Acute Rehospitalizations During Inpatient Rehabilitation for Spinal Cord Injury

Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study

INTRODUCTION

Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population.

OBJECTIVE

To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility.

DESIGN

Retrospective cohort study.

SETTING

An acute rehabilitation hospital associated with a community-based tertiary medical center.

PATIENTS

A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022.

MAIN OUTCOME MEASURE

The study outcome measure was readmission to acute care from an acute rehabilitation unit.

RESULTS

Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006).

CONCLUSIONS

This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

The primary and secondary causes of hospitalizations during the first five years after spinal cord injury

STUDY DESIGN

Cohort study. Retrospective analysis of uniform billing discharge data (UB-04).

OBJECTIVES

To compare and contrast the primary and secondary causes of hospitalization by type of admission, emergency department (ED) versus inpatient only (IP), during the first five years after the traumatic spinal cord injury (SCI).

SETTING

Academic Medical University in the Southeastern USA.

METHODS

At total of 2569 adults with traumatic SCI were identified from a population-based registry and matched to billing data. The main outcome measures were primary and secondary diagnoses associated with hospital admissions in non-federal, state hospitals.

RESULTS

Overall, there were 9733 hospital admissions in the five years after SCI onset, not including the initial hospitalization; 53% were admissions through the ED. The primary causes of hospitalizations after SCI varied by year post injury and admission type (ED versus IP). The top 15 secondary diagnoses included several secondary health conditions associated with SCI, as well as chronic health conditions.

CONCLUSIONS

Rehabilitation diagnoses were much more prominent during the first year, compared with subsequent years. Septicemia was the leading cause of admissions through the ED, whereas chronic ulcers of the skin were prominent for IP only admissions. This is consistent with the acute nature of septicemia compared with more planned hospitalization for rehabilitation and skin ulcers. These conditions should be targeted for prevention strategies that include patient/family education and early and appropriate access to primary care.

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.

Long-term rehabilitation reduces task error variability in cervical spinal cord contused rats

To promote skilled forelimb function following a spinal cord injury, we have evaluated whether long-term voluntary sensorimotor rehabilitation can promote substantial reaching and grasping recovery. Long-Evans rats were trained to reach single pellets and then received a moderate 100 kdyn contusion to the C5 lateral funiculi. During the first eight months post-injury, a group of animals was enrolled in daily skilled reaching rehabilitation consisting of grabbing and manipulating seeds from the bottom of a grid. Single-pellet reaching and grasping recovery was tested biweekly throughout the functional follow-up and the recovery was compared to a second group of contused but non-rehabilitated animals. Following the injury, reaching and grasping success dropped to zero in both groups and remained absent for three months post-injury, followed by a slight recovery that remained constant until the end of the follow-up. No differences in reaching success were found between groups. Nevertheless, the type of gesture errors in the failed attempts were categorized and scored. The errors ranged from the animal's inability to lift the paw and initiate the movement to the final stage of the attempt, in which the pellet falls during grasping and retraction of the paw towards the mouth. Both groups of animals exhibited similar types of errors but the animals with rehabilitation showed less error variability and those that occurred at the latest stages of the attempt predominated compared to those performed by the non-trained animals. Histological examination of the injury showed that injury severity was similar between groups and that the damage was circumscribed to the site of impact, affecting mainly the dorsal and medial region of the lateral funiculi, with preservation of the dorsal component of the corticospinal tract and the interneurons and motoneurons of the spinal segments beyond the site of injury. The results indicate that activity-dependent plasticity driven by voluntary rehabilitation decreases task error variability and drives the recovery of the movement gestures. However, the plasticity achieved is insufficient to attain full functional recovery to successfully reach, grasp and release the pellets in the mouth, indicating the necessity for additional interventional therapies to promote repair.

Factors associated with unplanned transfers among cancer patients at a freestanding acute rehabilitation facility

BACKGROUND

Cancer patients undergoing inpatient rehabilitation often have high risk of complications leading to unplanned transfer to acute care. Prior studies have identified factors associated with these transfers but have been limited to examining factors that pertain to initial admission to rehabilitation and were not conducted in a freestanding inpatient rehabilitation facility.

OBJECTIVE

The study aimed to include these prerehabilitation factors in addition to factors upon initial assessment in rehabilitation. It was hypothesized that specific factors from each of these periods would be associated with unplanned transfer to acute care.

DESIGN

Retrospective cohort study.

SETTING

Freestanding academic inpatient rehabilitation facility affiliated with an academic tertiary care facility with a comprehensive cancer center.

PATIENTS

Retrospective review of 330 specific encounters unique to 250 patients from March 2017 to September 2018.

MAIN OUTCOME MEASURES

The outcome measure was unplanned transfer to acute care. A binary logistic regression model was used to examine the relationship between factors from oncologic history, acute care course, and factors upon admission to rehabilitation to unplanned transfer to acute care.

RESULTS

From 330 encounters, there were 111 unplanned transfers (34%). Unplanned transfer to acute care was independently associated with gastrointestinal malignancy (odds ratio [OR] 4.4, p = .01), 6-minute walk test less than 90 m (OR 4.6, p = .003), and prior unplanned transfer (OR 3.5, p = .007).

CONCLUSIONS

The study suggests that oncologic and functional prerehabilitation markers are associated with an increased likelihood of unplanned transfer during inpatient cancer rehabilitation. These findings will provide a framework for creating predictive tools for unplanned transfers in cancer rehabilitation patients.

Natural History of Isolated Below-Knee Vein Thrombosis in Patients with Spinal Cord Injury

In the general population, serial imaging is recommended over anticoagulant therapy for below-knee deep vein thrombosis (BKDVT). However, no clinical trial in Asian patients with spinal cord injury and BKDVT has been performed. Therefore, we evaluated the natural course of BKDVT in patients with acute spinal cord injury. We retrospectively analyzed inpatients with spinal cord injury with BKDVT between 2016 and 2020. All patients underwent inpatient rehabilitation treatment and duplex ultrasonographic examination of both the lower extremities at follow-up. After screening 172 patients with acute spinal cord injury for deep vein thrombosis using duplex ultrasound, 27 patients with below-the-knee deep vein thrombosis were included in this study. The mean lower-extremity motor score (median, interquartile range) was 66.0, 54.0-74.5. Sixteen patients received a non-vitamin K antagonist oral anticoagulant (NOAC) for anticoagulation. None of the patients had proximal propagation according to the follow-up duplex ultrasonography. BKDVT disappearance was not significantly different between the NOAC treatment and non-treatment groups. Asian patients with spinal cord injury have a low incidence of venous thromboembolism and favorable natural history of BKDVT. We recommend serial imaging over anticoagulant therapy for BKDVT in these patients.

Serum albumin as a predictor of neurological recovery after spinal cord injury: a replication study

STUDY DESIGN

This was a secondary analysis on an observational cohort study.

OBJECTIVE

To determine if serum albumin significantly associates with long-term neurological outcome (i.e., 1-year post-injury) in a contemporary cohort of individuals with spinal cord injury.

SETTING

Six rehabilitation centers across the United States.

METHODS

A secondary analysis of neurological outcomes and serum albumin concentrations was performed on data from the Spinal Cord Injury Rehabilitation study. Data was accessed from the Archive of Data on Disability to Enable Policy and research (ADDEP). The primary analysis applied unbiased recursive partitioning to examine the relationship between serum albumin, injury severity, and long-term outcomes. The analysis is accessible via https://rpubs.com/AnhKhoaVo/586028 .

RESULTS

Serum albumin concentration was significantly associated with lower extremity motor scores (LEMS) and American Spinal Injury Association Impairment Scale (AIS) grade at admission to rehabilitation. Serum albumin concentrations alone were also significantly associated with change of LEMS and marked recovery (improvement of at least 2 AIS grades and/or recovery to walking) at 1-year post injury. However, after adjusting for admission to rehabilitation LEMS and AIS grade, serum albumin was not significant.

CONCLUSION

The current study partially confirms our previous observations that serum albumin concentrations are associated with neurological outcome after spinal cord injury. As a crude prognostic biomarker, serum albumin concentration could be useful in cases where injury severity cannot be accurately assessed.

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.

Assessing the Ability of Comorbidity Indexes to Capture Comorbid Disease in the Inpatient Rehabilitation Spinal Cord Injury Population

OBJECTIVE

To examine whether commonly used comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, the Centers for Medicare and Medicaid Services [CMS] comorbidity tiers) capture comorbidities in the acute traumatic and nontraumatic SCI inpatient rehabilitation population.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Data were obtained from the Uniform Data System for Medical Rehabilitation from October 1, 2015 to December 31, 2017 for adults with spinal cord injury (SCI) (Medicare-established Impairment Group Codes 04.110-04.230, 14.1, 14.3). This study included SCI discharges (N=66,235) from 833 inpatient rehabilitation facilities.

MAIN OUTCOME MEASURES

International Classification of Diseases-10th Revision-Clinical Modifications (ICD-10-CM) codes were used to assess 3 comorbidity indexes (Deyo-Charlson comorbidity index, Elixhauser comorbidity index, CMS comorbidity tiers). The comorbidity codes that occurred with >1% frequency were reported. The percentages of discharges for which no comorbidities were captured by each comorbidity index were calculated.

RESULTS

Of the total study population, 39,285 (59.3%) were men and 11,476 (17.3%) were tetraplegic. The mean number of comorbidities was 14.7. There were 13,939 distinct ICD-10-CM comorbidity codes. There were 237 comorbidities that occurred with >1% frequency. The Deyo-Charlson comorbidity index, Elixhauser comorbidity index, and the CMS tiers did not capture comorbidities of 58.4% (95% confidence interval, 58.08%-58.84%), 29.4% (29.07%-29.76%), and 66.1% (65.73%-66.46%) of the discharges in our study, respectively, and 28.8% (28.42%-29.11%) of the discharges did not have any comorbidities captured by any of the comorbidity indexes.

CONCLUSION

Commonly used comorbidity indexes do not reflect the extent of comorbid disease in the SCI rehabilitation population. This work suggests that alternative measures may be needed to capture the complexity of this population.

Inpatient Rehabilitation Delirium Screening: Impact on Acute Care Transfers and Functional Outcomes

BACKGROUND

Delirium is well studied in the acute care setting, but there is limited understanding of its impact in the postacute care setting, particularly in the inpatient rehabilitation facility (IRF).

OBJECTIVE

To investigate the prevalence and related outcomes of delirium in the IRF setting, particularly patients' transfers to acute care hospitals.

DESIGN

Retrospective cohort study.

SETTING

A freestanding IRF.

PARTICIPANTS

Patients discharged from an IRF between January 2016 and December 2016 (12 months).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Transfer to acute care hospitals, motor and cognitive Functional Independence Measures (FIM), length of stay, discharge disposition.

RESULTS

A total of 1567 patients (53.9% female, mean age 72.9 ± 13.9) were included in the analysis. Positive scores were found among 142 (9.1%) patients on a 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM), indicating delirium on admission. Fifty-nine (3.8%) were unscorable on 3D-CAM. Twice as many delirium patients were transferred to acute care hospitals compared to non-delirium patients (22.5% vs. 10.8%, P < .001). Multivariate logistic regression showed that, for patients with 3D-CAM positive scores, there was an increased risk of transfers to acute care hospitals at an odds ratio of 1.61 (1.03-2.53, P = .04) after adjusting for age, gender, neurological diagnosis, and motor FIM score. The delirium group also showed lower gains in motor function, increased lengths of stay, and reduced discharges to home when compared to the non-delirium group (P < .001).

CONCLUSIONS

This study finds that delirium on admission to an IRF is associated with worsened outcomes related to function, length of stay, discharge status, and transfer to acute care hospitals. Positive delirium screening is an independent predictor for transfer to acute care hospitals from an IRF. Early identification of delirium is recommended in order to mitigate preventable transfers.

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.

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.

Investigating neurogenic bowel in experimental spinal cord injury: where to begin?

The devastating losses following traumatic spinal cord injury (SCI) encompass the motor, sensory and autonomic nervous systems. Neurogenic bowel is a slow transit colonic dysfunction marked by constipation, rectal evacuation difficulties, decreased anorectal sensation, fecal incontinence or some combination thereof. Furthermore, neurogenic bowel is one of the most prevalent comorbidities of SCI and is recognized by afflicted individuals and caregivers as a lifelong physical and psychological challenge that profoundly affects quality of life. The restoration of post-injury control of movement has received considerable scientific scrutiny yet the daily necessity of voiding the bowel and bladder remains critically under-investigated. Subsequently, physicians and caregivers are rarely presented with consistent, evidence-based strategies to successfully address the consequences of dysregulated voiding reflexes. Neurogenic bowel is commonly believed to result from the interruption of the supraspinal control of the spinal autonomic circuits regulating the colon. In this mini-review, we discuss the clinical challenges presented by neurogenic bowel and emerging pre-clinical evidence that is revealing that SCI also initiates functional remodeling of the colonic wall concurrent with a decrease in local enteric neurons. Since the enteric input to the colonic smooth muscle is the final common pathway for functional contractions of the colon, changes to the neuromuscular interface must first be understood in order to maximize the efficacy of therapeutic interventions targeting colonic dysfunction following SCI.

Functional status predicts acute care readmission in the traumatic spinal cord injury population

CONTEXT/OBJECTIVE

Acute care readmission has been identified as an important marker of healthcare quality. Most previous models assessing risk prediction of readmission incorporate variables for medical comorbidity. We hypothesized that functional status is a more robust predictor of readmission in the spinal cord injury population than medical comorbidities.

DESIGN

Retrospective cross-sectional analysis.

SETTING

Inpatient rehabilitation facilities, Uniform Data System for Medical Rehabilitation data from 2002 to 2012.

PARTICIPANTS

traumatic spinal cord injury patients.

OUTCOME MEASURES

A logistic regression model for predicting acute care readmission based on demographic variables and functional status (Functional Model) was compared with models incorporating demographics, functional status, and medical comorbidities (Functional-Plus) or models including demographics and medical comorbidities (Demographic-Comorbidity). The primary outcomes were 3- and 30-day readmission, and the primary measure of model performance was the c-statistic.

RESULTS

There were a total of 68,395 patients with 1,469 (2.15%) readmitted at 3 days and 7,081 (10.35%) readmitted at 30 days. The c-statistics for the Functional Model were 0.703 and 0.654 for 3 and 30 days. The Functional Model outperformed Demographic-Comorbidity models at 3 days (c-statistic difference: 0.066-0.096) and outperformed two of the three Demographic-Comorbidity models at 30 days (c-statistic difference: 0.029-0.056). The Functional-Plus models exhibited negligible improvements (0.002-0.010) in model performance compared to the Functional models.

CONCLUSION

Readmissions are used as a marker of hospital performance. Function-based readmission models in the spinal cord injury population outperform models incorporating medical comorbidities. Readmission risk models for this population would benefit from the inclusion of functional status.

Perceived readiness for hospital discharge: Patients with spinal cord injury versus physiotherapists

BACKGROUND

Successful discharge from rehabilitation for patients with spinal cord injury (PWSCI) relies on a smooth transition home. Assessing readiness for hospital discharge (RHD) is important in reducing secondary health conditions and improving satisfaction and function. Perception of PWSCI on RHD may be different from their physiotherapists, leading to difficulties.

OBJECTIVE

To compare the perceptions of PWSCI and physiotherapists with regard to RHD.

METHOD

A comparative cross-sectional study included 50 PWSCI and their physiotherapists in Tshwane. They completed the Readiness for Hospital Discharge Scale (RHDS) and their responses to the subscales were compared. Data were analysed using descriptive and inferential statistics. Relationships between variables of interest and the general perception of RHD were determined using Pearson's chi-square test. An independent samples t-test was used to analyse the difference in RHDS scores (including subscale scores) between PWSCI and physiotherapists. Results were significant if p < 0.05.

RESULTS

The total score of the RHDS was not significantly different (t = 1.31, df = 98, p = 0.19). Patients had higher perceptions in coping ability and expected support subscales (t = 3.15, df = 85.97, p = 0.002 and t = 4.23, df = 98, p = 0.0001, respectively). Physiotherapists had higher perceptions in the knowledge subscale regarding what to do and not do at home (t = -2.05, df = 82.08, p = 0.044) and follow-up sessions (t = 2.625, df = 85.28, p = 0.010).

CONCLUSION

There was no difference in perception of readiness to go home, although physiotherapists gave lower scores for emotional readiness and ability to handle demands at home and higher scores for knowledge.

CLINICAL IMPLICATIONS

The use of the RHDS in the spinal cord rehabilitation units will better align the goals of rehabilitation and discharge planning to improve overall satisfaction with care and discharge outcomes. All members of a multidisciplinary team can achieve consensus and comparisons can be made on their patient's perceived RHD.

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

OBJECTIVES

To investigate the frequency of and reasons for readmissions to acute care (RTAC) during inpatient rehabilitation (IPR) after non-traumatic spinal cord injury (NT-SCI). To develop a predictive model for RTAC using identified risk factors.

DESIGN

Retrospective case-control.

SETTING

Academic IPR hospital.

PARTICIPANTS

Individuals with NT-SCI admitted to an academic SCI rehabilitation unit from January 2014-December 2015.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Readmissions to acute care services from IPR.

RESULTS

Thirty-seven participants (20%) experienced a RTAC for a total of 39 episodes. Thirty-five experienced 1 RTAC, while two had 2. The most common medical reasons for RTAC were infection (27%), neurological (27%), and noninfectious respiratory (16%). Multivariable logistic regression was used to develop a model to predict RTAC. Paraplegia was associated with 3.2 times increase in the odds of RTAC (P = 0.03). For every unit increase in FIM-Motor, there was a 5% reduction in the odds of RTAC (P = 0.03) Body mass index less than 30 decreased odds of RTAC by 61% (P = 0.004).

CONCLUSION

RTACs were associated with body mass index greater than 30, decreased FIM-Motor subscore on admission, and paraplegia. Physiatrists caring for the non-traumatic SCI patient need be more circumspect of individuals with these parameters to potentially prevent the problems necessitating acute care transfer.

Program Interruptions and Short-Stay Transfers Represent Potential Targets for Inpatient Rehabilitation Care-Improvement Efforts

OBJECTIVE

The objective of this work was to present comprehensive descriptive summaries of program interruptions and short-stay transfers among Medicare fee-for-service beneficiaries receiving inpatient rehabilitation after stroke, traumatic brain injury (TBI), and traumatic spinal cord injury (SCI).

DESIGN

Retrospective cohort study of Medicare beneficiaries with any of the 3 conditions of interest who were admitted to inpatient rehabilitation directly from an acute hospital between July 1, 2012, and November 15, 2013.

RESULTS

In the final sample (stroke, n = 71 769; TBI, n = 7109; SCI, n = 659), program interruption rates were 0.9% (stroke), 0.8% (TBI), and 1.4% (SCI). Short-stay transfer rates were 22.3% (stroke), 21.8% (TBI), and 31.6% (SCI); 14.7% of short-stay transfers and 12.3% of interruptions resulting in a return to acute care were identified as potentially preventable among those with stroke; 10.2% of transfers and 11.7% of interruptions among those with TBI, and 3.8% of transfers and 11.1% of interruptions among those with SCI.

CONCLUSIONS

Broad health care policies aimed at improving quality and reducing costs are currently being implemented. Reducing program interruptions and short-stay transfers during inpatient rehabilitative care represents a potential target for care-improvement efforts. Future research focused on identifying modifiable risk factors for potentially undesirable outcomes will allow for targeted preventative interventions.

Acute rehospitalisation during the first 3 months of in-patient rehabilitation for traumatic brain injury

OBJECTIVE

Unplanned re-admission to acute care hospitals during in-patient rehabilitation causes disruption to the rehabilitation program and increases the cost of health care. The aims of the present study were to identify the frequency, reasons and duration of disruption to rehabilitation because of acute re-admissions during the first 3 months of in-patient rehabilitation for traumatic brain injury (TBI) and to investigate the correlation between the duration of acute rehospitalisation and the discharge functional independence measure (FIM) score.

METHODS

A retrospective study was conducted on patients admitted for in-patient rehabilitation following TBI to a rehabilitation hospital in Auckland, New Zealand, between January 2009 and August 2013. Data on duration and reasons for acute rehospitalisation, as well as admission and discharge FIM scores, were obtained from electronic patient records. Pearson correlation was used to evaluate the relationship between the duration of acute rehospitalisation and the discharge FIM score.

RESULTS

Of the 628 patients admitted for brain injury rehabilitation, 71 (11.3%) required acute rehospitalisation within the first 3 months. The main reasons for acute rehospitalisation were preventable medical causes (43.8%), including urinary tract infections, respiratory tract infections and coronary artery disease. Of the acute re-admissions, 76.6% were within the first month of admission to the rehabilitation centre and 46.6% needed in-patient treatment in the acute care hospital for > 5 days. There was a moderately strong negative correlation between the duration of stay in the acute care hospital and the discharge FIM score (r = - 0.412; P = 0.0005).

CONCLUSION

A significant number of patients admitted for in-patient rehabilitation following TBI require acute rehospitalisation due to preventable medical causes. Because the duration of acute rehospitalisation has a negative impact on rehabilitation functional gain, preventive measures and surveillance need to be further investigated and optimised.

Profile and costs of secondary conditions resulting in emergency department presentations and readmission to hospital following traumatic spinal cord injury

INTRODUCTION

People with traumatic spinal cord injury (SCI) face complex challenges in their care, recovery and life. Secondary conditions can develop to involve many body systems and can impact health, function, quality of life, and community participation. These secondary conditions can be costly, and many are preventable. The aim of this study was to describe the type and direct costs of secondary conditions requiring readmission to hospital, or visit to an emergency department (ED), within the first two years following traumatic spinal cord injury (SCI).

METHODS

A retrospective cohort study using population-level linked data from hospital ED and admission datasets was undertaken in Victoria, Australia. The incidence and direct treatment costs of readmission to hospital and ED visit within 2-years post-injury for secondary conditions related to SCI were measured for the 356 persons with traumatic SCI with a date of injury from 2008 to 2011.

RESULTS

Of the 356 cases, 141 (40%) experienced 366 (median 2, range 1-11) readmissions to hospital for secondary conditions. 95 (27%) visited an ED at least once, within two years of injury for a secondary condition. The cost of hospital readmissions was AUD$5,553,004 and AUD$87,790 for ED visits. The mean±SD cost was AUD$15,172±$20,957 per readmission and AUD$670±$198 per ED visit. Urological conditions (e.g. urinary tract infection) were most common, followed by pressure areas/ulcers for readmissions, and fractures in the ED.

CONCLUSIONS

Hospitalisation for complications within two years of traumatic SCI was common and costly in Victoria, Australia. Improved bladder and pressure area management could result in substantial morbidity and cost savings following SCI.

Several time indicators and Barthel index relationships at different spinal cord injury levels

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To compare different injury levels in spinal cord injury (SCI) patients with respect to operation intervention time (OIT), rehabilitation intervention time (RIT), average length of hospital stay (ALOS) and Barthel Index (BI) on admission and discharge.

SETTING

China.

METHODS

We retrospectively analyzed data from 95 SCI cases who received treatment in our rehabilitation center from 2010-2013.

RESULTS

SCI resulted from high falls (55.79%), traffic accidents (28.42%), diseases (8.42%) and low falls (7.37%). We found no correlations between OIT, RIT, ALOS and discharge BI for all spinal segments (P>0.05). The OIT of thoracic SCI and lumbar SCI correlated negatively with RIT (P<0.01). The OIT of lumbar SCI correlated negatively with ALOS (P<0.05).

CONCLUSION

BI had no correlation with OIT, RIT or ALOS for all spinal segments; the OIT of thoracic and lumbar SCI correlated negatively with RIT; and the OIT of lumbar SCI correlated negatively with ALOS.

The practice of spinal cord injury core data collection among Chinese physicians: a survey-based study

STUDY DESIGN

This is a survey-based study.

OBJECTIVE

To investigate the practice of spinal cord injury (SCI) core data collection by Chinese physicians to measure the extent and accuracy of routine collection of elements contained in the International Spinal Cord Injury Core Data Set (ISCICDS).

SETTING

This study was conducted in a workshop in Peking University, China.

METHODS

During an SCI workshop, a survey questionnaire was administered to 48 physicians from 20 provinces of China. The questions were developed on the basis of the data elements within the ISCICDS including the following issues: date of birth, injury, acute admission and inpatient discharge, total hospitalized days, gender, injury etiology, vertebral injury, associated injury, spinal surgery, ventilatory assistance and place of discharge. In addition, data collection practice on neurologic examinations including date, neurological level, injury severity and frequency of examination were involved.

RESULTS

The self-reported practice of data collection regarding date of birth, acute admission and inpatient discharge, gender, vertebral injury, associated injury, spinal surgery and frequency of neurological examination are consistent with the information in the ISCICDS among the majority (⩾76%) of physicians. However, only gender, vertebral injury, associated injury and spinal surgery are completely consistent. The consistency percentages of other data elements ranged from 39.5 to 66.8%.

CONCLUSION

Apart from four data elements, which were collected consistently with the intention in the ISCICDS, the collection of other core data elements need to be documented according to the guidelines included in the ISCICDS to ensure consistency of practice among Chinese physicians and to support worldwide comparison of SCI data.Suggestion:Only four data elements are collected in complete accordance with the ISCICDS by Chinese physicians. ISCICDS guidelines for the remaining elements need to be more rigorously adhered to in order to promote consistency and comparability of data.

Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders

OBJECTIVE

Repeated hospital admissions (RHA) for ongoing pressure ulcer (PU) care remains a significant challenge in the clinical management of the spinal cord injury/disorders (SCI/D) population. The current study investigated the significance of risk factors for PU treatment and RHA.

METHOD

A retrospective chart review of veterans admitted to the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC) Spinal Cord Injury (SCI) unit for Category III or IV PUs was carried out. A random sample of 105 individuals with SCI/D, evaluated by the Wound Care Team (WCT) from 2006 to 2009 was assessed. Multiple PU development risk factors were extracted from the electronic health record system using standardised data collection forms and entered into the Spinal Cord Injury Pressure Ulcer Database (SCIPUD). Potential associations with RHA were analysed.

RESULTS

Twenty variables were initially identified as potentially related to PU development. Descriptive statistics and statistically significant associations between risk factors and RHA were determined. Demographic factors showed no significant association with RHA. Duration of injury, power wheelchair use and sub-optimally managed spasticity (SMS) were significantly associated with higher RHA. Sub-optimally managed neurogenic bowel (SMNB) at admission was significantly associated with reduced RHA.

CONCLUSION

Factors previously found to be predictive of initial PU development may not, in fact, be predictive of RHA. Some protective trends were observed, such as polypharmacy and marital status, but these did not reach statistical significance in this preliminary study of admission characteristics, warranting further research.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interests to declare.

CER, PBE, SCIRehab, NIDRR, and other important abbreviations

Comparative effectiveness research (CER) has been receiving much attention (and government funding) in recent years, stemming from dissatisfaction with much medical and health care research, which does not produce actionable evidence that can be used by clinicians, patients, and policymakers. Rehabilitation research has been characterized by similar weaknesses and by often inadequate research designs. The SCIRehab study of the outcomes of inpatient spinal cord injury rehabilitation is one of a small number of rehabilitation practice-based evidence (PBE) studies in recent years that allows for the comparison of interventions by all disciplines for relevant real-life outcomes. This introduction to a series of articles resulting from the SCIRehab project discusses the need for and the nature of CER, and places the SCIRehab study and other PBE studies in the light of CER. After a description of the highlights of the analyses in this supplement, we provide a preliminary evaluation of SCIRehab, counting the articles and presentations from the study, the resources that went into this vast project, and the lessons learned that may benefit future rehabilitation PBE investigators.