Longer Rehabilitation Length Of Stay Research Articles

Readmission to an Acute Care Hospital During Inpatient Rehabilitation for Traumatic Brain Injury

ObjectiveTo assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). DesignProspective observational cohort. SettingInpatient rehabilitation. ParticipantsIndividuals with TBI admitted consecutively for inpatient rehabilitation (N=2130). InterventionsNot applicable. Main Outcome MeasuresRTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. ResultsA total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. ConclusionsApproximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting.

Functional Outcomes after Inpatient Rehabilitation in a Prospective Stroke Cohort

Aim: Rehabilitation is proven to improve function following a stroke. The functional outcomes of stroke patients and benefits from rehabilitation are highly variable. We aim to describe functional outcomes and gains following inpatient rehabilitation post-stroke and identify factors associated with improved outcomes. Methods: In this five-years prospective study, data for 1332 consecutive stroke patients admitted to the Singapore General Hospital inpatient rehabilitation unit were charted into a custom-designed rehabilitation database. The primary outcome measure was the Functional Independence Measure (AFIM) and discharge (DFIM). The functional gain was defined as the DFIM-AFIM. Results: The mean age was 64.1±12.5 years, 58.9% were male patients and 78.9% consisted of ischaemic (versus haemorrhagic) strokes. The average rehabilitation length of stay (RLOS) was 18.7±13.9 days and the majority (87.7%) were discharged home. The most common risk factor was hypertension (78.4%) and urinary tract infection (21.2%) was the commonest post-stroke complication. The mean AFIM and DFIM scores were 67.9±23.0 and 83.2±23.5 respectively with a mean functional gain of 15.4±12.3 FIM points. Younger, male, and haemorrhagic stroke patients had better functional outcomes. Multiple regression analysis results revealed that higher DFIM score was associated with higher admission motor and cognitive FIM scores, younger age, male gender, employment at admission, single patients, presence of a caregiver, haemorrhagic stroke, right-sided motor impairments, absence of urinary tract infection or depression, acupunction treatment, and a longer RLOS. The regression model on functional gain was associated with similar independent predictors on DFIM scores except that a higher AFIM was associated with lower functional gains. Conclusion: In this large cohort study, stroke patients make significant functional gains and should be offered rehabilitation to improve outcomes. A comprehensive set of multiple interacting demographic, clinical, cultural, and social factors significanctly impact on stroke functional outcomes after inpatient rehabilitation. The identification of these factors allows optimising rehabilitation for individual patients, and is important for discharge and resource planning.

Acute Rehospitalizations During Inpatient Rehabilitation for Spinal Cord Injury

ObjectivesTo investigate frequency of and reasons for readmission to acute care (RTAC) during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to identify factors associated with RTAC. DesignProspective observational cohort. SettingInpatient rehabilitation. ParticipantsIndividuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation; 1032 randomly selected for model development; 344 selected for model cross-validation. InterventionsNot applicable. Main Outcome MeasuresRTAC, RTAC reasons, rehabilitation length of stay (LOS), discharge location and FIM, rehospitalization between discharge and year 1, and 1-year outcomes: FIM, Craig Handicap Assessment and Reporting Technique, and Patient Health Questionnaire-9. ResultsParticipants (n=116; 11%) experienced RTAC with a total 143 episodes—96 patients experienced only 1 RTAC, while 14 had 2 RTACs, 5 had 3 RTACs, and 1 had 4 RTACs. The most common RTAC reasons were surgery (36%), infection (22%), noninfectious respiratory (14%), and gastrointestinal (8%). Mean days ± SD from rehabilitation admission to first RTAC was 27±30 days. Seventy-four (7%) patients had at least 1 RTAC for medical reasons and 46 (4%) for surgical reasons. Regression analyses indicated several variables were associated with RTACs: greater admission medical severity, lower admission cognitive FIM, pressure ulcer acquired in acute care, and study site. Medical RTACs were associated with higher body mass index, lower admission cognitive and motor FIM, payer, and study site. Predictors of surgical RTAC were longer time from injury to rehabilitation admission and study site. After controlling for the other variables, the only outcome RTAC influenced was longer rehabilitation LOS. ConclusionsApproximately 11% of SCI patients experience RTAC during the course of rehabilitation for a variety of medical and surgical reasons. RTACs are associated with longer rehabilitation LOS.

Recognizing and Referring Suspected Elder Mistreatment

To investigate frequency of and reasons for readmission to acute care (RTAC) during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to identify factors associated with RTAC.Prospective observational cohort.Inpatient rehabilitation.Individuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation; 1032 randomly selected for model development; 344 selected for model cross-validation.Not applicable.RTAC, RTAC reasons, rehabilitation length of stay (LOS), discharge location and FIM, rehospitalization between discharge and year 1, and 1-year outcomes: FIM, Craig Handicap Assessment and Reporting Technique, and Patient Health Questionnaire-9.Participants (n=116; 11%) experienced RTAC with a total 143 episodes—96 patients experienced only 1 RTAC, while 14 had 2 RTACs, 5 had 3 RTACs, and 1 had 4 RTACs. The most common RTAC reasons were surgery (36%), infection (22%), noninfectious respiratory (14%), and gastrointestinal (8%). Mean days ± SD from rehabilitation admission to first RTAC was 27±30 days. Seventy-four (7%) patients had at least 1 RTAC for medical reasons and 46 (4%) for surgical reasons. Regression analyses indicated several variables were associated with RTACs: greater admission medical severity, lower admission cognitive FIM, pressure ulcer acquired in acute care, and study site. Medical RTACs were associated with higher body mass index, lower admission cognitive and motor FIM, payer, and study site. Predictors of surgical RTAC were longer time from injury to rehabilitation admission and study site. After controlling for the other variables, the only outcome RTAC influenced was longer rehabilitation LOS.Approximately 11% of SCI patients experience RTAC during the course of rehabilitation for a variety of medical and surgical reasons. RTACs are associated with longer rehabilitation LOS.

Apolipoprotein E epsilon 4 allele and outcomes of traumatic spinal cord injury in a Chinese Han population

The association between apolipoprotein E (APOE) epsilon 4 (ε4) allele and outcomes of traumatic spinal cord injury (SCI) is still controversial and ambiguous. The objective of this study was to test the hypothesis that APOE polymorphisms are associated with outcomes after SCI in Chinese Han patients. APOE polymorphisms were determined in 100 patients with cervical SCI (C3-C8). The genotype frequency of this polymorphism was determined by using a polymerase chain reaction-restriction fragment length polymorphism assay. Patients with an APOE ε4 allele had significantly less motor recovery during rehabilitation than did patients without an APOE ε4 allele (mean 3.7 vs. 6.1; P = 0.04) and a longer rehabilitation length of stay (LOS) (mean 117.4 vs. 94.5; P = 0.02), but better sensory-pinprick recovery (mean 6.1 vs. 4.0; P = 0.03). There were no significant differences by APOE ε4 allele status in sensory-light touch recovery or acute LOS. This study suggests that the APOE ε4 allele is associated with outcomes after SCI and longer rehabilitation LOS in Chinese Han patients.

Poster 14: Individuals With Severely Disordered Level of Consciousness: Factors Associated With Returning to Oral Feeding During Inpatient Rehabilitation

Objective: To identify factors associated with return to oral feeding in unconscious patients undergoing inpatient rehabilitation. Design: Retrospective, case-controlled study. Setting: 2 freestanding rehabilitation hospitals. Participants: 73 subjects admitted to acute inpatient rehabilitation at cognitive levels ranging from a Rancho Los Amigo Level I-III. Interventions: Not applicable. Main Outcome Measure: Return to some type of oral feeding during inpatient rehabilitation. Results: Group 1 (n=36) subjects remaining NPO during inpatient rehabilitation was 61% men, mean age ± SD of 41.86±18.11. Admission to inpatient rehabilitation on average 66.59±76.46 days after injury with 38.69 days average rehabilitation length of stay (LOS). Group 2 (n=37), subjects returning to some type of oral feeding during inpatient rehabilitation was primarily men (73%), mean age ± SD of 36.62±16.93. Admission to inpatient rehabilitation 63.32±71.9 days after injury with an average rehabilitation LOS of 49.81±20.224 days. Differences between age, duration of injury, and sex distribution were nonsignificant. Group 1 mean discharge cognitive FIM score was equal to 6.06 and motor FIM score was equal to 16.17. Group 2 mean discharge cognitive FIM score was equal to 9.22 and motor FIM score was equal to 25.89. Differences observed between the 2 groups were significant (cognitive FIM, t=−2.848, P=0.006; motor FIM, t=−2.965, P=0.004). Overall 12 (16.4%) of the 73 patients in the study sample developed pneumonia during inpatient rehabilitation with 8 (66.6%) of the 12 being in the NPO group and 4 (33.3%) of the 12 being in the oral feeding group (χ2=1.758, P=0.185). Group 2 discharge diet levels were: 18 (48.6%) of 37 therapeutic feedings with speech only, 9 (24.3%) of 37 dysphagia diet, 13 (35.1%) of 37 regular diet. Conclusions: Participants who were able to return to oral feedings during inpatient rehabilitation had longer rehabilitation LOS, higher discharge cognitive and motor FIM scores, and no increase in pneumonia rates as compared with subjects who were unable to return to oral feedings. The majority of patients who returned to oral feedings were able to advance to 3 meals daily.

Apolipoprotein E s4 Allele and Outcomes of Traumatic Spinal Cord Injury

Background/Objective: To test the hypothesis that apolipoprotein E (APOE) polymorphisms are associated with outcomes after spinal cord injury (SCI).Methods: Retrospective cohort study, from rehabilitation admission to discharge.Participants: Convenience sample of 89 persons with cervical SCI (C3-C8) treated from 1995 through 2003. Median age was 30 years (range 14-70); 67 were male (75%) and 83 were white (93%).Main Outcome Measures: American Spinal Injury Association (ASIA) motor and sensory scores, ASIA Impairment Scale (AIS), time from injury to rehabilitation admission, and length of stay (LOS) in rehabilitation.Results: Subjects with an APOE s4 allele (n = 15; 17%) had significantly less motor recovery during rehabilitation than did individuals without an s4 allele (median 3.0 vs 5.5; P < 0.05) and a longer rehabilitation LOS (median 106 vs 89 days; P = 0.04), but better sensory-pinprick recovery (median 5.0 vs 2.0; P = 0.03). There were no significant differences by APOE s4 allele status in sensory-light touch recovery, likelihood of improving AIS Grade, or time from injury to rehabilitation admission.Conclusions: APOE ε4 allele was associated with differences in neurological recovery and longer rehabilitation LOS. Genetic factors may be among the determinants of outcome after SCI and warrant further study.

Do preinjury alcohol problems predict poorer rehabilitation progress in persons with spinal cord injury?

Bombardier CH, Stroud MW, Esselman PC, Rimmele CT. Do preinjury alcohol problems predict poorer rehabilitation progress in persons with spinal cord injury? Arch Phys Med Rehabil 2004;85:1488–92. Objective To determine whether a history of alcohol-related problems is associated with inpatient rehabilitation progress. Design Cross-sectional cohort survey. Setting Acute inpatient rehabilitation program in a level I trauma center. Participants Seventy-six of 104 consecutive patients with spinal cord injury (SCI) who met inclusion criteria and had completed interviews and functional outcome data. Participants were on average 38 years old; 84% were white, and 86% were men. Forty-two percent had tetraplegia and 39% had a history of problem drinking. Interventions Not applicable. Main outcome measures FIM instrument admission, discharge, and efficiency scores as well as rehabilitation length of stay (LOS). Results The group with a history of problem drinking had significantly lower FIM admission, discharge, and efficiency scores and longer rehabilitation LOS. After controlling for potential confounding factors, a history of problem drinking accounted for a significant proportion of the variance in FIM efficiency scores. Conclusions A history of problem drinking may be a risk factor for poorer rehabilitation progress among patients with SCI. They may be more costly to rehabilitate and may be discharged before attaining an adequate level of independence. Despite this, the current rehabilitation prospective payment system does not recognize this common comorbid condition.

Poster 169: The effect of comorbidities on rehabilitation outcomes in orthopedic patients.

Objective: To investigate the effects of comorbidities (heart disease, diabetes, anemia, hypertension) on functional outcomes and rehabilitation length of stay after total knee or hip replacement or lower-extremity amputation. Design: Retrospective chart review study. Setting: A Veterans Affairs medical center in Texas. Participants: The medical records of 90 patients admitted to inpatient rehabilitation from the orthopedic ward between 1999 and 2002 were reviewed: 50 knee arthroplasty patients (age range, 47–85y; mean, 64.38y), 18 hip arthroplasty patients (age range, 46–85y; mean, 63.3y), and 22 amputees (age, 44–79y; mean, 64.82y). Interventions: Not applicable. Main Outcome Measures: Comorbidity data (heart disease, diabetes, anemia, hypertension) were obtained from the medical history taken prior to surgery. Hemoglobin was measured presurgery and at admission to rehabilitation. The motor subscale of the FIM™ instrument was administered at admission to and discharge from rehabilitation. Length of stay (LOS) in rehabilitation also was recorded. Results: Heart disease, diabetes, and anemia were more common among patients who had amputations than those who had knee and hip arthroplasty. Amputation patients tended to have lower discharge motor FIM scores and longer LOS than knee arthroplasty patients. However, all 3 groups made substantial motor FIM gains (amputation, 19; knee, 23; hip, 20). Patients with chronic anemia had longer rehabilitation LOS and lower discharge motor FIM scores. There were no differences between discharge motor FIM scores and motor FIM gains based on whether a person had heart disease, diabetes, or hypertension. Conclusions: The results indicate that patients admitted to rehabilitation for amputation or hip and knee arthroplasty have the potential to improve motor function regardless of comorbidities. However, the surgery itself and some comorbidities may affect functional recovery and LOS after surgery.

The association between gender, race and marital status on functional outcome at rehabilitation discharge after thromboembolic stroke: a prospective analysis1

Appropriate allocation of rehabilitation resources requires that the rehabilitation professional have a knowledge of reliable predictors of functional outcome. To determine what influence pre-morbid demographic variables have on functional outcome following thromboembolic stroke, we analyzed prospectively collected demographic and functional data from consecutive patients admitted to rehabilitation at a tertiary university medical center. Data from 117 patients were statistically analyzed for correlations between demographic factors and functional outcome as measured by the FIM scale and hospital length of stay (LOS). While no significant correlations were found between race or gender and functional outcome, Caucasians were found to stay an average of 5 days longer in acute care than African-Americans. Non-married patients were found to have significantly longer rehabilitation LOS and return home following discharge less often. It is concluded that non-married status is a significant negative prognostic factor for functional outcome after thromboembolic stroke, while gender and race have no correlation.