Characteristics of Acute Stroke Patients Readmitted to Inpatient Rehabilitation Facilities: A Cohort Study.

BACKGROUND: Reducing acute care readmissions from inpatient rehabilitation facilities (IRFs) is a healthcare reform goal. Stroke patients have higher acute readmission rates and persistent impairments, warranting second IRF hospitalization consideration. OBJECTIVE: To provide evidence-based information to justify IRF readmission for patients with post-stroke impairments. MAIN OUTCOME MEASURE: Variables that increase the likelihood of a second IRF hospitalization. DESIGN: Retrospective cohort study. SETTING: Seven-center rehabilitation network. PARTICIPANTS: Stroke patients, readmitted to acute care, who returned or did not return to an in-network IRF between 1 October 2014-31 December 2017(n = 380). INTERVENTIONS: Univariable analyses (Returned/Did Not Return to IRF) described demographics, stroke type and risk factors. Between group differences in readmission causes, motor impairments and functional independence measure (FIM) scores were examined. Return to IRF logistic regression model included variables with P < .1. Odds ratio and 95% CI were calculated; Relative risk was calculated for categorical variables. P < .05 equaled statistical significance. RESULTS: One hundred ninety-two stroke patients returned to IRF, 188 did not. Returned to IRF patients were younger (60.6 vs. 66 years; P < .001), sustained hemorrhagic strokes (22.4 vs. 14.2%; P = .01), had lower cardiac disease prevalence (41.7 vs. 55.3%; P = .008) or non-Medicare insurance (59.9 vs. 39.4%; P < .001). Did Not Return to IRF patients had higher admission and discharge motor and total FIM scores. Per point decrease in discharge FIM, second IRF hospitalization odds increased 4% (OR 1.04; 95% CI 1.01-1.07; P = .02). Hemorrhagic stroke patients had 33% increased odds or a 15% higher relative risk of second IRF hospitalization than patients with ischemic stroke [OR 1.33; 95% CI 1.21-1.47; RR 1.15; 95% CI 1.1-1.2; P < .001]. Non-Medicare insurance was associated with 39% increased odds or a 20% higher relative risk of second IRF hospitalization than Medicare [OR 1.39; 95% CI 1.01-1.92; RR 1.2, 95% CI 1.006-1.404; P = .04). CONCLUSIONS: Hemorrhagic stroke, non-Medicare insurance or lower discharge FIM score during the first IRF hospitalization predict a second IRF stay. Further work is needed to establish the validity of within IRF stay readmission measures.

Rehab MATRIX: Content Validity of a Nursing-Led Patient Assignment Algorithm.

PURPOSE: The provision of conscientious nursing care is at the forefront of health quality. Unfortunately, a lack of standardization in the assignment of patients to nurses can lead to care inequities. Rehab MATRIX is a nursing-led tool that equitably assigns patients using select acuity variables. DESIGN AND METHODS: In this initial study, we asked focus groups of 19 registered nurses and 8 patient care assistants to identify medical interventions that increase the effort of nursing care at a 24-bed inpatient rehabilitation facility (IRF). This IRF is affiliated with a comprehensive heart and vascular institute, a level I trauma center, and a The Joint Commission (TJC) Comprehensive Stroke Center. FINDINGS: Thirteen acuity variables were included in the Rehab MATRIX patient assignment grid. High-acuity patients with greater than 6 variables were color-coded "red," medium-acuity patients with 3 to 5 variables were color-coded "yellow," and low-acuity patients with less than 3 variables were color-coded "green." Each registered nurse and patient care assistant were assigned an equitable number of red-, yellow-, and green-coded patients per shift. New admissions were Rehab MATRIX color-coded during nursing report and assigned objectively. CONCLUSIONS: Nursing staff at a wide-ranging IRF created Rehab MATRIX, an equitable patient assignment tool, representative of nursing effort needed to provide quality care. CLINICAL RELEVANCE: Nursing-led patient assignment tools increase autonomy and provide the opportunity for all nursing staff to influence healthcare practice. These factors may lead to increased nursing satisfaction and decreased burnout.

Differential effects of Hsc70 and Hsp70 on the intracellular trafficking and functional expression of epithelial sodium channels.

The members of the cytoplasmic 70-kDa heat shock protein family are involved in appropriate folding and trafficking of newly synthesized proteins in the cell. Hsc70, which is expressed constitutively, and Hsp70, the expression of which is stress- and heat shock-induced, are often considered to have similar cellular functions in this regard, but there are suggestions that the intracellular functions of these homologous but not identical proteins may differ. We tested the hypothesis that Hsc70 and Hsp70 would have differential effects on the expression of the epithelial sodium channel (ENaC). In Xenopus oocytes, overexpression of human Hsc70 decreased the functional (defined as amiloride-sensitive whole-oocyte current) and surface expression of murine ENaC (mENaC) in a concentration-dependent fashion. In contrast, coinjection of a moderate amount of Hsp70 cRNA (10 ng) increased the functional and surface expression of mENaC, whereas a higher amount of coinjected Hsp70 cRNA (30 ng) decreased mENaC functional and surface expression. The increase in mENaC functional expression with coinjection of 10 ng of Hsp70 cRNA was antagonized by the additional coinjection of Hsc70 cRNA in a concentration-dependent fashion. These data are consistent with Hsc70 and Hsp70 having differential and antagonistic effects with regard to the intracellular trafficking of mENaC in oocytes, which may have an impact on our understanding and potential treatment of diseases of aberrant ion channel trafficking.