The Effect of Implementation of Preoperative and Postoperative Care Elements of a Perioperative Surgical Home Model on Outcomes in Patients Undergoing Hip Arthroplasty or Knee Arthroplasty.

BACKGROUND: The Perioperative Surgical Home (PSH) seeks to remedy the currently highly fragmented and expensive perioperative care in the United States. The 2 specific aims of this health services research study were to assess the association between the preoperative and postoperative elements of an initial PSH model and a set of (1) clinical, quality, and patient safety outcomes and (2) operational and financial outcomes, in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS: A 2-group before-and-after study design, with a nonrandomized preintervention PSH (PRE-PSH group, N = 1225) and postintervention PSH (POST-PSH group, N = 1363) data-collection strategy, was applied in this retrospective observational study. The 2 study groups were derived from 2 sequential 24-month time periods. Conventional inferential statistical tests were applied to assess group differences and associations, including regression modeling. RESULTS: Compared with the PRE-PSH group, there was a 7.2% (95% confidence interval [CI], 4.0%-10.4%, P < .001) increase in day of surgery on-time starts (adjusted odds ratio [aOR] 2.54; 95% CI, 1.70-3.80; P < .001); a 5.8% (95% CI, 3.1%-8.5%, P < .001) decrease in day of surgery anesthesia-related delays (aOR 0.66; 95% CI, 0.52-0.84, P < .001); and a 2.2% (95% CI, 0.5%-3.9%, P = .011) decrease in ICU admission rate (aOR 0.45; 95% CI, 0.31-0.66, P < .001) in the POST-PSH group. There was a 0.6 (95% CI, 0.5-0.7) decrease in the number of ICU days in the POST-PSH group compared with the PRE-PSH group (P = .028); however, there was no significant difference (0.1 day; 95% CI, -0.03 to 0.23) in the total hospital length of stay between the 2 study groups (P = .14). There was also no significant difference (1.2%; 95% CI, -0.6 to 3.0) in the all-cause readmission rate between the study groups (P = .18). Compared with the PRE-PSH group, the entire POST-PSH group was associated with a $432 (95% CI, 270-594) decrease in direct nonsurgery costs for the THA (P < .001) and a $601 (95% CI, 430-772) decrease in direct nonsurgery costs for the TKA (P < .001) patients. CONCLUSIONS: On the basis of our preliminary findings, it appears that a PSH model with its expanded role of the anesthesiologist as the "perioperativist" can be associated with improvements in the operational outcomes of increased on-time surgery starts and reduced anesthesia-related delays and day-of-surgery case cancellations, and decreased selected costs in patients undergoing THA and TKA.

Development of a Preoperative Patient Clearance and Consultation Screening Questionnaire.

The optimal timing of the preanesthesia evaluation varies with the patient's comorbidities. As anesthesiologists assume a broader role in perioperative care, there may be opportunities to provide additional patient management beyond historical routine anesthesia services. This study was thus undertaken to survey our institutional perioperative clinicians regarding their perceptions of patient medical conditions that (a) need additional time for preoperative clearance by anesthesiology before actually scheduling the date of surgery and (b) warrant additional preoperative evaluation and management services by an anesthesiologist. These data were used to create a pilot version of a Preoperative Patient Clearance and Consultation Screening Questionnaire.

Perceptions about the relative importance of patient care-related topics: a single institutional survey of its anesthesiologists, nurse anesthetists, and surgeons.

BACKGROUND: Persistently variable success has been experienced in locally translating even well-grounded national clinical practice guidelines, including in the perioperative setting. We have sought greater applicability and acceptance of clinical practice guidelines and protocols with our novel Perioperative Risk Optimization and Management Planning Tool (PROMPT™). This study was undertaken to survey our institutional perioperative clinicians regarding (a) their qualitative recommendations for (b) their quantitative perceptions of the relative importance of a series of clinical issues and patient medical conditions as potential topics for creating a PROMPT™. METHODS: We applied a mixed methods research design that involved collecting, analyzing, and "mixing" both qualitative and quantitative methods and data in a single study to answer a research question. Survey One was qualitative in nature and asked the study participants to list as free text up to 12 patient medical conditions or clinical issues that they perceived to be high priority topics for development of a PROMPT™. Survey Two was quantitative in nature and asked the study participants to rate each of these 57 specific, pre-selected clinical issues and patient medical conditions on an 11-point Likert scale of perceived importance as a potential topic for a PROMPT™. The two electronic, online surveys were completed by participants who were recruited from the faculty in our Department of Anesthesiology and Perioperative Medicine and Department of Surgery, and the cohort of hospital-employed certified registered nurse anesthetists. RESULTS: A total of 57 possible topics for a PROMPT™ was created and prioritized by our stakeholders. A strong correlation (r = 0.82, 95% CI: 0.71, 0.89, P < 0.001) was observed between the quantitative clinician survey rating scores reported by the anesthesiologists/certified registered nurse anesthetists versus the surgeons. The quantitative survey displayed strong inter-rater reliability (ICC = 0.92, P < 0.001). CONCLUSIONS: Our qualitative clinician stakeholder survey generated a comprehensive roster of clinical issues and patient medical conditions. Our subsequent quantitative clinician stakeholder survey indicated that there is generally strong agreement among anesthesiologists/certified registered nurse anesthetists and surgeons about the relative importance of these clinical issues and patient medical conditions as potential topics for perioperative optimization and risk management.

Network of movement and proximity sensors for monitoring upper-extremity motor activity after stroke: proof of principle.

OBJECTIVE: To test the convergent validity of an objective method, Sensor-Enabled Radio-frequency Identification System for Monitoring Arm Activity (SERSMAA), that distinguishes between functional and nonfunctional activity. DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: Participants (N=25) were ≥0.2 years poststroke (median, 9) with a wide range of severity of upper-extremity hemiparesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: After stroke, laboratory tests of the motor capacity of the more-affected arm poorly predict spontaneous use of that arm in daily life. However, available subjective methods for measuring everyday arm use are vulnerable to self-report biases, whereas available objective methods only provide information on the amount of activity without regard to its relation with function. The SERSMAA consists of a proximity-sensor receiver on the more-affected arm and multiple units placed on objects. Functional activity is signaled when the more-affected arm is close to an object that is moved. Participants were videotaped during a laboratory simulation of an everyday activity, that is, setting a table with cups, bowls, and plates instrumented with transmitters. Observers independently coded the videos in 2-second blocks with a validated system for classifying more-affected arm activity. RESULTS: There was a strong correlation (r=.87, P<.001) between time that the more-affected arm was used for handling objects according to the SERSMAA and functional activity according to the observers. CONCLUSIONS: The convergent validity of SERSMAA for measuring more-affected arm functional activity after stroke was supported in a simulation of everyday activity.

Method for enhancing real-world use of a more affected arm in chronic stroke: transfer package of constraint-induced movement therapy.

BACKGROUND AND PURPOSE: Constraint-induced movement therapy is a set of treatments for rehabilitating motor function after central nervous system damage. We assessed the roles of its 2 main components. METHODS: A 2 × 2 factorial components analysis with random assignment was conducted. The 2 factors were type of training and presence/absence of a set of techniques to facilitate transfer of therapeutic gains from the laboratory to the life situation (Transfer Package; TP). Participants (N=40) were outpatients ≥ 1-year after stroke with hemiparesis. The different treatments, which in each case targeted the more affected arm, lasted 3.5 hours/d for 10 weekdays. Spontaneous use of the more affected arm in daily life and maximum motor capacity of that arm in the laboratory were assessed with the Motor Activity Log and the Wolf Motor Function Test, respectively. RESULTS: Use of the TP, regardless of the type of training received, resulted in Motor Activity Log gains that were 2.4 times as large as the gains in its absence (P<0.01). These clinical results parallel previously reported effects of the TP on neuroplastic change. Both the TP and training by shaping enhanced gains on the Wolf Motor Function Test (P<0.05). The Motor Activity Log gains were retained without loss 1 year after treatment. An additional substudy (N=10) showed that a single component of the TP, weekly telephone contact with participants for 1 month after treatment, doubled Motor Activity Log scores at 6-month follow-up. CONCLUSIONS: The TP is a method for enhancing both spontaneous use of a more affected arm after chronic stroke and its maximum motor capacity. Shaping enhances the latter.

Tele-rehabilitation of upper-extremity hemiparesis after stroke: Proof-of-concept randomized controlled trial of in-home Constraint-Induced Movement therapy.

BACKGROUND: Although Constraint-Induced Movement therapy (CIMT) has been deemed efficacious for adults with persistent, mild-to-moderate, post-stroke upper-extremity hemiparesis, CIMT is not available on a widespread clinical basis. Impediments include its cost and travel to multiple therapy appointments. To overcome these barriers, we developed an automated, tele-health form of CIMT. OBJECTIVE: Determine whether in-home, tele-health CIMT has outcomes as good as in-clinic, face-to-face CIMT in adults ≥1-year post-stroke with mild-to-moderate upper-extremity hemiparesis. METHODS: Twenty-four stroke patients with chronic upper-arm extremity hemiparesis were randomly assigned to tele-health CIMT (Tele-AutoCITE) or in-lab CIMT. All received 35 hours of treatment. In the tele-health group, an automated, upper-extremity workstation with built-in sensors and video cameras was set-up in participants' homes. Internet-based audio-visual and data links permitted supervision of treatment by a trainer in the lab. RESULTS: Ten patients in each group completed treatment. All twenty, on average, showed very large improvements immediately afterwards in everyday use of the more-affected arm (mean change on Motor Activity Log Arm Use scale = 2.5 points, p < 0.001, d' = 3.1). After one-year, a large improvement from baseline was still present (mean change = 1.8, p < 0.001, d' = 2). Post-treatment outcomes in the tele-health group were not inferior to those in the in-lab group. Neither were participants' perceptions of satisfaction with and difficulty of the interventions. Although everyday arm use was similar in the two groups after one-year (mean difference = -0.1, 95% CI = -1.3-1.0), reductions in the precision of the estimates of this parameter due to drop-out over follow-up did not permit ruling out that the tele-health group had an inferior long-term outcome. CONCLUSIONS: This proof-of-concept study suggests that Tele-AutoCITE produces immediate benefits that are equivalent to those after in-lab CIMT in stroke survivors with chronic upper-arm extremity hemiparesis. Cost savings possible with this tele-health approach remain to be evaluated.

Rehabilitation of stroke patients with plegic hands: Randomized controlled trial of expanded Constraint-Induced Movement therapy.

PURPOSE: To evaluate the efficacy of an expanded form of Constraint-Induced Movement Therapy (eCIMT) that renders CIMT, originally designed for treating mild-to-moderate upper-extremity hemiparesis, suitable for treating severe hemiparesis. METHODS: Twenty-one adults ≥1 year after stroke with severe upper-extremity hemiparesis (with little or no capacity to make movements with the more-affected hand) were randomly assigned to eCIMT (n = 10), a placebo-control procedure (n = 4), or usual care (n = 7). The participants who received usual care were crossed over to eCIMT four months after enrollment. The CIMT protocol was altered to include fitting of orthotics and adaptive equipment, selected neurodevelopmental techniques, and electromyography-triggered functional electrical stimulation. Treatment was given for 15 consecutive weekdays with 6 hours of therapy scheduled daily for the immediate eCIMT group and 3.5 hours daily for the cross-over eCIMT group. RESULTS: At post-treatment, the immediate eCIMT group showed significant gains relative to the combination of the control groups on the Grade-4/5 Motor Activity Log (MAL; mean = 1.5 points, P < 0.001, f = 4.2) and a convergent measure, the Canadian Occupational Performance Measure (COPM; mean = 2.3, P = 0.014, f = 1.1; f values ≥0.4 are considered large, on the COPM changes ≥2 are considered clinically meaningful). At 1-year follow-up, the MAL gains in the immediate eCIMT group were only 13% less than at post-treatment. The short and long-term outcomes of the crossover eCIMT group were similar to those of the immediate eCIMT group. CONCLUSIONS: This small, randomized controlled trial (RCT) suggests that eCIMT produces a large, meaningful, and persistent improvement in everyday use of the more-affected arm in adults with severe upper-extremity hemiparesis long after stroke. These promising findings warrant confirmation by a large RCT.

The Pediatric SmartShoe: Wearable Sensor System for Ambulatory Monitoring of Physical Activity and Gait.

Cerebral palsy (CP) is a group of nonprogressive neuro-developmental conditions occurring in early childhood that causes movement disorders and physical disability. Measuring activity levels and gait patterns is an important aspect of CP rehabilitation programs. Traditionally, such programs utilize commercially available laboratory systems, which cannot to be utilized in community living. In this study, a novel, shoe-based, wearable sensor system (pediatric SmartShoe) was tested on 11 healthy children and 10 children with CP to validate its use for monitoring of physical activity and gait. Novel data processing techniques were developed to remove the effect of orthotics on the sensor signals. Machine learning models were developed to automatically classify the activities of daily living. The temporal gait parameters estimated from the SmartShoe data were compared against reference measurements on a GAITRite mat. A leave-one-out cross-validation method indicated a 95.3% average accuracy of activity classification (for sitting, standing, and walking) for children with CP and 96.2% for healthy children. Average relative errors in gait parameter estimation (gait cycle, stance, swing, and step time, % single support time on both lower extremities, along with cadence) ranged from 0.2% to 6.4% (standard deviation range = 1.4%-9.9%). These results suggest that the pediatric SmartShoe can accurately measure physical activity and gait of children with CP and can potentially be used for ambulatory monitoring.

Contribution of the shaping and restraint components of Constraint-Induced Movement therapy to treatment outcome.

Two important components of Constraint-Induced Movement therapy are thought to be intense training of the more-impaired arm and physical restraint of the less-impaired arm. This preliminary study examined the effects of type of training (task-practice, shaping) and restraint (sling, half-glove, no restraint) on treatment outcomes. Seventeen individuals at least 1-year post-stroke with mild/moderate upper extremity motor deficit were consecutively assigned to Sling and Task-practice, Sling and Shaping, Half-glove and Shaping, and Shaping Only groups. Task-practice involved repetitive more-impaired arm training on functional tasks for 6 hr/day for 10 consecutive weekdays. Shaping differed from task-practice in that task demands were progressively increased and immediate performance feedback was provided frequently and systematically. "Sling" groups placed the less-impaired arm in a resting hand-splint/sling assembly for most waking hours over the 2-week intervention, while the "Half-glove" group wore a modified gardening glove as a reminder not to use the more affected arm in the life situation. There were no between-group differences in outcome at post-treatment, although two-years afterwards Sling & Task-practice and Half-glove & Shaping participants showed larger and smaller retention of gains, respectively, than those in the Sling & Shaping group. Thus, long-term outcomes may have been affected by type of more-impaired arm motor training and less-impaired arm restraint. These variables, however, were confounded with between-group differences in training intensity, limiting confidence in this conclusion.

The influence of neuropsychological characteristics on the use of CI therapy with persons with traumatic brain injury.

The great prevalence of traumatic brain injury (TBI) and its high economic costs make reducing TBI-related disability a national health care priority. In our research laboratory, CI therapy has been found to significantly improve upper extremity function for persons with chronic TBI. The results have suggested that persons with TBI are less likely to adhere to critical components of the CI therapy protocol than participants with stroke in other studies. Treatment outcomes have also been more variable. Our findings suggest that some cognitive skills appear related to treatment outcome. In addition, cognitive and behavioral deficits, commonly seen with participants with TBI, challenge the delivery of the standard CI therapy protocol with some persons. We discuss the implications of these neuropsychological factors for CI therapy used for chronic TBI and propose further research to more thoroughly investigate these issues.

An electronic surgical order, undertaking patient education, and obtaining informed consent for regional analgesia before the day of surgery reduce block-related delays.

BACKGROUND: Obtaining patient informed consent for a regional analgesia block on the day of surgery can result in surgical case delays. We hypothesized that implementing a preoperative electronic surgical order, undertaking patient education, and obtaining informed consent for a regional block in our preoperative assessment clinic prior to the day of surgery would reduce surgical case delays attributed to our regional anesthesia pain service and increase the percentage of patients for whom our regional anesthesia pain service was requested to provide a block. METHODS: A prospective two-group time-series design, with a nonrandomized, pre- and post-intervention data collection strategy, was applied. Based upon the surgeons' newly implemented preoperative electronic outpatient orders, patients were identified by our preoperative assessment clinic staff to receive educational materials. The attending anesthesiologist in the preoperative assessment clinic then obtained written informed consent. Block-related delay and utilization data were analyzed with conventional inferential statistics. RESULTS: We observed a 14.8% (95% CI: 9.4%, 20.1%; P<0.001) decrease in surgical case delays, attributed to the regional nerve block, in the post- vs pre-intervention group. In addition, there was a 9.9% (95% CI: 4.7%, 15.1%); P<0.001) increase in the proportion of patients for whom a regional nerve block was ordered by our three high-volume orthopedic surgeons in the post- vs pre-intervention time periods. CONCLUSION: When performed before the day of surgery, a surgeon's electronic order, patient education, and informed consent for regional postoperative analgesia can improve patient throughput, thereby reducing block-related operating room delays. The preoperative assessment clinic can serve as a venue to achieve this goal, thereby adding value by decreasing downstream delays on the day of surgery.

Everyday movement and use of the arms: Relationship in children with hemiparesis differs from adults.

PURPOSE: In adults with hemiparesis amount of movement of the more-affected arm is related to its amount of use in daily life. In children, little is known about everyday arm use. This report examines the relationships between everyday movement of the more-affected arm and its (a) everyday use and (b) motor capacity in children with hemiparesis. METHODS: Participants were 28 children with a wide range of upper-extremity hemiparesis subsequent to cerebral palsy due to pre- or peri-natal stroke. Everyday movement of the more-affected arm was assessed by putting accelerometers on the children's forearms for three days. Everyday use of that arm and its motor capacity were assessed with the Pediatric Motor Activity Log-Revised and Pediatric Arm Function Test, respectively. RESULTS: Intensity of everyday movement of the more-affected arm was correlated with its motor capacity (rs ≥ 0.52, ps ≤ 0.003). However, everyday movement of that arm was not correlated with its everyday use (rs ≤ 0.30, ps ≥ $ 0.126). CONCLUSIONS: In children with upper-extremity hemiparesis who meet the study intake criteria amount of movement of the more-affected arm in daily life is not related to its amount to use, suggesting that children differ from adults in this respect.

The pediatric motor activity log-revised: assessing real-world arm use in children with cerebral palsy.

OBJECTIVE: Widely accepted models of disability suggest that actual use of an impaired upper extremity in everyday life frequently deviates from its motor capacity, as measured by laboratory tests. Yet, direct measures of real-world use of an impaired upper extremity are rare in pediatric neurorehabilitation. This paper examines how well the Pediatric Motor Activity Log-Revised (PMAL-R) measures this parameter, when the PMAL-R is administered as a structured interview as originally designed. DESIGN: Parents of 60 children between 2 and 8 years of age with upper-extremity hemiparesis due to cerebral palsy completed the PMAL-R twice. Additionally, the children were videotaped during play structured to elicit spontaneous arm use. More-affected arm use was scored by masked raters; it was thought to reflect everyday activity since no cues were given about which arm to employ. Testing sessions were separated by 3 weeks, during which 29 children received upper-extremity rehabilitation and 31 did not. RESULTS: The PMAL-R had high internal consistency (Cronbach's alpha = .93) and test-retest reliability (r = .89). Convergent validity was supported by a strong correlation between changes in PMAL-R scores and more-affected arm use during play, r(53) = .5, p < .001. CONCLUSIONS: The PMAL-R interview is a reliable and valid measure of upper-extremity pediatric neurorehabilitation outcome.

Pediatric Arm Function Test: reliability and validity for assessing more-affected arm motor capacity in children with cerebral palsy.

OBJECTIVE: Although there are several validated upper-extremity measures in young children with cerebral palsy, none of these primarily assess the capacity to carry out actions and tasks with the more-affected arm. To address this need, we developed the Pediatric Arm Function Test (PAFT), which involves the behavioral observation of how children use their more-affected arm during structured play in a laboratory or clinic. This article evaluates the reliability and validity of the PAFT Functional Ability scale. DESIGN: In study 1, a total of 20 children between 2 and 8 yrs old with a wide range of upper-extremity hemiparesis caused by cerebral palsy completed the PAFT on two occasions separated by 3 wks. In study 2, a total of 41 children between 2 and 6 yrs old with similar characteristics completed the PAFT and received a grade reflecting the severity of more-affected arm motor impairment. RESULTS: In study 1, the PAFT test-retest reliability correlation coefficient was 0.74. In study 2, convergent validity was supported by a strong inverse correlation (r = -0.6, P < 0.001) between the PAFT scores and the grade of impairment. CONCLUSIONS: The PAFT Functional Ability scale is a reliable and valid measure of more-affected arm motor capacity in children between 2 and 6 yrs old with cerebral palsy. It can be used to measure upper-extremity neurorehabilitation outcome.

Sensor-enabled RFID system for monitoring arm activity: reliability and validity.

After stroke, capacity to complete tasks in the treatment setting with the more-affected arm is an unreliable index of actual use of that extremity in daily life. Available objective methods for monitoring real-world arm use rely on placing movement sensors on patients. These methods provide information on amount but not type of arm activity, e.g., functional versus nonfunctional movement. This paper presents an approach that places sensors on patients and household objects, overcoming this limitation. An accelerometer and the transmitter component of a radio-frequency proximity sensor are attached to objects; the receiver component is attached to the arm of interest. The receiver triggers an on-board radio-frequency identification tag to signal proximity when that arm is within 23 cm of an instrumented object. In benchmark testing, this system detected perfectly which arm was used to move the target object on 200 trials. In a laboratory study with 35 undergraduates, increasing the amount of time target objects were moved with the arm of interest resulted in a corresponding increase in system output . Moreover, measurement error was low ( ≤ 2.5%). The results support this system's reliability and validity in individuals with unimpaired movement; testing is now warranted in stroke patients.

Sensor-enabled RFID system for monitoring arm activity in daily life.

After stroke, capacity to carry out tasks in the treatment setting with the more-affected arm is a poor index of actual use of that extremity in daily life. However, objective methods currently available for monitoring real-world upper-extremity use only provide information on amount of activity. These methods, which rely on movement sensors worn by patients, do not provide information about type of activity (e.g., functional vs. nonfunctional movement). The benchmark testing reported here evaluated an approach that involves placing sensors on patients and objects. An accelerometer and the transmitter component of a prototype radio frequency proximity sensor were attached to household objects. The receiver component was placed on the experimenter's right arm. This device triggered an on-board radio frequency identification tag to signal proximity when that arm was within 23 cm of the objects. The system detected > 99% of 6 cm or greater movements of objects. When handling of objects by the right or left arm was determined randomly, 100% of right arm trials were detected. No signals were recorded when objects were at rest or moved by the left arm. Testing of this approach, which monitors manipulation of objects (i.e., functional movement), is now warranted in stroke patients.

A telerehabilitation platform for home-based automated therapy of arm function.

Constraint-Induced Movement Therapy (CI therapy) has been shown to be an effective approach for improving arm function in stroke survivors with mild to severe hemiparesis. Given the time-intensive nature of the intervention, and the inherent costs and travel required to receive in-clinic treatment, the accessibility and availability of CI therapy is limited. To facilitate home-based CI therapy, a telerehabilitation platform has been developed. It consists of a table-top workstation configured with a range of physical task devices (e.g. pegboard, object flipping, threading, vertical reaching). A desktop PC is used to acquire data from sensors embedded in the task devices; display visual instructions, stimuli, and feedback to the patient during tasks; and provide videoconferencing and remote connection capabilities so the therapist can interact with and monitor the patient during at-home therapy sessions. This system has potential to greatly expand access to CI therapy and make it a more realistic option for a larger number of stroke survivors with upper extremity impairment.