Nelson Escobar

Dysphagia outcomes in patients with brain tumors undergoing inpatient rehabilitation.

The purpose of this retrospective study was to compare functional dysphagia outcomes following inpatient rehabilitation for patients with brain tumors with that of patients following a stroke. Group 1 (n = 24) consisted of consecutive admissions to the brain injury program with the diagnosis of brain tumor and dysphagia. Group 2 (n = 24) consisted of matched, consecutive admissions, with the diagnosis of acute stroke and dysphagia. Group 2 was matched for age, site of lesion, and initial composite cognitive FIM score. The main outcome measures for this study included the American Speech-Language-Hearing Association (ASHA) National Outcome Measurement System (NOMS) swallowing scale, length of stay, hospital charges, and medical complications. Results showed that swallowing gains made by both groups as evaluated by the admission and discharge ASHA NOMS levels were considered to be statistically significant. The differences for length of stay, total hospital charges, and speech charges between the two groups were not considered to be statistically significant. Three patients in the brain tumor group (12.5%) demonstrated dysphagia complications of either dehydration or pneumonia during their treatment course as compared to 0% in the stroke group. This study confirms that functional dysphagia gains can be achieved for patients with brain tumors undergoing inpatient rehabilitation and that they should be afforded the same type and intensity of rehabilitation for their swallowing that is provided to patients following a stroke.

Persons with disorders of consciousness: are oral feedings safe/effective?

Primary objective: Evaluate the safety and efficacy of providing oral feedings to persons early in coma recovery following a severe brain injury. Research design: Descriptive, retrospective study. Methods and procedures: Medical chart reviews of all patients admitted to a rehabilitation hospital following severe brain injury. Main outcomes and results: Twenty-five patients met the inclusion criteria, 22 had a tracheostomy, and all were NPO. Subjects were divided into two cohorts. Group 1, n = 10, mean age 43.5 years, received oral feedings early in coma recovery. Group 2, n = 15, mean age 45.2 years, did not. Group 1, 30% returned to an oral diet of three meals daily at discharge from inpatient rehabilitation as compared to 40% in group 2 (χ2 = 0.260, p = 0.610). Average cost of care for group 1 = US

Feasibility of instrumental swallowing assessments in patients with prolonged disordered consciousness while undergoing inpatient rehabilitation.

45 759 and group 2 = US

Poster 160: Dysphagia after West Nile virus: a report of 5 cases.1

41 056 (p = 0.634). Conclusion: Safe therapeutic oral feedings, in accordance with findings from instrumental swallowing examinations, are possible for patients with disordered consciousness. The therapeutic oral feedings do not significantly increase the cost of care, but the effectiveness of oral feedings early in coma recovery requires further investigation.

Poster 159: Contact precautions in a rehabilitation hospital.1

ObjectiveTo evaluate the feasibility, safety, and potential benefit of instrumental swallowing assessments for patients with prolonged disordered consciousness participating in rehabilitation. DesignCase-control, retrospective. ParticipantsThirty-five participants divided into 2 cohorts according to cognitive level at the time of baseline instrumental swallowing assessment. Group 1 (n = 17) participants were at Rancho Los Amigo (RLA) level II/III or RLA level III, while Group 2 (n = 18) participants were rated better than RLA level III. ResultsAspiration and laryngeal penetration rates for both groups were similar (aspiration rate Group 1 = 41%, Group 2 = 39%; laryngeal penetration rate Group 1 = 59%, Group 2 = 61%). Overall, 76% (13/17) of Group 1 and 72% (13/18) of Group 2 were able to receive some type of oral feedings following baseline video fluoroscopic swallow study (VFSS) or endoscopic exam of the swallow (FEES). ConclusionThe majority of participants who underwent an instrumental swallowing examination while still functioning at RLA level II/III or RLA level III were able to return to some form of oral feedings immediately following their baseline examination. Swallowing as a treatment modality can be considered a part of the overall plan to facilitate neurobehavioral recovery for patients with prolonged disordered consciousness participating in rehabilitation.

Metoprolol for action tremor following intracerebral hemorrhage

Abstract Setting: Free-standing rehabilitation hospital. Patients: 5 consecutive patients (3 men, 2 women; mean age, 57.20y; range, 34–72y) who presented with dysphagia after West Nile virus (WNV) infection. Case Descriptions: All patients presented with their initial symptoms in August and September 2002. All diagnoses were confirmed by lumbar puncture. 3 patients were initially not eating by mouth and required nonoral nutritional support. 3 patients experienced pneumonia; 2 patients required mechanical ventilation; and 1 patient required a tracheotomy tube. Assessment/Results: Swallowing therapy focused on compensatory swallowing safety strategies and swallowing rehabilitation and strengthening exercises. Videofluoroscopy was completed in 4 of the patients, with aspiration being present in 3 patients. Days from onset to discharge ranged from 24 to 183 (mean ± SD, 85.8±69.1d). The patient who required mechanical ventilation, a tracheotomy tube, and a gastrostomy tube had the longest length of stay. All patients were eventually able to return to oral feedings after swallowing therapy during their inpatient rehabilitation stay without requiring any supplemental tube feedings. All patients were weaned from the ventilators and tracheotomy tube. 4 of the 5 patients were receiving a regular diet of thin liquids and bread at discharge. Discussion: Physicians should recognize that dysphagia is a potential complication after WNV infection and should provide appropriate direction for the team management of dysphagia with these patients. Conclusion: Functional gains can be made for dysphagia after WNV infection.

Poster 10: People With Severely Disordered Level of Consciousness: Factors Associated With Returning to Oral Feeding During Inpatient Rehabilitation

Abstract Objectives: To develop a modification of the US Centers for Disease Control and Prevention (CDC) contact precautions applicable to the rehabilitation environment and to determine its impact on implementation and nosocomial infection rates of specific pathogens. Design: Descriptive epidemiologic study. Setting: 110-bed free-standing comprehensive inpatient rehabilitation teaching hospital. Participants: All hospital staff and inpatients. Interventions: An infection prevention program, based on CDC contact precautions directed at Clostridium difficile , methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE), was implemented. This program incorporated the following elements: new definitions for stop and start of precautions; establishment of criteria for private rooms and protective equipment utilization; institution of precautions within therapy departments; emphasis on housekeeping for prevention of environmental contamination; initiation of door-mounted isolation supplies; implementation of alcohol-based waterless hand hygiene; staff education; computer tracking of patients in isolation; surveillance of isolation implementation and compliance; and selective use of eradication therapy. Main Outcome Measures: The ability of staff to comprehend, implement, and adhere to the prevention program; efficiency in isolation resource utilization; and nosocomial rates for Clostridium difficile , MRSA, and VRE. Results: Staff demonstrated better understanding of precaution implementation and improved compliance with more reliable private room and protective equipment use. There was less disruption of the rehabilitation process. During the first year of program phase-in, the percentage of nosocomial infections decreased as follows: Clostridium difficile , 48.7%; MRSA, 69.5%; and VRE, 64.1%. Conclusion: We present a modification of the CDC contact precautions implementation specific for the rehabilitation environment that is more easily understood, more consistently and effectively implemented by staff, and that effectively prevents nosocomial transmission of epidemiologically important pathogens.