an urban level 1 trauma center between 2017 and 2019 (N = 96). Analysis was performed using R statistical software. SCI was the second most common diagnosis (21% of patients) and accounted for 36% of inpatient rehabilitation admissions. SCI patients were more likely to undergo rehabilitation at the level 1 trauma versus pediatric facility (relative risk [RR] = 2.43; 95% confidence interval [CI] = 1.08-5.44) compared to traumatic brain injury patients. Admission to trauma versus pediatric IRF was also associated with Black compared to White race (RR = 2.5; CI = 1.12-5.56), violence compared to other etiologies of injury (RR = 2.0; CI = 1.10-3.77), and Medicaid compared to private insurance (RR = 2.15; CI = 1.01-4.59). Admission to pediatric IRF was associated with longer length of stay than admission to adult IRF when adjusted for diagnosis (30.86 ± 21.82 vs. 24.33 ± 18.17 days; p = .046), but Functional Independence Measures did not differ. Adolescents with SCI and those experiencing systemic disadvantages, including racism and poverty, were more likely to be admitted to trauma compared to pediatric IRF.

Provider and Staff Responses to Non-Facility Specific Patient Experience Feedback with Post-Acute Care Transitions

While a large portion of efforts related to improving patient experience, reducing medical errors, and improving clinical outcomes have focused on acute care settings, improvements in the quality of post-acute care and patient experience with transitions from general acute care settings to post-acute levels of care are key to accomplishing population health goals. While patient experience surveys are utilized nationwide, there is evidence of a need for deliberate efforts to create and implement recommendations derived from analyzing patient experience data with healthcare staff and providers. In 2019, 14 focus group sessions were conducted with providers and staff, including nursing, pharmacy, therapy, and case management from skilled nursing facilities, long-term acute care hospitals, and inpatient rehabilitation facilities. To minimize bias while studying reactions to patient comments regarding care transitions, participants from different facilities were placed into groups together and provided de-identified patient comments to review and discuss key themes and potential solutions. Attribution, discourse, and summative content analyses were performed to identify the key themes. A framework was developed to understand provider and staff reactions to non-facility-specific patient experience feedback as well as recommendations for improving post-acute care transitions

Prognostic factors and outcomes in COVID-19 patients requiring prolonged mechanical ventilation: a retrospective cohort study.

Background:Mechanical ventilation (MV) in coronavirus disease 2019 (COVID-19) patients is associated with high mortality and extensive resource utilization. The aim of this study was to investigate prognostic factors and outcomes associated with prolonged mechanical ventilation (PMV) in COVID-19 patients.Methods:This was a retrospective cohort study of COVID-19 patients requiring invasive MV who were hospitalized between 1 March 2020 and 30 June 2021 in the intensive care units (ICUs) of three referral hospitals belonging to a single health system. Data were extracted from electronic health records. PMV was defined as > 17 days of MV.Results:Of 355 patients studied, 86 (24%) required PMV. PMV patients had lower PaO2/FiO2 ratio, higher PCO2, and higher plateau and driving pressures during the first 2 weeks of MV than their short MV (SMV; ⩽ 17 days) counterparts. PMV patients received more proning, neuromuscular blockade, and tracheostomy, had longer ICU and hospital length of stay (LOS), and required discharge to an inpatient rehabilitation facility more frequently (all p < 0.001). Overall 30-day mortality was 43.9%, with no statistically significant difference between PMV and SMV groups. In PMV patients, smoking, Charlson comorbidity index > 6, and week 2 PaO2/FiO2 ratio < 150 and plateau pressure ⩾ 30 were positively associated with 30-day mortality. In a multivariate model, results were directionally consistent with the univariate analysis but did not reach statistical significance.Conclusion:PMV is commonly required in COVID-19 patients with respiratory failure. Despite the higher need for critical care interventions and LOS, more than half of the PMV cohort survived to hospital discharge. Higher PaO2/FiO2 ratio, lower plateau pressure, and fewer comorbidities appear to be associated with survival in this group.

Relationship of Exercise and Hospital Readmission After Spinal Cord Injury: A Secondary Analysis.

After spinal cord injury (SCI), as many as 45% of people experience at least one hospital readmission within 1 yr. Identification of feasible low-cost interventions to reduce hospital readmissions after SCI is needed. To explore whether a relationship exists between routine exercise and hospital readmission rates 1 yr after SCI. We conducted a secondary analysis of data from the SCIRehab Project, a prospective cohort study. Five SCI inpatient rehabilitation facilities across the United States. Participants were people age 12 yr and older who had sustained an SCI, were admitted to a participating inpatient rehabilitation facility, completed the 12-mo postinjury interview, and reported exercising either monthly or not at all since discharge (N = 520). Outcomes and Measures: The SCIRehab Project conducted 12-mo post-inpatient rehabilitation discharge interviews. As part of the interviews, self-reported hospital readmissions and exercise frequencies since discharge (self-reported number of months, average days per week, and average minutes per day of exercise participation) were collected and analyzed. A χ2 analysis determined that a significant correlation (φ = -.091, p = .038) exists between monthly exercise and hospital readmissions 1 yr postinjury. Compared with those who did not exercise, participants who exercised monthly had 8.4% fewer hospital readmissions. A relationship exists between exercise and hospital readmission, but follow-up research is needed to determine whether regular exercise reduces hospital readmissions among this population. What This Article Adds: After discharge, 44% of the participants did not exercise during the first year after injury. Identifying or implementing accessible community exercise programs is an area of opportunity for occupational therapy practitioners and future researchers to explore.