Staff knowledge, attitudes and behaviours related to mobilisation in a rehabilitation setting: Short report of a multidisciplinary survey.

OBJECTIVES: Regular mobilising is important in inpatient rehabilitation, but objective measurements show low patient mobility. We sought to understand multidisciplinary staff perspectives on barriers and enablers to mobility in a rehabilitation setting. METHODS: A validated barriers survey (standardised score 0-100, higher representing greater barriers) was distributed to 99 clinical staff on two wards at a single rehabilitation facility. RESULTS: The survey was completed by 83 staff (52 nurses, 25 allied health professionals, 4 therapy assistants and 2 medical officers) and identified barriers in behaviour (mean 39, SD 11), attitudes (mean 34, SD 12) and knowledge (mean 23, SD 18). Prominent perceived barriers were nursing workload, unclear responsibility for mobilising, risk of staff injury, patient motivation and family participation; perceived enablers were good knowledge, positive outcome expectations and team communication. CONCLUSIONS: These barriers can inform locally tailored strategies to improve rehabilitation patient mobility.

'I will walk out of here': Qualitative analysis of older rehabilitation patients' perceptions of mobility.

OBJECTIVES: To understand the motivation of older rehabilitation inpatients for mobilisation, and identify barriers and enablers to greater mobilisation. METHODS: Qualitative semi-structured interviews were conducted with older rehabilitation inpatients. All interviews were audio-taped, transcribed verbatim and analysed using thematic and inductive techniques. RESULTS: From 23 interviews, we found that older patients strongly value mobilisation during rehabilitation admission, to get better and maintain identity, personhood and meaningful connections. At the patient level, mobilisation was impacted by patient's confidence, family support and symptom management. At the organisational level, barriers to mobilisation included lack of timely staff support, inflexible routines, limited social opportunities, lack of physical resources, and poor communication. CONCLUSIONS: Recognising and understanding motivators, enablers and barriers to mobilising during subacute hospitalisation of older patients is an essential step towards developing and implementing successful strategies to promote greater mobilisation. Addressing mobilisation barriers requires a multifaceted approach at the patient and organisational level.

An observational study of physical, cognitive and social activities in rehabilitation inpatients.

OBJECTIVES: To describe patient behaviour related to mobility in a rehabilitation inpatient setting and compare intensive and Transition Care Program (TCP, slow-stream rehabilitation) models. METHODS: Prospective cross-sectional design including weekday and weekend sampling in two rehabilitation wards (one intensive and one TCP) in a publicly funded facility. A single trained observer undertook behavioural mapping, observing patient location, mobility, activity and company on all inpatients 8 am-4 pm using a structured 2-minute observation protocol. Observations were summarised and compared between wards. RESULTS: We observed 74 inpatients on a Tuesday and 77 on a Sunday. Participants spent 7% (median) of daytime standing or walking. They spent 62%-87% in their room, 22%-40% sleeping or resting and 74%-86% alone. The only significant difference between wards was time spent off ward on Tuesday. Activity was lower on Sunday. CONCLUSIONS: Time spent in physical, cognitive and social activities is low in inpatient rehabilitation and TCP wards.

Predictors of discharge destination in a geriatric population after undergoing rehabilitation.

BACKGROUND AND PURPOSE: Patients undertaking inpatient rehabilitation comprise a diverse group, including patients with stroke and other neurological conditions, patients who have fallen with or without a resulting fracture, and patients with joint replacements, general debility, or various cardiopulmonary conditions. It is not clear whether diagnosis has an impact on discharge destination in a heterogeneous patient group. The purpose of this study was to determine whether diagnostic category matters or whether it is rehabilitation length of stay (LOS), ability on the 10-Meter Walk Test (10MWT), or Balance Outcome Measure for Elder Rehabilitation (BOOMER) at discharge that predicts discharge destination in elderly patients undergoing rehabilitation who had previously lived at home. METHODS: A retrospective audit was undertaken at a single rehabilitation facility in South East Queensland, Australia, that serviced 4 local short-term care hospitals. Participants were admitted consecutively to the facility between June 2010 and March 2012 who met inclusion criteria. These included a primary diagnosis category of orthopedic conditions, debility, stroke, and other neurological conditions according to the Australasian Rehabilitation Outcomes Centre and older than 60 years (n = 248). Interventions while being a rehabilitation inpatient comprised usual care physiotherapy individually tailored and incorporating elements of balance, strengthening, and functional exercise. Main outcome measures were discharge to residential aged care facility (RACF) versus home, differences between diagnostic categories in terms of discharge destination, LOS, and performance on outcome measures. Prediction of discharge destination by LOS, 10MWT, and BOOMER performance at discharge was explored. RESULTS: A total of 28 patients (12.3%) were discharged to RACF. Diagnosis was not correlated with discharge destination (Pearson χ2 = 1.26, P = .74). The variables rehabilitation LOS, an inability to perform the 10MWT at discharge, and discharge BOOMER score of less than 4 can predict discharge destination with 86.4% accuracy (P = .002). This model had a sensitivity of 71.4% (discharge to RACF) and specificity of 93.3% (discharge home). DISCUSSION: To return home after rehabilitation, patients need to be able to walk at least 10 m and undertake tasks such as moving from sitting to standing, turning around, as well as managing steps. The study revealed that a standardized suite of measures of functional ability and balance may not be appropriate for patients in all diagnostic categories undergoing rehabilitation. Therefore, just as intervention needs to be tailored for the individual patient, the measure of their progress also should be unique.

Activity limitations experienced by people with stroke who receive inpatient rehabilitation: differences between 2001, 2005, and 2011.

OBJECTIVE: To determine whether there were differences in characteristics and activity limitations relevant to physiotherapists among people receiving inpatient rehabilitation after stroke in 2001, 2005, and 2011. DESIGN: A multicenter observational study of 3 periods. SETTING: Inpatient rehabilitation units (N=15). PARTICIPANTS: Adult stroke survivors (N=738) admitted over 3 periods (2001, 2005, 2011). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Characteristics, hospital metrics, and Motor Assessment Scale (MAS) scores were recorded on admission and discharge. RESULTS: All 3 cohorts were similar in terms of sex, side affected by stroke, and length of time from stroke onset to rehabilitation admission. Stroke participants in the 2005 cohort were older than those in the 2011 and 2001 cohorts. Participants in the 2011 cohort had a longer inpatient rehabilitation length of stay, experienced lower average MAS gains per day (F>3.298, P<.038), and experienced more activity limitations in basic functional tasks involving bed mobility, standing up, and sitting balance on admission and discharge, and in walking and arm function at discharge only compared with earlier cohorts. CONCLUSIONS: In 2011, on average, people admitted for rehabilitation after stroke were approximately the same age as patients in 2005 and 2001 and it took approximately 2 weeks for all of these patients to be admitted to a rehabilitation unit, but patients in 2011 had a longer inpatient rehabilitation length of stay compared with patients in 2005 and 2001. In addition, activity limitations at inpatient rehabilitation admission and discharge appear to be worse, particularly for activities such as rolling, sitting up over the edge of the bed, and balanced sitting.

Changes in falls risk factors for geriatric diagnostic groups across inpatient, outpatient and domiciliary rehabilitation settings.

PURPOSE: To compare falls event rates and risk factors for falls across three rehabilitation settings. METHODS: A multi-centre prospective longitudinal cohort study was conducted of 1682 participants referred for rehabilitation from 18 sites (across two Australian states) and receiving physiotherapy treatment. Falls risk factors across multiple domains (rehabilitation settings, medical diagnoses, age, gender, standing balance, functional capacity, cognition, prior living arrangements, pre-admission use of gait aid and past history of falls) were collected by treating physiotherapists on admission to rehabilitation. Falls were measured by incident reporting and review of medical histories in the inpatient settings and by weekly interviews in the outpatient and domiciliary settings. RESULTS: Overall, outpatient and domiciliary settings demonstrated lower falls event rates compared to inpatient [IRR (95% CI): 0.58 (0.36-0.93) and 0.35 (0.24-0.51)], respectively. Cognitive status, functional ability and past history of falls were consistent risk factors across settings. However medical diagnoses of stroke, other neurological conditions, elective orthopaedic and other orthopaedic together with standing balance were inconsistent as risk factors or protective factors across settings. CONCLUSIONS: Risk factors for falls, including medical diagnosis, are not necessarily universal across settings. Balance performance was a significant risk factor for outpatient and domiciliary settings but was not a risk factor for inpatients. Cognitive status and a previous history of falls were, however, consistent risk factors across all settings. This suggests that different approaches for the prevention of falls may be required for the same diagnostic group of patients depending on the location of the rehabilitation setting.

Dose-response relationship between physiotherapy resource provision with function and balance improvements in patients following stroke: a multi-centre observational study.

RATIONALE, AIMS AND OBJECTIVES: Inpatient rehabilitation of patients following stroke can be resource intensive, with optimal models of service delivery unclear. This study investigates the dose-response curves between physiotherapy service delivery variables and balance and function clinical outcomes. METHOD: This was a multi-centre (15 sites), prospective, cohort study involving patients (n = 288) admitted for rehabilitation following stroke conducted across two states in Australia. Physiotherapy department resource provision variables were collected and examined for association with change in patient function and balance outcomes (Functional Independence Measure, step test, functional reach test) measured at admission and discharge from inpatient care. RESULTS: A greater amount of log-transformed physiotherapy department resource provision was associated with greater improvement in the functional independence measure [Regression coefficient (95% CI): 4.05 (1.15, 6.95)] and functional reach test [46.43 (17.03, 75.84)], while physiotherapist time provided to patients was associated with greater improvement for the step test [0.15 (0.03, 0.28)], and functional reach [0.35 (0.19, 0.52)]. CONCLUSION: Receiving a higher rate of physiotherapist input is an important factor in attaining a greater amount of recovery in function and balance outcomes; however, the improvement by patients who received the greatest amount of input was highly variable.

Further validation of the Balance Outcome Measure for Elder Rehabilitation.

OBJECTIVE: To determine the concurrent validity of the Balance Outcome Measure for Elder Rehabilitation (BOOMER) with both the Berg Balance Scale (BBS) and gait speed. DESIGN: Prospective cohort study. SETTING: Two geriatric rehabilitation units. PARTICIPANTS: Elderly adults (N=134) admitted to inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The BOOMER consists of timed static stance feet together eyes closed, Functional Reach, step test, and the Timed Up and Go test. Validity was determined using the Spearman correlation coefficient, comparing the BOOMER with the BBS and gait speed on admission and discharge. Responsiveness of the BOOMER was compared with the BBS and gait speed for the change scores between admission and discharge using the Spearman correlation coefficient. RESULTS: The BOOMER demonstrated high to very high correlation with the BBS at admission (ρ=.91; P<.01) and discharge (ρ=.89; P<.01), and with gait speed at admission (ρ=.67; P<.01) and discharge (ρ=.68; P<.01). Change scores between admission and discharge for the BOOMER and BBS displayed moderate correlation (ρ=.55; P<.01), while those between the BOOMER and gait speed displayed only fair correlation (ρ=.33 P<.01). CONCLUSION: The BOOMER appears to be a valid measure of the standing balance construct because it demonstrated high correlation with another measure of balance, and moderate correlation with a measure of a related construct (gait speed). The BOOMER may be a worthwhile alternative for more complex multi-item balance measures.

Measures of activity limitation on admission to rehabilitation after stroke predict walking speed at discharge: an observational study.

QUESTION: Which measures of activity limitation on admission to rehabilitation after stroke best predict walking speed at discharge? DESIGN: Prospective observational study. PARTICIPANTS: 120 people with stroke undergoing inpatient rehabilitation. OUTCOME MEASURES: Predictors were admission walking speed, Timed Up and Go, Motor Assessment Scale, Modified Elderly Mobility Scale, and Functional Independence Measure scores measured on admission to rehabilitation. The outcome of interest was walking speed at discharge from inpatient rehabilitation. RESULTS: Admission walking speed (B 0.47, 95% CI 0.27 to 0.67) and Item 2 of the Motor Assessment Scale, ie, moving from supine lying to sitting over the side of a bed (B 0.05, 95% CI 0.01 to 0.09) predicted walking speed on discharge from rehabilitation. These two predictors explained 36% of the variance in discharge walking speed. CONCLUSION: Walking speed at discharge from inpatient rehabilitation was best predicted by admission walking speed and Motor Assessment Scale Item 2.

Cost-effectiveness analysis of screening for risk of in-hospital falls using physiotherapist clinical judgement.

INTRODUCTION: Screening hospital patients for falls risk is now a contentious component of geriatric care despite its widespread clinical use. The economic implications of using a falls risk screening approach to deliver an effective falls prevention intervention have not previously been examined. METHODS: This was a multicenter prospective longitudinal cohort and incremental cost-effectiveness analysis. PARTICIPANTS/SETTING: One thousand one hundred twenty-three geriatric inpatients from 17 rehabilitation units across Australia. MEASURES: Physiotherapist accuracy in predicting patient who will fall was captured with the question "Will this patient experience one or more falls during their rehabilitation period?" Falls were measured using hospital incident reporting systems. PROCEDURE: The multicenter longitudinal cohort was undertaken to establish the predictive accuracy of physiotherapist clinical judgement. This data was used in the incremental cost-effectiveness analysis where estimates of the cost of falls and effectiveness of an intervention program were taken from previous research. RESULTS: The accuracy of physiotherapist clinical judgement in predicting falls was high relative to previous research (sensitivity = 0.61, specificity = 0.82, Youden index = 0.43). Selectively providing patient falls-prevention education using physiotherapist clinical judgement would reduce falls [2.2 (SD: 0.19) fallers per 100 inpatients reduction] and reduce resources spent on trying to prevent and treat injuries from in-hospital falls [$2704 AUD (SD: $432) per 100 inpatients reduction] compared with doing nothing. However, there was greater uncertainty as to whether the patient education intervention modeled should be provided selectively or universally. CONCLUSIONS: Preventing in-hospital falls using a targeted falls prevention intervention approach utilizing physiotherapist clinical judgement was more cost-effective than a "no intervention" approach.

Balance impairment not predictive of falls in geriatric rehabilitation wards.

BACKGROUND: Falls are common among hospital inpatients, particularly in rehabilitation wards. Standing balance impairment is widely held to be a contributing factor to falls, is a component of several falls risk screening tools, and has motivated the development of balance retraining programs for the reduction of in-hospital falls. Little rigorous investigation of the link between standing balance impairment and in-hospital falls has been undertaken. METHODS: We identified optimal cut-off points of four commonly used balance measures (functional reach, Timed Up and Go, step test, and timed static stance) in a prospective multicenter cohort study. Admission data (n = 1373) were clustered and matched by center then randomly allocated to development and validation data sets. RESULTS: Optimal cut-off points for each test were identified from the development data set. The predictive accuracy of all four balance tests was poor when the optimal cut-off was applied to the validation data set (Youden Index scores ranged between 0.02 and 0.15). CONCLUSIONS: These findings do not support an association between admission standing balance and falls in a geriatric rehabilitation setting. This result has implications for content of falls risk screening tools and interventions to prevent falls in a geriatric rehabilitation population.

Prediction of discharge destination after stroke using the motor assessment scale on admission: a prospective, multisite study.

OBJECTIVE: To determine if admission functional status, measured with the Motor Assessment Scale (MAS), was predictive of discharge destination to home or residential aged care in patients with stroke undergoing rehabilitation. DESIGN: Cohort study. SETTING: Inpatient rehabilitation units. PARTICIPANTS: Adults (N=566) diagnosed with stroke undergoing inpatient physiotherapy at one of 15 units in Australia. INTERVENTION: Multidisciplinary rehabilitation. MAIN OUTCOME MEASURE: Discharge home versus residential aged care. RESULTS: Prestroke residential status, gait ability measured with the MAS (MAS-5), rolling ability (MAS-1), and age were able to correctly predict 99% of patients with stroke discharged home and 33.3% discharged to residential aged care facilities, producing an accuracy of 87.3%. Odds ratios indicate that for every 1-point increase in MAS-5 (gait), subjects were 1.66 times more likely to go home (95% confidence interval [CI], 1.28-2.27; P<.001). Similarly, for every 1-point increase in MAS-1 (rolling), subjects were 1.28 times more likely to go home (95% CI, 1.11-1.49; P<.01). CONCLUSIONS: Two items of the MAS assessed on admission to rehabilitation-gait and rolling-in conjunction with basic demographic information of age and prestroke residential status, were highly predictive of discharge from rehabilitation to home.

Development and validation of the balance outcome measure for elder rehabilitation.

OBJECTIVE: To develop and investigate the internal consistency, criterion-related validation, and minimum clinically significant difference of a new standing balance outcome measure for Elder Rehabilitation. DESIGN: Three phases: (1) cross-sectional survey with expert panel, (2) multicenter prospective cohort randomly divided into development and validation datasets, and (3) prospective cohort (single site). SETTING: Geriatric and rehabilitation units across 2 states in Australia. PARTICIPANTS: A total of 1769 admissions across 17 geriatric assessment and rehabilitation units. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Balance Outcome Measure for Elder Rehabilitation (BOOMER) consisted of the step test, Timed Up & Go test, Functional Reach Test, and static standing with feet together and eyes closed test. Criterion-related validity was established through comparison to the Modified Elderly Mobility Scale (MEMS) and the FIM motor score. RESULTS: Items of the BOOMER were already used at a majority of rehabilitation facilities surveyed. The BOOMER showed high levels of internal consistency (Cronbach alpha>.87) and had good correlation with the FIM motor and the MEMS (rho>.72). The minimum clinically significant change in the BOOMER was 3 points over a 17-point scale range. CONCLUSIONS: The BOOMER is a clinically applicable measure of standing balance among older rehabilitation patients with evidence of content and construct validity.