Measuring Discharge Outcomes, Length of Stay, and Functional ADL Score During COVID-19 in Inpatient Rehabilitation Hospitals

Social determinants of health and COVID-19 recovery after inpatient rehabilitation

BACKGROUND

Neighborhoods with more social determinants of health (SDOH) risk factors have higher rates of infectivity, morbidity, and mortality from COVID-19. Patients with severe COVID-19 infection can have long-term functional deficits leading to lower quality of life (QoL) and independence measures. Research shows that these patients benefit greatly from inpatient rehabilitation facilities (IRF) admission, but there remains a lack of studies investigating long-term benefits of rehabilitation once patients are returned to their home environment.

OBJECTIVE

To determine SDOH factors related to long-term independence and QoL of COVID-19 patients after IRF stay.

DESIGN

Multisite cross-sectional survey.

SETTING

Two urban IRFs.

MAIN OUTCOME MEASURES

Primary outcome measures were Post-COVID Functional Status Scale (PCFS) and Short Form-36 (SF-36) scores. Secondary outcomes were quality indicator (QI) scores while at IRF and a health care access questionnaire. Results were analyzed using analysis of variance and multivariate logistic regression analyses.

RESULTS

Participants (n = 48) who were greater than 1 year post-IRF stay for severe COVID-19 were enrolled in the study. Higher SF-36 scores were associated with male gender (p = .002), higher income (≥$70,000, p = .004), and living in the city (p = .046). Similarly, patients who were of the male gender (p = .004) and had higher income (≥$70,000, p = .04) had a greater odds of a 0 or 1 on the PCFS. Age was not associated with differences. Women were more likely to seek follow-up care (p = .014). Those who sought follow-up care reported lower SF-36 overall and emotional wellness scores, p = .041 and p = .007, respectively. Commonly reported barriers to health care access were financial and time constraints.

CONCLUSIONS

Patients with SDOH risk factors need to be supported in the outpatient setting to maintain functional gains made during IRF stays. Female gender, income, and urban setting are potential predictors for long-term QoL and independence deficits after rehabilitation for COVID-19 infection. Low emotional wellness is an indicator for patients to seek out care as far out as 1 year from their rehabilitation stay.

Recovery of activities of daily living in COVID-19 patients requiring intensive care unit or medical care unit: an observational study on the role of rehabilitation in the subacute phase

Purpose

This study aims to describe the functional status of a cohort of subacute COVID-19 patients treated in a dedicated rehabilitation unit and to compare functional outcomes between patients previously hospitalized in the intensive care unit (ICU group) and patients assisted in the medical care unit (MCU group).

Materials and methods

Clinical and functional evaluations were performed at admission and discharge. The functional status was assessed using Barthel index (BI), functional ambulation categories (FAC), trunk control test (TCT), and dysphagia outcome and severity score (DOSS). All patients received multidisciplinary tailored rehabilitation.

Results

We evaluated 171 patients (with a mean age of 67.7 ± 11.9 years, 117 were males), 110 coming from the ICU (with a mean age of 63.24 ± 10.9 years), and 61 coming from the MCU (with a mean age of 75.75 ± 9.09 years). The ICU group showed a worse functional status at admission compared with the MCU group [BI 2.5 (0-20) vs. 20 (10-60), FAC 0 (0-0) vs. 0 (0-2), TCT 61 (42-100) vs. 100 (61-100), DOSS 5 (1-7) vs. 7 (7-7)] and had significantly longer hospital stay. At discharge, all functional scales were improved with no statistically significant differences between the two groups.

Conclusion

Early rehabilitation of COVID-19 survivors improves functional recovery closing the initial gap between the ICU and MCU groups. In addition, it is effective to improve the functional outcome reducing the costs for longer-term assistance of COVID-19 patients.

Baseline Characteristics and Outcomes for People With and Without COVID-19 Diagnoses Receiving Inpatient Rehabilitation Care Across the US in 2020-2021

Objective

To assess sociodemographic, medical complexity, and outcomes of persons receiving care at inpatient rehabilitation facilities (IRFs) with and without a diagnosis of COVID-19.

Design

A retrospective cohort study using electronic medical record (EMR) data from 138 IRFs across 34 states and Puerto Rico.

Setting

N/A.

Participants

IRF EMR data for 212,663 patients discharged between 04/01/2020 and 05/31/2021 (N=212,663), of which 16,199 (COVID-19 group) had a primary or secondary COVID-19 diagnosis based upon ICD codes set (ICD-10 codes U07.1, B94.8, Z86.19, Z86.16).

Main Outcome Measures

Four categories: (a) sociodemographic, (b) medical complexity, (c) process, that is, standard IRF processes, and clinical outcomes (collected routinely as part of administrative reporting), and (d) functional outcomes. Patients with missing functional data associated with short/incomplete stays (n=623) were excluded from analysis of functional outcomes category only. Standard descriptive analysis techniques were employed for comparing categorical and continuous variables between groups.

Results

Statistically significant differences were noted between the COVID-19 group and non-COVID groups for race (26.0% vs 19.7% non-minority, P<.001), Case Mix Index (1.49 vs 1.46, P<.001), Center for Medicare and Medicaid Services 60% rule qualification (79.0% vs 73.4%, P<.001), time to onset (24.3 vs 18.0 days, P<.001), length of stay (14.2 vs 12.9 days, P<.001), and discharge disposition (to community: 75.3% vs 81%, P<.001; to acute care facility: 15.6% vs 10.8%, P<.001). The COVID-19 group had higher frequency of respiratory and cardiovascular disease, diabetes, encephalopathy, morbid obesity, and critical illness neuropathy and myopathy. Clinically insignificant differences were noted for age, sex, depression, and cognitive assessment. Ability to participate and functional outcomes were comparable between the groups.

Conclusion

There are significant differences between the COVID-19 and non-COVID group in some sociodemographic, medical complexity, process and clinical outcomes, but not in functional outcomes. The ability to participate in the IRF-required intensity of therapy services along with attainment of comparable levels of functional outcomes supports the benefit of IRFs for persons with COVID-19.

All-Cause Readmission or Potentially Avoidable Readmission: Which Is More Predictable Using Frailty, Comorbidities, and ADL?

Background and Objectives

Readmission-related health care reforms have shifted their focus from all-cause readmissions (ACR) to potentially avoidable readmissions (PAR). However, little is known about the utility of analytic tools from administrative data in predicting PAR. This study determined whether 30-day ACR or 30-day PAR is more predictable using tools that assess frailty, comorbidities, and activities of daily living (ADL) from administrative data.

Research Design and Methods

This retrospective cohort study was conducted at a large general acute care hospital in Tokyo, Japan. We analyzed patients aged ≥70 years who had been admitted to and discharged from the subject hospital between July 2016 and February 2021. Using administrative data, we assessed each patient's Hospital Frailty Risk Score, Charlson Comorbidity Index, and Barthel Index on admission. To determine the influence of each tool on readmission predictions, we constructed logistic regression models with different combinations of independent variables for predicting unplanned ACR and PAR within 30 days of discharge.

Results

Among 16 313 study patients, 4.1% experienced 30-day ACR and 1.8% experienced 30-day PAR. The full model (including sex, age, annual household income, frailty, comorbidities, and ADL as independent variables) for 30-day PAR showed better discrimination (C-statistic: 0.79, 95% confidence interval: 0.77-0.82) than the full model for 30-day ACR (0.73, 0.71-0.75). The other prediction models for 30-day PAR also had consistently better discrimination than their corresponding models for 30-day ACR.

Discussion and Implications

PAR is more predictable than ACR when using tools that assess frailty, comorbidities, and ADL from administrative data. Our PAR prediction model may contribute to the accurate identification of at-risk patients in clinical settings who would benefit from transitional care interventions.

Characteristics and Outcomes of COVID-19 Survivors Requiring Inpatient Rehabilitation: A Comparison of Two Waves

OBJECTIVE

Many survivors of severe or critical COVID-19 have required rehabilitation during the pandemic. The primary objective was to compare characteristics and outcomes of survivors of severe or critical COVID-19 admitted to the inpatient rehabilitation facility during the first two waves of the pandemic. Our secondary objective was to identify the factors contributing to functional dependence on admission, discharge, and length of stay.

DESIGN

This is a retrospective cohort study of 138 patients admitted to an inpatient rehabilitation facility in two waves after hospitalization for severe or critical COVID-19 illness between April 1, 2020, and May 3, 2021.

RESULTS

Inpatient rehabilitation facility patients in wave 2 had significantly greater functional independence (GG scores) on admission (52; interquartile range, 44-58 vs 41; interquartile range, 28-52), lower incidence of dysphagia and anemia. The patients in both waves experienced similar functional improvement efficiencies with a median GG score change of 3.6 per day and similar discharge GG scores. Neurological sequela (odds ratio, 0.12; P < 0.001) and anemia (odds ratio, 1.35; P < 0.002) were identified as independent predictors of functional independence on admission.

CONCLUSIONS

Patients with functional deficits after COVID-19 should be considered for acute inpatient rehabilitation as both patient cohorts benefited from their inpatient rehabilitation facility stays with similar length of stays (11-12 days) and discharge to home rates (88%-90%).

Acute Occupational and Physical Therapy for Patients With COVID-19: A Retrospective Cohort Study

OBJECTIVE

To describe the function of patients with COVID-19 admitted to an acute care hospital early in the pandemic and to characterize change in function among those admitted to intensive care units (ICU) and to non-critical care services.

DESIGN

This descriptive, retrospective cohort study examined patients infected with SARS-CoV-2 admitted to a tertiary care medical center during the first wave of the pandemic in 2020. Included patients were stratified into 4 cohorts based on whether or not they received therapy during their hospitalization and whether or not their hospitalization included time in the ICU. Data on demographic characteristics, functional impairments, medical interventions, and functional outcomes were collected.

SETTING

Hospital.

PARTICIPANTS

432 adult patients were included in this study (N=432).

RESULTS

ICU patients receiving therapy were more likely to have impaired cognition, impaired strength, and impaired sensation than non-ICU patients receiving therapy. Patients made improvements from evaluation to discharge on the Functional Status Score for the ICU, Activity Measure for Post-Acute Care Daily Activity, and AM-PAC Basic Mobility Short Forms.

CONCLUSION

Patients admitted with COVID-19 experienced significant functional impairments but also demonstrated improvement during the course of their hospitalizations. This study can facilitate health care provider awareness of the detrimental functional effects of COVID-19 and the potential role of rehabilitation services for these patients.

Implementation considerations for delivering inpatient COVID rehabilitation: A qualitative study

RATIONALE

Patients recovering from significant COVID-19 infections benefit from rehabilitation; however, aspects of rehabilitative care can be difficult to implement amidst COVID infection control measures.

AIMS AND OBJECTIVES

We used the Consolidated Framework for Implementation Research (CFIR) to evaluate the rapid implementation of a COVID zone in an in-patient rehabilitation hospital at the onset of the first wave of the pandemic.

METHODS

Semistructured interviews were conducted with health care providers (n = 12) supporting the COVID zone, as well as with patients (n = 10) who were discharged from the COVID zone and their family caregivers (n = 5). The interviews explored the successes and challenges of working on the unit and the quality of care that was delivered to patients recovering from COVID.

RESULTS

Rapid implementation of the COVID zone was supported by champions at the middle-management level but challenged by a number of factors, including: conflicting expert opinions on best infection control practices (outer setting), limited flow of information from senior leaders to frontline staff (inner setting), lack of rehabilitation equipment and understanding of how to provide high quality rehabilitative care in this context (intervention characteristics), willingness and self-efficacy of staff working in the COVID zone (individual characteristics) and lack of time to reflect on and assess effectiveness (process).

CONCLUSIONS

While there was an apparent need for rapid implementation of a COVID rehabilitation zone, senior leadership, middle management and frontline staff faced several challenges. Future evaluations should focus on how to adapt COVID rehabilitation services during fluctuating pandemic restrictions, and to account for rehabilitative needs of people recovering from significant COVID infections.

The Impact of the Early COVID-19 Pandemic on Inpatient Clinical Experience for Physical Medicine and Rehabilitation Resident Physicians

ABSTRACT

The objective of this retrospective, observational study was to quantitatively study the impact of the early COVID-19 pandemic on the inpatient clinical experience of Physical Medicine and Rehabilitation resident physicians in an inpatient rehabilitation facility setting. Inpatient clinical experience as evidenced by admissions, rehabilitation diagnosis, medical emergencies, acute care transfers, and resident work hours from January to June 2019 (prepandemic) were compared January to June 2020 (immediately before and during pandemic). There was a statistically significant decrease in the mean daily admissions in April 2020 and a significant increase in medically complex admissions in June 2020, reflective of medical patterns due to the pandemic. There was a decrease in mean work hours during the pandemic, but no statistically significant difference in admission rate of other rehabilitation diagnoses, medical emergencies, or transfers to acute care. This study demonstrates no substantial pandemic-related impact on inpatient clinical experience for physical medicine and rehabilitation residents in the studied program.

Patient Outcomes and Lessons-Learned from Treating Patients with Severe COVID-19 at a Long-Term Acute Care Hospital: A Single-Center Retrospective Analysis

Background

With the continuation of the COVID-19 pandemic, shifting active COVID-19 care from short-term acute care hospitals (STACHs) to long-term acute care hospitals (LTACHs) could decrease STACH census during critical stages of the pandemic and maximize limited resources.

Objective

This study aimed to describe the characteristics, clinical management, and patient outcomes during and after the acute COVID-19 phase in an LTACH in the Northeastern United States.

Methods

This was a single-center group comparative retrospective analysis of the electronic medical records of patients treated for COVID-19–related impairments from March 19, 2020, through August 14, 2020, and a reference population of medically complex patients discharged between December 1, 2019, and February 29, 2020. This study was conducted to evaluate patient outcomes in response to the holistic treatment approach of the facility.

Results

Of the 127 total COVID-19 admissions, 118 patients were discharged by the data cutoff. At admission, 29.9% (38/127) of patients tested positive for SARS-CoV-2 infection. The mean age of the COVID-19 cohort was lower than that of the reference cohort (63.3, 95% CI 61.1-65.4 vs 65.5, 95% CI 63.2-67.8 years; P=.04). There were similar proportions of males and females between cohorts (P=.38); however, the proportion of non-White/non-Caucasian patients was higher in the COVID-19 cohort than in the reference cohort (odds ratio 2.79, 95% CI 1.5-5.2; P=.001). The mean length of stay in the COVID-19 cohort was similar to that in the reference cohort (25.5, 95% CI 23.2-27.9 vs 29.9, 95% CI 24.7-35.2 days; P=.84). Interestingly, a positive correlation between patient age and length of stay was observed in the COVID-19 cohort (r²=0.05; P=.02), but not in the reference cohort. Ambulation assistance scores improved in both the reference and COVID-19 cohorts from admission to discharge (P<.001). However, the mean assistance score was greater in the COVID-19 cohort than in the reference cohort at discharge (4.9, 95% CI 4.6-5.3 vs 4.1, 95% CI 3.7-4.7; P=.001). Similarly, the mean change in gait distance was greater in the COVID-19 cohort than in the reference cohort (221.1, 95% CI 163.2-279.2 vs 146.4, 95% CI 85.6-207.3 feet; P<.001). Of the 16 patients mechanically ventilated at admission, 94% (15/16) were weaned before discharge (mean 11.3 days). Of the 75 patients admitted with a restricted diet, 75% (56/75) were discharged on a regular diet.

Conclusions

The majority of patients treated at the LTACH for severe COVID-19 and related complications benefited from coordinated care and rehabilitation. In comparison to the reference cohort, patients treated for COVID-19 were discharged with greater improvements in ambulation distance and assistance needs during a similar length of stay. These findings indicate that other patients with COVID-19 would benefit from care in an LTACH.