Process and outcome during early inpatient rehabilitation after brain injury

Purpose: To describe aspects of process and outcome during early inpatient rehabilitation of younger adults after single incident brain injury.

Method: Analysis of a database of 290 patients discharged from an inner-city hospital based inpatient unit for younger adults after single incident neurological events, over a 5-year period.

Results: Analysis showed a stable case-mix of patients over the 5 years surveyed with a preponderance of young male patients after traumatic brain injury. Improvements in patients' disability and dependency, measured by the Barthel Index and Functional Independence Measure, were recorded in the majority of patients. The ethnic diversity of the patients, reflecting the multi-cultural nature of the catchment population, did not appear to affect rehabilitation outcome. Failure to record improvement in 15% of patients was related to the floor and ceiling effects of the instruments. A useful regression equation was produced relating length of stay to Barthel score on admission.

Conclusions: These data demonstrate the changes that occur during early inpatient rehabilitation after single incident brain injury. They explore clinical indicators of dependency and outcome, and aspects of resource utilization that characterize our service. Publication of data of this sort, from this and other units, should encourage the development and improvement of current rehabilitation service delivery after brain injury.     

Reading to stroke unit patients: perceived impact and potential of an innovative arts based therapy

Objective. This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.

Setting. The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.

Design. Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.

Intervention. The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.

Results. Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.

Conclusion. This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.     

Patterns of referral to a university hospital consultation service: failure to accurately predict need for physiatric services

The purpose of this study was to determine the predictive value of screening the narrative sections of the consultation request form to determine the need for physiatric intervention rather than PT intervention alone. We conducted a review of 107 requests for consultation from various acute care services at our hospital. After reviewing the referring physician's narrative summaries, we determined that 36% of 107 patients would require physiatric evaluation, and that the remaining patients could be "passed through" to PT for treatment. After evaluation of the medical records and examination of the patients, 54% of patients required physiatric assessment and only 45% could be "passed through" to PT. The hypothesis that this narrative information would be an adequate predictor of need for physiatric consultation was rejected at the p less than 0.005 level (chi 2 = 18.63; df = 1). In addition, the referring service indicated whether it wished PT or physiatry to evaluate the patient on the consultation form. The hypothesis that screening for the need for physiatric intervention by the indicated preference of the referral was rejected at the p less than 0.0005 level (chi 2 = 20.45; df = 1). We concluded that we could not reliably predict when patients required physiatric or only PT intervention based on the consultation request narrative. Ongoing physiatric involvement on a consultative basis, educational conferences, and other forms of education for house staff and attending physicians may serve to improve understanding of physiatric services and physiatric utilization.     

Client satisfaction with service delivery of assistive technology for outdoor mobility

Purpose : In the decentralized Dutch service delivery system, client satisfaction levels for the provision of assistive technology (AT) for outdoor mobility for elderly and disabled persons was measured to investigate whether or not differences exist between local service delivery systems and if so, how these can be explained.

Method : In June 1999 a postal questionnaire was sent to a random sample of 973 adult users from three local authorities who had received their AT in 1998. Client satisfaction with the service delivery process was measured using seven items (alpha=0.88) added to the 12 items of the QUEST 2.0 scale. Demographic, health status and service delivery outcome characteristics were also measured.

Results : The response was 57%, 503 respondents were included in the analysis (mean age 71 years, 68% women). The health status of the respondents was very poor. The characteristics of the clients were comparable between local authorities but differences were found in the provision of AT. Whilst the overall satisfaction was high (1.8) a difference was found between local authorities. The percentage of clients who were 'not completely satisfied' with aspects of the service delivery process varied from 8% to 30%. One of the most important factors involved in the explanation of differences in satisfaction levels between local authorities (R 2 =11.4%) is that of 'delivery time'.

Conclusion : Differences in clients' satisfaction between service delivery systems do exist and are determined by 'delivery time', 'user opinion', 'access' and 'quality of information'.     

Bridging the gap: transitional rehabilitation services for people with spinal cord injury

Purpose : To review the current international rehabilitation and healthcare climate and describe a new model of service delivery aimed at enhancing the continuity of care for people with spinal cord injury (SCI).

Method : An extensive literature review was undertaken and a new model of service delivery conceptualized and implemented in the Australian context of SCI rehabilitation.

Results : This new model of service delivery aims to improve the rehabilitation continuum for people with SCI by reducing the time spent in hospital, increasing consumer control over the rehabilitation environment and enhancing community re-integration. The new model recognizes the changing nature of the healthcare system, the legislative frameworks within which rehabilitation services are provided and the increasing role of the consumer.

Conclusions : Models of rehabilitation that address the need for shorter periods of hospitalization and attempt to improve client outcomes are integral to ensure sustainable rehabilitation services in the future.     

Medical care services for people with intellectual disabilities living in the general community: a cross-sectional survey of inpatient care utilization in Taiwan, 2001

Background. The medical care needs and problems of persons with intellectual disabilities (ID) living in the general community have received limited attention in previous studies. The aim of this article is to describe aspects of medical care utilization among people with ID living in the general community, with particular emphasis on examining the type and determinants of inpatient care utilization in Taiwan.

Methods. A cross-sectional survey of people with intellectual disabilities was employed. A total of 997 respondents who provided fully completed data concerning inpatient care utilization were recruited into the analysis.

Results. A total of 12.4% of individuals with intellectual disabilities had used inpatient care in the 7 months prior to the survey. The average number of inpatient care visits in that time was 1.43, with an average hospital stay of 16.91 days. Surgery, fever, gastrointestinal disorders, psychiatric disorders, and accident were the main causes of inpatient care utilization. A stepwise logistic model showed that the factors of holding a Major Illness Card, regular medicine-taking and self-perceived health status were statistically significant to inpatient care utilization of people with intellectual disabilities.

Conclusions. Medical care providers and policy makers need to be aware that many people with intellectual disabilities have increased medical care needs that may require modification of standard medical care practices and service models in society.     

How well are we doing? Families of adolescents or young adults with cerebral palsy share their perceptions of service delivery

Purpose : The satisfaction of families of adolescents and young adults with a diagnosis of cerebral palsy with the service delivery they had experienced in the areas of health, education, recreation, employment, housing and transportation was examined. Common themes across the six service areas were identified.

Method : Forty-nine adolescents (13-15 years) and 39 young adults (19-23 years) and their families rated their satisfaction with services and then participated in semi-structured interviews to discuss their experiences.

Results : Using a constant comparative method of analysis, common themes were identified from the transcribed interviews. Four themes were identified and named: caring and supportive people; fighting and fatigue; communication/information; and disability awareness.

Conclusions : Families continue to experience dissatisfaction and frustration with service delivery in the six areas examined. Both bureaucratic structure and attitudes of service providers contribute to their dissatisfaction.     

Functional outcome in patients with critical illness polyneuropathy

Purpose: To evaluate the functional outcome of intensive care patients with critical illness polyneuropathy (CIP), 6 and 12 months after the onset.

Methods: Design: A prospective observational cohort study and a cross-sectional study.

Setting: University hospital in the Netherlands.

Patients: Eight consecutive intensive care patients with CIP for the prospective study and eight patients diagnosed with CIP in the past 6 months for the cross-sectional study.

Main outcome measures: Functional outcome regarding body functions and structure, activities, participation and perceived quality of life.

Results: Nine patients (56%) died within one year. Functional outcome, participation and subjective health status in survivors varied widely at 6 and 12 months. After 12 months, physical functioning was improved in all patients. However activities related to mobility outdoors, autonomy, participation and quality of life were restricted in most patients.

Conclusions: The majority of survivors have persistent functional disabilities in activities, reduced quality of life and restrictions in autonomy and participation one year after the onset of CIP. Prolonged rehabilitation treatment is necessary for an increasing number of intensive care patients who develop CIP, in order to reduce handicaps and achieve optimal autonomy and social participation.     

Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: how guidelines change management

Purpose. To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).

Method. A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.

Results. Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.

Conclusions. Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.     

The implementation and evaluation of a community rehabilitation team: a case study

Purpose: In the UK, intermediate care schemes have been implemented with short-term funding, targeted at reducing pressures on hospitals/nursing homes. Many have lacked a reliable evidence-base and there are few publications on one form of intermediate care, the community rehabilitation team (CRT). This study was conducted to establish whether one specific CRT should gain recurrent funding.

Methods: This qualitative case study took a multi-method, multi-perspective approach. Data sources included: three focus groups and 40 semi-structured interviews with patients, carers and health services/local authority/CRT staff, document review, and field notes. The resulting data were analysed thematically.

Results: The CRT was designed without sufficient reference to reliable evidence and consultation with local health/social services, and implemented against a background of cultural divides between and within these services. It was also hampered by an ambitious remit and premature attempts at outcome evaluation. Patients/carers were satisfied with interventions, functional gains and social aspects of input but there was no reliable evidence of cost-effectiveness.

Conclusions: The study highlighted problems related to service implementation, which exposed flaws within current policy of providing short-term funding for schemes that must demonstrate cost-effectiveness quickly in order to gain recurrent funding.     

Five-year experience with the 'Sheba' model of comprehensive orthogeriatric care for elderly hip fracture patients

Background and purpose: The Sheba model of orthogerioatric medicine is a unique model of in-hospital care for elderly hip fractured patients, based upon the concept that a hip fracture represents a geriatric, rather than an orthopedic disease. The nature and feasibility of such a comprehensive orthogeriatric unit, taking care of all surgical, medical and rehabilitation needs, in a single geriatric-based setting (rather than orthopedic-based), were questioned. The aim of the study is to describe the results of its operation during a five-year period.

Method: A retrospective charts analysis of consecutive older patients with hip fractures, admitted from the emergency unit directly to the orthogeriatric unit of a department of geriatric medicine.

Results: A total number of 592 patients were admitted. Mean age of patients was 83.2 years, mostly women. A total of 538 (91%) were treated surgically. Delay to surgery was 3.6 ± 2.9 days. A total of 65.6% were suitable for rehabilitation, and had a mean Functional Independence Measure (FIM) gain of 22.3 ± 7.9. Mean total hospital length of stay was 29.9 days and 68.7% of patients returned to their previous living residence. Rates of major complications (4.1%) and in-hospital mortality (3.2%, equivalent to 30 days mortality) were low.

Conclusions: Treatment within this unit was associated with low rates of major morbidity and mortality, short stay and acceptable functional outcomes. The data provide clinical evidence supporting the implementation of this model of comprehensive orthogeriatric care, being a practical, applicable and feasible service for elderly hip fractured patients, and covering the various needs of these patients. The present model of organization could also help in skillful use of economic resources, facilitating effective treatment strategies.     

A nursing perspective on the relationship between nursing and allied health in inpatient rehabilitation

Purpose. To generate a deeper understanding of contextual factors influencing nursing's contribution to inpatient rehabilitation units in Australia.

Method. Grounded theory informed by the theoretical perspective of symbolic interactionism. Data were generated by interviews with nurses and observation of their everyday practice.

Results. Nursing and allied health work in inpatient rehabilitation was segregated by divided and dividing work practices. Several contextual conditions contributed to the segregation. These were 'limited acknowledgment of nursing's complex role', 'divisive work practices' and 'discontinuous teamwork'. Segregation limited the extent to which nurses could contribute to patient rehabilitation.

Conclusion. The delivery of multi-professional inpatient rehabilitation is complex. By focusing efforts to ameliorate segregation, progress can be made towards optimizing the contribution of all disciplines to patient rehabilitation.     

Predictors of assistive technology use: the importance of personal and psychosocial factors

Objective. To validate an assistive technology (AT) baseline and outcomes measure and to quantify the measure's value in determining the best match of consumer and AT considering consumer ratings of their subjective quality of life, mood, support from others, motivation for AT use, program/therapist reliance, and self-determination/self-esteem.

Design. Prospective multi-cohort study.

Setting. Vocational rehabilitation offices and community.

Participants. Over 150 vocational rehabilitation counselors in 25 U.S. states with one consumer each receiving new AT.

Interventions. Counselor training in the Matching Person and Technology (MPT) Model and consumer completion of the MPT measure, Assistive Technology Device Predisposition Assessment (ATD PA).

Main outcome measures. Total and subscale scores on the ATD PA as well as counselor-completed questionnaires.

Results. ATD PA items differentiated consumer predispositions to AT use as well as AT and user match. There were no significant differences due to gender, physical locality, or age within this sample of working-age adult consumers. Vocational rehabilitation counselors exposed to training in the MPT Model achieved enhanced AT service delivery outcomes.

Conclusions. The ATD PA is a valid measure of predisposition to use an AT and the subsequent match of AT and user. Rehabilitation practitioners who use the ATD PA will achieve evidence-based practice and can expect to see enhanced AT service delivery outcomes.     

A program of hospice and palliative care in a private, nonprofit U.S. Teaching hospital

A hospice and palliative care program was established at Northwestern Memorial Hospital, a 773-bed private nonprofit hospital located in the urban center of Chicago. The program consists of three components: consultation service, acute inpatient unit, and home-hospice program. The consultation service saw an average of 57 new patients per month (range 45-80) in fiscal year 1997. The 12-bed acute care inpatient unit had an average midnight census of 9.8 in fiscal 1996. This decreased to 6.9 in fiscal 1997 due to new treatment approaches for AIDS and has rebounded to nine in the third quarter of fiscal 1998. The unit cares for more than one third of dying patients in the hospital. Patients do not have to access hospice insurance benefits to be admitted to the unit. The home-hospice program has a median length of stay of 31 days and serves patients living within the city limits of Chicago. A total of 800 patients were referred to the program, and 370 patients died in the program in fiscal 1997. A total of 219 different physicians were attending physicians for patients in the program during a 3- year period. Revenue exceeded direct expenses by $1.48 million. Fee-for-service billing for physician services outside of those provided or billed under the Medicare Hospice Benefit are not included in these figures. The group practice that bills for the physicians collected an average of 50.5% of billed charges over 4 years. We conclude that a program of hospice and palliative care can be successful in a private teaching hospital in the United States.     

Pattern of disability among patients attending Taif Rehabilitation Center, Saudi Arabia

Purpose. Despite the growing awareness of the community about the economic, psychological and medical impact of disability, limited research has been carried out to determine the pattern of disabilities in Saudi Arabia.

Methods. This is a cross-sectional study of hospital records of patients who were admitted to Armed Forces Rehabilitation Center, Taif, Saudi Arabia, during the period from 1999 - 2005. A total of 850 patient records were reviewed. Data were collected on age, sex, nationality, data of admission and discharge and type of disability. Univariate and multivariate logistic regression analyses were performed to determine predictors of long stay at the hospital.

Results. Trauma as an etiology of disability was more common than non-traumatic incidents among male and middle age patients (16 - 45 years). Traumatic accidents mostly result in quadriplegia (72.8%). Male, single, less than 45 years old, patients with traumatic accidents and patients with paralytic types of disability were significantly more likely to stay longer at the hospital (≥6 months).

Conclusions. The home care program should be expanded to minimize duration of stay at the rehabilitation centers with lower cost as well as health education of the public would help in encouraging disabled patients to adapt to daily life activities.     

Use of health care among adults with chronic and complex physical disabilities of childhood

Purpose. The purpose of this study was to explore the patterns of health services utilization among adults with chronic and complex physical disabilities of childhood, specifically cerebral palsy, spina bifida, and acquired brain injuries.

Methods. A cohort of 345 young adults who had graduated from the Bloorview MacMillan Children's Centre was identified. Their health care records were extracted from Ontario Health Insurance Plan (OHIP) and Canadian Institute for Health Information (CIHI) databases, for a four-year period. These data were analysed to estimate the frequency of out-patient physician visits and admissions to hospital.

Results. The mean age of the sample was 21.9 years (range 19.0-26.9 years). The results show that 95% of the sample visited a physician at least once per year, and 24% had a primary care physician. On average, these adults visited physicians 11.5 times per year (approximately once per month) and were admitted to hospital once every 6.8 years.

Conclusions. These results suggest that adults with complex physical disabling conditions from childhood have ongoing health issues that require frequent service. Their admission rate is 9.0 times that of the general population, and few have a primary care physician. A new model of service may be necessary for this high-needs group.     

Assessing the additional impact of fitness training in depressed psychiatric patients receiving multifaceted treatment: a replicated single-subject design

Purpose: Exercise has been put forward as a therapeutic means for the treatment of clinical depression.

Methods: In this study, 29 patients, all with diagnosed with mood disorder, completed daily measurements of depression and physical well-being during periods ranging from 77 to 436 days (M = 146.5). Fitness training was added to the treatment after a period and changes before (A-phase) and after (B-phase) the implementation of this training were the subject of investigation. Data were analysed by means of randomization tests with an AB-design and time-series analysis. Replication of the findings was investigated using Fisher's multiplicative method.

Results: Adding fitness training to the treatment of clinical depression does not systematically lead to changes in self-reported feelings of depression on top of benefits that may be due to other treatments.

Conclusion: Since the present findings are not in agreement with previous studies, the absence of statistically significant changes in self-reported feelings of depression is discussed within the complexity of the 'exercise - depression' relationship in inpatient populations. These included the severity of their depression, the potential ceiling effect of a multifaceted treatment programme and the initial increase in depression due to the confrontational nature of the intervention.     

Referral of patients with neuromuscular disease to occupational therapy, physical therapy and speech therapy: usual practice versus multidisciplinary advice

Purpose. To compare the volume of occupational therapy (OT), physical therapy (PT) and speech therapy (ST) as currently received by patients with neuromuscular diseases with the volume of OT, PT and ST recommended by a multidisciplinary team.

Method. The use of OT, PT and ST was studied retrospectively and prospectively in a reference group (n = 106) receiving usual care and in an intervention group (n = 102) receiving advice based on multidisciplinary assessments. A cost analysis was made and the implementation of the advice was evaluated at 6 months.

Intervention. Multidisciplinary assessments consisted of a single consultation by OT, PT and ST each, followed by a multidisciplinary meeting and integrated advice.

Outcome variables. Volume (frequency times duration) of therapy, relative over- and underuse of therapy and costs of therapy and intervention.

Results. Compared to the multidisciplinary advice, there was 40% underuse of OT among patients with neuromuscular disease. For PT, there was 32% overuse and 22% underuse; for ST, there was neither over- nor underuse. Some 40% of patients received once-only advice regarding ST compared to 27% regarding OT and 19% regarding PT. The costs of the multidisciplinary advice were estimated at €245 per patient. If fully implemented, our multidisciplinary approach would result in a mean cost savings of €85.20 per patient. The recommended therapy had, however, been implemented only partially at 6 months follow-up.

Conclusions. Some patients with a neuromuscular disease do not receive any form of allied healthcare, whereas they should. Among patients with neuromuscular disease who do receive some form of allied healthcare, quite a few receive these treatments for too long periods of time. Ways need to be developed to improve implementation of the multidisciplinary advice and to obtain a more favourable balance between its costs and benefits.