A protocol to decrease postoperative chylous effusion duration in children.

OBJECTIVE: Our primary goal was to decrease time to resolution of postoperative chylothorax as demonstrated by total days of chest tube utilisation through development and implementation of a management protocol. METHODS: A chylothorax management protocol was implemented as a quality improvement project at a tertiary-care paediatric hospital in July, 2015. Retrospective analysis was completed on patients aged 0-17 years diagnosed with chylothorax within 30 days of cardiac surgery in a pre-protocol cohort (February, 2014 to June, 2015, n=20) and a post-protocol cohort (July, 2015 to March, 2016, n=22).Measurements and resultsPatient characteristics were similar before and after protocol implementation. Duration of mechanical ventilation and cardiac ICU and hospital lengths of stay were unchanged between cohorts. Following protocol implementation, total duration of chest tube utilisation decreased from 12 to 7 days (p=0.047) with a decrease in maximum days of chest tube utilisation from 44 to 13 days. Duration of medium-chain triglyceride feeds decreased from 42 days to 31 days (p=0.01). In total, three patients in the post-protocol cohort underwent additional surgical procedures to treat chylothorax with subsequent resolution of chylothorax within 24 hours. There were no chest tube re-insertions or re-admissions related to chylothorax in either the pre- or post-protocol cohorts. Protocol compliance was 81%. CONCLUSIONS: Adoption of a chylothorax management protocol is feasible, and in our small cohort of patients implementation led to a significant decrease in the duration of chest tube utilisation, while eliminating practice variability among providers.

Intravenous Acetaminophen for Perioperative Pain Control in Adult Elective Neurospine Surgical Patients: A Retrospective Case-Control Study.

Adding intravenous (IV) acetaminophen to an opioid-based regimen as multimodal pain management for perioperative pain control in adults undergoing spine surgery can lead to effective pain control, reduce the risk of opioid-related adverse effects, and facilitate postoperative neurologic evaluation for surgical outcomes. This descriptive pilot study investigated the analgesic effect of a single dose of IV acetaminophen administered intraoperatively as routine practice for perioperative pain management for adults undergoing elective spine surgery. A retrospective comparative cohort study compared an IV acetaminophen group with a group not receiving IV acetaminophen for primary outcomes measured by visual analog scale (VAS) and associated secondary outcomes. The IV acet-aminophen group had lower mean VAS scores than the group not receiving IV acetaminophen (4.33 vs 6.22, P = .01, at 60 minutes after entry into the postanesthesia care unit [PACU] for procedure level 4; 2.43 vs 3.11, P = .002, at PACU discharge for procedure level 3). The study did not show consistently lower VAS scores for the IV acetaminophen group vs the group not receiving IV acetaminophen. No difference was found for other secondary outcomes between groups. Future prospective studies are needed to assess the analgesic effects of IV acetaminophen for spine surgery cases.

A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index.

Objective: To develop a healing index for patients with diabetic foot ulcers (DFUs) for use in clinical practice, research analysis, and clinical trials. Approach: U.S. Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, etc.). Significant variables were identified with bivariate analyses. A multivariable logistic regression model was created based on significant factors (p < 0.05) and tested on a hold-out sample of data. Out of 13,266 DFUs from the original dataset, 6,440 were eligible for analysis. The logistic regression model included 5,239 ulcers, of which 3,462 healed (66.1%). The 10% validation sample utilized 555 ulcers, of which 377 healed (67.9%). Results: Variables that significantly predicted healing were as follows: wound age (duration in days), wound size, number of concurrent wounds of any etiology, evidence of bioburden/infection, patient age, Wagner grade, being nonambulatory, renal dialysis, renal transplant, peripheral vascular disease, and patient hospitalization for any reason. Innovation: We present a validated stratification system, previously described as the Wound Healing Index (WHI), which predicts healing likelihood of patients with DFUs, incorporating patient- and wound-specific variables. Conclusion: The DFU WHI is a comprehensive and user-friendly validated predictive model for DFU healing. It can risk stratify patients enrolled in clinical research trials, stratify patient data for quality reporting and benchmarking activities, and identify patients most likely to require costly therapy to heal.

Traumatic Brain Injury-Practice Based Evidence Study: Design and Patients, Centers, Treatments, and Outcomes.

OBJECTIVES: To describe study design, patients, centers, treatments, and outcomes of a traumatic brain injury (TBI) practice-based evidence (PBE) study and to evaluate the generalizability of the findings to the U.S. TBI inpatient rehabilitation population. DESIGN: Prospective, longitudinal, observational study. SETTING: Ten inpatient rehabilitation centers. PARTICIPANTS: Patients (N=2130) enrolled between October 2008 and September 2011 and admitted for inpatient rehabilitation after an index TBI injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Return to acute care during rehabilitation, rehabilitation length of stay, FIM at discharge, residence at discharge, and 9 months postdischarge rehospitalization, FIM, participation, and subjective well-being. RESULTS: The level of admission FIM cognitive score was found to create relatively homogeneous subgroups for the subsequent analysis of best treatment combinations. There were significant differences in patient and injury characteristics, treatments, rehabilitation course, and outcomes by admission FIM cognitive subgroups. TBI-PBE study patients were overall similar to U.S. national TBI inpatient rehabilitation populations. CONCLUSIONS: This TBI-PBE study succeeded in capturing naturally occurring variation in patients and treatments, offering opportunities to study best treatments for specific patient impairments. Subsequent articles in this issue report differences between patients and treatments and associations with outcomes in greater detail.

Effects of Patient Preinjury and Injury Characteristics on Acute Rehabilitation Outcomes for Traumatic Brain Injury.

OBJECTIVE: To examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS: Severity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups. CONCLUSIONS: Findings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics.

Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury.

OBJECTIVE: To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort. DESIGN: Prospective, multicenter, longitudinal cohort study. SETTING: Acute TBI rehabilitation programs. PARTICIPANTS: Patients (N=1946) receiving 138,555 therapy sessions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS). RESULTS: The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001). CONCLUSIONS: Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies.

Enteral Nutrition for Patients With Traumatic Brain Injury in the Rehabilitation Setting: Associations With Patient Preinjury and Injury Characteristics and Outcomes.

OBJECTIVE: To determine the association of enteral nutrition (EN) with patient preinjury and injury characteristics and outcomes for patients receiving inpatient rehabilitation after traumatic brain injury (TBI). DESIGN: Prospective observational study. SETTING: Nine rehabilitation centers. PARTICIPANTS: Patients (N=1701) admitted for first full inpatient rehabilitation after TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM at rehabilitation discharge, length of stay, weight loss, and various infections. RESULTS: There were many significant differences in preinjury and injury characteristics between patients who received EN and patients who did not. After matching patients with a propensity score of >40% for the likely use of EN, patients receiving EN with either a standard or a high-protein formula (>20% of calories coming from protein) for >25% of their rehabilitation stay had higher FIM motor and cognitive scores at rehabilitation discharge and less weight loss than did patients with similar characteristics not receiving EN. CONCLUSIONS: For patients receiving inpatient rehabilitation after TBI and matched on a propensity score of >40% for the likely use of EN, clinicians should strongly consider, when possible, EN for ≥25% of the rehabilitation stay and especially with a formula that contains at least 20% protein rather than a standard formula.

Group Therapy Use and Its Impact on the Outcomes of Inpatient Rehabilitation After Traumatic Brain Injury: Data From Traumatic Brain Injury-Practice Based Evidence Project.

OBJECTIVES: To describe the amount and content of group therapies provided during inpatient rehabilitation for traumatic brain injury (TBI), and to assess the relations of group therapy with patient, injury, and treatment factors and outcomes. DESIGN: Prospective observational cohort. SETTING: Inpatient rehabilitation. PARTICIPANTS: Consecutive admissions (N=2130) for initial TBI rehabilitation at 10 inpatient rehabilitation facilities (9 in the United States, 1 in Canada) from October 2008 to September 2011. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Proportion of sessions that were group therapy (≥2 patients were treated simultaneously by ≥1 clinician); proportion of patients receiving group therapy; type of activity performed and amount of time spent in group therapy, by discipline; rehabilitation length of stay; discharge location; and FIM cognitive and motor scores at discharge. RESULTS: Of the patients, 79% received at least 1 session of group therapy, with group therapy accounting for 13.7% of all therapy sessions and 15.8% of therapy hours. On average, patients spent 2.9h/wk in group therapy. The greatest proportion of treatment time in group format was in therapeutic recreation (25.6%), followed by speech therapy (16.2%), occupational therapy (10.4%), psychology (8.1%), and physical therapy (7.9%). Group therapy time and type of treatment activities varied among admission FIM cognitive subgroups and treatment sites. Several factors appear to be predictive of receiving group therapy, with the treatment site being a major influence. However, group therapy as a whole offered little explanation of differences in the outcomes studied. CONCLUSIONS: Group therapy is commonly used in TBI rehabilitation, to varying degrees among disciplines, sites, and cognitive impairment subgroups. Various therapeutic activities take place in group therapy, indicating its perceived value in addressing many domains of functioning. Variation in outcomes is not explained well by overall percentage of therapy time delivered in groups.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Prospective observational cohort. SETTING: Inpatient rehabilitation. PARTICIPANTS: Individuals with TBI admitted consecutively for inpatient rehabilitation (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. RESULTS: A total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. CONCLUSIONS: Approximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting.

Rehospitalization During 9 Months After Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Multicenter observational cohort. SETTING: Community. PARTICIPANTS: Individuals with TBI (N=1850) admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations. RESULTS: A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logistic regression analyses revealed that older age, history of seizures before injury or during acute care or rehabilitation, history of brain injuries, and non-brain injury medical severity increased the risk of rehospitalization. Injury etiology of motor vehicle collision and high motor functioning at discharge decreased rehospitalization risk. CONCLUSIONS: Approximately 28% of patients with TBI were rehospitalized within 9 months of TBI rehabilitation discharge owing to various medical and surgical reasons. Future research should evaluate whether some of these occurrences may be preventable (such as infections, injuries, and psychiatric disorders) and should evaluate the extent to which persons at risk may benefit from additional screening, surveillance, and treatment protocols.

Factors associated with pressure ulcer risk in spinal cord injury rehabilitation.

OBJECTIVE: The aim of this study was to identify patient and clinical factors most strongly associated with a spinal cord injury patient's risk for developing a pressure ulcer (PU) during rehabilitation. DESIGN: This is a prospective observational cohort study conducted at an urban rehabilitation hospital-based specialized spinal cord injury center. The main outcome measure was the onset of a stage 2 or higher PU. RESULTS: Study patients (N = 159) with new (n = 66) and patients with earlier (n = 99) spinal injuries had identical rates at which they acquired a new PU (stage ≥2) in rehabilitation--13.1%. The patients who came to rehabilitation with a PU or myocutaneous flap exhibited a higher rate of developing yet another PU while in rehabilitation (30.2%) than those who came to rehabilitation without an existing PU or flap (6.9%). Logistic regression analysis identified two variables that best predicted a patient's risk at admission for developing a PU during rehabilitation (c = 0.77)--entering rehabilitation with a PU and admission Functional Independence Measure transfers score of less than 3.5. CONCLUSIONS: The greatest risk of developing a new PU in rehabilitation is being admitted with an existing PU followed by admission Functional Independence Measure transfers score of less than 3.5. Using these two variables, one can develop a patient PU risk algorithm at admission that can alert clinicians for the need to enhance vigilance, skin monitoring, and early patient education.

Development of a wound healing index for patients with chronic wounds.

Randomized controlled trials in wound care generalize poorly because they exclude patients with significant comorbid conditions. Research using real-world wound care patients is hindered by lack of validated methods to stratify patients according to severity of underlying illnesses. We developed a comprehensive stratification system for patients with wounds that predicts healing likelihood. Complete medical record data on 50,967 wounds from the United States Wound Registry were assigned a clear outcome (healed, amputated, etc.). Factors known to be associated with healing were evaluated using logistic regression models. Significant variables (p < 0.05) were determined and subsequently tested on a holdout sample of data. A different model predicted healing for each wound type. Some variables predicted significantly in nearly all models: wound size, wound age, number of wounds, evidence of bioburden, tissue type exposed (Wagner grade or stage), being nonambulatory, and requiring hospitalization during the course of care. Variables significant in some models included renal failure, renal transplant, malnutrition, autoimmune disease, and cardiovascular disease. All models validated well when applied to the holdout sample. The "Wound Healing Index" can validly predict likelihood of wound healing among real-world patients and can facilitate comparative effectiveness research to identify patients needing advanced therapeutics.

The impact of oxandrolone on length of stay following major burn injury: a clinical practice evaluation.

INTRODUCTION: The anabolic agent oxandrolone (OX) has been found to decrease length of stay (LOS) following 20-60% total body surface area (TBSA) burn injury. This study uses the Comprehensive Severity Index (CSI) to control for severity of illness and explores the relationship between OX and LOS in a more broadly selected sample of burn patients and a natural practice setting. METHODS: A practice-based evidence study was conducted at a single regional burn center. Maximum severity of illness (MCSIC) was measured using a burn-specific version of CSI. Data on 167 consecutive surviving patients with TBSA≥15% were analyzed using case-control matching for MCSIC, TBSA, and age. Thirty-eight patients received OX. RESULTS: Median patient age for the entire patient sample was 42.7 years. Using a 1:1 match based upon MCSIC, TBSA, then age, mean LOS for patients who received OX was 33.6 days, as opposed to 43.4 days for those who were not managed with OX (p=0.03). If patients were matched >1:1 for controls: cases, mean LOS was 40.9 days (controls) versus 31.6 days (cases). CONCLUSIONS: OX is associated with shorter LOS after controlling for MCSIC, TBSA, and age. Future comparative effectiveness studies should better define which patients derive the greatest benefits from receipt of OX during their recovery from major burn injury.

Relation between inpatient and postdischarge services and outcomes 1 year postinjury in people with traumatic spinal cord injury.

OBJECTIVE: To examine the association between inpatient and postdischarge rehabilitation services and function, life satisfaction, and community participation 1 year after spinal cord injury (SCI). DESIGN: Prospective, observational. SETTING: Six rehabilitation facilities. PARTICIPANTS: Patients with SCI (N=1376). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Satisfaction with Life Scale (SWLS), Craig Handicap Assessment and Reporting Technique (CHART), motor FIM (mFIM), and return to work/school at 1 year post-SCI. RESULTS: Demographic and injury characteristics explained 49% of the variance in mFIM and 9% to 25% of the variance in SWLS and CHART social integration, mobility, and occupation scores. Inpatient rehabilitation services explained an additional 2% of the variance for mFIM and 1% to 3% of the variance for SWLS and CHART scores. More time in inpatient physical therapy (PT) was associated with higher mFIM scores; more time in inpatient therapeutic recreation (TR) and social work and more postdischarge nursing (NSG) were associated with lower mFIM scores. More inpatient PT and TR and more postdischarge PT were associated with higher mobility scores; more inpatient psychology (PSY) was associated with lower mobility scores. More postdischarge TR was associated with higher SWLS; more postdischarge PSY services was associated with lower SWLS. Inpatient TR was positively associated with social integration scores; postdischarge PSY was negatively associated with social integration scores. More postdischarge vocational counseling was associated with higher occupation scores. Differences between centers did not explain additional variability in the outcomes studied. CONCLUSIONS: Inpatient and postdischarge rehabilitation services are weakly associated with life satisfaction and societal participation 1 year after SCI. Further study of the type and intensity of postdischarge services, and the association with outcomes, is needed to ascertain the most effective use of therapy services after SCI.

Association of various comorbidity measures with spinal cord injury rehabilitation outcomes.

OBJECTIVE: To investigate the amount of variation in short- and medium-term spinal cord injury (SCI) rehabilitation outcomes explained by various comorbidity measures, over and above patient preinjury characteristics and neurologic and functional status. DESIGN: Prospective observational cohort study of traumatic SCI patients receiving inpatient rehabilitation and followed up at 1 year postinjury. SETTING: Inpatient rehabilitation and community follow-up at 6 SCI treatment centers. PARTICIPANTS: Participants (N=1376) included 1032 patients randomly selected for model development and 344 patients selected for cross-validation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay (LOS), return to acute care during rehabilitation, discharge motor FIM, discharge home, rehospitalization after discharge, 1-year return to work/school and 1-year depression symptomatology, motor FIM, and residence. Comorbidity measures used were case-mix groups tier weights, Charlson Comorbidity Index (CCI), and the Comprehensive Severity Index (CSI). RESULTS: Multivariable regression analyses, controlling for patient preinjury and injury characteristics, found that the maximum Comprehensive Severity Index (MCSI) was a significant and stronger predictor of LOS, return to acute care during rehabilitation, and 1-year motor FIM compared with the case-mix groups tier weight or the CCI. The admission CSI was a strong predictor of LOS. For rehospitalization after discharge, only the case-mix groups tier weight was significant. No comorbidity measure was significant beyond patient preinjury and injury characteristics for discharge home, discharge motor FIM, living at home, depression symptomatology, major depressive syndrome, and return to work/school. CONCLUSIONS: Patient preinjury and injury characteristics are sufficient to predict most SCI outcomes. For rehabilitation LOS and return to acute care during rehabilitation, one achieves substantially better explanation when taking clinical comorbidity based on the MCSI into account.

Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation.

OBJECTIVE: To determine rates of rehospitalization among discharged rehabilitation patients with traumatic spinal cord injury (SCI) in the first 12 months postinjury, and to identify factors associated with rehospitalization. DESIGN: Prospective observational cohort study. SETTING: Six geographically dispersed rehabilitation centers in the U.S. PARTICIPANTS: Consecutively enrolled individuals with new traumatic SCI (N=951), who were discharged from participating rehabilitation centers and participated in a 1-year follow-up survey. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrence of postrehabilitation rehospitalization within 1 year of injury, length of rehospitalization stays, and causes of rehospitalizations. RESULTS: More than one third (36.2%) of participants were rehospitalized at least once in the 12-month follow-up period; 12.5% were rehospitalized at least twice. The average number of rehospitalizations among those rehospitalized at least once was 1.37 times, with an average length of stay (LOS) of 15.5 days across all rehospitalization episodes. The 3 most common health conditions associated with rehospitalization were those related to the genitourinary system (eg, urinary tract infection), respiratory system (eg, pneumonia), and skin and subcutaneous tissue (eg, pressure ulcer). Being a woman (95% confidence interval [CI], 1.034-2.279), having Medicaid as the main payer (95% CI, 1.303-2.936), and more severe case mix were associated with increased odds of rehospitalization. Those who had more intensive physical therapy (95% CI, .960-.981) had lower odds of rehospitalization. Some center-to-center variation in rehospitalization rates remained unexplained after case mix and practice differences were considered. The 6 SCI rehabilitation centers varied nearly 2-fold in rates at which their former SCI patients were rehospitalized--from 27.8% to 50%. Center-to-center variation diminished when patient case mix was considered. CONCLUSIONS: Compared with earlier studies, rehospitalization rates among individuals with SCI in the first postinjury year remain high and vary by level and completeness of injury. Rehospitalization risk was associated with younger age, being a woman, unemployment and retirement, and Medicaid coverage. Those who had more intensive physical therapy had lower odds of rehospitalization. Future studies should examine center-to-center variations in rehospitalization rates and availability of patient education and community resources.

Acute rehospitalizations during inpatient rehabilitation for spinal cord injury.

OBJECTIVES: To investigate frequency of and reasons for readmission to acute care (RTAC) during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to identify factors associated with RTAC. DESIGN: Prospective observational cohort. SETTING: Inpatient rehabilitation. PARTICIPANTS: Individuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation; 1032 randomly selected for model development; 344 selected for model cross-validation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: RTAC, RTAC reasons, rehabilitation length of stay (LOS), discharge location and FIM, rehospitalization between discharge and year 1, and 1-year outcomes: FIM, Craig Handicap Assessment and Reporting Technique, and Patient Health Questionnaire-9. RESULTS: Participants (n=116; 11%) experienced RTAC with a total 143 episodes--96 patients experienced only 1 RTAC, while 14 had 2 RTACs, 5 had 3 RTACs, and 1 had 4 RTACs. The most common RTAC reasons were surgery (36%), infection (22%), noninfectious respiratory (14%), and gastrointestinal (8%). Mean days ± SD from rehabilitation admission to first RTAC was 27 ± 30 days. Seventy-four (7%) patients had at least 1 RTAC for medical reasons and 46 (4%) for surgical reasons. Regression analyses indicated several variables were associated with RTACs: greater admission medical severity, lower admission cognitive FIM, pressure ulcer acquired in acute care, and study site. Medical RTACs were associated with higher body mass index, lower admission cognitive and motor FIM, payer, and study site. Predictors of surgical RTAC were longer time from injury to rehabilitation admission and study site. After controlling for the other variables, the only outcome RTAC influenced was longer rehabilitation LOS. CONCLUSIONS: Approximately 11% of SCI patients experience RTAC during the course of rehabilitation for a variety of medical and surgical reasons. RTACs are associated with longer rehabilitation LOS.

Missed therapy time during inpatient rehabilitation for spinal cord injury.

OBJECTIVES: To investigate the frequency of and reasons for missed therapy sessions during inpatient rehabilitation after traumatic spinal cord injury (SCI), and to assess the influence of demographic, medical, and injury factors on the missing of therapy sessions. DESIGN: Prospective cohort study. SETTING: Six inpatient rehabilitation centers. PARTICIPANTS: Individuals with SCI (N=1376) consecutively admitted for inpatient rehabilitation at participating sites; 1032 participants were randomly selected for model development, and 344 participants were selected for model cross-validation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Total hours of missed therapy; total minutes missed per week; and reason for missed therapy. RESULTS: Patients missed an average of 153 minutes of therapies per week, or a total of 20 hours over their rehabilitation stay. Common reasons for missing physical, occupational, and speech therapy were lack of patient readiness and medical reasons. Therapeutic recreation sessions were commonly missed because of patient refusal. More missed therapy (for any reason) was predicted by having C5-8 tetraplegia, paraplegia, greater morbidity, higher motor and cognitive functional independence, higher percent of sessions limited by fatigue, violent SCI etiology, longer rehabilitation length of stay, and treatment center. Older age, ventilator use, and percent of sessions limited by spasticity were predictive of less therapy time missed. CONCLUSIONS: On average, patients missed about 2.5 hours of therapy weekly. In view of the potential impact on rehabilitation outcomes and given the potential cost of lost resources, missed therapy deserves further study and administrative attention. In addressing this issue, there may be potential for the rehabilitation facility to intervene to reduce such lost time, including addressing equipment/therapist availability, patient readiness, patient engagement, and center-specific approaches.

Group therapy utilization in inpatient spinal cord injury rehabilitation.

OBJECTIVE: To describe group therapy utilization in spinal cord injury (SCI) inpatient rehabilitation. DESIGN: Prospective observational study. SETTING: Six inpatient rehabilitation facilities. PARTICIPANTS: Patients (N=1376) receiving initial rehabilitation after traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Time spent in group versus individual therapy for physical therapy (PT), occupational therapy (OT), therapeutic recreation (TR), and psychology (PSY) therapies. RESULTS: The majority (98%) of patients participated in at least 1 group therapy session, with 83%, 81%, 80%, and 54% of patients receiving group PT, OT, TR, and PSY, respectively. On average, 24% of treatment sessions and 27% of treatment time was provided in group sessions, with TR providing the greatest percent of its time in groups. Group therapy time and time spent in specific activities varied among patient subgroups with different injury characteristics. Group therapy time also varied widely among centers (range, 1.2-6.6h/wk). Across all injury subgroups, individual and group therapy hours per week were negatively correlated for OT and positively correlated for TR. Patient characteristics, clinician experience, and treatment center predicted 32% of variance in group hours per week. PT and OT strengthening/endurance interventions and TR outings were the most common group activities overall. CONCLUSIONS: While the majority of inpatient SCI rehabilitation consists of individual sessions, most patients participate in group therapy, which contributes significantly to total therapy time. Patterns of group utilization fit with functional expectations and clinical goals. A trade-off between group and individual therapy may occur in some disciplines. Utilization of group therapy varies widely among centers, and further study is needed to identify optimal patterns of group therapy utilization.

Outcomes and weight-bearing status during rehabilitation after arthroplasty for hip fractures.

OBJECTIVE: To examine the association of weight-bearing status with patient-related variables and outcomes of inpatient rehabilitation after hip arthroplasty for acute hip fracture. DESIGN: A multi-site prospective observational cohort study. SETTING: Eighteen skilled nursing and inpatient rehabilitation facilities. SUBJECTS: Patients with hip fractures (N = 224) treated with hip arthroplasty and admitted to either skilled nursing or inpatient rehabilitation facilities; a subset (N = 84) with telephone follow-up outcomes 8 months after rehabilitation discharge. METHODS: Measurements included demographic variables, medical severity using the Comprehensive Severity Index, and functional levels using the Functional Independence Measure. MAIN OUTCOMES MEASUREMENT: Cognitive, motor, and total Functional Independence Measure scores at rehabilitation discharge and at 8-month follow-up; living location at discharge and follow-up. RESULTS: Patients on average (standard deviation) were 76.8 ± 11.4 years old, mainly women (78%), and mainly white (87%). In unadjusted analysis, weight bearing as tolerated (WBAT) was associated with less osteoarthritis (P = .025) and lower admission medical severity (ACSI) (P = .014). One participating facility had a significant preponderance of restricted weight-bearing cases. WBAT had no bivariate association with cognitive or motor function at discharge. Therapists cited restricted weight bearing as a barrier to therapy in 11% of cases. In logistic regressions, lower medical admission severity, older age, and one specified site significantly predicted WBAT (c statistic = 0.714). Significant predictors for home discharge included lower maximum severity (P < .001), younger age (P < .001), higher cognition (P = .037), and WBAT (P = .051) (c statistic = 0.863). CONCLUSIONS: WBAT is associated with a greater likelihood of home discharge and had similar functional outcomes compared with restricted weight bearing. These findings add support for allowing WBAT after arthroplasty for hip fracture.