Subacute Setting Research Articles

Surveillance of geriatric patients undergoing maintenance hemodialysis

The Geriatric Nutritional Risk Index (GNRI) is a promising tool for predicting nutrition-related issues in sub-acute care settings. The primary goal of this study was to verify the application of GNRI in elderly hospitalized patients by evaluating its predictive power of patient outcome using a comparison with the nutritional assessment and frequency of dialysis.: To study the surveillance in geriatric patients on maintenance of hemodialysis and to collect the demographic and blood sample from the patient, evaluate the blood sample using various technique. To assess the relationship between GNRI, dialysis frequency and adequacy.: It is a multi-speciality hospital -based cohort study. We enrolled patients, aged between 60-85 years undergoing maintenance hemodialysis patients were followed thrice a week .Nutritional risk index was assessed by the Geriatric Nutritional Risk Index (GNRI) adequacy of dialysis was calculated using Daugirdas dialyzer clearance of urea (Kt/V) method. The study population comprised 54 geriatric dialysis patients ranging from 60-85 years of age.57% of the chosen patient population had both diabetes mellitus and hypertension as co-morbid conditions. In contrast, 17% of the patients had only hypertension. 9% had only diabetes mellitus Rest of the patients presented with diabetes mellitus, hypertension, polycystic kidney disease and diabetic kidney disease as co-morbidities. Among these patients, 40% underwent twice-weekly dialysis and the remaining 60% underwent thrice-weekly dialysis.12% of these 54 patients were categorized as high risk on the GNRI, 9% as moderate risk and 22% of the patients were low risk. 57% of the patients were devoid of any risk on the GNRI. 43% of the study population fell in the normal BMI range between 18.5-24.9, whereas 33% were found to be overweight with their BMI ranging between 25-29.9, While 13% of the subjects were classified as being underweight with a BMI below 18.5,11% the patients were found to be obese (category4).The observations from the current study indicate that more frequent and adequate dialysis likely enhances the standard of living and lowers the GNRI risk in elderly dialysis patients.

Evaluation of nursing administration records of high‐risk medications at a hospital network: a retrospective audit

AbstractWithin our hospital network, the PINCH acronym (Potassium, Insulin, Narcotics, Chemotherapeutics, Heparin) designates high‐risk medications. As per local guidelines, double‐checking is mandated at the point of administration. This retrospective audit aimed to assess nursing and midwifery staff's ability to recognise PINCH medications by examining their adherence to double‐signing protocols, serving as an indicator of double‐checking. The analysis included overall compliance proportions, categorised by PINCH class and further stratified based on location, specialty, and staffs' level of training. An analysis of the first thousand PINCH medication administrations from 1 January 2023 was conducted, spanning four sites within our hospital network. Data sourced from the Electronic Medication Record system were refined to include one medication per patient per day, totalling 200 administrations per PINCH category. The results revealed that 896 (89.6%) out of 1000 medication administrations were co‐signed, with narcotics showing a co‐signature rate of 100%, followed by potassium at 99%, heparin at 98%, insulin at 97.5%, and chemotherapeutics at 53.5%. Among the orders lacking co‐signature, 90% pertained to chemotherapeutics and the remaining 10% were distributed across other categories. Stratifying by location showed 28 (17.6%) out of 159 administrations in a subacute setting lack co‐signature, compared to 76 (6%) from 841 in an acute setting. Compliance rates were highest in specialty medicine at 94.3%, followed by surgical at 86.2%, general medicine 84.5%, women and children's and mental health units at 83.3% each, and continuing care at 82.2%. Notably, enrolled nurses exhibited the highest level of compliance with co‐signatures. Future research could explore the impact of educational strategies on the administration of high‐risk medications. Ethical approval was granted by the Eastern Health Office of Research and Ethics (Reference no: QA23‐075‐101 386) and the study conforms to the Australian Statement on Ethical Conduct in Human Research.

Feasibility of accelerometry in a self-directed upper limb activity program of a subacute setting with stroke survivors.

Background Wearable devices, such as accelerometers, offer novel approaches to measuring post-stroke upper limb activity. Limited studies have explored feasibility of accelerometry. Guided by the Bowen Feasibility Framework, this feasibility study aimed to examine the practicality, acceptability, and limited efficacy of accelerometry in a self-directed upper limb program with stroke survivors using a pre-post study of sequentially eligible inpatients. Method Key metrics were: practicality (60% of participants had 10hours of wear per day for 3 or more days), acceptability (adherence to recommended wear-time), and limited efficacy (correlation between Wolf Motor Function Test (WMFT) and upper limb use from accelerometry data). Results Twelve stroke survivors were recruited over 7 months, mean age 73years (range 39-94years). Eight participants (67%) met the practicality and acceptability criteria. A moderate positive correlation existed between WMFT and upper limb use at admission (r s =0.33, P =0.42) and at discharge (r s =0.42, P =0.34). Conclusion Wearable devices were feasible and acceptable for most stroke survivors, however, one-third found the devices uncomfortable, and this should be factored into sample size calculations of future studies.

Multifactorial fall interventions for people over 65 years in the acute hospital setting: pre–post-test design

Background: Falls are the most reported patient safety incident for patients >65 years in acute hospital settings worldwide. While multifactorial fall interventions reduce the number of falls in subacute and rehabilitation settings, fall interventions in acute hospital settings are unknown. Aim: To evaluate the effectiveness of multifactorial fall interventions on the number of falls using codesigned education targeting staff and the patient and review the environment in acute hospital settings in NSW, Australia for patients over 65 years of age. Method: A pre–post-test design with a non-equivalent group was conducted. All acute hospital inpatient falls occurring both pre- and post-intervention within one health district were included in this study. The use of Quality Improvement methodology identified gaps in risk screening and assessment, education and information, communication of risk, and standardised fall prevention equipment. Codesigned interventions to address these gaps were undertaken. Results: The number of falls (p = 0.038) and injurious falls (p < 0.001) significantly decreased in the post-intervention group. There was a significant improvement in fall assessments (p < 0.001), delirium risk screening (p < 0.001), the provision of fall information (p < 0.001) and fall risk discussed at shift handover (p < 0.001) in the post-intervention group. Following the intervention, staff were significantly more likely to undertake fall education modules (p < 0.001) and develop a fall management plan (p < 0.001). Conclusion: Falls continue to have a significant economic impact on the acute hospital setting. Our findings highlight multifactorial fall interventions that included staff and patients in the development phases reduced the number of falls. Multifactorial fall interventions targeting staff, patients and the environment may influence a reduction in the number of falls and the severity of falls in the acute hospital setting.

Genotoxicity and safety profile of Eleview®: A submucosal injectable composition for endoscopic mucosal resection and endoscopic submucosal dissection

Background and Objectives: Eleview® submucosal injectable composition with methylene blue (MB), is intended for use in gastrointestinal endoscopic procedures. Given the recognised in vitro mutagenicity of MB, Eleview® mutagenic and genotoxic potentials and its safety profile in acute and subacute toxicity settings were assessed. Methods: Acute and subacute systemic toxicity were tested in rats and dogs, respectively. Ames test and chromosome aberration test in Chinese Hamster V79 cells, were performed. The ratio of polychromatic to normochromatic erythrocytes was assessed in rat bone marrow at the rat MTD. Results: Eleview® oral or intraperitoneal at 20 mL/kg or 50 mL/kg did not induce any acute toxic effects in rats. In dogs, Eleview® (15 mL) did not cause any relevant in-life observations or any histopathological changes in any organs/tissues or injection sites. Ames test demonstrated no concentration-related and reproducible increases in revertant colony numbers. No significant increase of chromosomally aberrant cells was noted in Chinese Hamster cells. Lastly, Eleview® did not elicit significant increase in micronucleated polychromatic erythrocyte frequency. Conclusion: No death or abnormal findings in the acute and subacute studies were observed for Eleview® administration. Eleview® is not genotoxic, nor mutagenic, proving to be a safe medical device to use in clinical practice.

Assistive technologies, including orthotic devices, for the management of contractures in adults after a stroke.

Contractures (reduced range of motion and increased stiffness of a joint) are a frequent complication of stroke. Contractures can interfere with function and cause cosmetic and hygiene problems. Preventing and managing contractures might improve rehabilitation and recovery after stroke. To assess the effects of assistive technologies for the management of contractures in adults after a stroke. We searched CENTRAL, MEDLINE, Embase, five other databases, and three trials registers in May 2022. We also searched for reference lists of relevant studies, contacted experts in the field, and ran forward citation searches. Randomised controlled studies (RCTs) that used electrical, mechanical, or electromechanical devices to manage contractures in adults with stroke were eligible for inclusion in this review. We planned to include studies that compared assistive technologies against no treatment, routine therapy, or another assistive technology. Three review authors (working in pairs) selected all studies, extracted data, and assessed risk of bias. The primary outcomes were passive joint range of motion (PROM) with and without standardised force, and indirect measures of PROM. The secondary outcomes included hygiene. We also wanted to evaluate the adverse effects of assistive technology. Effects were expressed as mean differences (MDs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs). Seven studies fulfilled the inclusion criteria. Five of these were meta-analysed; they included 252 adults treated in acute and subacute rehabilitation settings. All studies compared assistive technology with routine therapy; one study also compared assistive technology with no treatment, but we were unable to obtain separate data for stroke participants. The assistive technologies used in the studies were electrical stimulation, splinting, positioning using a hinged board, and active repetitive motor training using a non-robotic device with electrical stimulation. Only one study applied stretching to end range. Treatment duration ranged from four to 12 weeks. The overall risk of bias was high for all studies. We are uncertain whether: • electrical stimulation to wrist extensors improves passive range of wrist extension (MD -7.30°, 95% CI -18.26° to 3.66°; 1 study, 81 participants; very low-certainty evidence); • a non-robotic device with electrical stimulation to shoulder flexors improves passive range of shoulder flexion (MD -9.00°, 95% CI -25.71° to 7.71°; 1 study; 50 participants; very low-certainty evidence); • assistive technology improves passive range of wrist extension with standardised force (SMD -0.05, 95% CI -0.39 to 0.29; four studies, 145 participants; very low-certainty evidence): • a non-robotic device with electrical stimulation to elbow extensors improves passive range of elbow extension (MD 0.41°, 95% CI -0.15° to 0.97°; 1 study, 50 participants; very low-certainty evidence). One study reported the adverse outcome of pain when using a hinged board to apply stretch to wrist and finger flexors, and another study reported skin breakdown when using a thumb splint. No studies reported hygiene or indirect measures of PROM. Only seven small RCTs met the eligibility criteria of this review, and all provided very low-certainty evidence. Consequently, we cannot draw firm conclusions on the effects of assistive technology compared with routine therapy or no therapy. It was also difficult to confirm whether there is a risk of harm associated with treatment using assistive technology. Future studies should apply adequate treatment intensity (i.e. magnitude and the duration of stretch) and use valid and reliable outcome measures. Such studies might better identify the role of assistive technology in the management of contractures in adults after a stroke.

Transcranial Doppler With Microbubbles: Screening Test to Detect and Grade Right-to-Left Shunt After an Ischemic Stroke: A Literature Review.

Right-to-left shunt, mainly due to patent foramen ovale (PFO), is likely responsible for ≈5% of all ischemic strokes and 10% of those occurring in young and middle-aged adults. Randomized clinical trials demonstrated that, in selected young and middle-aged patients with otherwise cryptogenic acute ischemic stroke and high-risk PFO, percutaneous PFO closure is more effective than antiplatelet therapy alone in preventing recurrence. However, PFO is generally a benign finding and is present in about one-quarter of the population. Therefore, in clinical practice, identifying PFOs that are likely to be pathogenetic is crucial for selecting suitable patients for PFO closure to prevent recurrent stroke and to avoid potentially harmful and costly overtreatment. Contrast transthoracic echocardiography has a relatively low sensitivity in detecting PFO, whereas transesophageal echocardiography is currently considered the gold standard for PFO detection. However, it is a relatively invasive procedure and may not always be easily feasible in the subacute setting. Contrast transcranial Doppler is a noninvasive, inexpensive, accurate tool for the detection of right-to-left shunt. We conducted a literature review on the use of contrast transcranial Doppler to detect and grade right-to-left shunt after an acute ischemic stroke and present a clinical workflow proposal for young and middle-aged patients.

The impact of changes in physical activity on functional recovery for older inpatients in post-acute rehabilitation units.

The effect of increased physical activity duration on functional recovery in older inpatients in subacute settings is not well established. This study aimed to investigate the relationship between physical activity and functional recovery in older patients receiving post-acute and subacute care. We analyzed cohort data of hospitalized older patients (age ≥ 65years) in the post-acute rehabilitation units. The main outcome was functional independence measure (FIM) gain. Physical activity was measured using a triaxial accelerometer. Changes in sedentary behavior and total physical activity time from admission to discharge were measured as changes in each physical activity time. Logistic regression analysis was performed to examine the relationship between changes in physical activity and FIM gain. A total of 210 patients were eligible for analysis. The mean age of the study patients was 83.6 ± 7.2years, and 63.8% (n = 134) were female. According to the multivariate regression analysis, changes in sedentary behavior time were significantly associated with high recovery of FIM gain (odds ratio [OR] 0.996, 95% confidence interval [CI]: 0.993-1.000; p = 0.026), and changes in total physical activity time also showed a similar association (OR 1.006, 95% CI 1.000-1.011; p = 0.041). Decreased sedentary behavior time and increased total physical activity time were significantly associated with high functional recovery in post-acute rehabilitation units. These results suggest that interventions for physical activity duration may be effective in improving activities of daily living in older post-acute and subacute patients.

Allied health new graduates’ voice behavior – new perspectives using realist synthesized narratives

PurposeEffective voice behavior in healthcare workers is critical for patient safety, quality improvement and workforce well-being. A review of the literature on voice behavior in healthcare highlights that little is known about the voice behaviors of new graduates in allied health and that current theory, from medical and nursing research, does not adequately apply to this sector. New knowledge about voice behavior for this sector of the workforce will support education and healthcare institutions in building and sustaining a healthy voice behavior culture.Design/methodology/approachThis paper reports on phase two of a two-phase study looking at the voice behavior experiences of new allied health graduates over one year. Using a realist perspective and narrative analysis, we uncover and illustrate what works, with whom and under what conditions.FindingsFour synthesized narratives outline the contexts and mechanisms that result in different voice behavior outcomes – speaking up effectively, speaking up with unmet expectations, not speaking up and a reduction in speaking up over time. Experiences of positive interprofessional collaboration and reflective supervision supported effective voice behavior.Research limitations/implicationsThis study used a case study approach, focusing on healthcare providers within a large New Zealand city and a cohort of 10 participants. Some researchers argue that small numbers limit the generalization of findings to different populations. Realists argue that, given the way in which knowledge is developed using realist methodologies, the resultant theory is portable. Interviews were conducted online during the COVID-19 pandemic. This may have impacted the connection between the interviewer and interviewee, causing the interviewees to not express their true thoughts. However, the interviewer did take time to connect with the interviewees and build trust over the three interviews over one year. Participants did not capture the diversity in the allied health workforce – most identified as female and none identified as Māori/Indigenous. And finally, participants could inhibit or exaggerate information due to the influence of social desirability. This does not appear to be a significant limitation in this study, given the many examples shared by the participants highlighted their challenges.Practical implicationsThis study provides an in-depth exploration of how new graduates in allied health experience speaking up. Our findings enrich the knowledge of speaking up by using synthesized narratives to provide insights into what factors can enable a healthy speaking up culture within the new graduate allied health workforce. This is new knowledge that will be of interest at the individual, team and organizational levels of healthcare. The findings will support curriculum design and new graduate support frameworks for the education and health sectors. Highlighted in this study are the importance of the following factors in supporting speaking up for allied health new graduates: the employment of reflective supervision, purposeful facilitation of team belonging and interprofessional collaboration and tailored speaking up training for allied health new graduates and leaders in healthcare.Originality/valueBy taking a realist perspective and using narrative analysis, we gain an understanding of the voice behavior experiences of new graduates in allied health and the contextual factors and mechanisms that activate effective voice behavior in sub-acute and rehabilitation settings. These findings differ from nursing and medicine and highlight the benefits of reflective supervision and interprofessional collaborative practice.

Assessment of visual problems after acquired brain injury: a survey of current practice in Danish hospitals.

To explore current hospital practice in relation to the assessment of vision problems in patients with acquired brain injury. A survey study. A total of 143 respondents from hospital settings, with background in occupational therapy and physical therapy, participated in the survey. The survey questionnaire, developed collaboratively by Danish and Norwegian research groups, encompassed 22 items categorically covering "Background information", "Clinical experience and current practice", "Vision assessment tools and protocols", and "Assessment barriers". It was sent out online, to 29 different hospital departments and 18 separate units for occupational therapists and physiotherapists treating patients with acquired brain injury. Most respondents worked in acute or subacute hospital settings. Few departments had an interdisciplinary vision team, and very few therapists had formal education in visual problems after acquired brain injury. Visual assessment practices varied, and there was limited use of standardized tests. Barriers to identifying visual problems included patient-related challenges, knowledge gaps, and resource limitations. The study emphasized the need for enhanced interdisciplinary collaboration, formal education, and standardized assessments to address visual problems after acquired brain injury. Overcoming these challenges may improve identification and management, ultimately contributing to better patient care and outcomes in the future.

Electrophysiological Screening to Assess Foot Drop Syndrome in Severe Acquired Brain Injury in Rehabilitative Settings.

Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients. We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU. This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN. At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN. The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings.

Acceptability of two mobile applications to support cross-sectoral, person-centred and empowering stroke rehabilitation – a process evaluation

Aim To evaluate the acceptability of two co-designed mobile applications Mit Sygehus [a knowledge-based solution] and Genoptræn.dk [a self-training solution] to support a cross-sectoral, person-centred and empowering stroke rehabilitation. Setting The applications were implemented and tested throughout two stroke rehabilitation trajectories in Southern Denmark, comprising two acute, two sub-acute and two municipal stroke rehabilitation settings. Methods, participants and analysis A process evaluation focusing on acceptability was conducted. Individual and dyadic interviews were performed with ten stroke survivors (three women and seven men, aged 50–84) with moderate stroke and seven significant others (five women and two men, aged 50–78) post-rehabilitation. A constructivist Grounded Theory analysis was used to explore what, why, when, and how the apps worked or did not work throughout the stroke rehabilitation trajectory and if adaptions were needed. Results Participants found that Mit Sygehus provided adequate and sufficient knowledge and was easy to use, however, acceptability of Mit Sygehus declined throughout the rehabilitation process. Also, knowledge on ‘return-to-work’ and ‘re-gaining driver’s license/permission to drive’ needed to be developed. The content in Genoptræn.dk was perceived as acceptable, through content being person-centred, motivating and meaningful. Genoptræn.dk furthermore, supported the transfer between rehabilitation settings, provided a sense of progress throughout the rehabilitation process, facilitated positive habits regarding self-training, and relieved the burden on significant others. Genoptræn.dk was perceived most acceptable in the sub-acute rehabilitation setting and declined when rehabilitation continued in the municipal setting. Conclusion Stroke survivors and their significant others found Mit Sygehus and Genoptræn.dk acceptable to support cross-sectoral, person-centred and empowering stroke rehabilitation, however acceptability declined throughout the rehabilitation process. Further investigations are required to determine how cognitive rehabilitation can play a greater role in app-supported stroke rehabilitation and how the need for more long-term follow-up can be supported.

Aphasia disrupts usual care: “I’m not mad, I’m not deaf” – the experiences of individuals with aphasia and family members in hospital

Purpose Communication difficulties are highly prevalent in the stroke population, with implications for patient experience, safety and outcomes. This study explores the experiences of people with aphasia and family members regarding healthcare communication in acute and subacute stroke settings. Methods and materials A phenomenological approach was used to understand participants’ experiences. Participants took part in a focus group and data were analysed using an inductive thematic approach. Results For individuals with aphasia (n = 4) and family members (n = 2), five themes were generated: “aphasia makes it hard to communicate,” “hospital staff focus on the patient’s medical status only,” “people with aphasia do not get the help they need to improve,” “staff lack the skills to communicate with people with aphasia,” and “staff are crucial to improving healthcare communication.” Conclusions The stroke team has expertise in the medical management of stroke but struggle to communicate with patients with aphasia. Patients’ experience of healthcare communication is often one-way and limited to following instructions, with missed opportunities to discuss core topics such as prognosis, rehabilitation, and person-specific needs. Patients and families assert that all members of the stroke healthcare team should be able to adapt communication to accommodate patients.

Identifying communication difficulty and context-specific communication supports for patient-provider communication in a sub-acute setting: A prospective mixed methods study

Purpose To identify the sub-acute rehabilitation inpatients who have communication difficulty and the range of communication supports that can facilitate communicative success. Method A prospective cohort mixed methods study was conducted on two inpatient sub-acute rehabilitation wards. Nurses screened all new admissions for communication difficulty using the Inpatient Functional Communication Interview, Screening Questionnaire (IFCI-SQ). Patients identified as having communication difficulty were interviewed by a speech-language pathologist (SLP) using the Inpatient Functional Communication Interview (IFCI). During the interview, the SLP trialled different communication supports. The number of patients who had communication difficulty on the IFCI-SQ was calculated. The number and type of communication supports that improved communication within the patient-SLP interview were calculated. Deductive-dominant qualitative content analysis was conducted on the communication supports used during the IFCI. Result Seventy patients were screened. Nurses reported communication difficulty in 45/70 (64%) of patients. A total of 15/45 patients were interviewed by an SLP using the IFCI. The provision of communication supports improved communication for all patients within the context of the patient-SLP interview. Conclusion Many sub-acute rehabilitation inpatients have communication difficulty in the hospital setting. A range of communication supports facilitated communication. These insights could inform future communication partner training (CPT) programs.

"How Do I Test the Waters? How Do I Go Forward?": Codesigning a Supportive Pathway after Critical Illness.

Rationale: Long-term recovery after critical illness can be affected by post-intensive care syndrome (PICS), a significant burden, which can impact return to activities and work. There is a need for streamlined support for intensive care unit (ICU) patients in their recovery while enduring PICS symptoms. Objectives: To explore critical illness recovery from the experiences, perspectives, and beliefs of former ICU patients, their caregivers, and multidisciplinary clinicians to design a future rehabilitation intervention prototype to support ICU patients. Methods: This was an experience-based codesign (EBCD) study underpinned by the Behavior Change Wheel framework involving ICU patients (<5 years after illness), caregivers, and multidisciplinary clinicians with current clinical experience with ICU recovery at any point along the care continuum (ICU, acute, subacute, or community settings) from two metropolitan hospitals in Melbourne, Australia. Two rounds of experience-based codesign workshops were held between August 2021 and February 2022. Workshop content was analyzed via a reflective thematic approach to determine themes and develop an intervention. The intervention was mapped according to the template for intervention description and replication framework. Results: Forty people participated in the codesign process: 15 ICU patients, 2 caregivers, and 23 clinicians. Fifteen major themes were identified in the experience of ICU recovery. Returning home was a key time point for change, acceptance, and adjustment, with the burden of physical limitations and mental health problems becoming apparent. Most participants expressed that PICS was poorly understood in the community, and there was a lack of support to aid recovery. Based on these results, an intervention prototype was developed with a primary goal of improving care after hospital discharge. This was further refined in the second round of workshops. A resource toolkit was deemed most acceptable to end-users, including a hospital-directed support program involving psychology and physical therapy and an accompanying digital health package. Conclusions: A critical time point for more support in the recovery journey was the transition from hospital to home. To address this, a rehabilitation prototype including a physical and psychological support intervention and supporting digital health toolkit was codesigned. The intervention package will be developed and trialed with future ICU patients and their families. Clinical trial registered with www.clinicaltrials.gov (NCT05044221).

Insomnia Symptoms and Environmental Disruptors: A Preliminary Evaluation of Veterans in a Subacute Rehabilitation

ABSTRACT Objectives Evaluate insomnia symptoms and environmental disruptors at admission and discharge in a subacute rehabilitation care setting. Methods Veterans (age ≥50) admitted to a Veterans Health Administration (VA) Hospital subacute rehabilitation between March and August 2022 completed baseline (N = 46) and follow up (N = 33) assessments with the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), Epworth Sleepiness Scale (ESS), and an assessment of environmental sleep disruptors. Veterans were offered sleep resources after admission evaluations and outpatient referrals after discharge evaluations. Pearson correlation determined associations between length of stay (LOS), ISI, SNQ, and ESS scores at admission and discharge; chi-square and Wilcoxon Signed Rank Tests compared insomnia at admission and discharge. Results One-half of participants reported clinically meaningful insomnia symptoms and sleep needs at baseline with no significant change at discharge. Almost all (89.1%) Veterans reported sleep was disturbed by environmental factors, primarily staff awakenings. LOS was correlated with ESS scores at discharge (r = .52, p = .002). Conclusions Environmental sleep disruption was common during a subacute rehabilitation admission and were not adequately addressed through sleep resources and treatment due to low uptake. Clinical Implications Providers should assess sleep at admission and lessen environmental sleep disruptors by reducing noise, light, and non-essential awakenings at night.

Nurses' encounters with patients having end-of-life dreams and visions in an acute care setting - A cross-sectional survey study.

This study aimed to estimate the proportion of acute care nurses witnessing end-of-life dreams and visions or having these reported by a patient or relative, and to canvass their related attitudes and beliefs. A cross-sectional survey study was conducted from February 2023 to May 2023. Participants were medical and surgical nurses from a 200-bed acute care hospital in metropolitan Australia. Fifty-seven nurses participated from a workforce of 169 (34% response rate), of whom 35 (61%) reported they had encountered end-of-life dreams and visions. The nature of end-of-life dreams and visions encountered was similar to those reported in previous studies by patients and clinicians. Nurses generally held positive attitudes towards end-of-life dreams and visions but identified an unmet need for education and training on this aspect of end-of-life care. Our results suggest that nurses in acute care encounter end-of-life dreams and visions in a similar proportion to oncology and long-term care but lower than in palliative care settings. Education and training regarding end-of-life dreams and visions are needed to ensure the provision of comprehensive, patient-centred end-of-life care. No patient or public contribution. Research in sub-acute and long-term care settings suggests that end-of-life dreams and visions are a common accompaniment to the dying process. No research has yet focused on the acute care setting, despite this being the place of death for the majority of people in most high-income countries. This study demonstrates that acute care nurses encounter end-of-life dreams and visions in similar proportions to oncology and long-term care nurses but lower than palliative care nurses. Acute care nurses would benefit from education and training regarding end-of-life dreams and visions to enable the provision of holistic person-centred end-of-life care. This study was reported using the STROBE Checklist for cross-sectional studies.

Factors Predisposing Patients to Nonhome Discharge After Surgery for Degenerative Cervical Myelopathy: A Retrospective Analysis.

The objective of this study is to evaluate factors associated with discharge to subacute care after surgery for degenerative cervical myelopathy. This is a retrospective chart review of adults who underwent cervical spine surgery for degenerative cervical myelopathy between 2014 and 2020 ( N = 135). Patients discharged to a subacute setting were older (68.1 ± 8.6 vs. 64.1 yrs ± 8.8, P = 0.01), more likely to be unmarried (55.8% vs. 33.7% married, P = 0.01), and more likely to have Medicare or Medicaid (83.7% vs. 65.9% private insurance, P = 0.03) than patients discharged home. A posterior surgical approach was associated with discharge to a subacute setting (62.8% vs. 43.5% anterior approach, P = 0.04). A total of 87.8% of patients discharged to a subacute setting required moderate or maximum assistance for bed mobility versus 26.6% of patients discharged home ( P < 0.0001). Compared with patients discharged home, patients discharged to a subacute setting ambulated a shorter distance in their first physical therapy evaluation after surgery (8.9 ± 35.8 vs. 53.7 ± 61.78 m in the home discharge group, P < 0.0001). Analysis of these factors may guide discussions about patient expectations for postoperative discharge placement.

Identifying Visual Impairment After Acquired Brain Injury—Current Practice, Referrals, and Barriers

Purpose: Visual impairment (VI) is still underdiagnosed in patients with acquired brain injury despite the large impact on daily life activities and rehabilitation. The aim of this study was to explore the current practice of identification of VI, management plans, referrals, and experienced barriers in Norwegian hospital settings.Materials and Methods: An online survey was sent out to leaders (n = 62) in hospitals treating patients with acquired brain injury. Data from 22 items covering routines, interdisciplinary collaboration, assessment tools, protocols, barriers, referral practice, and background information were collected.Results: Respondents (n = 108) comprised various professions from mainly acute or subacute settings. Visual field deficits, oculomotor dysfunction, and neglect were most commonly but not routinely assessed (53%–57%). Besides medical examination, patient interviews, and observations rather than standardized tests or questionnaires (82% vs.25%) were used. Few workplaces seemed to have interdisciplinary vision teams (13%). Barriers were patient characteristics such as cognitive and language impairment and limited resources. Below half (45%) felt competent in assessing VI or had attended courses on the topic (44%).Conclusions: The study highlights the need to implement standardized assessment, improve interdisciplinary collaboration, and facilitate training courses to enable hospital staff to assess VI after brain injury. These steps could contribute to improved assessment and management of VI and contribute to overcome the indicated barriers leading to better patient care and outcome.

Clinical properties and rehabilitation needs of earthquake survivors in a subacute rehabilitation setting.

This descriptive analysis examines the victims of the February 6, 2023, earthquakes in Kahramanmaraş and Elbistan, Türkiye. It aims to detail the injury profiles related to neuro-musculoskeletal trauma, assess the rehabilitation needs of patients, and propose a comprehensive rehabilitation approach. The study included patients injured in the Kahramanmaraş-centered earthquake on February 6, 2023, who were transported to our hospital based on their rehabilitation needs. Data from patients treated at our hospital were recorded retrospectively. This included demographic information, accompanying pathologies, laboratory findings, rehabilitation programs, and treatments received during their hospital stay. Statistical analyses were conducted to examine the data. A total of 141 patients with musculoskeletal injuries were admitted due to injuries sustained from the earthquake. The mean age of the participants was 39.76 years, with a slight female predominance (56.7%). The majority of patients sustained injuries while trapped under debris (90.1%), with an average duration of 10 hours under rubble. Fractures were the most common form of injury (53.2%), predominantly affecting the lower extremities. Peripheral nerve injuries were present in 41.1% of patients, and amputations were observed in 30.5%. Complications included compartment syndrome (46.1%), crush syndrome (36.2%), and various infections. Pain was prevalent among patients, with somatic pain being the most reported type. Individualized rehabilitation programs were implemented, incorporating physical therapy, wound care, pain management, and psychosocial support. This study highlights the critical rehabilitation needs of earthquake survivors and emphasizes the importance of early and comprehensive rehabilitation interventions. Multidisciplinary rehabilitation programs were crucial in addressing medical issues, functional limitations, and psychological challenges faced by the survivors. The findings contribute to a deeper understanding of earthquake-related injuries and underscore the significance of well-coordinated rehabilitation strategies in disaster responses.