The Impact of Introducing a Physical Medicine and Rehabilitation Trauma Consultation Service to an Academic Level 1 Trauma Center

Expanding Integrated Physiatric Care: A Method to Building Capacity in Physical Medicine and Rehabilitation

ABSTRACT

Siloed and episodic care delivery is often not equitable, high quality, or sustainable. Transitioning from separate care settings, with potentially divergent care models, to an integrated care model is not always straightforward. Some experiences in expanding collaborative care between physiatrists and other healthcare providers for a variety of patient populations and care settings within a university physical medicine and rehabilitation division are shared as a means to inspire the uptake of care integration initiatives more broadly within the specialty. After an initial survey of care integration across multiple clinical sites, the university division highlighted successful integrated care models, discussed integrated care models at every divisional retreat, reached out to clinicians in other specialties to collaboratively explore expansion, developed a "one-pager" on what physiatrists do, and invited collaborative specialists from integrated clinics to physical medicine and rehabilitation national and/or international meetings. Since 2019, divisional activity in integrated care has grown and evolved substantially. Future work will focus on further expansion of integrated clinical care, scholarly evaluation of integrated care models, expansion of academic activity resulting from integration, and advocacy to healthcare providers, hospital administrators, and health system funders about the potential value of care integration in improving rehabilitation outcomes.

Interprofessional interventions that impact collaboration and quality of care across inpatient trauma care continuum: A scoping review

INTRODUCTION

Despite the recognized importance of interprofessional collaboration (IPC) in trauma care, healthcare professionals often work in silos. Interprofessional (IP) interventions are crucial for optimizing IPC and delivering high-quality care across clinical contexts, yet their effectiveness throughout the inpatient trauma care continuum is not well understood. Thus, this review aimed to examine the literature on the effectiveness of IP interventions on collaboration processes and related outcomes in inpatient trauma care.

METHODS

We conducted a scoping review following Joanna Briggs Institute's methodology. We searched six databases for studies from the last decade on IP interventions in inpatient trauma care. Two independent reviewers categorized IP interventions (education, practice, organization) and extracted their impact on IPC processes and related outcomes (team performance, patient, organization).

RESULTS

Of the 17,397 studies screened, 148 met the inclusion criteria. Most were cohort designs (72%), conducted in level I trauma centers (57%) and emergency departments (51%), and involved surgeons (56%) and nurses (53%). Studies focused on IP organization interventions (51%), such as clinical pathways; IP practice interventions (35%), such as trauma team activation protocols; and IP education interventions (14%) including multi-method education. IP practice interventions most effectively improved team performance results, while IP education interventions primarily improved IPC processes. Positive patient outcomes were limited, with few studies examining organizational effects.

CONCLUSIONS

Significant advancements are still required in IP interventions and trauma care research. Future studies should rigorously explore the effectiveness of interventions throughout the inpatient trauma care continuum and focus on developing robust measures for patient and organizational outcomes.

Delayed Diagnosis of Quadriceps Tendon Rupture

Quadriceps tendon (QT) injury classically presents with pain, inability to actively extend the knee, and a palpable defect in the suprapatellar region. Unilateral eccentric contraction and hyperflexion after ground level fall are the most common mechanisms of injury. Delayed QT repair may require additional operative procedures and is associated with poorer post-operative functional outcomes, persistent knee extensor weakness, and decreased range of motion. This report demonstrates a case of delayed diagnosis of QT rupture after a fall with injury to the contralateral extremity. Initial evaluation and X-ray did not reveal the rupture. Six weeks later, after multiple re-admissions to the acute hospital from inpatient rehabilitation for sepsis, Physical Medicine and Rehabilitation (PM&R) was consulted and noted a QT rupture on exam. The rupture was confirmed on MRI and the patient underwent surgery within days. This case demonstrates the value of an interdisciplinary approach and involvement of PM&R throughout the care continuum.

Rehabilitation after musculoskeletal injury: an overview of systems in the United States and Canada

As North America is largely industrialized with a variety of available private transportation options, trauma is a common occurrence, resulting in significant burdens of disability and costs to the health care system. To meet increasing trauma care needs, there is a robust organization of trauma and rehabilitation systems, particularly within the United States and Canada. The American and Canadian health care systems share multiple similarities, including well-equipped Level I trauma centers, specialized inpatient rehabilitation units for polytrauma patients, and thorough evaluations for recovery and post-discharge placement. However, they also have several key differences. In Canada, the criteria for admission to inpatient rehabilitation vary by location, and inpatient rehabilitation is universally accessible, whereas outpatient rehabilitation services are generally not covered by insurance. In the United States, these admission criteria for post-acute inpatient rehabilitation are standardized, and both inpatient and outpatient services are covered by private and government-funded insurance with varying durations. Overall, both health care systems face challenges in post-acute rehabilitation, including benefit limitations and limited provider access in rural areas, and must continue to evolve to meet the rehabilitation needs of injured patients as they reintegrate into their communities.

Perceptions regarding the multidisciplinary treatment of patients with severe trauma in Korea: a survey of trauma specialists

Purpose

Patients with multiple trauma necessitate assistance from a wide range of departments and professions for their successful reintegration into society. Historically, the primary focus of trauma treatment in Korea has been on reducing mortality rates. This study was conducted with the objective of evaluating the current state of multidisciplinary treatment for patients with severe trauma in Korea. Based on the insights of trauma specialists (i.e., medical professionals), we aim to suggest potential improvements.

Methods

An online questionnaire was conducted among 871 surgical specialists who were members of the Korean Society of Traumatology. The questionnaire covered participant demographics, current multidisciplinary practices, perceived challenges in collaboration with rehabilitation, psychiatry, and anesthesiology departments, and the perceived necessity for multidisciplinary treatment.

Results

Out of the 41 hospitals with which participants were affiliated, only nine conducted multidisciplinary meetings or rounds with nonsurgical departments. The process of transferring patients to rehabilitation facilities was not widespread, and delays in these transfers were frequently observed. Financial constraints were identified by the respondents as a significant barrier to multidisciplinary collaboration. Despite these hurdles, the majority of respondents acknowledged the importance of multidisciplinary treatment, especially in relation to rehabilitation, psychiatry, and anesthesiology involvement.

Conclusions

This survey showed that medical staff specializing in trauma care perceive several issues stemming from the absence of a multidisciplinary system for patient-centered care in Korea. There is a need to develop an effective multidisciplinary treatment system to facilitate the recovery of trauma patients.

Management of traumatic brain injury: practical development of a recent proposal

A recent article identified weaknesses in the management of patients with traumatic brain injury (TBI). The authors suggested some reasons but overlooked two of the reasons for the low quality of services: a lack of resources and a systemic failure to organise rehabilitation services. They suggested early involvement of a condition-specific service with a new 'neuroscience clinician' and additional neuro-navigators, but the evidence shows this approach does not work. Their proposal failed to acknowledge the neuroscience skills of existing rehabilitation medicine consultants and teams, and ignored the many non-TBI problems patients will have and the consequent need for expert rehabilitation input. We revise and develop their proposal, suggesting an alternative way to improve services. Rehabilitation teams should work in parallel with acute services and remain responsible for the rehabilitation of patients as they move through different settings. This suggested development of rehabilitation mirrors the development followed by geriatric medicine from 40 years ago.

The Effect of Physiatry Involvement for Patients With Acute Traumatic Spinal Cord Injury at a Level 1 Trauma Center

Objective

To explore the impact of physiatry on acute traumatic spinal cord injury (ATSCI) outcomes using a propensity score matching (PSM) analysis.

Methods

We retrospectively reviewed all patients with ATSCI at a level 1 trauma center from 2018 to 2019. In a 1:1 fashion, we matched patients who were evaluated by physiatry to those who were not. Our PSM analysis controlled for patient demographics, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), comorbidities, mechanism, and presence of a traumatic brain injury (TBI). Outcomes included complications, discharge disposition, and 30-day mortality. Survival analysis was performed using Kaplan-Meier plots.

Results

A total of 102 patients (physiatry 51; no physiatry 51) were matched. Median age was 38 (28-55) years, and median ISS was 25.5 (17-35); 82.4% (n = 84) were male, and 77.5% (n = 79) were bluntly injured. Rates of in-hospital complications were similar between groups. Physiatry involvement was associated with increased odds of discharge to inpatient rehabilitation (odds ratio, 4.6; 95% CI, 2-11.6; p < .001). There was a significant survival benefit seen with physiatry involvement at 30 days (92.6% vs. 78.6%, p = .004) that correlated with a decreased risk of mortality (hazard ratio, 0.2; 95% CI, 0.03-0.7; p = .01).

Conclusion

Incorporating physiatry into the management of patients with ATSCI is associated with improved survival and greater odds of discharge to rehabilitation. In this population, physiatry should be incorporated into the trauma care team to optimize patient outcomes.

Effects of an acute care brain injury medicine continuity consultation service on health care utilization and rehabilitation outcomes

INTRODUCTION

Although general physiatry acute-care consultation services are commonplace and improve length of stay (LOS), the benefits of a subspecialty physiatric continuity consultation service targeting patients with severe brain injury have not been reported.

OBJECTIVES

Our primary objective was to characterize patient care recommendations from a Brain Injury Medicine (BIM) Continuity Consult Service, and to investigate the effects on acute-care LOS relative to brain injury patients receiving General Physical Medicine & Rehabilitation (PM&R) Consult Services. Our secondary objectives were to examine inpatient rehabilitation (IPR) health care utilization metrics and costs between groups and evaluate clinical improvements during IPR and discharge disposition.

DESIGN

Retrospective cohort comparison study.

SETTING

Academic medical center with level 1 trauma center.

PARTICIPANTS

Adults with severe brain injury admitted to a single-site acute-care facility and subsequently admitted to a single inpatient brain injury rehabilitation unit over the same time period.

PHYSIATRIC CARE MODELS

BIM Continuity Consult Service versus General PM&R Consult Service.

MAIN OUTCOME MEASURES

Acute-care LOS; unplanned discharges to acute-care.

RESULTS

Despite no major demographic or clinical group differences, the BIM Consult Service had more patient comorbidities than General PM&R Consult Service (17.5±5.3 versus 16±5.1;P = .04). BIM Consult Service patients spent fewer days in acute care (30±11.8 versus 36±22.8; P = .008), and early BIM consult (≤7 days after admission) was associated with shorter acute-care LOS (P < .002). IPR LOS was similar between groups when considering unplanned transfers. Unplanned transfers among General PM&R Consult Service patients occurred twice as frequently as in BIM Consult Service patients; average readmission costs were $2778 per patient on the BIM Consult Service and $6702 per patient on the General PM&R Consult Service. More BIM Consult Service (85.7%) than General PM&R Consult Service (27.3%) patients emerged from disorders of consciousness during IPR (P = .02).

CONCLUSIONS

BIM Continuity Consultation Services were associated with shorter acute-care LOS, fewer unplanned acute-care transfers, and an increased likelihood of emerging from a minimally conscious state during IPR.

An Evaluation of Age-Based Differences in the Demographic Features and Clinical Outcomes of Trauma Rehabilitation Patients

OBJECTIVE

The aims of the study were to describe potential age-related differences in injury type and mechanism, comorbidities, and physical medicine and rehabilitation-relevant complications in patients admitted after major trauma and to examine whether functional outcomes vary by age group after traumatic injury.

DESIGN

This is a subanalysis of a pre-post study. Individuals admitted to a level 1 trauma center who sustained major trauma were divided into three age groups (young, middle age, and elderly). The demographic, acute care, and rehabilitation factors for these patients were then compared across the three age groups.

RESULTS

Based on an age distribution plot, the age categories were defined as follows: young, 18-39 yrs (n = 120); middle age, 40-64 yrs (n = 124); and elderly, 65 yrs or older (n = 85). Patients 65 yrs or older demonstrated a greater frequency of comorbidities (P < 0.001) and complications (P < 0.001). For individuals admitted to inpatient rehabilitation, admission and discharge functional independence measure scores were lower for the elderly individuals, but functional independence measure change was not significantly different between groups.

CONCLUSIONS

Although the elderly trauma patient demonstrates important differences from the younger one, capacity for improvement with rehabilitation seems similar.