Validity of the AM-PAC "6-Clicks" inpatient daily activity and basic mobility short forms

Activity Measure for Post-Acute care (AM-PAC) scores predict Short and Long-Term outcomes following glioblastoma resection

BACKGROUND

Glioblastoma patients may develop functional deficits post-operatively that affect activities of daily living and result in worse outcomes. The Activity Measure for Post-Acute Care (AM-PAC) instrument assigns patients basic mobility and daily activity scores, but it is unknown if these scores correlate with post-operative outcomes in glioblastoma patients.

METHODS

Adult (≥18 years) glioblastoma patients evaluated by physical/occupational therapy after resection at a single instution (June 2008-December 2020) were identified. Patient demographics, post-operative AM-PAC scores, and clinical outcomes were collected. Multivariate regression identified associations between AM-PAC scores and post-operative outcomes.

RESULTS

600 patients were included (mean age 59.3 years, 59.2 % male); 151 (25.3 %) and 246 (43.8 %) patients had low mobility (<42.9) and activity (<39.4) scores, respectively. 103 (17.2 %) and 177 (29.5 %) patients experienced extended lengths of stay (LOS) in the ICU (≥2 days) and overall (≥7 days), respectively. 154 (25.7 %) patients had non-home discharges. The 30-day readmission rate was 13.7 %. In multivariate analysis, low mobility scores correlated with increased odds of extended overall (p < 0.0001) and ICU (p = 0.0004) LOS, non-home discharge (p < 0.0001), and 30-day readmission (p = 0.0405). Low activity scores correlated with extended overall LOS (<0.0001) and non-home discharge (p < 0.0001). In log-rank analysis, median survival time was shorter for patients with low mobility (9.5 vs. 14.7 months, p < 0.0001) and activity (10.6 vs. 16.3 months, p < 0.0001) scores than for high-scoring patients.

CONCLUSION

AM-PAC basic mobility and daily activity scores are associated with outcomes after glioblastoma resection. These easily obtainable scores may be useful for prognosticating and guiding decision making in post-operative glioblastoma patients.

Development of a New Tool to Combine the Promotion of Patient Mobility With Safe Patient Handling Equipment: The Johns Hopkins Safe Patient Handling Mobility (JH-SPHM) Guide

BACKGROUND

Promoting safe patient mobility for providers and patients is a safety priority in the hospital setting. Safe patient handling equipment aids safe mobility but can also deter active movement by the patient if used inappropriately. Nurses need guidance to choose equipment that ensures their safety and that of the patients while promoting active mobility and preventing workplace-related injury.

METHODS

Using a modified Delphi approach with a diverse group of experts, we created the Johns Hopkins Safe Patient Handling Mobility (JH-SPHM) Guide. This diverse group of 10 experts consisted of nurses, nurse leaders, physical and occupational therapists, safe patient handling committee representatives, and a fall prevention committee leader. The application of the tool was then tested in the hospital environment by two physical therapists.

FINDINGS

Consensus was reached for safe patient handling (SPH) equipment recommendations at each level of the Johns Hopkins Mobility Goal Calculator (JH-Mobility Goal Calculator). Expert SPH equipment recommendations were then added to JH-Mobility Goal Calculator levels to create the JH-Safe Patient Handling Mobility Guide. JH-Safe Patient Handling Mobility Guide equipment suggestions were compared with equipment recommendations from physical therapists revealing strong agreement (n = 125, 88%).

CONCLUSION

The newly created JH-Safe Patient Handling Mobility Guide provides appropriate safe patient-handling equipment recommendations to help accomplish patients' daily mobility goals.

APPLICATIONS TO PRACTICE

The Johns Hopkins Safe Patient Handling Mobility Guide simultaneously facilitates patient mobility and optimizes safety for nursing staff through recommendations for safe patient-handling equipment for use with hospitalized patients.

Mobility Assessment Instruments

OBJECTIVES

Review commonly used mobility assessment instruments and discuss their use in multidisciplinary research and clinical practice.

METHODS

Data sources include peer-reviewed articles sourced in electronic databases (PubMed, CINAHL), government websites, national, and international best practice guidelines to describe frequently used mobility assessment instruments.

RESULTS

Numerous clinician-, observer-, patient-reported, and performance outcome instruments and evidence-based implementation program resources exist, though these vary in their intended purpose and setting. Wearable and ambient sensors provide new opportunities to collect passive, objective physical activity data and observe changes in mobility across settings.

CONCLUSIONS

Selection among multiple assessment tools requires consideration of the available evidence for use in the desired population, the outcomes of interest, whether use is feasible for the setting, and the strength of validity and reliability data for the tool.

IMPLICATIONS FOR NURSING PRACTICE

Nurses, especially in the inpatient setting, are typically in most frequent contact with patients and are well-positioned to assess mobility and ensure that safe, progressive mobility care plans are in place. Development of an organization-wide mobility culture requires a systematic, multidisciplinary approach and long-term commitment.

Early physical rehabilitation dosage in the intensive care unit associates with hospital outcomes after critical COVID-19

OBJECTIVE

To examine the relationship between physical rehabilitation parameters including an approach to quantifying dosage with hospital outcomes for patients with critical COVID-19.

DESIGN

Retrospective practice analysis from March 5, 2020, to April 15, 2021.

SETTING

Intensive care units (ICU) at four medical institutions.

PATIENTS

n = 3780 adults with ICU admission and diagnosis of COVID-19.

INTERVENTIONS

We measured the physical rehabilitation treatment delivered in ICU and patient outcomes: (1) mortality; (2) discharge disposition; and (3) physical function at hospital discharge measured by the Activity Measure-Post Acute Care (AM-PAC) "6-Clicks" (6-24, 24 = greater functional independence). Physical rehabilitation dosage was defined as the average mobility level scores in the first three sessions (a surrogate measure of intensity) multiplied by the rehabilitation frequency (PT + OT frequency in hospital).

MEASUREMENTS AND MAIN RESULTS

The cohort was a mean 64 ± 16 years old, 41% female, mean BMI of 32 ± 9 kg/m2 and 46% (n = 1739) required mechanical ventilation. For 2191 patients who received rehabilitation, the dosage and AM-PAC at discharge were moderately, positively associated (Spearman's rho [r] = 0.484, p < 0.001). Multivariate linear regression (model adjusted R2 = 0.68, p < 0.001) demonstrates mechanical ventilation (β = - 0.86, p = 0.001), average mobility score in first three sessions (β = 2.6, p < 0.001) and physical rehabilitation dosage (β = 0.22, p = 0.001) were predictive of AM-PAC scores at discharge when controlling for age, sex, BMI, and ICU LOS.

CONCLUSIONS

Greater physical rehabilitation exposure early in the ICU is associated with better physical function at hospital discharge.

Capturing patient mobility levels in the hospital: An examination of nursing charting and behavioural mapping

AIMS

Our study aimed to (1) validate the accuracy of nursing mobility documentation and (2) identify the most effective timings for behavioural mapping.

DESIGN

We monitored the mobility of 55 inpatients using behavioural mapping throughout a nursing day shift, comparing the observed mobility levels with the nursing charting in the electronic health record during the same period.

RESULTS

Our results showed a high level of agreement between nursing records and observed mobility, with improved accuracy observed particularly when documentation was at 12 PM or later. Behavioural mapping observations revealed that the most effective timeframe to observe the highest levels of patient mobility was between 10 AM AND 2 PM.

CONCLUSION

To truly understand patient mobility, comparing nursing charting with methods like behavioural mapping is beneficial. This comparison helps evaluate how well nursing records reflect actual patient mobility and offers insights into the best times for charting to capture peak mobility. While behavioural mapping is a valuable tool for auditing patient mobility, its high resource demands limit its regular use. Thus, determining the most effective times and durations for observations is key for practical implementation in hospital mobility audits.

IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE

Nurses are pivotal in ensuring patient mobility in hospitals, an essential element of quality care. Their role involves safely mobilizing patients and accurately charting their mobility levels during each shift. For nursing practice, this research underscores that nurse charting can accurately reflect patient mobility, and highlights that recording the patient's highest level of mobility later in the shift offers a more precise representation of their actual mobility.

REPORTING METHOD

Strobe.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Impact of the geriatric emergency medicine specialist intervention on final emergency department disposition

BACKGROUND

The Geriatric Emergency Medicine Specialist (GEMS) pilot program is an innovative approach that utilizes geriatric-trained advanced practice providers to facilitate geriatric assessments and care planning for older adults in the emergency department (ED). The objective of this study was to explore the effect of GEMS on the use of observation status and final ED disposition.

METHODS

This was a retrospective study under a target trial emulation framework. Geriatric patients (65+ years old) who presented to two ED sites within a large regional healthcare system between December 2020 and December 2022 were included. The primary outcome was final ED disposition (discharge, hospital inpatient admission, or hospital observation admission). Secondary outcomes included ED observation and ED length of stay. Non-GEMS patients were propensity score matched 5:1 to GEMS patients. Doubly robust regression was used to estimate the odds ratios and 95% confidence intervals of inpatient admission, discharge, hospital observation admission, ED observation admission, and estimate the mean ED length of stay.

RESULTS

A total of 427 of 43,064 total patients (1.0%) received a GEMS intervention during the study period. Our analysis included 2,302 geriatric ED patients (410 GEMS, 1,892 non-GEMS) after propensity score matching. Hospital admission rates were 34.1% for GEMS compared to 56.4% for conventional treatment. GEMS patients had decreased odds of inpatient admission (OR: 0.41, 95 CI: 0.34-0.51, p < 0.001), increased odds of discharge (OR: 1.19 95 CI: 1.00-1.42, p = 0.047), hospital observation admission (OR: 2.97, 95 CI: 2.35-3.75, p < 0.001), ED observation admission (OR: 4.84 95 CI: 3.67-6.38, p < 0.001), and had a longer average ED length of stay (170 min, 95 CI: 84.6-256, p < 0.001) compared to non-GEMS patients.

CONCLUSIONS

Patients seen by GEMS during their ED visit were associated with higher rates of hospital discharge and lower rates of hospital admissions.

High Risk of Readmission After THA Regardless of Functional Status in Patients Discharged to Skilled Nursing Facility

BACKGROUND

The postoperative period and subsequent discharge planning are critical in our continued efforts to decrease the risk of complications after THA. Patients discharged to skilled nursing facilities (SNFs) have consistently exhibited higher readmission rates compared with those discharged to home healthcare. This elevated risk has been attributed to several factors but whether readmission is associated with patient functional status is not known.

QUESTIONS/PURPOSES

After controlling for relevant confounding variables (functional status, age, gender, caregiver support available at home, diagnosis [osteoarthritis (OA) versus non-OA], Charlson comorbidity index [CCI], the Area Deprivation Index [ADI], and insurance), are the odds of 30- and 90-day hospital readmission greater among patients initially discharged to SNFs than among those treated with home healthcare after THA?

METHODS

This was a retrospective, comparative study of patients undergoing THA at any of 11 hospitals in a single, large, academic healthcare system between 2017 and 2022 who were discharged to an SNF or home healthcare. During this period, 13,262 patients were included. Patients discharged to SNFs were older (73 ± 11 years versus 65 ± 11 years; p < 0.001), less independent at hospital discharge (6-click score: 16 ± 3.2 versus 22 ± 2.3; p < 0.001), more were women (71% [1279 of 1796] versus 56% [6447 of 11,466]; p < 0.001), insured by Medicare (83% [1497 of 1796] versus 52% [5974 of 11,466]; p < 0.001), living in areas with greater deprivation (30% [533 of 1796] versus 19% [2229 of 11,466]; p < 0.001), and had less assistance available from at-home caregivers (29% [527 of 1796] versus 57% [6484 of 11,466]; p < 0.001). The primary outcomes assessed in this study were 30- and 90-day hospital readmissions. Although the system automatically flags readmissions occurring within 90 days at the various facilities in the overall healthcare system, readmissions occurring outside the system would not be captured. Therefore, we were not able to account for potential differential rates of readmission to external healthcare systems between the groups. However, given the large size and broad geographic coverage of the healthcare system analyzed, we expect the readmissions data captured to be representative of the study population. The focus on a single healthcare system also ensures consistency in readmission identification and reporting across subjects. We evaluated the association between discharge disposition (home healthcare versus SNF) and readmission. Covariates evaluated included age, gender, primary payer, primary diagnosis, CCI, ADI, the availability of at-home caregivers for the patient, and the Activity Measure for Post-Acute Care (AM-PAC) 6-clicks basic mobility score in the hospital. The adjusted relative risk (ARR) of readmission within 30 and 90 days of discharge to SNF (versus home healthcare) was estimated using modified Poisson regression models.

RESULTS

After adjusting for the 6-clicks mobility score, age, gender, ADI, OA versus non-OA, living environment, CCI, and insurance, patients discharged to an SNF were more likely to be readmitted within 30 and 90 days compared with home healthcare after THA (ARR 1.46 [95% CI 1.01 to 2.13]; p= 0.046 and ARR 1.57 [95% CI 1.23 to 2.01]; p < 0.001, respectively).

CONCLUSION

Patients discharged to SNFs after THA had a slightly higher likelihood of hospital readmission within 30 and 90 days compared with those discharged with home healthcare. This difference persisted even after adjusting for relevant factors like functional status, home support, and social determinants of health. These results indicate that for suitable patients, direct home discharge may be a safer and more cost-effective option than SNFs. Clinicians should carefully consider these risks and benefits when making postoperative discharge plans. Policymakers could consider incentives and reforms to improve care transitions and coordination across settings. Further research using robust methods is needed to clarify the reasons for higher SNF readmission rates. Detailed analysis of patient complexity, care processes, and causes of readmission in SNFs versus home health could identify areas for quality improvement. Prospective cohorts or randomized trials would allow stronger conclusions about cause-and-effect. Importantly, no patients should be unfairly "cherry-picked" or "lemon-dropped" based only on readmission risk scores. With proper support and care coordination, even complex patients can have good outcomes. The goal should be providing excellent rehabilitation for all, while continuously improving quality, safety, and value across settings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Are Your Patients Safe to Mobilize Alone in Their Room? The Johns Hopkins Hospital In-Room Independence Scale

OBJECTIVE

Given the stigma of falls while hospitalized, inpatient rehabilitation facilities often restrict the independent room mobility of their patients. We assessed the psychometric properties of a new tool, the Johns Hopkins In-Room Independence Scale, to evaluate its effectiveness at identifying independence for in-room mobility.

DESIGN

Construct validity was assessed by comparing the Johns Hopkins In-Room Independence Scale to its "gold standard" counterparts, The Johns Hopkins Falls Risk Assessment Tool, the Activity Measure for Post-Acute Care Mobility and Activity, and the Centers for Medicare Quality Indicators. Reliability was assessed via Cronbach α.

RESULTS

One hundred ninety-seven episodes were included. In construct validity, the Johns Hopkins In-Room Independence Scale had significantly negative low correlation to the Johns Hopkins Falls Risk Assessment Tool (Spearman ρ = -0.281), and a significant moderate correlation to the Activity Measure for Post-Acute Care Activity and Activity Measure for Post-Acute Care Mobility (Spearman ρ =0.678 and 0.530, respectively). The Johns Hopkins In-Room Independence Scale was moderately positively correlated to the quality indicators for mobility and activity (Spearman ρ = 0.577 and 0.643, respectively). All two-tailed, α levels were 0.01. The Johns Hopkins In-Room Independence Scale reliability was strong (Cronbach α = 0.822, 15 items). Sensitivity and specificity were both 100%.

CONCLUSIONS

Given the moderate validity, strong reliability, and high sensitivity/specificity, our study suggests that the Johns Hopkins In-Room Independence Scale be used to identify patients who have the capacity to mobilize independently in their room.

Changes in Interprofessional Practice During the COVID-19 Pandemic and the Effect on Patient Outcomes: A Retrospective Observational Study

BACKGROUND

Changes in healthcare delivery were required during the first year of the COVID-19 pandemic.

OBJECTIVE

The purpose of this study was to determine the impact of the approach to care of the COVID-19 patient on nursing sensitive indicators and nutrition therapy and the utilization of rehabilitation services during the first year of the pandemic in the acute care setting.

METHOD

A retrospective study of 894 patients admitted with a COVID-19 diagnosis was conducted between March 2020 and February 2021 in 3-month cohorts. All charts were reviewed for general demographics and hospital data, nursing quality indicators, and nutritional and rehabilitation services for the first 30 days of admission.

RESULTS

Differences in patient characteristics were noted among the cohorts. Variations were observed between time points in hospital-acquired pressure injury occurrence, with mechanical ventilation and proning being independent predictors of hospital-acquired pressure injuries. There were differences noted in the percentage of patients with a central line-associated bloodstream infection among the time points (P < .001), but there were no differences noted in catheter-associated urinary tract infections (P = .20). Overall, 15.5% had a malnutrition diagnosis, with most patients receiving 50% of prescribed calorie and protein needs. Rehabilitation services increased over time with these services being initiated earlier in the later cohorts (P < .001).

DISCUSSION

The results of this study demonstrated the impact of the pandemic on outcomes in the areas of nursing, nutrition, and rehabilitation, which varied across quarterly cohorts as we learned and developed new practices and adapted to a novel pandemic.

Early physical rehabilitation dosage in the IntensiveCare Unit predicts hospital outcomes after criticalCOVID-19

Objective

to examine the relationship between physical rehabilitation parameters including a novel approach to quantifying dosage with hospital outcomes for patients with critical COVID-19.

Design

Retrospective practice analysis from March 5, 2020, to April 15, 2021.

Setting

Intensive care units (ICU) at four medical institutions.

Patients

n = 3,780 adults with ICU admission and diagnosis of COVID-19.

Interventions

We measured the physical rehabilitation treatment delivered in ICU and patient outcomes: 1) mortality; 2) discharge disposition; and 3) physical function at hospital discharge measured by the Activity Measure-Post Acute Care (AM-PAC) "6-Clicks" (6-24, 24=greater functional independence). Physical rehabilitation dosage was defined as the average mobility level scores in the first three sessions (a surrogate measure of intensity) multiplied by the rehabilitation frequency (PT + OT frequency in hospital).

Measurements and Main Results

The cohort was a mean 64 ± 16 years old, 41% female, mean BMI of 32 ± 9 kg/m2 and 46% (n=1739) required mechanical ventilation. For 2191 patients with complete data, rehabilitation dosage and AM-PAC at discharge were moderately, positively associated (Spearman's rho [r] = 0.484, p < 0.001). Multivariate linear regression (model adjusted R2= 0.68, p <0.001) demonstrates mechanical ventilation (β = -0.86, p = 0.001), average mobility score in first three sessions (β = 2.6, p <0.001) and physical rehabilitation dosage (β = 0.22, p = 0.001) were predictive of AM-PAC scores at discharge when controlling for age, sex, BMI, and ICU LOS.

Conclusions

Greater physical rehabilitation exposure early in the ICU is associated with physical function at hospital discharge.

Early ambulation after fibular free flap surgery is associated with reduced length of stay, increased mobility independence, and discharge to home

BACKGROUND

Fibula free flaps (FFF) are one of the most common bony flaps utilized. This paper describes a quality improvement project aimed at increasing early ambulation.

METHODS

A review of FFF patients at an academic hospital was completed (2014-2023). In 2018, an institutional change to encourage early ambulation without placement of a boot was made. Changes in hospital disposition and physical therapy outcomes were evaluated.

RESULTS

A total of 168 patients underwent FFF reconstruction. There was a statistically significant lower length of stay in Group 2 (early ambulation, no boot) (8.1 vs. 9.4; p = 0.04). A higher rate of discharge to a skilled nursing facility was noted in Group 1 (delayed ambulation with boot) (21.3% vs. 11.9%; p = 0.009). A higher proportion of patients in Group 2 demonstrated independence during bed mobility, transfers, and gait (p < 0.05).

CONCLUSIONS

Early ambulation without boot placement after FFF is associated with decreased length of hospital stay, improved disposition to home and physical therapy outcomes.

"Beyond waking and walking. Intensive rehabilitation in patients requiring extended durations of advanced mechanical circulatory support: A case series"

Physical therapy (PT) utilization in patients requiring mechanical circulatory support (MCS) and extracorporeal membrane oxygenation (ECMO) has been reported; however, little is known about intensive rehabilitation and associated outcomes in patients requiring extended complex MCS and/or ECMO support.

Authors sought to explore safety, feasibility and outcomes associated with active rehabilitation in patients requiring prolonged advanced MCS/ECMO support.

Single-center retrospective series evaluated functional, clinical, and longitudinal outcomes of sample of eight critically ill, adult (≥18 years of age) patients who underwent a intensive rehabilitation while receiving prolonged MCS/ECMO through advanced configurations including: venovenous (VV-ECMO), venoarterial (VA-ECMO), oxygenator with right ventricular assist device (Oxy-RVAD) and right ventricular assist device (RVAD).

406 sessions were conducted; 246 during provision of advanced MCS/ECMO support.

Incidence of major adverse events-accidental decannulation, migration of cannulas, circuit failure, hemorrhage, major flow limitations, and major hemodynamic instability-was 1.2 events per 100 sessions. None of reported major adverse events impeded longitudinal ability to participate in PT. Increased time to PT initiation was associated with a statistically significant increase in intensive care unit (ICU) length-of-stay (β1 1.93, CI 0.55-3.30) and reduced ambulatory distance during last session on MCS/ECMO (β1 -47.64, CI - 93.93, -1.66). All patients survived to hospital discharge and 12 months from sentinel hospitalization. Amongst those patients discharged to an inpatient rehabilitation center (n = 4), all were discharged home within 3 months.

Findings support the safety and feasibility of active rehabilitational PT in patients requiring extended durations of advanced MCS/ECMO support. Moreover, it highlights potentially associated benefits of this degree of intensive rehabilitation for these unique patients. Further investigation is needed to identify associations with longitudinal clinical outcomes, as well as predictors of success in this population.

Virtual Reality Distraction for Reducing Acute Postoperative Pain After Hip Arthroplasty: A Randomized Trial

BACKGROUND

Relaxation and distraction provided by virtual reality presentations might be analgesic and reduce the need for opioid analgesia. We tested the hypothesis that a virtual reality program (AppliedVR) decreases acute postoperative pain and opioid requirements in patients recovering from hip arthroplasty. We also evaluated whether virtual reality distraction improves patient mobility and reduces the need for antiemetics.

METHODS

We evaluated 106 adults who were recovering from elective primary total hip arthroplasty. Participating patients were randomized to 2- to 8-minute-long 3-dimensional immersive virtual reality relaxation and distraction video presentations (eg, guided breathing exercises, games, mindfulness) or to 2-dimensional presentations of nature short films (eg, forest wildlife) with neutral music that was chosen to be neither overly relaxing nor distracting, presented through identical headsets. Our primary outcome was pain after virtual reality or sham video presentations, adjusted for pretreatment scores. Secondary outcomes included total opioid consumption, pain scores obtained per routine by nurse staff, perception of video system usability, and pain 1 week after hospital discharge.

RESULTS

Fifty-two patients were randomized to virtual reality distraction and relaxation, and 54 were assigned to 2-dimensional sham presentations. Virtual reality presentations were not found to affect pain scores before and after presentations, with an estimated difference in means (virtual reality minus sham video) of -0.1 points (95% confidence interval [CI], -0.5 to 0.2; P = .391) on a 0 to 10 scale, with 10 being the worst. The mean (standard error [SE]) after-intervention pain score was estimated to be 3.4 (0.3) in the virtual reality group and 3.5 (0.2) in the reference group. Virtual reality treatment was not found to affect postoperative opioid consumption in morphine milligram equivalents, with an estimated ratio of geometric means (virtual reality/sham video) of 1.2 (95% CI, 0.6-2.1; P = .608). Virtual reality presentations were not found to reduce pain scores collected every 4 hours by nursing staff, with an estimated difference in means of 0.1 points (95% CI, -0.9 to 0.7; P = .768).

CONCLUSIONS

We did not observe statistically significant or clinically meaningful reductions in average pain scores or opioid consumption. As used in our trial, virtual reality did not reduce acute postoperative pain.

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.

Optimization of Patient Progression in a New Era: A Comprehensive Framework

PURPOSE/OBJECTIVES

The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments.

PRIMARY PRACTICE SETTINGS

Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign.

FINDINGS

Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days).

CONCLUSIONS

Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

Addressing the functional needs of left ventricular assist device candidates: Development and feasibility of an occupational therapy pre-operative evaluation

BACKGROUND

Everyday living with a left ventricular assist device (LVAD) is complex, particularly for people with physical or cognitive impairments or limited social supports. There is a need for standardized pre-operative functional evaluations.

OBJECTIVES

Our objectives were to describe a pre-operative occupational therapy (OT) evaluation for LVAD candidates, assess its feasibility in routine care, and characterize functional needs.

METHODS

We retrospectively reviewed electronic medical records of pre-operative OT consultations for LVAD candidates over four years (n = 209). Occupational profile, vision, and sensation were operationalized from documentation narratives. Daily functioning was measured with Activity Measure for Post-Acute Care, grip strength with dynamometer, cognition with Montreal Cognitive Assessment and Allen Cognitive Level Screen-5, and LVAD self-management with a performance-based ordinal scale.

RESULTS

89.5 % of consultations were completed, averaging 61.2 min (n = 187): 79.1 % (148/187) inpatient and 20.9 % (39/187) outpatient. Patients completed 87.7 % (164/187) to 100.0 % (187/187) of evaluation components. 21.9 % (41/187) of candidates lived alone. 6.4 % (12/187) and 7.0 % (13/185) had visual and sensory dysfunction. 57.4 % were independent with daily activities (104/181). 17.7 % (32/181) had impaired grip strength. 69.3 % (124/179) had impaired cognition, 29.7 % (51/172) with impaired functional cognition for everyday activities. 88.4 % (145/164) required physical or cueing assistance while practicing LVAD batteries management. OTs interpreted that 20.9 % (39/187) would likely require 24/7 post-operative support with LVAD self-care.

CONCLUSION

Pre-operative OT evaluations were feasible and emphasized complex functional needs. Assessing LVAD self-care abilities may inform candidacy and facilitate early interventions to optimize functioning. OT should be consulted within interprofessional teams for all LVAD candidates.

Prediction of Changes in Functional Outcomes During the First Year After Inpatient Stroke Rehabilitation: A Longitudinal Study

OBJECTIVE

To identify meaningful changes in patients in 3 functional domains (basic mobility [BM], daily activity [DA], and applied cognition [AC]) after discharge from inpatient stroke rehabilitation and to identify the predictors of 1-year functional improvement.

DESIGN

A longitudinal, multicenter, prospective cohort study.

SETTING

The acute care wards of 3 hospitals in the Greater Taipei area of Taiwan.

PARTICIPANTS

Five hundred patients with stroke in acute care wards (mean age=60±12.2 years, 62% men, N=500).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

The Mandarin version of the Activity Measure for Post-Acute Care (AM-PAC) short forms were assessed at discharge and 3-, 6-, and 12-month follow-up. The minimal detectable change (MDC) was used to categorize changes in the scores as improved and unimproved at the 4 time points.

RESULTS

The mean scores of the AM-PAC BM and DA subscales substantially increased over the first 3 months after discharge (86% of participants exhibited improvement) and slightly increased during the subsequent 9 months (5∼26% of participants exhibited improvement). However, the mean score of the AC subscale decreased within the first 3 months and increased over the subsequent 9 months (22-23% of participants exhibited improvement). The BM, AC scores at discharge were the dominant predictors of subsequent functional improvement (P<.05). Patients with a higher functional stage at discharge were more likely to experience significant improvement.

CONCLUSION

This study established the capacity of the AM-PAC to predict functional improvement in 3 domains during the early, middle, and late stages of recovery. The findings can assist clinicians in identifying patients at risk of unfavorable long-term functional recovery and providing such patients with tailored interventions during the early stage of rehabilitation.

RAPT and AM-PAC "6-Clicks": Do They Correlate on Predicting Discharge Destination After Total Joint Arthroplasty?

Background: The Risk Assessment and Prediction Tool (RAPT) and the Activity Measure for Post-Acute Care "6-Clicks" Mobility Score (AM-PAC) are validated discharge planning tools for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Planning for discharge with these tools considers very different factors and it is important to determine if they relate. Purpose: We sought to determine whether the preoperative RAPT score would correlate with postoperative AM-PAC score for predicting discharge destination for THA and TKA populations. Secondarily, we sought to examine whether the AM-PAC and RAPT scores would remain statistically significant predictors of discharge destination despite covariates. Methods: A retrospective cohort study was performed for patients who underwent THA or TKA from January 2020 to December 2022 at a specialty orthopedic hospital. Primary variables included the RAPT score, the AM-PAC score, and discharge disposition. Correlation between AM-PAC and RAPT scores was tested using Pearson's correlation coefficient, and association between both scores and discharge destination was tested using chi-square tests and multivariable logistic regression. Results: Our comparison of AM-PAC scores and RAPT scores found a statistically significant, positive correlation in both THA and TKA patients. Regression analysis found that increased RAPT and AM-PAC scores resulted in higher odds of being discharged home for both populations, after adjusting for all other variables. In both cohorts, patients discharged to a facility were more likely to be female, be over the age of 70 years, have Medicare/Medicaid insurance, and have a higher number of preoperative social work visits or any incidence of an intraoperative or hospital complication. Conclusions: This retrospective study found that RAPT score correlated with AM-PAC score for predicting discharge destination for elective THA and TKA populations, suggesting that these scores may be predictors of home discharge destination even when accounting for covariates. Further study is recommended.

Pain relief with elastic therapeutic taping

BACKGROUND AND PURPOSE

Chemotherapy-induced peripheral neuropathy (CIPN) occurs in 19%-85% of patients undergoing cancer treatment. Due to the high symptom burden, specifically pain in the soles of feet, we explore the role of elastic therapeutic (ET) taping for treatment of CIPN.

CASE DESCRIPTION

We report two cases of patients with CIPN-induced foot pain while admitted to the hospital. Their background information, including chemotherapy history, treatments trialed and effects of ET on their pain, is discussed. Each patient underwent ET using the epidermis, dermis, fascia technique for CIPN. An occupational therapist applied ET to the plantar surface of both feet to the ankle with 0% stretch on the tape for 24-96 hours. We also showed the effect of symptom improvement in their individualized rehabilitation session following application of ET.

OUTCOMES

Pain score, verbally documented by 10 point numerical pain rating scale, decreased by >50% in both patients within 24 hours of application. This reflects a substantial improvement in pain with the intervention of ET. This allowed for improved tolerance in engaging in functional mobility, with improvement in distances ambulated.

DISCUSSION

ET taping of the distal leg and foot showed pain improvement for these two patients. Our findings suggest that a clinical trial aimed at better characterising the role of ET in these patients is justified.

Inpatient physical activity across a large university city hospital: a behavioral mapping study

BACKGROUND

Physical inactivity is common during hospitalization. Physical activity has been described in different inpatient populations but never across a hospital.

PURPOSE

To describe inpatient movement behavior and associated factors throughout a single university hospital.

METHODS

A prospective observational study was performed. Patients admitted to clinical wards were included. Behavioral mapping was undertaken for each participant between 9AM and 4PM. The location, physical activity, daily activity, and company of participants were described. Barriers to physical activity were examined using linear regression analyses.

RESULTS

In total, 345 participants from 19 different wards were included. The mean (SD) age was 61 (16) years and 57% of participants were male. In total, 65% of participants were able to walk independently. On average participants spent 86% of observed time in their room and 10% of their time moving. A physiotherapist or occupational therapist was present during 1% of the time, nursing staff and family were present 11% and 13%, respectively. Multivariate regression analysis showed the presence of an intravenous line (p = .039), urinary catheter (p = .031), being female (p = .034), or being dependent on others for walking (p = .016) to be positively associated with the time spent in bed. Age > 65, undergoing surgery, receiving encouragement by a nurse or physician, reporting a physical complaint or pain were not associated with the time spent in bed (P > .05).

CONCLUSION

As family members and nursing staff spend more time with patients than physiotherapists or occupational therapists, increasing their involvement might be an important next step in the promotion of physical activity.

Opioid Consumption and Mobilization in Staged Bilateral Total Joint Arthroplasty: Did We Learn Our Lesson the First Time?

BACKGROUND

In patients who require bilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA), staged procedures are a reasonable option for treatment of bilateral osteoarthritis. We sought to determine whether perioperative outcomes differed between first and second total joint arthroplasty (TJA).

METHODS

This was a retrospective review of all patients who underwent staged, bilateral THA or TKA between January 30, 2017, and April 8, 2021. All patients who were included underwent their second procedure within 1 year of the first. Patients were separated based on whether both their procedures took place before or subsequently after an institution-wide opioid-sparing protocol that was implemented on October 1, 2018. A total of 961 patients who underwent 1,922 procedures met the inclusion criteria for this study. For THA, 388 unique patients comprised 776 procedures, while 573 unique patients comprised 1,146 TKAs. Opioid prescriptions were prospectively documented on nursing opioid administration flowsheets and converted to morphine milligram equivalents (MME) for comparison. Activity measure scores for postacute care (AM-PAC) were used as a measurement of physical therapy progression.

RESULTS

Hospital stays, home discharges, perioperative opioid usages, pain scores, and AM-PAC scores were not significantly different for the second THA or TKA compared to first procedure, regardless of timing in relation to the opioid-sparing protocol.

CONCLUSION

Patients experienced similar outcomes following their first versus their second TJA. Limited opioid prescriptions following TJA do not negatively impact pain and functional outcomes. These protocols can safely be instituted to help mitigate the opioid epidemic.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Reducing Physical Therapy Consults for Patients With High Functional Mobility in the Acute Medical Inpatient Setting: A Difference-in-Difference Analysis

OBJECTIVE

To evaluate the effectiveness of clinical decision support for reducing misallocation of physical therapy (PT) consults.

DESIGN

A prospective quasi-experimental study. Between October 2018 and November 2021, routinely documented data on functional status and physical therapy referrals were collected from electronic medical records.

SETTING

Hospital Medicine and General Internal Medicine service lines at a large quaternary academic medical center.

PARTICIPANTS

20,810 adult patients hospitalized on any of the included treatment (hospital medicine) or control (general internal medicine) service lines.

MAIN OUTCOME MEASURE

The primary outcome was "change in proportion of misallocated PT consults" measured as likelihood of PT consults for patients admitted with high functional mobility scores. Changes in the primary outcome from the pre-intervention to post-intervention period were compared in the control and treatment groups using propensity score-weighted difference-in-differences multivariable logit regression adjusting for clinically relevant covariates.

INTERVENTION

The intervention period was measured for 20 months and consisted of a clinical decision support tool embedded in the daily note templates for hospital medicine providers. The tool provided education on patient mobility scores and their relation to need for PT consult. The tool was rolled out without any further announcements or education.

RESULTS

Our cohort included 20,810 unique admissions (mean age 58.9, 55% women, 83% Black). Post-intervention, the likelihood of PT referrals for patients with high baseline mobility (AM-PAC >18) decreased by 7.3% (P<.001) for the treatment group compared with control, adjusted for age, sex, race, ethnicity, length-of-stay, and mobility change.

CONCLUSION

Mobility score-based clinical decision support can decrease unneeded PT consults in the inpatient setting. This could help allocate therapy time for at-risk patients while also having a positive effect on health care systems.

Changes in Patterns of Referral for Inpatient Rehabilitation Cancer Patients Due to COVID-19: A Retrospective Study

ABSTRACT

There is a paucity of literature on the effect of COVID-19 on hospital processes. We hypothesized that COVID-19 was associated with decreased cancer physiatry referrals in 2020. This is a retrospective cohort study of consecutive patients from April to July 2019 and 2020 admitted at an academic quaternary cancer center. The main outcomes were number of hospital admissions, rate, and characteristics of inpatient rehabilitation admissions and change in percentage of physiatry referrals as the primary endpoint. Results showed that in 2019, there were 387 referrals from 10,274 inpatient admissions (3.8%; 95% confidence interval, 2.4-4.2), compared with 337 referrals from 7051 admissions in 2020 (4.8%; 95% confidence interval, 4.3-5.3, P = 0.001). Hematology services referred more patients than neurosurgery in 2020 (20.4% vs. 31.4%; 48.2% vs. 26.5%, P = 0.01). Discharge disposition reflected an increased frequency of return to acute care service in 2020 (10.2% vs. 21.8%, P = 0.03). In conclusion, there was an increase in the rate of physiatry referrals despite a decrease in hospital admissions. There was an increase in referrals by hematology, likely due to emphasis on safe discharge and the populations hospitalized.

Impaired hospitalized patient mobility is associated with nurse injuries

BACKGROUND

Staff injuries adversely affect the health of staff members as well the ability of health care teams to effectively care for patients. Identifying patients who pose an increased risk of injury may allow for the planning of risk mitigation strategies, but few studies have examined patient factors associated with staff injury risk.

AIMS

Examine the relationship between staff injury and patient mobility, which has been linked to other key hospital outcomes.

METHODS

Linking occupational health and electronic medical record data, we examined documented patient mobility levels, based on the Activity Measure for Post-Acute Care (AM-PAC) and the Johns Hopkins Highest Level of Mobility (JH-HLM) Scale, on the day prior to injury. In addition, we created a matched cohort of control patients not associated with staff injury to examine the influence of patient mobility on the odds of staff injury.

RESULTS

We identified 199 staff injuries associated with 181 patients with 1063 matched controls. Patients had median scores of 11 and 3 on the AM-PAC and JH-HLM, respectively, indicating moderate-severe mobility impairments. In addition, scores in the lowest AM-PAC tertile (6-15) and lowest JH-HLM tertile (1-4) were associated with a 4.46-fold and 2.90-fold increase in the odds of nurse injury, respectively.

CONCLUSIONS

These results indicate that moderate-severe mobility impairments are associated with increased risk of nurse injury. Hospitals and clinical care teams should consider documenting mobility routinely and utilizing these values to identify patients who pose an increased risk of nurse injury.

Considering Mobility Status and Home Environment in Readmission Risk After Total Knee Arthroplasty

BACKGROUND

Discharge disposition following total knee arthroplasty (TKA) offers varying levels of post-acute care monitoring depending on the medical status of the patient and his or her ability to function independently. Discharge disposition following TKA is associated with 30-day and 90-day hospital readmission, but prior studies have not consistently considered confounding due to mobility status after TKA, available caregiver support, and measures of home area deprivation. The purpose of this study was to examine 30-day and 90-day readmission risk for patients discharged to a skilled nursing facility (SNF) following TKA after controlling specifically for these factors, among other covariates.

METHODS

This was a retrospective cohort study of patients undergoing TKA at any of 11 hospitals in a single, large, academic health-care system between January 2, 2017, and August 31, 2022, who were discharged to an SNF or home health care (HHC). The adjusted relative risk of readmission within 30 and 90 days of discharge to an SNF compared with HHC was estimated using modified Poisson regression models.

RESULTS

There were 15,212 patients discharged to HHC and 1,721 patients discharged to SNFs. Readmission within 30 days was 7.1% among patients discharged to SNFs and 2.4% among patients discharged to HHC; readmission within 90 days was 12.1% for the SNF group and 4.8% for the HHC group. The adjusted relative risk after discharge to an SNF was 1.07 (95% confidence interval [CI], 0.79 to 1.46; p = 0.65) for 30-day readmission and 1.45 (95% CI, 1.16 to 1.82; p < 0.01) for 90-day readmission.

CONCLUSIONS

Discharge to an SNF compared with HHC was independently associated with 90-day readmission, but not with 30-day readmission, after controlling for mobility status after TKA, available caregiver support, and home Area Deprivation Index, among other covariates.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Prehospital tourniquet application in extremity vascular trauma: Improved functional outcomes

BACKGROUND

Support for prehospital tourniquet use has increased, with recent data suggesting that tourniquet usage decreases shock without increasing limb complications. We hypothesized that prehospital tourniquet application in extremity vascular trauma, compared with no prehospital tourniquet application, is associated with lower rates of delayed amputation and better functional mobility.

METHODS

We retrospectively studied adult patients with extremity vascular trauma at an urban civilian Level 1 trauma center (June 2016-May 2021). Outcomes of interest included delayed amputation and mobility at hospital discharge, measured by the Activity Measure for Post-Acute Care "6 Clicks" Basic Mobility Score. The "6 Clicks" Basic Mobility Score was documented by physical therapy; higher scores indicate more independent mobility. Injury mechanism, initial lactate, 24-hour transfusions, mortality, and acute kidney injury were also collected. Comparisons were performed using χ2 analysis and Fisher Exact and Wilcoxon rank-sum tests.

RESULTS

Of 232 patients, prehospital tourniquet application was not associated with mortality or lactate level (both P > .05). The prehospital tourniquet application group had more transfusions, lower rates of acute kidney injury, and fewer delayed amputations (all P < .05). Ninety-one patients (45 prehospital tourniquet application and 46 without prehospital tourniquet application) were evaluated for "Moving between Bed and Chair" in the "6 Clicks" Basic Mobility Score, with patients in the prehospital tourniquet application group demonstrating higher levels of independence (P = .034).

CONCLUSION

Prehospital tourniquet application was associated with favorable outcomes, including higher functional mobility and decreased delayed amputation. This suggests that tourniquet use should be encouraged in the civilian setting to improve outcomes and reduce the risk of limb loss.

Improving physical activity in hospitalized patients: The preliminary effectiveness of a goal-directed movement intervention

OBJECTIVE

To evaluate the preliminary effectiveness of a goal-directed movement intervention using a movement sensor on physical activity of hospitalized patients.

DESIGN

Prospective, pre-post study.

SETTING

A university medical center.

PARTICIPANTS

Patients admitted to the pulmonology and nephrology/gastro-enterology wards.

INTERVENTION

The movement intervention consisted of (1) self-monitoring of patients' physical activity, (2) setting daily movement goals and (3) posters with exercises and walking routes. Physical activity was measured with a movement sensor (PAM AM400) which measures active minutes per day.

MAIN MEASURES

Primary outcome was the mean difference in active minutes per day pre- and post-implementation. Secondary outcomes were length of stay, discharge destination, immobility-related complications, physical functioning, perceived difficulty to move, 30-day readmission, 30-day mortality and the adoption of the intervention.

RESULTS

A total of 61 patients was included pre-implementation, and a total of 56 patients was included post-implementation. Pre-implementation, patients were active 38 ± 21 minutes (mean ± SD) per day, and post-implementation 50 ± 31 minutes per day (Δ12, P = 0.031). Perceived difficulty to move decreased from 3.4 to 1.7 (0-10) (Δ1.7, P = 0.008). No significant differences were found in other secondary outcomes.

CONCLUSIONS

The goal-directed movement intervention seems to increase physical activity levels during hospitalization. Therefore, this intervention might be useful for other hospitals to stimulate inpatient physical activity.

Identifying Unique Subgroups of Individuals With Stroke Using Heart Rate and Steps to Characterize Physical Activity

Background Low physical activity (PA) is associated with poor health outcomes after stroke. Step counts are a common metric of PA; however, other physiologic signals (eg, heart rate) may help to identify subgroups of individuals poststroke at varying levels of risk of poor health outcomes. Here, we aimed to identify clinically relevant subgroups of individuals poststroke based on PA profiles that leverage multiple data sources, including step count and heart rate data, from wearable devices. Methods and Results Seventy individuals poststroke participated. Participants wore a Fitbit Inspire 2 for 1 year and completed clinical assessments. We defined a group-based steps-per-minute threshold and an individual heart rate threshold to categorize each minute of PA into 1 of 4 states: high steps/high heart rate, low steps/low heart rate, high steps/low heart rate, and low steps/high heart rate. We used the proportion of time spent in each state along with steps per day, sedentary time, mean steps among minutes with high steps and high heart rate, and resting heart rate in a k-means clustering algorithm to identify subgroups and compared Activity Measure for Post-Acute Care Mobility T Score, Stroke Impact Scale, and gait speed among subgroups. We identified 3 subgroups, Active (n=8), Sedentary (n=29), and Deconditioned (n=33), which differed significantly on all clustering variables except resting heart rate. We observed significant differences in Activity Measure for Post-Acute Care Mobility T scores between subgroups, with the Deconditioned subgroup exhibiting the lowest score. Conclusions Quantifying PA with heart rate and step count using readily available wearable devices can identify clinically meaningful subgroups of individuals poststroke.

Assessing independence in mobility activities in trauma care: Validity and reliability of the Activity Independence Measure-Trauma (AIM-T) in humanitarian settings

The importance of measuring outcomes after injury beyond mortality and morbidity is increasingly recognized, though underreported in humanitarian settings. To address shortcomings of existing outcome measures in humanitarian settings, the Activity Independence Measure-Trauma (AIM-T) was developed, and is structured in three subscales (i.e., core, lower limb, and upper limb). This study aimed to assess the AIM-T construct validity (structural validity and hypothesis testing) and reliability (internal consistency, inter-rater reliability and measurement error) in four humanitarian settings (Burundi, Iraq, Cameroon and Central African Republic). Patients with acute injury (n = 195) were assessed using the AIM-T, the Barthel Index (BI), and two pain scores. Structural validity was assessed through confirmatory factor analysis. Hypotheses were tested regarding correlations with BI and pain scores using Pearson correlation coefficient (PCC) and differences in AIM-T scores between patients' subgroups, using standardized effect size Cohen's d (d). Internal consistency was assessed with Cronbach's alpha (α). AIM-T was reassessed by a second rater in 77 participants to test inter-rater reliability using intraclass correlation coefficient (ICC). The results showed that the AIM-T structure in three subscales had an acceptable fit. The AIM-T showed an inverse weak to moderate correlation with both pain scores (PCC<0.7, p≤0.05), positive strong correlation with BI (PCC≥0.7, p≤0.05), and differed between all subgroups (d≥0.5, p≤0.05). The inter-rater reliability in the (sub)scales was good to excellent (ICC 0.86-0.91) and the three subscales' internal consistency was adequate (α≥0.7). In conclusion, this study supports the AIM-T validity in measuring independence in mobility activities and its reliability in humanitarian settings, as well as it informs on its interpretability. Thus, the AIM-T could be a valuable measure to assess outcomes after injury in humanitarian settings.

Using Nursing Assessments of Mobility and Activity to Prioritize Patients Most Likely to Need Rehabilitation Services

OBJECTIVE

To identify nursing assessments of mobility and activity associated with lower-value rehabilitation services.

DESIGN

Retrospective cohort analysis of admissions from December 2016 to September 2019 SETTING: Medicine, neurology, and surgery units (n=47) at a tertiary hospital.

PARTICIPANTS

We included patients with a length of stay ≥7 days on units that routinely assessed patient function (n=18,065 patients).

INTERVENTIONS

Not applicable.

MAIN OUTCOME

We examined the utility of nursing assessments of function to identify patients who received lower-value rehabilitation consults, defined as those who received ≤1 therapy visit.

MEASURES

Patient function was assessed using 2 Activity Measure for Post-Acute Care (AM-PAC or "6 clicks") inpatient short forms: (1) basic mobility (eg, bed mobility, walking) and (2) daily activity (eg, grooming, toileting).

RESULTS

Using an AM-PAC cutoff value of ≥23 correctly identified 92.5% and 98.7% of lower-value physical therapy and occupational therapy visits, respectively. In our cohort, using a cutoff value of ≥23 on the AM-PAC would have eliminated 3482 (36%) of lower-value physical therapy consults and 4076 (34%) of lower-value occupational therapy consults.

CONCLUSIONS

Nursing assessment, using AM-PAC scores, can be used to help identify lower-value rehabilitation consults, which can then be reallocated to patients with greater rehabilitation needs. Based on our results, an AM-PAC cutoff value of ≥23 can be used as a guide to help prioritize patients with greater rehabilitation needs.

Adaptive Neuroplasticity in Brain Injury Recovery: Strategies and Insights

This review addresses the relationship between neuroplasticity and recovery from brain damage. Neuroplasticity's ability to adapt becomes crucial since brain injuries frequently result in severe impairments. We begin by describing the fundamentals of neuroplasticity and how it relates to rehabilitation. Examining different forms of brain injuries and their neurological effects highlights the complex difficulties in rehabilitation. By revealing cellular processes, we shed light on synaptic adaptability following damage. Our study of synaptic plasticity digs into axonal sprouting, dendritic remodeling, and the balance of long-term potentiation. These processes depict neural resilience amid change. Then, after damage, we investigate immediate and slow neuroplastic alterations, separating reorganizations that are adaptive from those that are maladaptive. As we go on to rehabilitation, we evaluate techniques that use neuroplasticity's potential. These methods take advantage of the brain's plasticity for healing, from virtual reality and brain-computer interfaces to constraint-induced movement therapy. Ethics and individualized neurorehabilitation are explored. We scrutinize the promise of combination therapy and the difficulties in putting new knowledge into clinical practice. In conclusion, this analysis highlights neuroplasticity's critical role in brain injury recovery, providing sophisticated approaches to improve life after damage.

Activities of Daily Living Assessment Early in Hospitalization Is Associated With Key Outcomes

IMPORTANCE

Assessing patients' activities of daily living (ADLs) function early in hospitalization may help identify patients at risk for poor outcomes.

OBJECTIVE

To investigate the association between patients' ADL function at hospital admission and length of stay, inpatient falls, hospital-acquired pressure injuries, and discharge disposition.

DESIGN

Retrospective cohort study using scores collected on the Activity Measure for Post-Acute Care Inpatient Activity Short Form (AM-PAC IASF) in routine care at admission.

SETTING

Two inpatient units at the Johns Hopkins Hospital.

PARTICIPANTS

Hospitalized patients with various diagnoses, including neurosurgical, stroke, and general neurology (N = 1,899).

RESULTS

People with lower AM-PAC scores (every 10-point difference) had increased odds (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.4-1.8) of being in the highest length-of-stay quartile (≥8 days), having an injurious fall (OR = 1.7; 95% CI = 1.3-2.2), acquiring a pressure injury (OR = 2.7; 95% CI = 1.5-5.3), and being discharged to a postacute care facility (OR = 3.02; 95% CI = 2.1-2.7).

CONCLUSIONS AND RELEVANCE

Greater functional impairments in ADLs, measured with the AM-PACS IASF, were significantly associated with worse outcomes. AM-PAC IASF scores may be useful in identifying patients with ADL deficits and targeting occupational therapy services for patients who are at higher risk for negative outcomes. What This Article Adds: Early assessment of ADL function in routine care of hospitalized patients may aid in treatment and care plan decisions, particularly for inpatients who may be at higher risk for adverse outcomes.

Peripheral Nerve Catheter Reduces Postoperative Opioid Consumption and Pain in Revision Total Knee Arthroplasty

Background

Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels.

Methods

A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively.

Results

Compared to the control group, the PNC group demonstrated significantly lower overall inpatient opiate consumption (98.68 ± 117.03 vs 176.69 ± 203.47 morphine milligram equivalents; 44.15% decrease, P = .021) and lower verbal rating scale pain scores at 60 to 72 hours postoperatively (4.85 ± 1.24 vs 5.83 ± 1.35; 16.81% decrease, P = .038). There was no significant difference in Activity Measure for Post-Acute Care scores postoperatively (raw score: 19.41 ± 3.61 vs 19.46 ± 3.18; 0.26% decrease, P = .952). Finally, the PNC cohort was significantly less likely to be readmitted within 90 days after surgery (0.0% vs 12.0%; P = .012).

Conclusions

In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control.

Level III Evidence

Retrospective Cohort Study.

Assisted ambulation to improve health outcomes for older medical inpatients (AMBULATE): study protocol for a randomized controlled trial

BACKGROUND

Hospitalized older adults spend as much as 95% of their time in bed, which can result in adverse events and delay recovery while increasing costs. Observational studies have shown that general mobility interventions (e.g., ambulation) can mitigate adverse events and improve patients' functional status. Mobility technicians (MTs) may address the need for patients to engage in mobility interventions without overburdening nurses. There is no data, however, on the effect of MT-assisted ambulation on adverse events or functional status, or on the cost tradeoffs if a MT were employed. The AMBULATE study aims to determine whether MT-assisted ambulation improves mobility status and decreases adverse events for older medical inpatients. It will also include analyses to identify the patients that benefit most from MT-assisted mobility and assess the cost-effectiveness of employing a MT.

METHODS

The AMBULATE study is a multicenter, single-blind, parallel control design, individual-level randomized trial. It will include patients admitted to a medical service in five hospitals in two regions of the USA. Patients over age 65 with mild functional deficits will be randomized using a block randomization scheme. Those in the intervention group will ambulate with the MT up to three times daily, guided by the Johns Hopkins Mobility Goal Calculator. The intervention will conclude at hospital discharge, or after 10 days if the hospitalization is prolonged. The primary outcome is the Short Physical Performance Battery score at discharge. Secondary outcomes are discharge disposition, length of stay, hospital-acquired complications (falls, venous thromboembolism, pressure ulcers, and hospital-acquired pneumonia), and post-hospital functional status.

DISCUSSION

While functional decline in the hospital is multifactorial, ambulation is a modifiable factor for many patients. The AMBULATE study will be the largest randomized controlled trial to test the clinical effects of dedicating a single care team member to facilitating mobility for older hospitalized patients. It will also provide a useful estimation of cost implications to help hospital administrators assess the feasibility and utility of employing MTs.

TRIAL REGISTRATION

Registered in the United States National Library of Medicine clinicaltrials.gov (# NCT05725928). February 13, 2023.

Identifying Comorbid Subtypes of Patients With Acute Respiratory Failure

BACKGROUND

Patients with acute respiratory failure have multiple risk factors for disability following their intensive care unit stay. Interventions to facilitate independence at hospital discharge may be more effective if personalized for patient subtypes.

OBJECTIVES

To identify subtypes of patients with acute respiratory failure requiring mechanical ventilation and compare post-intensive care functional disability and intensive care unit mobility level among subtypes.

METHODS

Latent class analysis was conducted in a cohort of adult medical intensive care unit patients with acute respiratory failure receiving mechanical ventilation who survived to hospital discharge. Demographic and clinical medical record data were collected early in the stay. Clinical characteristics and outcomes were compared among subtypes by using Kruskal-Wallis tests and χ2 tests of independence.

RESULTS

In a cohort of 934 patients, the 6-class model provided the optimal fit. Patients in class 4 (obesity and kidney impairment) had worse functional impairment at hospital discharge than patients in classes 1 through 3. Patients in class 3 (alert patients) had the lowest magnitude of functional impairment (P < .001) and achieved the earliest out-of-bed mobility and highest mobility level of all subtypes (P < .001).

CONCLUSIONS

Acute respiratory failure survivor subtypes identified from clinical data available early in the intensive care unit stay differ in post-intensive care functional disability. Future research should target high-risk patients in early rehabilitation trials in the intensive care unit. Additional investigation of contextual factors and mechanisms of disability is critical to improving quality of life in acute respiratory failure survivors.

Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury

IMPORTANCE

Occupational therapy practitioners are uniquely qualified to address the occupational needs of people with traumatic brain injury (TBI) and their caregivers to maximize participation, health, and well-being.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews of the effectiveness of interventions that address impairments and skills to improve the occupational performance of people with TBI, as well as interventions for caregivers of people with TBI. The purpose of these guidelines is to summarize the current evidence available to assist clinicians' clinical decision-making in providing interventions for people with TBI and their caregivers.

METHOD

We reviewed six systematic reviews and synthesized the results into clinical recommendations to be used in occupational therapy clinical practice.

RESULTS

Sixty-two articles served as the basis for the clinical recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports multimodal sensory stimulation, unimodal auditory stimulation, physical activity, virtual reality, cognitive interventions, vision therapy, goal-focused interventions, individual and group training and education, and caregiver supports. Occupational therapy practitioners should incorporate these interventions into individual and group sessions to maximize recovery and promote occupational participation. Additional interventions are also available, based on emerging evidence and expert opinion, including prevention approaches, complexity of injury, and the use of occupation-based performance assessments. What This Article Adds: These Practice Guidelines provide a summary of evidence in clinical recommendations tables supporting occupational therapy interventions that address impairments resulting from and skills to improve occupational performance after TBI. The guidelines also include case study examples and evidence graphics for practitioners to use to support clinical reasoning when selecting interventions that address the goals of the person with TBI and their caregiver's needs.

Inspiratory Muscle Training While Hospitalized With Acute COVID-19 Respiratory Failure: A Randomized Controlled Trial

Although inspiratory muscle training (IMT) has been used in outpatient settings for patients who recovered from COVID-19 respiratory failure, little data exist to support earlier implementation in acute care hospitals. This study aimed to assess the safety and feasibility of IMT during the acute disease phase of COVID-19.

Design Setting and Patients

Sixty patients presenting with COVID-19 to a single academic medical center were randomized to control or intervention groups using systematic randomization.

Measurements

Participants in the control group had their maximal inspiratory pressure (MIP) measured at enrollment and hospital discharge. They were also asked for their rating of perceived exertion on the Revised Borg Scale for Grading Severity of Dyspnea and were scored by researchers on the Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks Mobility Scale and the Intensive Care Unit Mobility Scale (IMS). Control group patients otherwise received standard care. Participants in the intervention group, in addition to the measures described previously, received inspiratory threshold trainers with the goal of doing 2 sessions daily with a physical therapist for the duration of their inpatient hospitalization. In these sessions, the patient completed 3 sets of 10 breaths with the trainer. Initial resistance was set at 30% of their MIP, with resistance increasing 1 level for the subsequent session if the patients rated their during-activity rating of perceived exertion as less than 2. Changes in functional outcome measures, amount of supplemental oxygen, hospital length of stay (LOS), discharge location, adverse events, and mortality were assessed in group comparisons.

Results

Of 60 enrolled patients, 41 (n = 19 in intervention and n = 22 in control) were included in the final data set, which required completion of the study, initial and discharge data points collected, and survival of hospitalization. Final groups were statistically similar. A total of 161 sessions of IMT were completed among the 19 patients in the intervention group. Mortality totaled 2 in the control group and 3 in the intervention group and adverse events during intervention occurred in only 3 (1.8%) sessions, all of which were minor oxygen desaturations. Sessions were unable to be completed for all potential reasons 11% of possible times. Dropout rate in the intervention group was 3 (10%). Both intervention and control groups demonstrated improved MIP, decreased supplemental oxygen requirements, improved function on the AM-PAC, and slightly decreased function on the IMS. Length of stay was shorter in the intervention group, and discharge disposition was similar between groups.

Conclusions

With a low number of recorded adverse events, similar mortality between groups, and successful completion of 161 exercise sessions, IMT may be a feasible and safe intervention for some hospitalized patients with COVID-19.

The Risk Assessment and Prediction Tool (RAPT) Score Predicts Discharge Destination, Length of Stay, and Postoperative Mobility after Total Joint Arthroplasty

INTRODUCTION

Predicting an arthroplasty patient's discharge disposition, length of stay, and physical function is helpful because it allows for preoperative patient optimization, expectation management, and discharge planning. The goal of this study was to evaluate the ability of the Risk Assessment and Prediction Tool (RAPT) score to predict discharge destination, length of stay, and postoperative mobility in patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

Primary unilateral TKAs (n=9,064) and THAs (n=8,649) performed for primary osteoarthritis at our institution from 2018 to 2021 (excluding March to June 2020) were identified using a prospectively maintained institutional registry. We evaluated the associations between preoperative RAPT score and (1) discharge destination, (2) length of stay, and postoperative mobility as measured by (3) successful ambulation on the day of surgery and (4) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" score.

RESULTS

On multivariable analyses adjusting for multiple covariates, every one-point increase in RAPT score among TKA patients was associated with a 1.82-fold increased odds of home discharge (P<0.001), 0.22 days shorter length of stay (P<0.001), 1.13-fold increased odds of ambulating on postoperative day 0 (P<0.001), and 0.25-point higher AM-PAC score (P<0.001). Similar findings were seen among THAs. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict home discharge.

CONCLUSION

Among nearly 18,000 TKA and THA patients, RAPT score was predictive of discharge disposition, length of stay, and postoperative mobility. A RAPT score of 8 or higher was the most sensitive and specific cutoff to predict discharge to home. In contrast to prior studies of the RAPT score which have grouped TKAs and THAs together, this study ran separate analyses for TKAs and THAs and found that THA patients seemed to perform better than TKA patients with equal RAPT scores, suggesting that RAPT may behave differently between TKAs and THAs, particularly in the intermediate risk RAPT range.

How oral intake, mobility, and activity measures can inform discharge recommendations: A retrospective analysis of hospitalized inmate and non-inmate COVID-19 patients

BACKGROUND

Patients who were incarcerated were disproportionately impacted by COVID-19 compared to the general public. Further, the impact of multidisciplinary rehabilitation assessments and interventions on the outcomes of patients admitted to the hospital with COVID-19 is limited.

OBJECTIVE

To compare functional outcomes of oral intake, mobility, and activity between inmates and non-inmates who were diagnosed with COVID-19 and examine the relationships among these functional measures and discharge destination.

METHODS

A retrospective analysis was performed on patients admitted to the hospital for COVID-19 at a large academic medical center. Scores on functional measures including Functional Oral Intake Scale (FOIS) and Activity Measure for Post-Acute Care (AM-PAC) were collected and compared between inmates and non-inmates. Binary logistic regression models were used to evaluate the odds of 1) whether patients were discharged to the same place they were admitted and 2) patients being discharged with a total oral diet with no restrictions. Independent variables were considered significant if the 95% CIs of the odds ratios (ORs) did not include 1.0.

RESULTS

A total of 83 patients (inmates, n=38; non-inmates, n=45) were included in the final analysis. There were no differences between inmates and non-inmates on initial (P=.39) and final FOIS scores (P=.35) or on initial, final, or change scores (P>.05) on the AM-PAC. When examining separate regression models using AM-PAC mobility or AM-PAC activity scores as independent variables, greater age upon admission decreased the odds (OR=0.922; 95%CI=0.875 to 0.972 and OR=0.918; 95%CI=0.871 to 0.968) of patients being discharged with a total oral diet with no restrictions. The following factors increased the odds of patients being discharged to the same place they were admitted from: being an inmate (OR=5.285; 95%CI= 1.334 to 20.931) and (OR=6.083; 95%CI=1.548 to 23.912); "Other" race (OR=7.596; 95%CI=1.203 to 47.968) and (OR=8.515; 95%CI=1.311 to 55.291); and female sex (OR=4.671; 95%CI=1.086 to 20.092) and (OR=4.977; 95%CI=1.146 to 21.615).

CONCLUSIONS

Results from this study provide an opportunity to learn how functional measures may be used to better understand discharge outcomes in both inmate and non-inmate patients admitted to the hospital with COVID-19 during the initial period of the pandemic.

CLINICALTRIAL

Postoperative Mobilization Protocol in Lumbar Laminectomy Patients

There are often misconceptions associated with early mobilization in postoperative spine surgery patients related to initiating mobility and staff responsibilities. Nursing staff and nursing certified technicians are responsible for ambulating patients after lumbar laminectomy surgery, resulting in improvement in clinical outcomes (Rupich et al., 2018). Lack of early mobilization in postoperative lumbar laminectomy patients may result in complications such as hospital-acquired weakness, infection, and increased length of hospital stay (Fiasconaro et al., 2020). The purpose of this quality improvement (QI) project was to increase mobilization at 24 and 48 hours in postoperative lumbar laminectomy patients as evidenced by improved electronic medical record (EMR) documentation. The Plan-Do-Check-Act (PDCA) model was used to frame the project, which took place on a neurological focused care unit in a Midwest tertiary care center. A retrospective chart audit indicated that documentation of mobility in the postoperative lumbar laminectomy patients was lacking. Staff education, using a self-paced module, was initiated related to the benefits of mobility in postoperative lumbar laminectomy patients and the importance of documentation in the EMR. The use of the John Hopkins Highest Level of Mobility scale and 6-clicks scale was discussed. A secondary chart review over 4 weeks posteducation showed results of improved documentation of early mobilized patients. This QI project demonstrated the impact of staff education on promoting mobility and appropriate documentation in the postoperative laminectomy patient. Future retrospective chart reviews will be undertaken to determine the effectiveness of a one-time education workshop on the impact of early ambulation over time.

Revealing the tension: The relationship between high fall risk categorization and low patient mobility

BACKGROUND

Using an inpatient fall risk assessment tool helps categorize patients into risk groups which can then be targeted with fall prevention strategies. While potentially important in preventing patient injury, fall risk assessment may unintentionally lead to reduced mobility among hospitalized patients. Here we examined the relationship between fall risk assessment and ambulatory status among hospitalized patients.

METHODS

We conducted a retrospective cohort study of consecutively admitted adult patients (n = 48,271) to a quaternary urban hospital that provides care for patients of broad socioeconomic and demographic backgrounds. Non-ambulatory status, the primary outcome, was defined as a median Johns Hopkins Highest Level of Mobility <6 (i.e., patient walks less than 10 steps) throughout hospitalization. The primary exposure variable was the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) category (Low, Moderate, High). The capacity to ambulate was assessed using the Activity Measure for Post-Acute Care (AM-PAC). Multivariable regression analysis controlled for clinical demographics, JHFRAT items, AM-PAC, comorbidity count, and length of stay.

RESULTS

8% of patients at low risk for falls were non-ambulatory, compared to 25% and 54% of patients at moderate and high risk for falls, respectively. Patients categorized as high risk and moderate risk for falls were 4.6 (95% CI: 3.9-5.5) and 2.6 (95% CI: 2.4-2.9) times more likely to be non-ambulatory compared to patients categorized as low risk, respectively. For patients with high ambulatory potential (AM-PAC 18-24), those categorized as high risk for falls were 4.3 (95% CI: 3.5-5.3) times more likely to be non-ambulatory compared to patients categorized as low risk.

CONCLUSIONS

Patients categorized into higher fall risk groups had decreased mobility throughout their hospitalization, even when they had the functional capacity to ambulate.

Early initiation of physical and occupational therapy while on extracorporeal life support improves patients' functional activity

PURPOSE

Managing acute respiratory distress syndrome (ARDS) patients on venovenous extracorporeal membrane oxygenation (V-V ECMO), without sedation/neuromuscular blockade to allow physical and occupational therapy (PT/OT) participation, is untraditional. Here, we investigate the impact of early PT/OT initiation on discharge functional activity for ARDS patients managed on V-V ECMO.

METHODS

This is a retrospective review of 67 ARDS patients managed with V-V ECMO at a single academic center from February 2018 to June 2021. Data collected included patient characteristics, days of V-V ECMO support, day of PT/OT initiation, and ambulation distance and Activity Measure for Post-Acute Care (AMPAC) Six-Clicks score on day of discharge.

RESULTS

Patients with >7 days of V-V ECMO support had decreased ambulation and AMPAC scores compared to those with <7 days (70.5 vs. 162.1, p < 0.01 and 12.3 vs. 16.4, p = 0.01, respectively). PT/OT initiation within 7 days after starting V-V ECMO significantly improved ambulation and AMPAC scores (163.5 vs. 59.5, p < 0.001, and 16.6 vs. 11.8, p < 0.01, respectively). Additionally, in patients with >7 days of V-V ECMO support, those who began PT/OT within 8 days of V-V ECMO cannulation had significantly improved ambulation and AMPAC scores (151.8 vs. 44.2, p < 0.01, and 16.5 vs. 11.0, p < 0.01, respectively).

CONCLUSION

Early PT/OT initiation in severe ARDS patients managed on V-V ECMO is associated with improved patient functional activity on day of discharge. Our study further supports the use of V-V ECMO in treatment of severe ARDS without sedation/neuromuscular blockade and specifically demonstrates PT/OT should be started early following V-V ECMO cannulation.

Rehabilitation Therapy Allocation and Changes in Physical Function Among Patients Hospitalized Due to COVID-19: A Retrospective Cohort Analysis

OBJECTIVE

Limited staffing and initial transmission concerns have limited rehabilitation services during the COVID-19 pandemic. The purpose of this analysis was to determine the associations between Activity Measure for Post-Acute Care (AM-PAC) mobility categories and allocation of rehabilitation, and in-hospital AM-PAC score change and receipt of rehabilitation services for patients with COVID-19.

METHODS

This was a retrospective cohort study of electronic health record data from 1 urban hospital, including adults with a COVID-19 diagnosis, admitted August 2020 to April 2021. Patients were stratified by level of medical care (intensive care unit [ICU] and floor). Therapy allocation (referral for rehabilitation, receipt of rehabilitation, and visit frequency) was the primary outcome; change in AM-PAC score was secondary. AM-PAC Basic Mobility categories (None [21-24], Minimum [18-21], Moderate [10-17], and Maximum [6-9]) were the main predictor variable. Primary analysis included logistic and linear regression, adjusted for covariates.

RESULTS

A total of 1397 patients (ICU: n = 360; floor: n = 1037) were included. AM-PAC mobility category was associated with therapy allocation outcomes for floor but not patients in the ICU: the Moderate category had greater adjusted odds of referral (adjusted odds ratio [aOR] = 10.88; 95% CI = 5.71-21.91), receipt of at least 1 visit (aOR = 3.45; 95% CI = 1.51-8.55), and visit frequency (percentage mean difference) (aOR = 42.14; 95% CI = 12.45-79.67). The secondary outcome of AM-PAC score improvement was highest for patients in the ICU who were given at least 1 rehabilitation therapy visit (aOR = 5.31; 95% CI = 1.90-15.52).

CONCLUSION

AM-PAC mobility categories were associated with rehabilitation allocation outcomes for floor patients. AM-PAC score improvement was highest among patients requiring ICU-level care with at least 1 rehabilitation therapy visit.

IMPACT

Use of AM-PAC Basic Mobility categories may help improve decisions for rehabilitation therapy allocation among patients who do not require critical care, particularly during times of limited resources.

The AAHKS Best Podium Presentation Research Award: A Second Dose of Dexamethasone Reduces Postoperative Opioid Consumption and Pain in Total Joint Arthroplasty

BACKGROUND

The optimal administration of dexamethasone for postoperative pain management and recovery following primary elective total joint arthroplasty (TJA) remains unclear. This study aimed to evaluate the effect of a second intravenous (IV) dose of dexamethasone on postoperative pain scores, inpatient opioid consumption, and functional recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

A retrospective review was conducted of 2,256 primary elective THAs and 1,951 primary elective TKAs between May 2020 and April 2021. Patients who received 2 perioperative doses (2D) of dexamethasone 10 mg IV were propensity-matched 1:1 to a control group who received 1 perioperative dose (1D). Primary outcomes were opiate consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and functional status assessed by the Activity Measure for Post-Acute Care (AM-PAC) scores.

RESULTS

The 2D THA and 2D TKA cohorts consumed significantly less opiates at the 24 to 48-hour and 48 to 72-hour intervals. The 2D TKA cohort had significantly lower total opiate consumption compared to the 1D TKA cohort. Compared to the 1D cohorts, the 2D THA cohort and 2D TKA cohorts had significantly lower pain scores at the 48 to 60-hour interval; additionally, the 2D TKA cohort had significantly lower pain scores in the 36 to 48-hour interval. AM-PAC scores did not differ between cohorts for both TKA and THA at any interval.

CONCLUSION

The administration of a second perioperative dexamethasone dose significantly decreased opioid consumption in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining comparable functional recovery and superior pain control.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Frequency and reasons for unplanned transfer to the primary acute care service of inpatient rehabilitation glioblastoma multiforme patients

PURPOSE

To determine the percentage of and factors associated with unplanned transfer to the acute care service of glioblastoma multiforme acute rehabilitation inpatients.

METHODS

Retrospective review of glioblastoma multiforme acute rehabilitation inpatients admitted 4/1/2016-3/31/2020 at a National Cancer Institute Comprehensive Cancer Center.

RESULTS

One hundred thirty-nine consecutive admissions of unique glioblastoma multiforme acute rehabilitation inpatients were analyzed. Fifteen patients (10.7%, 95% confidence interval 6.5-17.1%) were transferred to the acute care service for unplanned reasons. The most common reasons for transfer back were neurosurgical complication 6/15(40%), neurologic decline due to mass effect 4/15(26.7%), and pulmonary embolism 2/15(13.3%). Older age (p = 0.010), infection prior to acute inpatient rehabilitation transfer (p = 0.020), and lower activity measure of post-acute care 6-click basic mobility scores (p = 0.048) were significantly associated with transfer to the acute care service. Patients who transferred to the acute care service had significantly lower overall survival than patients who did not transfer off (log-rank test p = 0.001).

CONCLUSION

Acute inpatient physiatrists should closely monitor patients for neurosurgical and neurologic complications. The variables significantly associated with transfer to the acute care service may help identify patients at increased risk for medical complications who may require closer observation.

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.

Determinants of acute care discharge in adults with chronic obstructive pulmonary disease

CONCLUSIONS

In adults with COPD basic mobility scores on the AM-PAC "6-clicks" measure completed at discharge had the best sensitivity and specificity for predicting discharge to home and need for rehab services.

Prognosis of Individual-Level Mobility and Daily Activities Recovery From Acute Care to Community, Part 2: A Proof-of-Concept Single Group Prospective Cohort Study

OBJECTIVE

To demonstrate a proof-of-concept for prognostic models of post-stroke recovery on activity level outcomes.

DESIGN

Longitudinal cohort with repeated measures from acute care, inpatient rehabilitation, and post-discharge follow-up to 6 months post-stroke.

SETTING

Enrollment from a single Midwest USA inpatient rehabilitation facility with community follow-up.

PARTICIPANTS

One-hundred fifteen persons recovering from stroke admitted to an acute rehabilitation facility (N=115).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Activity Measure for Post-Acute Care Basic Mobility and Daily Activities domains administered as 6 Clicks and patient-reported short forms.

RESULTS

The final Basic Mobility model defined a group-averaged trajectory rising from a baseline (pseudo-intercept) T score of 35.5 (P<.001) to a plateau (asymptote) T score of 56.4 points (P<.001) at a negative exponential rate of -1.49 (P<.001). Individual baseline scores varied by age, acute care tissue plasminogen activator, and acute care length of stay. Individual plateau scores varied by walking speed, acute care tissue plasminogen activator, and lower extremity Motricity Index scores. The final Daily Activities model defined a group-averaged trajectory rising from a baseline T score of 24.5 (P<.001) to a plateau T score of 41.3 points (P<.001) at a negative exponential rate of -1.75 (P<.001). Individual baseline scores varied by acute care length of stay, and plateau scores varied by self-care, upper extremity Motricity Index, and Berg Balance Scale scores.

CONCLUSIONS

As a proof-of-concept, individual activity-level recovery can be predicted as patient-level trajectories generated from electronic medical record data, but models require attention to completeness and accuracy of data elements collected on a fully representative patient sample.