Skilled Nursing Facility Rehabilitation Research Articles

SYSTEMATIC REVIEW OF REHABILITATION IN SKILLED NURSING FACILITIES FOR PERSONS LIVING WITH DEMENTIA

Abstract We conducted a systematic review of published literature though April 2023 to identify the experiences and outcomes of persons living with dementia (PLWD) undergoing post-acute care rehabilitation in skilled nursing facilities (SNF). A systematic search for studies published in English was carried out in eight databases including PubMed, Scopus, Google Scholar, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. Forty-one articles met inclusion criteria. There was heterogeneity of study designs with most articles (n=33) being observational and cross-sectional, while randomized clinical trials (n=3) and qualitative studies (n=5) were less represented. Certain themes emerged from the results regarding patient outcomes and experiences. Measured outcomes demonstrated increased health service utilization, varied functional outcomes, and suboptimal patient care. Patient experiences included significant challenges with health care transitions, gaps in healthcare worker and caregiver knowledge & education, emphasis on alternate models of care, and importance of goal alignment. Overall, this systematic review provides a comprehensive understanding of the outcomes and experiences of post-acute care rehabilitation in SNFs for PLWD. The findings highlight the need for alternative care pathways, improved healthcare transitions, tailored rehabilitation approaches, enhanced dementia training for healthcare professionals, and person-centered goal setting. By addressing these critical aspects, future interventions can be developed to improve the delivery of post-acute care for PLWD and enhance their health outcomes.

Current Evidence on the Impact of Medicare Payment Policy on Stroke Rehabilitation in Skilled Nursing Facilities

Current Evidence on the Impact of Medicare Payment Policy on Stroke Rehabilitation in Skilled Nursing Facilities

Higher Movement-Evoked Pain Is Associated With Slower Walking Speed In Older Adults Undergoing Skilled Nursing Facility Rehabilitation

Higher Movement-Evoked Pain Is Associated With Slower Walking Speed In Older Adults Undergoing Skilled Nursing Facility Rehabilitation

Association Between Cognitive Impairment and Repeat Fractures in Medicare Beneficiaries Recently Hospitalized for Hip Fracture.

Repeat fractures contribute substantially to fracture incidents in older adults. We examined the association between cognitive impairment and re-fractures during the first 90days after older adults with hip fractures were discharged home from a skilled nursing facility rehabilitation short stay. Multilevel binary logistic regression was used to analyze 100% of U.S.national postacute-care fee-for-service Medicare beneficiaries who had a hospital admission for hip fracture from January 1, 2018, to July 31, 2018; were admitted for a skilled nursing facility stay within 30days of hospital discharge; and were discharged to the community after a short stay. Our primary outcome was rehospitalization for any re-fractures within 90days of skilled nursing facility discharge. Cognitive status assessed at skilled nursing facility admission or before discharge was classified as either intact or having mild or moderate/severe impairment. In 29558 beneficiaries with hip fracture, odds of any re-fracture were higher in those with minor (odds ratio: 1.48; 95% confidence interval: 1.19-1.85; p < .01) and moderate/major cognitive impairment (odds ratio: 1.42; 95% confidence interval: 1.07-1.89; p=.0149) than in those classified as intact. Beneficiaries with cognitive impairment were more likely than their counterparts with no cognitive impairment to experience re-fractures. Community-dwelling older adults with minor cognitive impairment may experience a higher likelihood of experiencing a repeat fracture leading to rehospitalization.

THE SUBSEQUENT IMPACT OF COVID-19 FOR BOTH IMMUNE DYSREGULATION AND OPPORTUNISTIC INFECTIONS

THE SUBSEQUENT IMPACT OF COVID-19 FOR BOTH IMMUNE DYSREGULATION AND OPPORTUNISTIC INFECTIONS

Feasibility of Measuring Frailty and Patient-Reported Outcomes During and After Post-Acute Skilled Nursing Facility Rehabilitation.

Functional status and quality of life are not routinely assessed after skilled nursing facility (SNF) discharge. We determined feasibility of measuring frailty among adults ≥65 years admitted to SNF after hospitalization, and post-discharge outcomes. We calculated a frailty index (non-frail [≤0.25], mild frailty [0.26–0.35], moderate [0.36–0.45], and severe [>0.45]). After SNF discharge, we conducted serial telephone interviews measuring ability to perform functional activities and Patient Reported Outcome Measurement Information System (PROMIS) scores. Overall of 68 screened patients, 42 were eligible, and 24 (57.1%) eligible patients were enrolled. Of these, 5 (20.8%) were admitted after elective hospitalizations, 17 (70.8%) were female, and 11 (45.8%) had moderate-to-severe frailty. Frailty was measured in all participants in a mean 32.1 minutes. At 90 days, a total of three participants died, and two were lost to follow-up. Post-discharge functional status varied by frailty, with moderate-to-severe frailty having persistent impairment and lower PROMIS scores (worse quality of life) compared to those with no or mild frailty (38.2 [13.7] vs. 47.3 [8.1] p = .04). Measuring frailty and quality of life in older patients admitted to SNF is feasible. Furthermore, measuring frailty may help identify those at particularly high risk of poor recovery and lower quality of life after discharge.

Medicare payment policy in skilled nursing facilities: Lessons from a history of mixed success.

The current policy environment for rehabilitation in skilled nursing facilities (SNFs) is complex and dynamic, and SNFs are facing the dual challenges of recent Medicare payment policy change that disproportionately impacts rehabilitation for older adults and the COVID-19 pandemic. This article introduces an adapted framework based on Donabedian's model for evaluating quality of care and applies it to decades of Medicare payment policy to provide a historical view of how payment policy changes have impacted rehabilitation processes and patient outcomes for Medicare beneficiaries in SNFs. This review demonstrates how SNF responses to Medicare payment policy have historically varied based on organizational factors, highlighting the importance of considering such organizational factors in monitoring policy response and patient outcomes. This historical perspective underscores the mixed success of previous Medicare policies impacting rehabilitation and patient outcomes for older adults receiving care in SNFs and can help in predicting SNF industry response to current and future Medicare policy changes.

Physical Performance is Significantly More Important Than Health Condition When Considering Rehabilitation Outcome

<h3>Research Objectives</h3> To determine the most important features in a rehabilitation prediction model using machine learning. <h3>Design</h3> Physical performance data were collected at evaluation and discharge from physical (PT) and occupational therapy (OT) in skilled nursing (SNF). These data along with the patient's prior living situation, medical diagnosis (grouped in broad categories), prior living situation, and age were used in a retrospective k-means cluster analysis. A profile of each group was developed using additional demographic and clinical process data. A predictive model was generated using an XGboost model with hyperparameters tuning. <h3>Setting</h3> Infinity Rehab is a post-acute therapy provider in over 150 skilled nursing facilities (SNF) treating approximately 13000 patients/year. <h3>Participants</h3> Data from 25000 older adult patients admitted to skilled nursing facilities were used for model development. <h3>Interventions</h3> The model was trained on 80% of the cases and tested on the remainder. <h3>Main Outcome Measures</h3> Time to rise from a chair 5 times (5xSTS), gait speed over 4 meters, 6-minute Walk Test (6MWT), grip strength (Grip), the Continuity Assessment Record Evaluation (CARE) mobility and self-care item set, and the St. Louis Mental Status Examination (SLUMS). <h3>Results</h3> The cluster analysis yielded 5 patient groupings who were different in baseline and discharge characteristics, change values, rehabilitation value, and prior and discharge living situation. 20 features were identified as contributing to the group assignment. The 3 most important features were initial 5xSTS, 6MWT, and gait speed, followed by measures of activity limitation. Of the 20 features, only 7 were medical diagnosis categories with the highest of these (non-stroke, tumor, or degenerative brain disorders) in the 13th position. Of the 7 medical diagnosis categories, 4 were neurological in nature. <h3>Conclusions</h3> When considering outcomes from rehabilitation in SNF, measures reflecting impairment in functional strength, activity tolerance, and speed are more important than activity limitations and much more important than medical diagnosis. Medical diagnosis impacted cluster group assignment the most when it was a neurological condition. <h3>Author(s) Disclosures</h3> The authors have nothing to disclose.

CO-FLOW: COvid-19 Follow-up care paths and Long-term Outcomes Within the Dutch health care system: study protocol of a multicenter prospective cohort study following patients 2\u2009years after hospital discharge

BackgroundFirst studies indicate that up to 6 months after hospital discharge, coronavirus disease 2019 (COVID-19) causes severe physical, cognitive, and psychological impairments, which may affect participation and health-related quality of life (HRQoL). After hospitalization for COVID-19, a number of patients are referred to medical rehabilitation centers or skilled nursing facilities for further treatment, while others go home with or without aftercare. The aftercare paths include 1] community-based rehabilitation; 2] in- and outpatient medical rehabilitation; 3] inpatient rehabilitation in skilled nursing facilities; and 4] sheltered care (inpatient). These aftercare paths and the trajectories of recovery after COVID-19 urgently need long-term in-depth evaluation to optimize and personalize treatment. CO-FLOW aims, by following the outcomes and aftercare paths of all COVID-19 patients after hospital discharge, to systematically study over a 2-year period: 1] trajectories of physical, cognitive, and psychological recovery; 2] patient flows, healthcare utilization, patient satisfaction with aftercare, and barriers/facilitators regarding aftercare as experienced by healthcare professionals; 3] effects of physical, cognitive, and psychological outcomes on participation and HRQoL; and 4] predictors for long-term recovery, health care utilization, and patient satisfaction with aftercare.MethodsCO-FLOW is a multicenter prospective cohort study in the mid-west of the Netherlands with a 2-year follow-up period. Measurements comprise non-invasive clinical tests and patient reported outcome measures from a combined rehabilitation, pulmonary, and intensive care perspective. Measurements are performed at 3, 6, 12, and 24 months after hospital discharge and, if applicable, at rehabilitation discharge. CO-FLOW aims to include at least 500 patients who survived hospitalization for COVID-19, aged ≥18 years.DiscussionCO-FLOW will provide in-depth knowledge on the long-term sequelae of COVID-19 and the quality of current aftercare paths for patients who survived hospitalization. This knowledge is a prerequisite to facilitate the right care in the right place for COVID-19 and comparable future infectious diseases.Trial registrationThe Netherlands Trial Register (NTR), https://www.trialregister.nl. Registered: 12-06-2020, CO-FLOW trialregister no. NL8710.

Skilled Nursing Facilities Modify the Relationship Between Depressive Symptoms and Hospital Readmissions but Not Health Outcomes Among Older Adults

Objectives: Despite detrimental effects of depressive symptoms on self-care and health, hospital discharge practices and the benefits of different discharge settings are poorly understood in the context of depression. Methods: This retrospective cohort study comprised 23,485 hospitalizations from Medicare claims linked to the Health and Retirement Study (2000-2014). Results: Respondents with depressive symptoms were no more likely to be referred to home health, whereas the probability of discharge to skilled nursing facilities (SNFs) went up a half percentage point with each increasing symptom, even after adjusting for family support and health. Rehabilitation in SNFs, compared to routine discharges home, reduced the positive association between depressive symptoms and 30-day hospital readmissions (OR = 0.95, p = 0.029) but did not prevent 30-day falls, 1-year falls, or 1-year mortality associated with depressive symptoms. Discussion: Depressive symptoms were associated with discharges to SNFs, but SNFs do not appear to address depressive symptoms to enhance functioning and survival.

Mixed-Methods Approach to Understanding Determinants of Practice Change in Skilled Nursing Facility Rehabilitation: Adapting to and Sustaining Value With Postacute Reform.

Postacute care reform is driving physical and occupational therapists in skilled nursing facilities (SNFs) to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. This study explored what determinants impacted change in care delivery at 2 SNFs that implemented a high-intensity resistance training intervention. We used a mixed-methods, sequential explanatory design to explain quantitative findings using qualitative methods with a multiple-case study approach. Quantitative data were collected on therapists' attitudes toward evidence-based practice and aspects of intervention implementation. We conducted focus groups with therapists (N = 15) at 2 SNFs, classified as either high- (SNF-H) or low-performing (SNF-L) based on implementation fidelity and sustainability. Determinants of SNF rehabilitation practice change included the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions. A patient-centered system, positive team dynamics, and ability to overcome preconceived notions fostered practice change at SNF-H. While self-efficacy and perception of effectiveness positively impacted change in practice at both SNFs, these determinants were not enough to overcome challenges at SNF-L. To adapt to changes and sustain rehabilitation value, further research must identify the combination of determinants that promote application of evidence-based practice. This study is the first step in understanding what drives change in SNF rehabilitation practice. As SNF rehabilitation continues to face changes in health care delivery and reimbursement, therapists will need to adapt, by changing practice patterns and adopting evidence-based approaches, to demonstrate value in postacute care.

Post-Hospital Care Intensity Modifies the Relationship Between Depressive Symptoms and Hospital Readmissions

The objective of this study was to examine whether more structured post-acute care reduces the deleterious impact of depressive symptoms on older adults’ post-hospital outcomes (30-day hospital readmissions, 30-day falls, 1-year falls, and 1-year mortality). The sample comprised 23,485 eligible index hospitalizations from 7,151 unique fee-for-service Medicare beneficiaries from Health and Retirement Study linked to Medicare claims from 2000 to 2014. Depressive symptoms were measured using the eight-item Center for Epidemiologic Scale - Depression. We ran multinomial probit models regressing post-hospital setting on depressive symptoms while adjusting for sociodemographic factors, socioeconomic factors, family support, and health status. Then, we ran adjusted logistic regression models of each outcome while interacting depressive symptoms with post-acute care setting. We found that 62% of hospitalizations were routine discharges home, 17% were discharged to home health, and 21% were discharged to a Skilled Nursing Facilities (SNF). When adjusting for sociodemographic and socioeconomic factors, each increasing depressive symptom was associated with a half percentage point higher probability of referral to home health and 1.6 percentage points higher probability of discharge to SNFs, driven by differences in family support and health status. Rehabilitation in SNFs, compared to routine discharges home, reduced the positive association between depressive symptoms and 30-day readmissions (OR=0.95, p=0.027). However, post-acute care settings did not modify the association of depressive symptoms with falls or mortality. Considering depressive symptoms in discharge decisions, above and beyond their associations with family support or health status, may help hospitals avoid readmissions but may not improve health and functioning.

S2683 A Case of Patient With Stage VI Hepatocellular Carcinoma With Metastasis to the Spine Presenting With Acute Neurological Symptoms

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most prevalent primary malignant tumor of the liver. Hepatitis B and C infections are well known causes of HCC. Signs and symptoms of late stage HCC include abdominal pain, ascites, jaundice, unexplained weight loss and easy bruising or bleeding. The most common metastasis sites of HCC are the lungs, lymph nodes and bone. Here, we have a patient with previously undiagnosed HCC whose only symptoms at presentation were acute neurological deficits. CASE DESCRIPTION/METHODS: A 76-year-old female with a past medical history of chronic hepatitis B and C infection presented with six hours of lower extremity weakness and inability to walk. Physical examination of the lower extremities demonstrated decreased sensation throughout and 2/5 strength at the hips and knees. Spine magnetic resonance imaging revealed a T4 pathologic fracture with cord compression and mass effect (Image 1). Lesions were found also in the T9, L2 and L4 vertebral bodies. She had an emergent T4 corpectomy/laminectomy for tumor resection and T2-T6 posterior fusion with instrumentation by neurosurgery. Excisional biopsy of the T4 epidural tumor revealed extensive necrotic tissue with possibility of metastatic HCC. Liver imaging revealed numerous lesions. She was diagnosed with primary HCC after biopsy of one of those lesions was positive for HCC. She was later discharged to a skilled nursing facility for rehabilitation, and to radiation oncology for palliative chemotherapy. She unfortunately passed away two months later due to cardiac arrest secondary to hemorrhagic shock. A computed tomography scan of the abdomen at that time showed intraperitoneal hemorrhage due to tumor rupture. DISCUSSION: This patient presented with acute neurological symptoms due to pathological spinal fracture caused by metastatic HCC. Interestingly, this patient had no other signs and symptoms of stage VI HCC as stated above in the introduction. Similar to this patient, many others with HCC may be asymptomatic and remain undiagnosed till it progresses to the late stage. Successful intervention and treatment on these patients can become a challenge. Therefore, patients with histories of hepatitis B and C infections should be routinely screened to evaluate for progression into HCC. Early detection and treatment can prevent adverse health outcomes, increased healthcare cost and even death.Figure 1.: Magnetic Resonance Imaging revealed a T4 pathological fracture, with the epidural component compressing the cord and severely narrowing the thecal sac.

Challenges and Strategies for Managing Diabetes in the Elderly in Long-Term Care Settings.

Diabetes affects a large number of patients in the long-term care (LTC) setting, and their care is often complicated because of multimorbidity, diabetes-related complications, disability, dependency on caregivers, and geriatric syndromes, including frailty and cognitive impairment. This population includes patients receiving short-term rehabilitation in skilled nursing facilities, those who are residents in LTC facilities, and those receiving palliative or end-of-life care. An individualized approach to care based on clinical complexity, diabetes trajectory, and patients' preferences and goals is required. Such patients may experience one or more transitions of care and decline in condition. They are also prone to adverse drug events, cardiovascular events, and hypoglycemia. Facility-related challenges include varying staff competencies and practitioner preferences, inconsistent interdisciplinary communication, overly complex medication regimens, and poorly implemented care transitions.

Return home after dysvascular major amputation of the lower limb: A multicentre observational study in the Netherlands.

To report the rates of persons returning home within one year following dysvascular major amputation of the lower limb in the Netherlands, and to identify factors associated with returning home directly after hospital admission and after discharge to care facilities. Retrospective cohort study. Dysvascular major amputation of the lower limb, n = 382, mean age 71.9 years (standard deviation (SD) 12.5 years), 65% male. Medical records of all persons undergoing major amputation of the lower limb in 2012-2013 in 12 hospitals in Northern Netherlands were reviewed. Odds ratios (OR) were calculated using multivariate logistic regression. Among persons admitted from home and surviving the hospital admission, 21% returned home, with higher odds of returning home being associated with living with a partner (OR = 2.8, p = 0.006) and younger age (< 65 years). Among those discharged to care and surviving the first year, 77% returned home within one year after amputation, with higher odds being associated with younger age (<75 years) and admission to inpatient rehabilitation (OR = 10.6, p = 0.004) or geriatric rehabilitation in skilled nursing facilities (OR = 3.5, p = 0.030). Four out of 5 persons surviving dysvascular major amputation of the lower limb return home within one year, although a majority requires care in either inpatient rehabilitation or a skilled nursing facilities setting.

Comparison of Functional Status Improvements Among Patients With Stroke Receiving Postacute Care in Inpatient Rehabilitation vs Skilled Nursing Facilities

Health care reform legislation and Medicare plans for unified payment for postacute care highlight the need for research examining service delivery and outcomes. To compare functional outcomes in patients with stroke after postacute care in inpatient rehabilitation facilities (IRF) vs skilled nursing facilities (SNF). This cohort study included patients with stroke who were discharged from acute care hospitals to IRF or SNF from January 1, 2013, to November 30, 2014. Medicare claims were used to link to IRF and SNF assessments. Data analyses were conducted from January 17, 2017, through April 25, 2019. Inpatient rehabilitation received in IRFs vs SNFs. Changes in mobility and self-care measures during an IRF or SNF stay were compared using multivariate analyses, inverse probability weighting with propensity score, and instrumental variable analyses. Mortality between 30 and 365 days after discharge was included as a control outcome as an indicator for unmeasured confounders. Among 99 185 patients who experienced a stroke between January 1, 2013, and November 30, 2014, 66 082 patients (66.6%) were admitted to IRFs and 33 103 patients (33.4%) were admitted to SNFs. A higher proportion of women were admitted to SNFs (21 466 [64.8%] women) than IRFs (36 462 [55.2%] women) (P < .001). Compared with patients admitted to IRFs, patients admitted to SNFs were older (mean [SD] age, 79.4 [7.6] years vs 83.3 [7.8] years; P < .001) and had longer hospital length of stay (mean [SD], 4.6 [3.0] days vs 5.9 [4.2] days; P < .001) than those admitted to IRFs. In unadjusted analyses, patients with stroke admitted to IRF compared with those admitted to SNF had higher mean scores for mobility on admission (44.2 [95% CI, 44.1-44.3] points vs 40.8 [95% CI, 40.7-40.9] points) and at discharge (55.8 [95% CI, 55.7-55.9] points vs 44.4 [95% CI, 44.3-44.5] points), and for self-care on admission (45.0 [95% CI, 44.9-45.1] points vs 41.8 [95% CI, 41.7-41.9] points) and at discharge (58.6 [95% CI, 58.5-58.7] points vs 45.1 [95% CI, 45.0-45.2] points). Additionally, patients in IRF compared with those in SNF had larger improvements for mobility score (11.6 [95% CI, 11.5-11.7] points vs 3.5 [95% CI, 3.4-3.6] points) and for self-care score (13.6 [95% CI, 13.5-13.7] points vs 3.2 [95% CI, 3.1-3.3] points). Multivariable, propensity score, and instrumental variable analyses showed a similar magnitude of better improvements in patients admitted to IRF vs those admitted to SNF. The differences between SNF and IRF in odds of 30- to 365-day mortality (unadjusted odds ratio, 0.48 [95% CI, 0.46-0.49]) were reduced but not eliminated in multivariable analysis (adjusted odds ratio, 0.72 [95% CI, 0.69-0.74]) and propensity score analysis (adjusted odds ratio, 0.75 [95% CI, 0.72-0.77]). These differences were no longer statistically significant in the instrumental variable analyses. In this cohort study of a large national sample, inpatient rehabilitation in IRFs for patients with stroke was associated with substantially improved physical mobility and self-care function compared with rehabilitation in SNFs. This finding raises questions about the value of any policy that would reimburse IRFs or SNFs at the same standard rate for stroke.

Rehabilitation Providers' Prediction of the Likely Success of the SNF-to-Home Transition Differs by Discipline

ObjectivesOur article's primary objective is to examine whether rehabilitation providers can predict which patients discharged from skilled nursing facility (SNF) rehabilitation will be successful in their transition to home, controlling for sociodemographic factors and physical, mental, and social health characteristics. DesignLongitudinal cohort study. Setting and ParticipantsOne hundred-twelve English-speaking adults aged 65 years and older admitted to 2 SNF rehabilitation units. MeasuresOur outcome is time to “failed transition to home,” which identified SNF rehabilitation patients who did not successfully transition from the SNF to home during the study. Our primary independent variable consisted of the prediction of medical providers, occupational therapists, physical therapists, and social workers about the likely success of their patients' SNF-to-home transition. We also examined the association of sociodemographic factors and physical, mental, and social health with a failed transition to home. ResultsThe predictions of occupational and physical therapists were associated with whether patients successfully transitioned from the SNF to their homes in bivariate [hazard ratio (HR) = 4.96, P = .014; HR = 10.91, P = .002, respectively] and multivariate (HR = 5.07, P = .036; HR = 53.33, P = .004) analyses. The predictions of medical providers and social workers, however, were not associated with our outcome in either bivariate (HR = 1.44, P = .512; HR = 0.84, P = .794, respectively) or multivariate (HR = 0.57, P = .487; HR = 0.54, P = .665) analyses. Living alone, more medical conditions, lower physical functioning scores, and greater depression scores were also associated with time to failed transition to home. Conclusions/ImplicationsThese findings suggest that occupational and physical therapists may be better able to predict post-SNF discharge outcomes than are other rehabilitation providers. Why occupational and physical therapists' predictions are associated with the SNF-to-home outcome whereas the predictions of medical providers and social workers are not is uncertain. A better understanding of the factors informing the postdischarge predictions of occupational and physical therapists may help identify ways to improve the SNF-to-home discharge planning process.

Acute reversal of dabigatran with Idarucizumab for intravenous thrombolysis as acute stroke treatment

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) for acute ischemic stroke (AIS) is contraindicated in patient taking either Factor Xa inhibitors or direct thrombin inhibitors. Idarucizumab completely reverses the biologic effect of dabigatran within minutes. Intravenous rt-PA treatment results in a significant benefit in functional outcome when administered 3–4.5 h after stroke onset or last seen normal time. There is little reported data and no large-scale studies of the reversal of dabigatran with Idarucizumab for the purpose of treating AIS with IV rt-PA. We describe the case of a 73 year old male with AIS and active dabigatran use. Idarucizumab was administered per an approved medical center protocol and the patient was subsequently treated with IV rt-PA. The patient had a severe stroke with no other contraindications to IV rt-PA other than dabigatran use. The patient was administered Idarucizumab and IV rt-PA was given. Within 24 h of treatment, the patient had minimal stroke deficits. Imaging revealed a right middle cerebral artery patchy infarct. The patient was restarted on dabigatran therapy for his atrial fibrillation and was discharged to a skilled nursing facility for rehabilitation. The patient did not experience any symptomatic or asymptomatic intracranial hemorrhage after treatment or through day 90. Though no randomized evidence exists for the risk of IV rt-PA after dabigatran reversal with Idarucizumab, the case experiences are mounting. This case of successful stroke treatment after reversal adds to the anecdotal literature and supports the study of dabigatran reversal with Idarucizumab for thrombolysis in AIS.

Outcomes in nursing home patients with traumatic brain injury

BackgroundTraumatic brain injury is a leading cause of death and disability in the United States. In survivors, traumatic brain injury remains a leading contributor to long-term disability and results in many patients being admitted to skilled nursing facilities for postacute care. Despite this very large population of traumatic brain injury patients, very little is known about the long-term outcomes of traumatic brain injury survivors, including rates of discharge to home or risk of death in long-term nursing facilities. We hypothesized that patient demographics and functional status influence outcomes of patients with traumatic brain injury admitted to skilled nursing facilities. MethodsWe conducted a retrospective cohort study of Medicare fee-for-service beneficiaries aged 65 and older discharged alive and directly from hospital to a skilled nursing facility between 2011 and 2014 using the prospectively maintained Federal Minimum Data Set combined with Medicare claims data and the Centers for Medicare and Medicaid Services Vital Status files. Records were reviewed for demographic and clinical characteristics at admission to the skilled nursing facility, including age, sex, cognitive function, ability to communicate, and motor function. Activities of daily living were reassessed at discharge to calculate functional improvement. We used robust Poisson regression with skilled nursing facility fixed effects to calculate relative risks and 99% confidence intervals for mortality and functional improvement associated with the demographic and clinical characteristics present at admission. Linear regression was used to calculate adjusted mean duration of stay. ResultsOverall, 87,292 Medicare fee-for-service beneficiaries with traumatic brain injury were admitted to skilled nursing facilities. The mean age was 84 years, with 74% of patients older than age 80. Generally, older age, male sex, and poor cognitive or functional status at admission to a skilled nursing facility were associated with increased risk for poorer outcomes. Older patients (age ≥80 years) with traumatic brain injury had a 1.5 times greater risk of death within 30 days of admission compared with adults younger than 80 years (relative risk = 1.49, 99% confidence interval = 1.36, 1.64). Women were 37% less likely to die than men were (relative risk = 0.63, 99% confidence interval = 0.59, 0.68). The risk of death was greater for patients with poor cognitive function (relative risk = 2.55, 99% confidence interval = 2.32, 2.77), substantial motor impairment (relative risk = 2.44, 99% confidence interval = 2.16, 2.77), and patients with impairment in communication (relative risk = 2.58, 99% confidence interval = 2.32, 2.86) compared with those without the respective deficits. One year after admission, these risk factors continued to confer excess risk for mortality. Duration of stay was somewhat greater for older patients (30.1 compared with 27.5 average days) and patients with cognitive impairment (31.7 vs 27.5 average days). At discharge, patients with cognitive impairment (relative risk = 0.86, 99% confidence interval = 0.83, 0.88) and impairment in the ability to communicate (relative risk = 0.67, 99% confidence interval = 0.54, 0.82) were less likely to improve in physical function. ConclusionOur results suggest that among patients with traumatic brain injury admitted to skilled nursing facilities, the likelihood of adverse outcomes varies significantly by key demographic and clinical characteristics. These findings may facilitate setting expectations among patients and families as well as providers when these patients are admitted to skilled nursing facilities for rehabilitation after their acute episode.

Longitudinal follow-up study on fear of falling during and after rehabilitation in skilled nursing facilities.

BackgroundFear of falling (FoF) is regarded as a major constraint for successful rehabilitation in older people. However, few studies have investigated FoF in vulnerable older people who rehabilitate in a skilled nursing facility (SNF). Therefore, this study measures the prevalence of FoF during and after rehabilitation and assesses differences between those with and without FoF. The relation between FoF and instrumental activities of daily living (IADL) after discharge was also assessed.MethodsIn this longitudinal follow-up study, patients who rehabilitated in a SNF were assessed at admission and at 4 weeks after discharge. A one-item instrument was used to measure FoF at admission; based on their answer, the patients were divided into groups with no FoF and with FoF. To study FoF after discharge, the one-item instrument and the short Falls Efficacy Scale-International (FES-I) were used. IADL after discharge was assessed with the Frenchay Activities Index (FAI).ResultsOf all participants, 62.5 % had FoF at admission. The participants with FoF were older, more often female, and had a higher average number of falls per week, more depressive symptoms and a lower level of self-efficacy. Four weeks after discharge, 82.1 % of the participants had FoF. IADL after discharge was considerably lower in patients with FoF (FAI of 27.3 vs. 34.8; p = 0.001).ConclusionsFoF is common among older persons who rehabilitate in SNF. FoF seems to be persistent and may even increase after rehabilitation, thereby hampering IADL after discharge. Interventions are needed to reduce FoF to ensure better outcomes in older patients rehabilitating in a SNF.