Combining the AM-PAC "6-Clicks" and the Morse Fall Scale to Predict Individuals at Risk for Falls in an Inpatient Rehabilitation Hospital

Designing a Fall Prediction Model for Inpatient Rehabilitation Facilities Using Readily Available Data

OBJECTIVE

To create a fall risk assessment tool for inpatient rehabilitation facilities (IRFs) using available data and compare its predictive accuracy with that of the Morse Fall Scale (MFS).

DESIGN

We conducted a secondary analysis from a retrospective cohort study. Using a nomogram that displayed the contributions of QI codes associated with falls in a multivariable logistic regression model, we created a novel fall risk assessment, the Inpatient Rehabilitation Fall Scale (IRF Scale). To compare the predictive accuracy of the IRF Scale and MFS, we used receiver operator characteristic (ROC) curve analysis.

SETTING

We included data from 4 IRFs owned and operated by Intermountain Health.

PARTICIPANTS

Data came from the medical records of 1699 patients. All participants were over the age of 14 and were admitted and discharged from 1 of the 4 sites between January 1 and December 31, 2020.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

We assigned point values on the IRF Scale based on the adjusted associations of QI codes with falls. Using ROC curve analysis, we discovered an optimal cutoff score, sensitivity, specificity, and overall AUC of the IRF Scale and MFS.

RESULTS

ROC curve analysis revealed the optimal IRF Scale cutoff score of 22.4 yielded a sensitivity of 0.74 and a specificity of 0.63. With an AUC of 0.72, the IRF Scale demonstrated acceptable accuracy at identifying patients who fell in our retrospective cohort.

CONCLUSIONS

Because the IRF Scale uses readily available data, it minimizes staff assessment and outperforms the MFS at identifying patients who previously fell. Prospective research is needed to investigate if it can adequately identify in advance which patients will fall during their IRF stay.

AM-PAC Mobility Score <13 Predicts Development of Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine whether the Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score is associated with the development of postoperative ileus.

SUMMARY OF BACKGROUND DATA

Adult spinal deformity (ASD) surgery has a high complication rate. One common complication is postoperative ileus, and poor postoperative mobility has been implicated as a modifiable risk factor for this condition.

METHODS

Eighty-five ASD surgeries in which ≥5 levels were fused were identified in a single institution database. A physical therapist/physiatrist collected patients' daily postoperative AM-PAC scores, for which we assessed first, last, and daily changes. We used multivariable linear regression to determine the marginal effect of ileus on continuous AM-PAC scores; threshold linear regression with Bayesian information criterion to identify a threshold AM-PAC score associated with ileus; and multivariable logistic regression to determine the utility of the score thresholds when controlling for confounding variables.

RESULTS

Ten of 85 patients (12%) developed ileus. The mean day of developing ileus was postoperative day 3.3±2.35. The mean first and last AM-PAC scores were 16 and 18, respectively. On bivariate analysis, the mean first AM-PAC score was lower in patients with ileus than in those without (13 vs. 16; P<0.01). Ileus was associated with a first AM-PAC score of 3 points lower (Coef. -2.96; P<0.01) than that of patients without ileus. Patients with an AM-PAC score<13 had 8 times greater odds of developing ileus (P=0.023). Neither the last AM-PAC score nor the daily change in AM-PAC score was associated with ileus.

CONCLUSIONS

In our institutional cohort, a first AM-PAC score of <13, corresponding to an inability to walk or stand for more than 1 minute, was associated with the development of ileus. Early identification of patients who cannot walk or stand after surgery can help determine which patients would benefit from prophylactic management.

LEVEL OF EVIDENCE

Level-III.

Effects of sarcopenia and frailty on postoperative recovery in elderly patients: A prospective cohort study

BACKGROUND

Sarcopenia and frailty are both age-related declines in functional reserve that are linked to adverse health outcomes. It is critical to know about the outcomes of a combination of these conditions. The study aimed to investigate the effects of sarcopenia and frailty on postoperative recovery in elderly patients and to explore risk factors.

METHODS

This prospective cohort study was conducted among 608 patients aged ≥60 years, American Society of Anesthesiologists I-III, who were scheduled to undergo thoracic (non-cardiac) and abdominal surgery from 1 March 2022 to 31 October 2022 at the Affiliated Hospital of Xuzhou Medical University. Frailty was measured by the 28-item frailty index, and sarcopenia was assessed sarcopenia was assessed by skeletal muscle index in computed tomographic scan, handgrip strength and 6-m walk. Participants were classified as follows: Group A: both sarcopenia and frailty; Group B: sarcopenia only; Group C: frailty only; and Group D: neither frailty nor sarcopenia. The primary outcome was 90-day morbidity. Multivariable logistic regression model was used to estimate the association between sarcopenia, frailty and 90-day morbidity.

RESULTS

The median (interquartile range) age of participants was 68 (64-72) years, and 62.7% were men. The prevalence rates of sarcopenia and frailty were 32.8% and 47.6%, respectively. The 90-day morbidity in Group A was 58.5%, in Group B was 46.2%, in Group C was 42.0% and in Group D was 28.8%, and the difference was significant (P < 0.001). In the multivariable analysis, both sarcopenia and frailty [odds ratio (OR), 2.21; 95% confidence interval (CI), 1.26-3.89], sarcopenia only (OR, 1.84; 95% CI, 1.01-3.36), frailty only (OR, 1.77; 95% CI, 1.03-3.03), women (OR, 0.67; 95% CI, 0.45-0.99), body mass index (OR, 0.94; 95% CI, 0.88-0.99), pre-operative albumin (OR, 0.96; 95% CI, 0.91-1.00) and operative stress score (OSS) [OSS 3 (OR, 2.09; 95% CI, 1.21-3.67); OSS 4-5 (OR, 3.81; 95% CI, 2.31-6.42)] were independently associated with 90-day morbidity. In the multivariable analysis with inverse probability weighting adjusted cohort, sarcopenia and frailty were also significantly associated with 90-day morbidity.

CONCLUSIONS

Sarcopenia and frailty were associated with higher risks of postoperative 90-day morbidity in elderly patients alone and in combination. Sex, body mass index, pre-operative albumin and operative stress were also independent factors for postoperative morbidity within 90 days.

A protocol for randomized controlled trial on multidisciplinary interventions for mobility limitation in the older adults (M-MobiLE)

BACKGROUND

Mobility limitation-the loss of exercise capacity or independent living ability-is a common geriatric syndrome in older adults. As a potentially reversible precursor to disability, mobility limitation is influenced by various factors. Moreover, its complex physiological mechanism hinders good therapeutic outcomes with a single-factor intervention. Most hospitals have not incorporated the diagnosis and evaluation of mobility limitation into medical routines nor developed a multidisciplinary team (MDT) treatment plan. We aim to conduct a clinical trial titled "A Multidisciplinary-team approach for management of Mobility Limitation in Elderly (M-MobiLE)" to explore the effect of the MDT decision-making intervention for mobility limitation.

METHODS

The M-MobiLE study will be a multicenter, randomized, and controlled trial. We will recruit a minimum of 66 older inpatients with mobility limitation from at least five hospitals. Older patients with mobility limitation admitted to the geriatrics department will be included. Short-Physical Performance Battery (SPPB), Activities of Daily Living (ADL), Function Impairment Screening Tool (FIST), Geriatric Depression Scale (GDS-15), Short Form - 12 (SF-12), Fried frailty phenotype, social frailty, Morse Fall Risk Scale, SARC-CalF, Mini-Mental State Examination (MMSE), Mini-Nutritional Assessment Short-Form (MNA-SF), and intrinsic capacity will be assessed. The intervention group will receive an exercise-centered individualized MDT treatment, including exercise, educational, nutritional, medical, and comorbidity interventions; the control group will receive standard medical treatment. The primary outcome is the change in the SPPB score, and the secondary outcomes include increased SF-12, ADL, FIST, MMSE, MNA-SF, and intrinsic capacity scores and decreased GDS-15 and SARC-CalF scores.

CONCLUSION

Our results will help develop a multidisciplinary decision-making clinical pathway for inpatients with mobility limitation, which can be used to identify patients with mobility limitation more effectively, improve mobility, and reduce the risk of falls, frailty, and death in older inpatients. The implementation of this MDT strategy may standardize the treatment of mobility limitation, reduce adverse prognosis, and improve quality of life.

TRIAL REGISTRATION

ChiCTR, ChiCTR2200056756, Registered 19 February 2022.

Predicting Falls in Rehabilitation: A Comparison of Three Instruments Including Hester Davis

PURPOSE

The aim of this study was to evaluate the ability of the Hester Davis Scale (HDS), Section GG, and facility fall risk assessment scores to predict patients who fall during inpatient rehabilitation.

DESIGN

This study is an observational quality improvement project.

METHODS

Nurses administered the HDS in parallel to the facility's current fall risk assessment and Section GG of the Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument. Receiver operating characteristic curves were compared in 1,645 patients. Relationships of individual scale items to falls were also assessed.

RESULTS

The HDS (area under the curve [AUC] = .680, 95% CI [.626, .734]), facility fall risk assessment (AUC = .688, 95% CI [.637, .740]), and Section GG scores (AUC = .687, 95% CI [.638, .735]) adequately identified patients who fell. AUCs did not significantly differ between assessments. HDS scores of ≥13, facility scores of ≥14, and Section GG scores of ≤51 resulted in the highest sensitivity/specificity balance.

CONCLUSIONS

HDS, facility fall risk assessment, and Section GG scores adequately and similarly identified patients of mixed diagnoses at risk of falling in inpatient rehabilitation.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

Rehabilitation nurses have several options including the HDS and Section GG to identify patients at greatest risk of falling.