Predictors of readmission to acute care during inpatient rehabilitation for non-traumatic spinal cord injury

Frequency and Characteristics of Medical Complications in Rehabilitation Settings: A Scoping Review

OBJECTIVE

To synthesize the available evidence on medical complications occurring in adult patients in subacute inpatient rehabilitation, and to describe the impact on subacute length of stay and readmission to acute care.

DESIGN

Scoping review.

SUBJECTS

Adult patients, within the inpatient rehabilitation environment, who experienced medical complications, clinical deterioration and/or the requirement of transfer to acute care.

METHODS

A systematic search of MEDLINE and CINAHL electronic databases was undertaken to identify primary research studies published in English and French during the period 2000-2021. Study reporting followed the standards indicated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist (PRISMA-ScR).

RESULTS

A total of 47 studies were identified for inclusion. Key results included differences in the type and frequency of complications according to admission type, the proportion of patients experiencing at least 1 complication, and complications associated with transfer to acute care.

CONCLUSION

Patients admitted for inpatient rehabilitation are at high risk of medical complications and may not be medically stable during their admission, requiring care by clinicians with expertise in functional rehabilitation, and ongoing management by members of the multidisciplinary team with expertise in acute general medicine, infectious diseases and recognition and response to clinical deterioration.

Effect of Comprehensive Nursing on Traumatic Paraplegia Patients by Evaluation of Magnetic Resonance Imaging Features

This research aimed to discuss the comprehensive nursing under the Omaha system in the treatment of patients with traumatic paraplegia (TP) and the changes in magnetic resonance imaging (MRI) features of patients. In total, 60 patients with TP were included as the research objects, and they were randomly divided into the experimental group (Omaha system-based comprehensive nursing) and the control group (routine nursing). All the objects underwent parallel MRI multisequence scanning. The scores of the quality of life, role change, mental health, care, oral hygiene, skin, neuromusculoskeletal (NMS) system, defecation function, urination function, contagion/infection, nutrition, healthcare supervision, and rest/sleep pattern in the experimental group were all significantly higher than those in the control group 3 months and 6 months after discharge (P < 0.05). The caregiving burden scores in the experimental group 3 months and 6 months after discharge from the hospital were 48.67 ± 6.97 and 43.40 ± 4.97, respectively, statistically lower than those in the control group (52.83 ± 6.37; 50.07 ± 7.14) (P < 0.05). On admission, MRI showed that the white lines disappeared from the compression of the dural sac, the spinal cord was compressed, and the intramedullary signal was abnormal. Then, six months after discharge, MRI showed that the compression of the dural sac was relieved, and the double white lines recovered. The apparent diffusion coefficient (ADC) of patients in the experimental group 6 months after discharge (1.063 ± 0.148) was highly lower than that in the control group (1.325 ± 0.245), with a difference of statistical significance (P < 0.05). In conclusion, comprehensive nursing under the Omaha system could improve the clinical treatment effect of patients with spinal cord injury (SCI) effectively, reduce the incidence of complications, and improve the quality of life and nursing outcomes of patients.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation After Stroke

OBJECTIVE

The aim of the study was to identify causes for readmission to acute care of patients admitted to inpatient rehabilitation facility after stroke.

DESIGN

The institutional Uniform Data System for Medical Rehabilitation database was used to identify stroke patients who experienced readmission to acute care and an equal number of age-/sex-matched group of patients who successfully completed their inpatient rehabilitation facility stay during 2005-2018. Retrospective chart review was used to extract clinical data. The two study groups were compared using univariate and multivariate analyses.

RESULTS

The rate of readmission to acute care was 4.7% (n = 89; age = 65 ± 14 yrs; 37% female; 65% White; 73% ischemic stroke). The most common indications for transfer were neurological (31%) and cardiovascular (28%). Compared with control group, the readmission to acute care group had statistically higher rates of comorbid conditions, lower median (interquartile range) Functional Independence Measure score on inpatient rehabilitation facility admission (55 [37-65] vs. 64 [51-78], P < 0.001), and a higher rate of sedative/hypnotic prescription (82% vs. 23%, P < 0.001).

CONCLUSIONS

Readmission to acute care is not common in our cohort. Patients who experienced readmission to acute care had higher medical complexity and were prescribed more sedative/hypnotic medications than the control group. Practitioners should be vigilant in patients who meet these criteria.

Neuromuscular rehabilitation interventions and COVID-19 management in a case of incomplete paraplegia with neurogenic bladder, post T3-T5 ependymoma

Spinal ependymomas are a group of mostly slow-growing tumors that can cause non-traumatic spinal cord injury with insidious clinical symptomatology ranging from neck or back pain to as-sociated sensory-motor impairment. Due to their neurological and systemic frailty, patients with spinal cord injury might be especially vulnerable to the effects of SARS-CoV-2 infection and the resulting respiratory impairment. CASE PRESENTATION: We present the case of a 66 year old women admitted in our Neuromuscular Rehabilitation Clinic Division for severe in-complete paraplegia and neurogenic bladder. She was previously diagnosed in the Neurosurgi-cal Ward with a thoracic grade II (classic) ependymoma and underwent a gross tumor resection. During the neurorehabilitation program the patient was diagnosed with COVID-19. The multi-drug related treatments were associated with supportive oxygen therapy and neuromuscular and respiratory rehabilitation techniques. RESULTS: Despite of the patient’s favorable rehabili-tation, consisting of walking abilities with support in a walking frame on short distances, her prognosis may be worsened by resting neurogenic bladder symptoms. COVID-19 has led to im-portant acute respiratory morbidity in our patient, regardless of the mild course of the disease, and might further cause a post-infectious respiratory impairment. ONCLUSION: Spinal cord in-jury remains a life-long condition and emphasizes the necessity of supporting the affected pati-ents on the long run. Keywords: students, balance, postural stability, physical exercise, progress, motor skills

Acute inpatient rehabilitation improves function independent of comorbidities in medically complex patients

Objectives

(1) To evaluate the benefits of acute inpatient rehabilitation for a medically complex patient population and (2) to assess the effect of comorbid conditions on rehabilitation outcomes.

Design

Retrospective cohort study.

Setting

Freestanding inpatient rehabilitation facility.

Participants

A total of 270 medically complex adult patients including those with cardiac, pulmonary, and orthopedic conditions, with mean age of 73.6 years; 52.6% were female and 47.4% were male (N=270).

Interventions

Not applicable.

Main Outcome Measures

Functional Independence Measure (FIM) gain, FIM efficiency, rehabilitation length of stay (RLOS), home discharge rate, and readmission to acute care (RTAC).

Results

Among 270 medically complex patients, mean total FIM gain, mean RLOS, and mean FIM efficiency with SD were 26.0±13.6 points, 12.6±5.9 days, and 2.3±1.6, respectively. A total of 71.9% of patients were discharged to home, 12.2% for RTAC, and 15.9% to a skilled nursing facility (SNF). Hypertension (HTN) was the only comorbidity significantly associated with FIM gain (53.7% [total FIM gain ≥27] vs 67.2% [total FIM gain <27]; P=.024) and FIM efficiency (53.3% [FIM efficiency ≥2.12] vs 67.4% [FIM efficiency <2.12]; P=.025), independent of age, body mass index, sex, race, ethnicity, insurance type, and Charlson Comorbidity Index. The 5 most common reasons for RTAC were cardiac, pulmonary, acute blood loss anemia, infection, and neurologic conditions.

Conclusions

Among 270 medically complex patients, 71.9% were discharged to home, 15.9% to an SNF, and 12.2% for RTAC with a mean RLOS 12.6 days, mean total FIM gain of 26 points, and mean FIM efficiency of 2.3, which were all better than those of all admissions at our facility in 2018. Furthermore, RLOS, total FIM gain and FIM efficiency in this study were all better than their corresponding eRehabData weighted national benchmarks (RLOS, 15.82 days; FIM gain, 25.57; FIM efficiency, 2.13) for a total of 202,520 discharges in 2018. These findings support acute inpatient rehabilitation for this patient population. With the exception of HTN, no medical comorbidities or demographic variables were associated with rehabilitation outcomes.

Retrospective study of functional outcomes and disability after non-ischaemic vascular causes of spinal cord dysfunction

Objective: Describe demographic characteristics, functional outcomes and disability following rehabilitation for non-ischemic vascular spinal cord dysfunction (SCDys).Design: Retrospective, open cohort, case series.Setting: Tertiary rehabilitation unit, Victoria, Australia.Participants: Patients with non-ischemic vascular SCDys admitted over a 21-year-period (01/01/1995-31/12/2015) were identified using International Classification of Diseases codes.Outcome Measures: Demographic characteristics, etiology, neurologic classification, length of stay (LOS), and complications. On admission and discharge, the following were collected: functional independence measure (FIM) motor subscale, details on bowel, bladder, mobility, living arrangement, and support services.Results: 36 patients (female 58%; mean age 69 ± 16 years) were identified. The main causes of non-ischemic vascular SCDys were epidural hematoma (39%), dural arteriovenous fistula (17%), and arteriovenous malformation (11%). 22 cases (61%) were iatrogenic. Most (86%) had incomplete paraplegia. Urinary tract infection was the most common complication (64%). Median LOS in rehabilitation was 68 days. Significant improvement in FIM motor scores was observed from admission (median 25, interquartile range [IQR] 20-38) to discharge (median 69, IQR 38-77) (P < 0.001). On discharge, 4 patients (11%) walked >100 m unaided, 6 (17%) walked >100 m with assistive device, 10 (28%) walked >10 m with assistive device, 15 (41%) were wheelchair dependent and 1 (3%) patient remained non-mobile. 20 patients (56%) were discharged home, 8 (22%) to nursing home, and 8 (22%) transferred to another hospital.Conclusion: Most patients returned home with significantly improved functional outcomes compared to rehabilitation admission, but with the majority having ongoing major disabilities based on FIM motor scores.

Risk of Hospital Readmission among Older Patients Discharged from the Rehabilitation Unit in a Rural Community Hospital: A Retrospective Cohort Study

Rehabilitation for hospitalized older people can improve their independence for performing activities of daily living (ADL), but determining its appropriateness can be challenging because of inherent limitations in their ADL and short life expectancy. Thus, we aimed to clarify the benefit of rehabilitation among older Japanese patients. We retrospectively evaluated consecutive older patients (age > 65 years) admitted to the rehabilitation unit of a rural community hospital between 1 April 2016 and 31 March 2020. The primary outcome measure was readmission for acute conditions. Of the 732 patients evaluated, 311 patients (42.5%) were readmitted. Readmission was significantly associated with body mass index (BMI) (p < 0.001), dependent condition (p < 0.001), higher cognitive domain scores in the functional independence measure (FIM) (p = 0.019), and polypharmacy (p = 0.026). The most frequent cause of readmission was pyelonephritis (11.9%), followed by pneumonia (10.9%), compression fracture (10.6%), heat stroke (8.4%), and cerebral stroke (8.0%). In conclusion, older Japanese patients discharged from rehabilitation units have lower readmission rates than those previously reported. Thus, better nutritional control, a multidisciplinary approach to the management of cognitive dysfunction, and a decrease in polypharmacy could be associated with improved outcomes among discharged older patients.

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 unplanned readmission to acute care from inpatient brain injury rehabilitation

AIMS AND OBJECTIVES

To identify the predictors of unplanned readmission to acute care (RTAC) from inpatient brain injury rehabilitation and to develop a risk prediction model.

BACKGROUND

RTAC from inpatient rehabilitation is not uncommon. Individual rehabilitation patient populations require their own body of evidence regarding predictors of RTAC.

DESIGN

Retrospective cohort study.

METHODS

Adult patients with new onset acquired brain injury admitted to a stand-alone rehabilitation facility between 1 January 2012-31 December 2018 were included in the study. The main measures were RTAC, sensitivity, specificity, the C-statistic and Youden's index. This paper is reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

RESULTS

Of 383 patients admitted for rehabilitation, 83 (22%) experienced a RTAC; 69 (18%) patients had at least one unplanned RTAC episode. Patients requiring unplanned RTAC were more likely to have lower Glasgow Coma Scale (GCS) and Functional Independence Measure (FIM) scores on rehabilitation admission, a higher burden of care on rehabilitation discharge and be discharged to a nonhome residence. Rehabilitation admission GCS and motor FIM were identified as the independent RTAC predictors in multivariate regression modelling. The combined C-statistic was 0.86. A GCS cut-off score of ≤14 and motor FIM cut-off score of ≤40 were identified as optimal, yielding a combined Youden's index of 0.56 (sensitivity = 0.72; specificity = 0.83).

CONCLUSION

Patients requiring an unplanned RTAC had a lower functional status on rehabilitation admission. A prediction model for unplanned RTAC has been developed using validated and readily available clinical measures.

RELEVANCE TO CLINICAL PRACTICE

The developed RTAC risk prediction model is the first step in preventing unplanned RTAC from inpatient brain injury rehabilitation. Future research should focus on discrete interventions for preventing unplanned RTAC from inpatient brain injury rehabilitation.

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.