Functioning and subjective health among stroke survivors after discharge from hospital

AIM: This paper reports a study exploring functioning (functions, activities and participation) and subjective health among stroke survivors 6 months after discharge from hospital. A further aim was to investigate patterns of functions and activities, and associations between functioning and subjective health. BACKGROUND: Nurses tend to emphasize functional and activity outcomes and rarely look to people's participation in their social world. By integrating individual and social contextual factors in their assessments, nurses will have a powerful tool to broaden their outlook. The International Classification of Functioning, Disability and Health can be used as a framework for understanding the consequences of stroke. Studies are needed, however to make the International Classification of Functioning operational for practical use. METHODS: A cross-sectional and explorative design was used using structured interviews and assessments with a number of scales with 89 stroke survivors 6 months after their hospital stay. The measures used were Personal Activities of Daily Living, including cognitive ability, transfer, dressing, bathing, energy to eat, ingestion, swallowing, going to the toilet, faecal continence, and urinary continence; and Instrumental Activities of Daily Living, including washing clothes, cooking, cleaning, transport and shopping. Factor analysis was performed for functions and activities and the final solution had an explained variance of 70%. The data were collected during autumn 2003 and spring 2004. FINDINGS: Close associations (r(s) > 0.5) were found between Activities of Daily Living in relation to participation and subjective physical health. CONCLUSION: Existing Activities of Daily Living scales were expanded and found to relate to a participation scale and a subjective health scale. Using these scales in nursing care has the potential to correct current bias towards functions and activities by broadening the focus to include the social as well as the physical.     

Racial disparities in stroke functional outcomes upon discharge from inpatient rehabilitation facilities

Purpose.?Analyse racial disparities in clinical outcomes after stroke in inpatient rehabilitation facilities (IRF).

Methods.?Analyses based on data from a multi-center prospective observational cohort study on inpatient stroke rehabilitation in six IRFs from across the United States. Multivariate models examined racial disparities in functional outcomes upon discharge, taking into account patient characteristics and detailed information on processes of care.

Results.?In the moderate stroke group (N?=?397), functional scores on admission were not significantly different between African-Americans and whites. In the severe stroke group (N?=?335), whites showed significantly lower functional scores at admission [Functional Independence Measurement, (FIM)], mean scores, 44 versus 49 for African-Americans, p?<?0.001). Multivariate analyses predicting discharge motor FIM score found no significant differences between African-American and white stroke patients (p?=?0.2194 and p?=?0.3547 in the moderate and severe stroke group, respectively).

Conclusion.?Controlling for patient characteristics, therapy intensity and processes of care results in non-significant differences between African-Americans and whites in motor FIM scores upon discharge. The absence of significant differences in recovery while patients were on the rehabilitation unit suggests that racial disparities in long-term functional recovery after stroke are likely to have originated before or after the inpatient rehabilitation stay.     

Measuring patient-reported outcomes after discharge from inpatient rehabilitation settings.

OBJECTIVE: To examine the sensitivity of the Short Form Activity Measure for Post-Acute Care (AM-PAC) in comparison to the Functional Independence Measure (FIM) across a 12-month period after discharge from rehabilitation hospital. DESIGN: Prospective longitudinal study. Patients were recruited while receiving inpatient services from facilities in the north-east USA and interviewed 1, 6 and 12 months thereafter. PATIENTS: Convenience sample of 516 patients at baseline (65% retention at the final follow-up) receiving rehabilitation services for neurological, lower extremity orthopedic, or complex medical conditions. Mean age 68.3 years; 47% male. MAIN OUTCOME MEASURES: AM-PAC Physical and Movement, Personal Care and Instrumental, and Applied Cognitive Activity scales; FIM Motor and Cognitive scales. RESULTS: All 3 AM-PAC scales were sensitive to both positive and negative change across the follow-up period. Standardized response means for the AM-PAC were consistently larger than for the FIM across patient and severity groups. A greater percentage of patients showed positive change that exceeded the minimal detectable change on the AM-PAC than on the FIM both 6- and 12-month follow-ups. CONCLUSION: The short-form AM-PAC scales are more sensitive measures of change in functional activity performance over time in the general population of persons who receive inpatient rehabilitation services compared to the FIM. Thus, the AM-PAC offers a short, comprehensive, and sensitive measure of positive and/or negative change in patients' ability to perform important activities of daily life.     

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.

     

Life experiences after stroke among Iranian stroke survivors

DALVANDI A., HEIKKILÄ K., MADDAH S.S.B., KHANKEH H.R. & EKMAN S.L. (2010) Life experiences after stroke among Iranian stroke survivors. International Nursing Review 57 , 247–253 Background: Stroke is a major cause of disability worldwide. It is a life‐threatening and life‐altering event, which leaves many physical and mental disabilities, thus creating major social and economic burdens. Experiencing a stroke and its aftermath can be devastating for patients and their families. In Iran, many services are not available for those who lack property; this may result in many difficulties and long‐term problems for stroke survivors and their family members who are usually the main caregivers in Iranian cultural. Despite its effect on their lives, little is known about how the survivors perceive stroke in the Iranian context, therefore, knowing more about this process may enhance problem identification and problem solving. Aim: To illuminate how stroke survivors experience and perceive life after stroke. Method: A grounded theory approach was recruited using semi‐structured interviews with 10 stroke survivors. Findings: The survivors perceived that inadequate social and financial support, lack of an educational plan, lack of access to rehabilitative services, physical and psychological problems led them to functional disturbances, poor socio‐economical situation and life disintegration. The core concept of life after stroke was functional disturbances. Conclusions: The study shows the need to support the stroke survivors in their coping process with their new situation by providing appropriate discharge plans, social and financial support, social insurances and training programmes for the stroke survivors and their families.     

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

Bland MD, Sturmoski A, Whitson M, Connor LT, Fucetola R, Huskey T, Corbetta M, Lang CE. Prediction of discharge walking ability from initial assessment in a stroke inpatient rehabilitation facility population.ObjectivesTo (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF.DesignRetrospective cohort study.SettingIRF.ParticipantsTwo samples of participants (n=110 and 159) admitted with stroke.InterventionsA multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4–0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants.Main Outcome MeasureDischarge 10-m walk speed.ResultsAdmission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6–63) for sample 1 and 32 (95% CI, 10–96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present.ConclusionsA Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.     

Length of stay benchmarks for inpatient rehabilitation after stroke

Purpose: In Canada, no standardized benchmarks for length of stay (LOS) have been established for post-stroke inpatient rehabilitation. This paper describes the development of a severity specific median length of stay benchmarking strategy, assessment of its impact after one year of implementation in a Canadian rehabilitation hospital, and establishment of updated benchmarks that may be useful for comparison with other facilities across Canada. Method: Patient data were retrospectively assessed for all patients admitted to a single post-acute stroke rehabilitation unit in Ontario, Canada between April 2005 and March 2008. Rehabilitation Patient Groups (RPGs) were used to establish stratified median length of stay benchmarks for each group that were incorporated into team rounds beginning in October 2009. Benchmark impact was assessed using mean LOS, FIM^® gain, and discharge destination for each RPG group, collected prospectively for one year, compared against similar information from the previous calendar year. Benchmarks were then adjusted accordingly for future use. Results: Between October 2009 and September 2010, a significant reduction in average LOS was noted compared to the previous year (35.3 vs. 41.2 days; p < 0.05). Reductions in LOS were noted in each RPG group including statistically significant reductions in 4 of the 7 groups. As intended, reductions in LOS were achieved with no significant reduction in mean FIM^® gain or proportion of patients discharged home compared to the previous year. Adjusted benchmarks for LOS ranged from 13 to 48 days depending on the RPG group. Conclusions: After a single year of implementation, severity specific benchmarks helped the rehabilitation team reduce LOS while maintaining the same levels of functional gain and achieving the same rate of discharge to the community.

Implications for Rehabilitation

• Efficient post-stroke rehabilitation can help to improve patient outcomes and reduce the financial burden placed on the healthcare system.

• Yet, unnecessarily long lengths of stay in rehabilitation are not in the best interest of the patient and act to increase the cost of care.

• This study illustrates how a length of stay benchmarking system can help to promote efficiency in post-stroke rehabilitation and reduce the cost of care without negatively impacting patient recovery.

     

Caregiver availability for severe stroke results in improved functional ability at discharge from inpatient rehabilitation

Purpose: To evaluate the predictive capacity of caregiver availability on functional ability at time of discharge from inpatient rehabilitation in individuals with severe first-time stroke.

Methods: A retrospective chart review was conducted of severe stroke inpatients admitted to a stroke rehabilitation unit between April 2005 and December 2009. Follow-up telephone interviews were conducted with patients to determine caregiver availability at time of discharge. Hierarchical linear regression analysis was performed to assess the predictive capacity of caregiver availability on functional ability at discharge from an inpatient rehabilitation unit after controlling for covariates.

Results: Data from 180 individuals were included in the analysis. Individuals with a caregiver had significantly higher levels of functional ability at discharge compared to those without (85.8?±?23.6 versus 72.9?±?20.3; p?F (5,174)?=?26.21, p?Conclusions: The presence of a caregiver at time of discharge from inpatient rehabilitation is predictive of significantly higher functional ability at discharge in individuals with severe stroke.

• Implications for rehabilitation

• The availability of a caregiver at time of discharge from inpatient rehabilitation is predictive of improved functional ability at discharge in individuals with severe stroke.

• The presence of an available caregiver positively influences the functional recovery of individuals with severe stroke and may be an important element to successful rehabilitation.

     

Predicting walking at discharge from inpatient rehabilitation after a traumatic spinal cord injury

OBJECTIVE: To investigate how injury level and American Spinal Injury Association Impairment Scale (AIS) grade at rehabilitation admission are related to walking at discharge after traumatic spinal cord injury (SCI). DESIGN: Retrospective study. SETTING: Comprehensive rehabilitation hospital. PARTICIPANTS: A total of 343 adult inpatients with traumatic SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: FIM instrument walking rating of 3 (moderate assistance) or higher at discharge. RESULTS: Significantly more subjects admitted with AIS grade C (28.3%) than AIS grade A or B injuries (0.9%) walked at discharge. Significantly more subjects admitted with AIS grade D (67.2%) than AIS grade C (28.3%) injuries walked at discharge. Level of injury did not significantly affect walking after AIS grade C or D injuries. Being 50 years or older had a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries. CONCLUSIONS: Admission AIS grades give information about walking for treatment and discharge planning during acute inpatient rehabilitation, including the following: (1) patients admitted with AIS grade C injuries should not be considered functionally complete when predicting walking (FIM score > or = 3; no more than moderate assistance) at discharge, (2) level of injury does not affect walking for those with AIS grade C or D injuries, and (3) being 50 years or older has a significant negative affect on walking in subjects with AIS grade D but not AIS grade C injuries.     

Evidence-based educational guidelines for stroke survivors after discharge home

Stroke survivors today are discharged home from the hospital more quickly than in the past because of shifting economic realities. Survivors continue to experience significant impairments after discharge and families may be poorly prepared for the full extent of caregiving responsibilities. This article describes 39 comprehensive educational guidelines that have been tested with 72 stroke survivors and families during 1,150 home visits throughout the first 6 months after discharge from inpatient rehabilitation. Two case studies illustrate use of the guidelines with stroke survivors and their families.     

Benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke

OBJECTIVE: To analyze the benefit of inpatient multidisciplinary rehabilitation up to 1 year after stroke. DESIGN: Retrospective cohort study. SETTING: Inpatient rehabilitation hospital in Japan. PARTICIPANTS: A total of 1056 patients with stroke were divided into 3 groups based on the interval between stroke onset and admission to the rehabilitation hospital: group I, within 90 days (n=507, 48%); group II, 91 to 180 days (n=377, 36%); and group III, more than 180 days (n=172, 16%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional outcome (A to D; independent to totally dependent) in walking, affected upper extremity, and activities of daily living (ADLs) and discharge disposition. RESULTS: Walking status improved in 70.9% of nonambulatory patients in group I, in 54.8% in group II, and in 43.9% in group III. Similarly, ADLs improved in 66.7% of the totally dependent patients in group I and in approximately 50% in groups II and III. Functional gain in those with a totally nonfunctional upper extremity at admission was poor (29.7%). Initial functional categories affected each outcome (P<.0001). On discharge, 73.8% in group I and approximately 60% in groups II and III went home. CONCLUSION: Approximately half of all patients regained their abilities in walking and ADLs after inpatient multidisciplinary rehabilitation up to 1 year after stroke. However, there was considerable limitation in functional recovery of the affected upper extremity.     

Short term results of outpatient vs. inpatient rehabilitation after stroke

Fifty stroke patients who had already regained basic ADL-functions were investigated at the beginning and end of either inpatient or outpatient rehabilitation of similar therapeutic intensity in the same institution. For geographic reasons, outpatient treatment could only be offered to a subgroup of patients. Neurological deficits, extended ADL-functions and quality of life (SF-36) were assessed. Patients who chose outpatient rehabilitation exhibited milder neurological deficits and better ADL-function at onset. On average, outpatient rehabilitation took about 8 days more than inpatient treatment. Under rehabilitation, gains with respect to ADL-functions and the QoL-dimensions "physical role function" and "physical functional ability" were realized. The magnitude of changes did not depend on setting. A decrease in "general health perception" may be related to the inpatient treatment of patients who would have preferred an outpatient setting. Brief periods between stroke and onset of rehabilitation and longer duration of rehabilitation treatment were significantly associated with better outcome with respect to ADL-functions.     

Effectiveness of a fall-risk reduction programme for inpatient rehabilitation after stroke

Purpose: To evaluate effectiveness of fall-risk-assessment-based fall prevention for stroke rehabilitation inpatients.

Method: A consecutive series of 232 patients admitted for the first time to a subacute stroke-rehabilitation ward during 2010–2011 was studied in detail. The Assessment Sheet for Fall Prediction in Stroke Inpatients (ASFPSI by Nakagawa et al.) was used to assess fall-risk upon admission. Association of ASFPSI score and patient characteristics with actual falls was statistically tested. Yearly incidence of falls per 1000 hospital days (HD) was retrospectively audited for the 2006–2014 period to evaluate effectiveness of fall-risk reduction measures.

Results: The observed incidence of falls over the detailed-study-period was 3.0/1000 HD; 39% of the fallers fell during the first week after admission. ASFPSI score was not significantly associated with falls. Longer hospital stay, left body-side affected and non-extreme FIM score (55–101) were associated with higher odds of fall. Introduction of fall-risk reduction measures followed by compulsory fall-risk assessment lead to incidence of falls dropping from 7.1/1000 HD in 2006 to 2.8/1000 HD in 2011 and remaining at that level until 2014.

Conclusions: The fall-risk-assessment-based measures appear to have led to decreasing falls risk among post-stroke rehabilitation inpatients classified as being at high risk of falls. The fall prevention programme as a whole was successful. Patients with non-extreme level of functional independence should receive enhanced fall prevention.

• Implications for Rehabilitation

• Recognising the fall risk upon the patient's admission is essential for preventing falls in rehabilitation wards.

• Assessing the fall risk is a team tasks and combines information from various sources.

• Assessing fall risk in stroke patients using the assessment sheet by Nakagawa et al. immediately upon admission systematically draws attention to the risk of falls in each individual patient.