Clinician adherence to a standardized assessment battery across settings and disciplines in a poststroke rehabilitation population.

OBJECTIVES: (1) To examine clinician adherence to a standardized assessment battery across settings (acute hospital, inpatient rehabilitation facilities [IRFs], outpatient facility), professional disciplines (physical therapy [PT], occupational therapy, speech-language pathology), and time of assessment (admission, discharge/monthly), and (2) to evaluate how specific implementation events affected adherence. DESIGN: Retrospective cohort study. SETTING: Acute hospital, IRF, and outpatient facility with approximately 118 clinicians (physical therapists, occupational therapists, speech-language pathologists). PARTICIPANTS: Participants (N=2194) with stroke who were admitted to at least 1 of the above settings. All persons with stroke underwent standardized clinical assessments. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Adherence to Brain Recovery Core assessment battery across settings, professional disciplines, and time. Visual inspections of 17 months of time-series data were conducted to see if the events (eg, staff meetings) increased adherence ≥5% and if so, how long the increase lasted. RESULTS: Median adherence ranged from .52 to .88 across all settings and professional disciplines. Both the acute hospital and the IRF had higher adherence than the outpatient setting (P≤.001), with PT having the highest adherence across all 3 disciplines (P<.004). Of the 25 events conducted across the 17-month period to improve adherence, 10 (40%) resulted in a ≥5% increase in adherence the following month, with 6 services (60%) maintaining their increased level of adherence for at least 1 additional month. CONCLUSIONS: Actual adherence to a standardized assessment battery in clinical practice varied across settings, disciplines, and time. Specific events increased adherence 40% of the time with those gains maintained for >1 month 60% of the time.

Prediction of discharge walking ability from initial assessment in a stroke inpatient rehabilitation facility population.

OBJECTIVES: To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF. DESIGN: Retrospective cohort study. SETTING: IRF. PARTICIPANTS: Two samples of participants (n=110 and 159) admitted with stroke. INTERVENTIONS: A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4-0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants. MAIN OUTCOME MEASURE: Discharge 10-m walk speed. RESULTS: Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6-63) for sample 1 and 32 (95% CI, 10-96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present. CONCLUSIONS: A Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.

The brain recovery core: building a system of organized stroke rehabilitation and outcomes assessment across the continuum of care.

This Special Interest article describes a multidisciplinary, interinstitutional effort to build an organized system of stroke rehabilitation and outcomes measurement across the continuum of care. This system is focused on a cohort of patients who are admitted with the diagnosis of stroke to our acute facility, are discharged to inpatient and/or outpatient rehabilitation at our free-standing facility, and are then discharged to the community. This article first briefly explains the justification, goals, and purpose of the Brain Recovery Core system. The next sections describe its development and implementation, with details on the aspects related to physical therapy. The article concludes with an assessment of how the Brain Recovery Core system has changed and improved delivery of rehabilitation services. It is hoped that the contents of this article will be useful in initiating discussions and potentially facilitating similar efforts among other centers.

Assessment of patients with mild concussion in the emergency department.

OBJECTIVES: (1) To test the validity of the Standardized Assessment of Concussion (SAC) in characterizing the early evolution of concussion-related symptoms and mental status changes in the emergency department (ED) setting and (2) to compare it to the Conner's Continuous Performance Test 2nd Edition (CPT-II). DESIGN: Prospective within-subject (repeated measures) design. PARTICIPANTS: Sixty-two persons with concussion (Glasgow Coma Scale = 15) and negative head computed tomographic scan results were examined on arrival in the ED and 3 and 6 hours later. SETTING: A large urban, tertiary medical center ED. MAIN OUTCOME MEASURES: SAC; CPT-II; Post-Concussion Symptom Scale-Revised (PCS-R). RESULTS: SAC and CPT-II scores improved significantly over the time course in the ED. Symptoms did not correlate with improvement, with many subjects complaining of headache or nausea after their scores improved. The average initial score on the SAC was 21 +/- 5.4/30. CONCLUSION: The SAC appears sensitive to the acute changes following concussion. It may be a useful tool for clinicians in detecting mental status changes after a concussion, when Glasgow Coma Scale and radiologic findings are normal.