Impact of transfer delays to rehabilitation in patients with severe trauma

Association Between Initiation of Rehabilitation and Length of Hospital Stay for Workers with Moderate to Severe Work-Related Traumatic Brain Injury

Background

In workers with moderate to severe work-related traumatic brain injury (wrTBI), this study aimed to investigate the effect of the timing of rehabilitation therapy initiation on the length of hospital stay and the factors that can influence this timing.

Methods

We used data obtained from the Republic of Korea's nationwide Workers' Compensation Insurance. In the Republic of Korea, between the years 2010 and 2019, a total of 26,324 workers filed a claim for compensation for moderate to severe wrTBI. Multiple regression modeling was performed to compare the length of hospital stay according to the timing of rehabilitation therapy initiation following wrTBI. According to the timing of the initiation of rehabilitation therapy following TBI, the proportions of healthcare institutions that provided medical care during each admission step were compared.

Results

The length of hospital stay for workers who started rehabilitation therapy within 90 days was significantly shorter than that for workers who started rehabilitationment were first admitted to tertiary hospitals. Approximately 39% of patients who received delayed rehabilitation treatment were first admitted to general hospitals, and 28.5% were first admitted to primary hospitals.

Conclusions

Our findings demonstrate the importance of early rehabilitation initiation and that the type of healthcare institution that the patient is first admitted to after wrTBI may influence the timing of rehabilitation initiation. The results of this study also emphasize the need to establish a Worker's Compensation Insurance-specialized rehabilitation healthcare delivery system.

Association Between Delayed Discharge From Acute Care and Rehabilitation Outcomes and Length of Stay: A Retrospective Cohort Study

OBJECTIVE

To examine the association between discharge delays from acute to rehabilitation care because of capacity strain in the rehabilitation units, patient length of stay (LOS), and functional outcomes in rehabilitation.

DESIGN

Retrospective cohort study using an instrumental variable to remove potential biases because of unobserved patient characteristics.

SETTING

Two campuses of a hospital network providing inpatient acute and rehabilitation care.

PARTICIPANTS

Patients admitted to and discharged from acute care categories of Medicine and Neurology/Musculoskeletal (Neuro/MSK) and subsequently admitted to and discharged from inpatient rehabilitation between 2013 and 2019 (N=10486).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Rehabilitation LOS, FIM scores at admission and discharge, and rehabilitation efficiency defined as FIM score improvement per day of rehabilitation.

RESULTS

The final cohort contained 3690 records for Medicine and 1733 for Neuro/MSK categories. For Medicine, 1 additional day of delayed discharge was associated with an average 5.1% (95% confidence interval [CI], 3%-7.3%) increase in rehabilitation LOS and 0.08 (95% CI, 0.03-0.13) reduction in rehabilitation efficiency. For Neuro/MSK, 1 additional day of delayed discharge was associated with an average 11.6% (95% CI, 2.8%-20.4%) increase in rehabilitation LOS and 0.08 (95% CI, -0.07 to 0.23) reduction in rehabilitation efficiency.

CONCLUSIONS

Delayed discharge from acute care to rehabilitation because of capacity strain in rehabilitation had a strong association with prolonged LOS in rehabilitation. An important policy implication of this "cascading" effect of delays is that reducing capacity strain in rehabilitation could be highly effective in reducing discharge delays from acute care and improving rehabilitation efficiency.

Disability, economic and work-role status of individuals with unilateral lower-limb amputation and their families in Bangladesh, post-amputation, and pre-rehabilitation: A cross-sectional study

BACKGROUND: Amputation has significant negative impacts on physical, psychological, social and economic wellbeing of individuals and families. This is potentially compounded by significant delays to rehabilitation in Bangladesh. OBJECTIVE: To quantify disability, occupation and socioeconomic status of people with unilateral lower-limb amputation (LLA) and their families in Bangladesh, post-amputation and pre-rehabilitation. METHODS: Between November 2017 and February 2018, people with unilateral LLA attending two locations of Center for the Rehabilitation of the Paralyzed, Bangladesh, for prosthetic rehabilitation were surveyed pre-rehabilitation, using the World Health Organization Disability Assessment Schedule (WHODAS-2.0) with additional socio-economic questions. Data were analysed descriptively, using cross-tabulation with Chi-square and Fisher’s exact tests. RESULTS: Seventy-six individuals participated. The majority had traumatic (64.5%), transtibial amputation (61.8%), were young adults (37.92±12.35 years), in paid work prior to LLA (80%), married (63.2%), male (81.6%), from rural areas (78.9%), with primary/no education (72.4%). After LLA mobility (WHODAS score 74.61±13.19) was their most negatively affected domain. Most (60.5%) did not return to any occupation. Acute healthcare costs negatively impacted most families (89.5%), over 80% becoming impoverished. Nearly 70% of previous income-earners became economically dependent changing traditional family roles. CONCLUSIONS: Following LLA, most participants experienced significant mobility impairment and became economically dependent. The impact of LLA extends beyond the individual, to families who often face challenges to traditional primary earner gendered roles. Improved access to timely and affordable rehabilitation is required to reduce the significant personal and societal costs of disability after LLA.

Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients?

Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants’ demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group’s time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6–20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury.

Targeted rehabilitation may improve patient flow and outcomes: development and implementation of a novel Proactive Rehabilitation Screening (PReS) service

Rehabilitation programmes can be delivered to patients receiving acute care (‘in-reach rehabilitation’) and/or those who have completed acute care but experience ongoing functional impairments (‘subacute rehabilitation’). Access to these programmes depends on a rehabilitation assessment, but there are concerns that referrals for this assessment are often triggered too late in the acute care journey. We describe a Proactive Rehabilitation Screening (PReS) process designed to systematically screen patients during an acute hospital admission, and identify early those who are likely to require specialist rehabilitation assessment and intervention. The process is based on review of patient medical records on day 5 after acute hospital admission, or day 3 after transfer from intensive care to an acute hospital ward. Screening involves brief review of documented care needs, pre-existing and new functional disabilities, the need for allied health interventions and non-medical factors delaying discharge. From May 2017 to February 2019, the novel screening process was implemented as part of a service redesign of the rehabilitation consultation service. Four thousand consecutive screens were performed at the study site. Of those ‘ruled in’ by screening as needing a rehabilitation assessment, 86.0% went on to receive inpatient rehabilitation interventions. Of those ‘ruled out’ by screening, 92.1% did not go on to receive a rehabilitation intervention, while 7.9% did receive some form of rehabilitation intervention. Of all patients accepted into a rehabilitation programme (n=516), PReS was able to identify 53.6% (n=282) of them before the acute care teams made a referral (based on traditional criteria). In conclusion, we have designed and implemented a systematic, PReS service in one metropolitan Australian hospital. The process described was found to be time efficient and feasible to implement in an acute hospital setting. Further, it appeared to identify the majority of patients who went on to receive formal inpatient rehabilitation interventions.

Factors associated with delays in discharge for trauma patients at an urban county hospital

Background

Discharge delays for non-medical reasons put patients at unnecessary risk for hospital-acquired infections, lead to loss of revenue for hospitals and reduce hospital capacity to treat other patients. The objective of this study was to determine prevalence of, and patient characteristics associated with, delays in discharge at an urban county trauma service.

Methods

We performed a retrospective cohort study with data from Zuckerberg San Francisco General Hospital (ZSFGH), a level-1 trauma center and safety net hospital in San Francisco, California. The study included 1720 patients from the trauma surgery service at ZSFGH. A ‘delay in discharge’ was defined as days in the hospital, including an initial overnight stay, after all medical needs had been met. We used logistic and zero-inflated negative binomial regression models to test whether the following factors were associated with prolonged, non-medical length of stay: age, gender, race/ethnicity, housing, disposition location, type of insurance, having a primary care provider, primary language and zip code.

Results

Of the 1720 patients, 15% experienced a delay in discharge, for a total of 1147 days (median 1.5 days/patient). The following were statistically significant (p<0.05) predictors of delays in discharge in a multivariable logistic regression model: older age, unhoused status or disposition to home health or postacute care (compared with home discharge) were associated with increased likelihood of delays. Having private insurance or Medicare (compared with public insurance) and discharge against medical advice or absent without leave (compared with home discharge) were associated with reduced likelihood of delays in discharge after all medical needs were met.

Discussion

These results suggest that policymakers interested in reducing non-medical hospital stays should focus on addressing structural determinants of health, such as lack of housing, bottlenecks at postacute care disposition destinations and lack of adequate insurance.

Level of evidence

Epidemiological, Level III

The utility of emergency department physical therapy and case management consultation in reducing hospital admissions

BACKGROUND

A significant number of patients who present to the emergency department (ED) following a fall or with other injuries require evaluation by a physical therapist. Traditionally, once emergent conditions are excluded in the ED, these patients are admitted to the hospital for evaluation by a physical therapist to determine whether they should be transferred to a sub-acute rehabilitation facility, discharged, require services at home, or require further inpatient care. Case management is typically used in conjunction with a physical therapist to determine eligibility for recommended services and to aid in placement.

OBJECTIVE

To evaluate the benefit of using ED-based physical therapist and case management services in lieu of routine hospital admission.

METHODS

Retrospective, observational study of consecutive patients presenting to an urban, tertiary care academic medical center ED between December 1, 2017, and November 30, 2018, who had a physical therapist consult placed in the ED. We additionally evaluated which of these patients were placed into ED observation for physical therapist consultation, how many required case management, and ED disposition: discharged home from the ED or ED observation with or without services, placed in a rehabilitation facility, or admitted to the hospital.

RESULTS

During the 12-month study period, 1296 patients (2.4% of the total seen in the ED) were assessed by a physical therapist. The mean age was 75.5 ± 15.2 and 832 (64.2%) were female. Case management was involved in 91.8% of these cases. The final patient disposition was as follows: admission 24.3% (95% CI = 22.1-26.7%), home discharge with or without services 47.8% (95% CI = 45.1-50.5%), rehabilitation (rehab) setting 27.9% (95% CI = 25.6%-30.4). The median (interquartile range) time in observation was 13.1 (6.0-20.3), 9.9 (1.8-15.8), and 18.4 (14.1-24.8) hours for patients admitted, discharged home, or sent to rehabilitation (P < 0.001). Among the 979 patients discharged home or sent to rehabilitation, 17 (1.7%) returned to the ED within 72 hours and were ultimately admitted.

CONCLUSION

Given that the standard of care would otherwise be an admission to the hospital for 1 day or more for all patients requiring physical therapist consultation, an ED-based physical therapy and case management system serves as a viable method to substantially decrease hospital admissions and potentially reduce resource use, length of hospital stay, and cost both to patients and the health care system.

An examination of the nature and characteristics of patients readmitted to acute care from inpatient brain injury rehabilitation

AIM

To describe the nature of readmission to acute care and identify patient characteristics associated with avoidable readmission to acute care from inpatient brain injury rehabilitation.

DESIGN

A retrospective cohort design.

METHODS

Data prospectively documented between 1 January 2012 -31 December 2018 in local clinical and administrative database were used. Patient medical records were accessed when missing data were identified. Descriptive statistics were used to describe the nature of readmission episodes and univariate and multivariable logistic regression were used to identify patient characteristics associated with readmission to acute care.

RESULTS

Of the 383 patients admitted for rehabilitation, 83 (22%) experienced readmission to acute care for a total of 171 episodes. Thirty-seven percent of readmission episodes were due to hospital acquired complications and therefore potentially avoidable. Infection accounted for 63% of hospital acquired complications. Patients with an avoidable readmission episode (N = 38) were more likely to have a significantly lower Functional Independence Measure score, be incontinent, have a tracheostomy, require a mobility aid, and be prescribed a dysphagia diet on rehabilitation admission. Patients with a tracheostomy on rehabilitation admission had a 56% probability for an avoidable readmission to acute care.

CONCLUSION

Brain injury rehabilitation patients with an avoidable readmission to acute care were more likely to have a higher burden of care on rehabilitation admission and infection was the leading cause of avoidable readmission episodes.

IMPACT

Research into readmission to acute care in the mixed brain injury inpatient rehabilitation population is limited. In this patient population, readmission to acute care is a contemporary issue that can occur at any time during a patient's rehabilitation admission. This study provides valuable information informing practice change for preventing avoidable readmission episodes. Locally developed policy aimed at preventing readmission episodes should include proactive prevention, early recognition of complications and discrete escalation care pathways.

Predictors of Readmission to Acute Care from Inpatient Rehabilitation: An Integrative Review

Readmission to acute care (RTAC) from inpatient rehabilitation can have negative consequences for individuals and associated financial costs are increasing. Consequently, preventing avoidable RTAC represents a target for improvement in quality of care. The aim of this integrative review was to identify predictors of RTAC from inpatient rehabilitation. A systematic search of MEDLINE, EMBASE, ProQuest, and CINAHL databases was used. Thematic analysis was used to examine extracted data. Strong evidence indicating that the principal predictors of RTAC are lower functional status on admission to rehabilitation, a more severe injury and a higher number of comorbidities was identified in this review. This is despite the heterogeneous nature of impairment groups and factors/measures examined. However, the relevance of some predictors of RTAC (such as patient demographics, invasive devices and primary diagnoses) may be dependent on rehabilitation setting, impairment group or time between rehabilitation admission and RTAC (eg, below 3 vs 30 days). Consequently, findings of this integrative review highlight that RTAC is a complex, multifactorial patient issue with a complex interplay between the predictors and reasons for RTAC. LEVEL OF EVIDENCE: IV.

Predicting discharge placement after elective surgery for lumbar spinal stenosis using machine learning methods

PURPOSE

An excessive amount of total hospitalization is caused by delays due to patients waiting to be placed in a rehabilitation facility or skilled nursing facility (RF/SNF). An accurate preoperative prediction of who would need a RF/SNF place after surgery could reduce costs and allow more efficient organizational planning. We aimed to develop a machine learning algorithm that predicts non-home discharge after elective surgery for lumbar spinal stenosis.

METHODS

We used the American College of Surgeons National Surgical Quality Improvement Program to select patient that underwent elective surgery for lumbar spinal stenosis between 2009 and 2016. The primary outcome measure for the algorithm was non-home discharge. Four machine learning algorithms were developed to predict non-home discharge. Performance of the algorithms was measured with discrimination, calibration, and an overall performance score.

RESULTS

We included 28,600 patients with a median age of 67 (interquartile range 58-74). The non-home discharge rate was 18.2%. Our final model consisted of the following variables: age, sex, body mass index, diabetes, functional status, ASA class, level, fusion, preoperative hematocrit, and preoperative serum creatinine. The neural network was the best model based on discrimination (c-statistic = 0.751), calibration (slope = 0.933; intercept = 0.037), and overall performance (Brier score = 0.131).

CONCLUSIONS

A machine learning algorithm is able to predict discharge placement after surgery for lumbar spinal stenosis with both good discrimination and calibration. Implementing this type of algorithm in clinical practice could avert risks associated with delayed discharge and lower costs. These slides can be retrieved under Electronic Supplementary Material.

A comparison of patients managed in specialist versus non-specialist inpatient rehabilitation units in Australia

Aim: To compare the rehabilitation of patients with brain and spinal cord injury in specialist rehabilitation units and non-specialist rehabilitation units in Australia over a 10-year period.Method: A retrospective cohort study design was used. Epidemiological descriptive analysis was used to examine inpatient rehabilitation data held in the Australasian Rehabilitation Outcomes Centre Registry Database at four discrete time points: 2007, 2010, 2013 and 2016. Data sets included patient demographics, length of stay and the Functional Independence Measure. Data sets were examined for differences between specialist and non-specialist rehabilitation units.Results: Over the 10-year study period, compared to patients admitted to non-specialist rehabilitation units patients admitted to specialist rehabilitation units: (1) were younger and more likely to be male; (2) had a longer time between onset of illness/injury and rehabilitation admission; (3) had a longer median rehabilitation length of stay; (4) had a higher burden of care on admission to rehabilitation; however (5) had a greater functional gain. Patients in specialist rehabilitation units had a lower relative functional efficiency per day of rehabilitation, but higher percentage of Functional Independence Measure gain. In 2016, 66% of brain injury and 51% of spinal cord injury patients were not rehabilitated in specialist rehabilitation units.Conclusion: There are differences in the characteristics of patients admitted to specialist versus non-specialist rehabilitation units. Patients admitted to specialist rehabilitation units have greater functional gain. A noteworthy proportion of brain and spinal cord injury patients are not being rehabilitated in specialist rehabilitation units, particularly patients with non-traumatic injuries.Implications for rehabilitationPatients with a brain or spinal cord injury rehabilitated in specialist rehabilitation units achieve a greater functional gain than those in non-specialist units.Development of best practice admission guidelines would better enable the right care for the right patient in the right setting at the right time.There is a need for longitudinal examination of patient outcomes to better understand the long-term benefits of being rehabilitated in specialist rehabilitation units compared to non-specialist rehabilitation units.

Brain injury rehabilitation after road trauma in new South Wales, Australia - insights from a data linkage study

Background

Population-based patterns of care studies are important for trauma care but conducting them is expensive and resource-intensive. Linkage of routinely collected administrative health data may provide an efficient alternative. The aims of this study are to describe the rehabilitation pathway for trauma survivors and to analyse the brain injury rehabilitation outcomes in the two care settings (specialist brain injury and non-specialist general rehabilitation units).

Methods

This is an observational study using routinely collected registry data (New South Wales Trauma Registry linked with the Australasian Rehabilitation Outcomes Centre Inpatient Dataset). The study cohort includes 268 road trauma patients who were admitted to trauma services between 2009 and 2012 and received inpatient rehabilitation because of a brain injury.

Results

Of those who need inpatient rehabilitation, 62% (n = 166) were admitted to specialist units with the remainder (n = 102) admitted to non-specialist units. Those admitted to a specialist units were younger (p < 0.001), had a lower cognitive FIM score (p = 0.003) on admission than those admitted to non-specialist units. Specialist units achieved better overall FIM score improvements from admission to discharge (43 vs 30 points, p > 0.001) but at a cost of longer length of stay (median 47 vs 24 days, p < 0.001). There were very few discharges to residential aged care facilities from rehabilitation (2% in non-specialist units and none from specialist units). There was a long time lag between trauma and admission to inpatient rehabilitation with only a quarter of the patients admitted to a specialist unit by end of week four. Few older patients (19%) with brain injury were admitted to specialist units.

Conclusions

It is feasible to use routinely collected registry data to monitor inpatient rehabilitation outcomes of trauma care. There were differences in characteristics and outcomes of patients with traumatic brain injury admitted to specialist units compared with non-specialist units.

Trajectories of Functional Change After Inpatient Rehabilitation for Traumatic Brain Injury

OBJECTIVE

To examine trajectories of functional recovery after rehabilitation for traumatic brain injury (TBI).

DESIGN

Prospective study.

SETTING

Inpatient rehabilitation hospitals in the Uniform Data System for Medical Rehabilitation.

PARTICIPANTS

A subset of individuals receiving inpatient rehabilitation services for TBI from 2002 to 2010 who also had postdischarge measurement of functional independence (N=16,583).

INTERVENTIONS

Inpatient rehabilitation.

MAIN OUTCOMES MEASURES

Admission, discharge, and follow-up data were obtained from the Uniform Data System for Medical Rehabilitation. We used latent class mixture models to examine recovery trajectories for both cognitive and motor functioning as measured by the FIM instrument.

RESULTS

Latent class models identified 3 trajectories (low, medium, high) for both cognitive and motor FIM subscales. Factors associated with membership in the low cognition trajectory group included younger age, male sex, racial/ethnic minority, Medicare or Medicaid (vs commercial or other insurance), comorbid conditions, and greater duration from injury date to rehabilitation admission date. Factors associated with membership in the low motor trajectory group included older age, racial/ethnic minority, Medicare or Medicaid coverage, comorbid conditions, open head injury, and greater duration to admission.

CONCLUSIONS

Standard approaches to assessing recovery patterns after TBI obscure differences between subgroups with trajectories that differ from the overall mean. Select demographic and clinical characteristics can help classify patients with TBI into distinct functional recovery trajectories, which can enhance both patient-centered care and quality improvement efforts.

Process of implementing collaborative care and its impacts on the provision of care and rehabilitation services to patients with a moderate or severe traumatic brain injury

Objective

The introduction of new services in a rehabilitation center is a unique opportunity to introduce a new model of care and services between two institutions. A hospital and a rehabilitation center experienced a clinical management model inspired by an American approach – collaborative care. The purpose of this study was to describe the implementation of this approach and to provide a perception of the quality of care and services provided to patients with moderate or severe traumatic brain injury and to their caregivers.

Materials and methods

In this qualitative study, individual semistructured interviews were conducted with patients and their caregivers in the hospital and rehabilitation center where the patients were treated. Individual semistructured interviews were conducted with administrators, and two focus groups were held with clinicians before and after the implementation.

Results and conclusion

Ten days’ waiting time were saved with the collaborative approach. Implementing the collaborative care approach has been found to have several benefits, including improved communication, coordination of services between institutions, and better preparation, awareness, and involvement of patients and their families. Administrators, clinicians, patients, and caregivers expressed their opinions on the organization of care and services, the needs and expectations of patients and their caregivers, their participation in terms of roles and responsibilities, their perception of continuity of care, their satisfaction with the care process, and their suggestions for improvements.

A pilot project of early integrated traumatic brain injury rehabilitation in singapore

Objective. Document acute neurosurgical and rehabilitation parameters of patients of all traumatic brain injury (TBI) severities and determine whether early screening along with very early integrated TBI rehabilitation changes functional outcomes. Methods. Prospective study involving all patients with TBI admitted to a neurosurgical department of a tertiary hospital. They were assessed within 72 hours of admission by the rehabilitation team and received twice weekly rehabilitation reviews. Patients with further rehabilitation needs were then transferred to the attached acute inpatient TBI rehabilitation unit (TREATS) and their functional outcomes were compared against a historical group of patients. Demographic variables, acute neurosurgical characteristics, medical complications, and rehabilitation outcomes were recorded. Results. There were 298 patients screened with an average age of 61.8 ± 19.1 years. The most common etiology was falls (77.5%). Most patients were discharged home directly (67.4%) and 22.8% of patients were in TREATS. The TREATS group functionally improved (P < 0.001). Regression analysis showed by the intervention of TREATS, that there was a statistically significant FIM functional gain of 18.445 points (95% CI −30.388 to −0.6502, P = 0.03). Conclusion. Our study demonstrated important epidemiological data on an unselected cohort of patients with TBI in Singapore and functional improvement in patients who further received inpatient rehabilitation.

Reducing the length of stay for acute hospital patients needing admission into inpatient rehabilitation: a multicentre study of process barriers

BACKGROUND

Patient flow is a major problem in hospitals. Delays in accessing inpatient rehabilitation have not been well studied.

AIMS

Measure the time taken for key processes in the patient journey from acute hospital admission through to inpatient rehabilitation admission in order to identify opportunities for improvement.

METHODS

Retrospective open cohort study. All patients admitted over 8- and 10-month periods during 2008 into two inpatient rehabilitation units in Melbourne, Australia. Main outcome measures were the duration of the following key processes: acute hospital admission until referral for rehabilitation, referral until assessment by the rehabilitation service, assessment until deemed ready for transfer to rehabilitation, ready for transfer until rehabilitation admission.

RESULTS

Three hundred and sixty patients were in the study sample (females = 186; 51.7%); mean age = 58.4 (standard deviation = 15.0) years. There was a median of 7 (interquartile range [IQR] 4-13) days from acute hospital admission till referral for rehabilitation, a median of 1 (IQR 0-1) day from referral till assessment, a median of 0 (IQR 0-2) days from assessment till deemed ready for transfer and a median of 1 (IQR 0-3) day from ready till admission into rehabilitation. Overall, patients spent 12.0% (804/6682) of their acute hospital admission waiting for a rehabilitation bed.

CONCLUSIONS

There are opportunities to improve the efficiency of key processes in the acute hospital journey for patients subsequently admitted to inpatient rehabilitation; in particular, reducing the time from acute hospital admission till referral for rehabilitation and from being deemed ready for transfer to rehabilitation till admission.

Breaking down the barriers! Factors contributing to barrier days in a mature trauma center

BACKGROUND

As we enter the brave new world of the Patient Protection and Affordable Care Act of 2010, it is imperative that trauma centers provide not only excellent but also cost-effective trauma care. To that end, we sought to determine those factors that contribute significantly to barrier days (BDs), when a patient is medically cleared for discharge but unable to leave the hospital. We hypothesized that there would be significant demographic and payor factors associated with BDs.

METHODS

All trauma admissions to a Level II trauma center discharged alive from 2010 to 2012 were queried from the trauma registry. BDs were identified and recorded at daily sign-out. Patients with a hospital length of stay of 24 hours or less or transferred to another hospital were excluded. Univariate logistic regression was used to analyze which factors were significant (p ≤ 0.05) for BDs. Significant variables were then included in a multivariate logistic regression model.

RESULTS

A total of 3,056 patients were included in the study, 105 (3.44%) of whom had at least one BD. Multivariate analysis revealed that patients awaiting nursing home placement and rehabilitation placement were at 6.39 and 2.79 times higher odds of having significant barriers to discharge, respectively, compared with patients who were discharged home. The multivariate model also showed that Medicaid coverage, one or more comorbidities, Injury Severity Score of 9 or greater, and one or more ventilation days had a significant correlation with the incidence of BDs.

CONCLUSION

This study suggests that discharge destination is a significant factor associated with BDs. Understanding what type of patient is prone to develop barriers to discharge will allow case managers and social workers to intervene with discharge planning early in that patient's hospital course to secure placement and possibly reduce health care costs and improve functional outcome.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

What elements of the informational, management, and relational continuity are associated with patient satisfaction with rehabilitation care and global rating change?

OBJECTIVE

To describe the quality of patients' continuity experiences in a population of outpatients receiving postacute rehabilitation care, and to check which elements and types of continuity most strongly determine their satisfaction with care and functional changes.

DESIGN

Cross-sectional self-report survey.

SETTING

Three postacute ambulatory centers in metropolitan areas.

PARTICIPANTS

Outpatients (N=218; mean age ± SD, 38.5±11.7y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The questionnaire included experiences regarding aspects of informational (transference of information, accumulated knowledge), management (consistency and flexibility of care), and relational (established relation and consistency of provider) continuity, as well as questions concerning patients' sociodemographic characteristics, satisfaction with care, and global rating change.

RESULTS

Respondents indicated more problems in terms of management and relational continuity than in informational continuity. For all patient groups, experiences regarding elements of management continuity (R(2)=15.3%-22.4%), followed by relational continuity (R(2)=14.3%-25.2%), explained most of the variance of satisfaction. Consistency and flexibility of care, together with an established relation, were the most determining elements of satisfaction. Experiences regarding elements of management continuity explained most of the variance of change (18.5%), and flexibility was the most decisive element.

CONCLUSIONS

Patient satisfaction and functional changes are related with experiences in aspects of management continuity, where there is room for improvement. Measures of management continuity may be promising as indicators of continuity, and they should be prioritized.

Acute neurorehabilitation versus treatment as usual

Several clinical and government reviews have recommended specialised rehabilitation services for those recovering from neurological insult or neurosurgical intervention. Despite this, provision of 'rapid access'/acute neurorehabilitation units is extremely limited in the UK. In some areas, millions of people have no access to such facilities. Numerous articles have indicated that delayed access to neurorehabilitation in the acute recovery stage may worsen clinical outcomes and increase length of stay for patients. However, there has been a lack of studies directly comparing clinical outcomes between matched samples of patients in acute neurorehabilitation units versus patients receiving treatment-as-usual. In a study believed to be the first of its kind, this paper: (A) Describes the rationale and evidence base for acute neurorehabilitation. (B) Provides a comparison of clinical outcome scores Functional Independence Measure/Functional Assessment Measure (FIM-FAM) and also length of stay times for both of the aforementioned groups. The results show that all outcome areas except the 'communication' domain saw clinically and statistically significant improvements in the acute neurorehabilitation group. Length of stay was significantly reduced in the acute neurorehabilitation group. The case for reviewing the provision of acute neurorehabilitation units is now even more urgent and difficult to ignore.

Wasted Hospital Days Impair the Value of Length-of-Stay Variables in the Quality Assessment of Trauma Care

Hospital length of stay (LOS) is frequently used to evaluate the quality of trauma care but LOS may be impacted by nonmedical factors as well. We reviewed our experience with delays in patient discharge to determine its financial consequences and its impact on LOS. We performed an analysis of linked trauma registry and “delayed discharge” databases. Actual LOS (A-LOS) values were compared with calculated ideal LOS (I-LOS) values, and the per cent increase in LOS was calculated. Linear regression analysis was used to identify significant predictors of prolonged LOS. One thousand, five hundred and seventeen patients were studied, with an A-LOS of 6.54 days. Seven per cent of patients experienced discharge delays, resulting in 580 excess hospital days. Calculated I-LOS was 6.15 days, 6.34 per cent lower than A-LOS. Other I-LOS estimates were as much as 25 per cent lower than A-LOS. Estimated excess patient charges associated with delayed discharges were $4,000,000 to $15,000,000. Discharge delays are an infrequent, although costly, occurrence that has a significant impact on LOS. LOS therefore may not be an appropriate metric for assessing the quality of trauma care, and should only be used if it has been corrected for discharge delays. Concerted efforts should be directed towards identifying and correcting the factors responsible for delayed discharge in trauma patients.

Inappropriate acute neurosurgical bed occupancy and short falls in rehabilitation: implications for the National Service Framework

Patients undergoing neurosurgical intervention may require different types of organized rehabilitation. A prospective study was performed of the care needs of neurosurgical inpatients between the ages of 16 and 70 years who were in acute wards for more than 2 weeks. Only 58% of bed occupancy days were devoted to essential acute neurosurgical ward management. This figure was even lower for patients admitted with subarachnoid haemorrhage (36%) or traumatic brain injury (38%). Overall, 21% of bed days would have more appropriately spent in 'rapid access'/acute rehabilitation beds, 13% in 'active participation' rehabilitation beds and 5% in cognitive/behavioural rehabilitation units. Addressing this unmet need would increase the availability of acute neurosurgery beds, without needing to build and staff more neurosurgery wards.

The burden of hospitalized hip fractures: patterns of admissions in a level I trauma center over 20 years

BACKGROUND

To describe trends over 20 years in (1) number of admissions for hip fracture, (2) patients' demographics, type of fractures sustained by the patients, and their health status at admission, (3) surgical delays, and (4) acute care outcomes.

METHODS

This trend was a study conducted in a Level I trauma center in Quebec, Canada. All patients (n = 3174) aged 65 and older, admitted with a hip fracture between 1985 and 2005 were included. Outcome measures were: number of admissions, age, gender, comorbidities at admission, surgical delays, postsurgical complications, inpatient mortality, discharge destinations.

RESULTS

From 1985 to 2005, the number of admissions increased from 56 to 271, age at admission has increased by 2 years both in men and women (p < 0.01), women/men proportion has remained stable (3.2) over time. The adjusted proportions of minor and severe comorbidities at admission increased by 13% and 5% yearly (p < 0.01). Surgical delays decreased from 4.7 days +/- 16.5 days to 0.9 days +/- 1.9 days (p < 0.01). Acute care length of stay has drastically decreased from 37.0 days +/- 70.9 days to 16.7 days +/- 14.2 days (p < 0.01). Although severe postsurgical complications did not increase over time, the proportion of patients suffering from minor postsurgical complications increased by 22%. Inpatient death has decreased by 4% each year.

CONCLUSION

The tremendous increase in the volume of older and sicker patients admitted for hip fracture has put an enormous demand on our Level I trauma center. The changes in clinical management implemented to face this challenge have helped improve acute care outcomes.