Impact of a function-based payment model on the financial performance of acute inpatient medical rehabilitation providers: A simulation analysis

Objectives: To operationalize research findings about a medical rehabilitation classification and payment model by building a prototype of a prospective payment system, and to determine whether this prototype model promotes payment equity. This latter objective is accomplished by identifying whether any facility or payment model characteristics are systematically associated with financial performance.Design: This study was conducted in two phases. In Phase 1 the components of a diagnosis-related group (DRG)-like payment system, including a base rate, function-related group (FRG) weights, and adjusters, were identified and estimated using hospital cost functions. Phase 2 consisted of a simulation analysis in which each facility's financial performance was modeled, based on its 1990–1991 case mix. A multivariate regression equation was conducted to assess the extent to which characteristics of 42 rehabilitation facilities contribute toward determining financial performance under the present Medicare payment system as well as under the hypothetical model developed.Participants: Phase 1 (model development) included 61 rehabilitation hospitals. Approximately 59% were rehabilitation units within a general hospital and 48% were teaching facilities. The number of rehabilitation beds averaged 52. Phase 2 of the stimulation analysis included 42 rehabilitation facilities, subscribers to UDS in 1990–1991. Of these, 69% were rehabilitation units and 52% were teaching facilities. The number of rehabilitation beds averaged 48.Main Outcome Measure: Financial performance, as measured by the ratio of reimbursement to average costs.Results: Case-mix index is the primary determinant of financial performance under the present Medicare payment system. None of the facility characteristics included in this analysis were associated with financial performance under the hypothetical FRG payment model.Conclusions: The most notable impact of an FRG-based payment model would be to create a stronger link between resource intensity and level of reimbursement, resulting in greater equity in the reimbursement of inpatient medical rehabilitation hospitals.     

Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice

Hubbard IJ, Harris D, Kilkenny MF, Faux SG, Pollack MR, Cadilhac DA. Adherence to clinical guidelines improves patient outcomes in Australian audit of stroke rehabilitation practice.ObjectiveTo study the correlation between adherence to recommended management and good recovery outcomes in an Australian cohort of inpatients receiving rehabilitation.DesignProcesses of care were audited and included those recommended in the Australian Clinical Guidelines for Stroke Rehabilitation and Recovery.SettingNational audit data from 68 rehabilitation units were used, with each hospital contributing up to 40 consecutive cases.ParticipantsNot applicable.InterventionsNot applicable.Main Outcome MeasuresDischarged home or an increase of greater than or equal to 22 in FIM scores between admission and discharge. Multivariable logistic regression models controlling for patient clustering were used to assess the associations between adherence to recommended management and recovery outcomes (dependent variables).ResultsHospitals contributed 2119 patients (median age 75y, 53% men). We found that rehabilitation units providing evidence-based management (eg, treatment for sensorimotor impairment 38%, hypertonicity 56%, mobility 94%, and home assessments 71%) were more likely to provide better recovery outcomes for people with stroke. A discharge FIM score of 100 was clinically relevant and was strongly correlated with whether or not a patient was discharged home. We found very good correlation between admission and discharge FIM scores in stroke rehabilitation.ConclusionsThis is one of the first study comparing adherence to recommended management in Australian rehabilitation units and stroke recovery outcomes based on national audit data. Novel findings include the significance of an FIM score between 80 and 100 and the clinical significance of various management processes.     

Delivering high quality hip fracture rehabilitation: the perspective of occupational and physical therapy practitioners

Aim: The majority of post-acute hip fracture rehabilitation in the US is delivered in skilled nursing facilities (SNFs). Currently, there are limited guidelines that equip occupational and physical therapy practitioners with a summary of what constitutes evidence-based high quality rehabilitation. Thus, this study aimed to identify rehabilitation practitioners’ perspectives on the practices that constitute high quality hip fracture rehabilitation.

Methods: Focus groups were conducted with 99 occupational and physical therapy practitioners working in SNFs in southern California. Purposive sampling of facilities was conducted to capture variation in key characteristics known to impact care delivery for this patient population (e.g., financial resources, staffing, and patient case-mix). Questions aimed to elicit practitioners’ perspectives on high quality hip fracture rehabilitation practices. Each session was audio-recorded and transcribed. Data were systematically analyzed using a modified grounded theory approach.

Results: Seven themes emerged: objectives of care; first 72?h; positioning, pain, and precautions; use of standardized assessments; episode of care practices; facilitating insight into progress; and interdisciplinary collaboration.

Conclusions: Clinical guidelines are critical tools to facilitate clinical decision-making and achieve desired patient outcomes. The findings of this study highlight the practitioners’ perspective on what constitutes high quality hip fracture rehabilitation. This work provides critical information to advance the development of stakeholder-driven rehabilitation clinical guidelines. Future research is needed to verify the findings from other stakeholders (e.g., patients), ensure the alignment of our findings with current evidence, and develop measures for evaluating their delivery and relationship to desired outcomes.

• Implications for Rehabilitation

• This study highlights occupational and physiotherapy therapy practitioners’ perspectives on the cumulative best practices that reflect high quality care, which should be delivered during hip fracture rehabilitation.

• While this study was limited to two professions within the broader interdisciplinary team, consistently occupational and physiotherapy therapy practitioners situated their role and practices within the team, emphasizing that high quality care was driven by collaboration among all members of the team as well as the patient and caregivers.

• Future research needs to evaluate the (a) frequency at which these practices are delivered and the relationship to patient-centered outcomes, and (b) perspectives of rehabilitation practitioners working in other PAC settings, patients, caregivers, as well as the other members of the interdisciplinary PAC team.

     

Feasibility of incorporating functionally relevant virtual rehabilitation in sub-acute stroke care: perception of patients and clinicians

Purpose: To determine user satisfaction and safety of incorporating a low-cost virtual rehabilitation intervention as an adjunctive therapeutic option for cognitive-motor upper limb rehabilitation in individuals with sub-acute stroke.

Methods: A low-cost upper limb virtual rehabilitation application incorporating realistic functionally-relevant unimanual and bimanual tasks, specifically designed for cognitive-motor rehabilitation was developed for patients with sub-acute stroke. Clinicians and individuals with stroke interacted with the intervention for 15–20 or 20–45 minutes, respectively. The study had a mixed-methods convergent parallel design that included a focus group interview with clinicians working in a stroke program and semi-structured interviews and standardized assessments (Borg Perceived Exertion Scale, Short Feedback Questionnaire) for participants with sub-acute stroke undergoing rehabilitation. The occurrence of adverse events was also noted.

Results: Three main themes emerged from the clinician focus group and patient interviews: Perceived usefulness in rehabilitation, satisfaction with the virtual reality intervention and aspects to improve. All clinicians and the majority of participants with stroke were highly satisfied with the intervention and perceived its usefulness to decrease arm motor impairment during functional tasks. No participants experienced major adverse events.

Conclusions: Incorporation of this type of functional activity game-based virtual reality intervention in the sub-acute phase of rehabilitation represents a way to transfer skills learned early in the clinical setting to real world situations. This type of intervention may lead to better integration of the upper limb into everyday activities.

• Implications for Rehabilitation

• ??Use of a cognitive-motor low-cost virtual reality intervention designed to remediate arm motor impairments in sub-acute stroke is feasible, safe and perceived as useful by therapists and patients for stroke rehabilitation.

• ??Input from end-users (therapists and individuals with stroke) is critical for the development and implementation of a virtual reality intervention.

     

Understanding nursing practice in stroke units: a Q-methodological study

Abstract

Purpose: Nurses represent the largest professional group working with stroke-survivors, but there is limited evidence regarding nurses’ involvement in post-stroke rehabilitation. The purpose of this study was to identify and explore the perspectives of nurses and other multidisciplinary stroke team members on nurses’ practice in stroke rehabilitation. Method: Q-methodological study with 63 multidisciplinary stroke unit team members and semi-structured interviews with 27 stroke unit team members. Results: Irrespective of their professional backgrounds, participants shared the view that nurses can make an active contribution to stroke rehabilitation and integrate rehabilitation principles in routine practice. Training in stroke rehabilitation skills was viewed as fundamental to effective stroke care, but nurses do not routinely receive such training. The view that integrating rehabilitation techniques can only occur when nursing staffing levels were high was rejected. There was also little support for the view that nurses are uniquely placed to co-ordinate care, or that nurses have an independent rehabilitation role. Conclusions: The contribution that nurses with stroke rehabilitation skills can make to effective stroke care was understood. However, realising the potential of nurses as full partners in stroke rehabilitation is unlikely to occur without introduction of structured competency-based multidisciplinary training in rehabilitation skills.

• Implications for Rehabilitation

• Multidisciplinary rehabilitation in stroke units is a cornerstone of effective stroke care.

• Views of stroke unit team members on nurses’ involvement in rehabilitation have not been reported previously.

• Nurses can routinely incorporate rehabilitation principles in their care.

• Specialist competency-based stroke rehabilitation training needs to be provided for nurses as well as for allied health professionals.

     

IMPLEMENTATION OF EVIDENCE-BASED ASSESSMENT OF UPPER EXTREMITY IN STROKE REHABILITATION: FROM EVIDENCE TO CLINICAL PRACTICE

ObjectiveThere is an evidence–practice gap in assessment of the upper extremities during acute and subacute stroke rehabilitation. The aim of this study was to target this gap by describing and evaluating the implementation of, and adherence to, an evidence-based clinical practice guideline for occupational therapists and physiotherapists.MethodsThe upper extremity assessment implementation process at Sahlgrenska University Hospital comprised 5 stages: mapping clinical practice, identifying evidence-based outcome measures, development of a guideline, implementation, and evaluation. A systematic theoretical framework was used to guide and facilitate the implementation process. A survey, answered by 44 clinicians (23 physiotherapists and 21 occupational therapists), was used for evaluation.ResultsThe guideline includes 6 primary standardized assessments (Shoulder Abduction, Finger Extension (SAFE), 2 items of the Actions Research Arm Test (ARAT-2), Fugl-Meyer Assessment of Upper Extremity (FMA-UE), Box and Block Test (BBT), 9-Hole Peg Test (9HPT), and grip strength (Jamar hand dynamometer)) performed at specified time-points post-stroke. More than 80% (35 to 42) clinicians reported reported being content with the guideline and the implementation process. Approximately 60–90% of the clinicians reported good adherence to specific assessments, and approximately 50% reported good adherence to the agreed time-points. Comprehensive scales were more difficult to implement compared with the shorter screening scales. High levels of work rotation among staff, and the need to prioritize other assessments during the first week after stroke, hindered to implementation.ConclusionThe robustness of evidence, adequate support and receptive context facilitated the implementation process. The guideline enables a more structured, knowledge-based and consistent assessment, and thereby supports clinical decision-making and patient involvement.LAY ABSTRACTCurrently available clinical practice guidelines do not specify which outcome measures should be used at which time-points for people after stroke. This study describes the implementation process and evaluation of a clinical practice guideline developed for the assessment of upper extremity function after stroke. The guideline is based on recent research evidence and defines the assessments, and the time-points at which the assessments should be performed. An evaluation survey showed that clinicians valued the clear structure of the guideline and found it useful for prognosis and treatment planning. Robust evidence, and active involvement of clinicians and leaders, were important elements of implementation. The guideline will potentially improve the quality of rehabilitation through increased knowledge of prognosis and treatment effects, based on the assessment of arm function in people with stroke, thereby enabling a more evidence-based, consistent, and individually tailored rehabilitation.Key words: clinical practice guideline, evidence-based practice, implementation science, stroke, rehabilitation, knowledge translation, upper extremity, assessment

Considerable efforts have been made recently in the field of stroke rehabilitation to develop evidence-based agreed guidelines for upper extremity assessment (1–4). Advances in predicting stroke outcomes, in terms of motor function and activity, have been the primary driver of this development (5–7). There is, however, a clear evidence–practice gap, since the use of recommended upper extremity outcome measures in day-to-day clinical practice is sparse. It is well recognized that valid, reliable and responsive outcome measures, performed at pre-defined time-points after stroke, are required for effective rehabilitation (2–4). Currently available clinical guidelines recommend the use of standardized outcome measures, but often do not specify what outcome measures should be used, at what frequency, or in what settings (2).The implementation of standardized recommended upper extremity outcome measures in clinical routine practice takes time and effort. Increased and consistent use of such measures is, however, required to enable person-centred informed clinical decision-making throughout the rehabilitation pathway, and thereby improve patient outcomes. Overall adherence to stroke guidelines varies, but, in general, it is greater when the implementation process includes systematic and well-defined activities (8–10). There are no recognized “gold standard” implementation activities, although multifaceted interventions involving educational outreach and a structured theoretical approach have been suggested to work best (8, 9). Organizational and multidisciplinary team factors, staff beliefs regarding the guidelines, integration of patient-centred recommendations into practice, awareness of guidelines, changing routines, and necessary time investment, are known factors affecting adherence (8, 10).The successful implementation of evidence into practice is dependent on the quality of evidence, the context, and how the evidence is introduced into practice (facilitators) (11). These 3 key elements, being part of the Promoting Action on Research Implementation in Health Services (PARIHS) theoretical framework, have been employed widely in different implementation activities (11, 12). This theoretical model prerequisites that the evidence is robust, practitioners agree with it, and the context is receptive, including the formal leaders, and that appropriate facilitation is ensured (11, 13). The Knowledge to Action (KTA) framework is another theoretical tool that has been widely used to make the process of knowledge translation into practice more systematic (14). The KTA emphasizes the importance of adapting knowledge to the local context, of involving stakeholders, and of being aware of barriers, facilitators and user needs (14).The literature is extensive regarding the implementation of stroke guidelines into clinical practice (8, 9), but only a few studies have specifically targeted assessment and use of standardized outcome measures (15, 16). More recent work on recommendations regarding upper extremity outcome measures (3) also imply a need to move this research evidence into stroke rehabilitation practice.The aim of this study was to describe and evaluate the implementation process and adherence to an evidence-based clinical practice guideline (CPG) for physical therapists (PT) and occupational therapists (OT) in the assessment of upper extremity function and activity during acute and subacute stroke rehabilitation.     

IMPACT OF REHABILITATION START TIME ON FUNCTIONAL OUTCOMES AFTER STROKE

ObjectiveTo investigate the optimum rehabilitation start timing for improved functional outcomes after stroke in Japan.DesignA retrospective database study.SubjectsA total of 140,655 patients with stroke from 1,161 acute hospitals in Japan. Only data for those patients who were discharged alive was included in the analysis.MethodsActivities of daily living were assessed. Comparisons were made using the rehabilitation start day after hospital admission. Reference day 2 was compared with days 1, 3, 4, 5, and 6 or later. Modified Rankin Scale at time of discharge was used as the primary outcome. In addition, cases of ischaemic stroke and haemorrhagic stroke were analysed as separate subgroups.ResultsUnivariate and multivariate logistic regression analyses showed that starting rehabilitation on day 2 resulted in a better outcome than starting on day 3 or later. There was no significant difference in outcome between starting rehabilitation on days 1 or 2 in all cases and subgroup of patient with infarction stroke. For a subgroup of patients with haemorrhagic stroke, starting rehabilitation on day 2 resulted in a better outcome than starting on day 1.ConclusionStarting post-stroke rehabilitation on the day of admission or second day of hospitalization may be the optimum timing for functional outcomes. However, for haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may be more effective than on the day of admission.LAY ABSTRACTThis study examined the effect on functional outcomes of the time after stroke of starting rehabilitation. A large national database was searched for eligible stroke patients, resulting in a total of 140,655 patients from 1,161 hospitals. Starting rehabilitation on the day of admission or second day of hospitalization after stroke was found to be associated with better functional outcomes at discharge than starting rehabilitation on the third day or later. For patients with haemorrhagic stroke, those who started rehabilitation on the second day of hospitalization had better functional outcome at discharge than those who started on the day of admission. Thus, starting rehabilitation on the day of admission or the second day of hospitalization after stroke may be the best timing for improved functional outcomes. However, among patients with haemorrhagic stroke, starting rehabilitation on the second day of hospitalization may result in better outcomes than starting on the day of admission.Key words: early ambulation, recovery of function, stroke, time factor

Stroke is a major factor in causing functional impairment and often requires more resources for long-term care according to the Comprehensive Survey of Living Conditions in Japan (1). The number of people requiring nursing care and support in Japan’s long-term care insurance system has been increasing every year, with more than 6 million elderly people in 2015. In recent years, there has been increasing emphasis on stroke prevention and quality stroke care to control the further expansion of the number of people requiring care (2).For good-quality stroke care, early rehabilitation after stroke onset has been proposed in several Stroke Treatment Guidelines (3–5). Mechanism that may support the effectiveness of early rehabilitation include restoration of brain function, which promotes neuroplasticity (6), and reduction of bedridden syndrome, infections, deep vein thrombosis, and pressure sores (7). However, some researchers are concerned that starting too early rehabilitation may be harmful. One reason is that a head-up position reduces reperfusion of the penumbra region (8). Another reason is that the destabilization of blood pressure with exercise can inhibit the recovery of brain function (9). In addition, most stroke specialists have concerns about very early rehabilitation, especially in cases of haemorrhagic stroke. A possible reason is that patients with haemorrhagic stroke tend to die early after the attack, although the evidence regarding the timing of rehabilitation is insufficient (10).Several randomized controlled trials (RCTs) have examined the effectiveness of early rehabilitation, but it remains a controversial topic. Two RCTs have provided evidence that early rehabilitation is effective for physical functioning (11, 12), while other RCTs (13, 14) have not found such evidence. The latest multicentre RCT (14) concludes that very early rehabilitation leads to poor outcomes for physical functioning. However, some researchers have criticized the study design due to the short mean difference in rehabilitation start times between the intervention and control groups, being only 4 h. In addition, the variation in the timing of rehabilitation initiation in each RCT makes it difficult to interpret the effectiveness of early rehabilitation. For example, in the AKEMIS study (13), the mean time from stroke onset was set at 13.1 h in the intervention group and 33.3 h in the control group, compared with 18 and 22 h in the AVERT III study, and 27 and 32 h in the VERITAS study (12). Hence, the results of these RCTs may lead many clinicians to query when is the optimum time to start early rehabilitation after stroke.From the clinician’s point of view, it is important to determine whether rehabilitation should be provided very early after stroke, and when is the optimum time to start rehabilitation for good physical functioning outcomes. This study aimed to clarify these clinical questions, by investigating the impact of the timing of rehabilitation initiation after acute stroke on functional outcomes, using patient data from a Japanese multicentre database.     

Cognitive and functional assessments of stroke patients: An analysis of their relation

Objectives: To improve the assessment of stroke patients for the purpose of designing rehabilitation treatments and predicting rehabilitation outcomes. Specific objectives included the evaluation of the power of functional scales to properly assess both physical and cognitive disabilities, and the evaluation of the relations between functional, neurological, physical, and cognitive assessments. The hypothesis was that the relations between different assessment types (eg, functional, neurological, etc) can be assessed by the relations between the results of these assessments when administered to stroke patients.Design: Sixty-six stroke patients were administered a series of tests including functional assessments (Functional Independence Measure, Barthel Index, Rankin Functional Scale), neurological assessments (Canadian Neurological Scale, National Institute of Health Stroke Scale), physical assessments (Stages of Motor Recovery, Clinical Outcome Variables Scale), and cognitive assessments (Stroke Unit Mental Status Examination, Mini Mental State, Raven Matrices, Boston Naming Test).Results: Analysis of correlation coefficients revealed that the stronger relationships were observed between functional assessments and physical assessments, and between functional assessments and neurological assessments. Cognitive tests did not correlate highly with any of the functional tests used in this study. Three factors were extracted using factor analysis. They were interpreted as being a physical disability factor (50% of the variance), a cognitive disability factor (23% of the variance), and a dementia factor (12% of variance). Functional scales obtained higher loads on the physical disability factor only.Conclusions: Considering that cognitive functions are frequently affected in stroke patients, cognitive impairment needs to be more seriously considered when describing and/or predicting a patient's level of independence. In brain injured patients, such as stroke patients, we suggest that the total score provided by standardized functional scales should be interpreted with care. We believe that rehabilitation outcome could be better predicted if the results of functional assessment were coupled with in-depth cognitive assessment.     

深圳市卫生系统康复资源调查及对策分析

目的了解深圳市卫生系统康复资源的分布和配置。方法采用调查表通过走访的形式调查深圳市卫生系统90家医疗机构,了解康复医学科的设置、人员、场地和设备等情况。结果90家医疗机构中,55家(61.1%)设有康复医学科,15家(16.7%)设有病床,共有病床384张,康复医师207人(平均2.3人),康复治疗师110人(平均1.2人);每家医疗机构康复设备价值平均为49.3万元,康复训练场地为155.6m2。结论深圳市医疗机构在康复医学科设置、康复专业人员数量方面存在明显不足,尽管场地和设备的总量较高,但分布不均衡,主要集中在大医院,基层医院较少。     

A comprehensive assessment of family caregivers of stroke survivors during inpatient rehabilitation

Abstract

Purpose: Stroke caregivers have been identified as a group at high risk for poor outcomes as a result of the suddenness of stroke and a potentially high level of care needed due to significant functional limitations of the patient. However, there is little research on the assessment of family members who will assume the caregiving role prior to patient discharge from rehabilitation. The purpose of this article is to delineate critical assessment domains identified by a subset of spousal stroke caregivers. Methods: Semi-structured interviews were conducted pre- and post-discharge from rehabilitation as part of a larger study that focused on identifying caregiver and stroke survivor needs as they transitioned home from inpatient rehabilitation. For this study, two semi-structured interviews with 14 spousal caregivers were analyzed using grounded theory methods. Results: Long-term stroke survivor outcomes were dependent upon the commitment, capacity and preparedness of the family caregiver. Twelve domains of assessment were identified and presented. Conclusions: A comprehensive, systematic caregiver assessment to understand the caregiver’s concerns about stroke should be conducted during rehabilitation to help the team to develop a plan to address unmet needs and better prepare family caregivers to take on the caregiving role.

• Implications for Rehabilitation

• Stroke is a sudden event that often leaves stroke survivors and their families in crisis.

• The needs of stroke family caregivers are not often systematically assessed as part of inpatient rehabilitation.

• Long-term stroke survivor outcomes are dependent upon the commitment, capacity and preparedness of the family caregiver.

• Stroke caregiver assessment should include the commitment, capacity and preparedness to provide care, and the overall impact of stroke in order to develop discharge plans that will adequately address the needs of the stroke survivor/caregiver dyad.

     

Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation

Purpose.?The International Classification of Functioning, Disability and Health (ICF) is advocated as a tool to structure rehabilitation and a universal language to aid communication, within the multi-disciplinary team (MDT). The ICF may also facilitate clarification of team roles and clinical reasoning for intervention. This article aims to explore both factors in stroke rehabilitation.

Method.?Following a review of the literature, a summary was presented and discussed with clinicians working within stroke rehabilitation, to gather expert opinions. The discussions were informal, being part of service development and on-going education. The clinicians summarised key themes for the potential use of the ICF within clinical practice.

Results.?Two key themes emerged from the literature and expert opinion for the potential use of the ICF in stroke rehabilitation: (i) to aid communication and structure service provision, (ii) to clarify team roles and aid clinical reasoning. Expert opinion was that clarification of team roles needs to occur at a local level due to the skill mix, particular interests, setting and staffing levels within individual teams. The ICF has the potential to demonstrate/facilitate clinical reasoning, especially when different MDT members are working on the same intervention.

Conclusion.?There is potential for the ICF to be used to clarify team roles and demonstrate clinical reasoning within stroke rehabilitation. Further experiential research is required to substantiate this view.     

Effect of early and intensive rehabilitation in acute stroke patients: retrospective pre-/post-comparison in Japanese hospital

Purpose: There is little high-quality or large-scale clinical research focusing on the effect of early and intensive rehabilitation in Eastern countries. This study aimed to determine whether an early and intensive rehabilitation program in a Japanese hospital affects functional outcomes of acute stroke patients.

Methods: In total, 1588 stroke patients were investigated. A maintained database of all hospitalized acute stroke patients admitted to our facility over two consecutive 2-year periods was reviewed. We relaunched of a new rehabilitation program to be earlier and more intensive at the midpoint of this two periods. The functional outcomes of the patients in the first 2-year period and the subsequent 2-year period were compared.

Results: The total time of rehabilitation exercises per day was significantly increased from the first period to the second period. The number of patients who started rehabilitation within 24?h after admission was significantly increased in the patients admitted during the second period compared with those admitted during the first period. The Functional Independence Measure (FIM) efficiency was significantly higher in the patients admitted during the second period than in those admitted during the first period.

Conclusions: An early and intensive rehabilitation program in a Japanese hospital affects functional outcomes of acute stroke patients.

• Implications for Rehabilitation

• Early and intensive rehabilitation for the stroke patients is an effective means of improving FIM score.

• Early and intensive rehabilitation affects the improvement of FIM efficiency without increasing adverse events.

     

Crossed Cerebellar Diaschisis Has an Adverse Effect on Functional Outcome in the Subacute Rehabilitation Phase of Stroke: A Case-Control Study

ObjectiveTo investigate whether crossed cerebellar diaschisis (CCD) is associated with functional outcome in the subacute rehabilitation phase of stroke.DesignRetrospective case-control study.SettingHospital-based cohort.ParticipantsThe study enrolled participants who underwent brain single-photon emission computed tomography (N=48). Patients with CCD were identified (n=24). Twenty-four controls were selected for each case-patient by matching age, stroke type (ischemic or hemorrhagic), lesion laterality, and lesion location.InterventionNot applicable.Main Outcome MeasuresThe functional ambulation category (FAC), modified Barthel Index (MBI), and Mini-Mental State Examination (MMSE) were administered at the initial (initiation of rehabilitation therapy) and the follow-up (4wk after rehabilitation therapy) assessments.ResultsThe CCD group had lower MMSE, FAC, MBI, and MMSE scores at the initial assessment (P=.032, .016, and .001, respectively) and lower FAC and MBI scores at the follow-up assessment, than the non-CCD group (P=.001 and .036, respectively). Although CCD was not associated with cognitive impairment, nonambulatory status, and dependent activities of daily living (ADL) at the initial assessment (P=.538, .083, and >.99, respectively), the CCD group had a higher risk of cognitive impairment (adjusted odds ratio [aOR]=4.044; 95% confidence interval [CI], 1.071-15.270; P=.039), nonambulatory status (aOR=7.000; 95% CI, 1.641-29.854; P=.009) and dependent ADL (aOR=13.500; 95% CI, 1.535-118.692; P=.019) at the follow-up assessment.ConclusionsCCD is associated with severe functional impairment and may have an adverse effect on functional outcomes related to cognition, ambulatory function, and ADL during the subacute rehabilitation phase of stroke. This suggests that CCD may be a valuable predictor of functional outcome in the subacute rehabilitation phase of stroke.     

Incentives for Uptake of and Adherence to Outpatient Stroke Rehabilitation Services: A 3-Arm Randomized Controlled Trial

ObjectiveTo determine if rehabilitation uptake and adherence can be increased by providing coordinated transportation (increased convenience) and eliminating out-of-pocket costs (reduced expense).DesignThree-arm randomized controlled trial.SettingStroke units of 2 Singapore tertiary hospitals.ParticipantsSingaporeans or permanent residents 21 years or older who were diagnosed as having stroke and were discharged home with physician's recommendation to continue outpatient rehabilitation (N=266).InterventionsA Transportation Incentives arm (T), which provides free transportation services, a Transportation & Sessions Incentives arm (T&S), offering free transportation and prescribed stroke rehabilitation sessions, and a control arm, Education (E), consisting of a stroke rehabilitation educational program.Main Outcome MeasuresThe primary study outcome was uptake of outpatient rehabilitation services (ORS) among patients poststroke and key predefined secondary outcomes being number of sessions attended and adherence to prescribed sessions.ResultsUptake rate of ORS was 73.0% for E (confidence interval [CI], 63.8%-82.3%), 81.8% for T (CI, 73.8%-89.8%), and 84.3% for T&S (CI, 76.7%-91.8%). Differences of T and T&S vs E were not statistically significant (P=.22 and P=.10, respectively). However, average number of rehabilitation sessions attended were significantly higher in both intervention arms: 5.50±7.65 for T and 7.51±9.52 for T&S vs 3.26±4.22 for control arm (E) (T vs E: P=.017; T&S vs E: P<.001). Kaplan-Meier analysis indicated that persistence was higher for T&S compared with E (P=.029).ConclusionsThis study has demonstrated a possibility in increasing the uptake of and persistence to stroke ORS with free transportation and sessions. Incentivizing survivors of stroke to take up ORS is a new strategy worthy of further exploration for future policy change in financing ORS or other long-term care services.     

Critical care capacity in Addis Ababa,Ethiopia: A citywide survey of public hospitals

PurposeWe evaluated critical care capacity in the 15 intensive care units (ICUs) in public hospitals in Addis Ababa, Ethiopia to determine the current state of critical care in the city and inform capacity-building efforts.MethodsWe conducted a cross-sectional survey of ICU medical and nursing directors or their delegates using a standardized questionnaire based on World Federation of Society of Intensive and Critical Care Medicine (WFSICCM) criteria.ResultsICU size ranged from 3 to 15 beds. All ICUs had capacity for mechanical ventilation and vasopressor support, and 53% had intensivists on staff. Ultrasound was available in 93%, while 40% had capacity for invasive blood pressure monitoring. Identified barriers to care included a lack of essential equipment, supplies, medications and specially trained providers. Respondents considered increasing available beds and coordinating between hospitals crucial for capacity building.ConclusionsThere is burgeoning critical care capacity in Addis Ababa, Ethiopia with 103 ICU beds in public hospitals, and the WFSICCM criteria provide a useful framework for evaluating critical care capacity and identifying priorities for capacity building. All ICUs in public hospitals in Addis Ababa were able to provide basic support for patients with life-threatening organ failure but demonstrated marked heterogeneity in critical care capacity.     

Facilitating recovery: evidence for organized stroke care.

Despite dramatic advances in the management of thrombolysis and acute stroke, organized rehabilitation remains the cornerstone of recovery from stroke. The importance of organized stroke care in facilitating recovery has been recognized for the last 10 years, but it is still unclear how organized rehabilitation contributes to improved outcomes. This paper presents a synthesis of evidence of the benefits of organized care, especially with respect to stroke severity and different types of organized stroke care. It presents an overview of possible processes within organized rehabilitation that may contribute to good outcomes. The role of integrated care pathways within rehabilitation settings is discussed, highlighting the limitations of current evidence and uncertainty about their benefits. Finally, some key challenges have been identified for stroke units in improving rehabilitation outcomes over the next decade and for healthcare planners in investing adequately in organized stroke services.     

Code gray--an organized approach to inpatient stroke

This article reviews the need for planning and implementation of an organized emergency response to stroke as a secondary diagnosis. Patients who are admitted to hospitals with a diagnosis other than stroke and experience stroke symptoms warrant immediate identification and rapid intervention. Code Gray is an emergency team response for inpatient stroke. Modeled after the response for Code Blue, this team quickly assesses, obtains further diagnostic studies, and provides appropriate intervention to patients who experience stroke symptoms while being hospitalized for some other diagnosis or problem. This emergency team response provides the ingredients for improved patient outcomes and promotes quality patient care.     

Gait and Balance Outcome Measures Are Responsive in Severely Impaired Individuals Undergoing Inpatient Stroke Rehabilitation

ObjectiveTo investigate whether gait and balance outcome measures in patients with severe gait and balance impairments at admission to inpatient rehabilitation provided additional and meaningful information beyond customary measures. Specifically, this study investigated whether individuals who obtained low scores at admission exhibited improvements that exceeded the established minimal detectable change during inpatient rehabilitation. We also investigated whether gait outcomes would capture changes in function not identified by customary measures.DesignSecondary analysis of a knowledge translation project aimed at increasing the systematic collection of these outcome measures in a poststroke cohort.SettingSubacute inpatient rehabilitation facility.ParticipantsIndividuals<2 months poststroke (N=157) with 34-43 with severe deficits including Berg Balance Scale≤5, 10-meter walk test=0 m/s, or 6-minute walk test=0 m.InterventionNot applicable.Main outcome measuresBerg Balance Scale, 10-meter walk test, 6-minute walk test.ResultsAfter 1 week of rehabilitation, 41%-53% of severely impaired individuals had changes above minimal detectable changes in gait and balance outcomes, which increased to 68%-84% at discharge. Across the entire cohort, FIM locomotion scores failed to identify changes in gait function for 35% of participants after 1 week of rehabilitation.ConclusionsRoutine assessment of gait and balance outcome measures in patients with severe deficits early poststroke may be beneficial. These measures were responsive after 1 week of rehabilitation and detected changes not captured by customary measures. Routine use of a standardized gait and balance assessments may provide clinicians with important information to guide clinical decision making.     

Needs,priorities, and desired rehabilitation outcomes of family members of young adults who have had a stroke: findings from a phenomenological study

Purpose: This study explored the experience of stroke from the perspective of family members of young adults who have had a stroke. Gaining understanding of the short, medium and long-term needs and desired rehabilitation outcomes of family members assisted identification of appropriate family-centred multidisciplinary rehabilitation interventions. Method: A qualitative approach based on Merleau-Ponty’s existential phenomenology enabled exploration of family members’ experience of stroke. Eleven family members, including parents, spouses, children and siblings, participated in 24 interviews over 2 years. A subsequent iterative process of critical reflection was used to identify family-centred needs, priorities and associated rehabilitation outcomes. Results: Within a thematic framework, family members’ experience was conceptualised as Disruption of Temporal Being. Against this overarching theme or (back)ground, figural themes were identified: Uncertainty, Disrupted and Altered Relationships, and Situatedness. In addition, sixteen short, medium and long-term effects of stroke were identified along with associated family-centred needs and rehabilitation outcomes. Conclusion: An empathetic understanding of the experience of stroke from the perspective of family members, combined with research evidence and professional expertise enables the multidisciplinary rehabilitation team to deliver tailored interventions based on identified needs and priorities, and negotiation of mutually agreed goals.

Implications for Rehabilitation

• Following stroke in a young adult, families’ needs, priorities and associated rehabilitation outcomes change over time; rehabilitation services should reflect this dynamic process.

• To deliver family-centred care, rehabilitation professionals need to develop a deeper understanding of the experience of families affected by stroke, gained from qualitative research findings and from their own reflective practice.

• Gaining understanding of the experience of family members of young adults who have had a stroke will enable health professionals to consider how they may improve practice and enhance service provision to ensure delivery of effective, family-centred interventions.

• The table of family-centred needs and outcomes can be used by members of the multidisciplinary stroke rehabilitation team in conjunction with their own knowledge, experience and resources to inform family-centred practice.