Erik H. Hoyer

Understanding and enhancing motor recovery after stroke using transcranial magnetic stimulation

Stroke is the leading cause of long-term disability. Understanding how people recover from stroke and other brain lesions remain one of the biggest conundrums in neuroscience. As a result, concerted efforts in recent years have focused on investigating the neurophysiological changes that occur in the brain after stroke, and in developing novel strategies to enhance motor recovery. In particular, transcranial magnetic stimulation (TMS) is a non-invasive tool that has been used to investigate the brain plasticity changes resulting from stroke and as a therapeutic modality to safely improve motor function. In this review, we discuss the contributions of TMS to understand how different motor areas, such as the ipsilesional hemisphere, secondary motor areas, and contralesional hemisphere are involved in motor recovery. We also consider recent studies using repetitive TMS (rTMS) in stroke patients to enhance upper extremity function. Although further studies are needed, these investigations provide an important starting point to understand the stimulation parameters and patient characteristics that may influence the optimal response to non-invasive brain stimulation. Future directions of rTMS are discussed in the context of post-stroke motor recovery.

Barriers to Early Mobility of Hospitalized General Medicine Patients: Survey Development and Results

Objective Functional status decline commonly accompanies hospitalization making patients vulnerable to complications. Such decline can be mitigated through hospital-based early mobility programs. Success in implementing patient mobility quality improvement processes requires evaluating providers’ knowledge, attitudes, and behaviors. Design A cross-sectional, self-administered survey in two different hospital settings was completed by 120 nurses and physical and occupational therapists (rehabilitation therapists, 38; nurses, 82) from six general medicine units. The survey was developed using published guidelines, literature review, and provider meetings and refined through pilot testing. Psychometric properties were assessed, and regression analyses were conducted to examine barriers to early mobility by hospital site, provider discipline, and years of experience. Results Internal consistency reliability, item consistency, and discriminant validity psychometric characteristics were acceptable. In multivariable regression analysis, overall perceived barriers were similar between the two hospitals (P = 0.25) and significantly higher for staff with less experience (P = 0.02) and for nurses vs. rehabilitation therapists (P < 0.001).The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific. Conclusions This novel survey identified important barriers to mobilizing medical inpatients that were similar across two hospital settings. These results can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility.

Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland.

OBJECTIVE Hospital discharge summaries can provide valuable information to future providers and may help to prevent hospital readmissions. We sought to examine whether the number of days to complete hospital discharge summaries is associated with 30-day readmission rate. PATIENTS AND METHODS This was a retrospective cohort study conducted on 87,994 consecutive discharges between January 1, 2013 and December 31, 2014, in a large urban academic hospital. We used multivariable logistic regression models to examine the association between days to complete the discharge summary and hospital readmissions while controlling for age, gender, race, payer, hospital service (gynecology-obstetrics, medicine, neurosciences, oncology, pediatrics, and surgical sciences), discharge location, length of stay, expected readmission rate in Maryland based on diagnosis and illness severity, and the Agency for Healthcare Research and Quality Comorbidity Index. Days to complete the hospital discharge summary-the primary exposure variable-was assessed using the 20th percentile (>3 vs ≤3 days) and as a continuous variable (odds ratio expressed per 3-day increase). The main outcome was all-cause readmission to any acute care hospital in Maryland within 30 days. RESULTS Among the 87,994 patients, there were 14,248 (16.2%) total readmissions. Discharge summary completion >3 days was significantly associated with readmission, with adjusted odds ratio (OR) (95% confidence interval [CI]) of 1.09 (1.04 to 1.13, P = 0.001). We also found that every additional 3 days to complete the discharge summary was associated with an increased adjusted odds of readmission by 1% (OR: 1.01, 95% CI: 1.00 to 1.01, P < 0.001). CONCLUSION Longer days to complete discharge summaries were associated with higher rates of all-cause hospital readmissions. Timely discharge summary completion time may be a quality indicator to evaluate current practice and as a potential strategy to improve patient outcomes. Journal of Hospital Medicine 2016;11:393-400. 2016 Society of Hospital Medicine.

Promoting mobility and reducing length of stay in hospitalized general medicine patients: A quality-improvement project.

OBJECTIVE To determine whether a multidisciplinary mobility promotion quality-improvement (QI) project would increase patient mobility and reduce hospital length of stay (LOS). PATIENTS AND METHODS Implemented using a structured QI model, the project took place between March 1, 2013 and March 1, 2014 on 2 general medicine units in a large academic medical center. There were 3352 patients admitted during the QI project period. The Johns Hopkins Highest Level of Mobility (JH-HLM) scale, an 8-point ordinal scale ranging from bed rest (score = 1) to ambulating ≥250 feet (score = 8), was used to quantify mobility. Changes in JH-HLM scores were compared for the first 4 months of the project (ramp-up phase) versus 4 months after project completion (post-QI phase) using generalized estimating equations. We compared the relative change in median LOS for the project months versus 12 months prior among the QI units, using multivariable linear regression analysis adjusting for 7 demographic and clinically relevant variables. RESULTS Comparing the ramp-up versus post-QI phases, patients reaching JH-HLMs ambulation status increased from 43% to 70% (P < 0.001), and patients with improved JH-HLM mobility scores between admission and discharge increased from 32% to 45% (P < 0.001). For all patients, the QI project was associated with an adjusted median LOS reduction of 0.40 (95% confidence interval [CI]: -0.57 to -0.21, P < 0.001) days compared to 12 months prior. A subgroup of patients expected to have a longer LOS (expected LOS >7 days), were associated with a significantly greater adjusted median reduction in LOS of 1.11 (95% CI: -1.53 to -0.65, P < 0.001) days. Increased mobility was not associated with an increase in injurious falls compared to 12 months prior on the QI units (P = 0.73). CONCLUSIONS AND RELEVANCE Active prevention of a decline in physical function that commonly occurs during hospitalization may be achieved with a structured QI approach. In an adult medicine population, our QI project was associated with improved mobility, and this may have contributed to a reduction in LOS, particularly for more complex patients with longer expected hospital stay. Journal of Hospital Medicine 2016.

Associations between hospital-wide readmission rates and mortality measures at the hospital level: Are hospital-wide readmissions a measure of quality?

The Centers for Medicare & Medicaid Services (CMS) have sought to reduce readmissions in the 30 days following hospital discharge through penalties applied to hospitals with readmission rates that are higher than expected. Expected readmission rates for Medicare fee-for-service beneficiaries are calculated from models that use patientlevel administrative data to account for patient morbidities. Readmitted patients are defined as those who are discharged from the hospital alive and then rehospitalized at any acute care facility within 30 days of discharge. These models explicitly exclude sociodemographic variables that may impact quality of and access to outpatient care. Specific exclusions are also applied based on diagnosis codes so as to avoid penalizing hospitals for rehospitalizations that are likely to have been planned. More recently, a hospital-wide readmission measure has been developed, which seeks to provide a comprehensive view of each hospital’s readmission rate by including the vast majority of Medicare patients. Like the conditionspecific readmission measures, the hospital-wide readmission measure also excludes sociodemographic variables and incorporates specific condition-based exclusions so as to avoid counting planned rehospitalizations (e.g., an admission for cholecystectomy following an admission for biliary sepsis). Although not currently used for payfor-performance, this measure has been included in the CMS Star Report along with other readmission measures. CMS does not currently disseminate a hospitalwide mortality measure, but does disseminate hospitallevel adjusted 30-day mortality rates for Medicare beneficiaries with discharge diagnoses of stroke, heart failure, myocardial infarction (MI), chronic obstructive pulmonary disease (COPD) and pneumonia, and principal procedure of coronary artery bypass grafting (CABG). It is conceivable that aggressive efforts to reduce readmissions might delay life-saving acute care in some scenarios, and there is prior evidence that heart failure readmissions are inversely (but weakly) related to heart failure mortality. It is also plausible that keeping tenuous patients alive until discharge might result in higher readmission rates. We sought to examine the relationship between hospital-wide adjusted 30-day readmissions and death rates across the acute care hospitals in the United States. Lacking a measure of hospital-wide death rates, we examined the relation between hospital-wide readmissions and each of the 6 condition-specific mortality measures. For comparison, we also examined the relationships between condition-specific readmission rates and mortality rates.

The effects of task demands on bimanual skill acquisition

Bimanual coordination is essential for everyday activities. It is thought that different degrees of demands may affect learning of new bimanual patterns. One demand is at the level of performance and involves breaking the tendency to produce mirror-symmetric movements. A second is at a perceptual level and involves controlling each hand to separate (i.e., split) goals. A third demand involves switching between different task contexts (e.g., a different uni- or bimanual task), instead of continuously practicing one task repeatedly. Here, we studied the effect of these task demands on motor planning (reaction time) and execution (error) while subjects learned a novel bimanual isometric pinch force task. In Experiment 1, subjects continuously practiced in one of the two extremes of the following bimanual conditions: (1) symmetric force demands and a perceptually unified target for each hand or (2) asymmetric force demands and perceptually split targets. Subjects performing in the asymmetric condition showed some interference between hands, but all subjects, regardless of group, could learn the isometric pinch force task similarly. In Experiment 2, subjects practiced these and two other conditions, but in a paradigm where practice was briefly interrupted by the performance of either a unimanual or a different bimanual condition. Reaction times were longer and errors were larger well after the interruption when the main movement to be learned required asymmetric forces. There was no effect when the main movement required symmetric forces. These findings demonstrate two main points. First, people can learn bimanual tasks with very different demands on the same timescale if they are not interrupted. Second, interruption during learning can negatively impact both planning and execution and this depends on the demands of the bimanual task to be learned. This information will be important for training patient populations, who may be more susceptible to increased task demands.

Using a Real-Time Location System for Assessment of Patient Ambulation in a Hospital Setting

OBJECTIVE To assess the feasibility of using an infrared-based Real-Time Location System (RTLS) for measuring patient ambulation in a 2-minute walk test (2MWT) by comparing the distance walked and the Johns Hopkins Highest Level of Mobility (JH-HLM) score to clinician observation as a criterion standard. DESIGN Criterion standard validation study. SETTING Inpatient, university hospital. PARTICIPANTS Patients (N=25) in an adult neuroscience/brain rescue unit. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES RTLS and clinician-reported ambulation distance in feet, and JH-HLM score on an 8-point ordinal scale. RESULTS The RTLS ambulation distance for the 25 patients in the 2MWT was between 68 and 516ft. The mean difference between clinician-reported and RTLS ambulation distance was 8.4±11.7ft (2.7%±4.6%). The correlation between clinician-reported and RTLS ambulation distance was 97.9% (P<.01). The clinician-reported ambulation distance for 2 patients was +100ft and -99ft compared with the RTLS distance, implying clinician error in counting the number of laps (98ft). The correlation between the RTLS distance and clinician-reported distance excluding these 2 patients is 99.8% (P<.01). The accuracy of the RTLS for assessment of JH-HLM score for all 25 patients was 96%. The average patient speed obtained from RTLS data varied between 0.4 and 3.0mph. CONCLUSIONS The RTLS is able to accurately measure patient ambulation and calculate JH-HLM for a 2MWT when compared with clinician observation as the criterion standard.

Reconsidering Hospital Readmission Measures

Current hospital readmission measures are part of the Centers for Medicare & Medicaid Services Five-Star Quality Rating System but are inadequate for reporting hospital quality. We review potential biases in the readmission measures and offer policy recommendations to address these biases. Hospital readmission rates are influenced by multiple sources of variation (eg, mix of patients served, bias in the performance measure); true differences in quality of care are often a much smaller source of this variation. Thus, variation from caring for large proportions of socioeconomically disadvantaged or tertiary-care patients will bias a hospitals ratings. Ratings aside, readmission measures may indirectly harm patients because low readmission rates do not correlate with reduced mortality, yet the Five-Star Quality Rating System weighs readmission equally with mortality. We propose that hospital quality rankings not use readmission measures as currently constructed.

Choosing Wisely Together: Physical and Occupational Therapy Consultation for Acute Neurology Inpatients:

Background: Although many hospitalized neuroscience patients have physical and occupational therapy (rehabilitation) needs, patients with none or minimal physical impairments frequently receive rehabilitation consultation, diverting from patients with greatest need. Methods: A multidisciplinary team on the general and cerebrovascular neurology acute inpatient services mapped the rehabilitation consultation process, resulting in multiple implemented interventions including physician education on appropriate acute rehabilitation consultations, modification of multidisciplinary rounds, and discussion of patient rehabilitation needs throughout hospitalization. Nurses used the same functional impairment measurement tool used by physical and occupational therapists, the Activity Measure for Post-Acute Care Inpatient Short Forms (Basic Mobility and Activity domains). Results: The rate for initial rehabilitation consults for patients with no limitations in mobility or activity during the 6-month baseline period was 12%, which was decreased to 7% and 10% during the 6-month intervention and sustain periods, respectively (P < .001). The baseline rate for patients with no limitations receiving both physical therapy and occupational therapy consultations was 62% and was decreased to 21% and 39% in the intervention and sustain periods, respectively (P < .001). Rehabilitation sessions per hospital day increased for patients with high functional impairments, from 0.52 at baseline to 0.64 in the intervention and 0.66 in the sustain periods (P = .02), which equated to 1 more rehabilitation visit per patient hospitalization. Conclusions: A multifaceted intervention led to improved utilization of acute inpatient rehabilitation consultation while increasing the frequency of rehabilitation treatment for patients with highest functional impairment.

Increasing patient mobility through an individualized goal-centered hospital mobility program: A quasi-experimental quality improvement project

BACKGROUND Hospital-acquired functional decline due to decreased mobility has negative impacts on patient outcomes. Current nurse-directed mobility programs lack a standardized approach to set achievable mobility goals. PURPOSE We aimed to describe implementation and outcomes from a nurse-directed patient mobility program. METHOD The quality improvement mobility program on the project unit was compared to a similar control unit providing usual care. The Johns Hopkins Mobility Goal Calculator was created to guide a daily patient mobility goal based on the level of mobility impairment. FINDINGS On the project unit, patient mobility increased from 5.2 to 5.8 on the Johns Hopkins Highest Level of Mobility score, mobility goal attainment went from 54.2% to 64.2%, and patients exceeding the goal went from 23.3% to 33.5%. All results were significantly higher than the control unit. DISCUSSION An individualized, nurse-directed, patient mobility program using daily mobility goals is a successful strategy to improve daily patient mobility in the hospital.