Validity of the Early Functional Ability scale (EFA) among critically ill patients undergoing early neurological rehabilitation

Rehabilitation outcomes after comprehensive post-acute inpatient rehabilitation following moderate to severe acquired brain injury-study protocol for an overall prognosis study based on routinely collected health data

BACKGROUND

The initial theme of the PROGRESS framework for prognosis research is termed overall prognosis research. Its aim is to describe the most likely course of health conditions in the context of current care. These average group-level prognoses may be used to inform patients, health policies, trial designs, or further prognosis research. Acquired brain injury, such as stroke, traumatic brain injury or encephalopathy, is a major cause of disability and functional limitations, worldwide. Rehabilitation aims to maximize independent functioning and meaningful participation in society post-injury. While some observational studies can allow for an inference of the overall prognosis of the level of independent functioning, the context for the provision of rehabilitation is rarely described. The aim of this protocol is to provide a detailed account of the clinical context to aid the interpretation of our upcoming overall prognosis study.

METHODS

The study will occur at a Danish post-acute inpatient rehabilitation facility providing specialised inpatient rehabilitation for individuals with moderate to severe acquired brain injury. Routinely collected electronic health data will be extracted from the healthcare provider's database and deterministically linked on an individual level to construct the study cohort. The study period spans from March 2011 to December 2022. Four outcomes will measure the level of functioning. Rehabilitation needs will also be described. Outcomes and rehabilitation needs will be described for the entire cohort, across rehabilitation complexity levels and stratified for relevant demographic and clinical parameters. Descriptive statistics will be used to estimate average prognoses for the level of functioning at discharge from post-acute rehabilitation. The patterns of missing data will be investigated.

DISCUSSION

This protocol is intended to provide transparency in our upcoming study based on routinely collected clinical data. It will aid in the interpretation of the overall prognosis estimates within the context of our current clinical practice and the assessment of potential sources of bias independently.

Development and Effect Evaluation of an Action-Oriented Interdisciplinary Weaning Protocol for Cuffed Tracheostomy Tubes in Patients with Acquired Brain Injury

The objective was to develop an interdisciplinary weaning protocol (IWP) for patients with tracheostomy tubes due to acquired brain injury, and to effect evaluate implementation of the IWP on decannulation rates and weaning duration. An expert panel completed a literature review in 2018 to identify essential criteria in the weaning process. Based on consensus and availability in clinical practice, criteria for guiding the weaning process were included in the protocol. Using the IWP, dysphagia is graded as either severe, moderate, or mild. The weaning process is guided through a protocol which specified the daily duration of cuff deflation until decannulation, along with recommendations for treatment and rehabilitation interventions. Data from 337 patient records (161 before and 176 after implementation) were included for effect evaluation. Decannulation rate during hospitalization was unchanged at 91% vs. 90% before and after implementation (decannulation rate at 60 days was 68% vs. 74%). After implementation, the weaning duration had decreased compared to before implementation, hazard ratio 1.309 (95%CI: 1.013; 1.693), without any increased risk of tube-reinsertion or pneumonia. Furthermore, a tendency toward decreased length of stay was seen with median 102 days (IQR: 73-138) and median 90 days (IQR: 58-119) (p = 0.061) before and after implementation, respectively. Scientific debate on weaning protocols for tracheostomy tubes are encouraged.

Subacute prognosis of oral nutrition (SPOON): Development of a multivariable prognostic model for complete oral intake in tube-fed subjects with acquired brain injury

BACKGROUND & AIMS

Enteral feeding is very common following an acquired brain injury. However, no prognostic models for oral food intake have been developed for subacute rehabilitation. The aim of this study was to develop a prognostic model and online tool, coined "subacute prognosis of oral nutrition" (SPOON), for complete oral intake in tube-fed subjects with acquired brain injury.

METHODS

The model was developed using routinely gathered clinical data from a cohort of 1233 adult patients who were tube-fed at admission for sub-acute inpatient rehabilitation. Candidate predictors were included based on scientific evidence and their availability in the medical records within the first days following admission. The outcome was time until achieving complete oral food intake without any tube-feeding supplements. Time until complete oral intake was analyzed by discrete time-to-event analysis with logit-link and presented as daily odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

The following predictors of complete oral intake were included in the model: age, diagnosis, cuffed tracheostomy tube, days from injury to admission for rehabilitation, and the Early Functional Abilities (EFA) sum score. Multiple adjusted analyses were performed stratified by cuffed tracheostomy tube status. Some of the strongest predictors of complete oral intake were age 18-40 years, OR 1.99 (95%CI: 1.53; 2.59); 0-2 weeks since injury, OR 3.75 (95%CI: 2.72; 5.16); and EFA 61-100 (slight/no disturbance in function), OR 5.81 (95%CI: 4.47; 7.55). The online prognostic tool SPOON was evaluated in a usability study. Based on feedback from clinicians, the tool was further refined to enable extraction of data for prediction directly from medical records.

CONCLUSIONS

The objective of SPOON is to complement the planning of rehabilitation initiatives and inform discussions to determine if a percutaneous endoscopic gastrostomy (PEG) tube should be inserted. SPOON is being implemented locally, but external validation based on appropriate data modeling is warranted before further clinical implementation.