Michelle Camicia

Time to Inpatient Rehabilitation Hospital Admission and Functional Outcomes of Stroke Patients

To study the association of time to inpatient rehabilitation hospital (IRH) admission and functional outcomes of patients who have had a stroke.

Daily Treatment Time and Functional Gains of Stroke Patients During Inpatient Rehabilitation

To study the effects of daily treatment time on functional gain of patients who have had a stroke.

Postacute Care and Ischemic Stroke Mortality: Findings From an Integrated Health Care System in Northern California

To study the association of postacute care (PAC) settings and mortality outcome of patients who sustained an ischemic stroke.

The Essential Role of the Rehabilitation Nurse in Facilitating Care Transitions: A White Paper by the Association of Rehabilitation Nurses

The current process of care transitions for individuals with disabling conditions is both ineffective and inefficient. There is a need for clinicians with the necessary knowledge and skills to advocate and facilitate transitions that result in the greatest value to the patients, their families, and the healthcare delivery system. A review of the literature reveals significant problems with transitions to postacute care (PAC) settings. Care is fragmented, disorganized, and guided by factors unrelated to the quality of care or patient outcomes. Studies have demonstrated that the selection of a PAC setting for patients is influenced by multiple factors (Sandel et al., 2009; Gage, 2009). Patients’ clinically assessed needs often do not match the level of care determined by decision makers because optimal patient outcomes may not be the primary factor considered. Competing factors include proximity of providers, relationships between providers of care, payer source, and variation in the interpretations of regulations regarding PAC. Decision makers may include the patient, family members, discharge planners, physicians, insurance company representatives, social workers, and other healthcare providers. Many times, these decision makers lack adequate information to make the best decision during care transition planning. Consequently, care transitions remain a confusing time for patients and their families and can result in both overuse and underuse of PAC services and sub-optimal quality of care and clinical outcomes. Families involved in PAC transitions often feel overwhelmed and dissatisfied (Lutz, Young, Cox, Martz, & Creasy, 2011). PAC is a significant part of the overall care of many Medicare patients. Up to 35% of Medicare patients are discharged each year to a PAC setting (Gage, 2009). Of those Medicare patients discharged, almost one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within 30 days (Mor, Intrator, Feng, & Grabowski, 2010). PAC is provided in various settings, including skilled nursing facilities, inpatient rehabilitation facilities, longterm care hospitals, in the home by home healthcare agencies, and outpatient centers. PAC is provided by a wide array of specialized clinicians from physical therapists, occupational therapists, physicians, speech-language pathologists, neuropsychologists, social workers, discharge planners, and nurses with and without rehabilitation expertise. Rehabilitation is a key component of the care provided in each of these settings. About 30%–60% of the older patients develop new dependence in activities of daily living (ADL) during an acute care hospital stay, which can result in progressive disability after discharge (Huang, Chang, Liu, Lin, & Chen, 2013). Determining the best setting for the patient requires a thorough understanding of rehabilitation services and evidenced-based outcomes to evaluate appropriateness of care for the patient. Pilot studies have demonstrated that when a nurse with an understanding of care transitions is integrated into the process, unplanned 30-day hospital readmission rates decline and outcomes are improved (Congressional Research Service [CRS], 2010).

Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities.

ObjectiveThe aim of this study was to examine the impact of pressure ulcers on inpatient rehabilitation facility (IRF) outcomes. DesignThis is a retrospective analysis of the IRF data in the United States from the Uniform Data System for Medical Rehabilitation between 2009 and 2011. The study sample included 2902 pairs of pressure ulcer and pressure ulcer–free patients upon IRF admission, matching on age at admission, sex, impairment groups, and comorbidity tier measures. The study outcomes were cognition and motor functional gains measured by the Functional Independence Measure instrument, IRF length of stay, and discharge to the community. ResultsThe mean pressure ulcer prevalence upon IRF admission was 5.23%. After controlling for other covariates under study, the pressure ulcer group had a lower motor gain (20.12 vs. 21.58, P < 0.0001), had a longer length of stay (16.5 vs. 15.5, P < 0.0001), and were less likely to be discharged to the community after IRF stay (odds ratio, 0.72; 95% confidence interval, 0.62–0.84) than the patients without a pressure ulcer. ConclusionsThe presence of a pressure ulcer among the patients seen in United States IRFs had no impact on cognition functional gain but was associated with a minor lower motor gain, a longer IRF length of stay, and lower odds of being discharged to the community.

Length of Stay at Inpatient Rehabilitation Facility and Stroke Patient Outcomes

Purpose: To examine the association of inpatient rehabilitation facility (IRF) length of stay (LOS) with stroke patient outcomes. Design: A secondary data analysis of the Uniform Data System for Medical Rehabilitation database. Methods: Stroke patients discharged from IRFs in the United States between 2009 and 2011 were identified and divided into mild (n = 639), moderate (n = 2,065), and severely (n = 2,077) impaired groups. Study outcomes included cognition and motor functional gains measured by the Functional Independence Measure (FIM) instrument and discharge to the community. Findings: The average LOS was 8.9, 13.9, and 22.2 days for mild, moderate, and severely impaired stroke patients, respectively. After controlling for FIM admission and other important covariates, a longer LOS was associated with a modest increase in cognition gain (&bgr; = 0.038, p = .0045) for the moderately impaired patients, and a modest increase in cognition (&bgr; = 0.13, p < .0001) and motor gains (&bgr; = 0.25, p < .0001) as well as a tendency for discharge to the community (OR = 1.01, 95% CI = 1.00–1.02) among the severely impaired patients. However, a longer LOS showed a negative association with functional gains among the mildly impaired patients as well as discharge to community for both mild and moderately impaired patients. Conclusion: The association of IRF LOS and patient outcomes varied by stroke impairment severity, positively for more severely impaired patients and negatively for mildly impaired patients. Clinical Relevance: The study provides evidence for the care of stroke patients at the IRF setting.

Early inpatient rehabilitation admission and stroke patient outcomes.

ObjectiveThe aim of this study was to examine the associations of onset days, time from stroke onset to inpatient rehabilitation facility (IRF) admission, and patient outcomes (FIM gain, discharge destination, and IRF length of stay), using nationally representative data. DesignA secondary data analysis was conducted on a random sample of stroke patients discharged from IRFs in the United States between 2009 and 2011, including mildly (n = 649), moderately (n = 2185), and severely (n = 2390) impaired patients. ResultsThe study sample had a median of onset days of 5.5, with an interquartile range of 4–9. With the use of 15–365 days as reference, the severely impaired patients had a higher cognition gain (P < 0.01) and were more likely to be discharged to the community (odds ratio, 1.45; 95% confidence interval, 1.12–1.87) when admitted within 7 days, a greater motor gain when admitted within 14 days (P < 0.01), and a lower risk for acute hospital transfer when admitted 3–7 days (odds ratio, 0.62; 95% confidence interval, 0.43–0.90). The moderately impaired patients had a greater motor gain when admitted within 7 days (P < 0.01). Early IRF admission was also associated with a shorter length of stay. ConclusionsEarlier IRF admission was beneficial among severely and moderately impaired patients. IRF admission within 7 days is recommended for stroke patients who achieved medical stability.

Nursing’s Role in Successful Transitions Across Settings

Care transitions across settings (hospital, other institutional settings, and home) are vulnerable exchange points for patients and family caregivers that contribute to higher risk of poor health outcomes.1 The Institute of Medicine and National Quality Forum identified improving transitions across the continuum from acute care to home as a national priority.2,3 Despite this, care transitions for individuals with disabling conditions, such as stroke, remain inefficient, resulting in unmet patient and caregiver needs, increased safety risks, high rates of preventable readmissions, and increased healthcare costs.4 Nurses have an integral role in care coordination activities at various practice levels and settings, thus nurses can help transform healthcare delivery for stroke survivors through improving transitions. Stroke is the leading cause of major disability. Annually, ≈800 000 people are hospitalized for stroke in the United States. In 2010, there were ≈6.6 million stroke survivors with a predicted increase in prevalence of >20% over the next 20 years.5 Despite medical advances resulting in reduced stroke mortality, disability after stroke remains a major concern and adds complexity to care transitions for this population. Given stroke prevalence, improving nurses’ engagement in optimizing care transitions for this population is essential. Readmissions after discharge from institutional settings to the community are a closely monitored measurement of care transition effectiveness. Readmissions may indicate unresolved problems, discharge to an inappropriate level of care, quality of immediate posthospital care, or a combination of these factors.6 Thirty-day readmission rates after hospital discharge are reported at 14.4%, with 11.9% of these determined as preventable.7 Readmissions after discharge from inpatient rehabilitation facilities range from 9.0% to 16.7%, varying with the severity of stroke impairment.8 Patients discharged to skilled nursing facilities have the highest 30-day readmission rates.9 Readmissions are associated with substantial economic burden on the healthcare …

Impact of Pressure Ulcers on Outcomes in Inpatient Rehabilitation Facilities

Disclosures: M. Sohn, NoDisclosures: I Have Nothing To Disclose. Objective: To investigate the correlation between quantitative sonography and electrophysiologic study in patients with carpal tunnel syndrome (CTS) and to assess the clinical significance of quantitative sonography for the diagnosis of CTS. Setting: Forty hands with suggestive symptoms and signs of CTS and 40 hands from asymptomatic volunteers were prospectively evaluated by ultrasonography and electrodiagnostic studies. Electrodiagnostic study contained nerve conduction studies including median and ulnar nerves, and electromyography of abductor pollicis brevis (APB) and abductor digiti minimi (ADM). Ultrasonography was conducted in APB and ADM muscles. The muscle thickness, cross-sectional area (CSA) and echo intensity (EI) were determined in each muscle. The echo intensity was measured using computer-assisted grayscale analysis. Results or Clinical Course: There were significant differences in muscle thickness, CSA, EI of APB between the CTS and the control group (p<.05), whereas no significant differences in ADM. EI showed highly significant, positive correlation with electrophysiological severity, distal latency of median motor and sensory nerve. Muscle thickness and CSA showed significant, negative correlation with them. Conclusions: The quantitative muscle ultrasonography has clinical significance in the diagnosis of CTS.

Stroke Onset to Rehabilitation Admission and Patient Outcomes

Disclosures: M. A. DiVita, No Answer. Objective: To study the effect of stroke onset to inpatient rehabilitation facility (IRF) admission on patient outcomes. Design: A retrospective study using information from the Uniform Data System for Medical Rehabilitation (UDSMR) between 2009 and 2011. Setting: U.S. IRFs included in the UDSMR database. Participants: Mildly (n1⁄4649), moderately (n1⁄42,185), and severely (n1⁄42,390) impaired stroke patients. Interventions: None. Main Outcome Measures: Cognition and motor functional gains measured by the FIM instrument, and discharge to acute care hospital and community. Results or Clinical Course: The three stroke groups differed significantly in patient characteristics, medical conditions, facility level measures, and onset to IRF admission duration (onset days), with an average of 6.9, 8.3, and 12.7 days for mildly, moderately, and severely impaired groups, respectively. After controlling for admission FIM and covariates under study, a short onset day was significantly associated with an increased cognition gain for severely impaired patients as well as an increased motor gain for both moderately and severely impaired patients. In comparison to patient with an onset day of 15 days or longer, patients with an onset day between 3 and 7 days was also more likely to be discharged to community after IRF stay (OR1⁄41.39, 95% CI1⁄41.061.84). However, onset days were not significantly associated with discharge to acute care in the moderately and severely impaired groups as well as any patient outcomes in the mildly impaired group. Conclusions: Early IRF admission had a significant effect on functional gain and discharge to community for moderately and severely impaired stroke patients.