Impact of a Centralized Inpatient Hospice Unit in an Academic Medical Center.

OBJECTIVE: Rush University Medical Center (RUMC) and Horizon Hospice opened the first centralized inpatient hospice unit (CIPU) in a Chicago academic medical center in 2012. This study examined if there was a difference in cost or length of stay (LOS) in a CIPU compared to hospice care in scattered beds throughout RUMC. STUDY DESIGN AND METHODS: This retrospective, cross-sectional study compared cost and LOS for patients admitted to the CIPU (n = 141) and those admitted to hospice scattered beds (SBM) throughout RUMC (n = 56). RESULTS: The CIPU patients had a median LOS of 6.0 days versus 2.0 days for SBM patients. CONCLUSIONS: The CIPU patients had longer hospice LOS but lower hospital costs. Academic medical centers may benefit from aggregating hospice beds.

Institutional Variation in Traumatic Brain Injury Acute Rehabilitation Practice.

OBJECTIVE: To describe institutional variation in traumatic brain injury (TBI) inpatient rehabilitation program characteristics and evaluate to what extent patient factors and center effects explain how TBI inpatient rehabilitation services are delivered. DESIGN: Secondary analysis of a prospective, multicenter, cohort database. SETTING: TBI inpatient rehabilitation programs. PARTICIPANTS: Patients with complicated mild, moderate, or severe TBI (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mean minutes; number of treatment activities; use of groups in occupational therapy, physical therapy, speech therapy, therapeutic recreation, and psychology inpatient rehabilitation sessions; and weekly hours of treatment. RESULTS: A wide variation was observed between the 10 TBI programs, including census size, referral flow, payer mix, number of dedicated beds, clinician experience, and patient characteristics. At the centers with the longest weekday therapy sessions, the average session durations were 41.5 to 52.2 minutes. At centers with the shortest weekday sessions, the average session durations were approximately 30 minutes. The centers with the highest mean total weekday hours of occupational, physical, and speech therapies delivered twice as much therapy as the lowest center. Ordinary least-squares regression modeling found that center effects explained substantially more variance than patient factors for duration of therapy sessions, number of activities administered per session, use of group therapy, and amount of psychological services provided. CONCLUSIONS: This study provides preliminary evidence that there is significant institutional variation in rehabilitation practice and that center effects play a stronger role than patient factors in determining how TBI inpatient rehabilitation is delivered.

Readmission to an Acute Care Hospital During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the incidence of, causes for, and factors associated with readmission to an acute care hospital (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Prospective observational cohort. SETTING: Inpatient rehabilitation. PARTICIPANTS: Individuals with TBI admitted consecutively for inpatient rehabilitation (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. RESULTS: A total of 183 participants (9%) experienced RTAC for a total of 210 episodes. Of 183 participants, 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. The mean time from rehabilitation admission to first RTAC was 22±22 days. The mean duration in acute care during RTAC was 7±8 days. Eighty-four participants (46%) had ≥1 RTAC episodes for medical reasons, 102 (56%) had ≥1 RTAC episodes for surgical reasons, and 6 (3%) participants had RTAC episodes for unknown reasons. Most common surgical RTAC reasons were neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurological (23%), and cardiac (12%). Any RTAC was predicted as more likely for patients with older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission. RTAC was less likely for patients with higher admission FIM motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. CONCLUSIONS: Approximately 9% of patients with TBI experienced RTAC episodes during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation for RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting.

Rehospitalization During 9 Months After Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Multicenter observational cohort. SETTING: Community. PARTICIPANTS: Individuals with TBI (N=1850) admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations. RESULTS: A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logistic regression analyses revealed that older age, history of seizures before injury or during acute care or rehabilitation, history of brain injuries, and non-brain injury medical severity increased the risk of rehospitalization. Injury etiology of motor vehicle collision and high motor functioning at discharge decreased rehospitalization risk. CONCLUSIONS: Approximately 28% of patients with TBI were rehospitalized within 9 months of TBI rehabilitation discharge owing to various medical and surgical reasons. Future research should evaluate whether some of these occurrences may be preventable (such as infections, injuries, and psychiatric disorders) and should evaluate the extent to which persons at risk may benefit from additional screening, surveillance, and treatment protocols.