Estelle Lécureux

Predictors of Functional Recovery in Patients Admitted to Geriatric Postacute Rehabilitation

OBJECTIVE To examine characteristics associated with functional recovery in older patients undergoing postacute rehabilitation. DESIGN Observational study. SETTING Postacute rehabilitation facility. PARTICIPANTS Patients (N=2754) aged ≥65 years admitted over a 4-year period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Functional status was assessed at admission and again at discharge. Functional recovery was defined as achieving at least 30% improvement on the Barthel Index score from admission compared with the maximum possible room for improvement. RESULTS Patients who achieved functional recovery (70.3%) were younger and were more likely to be women, live alone, and be without any formal home care before admission, and they had fewer chronic diseases (all P<.01). They also had better cognitive status and a higher Barthel Index score both at admission (mean ± SD, 63.3±18.0 vs 59.6±24.7) and at discharge (mean ± SD, 86.8±10.4 vs 62.2±22.9) (all P<.001). In multivariate analysis, patients <75 years of age (adjusted odds ratio [OR]=1.51; 95% confidence interval [CI], 1.16-1.98; P=.003), women (adjusted OR=1.24; 95% CI, 1.01-1.52; P=.045), patients living alone (adjusted OR=1.61; 95% CI, 1.31-1.98; P<.001), and patients without in-home help prior to admission (adjusted OR=1.39; 95% CI, 1.15-1.69; P=.001) remained at increased odds of functional recovery. In addition, compared with those with moderate-to-severe cognitive impairment (Mini-Mental State Examination score <18), patients with mild-to-moderate impairment (Mini-Mental State Examination score 19-23) and those cognitively intact also had increased odds of functional recovery (adjusted OR=1.56; 95% CI, 1.13-2.15; P=.007; adjusted OR=2.21; 95% CI, 1.67-2.93; P<.001, respectively). CONCLUSIONS Apart from sociodemographic characteristics, cognition is the strongest factor that identifies older patients more likely to improve during postacute rehabilitation. Further study needs to determine how to best adapt rehabilitation processes to better meet the specific needs of this population and optimize their outcome.

The impact of an enhanced recovery pathway on nursing workload: A retrospective cohort study ☆

BACKGROUND & AIMS The importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably complete fulfillment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery. METHODS The program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol. RESULTS The study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 (P = 0.005) and 51.6 ± 18.6 (P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload (ρ = -0.42; P < 0.001). CONCLUSIONS Nursing workload is--against a common belief--decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses!

Reliability of the Knee Smartphone-Application Goniometer in the Acute Orthopedic Setting.

Abstract The standard goniometer (SG) is the most commonly used tool to assess range of motion (ROM) in patients with knee restrictions. Several medical applications have been designed to measure joint ROM. Little data are available on their reliability in the postoperative clinical setting. The purpose of this study was to assess whether a smartphone accelerometer‐based knee goniometer application (App) is as reliable as the SG to measure knee ROM in clinical settings. A total of 60 subjects were included in this cross‐sectional reliability trial. Overall, 20 healthy subjects (HS) and 20 acute postoperative patients (PO) underwent three active and three passive measurements in knee flexion and extension, using the SG and the smartphone knee goniometer App. To determine the fatigability of postoperative patients, a third group of 20 patients underwent a single active measurement in knee flexion and extension (PO1). Measurements were performed by three clinicians. For intraobserver reliability, mean intraclass correlation coefficient (ICC) values were higher for the App in all circumstances (overall mean SG 0.85, App 0.91), indicating an excellent correlation. For interobserver reliability, the highest ICC scores were in the PO1 group, with the App more consistent than the SG in all movements. Interobserver reliability was lower in the PO group versus PO1. Interobserver reliability was better for active ROM than for passive measurements. The overall concordance coefficient was very good to excellent with active measurements (range, 0.60‐0.97). In conclusion, the App is a reliable tool for use in acute orthopedic care and offers better intra‐ and interobserver correlation scores for a single active measurement.

Measurement Properties of the Smartphone-Based B-B Score in Current Shoulder Pathologies

This study is aimed at the determination of the measurement properties of the shoulder function B-B Score measured with a smartphone. This score measures the symmetry between sides of a power-related metric for two selected movements, with 100% representing perfect symmetry. Twenty healthy participants, 20 patients with rotator cuff conditions, 23 with fractures, 22 with capsulitis, and 23 with shoulder instabilities were measured twice across a six-month interval using the B-B Score and shoulder function questionnaires. The discriminative power, responsiveness, diagnostic power, concurrent validity, minimal detectable change (MDC), minimal clinically important improvement (MCII), and patient acceptable symptom state (PASS) were evaluated. Significant differences with the control group and significant baseline—six-month differences were found for the rotator cuff condition, fracture, and capsulitis patient groups. The B-B Score was responsive and demonstrated excellent diagnostic power, except for shoulder instability. The correlations with clinical scores were generally moderate to high, but lower for instability. The MDC was 18.1%, the MCII was 25.2%, and the PASS was 77.6. No floor effect was observed. The B-B Score demonstrated excellent measurement properties in populations with rotator cuff conditions, proximal humerus fractures, and capsulitis, and can thus be used as a routine test to evaluate those patients.

Effect of Manual Lymphatic Drainage After Total Knee Arthroplasty: A Randomized Controlled Trial.

OBJECTIVE To evaluate the effects of manual lymphatic drainage (MLD) on knee swelling and the assumed consequences of swelling after total knee arthroplasty (TKA). DESIGN Randomized controlled trial. SETTING Primary care hospital. PARTICIPANTS Two groups of 30 patients were randomized before TKA surgery (N=60; 65% women [39]; mean age, 70.7±8.8y; weight, 77.8±11.3kg; size, 1.64±0.08m; body mass index, 29.9±4.1kg/m(2)). INTERVENTIONS Participants received either 5 MLD treatments or a placebo, added to rehabilitation, in between the second day and the seventh day after surgery. MAIN OUTCOME MEASURES Swelling was measured by blinded evaluators before surgery and at second day, seventh day, and 3 months using bioimpedance spectroscopy and volume measurement. Secondary outcomes were active and passive range of motion, pain, knee function, and gait parameters. RESULTS At seventh day and 3 months, no outcome was significantly different between groups, except for the knee passive flexion contracture at 3 months, which was lower and less frequent in the MLD group (-2.6°; 95% confidence interval, -5.0° to -0.21°; P=.04; absolute risk reduction, 26.6%; 95% confidence interval, 0.9%-52.3%; number needed to treat, 4). The mean pain level decreased between 5.8 and 8.2mm on the visual analog scale immediately after MLD, which was significant after 4 of 5 MLD treatments. CONCLUSIONS MLD treatments applied immediately after TKA surgery did not reduce swelling. It reduced pain immediately after the treatment. Further studies should investigate whether the positive effect of MLD on knee extension is replicable.

Heightened clinical utility of smartphone versus body-worn inertial system for shoulder function B-B score

Background The B-B Score is a straightforward kinematic shoulder function score including only two movements (hand to the Back + lift hand as to change a Bulb) that demonstrated sound measurement properties for patients for various shoulder pathologies. However, the B-B Score results using a smartphone or a reference system have not yet been compared. Provided that the measurement properties are comparable, the use of a smartphone would offer substantial practical advantages. This study investigated the concurrent validity of a smartphone and a reference inertial system for the measurement of the kinematic shoulder function B-B Score. Methods Sixty-five patients with shoulder conditions (with rotator cuff conditions, adhesive capsulitis and proximal humerus fracture) and 20 healthy participants were evaluated using a smartphone and a reference inertial system. Measurements were performed twice, alternating between two evaluators. The B-B Score differences between groups, differences between devices, relationship between devices, intra- and inter-evaluator reproducibility were analysed. Results The smartphone mean scores (SD) were 94.1 (11.1) for controls and 54.1 (18.3) for patients (P < 0.01). The difference between devices was non-significant for the control (P = 0.16) and the patient group (P = 0.81). The analysis of the relationship between devices showed 0.97 ICC, −0.6 bias and −13.2 to 12.0 limits of agreement (LOA). The smartphone intra-evaluator ICC was 0.92, the bias 1.5 and the LOA −17.4 to 20.3. The smartphone inter-evaluator ICC was 0.92, the bias 1.5 and the LOA −16.9 to 20.0. Conclusions The B-B Score results measured with a smartphone were comparable to those of an inertial system. While single measurements diverged in some cases, the intra- and inter-evaluator reproducibility was excellent and was equivalent between devices. The B-B score measured with a smartphone is straightforward and as efficient as a reference inertial system measurement.

Assessment of Avoidable Readmissions in a Visceral Surgery Department with an Algorithm: Methodology, Analysis and Measures for Improvement

BackgroundStandardized quality indicators assessing avoidable readmission become increasingly important in health care. They can identify improvements area and contribute to enhance the care delivered. However, the way of using them in practice was rarely described.MethodsRetrospective study uses prospective inpatients’ information. Thirty-day readmissions were deemed potentially avoidable or non-avoidable by a computerized algorithm, and annual rate was reported between 2010 and 2014. Observed rate was compared to expected rate, and medical record review of potentially avoidable readmissions was conducted on data between January and June 2014.ResultsDuring a period of ten semesters, 11,011 stays were screened by the algorithm and a potentially avoidable readmission rate (PAR) of 7% was measured. Despite stable expected rate of 5 ± 0.5%, an increase was noted concerning the observed rate since 2012, with a highest value of 9.4% during the first semester 2014. Medical chart review assessed the 109 patients screened positive for PAR during this period and measured a real rate of 7.8%. The delta was in part due to an underestimated case mix owing to sub-coded comorbidities and not to health care issue.ConclusionsThe present study suggests a methodology for practical use of data, allowing a validated quality of care indicator. The trend of the observed PAR rate showed a clear increase, while the expected PAR rate was stable. The analysis emphasized the importance of adequate “coding chain” when such an algorithm is applied. Moreover, additional medical chart review is needed when results deviate from the norm.