Post-acute Unit Research Articles

Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation.

Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. Cross-sectional study. Post-acute Unit of Neurorehabilitation. DOC due to severe brain injury. Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.

Healthcare-associated infections and antimicrobial resistance in severe acquired brain injury: a retrospective multicenter study.

Recent studies underscore that healthcare-associated infections (HAIs) and multidrug-resistant (MDR) HAIs affect rehabilitation outcomes and hospital length of stay (LOS) for severe acquired brain injury (sABI). This study aimed to estimate HAI incidence in different sABI rehabilitation settings and determine risk factors and HAI impact on neuromotor and cognitive recovery. We conducted a retrospective multicenter study in two semi-intensive units (SICUs), two high-specialty post-acute units (PAUs), and one long-term care (LTC) rehabilitation facility. Data extraction was performed by experienced clinicians, using a structured Excel file and they agreed upon criteria for case definitions of healthcare. The main outcome measures were the HAI and MDR HAI incidence and the LOS, the functional recovery was measured using the Level of Cognitive Functioning and Disability Rating Scale. There were 134 sABI participants. The calculation of the probability level was adjusted for three pairwise comparisons among settings (0.05/3 = 0.017). The HAI and MDR HAI incidences were significantly higher in SICU (3.7 and 1.3 per 100 person-days) than in other settings (LTC: 1.9, p = 0.034 and 0.5, p = 0.026; PAU: 1.2, p < 0.001 and 0.3, p < 0.001). HAI and MDR HAI risk variables included older age, an increased number of devices, and carbapenemase-producing Enterobacteriaceae (CPE) colonization, while a high prealbumin plasma value seemed to have a protective effect. HAIs are related to longer LOS, and colonization is associated with poor prognosis and poor functional outcomes with reduced ability to achieve the cognitive capacity of self-care, employability, and independent living. The need to ensure the protection of non-colonized patients, especially those with severe disabilities on admission, is highlighted.

Absence of negativization of nasal swab test and frailty as risk factors for mortality in elderly COVID-19 patients admitted in long-term care facilities.

A limited amount of data is now available on prognostic factors and mortality among elderly people resident in Long-Term Care facilities and in post-acute units. These populations (in particular those with underlying chronic medical conditions) seem to have higher risk of morbidity and mortality related to COVID-19 disease, but further evidence is needed. The aim of our study is to investigate the impact of some well-known prognostic factors in elderly patients (≥ 65years) with COVID-19 admitted in the Long-Term Care setting in AUSL Ferrara, Italy. We performed binary regression logistic analysis for some variables (demographic data, clinical data including nasal swab test (NST) at discharge and frailty assessments) to find potential predictors of mortality. We subsequently tested statistically significant variables using Kaplan-Meier curves and Cox-regression models to find survival outcomes and related hazard ratio. Risk factors associated with increased mortality resulted NST at discharge,infection, age and frailty.At a further secondary analysis carried out between NST at discharge, age and clinical frailty scale (CFS) < 5, we found a positive correlation between NST at discharge and CFS < 5. Kaplan-Meier curves showed a statistically significant difference regarding frailty and NST at discharge but not for age. Our study showed that absence of negativization of NST at discharge and frailty are strong predictors for mortality in elderly COVID-19 patients admitted in Long-Term Care facilities, while age and the comorbidity burden are less important.

A Better World in the Future

A Better World in the Future

Does a Surgical Post-Acute Unit Help Elders With Rib Fractures? Definitely Maybe!

A surgical post-acute treatment unit (SPA) was developed for acutely injured elderly patients who no longer warranted acute care in an intensive care setting to decrease complications by focusing increased bedside attention to cognition, nutrition, respiration, and mobilization. A retrospective review was performed comparing patients 65 years and older with isolated rib fractures treated before the SPA was opened with patients treated in the SPA. The 2 populations were comparable except the SPA group had a higher mean Injury Severity Score. Nine complications occurred in the pre-SPA group, and no complications occurred in the SPA patient population. Four patients in the pre-SPA group died compared with zero deaths for the SPA group. The rates of complications and mortality between elderly patients with isolated rib fractures were not statistically different between patients treated with a traditional admission to an inpatient ward and patients admitted to the SPA, even though the SPA patients had significantly more severe chest injuries. Establishing a physical environment to support the needs of elderly trauma patients with isolated rib fractures who no longer need the intensive care unit (ICU) is effective in decreasing the complications and unplanned returns to the ICU.

Does a Surgical Post-Acute Unit Help Elders With Rib Fractures? Definitely Maybe!

Does a Surgical Post-Acute Unit Help Elders With Rib Fractures? Definitely Maybe!

The Power of Process Improvement

The Power of Process Improvement

Does the presence of pressure ulcers entail "high risk of negative outcomes" in geriatric rehabilitation? Results from a retrospective cohort study.

A retrospective cohort study was performed in order to evaluate the prevalence of pressure ulcers (PrUs) in older patients admitted to a geriatric rehabilitation unit of a postacute care hospital and to investigate the impact of the presence of PrUs on clinical outcomes of the rehabilitation process. We studied 668 post-acute patients consecutively attended, from January 2010 to December 2011. The effect of having PrUs at admission was evaluated based on its impact on outcomes: final destination, functional status, mortality and length of stay in the rehabilitation unit. PrUs prevalence at admission was 16%. Patients with PrUs were older, more disabled and had more complex conditions, including malnutrition and cognitive impairment. In the bivariate analysis, we found patients with PrUs at admission had worst final outcome (%): discharge home (69.2 vs.82.5), discharge long term care setting (14 vs.6.4), discharge acute care (8.4 vs.6.2) and death (8.4 vs.4.8); p < 0.001, and worst Barthel Index score at discharge 57 (SD 34.1) vs.83 (SD 33.6); p < 0.001, with longer length of stay in the unit 61 (SD 42.3) vs.53 (SD 37.1); p 0.004. In the multivariate analysis, PrUs presence was found as one of the variables with significant association to no return to home. Finally, a negative association between PrUs at admission and functional gain at discharge of the postacute unit was identified. PrUs were prevalent and had negative impact on clinical outcomes of our geriatric unit, as discharge destination, functional gain and Length of Stay, in vulnerable patients.

When Returning Home Is Not a Good Option

When Returning Home Is Not a Good Option

Self-Reported Health and Safety Awareness Improves Prediction of Level of Care Needs in Veterans Discharged From a Postacute Unit

ObjectivesTo evaluate the differential value of a self-reported health and safety awareness measure relative to other medical, psychosocial, and cognitive factors in predicting level of care (LOC) needs after hospital discharge. DesignRetrospective medical record review. SettingCommunity living center postacute care (CLC-PAC) unit at a Veterans Affairs hospital. ParticipantsA total of 175 veterans admitted to the Veterans Affairs hospital or directly to the CLC-PAC from home. MethodsCognitive status was assessed with the Mini-Mental State Examination, Digit Span Backward subtest, Trail Making Test (Part B), and Hopkins Verbal Learning Test-Revised. Self-report of health and safety awareness was measured with the Independent Living Scales Health and Safety (ILS-HS) subscale. Additional demographic and admission-related variables were coded, along with medical comorbidity, with the Charlson Comorbidity Index and depression using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision Depression Checklist. Main Outcome MeasurementsIncreased level of care was collected from social work and occupational therapy notes and defined as increased assistance with activities of daily living or nursing home placement comparing prehospitalization with CLC-PAC discharge. ResultsA total of 19% (n = 34) of residents required increased LOC on CLC-PAC discharge. The ILS-HS was a significant predictor of increased LOC above and beyond age and Mini Mental Status Examination score; for each standard deviation decrease in ILS-HS, there was an increased likelihood of greater LOC (odds ratio 0. 54, 95% confidence interval 0.35-0.83). Other neuropsychological tests (memory, executive functioning) did not significantly improve the model. ConclusionsThe inclusion of the ILS-HS to a standard cognitive screen (Mini Mental Status Examination) can improve prediction of increased LOC. Although select aspects of memory and executive functioning independently contribute to increased LOC prediction, the ILS-HS likely measures a unique aspect of cognitive functioning that may be specific to discharge planning needs in CLC-PAC residents. Level of EvidenceII

No Storm Too Big for Medical Director of the Year

No Storm Too Big for Medical Director of the Year

When the Snake Oil Salesman Knocks on Your Door

When the Snake Oil Salesman Knocks on Your Door

Observations of oral hygiene care interventions provided by nurses to hospitalized older people

Dependent older hospitalized patients rely on nurses to assist them with the removal of plaque from their teeth, dentures, and oral cavities. Oral care interventions by 25 nurses on post-acute units, where patients have longer hospital stays, were observed during evening care. In addition to efforts to engage patients in oral care, nurses provided the following interventions: (a) supporting the care of persons with dentures; (b) supporting the care of natural teeth; (c) cleansing the tongue and oral cavity; and (d) moisturizing lips and oral tissues. Patients' oral hygiene care was supported in just over one-third of encounters. Denture care was inconsistently performed, and was infrequently followed by care of the oral cavity. Nurses did not encourage adequate self-care of natural teeth by patients, and infrequently moisturized tissues. Evidence-based oral hygiene care standards are required to assist nurses to support patients in achieving optimal oral hygiene outcomes.

I’ll See You Again in 30 Days

I’ll See You Again in 30 Days

Evaluation at five years of post-acute unit (UPR) at the Saint-Hélier Pole, Rennes

Evaluation at five years of post-acute unit (UPR) at the Saint-Hélier Pole, Rennes

Recovery of Functional Impairment after Acute Illness and Mortality: One-Year Follow-Up Study

Background: Functional status in older people is a dynamic situation, which makes it necessary to evaluate functional capacity at different times to determinate their prognostic value. Objective: To examine the association between functional status (baseline and change after acute illness) and mortality and functional changes at 1 year. Methods: Hospital-based prospective longitudinal cohort study of all patients over 65 years old, admitted for multidisciplinary treatment of functional impairment after acute illness in a medium-stay unit (post-acute geriatric unit) of a teaching hospital ascribed to the Spanish National Health Service from Spain during 15 consecutive months. Functional status (Barthel Index, BI) was assessed prior to the acute illness, at admission in a post-acute unit, at discharge and 1 year later. At admission, other variables were collected: sociodemographic, main diagnostic for hospitalization (stroke, orthopedic process, or deconditioning), serum albumin, comorbidity (Charlson Index), cognitive status (Pfeiffer´s Short Portable Mental Status Questionnaire). In order to analyze mortality 1 year after discharge, a Cox regression analysis was performed. Results: Three hundred and sixty-nine patients consituted the study population, mean age was 80.74 years (SD 7.4), 66.6% were female and 1 year after discharge mortality was 20%. In the multivariate analysis, variables associated with a higher 1-year mortality were age (HR 1.06; 95% CI = 1.00–1.07) male gender (HR 2.11; 95% CI = 1.26–3.55), worse prior functional status (HR 0.98; 95% CI = 0.96–0.99), and higher functional loss in BI at admission (HR 1.02; 95% CI = 1.00–1.04). On the other hand, a greater functional gain in BI at discharge was associated with a lower 1-year mortality (HR 0.98; 95% CI = 0.96–0.99). Conclusions: The main functional gain obtained after treatment in a multidisciplinary post-acute geriatric unit is independently associated with a reduction in long-term mortality. In addition to baseline functional status and after acute illness, the subsequent potential recovery is very important to predict poor long-term outcomes.

Estudio multicéntrico prospectivo de reacciones adversas a medicamentos en pacientes ancianos hospitalizados

The incidence of adverse drug reactions (ADRs) in hospitalized elderly patients is an important clinical problem. The purpose of this study was to determine the incidence of ADRs in elderly in-patients, to analyze the factors involved in their presentation and to evaluate the reactions detected. Prospective multicenter study in patients older than 65 years during their stay in hospital or nursing home. The assessment consisted of a complete geriatric evaluation and a protocol for collecting information on suspected ADRs during hospitalization or nursing home stay. A multivariate analysis by multiple logistic regression was performed. The study included 865 patients: 185 (21%) from 5 hospital units; 325 (38%) from 8 convalescent centers; and 355 (41%) from 8 long-term centers. The incidence of ADRs was 9%. In acute units the incidence was 15%; in post-acute units, 5%; and in long-term centers, 10% (p < 0.004). In the global multivariate analysis, the risk of experiencing an ADR was associated with a greater use of medications (OR = 1.15; 1.07 1.23 for each additional drug), the presentation of delirium (OR = 3.6; 1.95-6.85) and the type of unit (acute OR = 2.6; 1.16-6.01; long-term OR = 3.3; 1.62-7.05). Fifty type A ADRs were detected (65%). With regard to severity, 36 (47%) were moderate, 27 (35%) were mild, and 14 (18%) were severe. Causality: 58 (76%) probable and 17 (20%) possible. Potential avoidability: 39 (51%) were unavoidable and 38 (49%) were totally or partially avoidable; of these, 15 (39%) were the result of an interaction with another drug. The incidence of ADRs in our study was close to 10%. ADRs were associated with the frequency of use, presence of delirium and type of unit, and occurred most frequently in acute and long-term units. ADRs were principally type A, moderate severity, probable causality and partially avoidable.