The Incidence and Nature of Adverse Events During Inpatient Rehabilitation: A Retrospective Case Series.

OBJECTIVE: To describe and compare adverse event (AE) incidence, type, severity, and preventability in the Canadian inpatient rehabilitation setting. DESIGN: In this retrospective case series, AEs were identified through chart reviews from two Canadian academic tertiary post-acute care hospitals. AEs were characterized through descriptive statistics and compared using the Mantel-Haenszel and Fisher's exact tests. RESULTS: During the study period, one site (n = 120) had 28 AEs and an incidence of 9.7 (95% CI 6.1-13.3) per 1000 patient days, and the other (n = 48) had 15 AEs and an incidence of 13.9 (95% CI 6.9-21) per 1000 patient days (p = 0.82). The two sites differed significantly in AE type (p = 0.033) and preventability (p = 0.002) but not severity. The most common AE type was medication/intravenous fluids-related (16/28, 57%) at one site and patient incidents (e.g., falls, pressure ulcers) at the other. Four percent (1/28) of AEs were preventable at one site, and 53% (8/15) at another. Most AEs at both sites were mild in severity. CONCLUSIONS: AEs significantly differed in type and preventability between the two sites. These results suggest the importance of context and the need for an organization-specific and tailored approach when addressing patient safety in inpatient rehabilitation settings.

Expanding Integrated Physiatric Care: A Method to Building Capacity in Physical Medicine and Rehabilitation.

ABSTRACT: Siloed and episodic care delivery is often not equitable, high-quality, or sustainable. Transitioning from separate care settings, with potentially divergent care models, to an integrated care model is not always straightforward. Some experiences in expanding collaborative care between physiatrists and other healthcare providers for a variety of patient populations and care settings within a university physical medicine and rehabilitation (PM&R) division are shared as a means to inspire the uptake of care integration initiatives more broadly within the specialty. After an initial survey of care integration across multiple clinical sites, the university division: highlighted successful integrated care models; discussed integrated care models at every divisional retreat; reached out to clinicians in other specialties to collaboratively explore expansion; developed a "one-pager" on what physiatrists do; and invited collaborative specialists from integrated clinics to PM&R national and/or international meetings. Since 2019, divisional activity in integrated care has grown and evolved substantially. Future work will focus on: further expansion of integrated clinical care; scholarly evaluation of integrated care models; expansion of academic activity resulting from integration; and advocacy to healthcare providers, hospital administrators, and health system funders about the potential value of care integration in improving rehabilitation outcomes.

Musculoskeletal mimics of lumbosacral radiculopathy.

Electrodiagnostic evaluations are commonly requested for patients with suspected radiculopathy. Understanding lower extremity musculoskeletal conditions is essential for electrodiagnostic medicine specialists, as musculoskeletal disorders often mimic or coexist with radiculopathy. This review delineates radicular pain from other types originating from the lumbosacral spine and describes musculoskeletal conditions frequently mimicking radiculopathy, such as those that cause radiating pain and sensorimotor dysfunction. In clinical evaluation, a history of pain radiating along a specific dermatomal territory with associated sensory disturbance suggests radiculopathy. Physical examination findings consistent with radiculopathy include myotomal weakness, depressed or absent muscle stretch reflexes, focal atrophy along a discrete nerve root territory, and potentially positive dural tension maneuvers like the straight leg raise. However, electrodiagnostic medicine specialists must be knowledgeable of musculoskeletal mimics, which may manifest as incomplete radiation within or beyond a dermatomal territory, non-radiating pain, tenderness, and give-way weakness, in the context of a normal neurological examination. A systematic approach to musculoskeletal examination is vital, and this review focuses on high-yield physical examination maneuvers and diagnostic investigations to differentiate between musculoskeletal conditions and radiculopathy. This approach ensures accurate diagnoses, promotes resource stewardship, enhances patient satisfaction, and optimizes care delivery. Musculoskeletal conditions resembling L1 to S4 radiculopathy are reviewed, emphasizing their distinctive features in history, physical examination, and diagnostic investigation. Among the more than 30 musculoskeletal disorders reviewed are hip and knee osteoarthritis, lumbar facet syndrome, myofascial pain syndrome, greater trochanteric pain syndrome, and plantar fasciitis.

Comparing stroke rehabilitation inpatients and clinical trials eligibility criteria: A secondary chart review analysis revealing that most patients could have been excluded from rehabilitation trials based on comorbidity status.

Background: The generalizability of treatments examined in rehabilitation randomized controls trials (RCTs) partly depend on the similarity between trial subjects and a stroke rehabilitation inpatient population. The aim of this study was to determine the proportion of stroke rehabilitation inpatients that would have been eligible or ineligible to participate in published stroke RCTs. Methods: This was a secondary analysis of chart review data collected as part of an independent quality improvement initiative. Data pertaining to the characteristics of stroke rehabilitation inpatients (e.g. age, cognitive impairment, previous stroke, comorbidities) were extracted from the medical charts of patients consecutively admitted to an inpatient stroke rehabilitation unit at a large urban rehabilitation hospital in Canada. Using the exclusion criteria categories of stroke RCTs identified from a systematic scoping review of 428 RCTs, we identified how many stroke rehabilitation inpatients would have been eligible or ineligible to participate in stroke RCTs based on their age, cognitive impairment, previous stroke and presence of comorbidities. Results: In total, 110 stroke rehabilitation inpatients were included. Twenty-four percent of patients were 80 years of age or older, 84.5% had queries or concerns regarding patient cognitive abilities, 28.0% had a previous stroke, and 31.8% had a severe stroke. Stroke rehabilitation inpatients had six comorbidities on average. Based on these factors, most stroke rehabilitation inpatients could have been excluded from stroke RCTs, with cognitive impairment the most common RCT exclusion criteria. Conclusions: Changes to the design of RCTs would support the development of clinical practice guidelines that reflect stroke rehabilitation inpatient characteristics, enhancing equity, diversity, and inclusion within samples and the generalizability of results.

Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety.

Introduction: Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation. Methods: This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence. Conclusion: Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

A qualitative study of hospital and community providers' experiences with digitalization to facilitate hospital-to-home transitions during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has triggered substantial changes to the healthcare context, including the rapid adoption of digital health to facilitate hospital-to-home transitions. This study aimed to: i) explore the experiences of hospital and community providers with delivering transitional care during the COVID-19 pandemic; ii) understand how rapid digitalization in healthcare has helped or hindered hospital-to-home transitions during the COVID-19 pandemic; and, iii) explore expectations of which elements of technology use may be sustained post-pandemic. METHODS: Using a pragmatic qualitative descriptive approach, remote interviews with healthcare providers involved in hospital-to-home transitions in Ontario, Canada, were conducted. Interviews were analyzed using a team-based rapid qualitative analysis approach to generate timely results. Visual summary maps displaying key concepts/ideas were created for each interview and revised based on input from multiple team members. Maps that displayed similar concepts were then combined to create a final map, forming the themes and subthemes. RESULTS: Sixteen healthcare providers participated, of which 11 worked in a hospital, and five worked in a community setting. COVID-19 was reported to have profoundly impacted healthcare providers, patients, and their caregivers and influenced the communication processes. There were several noted opportunities for technology to support transitions. INTERPRETATION: Several challenges with technology use were highlighted, which could impact post-pandemic sustainability. However, the perceived opportunities for technology in supporting transitions indicate the need to investigate the optimal role of technology in the transition workflow.

Predictors of Exceeding Target Inpatient Rehabilitation Length of Stay After Hip Fracture.

OBJECTIVE: The aim of the study was to identify factors associated with exceeding a target inpatient rehabilitation length of stay of 28 days or less for individuals with hip fracture. DESIGN: Retrospective cohort study of hip fracture patients admitted to an urban Canadian inpatient rehabilitation facility between January 1, 2013, and January 1, 2018. Patient characteristics previously shown to be associated with individual outcomes and/or length of stay after hip fracture were extracted from the institution's data warehouse. Regression models were used to examine factors associated with exceeding target length of stay as well as overall length of stay. RESULTS: Four hundred ninety-three subjects were included in the analysis. Three hundred forty-five (70%) met and 148 (30%) exceeded their target length of stay. Patients who exceeded their target were more likely to be elderly (odds ratio, 1.05; 95% confidence interval, 1.02-1.08), to live alone prefracture (odds ratio, 1.72; 95% confidence interval, 1.02-2.91), to have dementia (odds ratio, 2.79; 95% confidence interval, 1.12-6.97), and higher admission pain scores (severe pain odds ratio, 2.51; 95% confidence interval, 1.06-5.93). Higher admission motor Functional Independence Measure scores (odds ratio, 0.95; 95% confidence interval, 0.92-0.98) were protective. CONCLUSIONS: Advancing age, having dementia, living alone prefracture, and reporting moderate or severe pain at the time of admission not only increased the odds of an individual exceeding their target length of stay but also was associated with an overall increase in length of stay. Conversely, having a higher admission motor Functional Independence Measure score was protective.

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study.

OBJECTIVE: To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI). DESIGN: A retrospective cohort design was employed, using data retrieved from administrative databases. SETTING: Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011. PARTICIPANTS: Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation. OUTCOME MEASURES: Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics. RESULTS: There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%). CONCLUSION: Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.

The economic value of Quebec's water fluoridation program.

AIM: Dental caries is a major public health problem worldwide, with very significant deleterious consequences for many people. The available data are alarming in Canada and the province of Quebec. The water fluoridation program has been shown to be the most effective means of preventing caries and reducing oral health inequalities. This article analyzes the cost-effectiveness of Quebec's water fluoridation program to provide decision-makers with economic information for assessing its usefulness. METHODS: An approach adapted from economic evaluation was used to: (1) build a logic model for Quebec's water fluoridation program; (2) determine its implementation cost; and (3) analyze its cost-effectiveness. Documentary analysis was used to build the logic model. Program cost was calculated using data from 13 municipalities that adopted fluoridation between 2002 and 2010 and two that received only infrastructure grants. Other sources were used to collect demographic data and calculate costs for caries treatment including costs associated with travel and lost productivity. RESULTS: The analyses showed the water fluoridation program was cost-effective even with a conservatively estimated 1 % reduction in dental caries. The benefit-cost ratio indicated that, at an expected average effectiveness of 30 % caries reduction, one dollar invested in the program saved $71.05-$82.83 per Quebec's inhabitant in dental costs (in 2010) or more than $560 million for the State and taxpayers. CONCLUSION: The results showed that the drinking-water fluoridation program produced substantial savings. Public health decision-makers could develop economic arguments to support wide deployment of this population-based intervention whose efficacy and safety have been demonstrated and acknowledged.

Evaluation of an HIV and STD prevention program for adolescents in juvenile rehabilitation centers.

The aim of this study was to evaluate a sexual and STD/AIDS prevention program tailored for adolescents with social adaptation difficulties in juvenile rehabilitation facilities. The impact of the intervention on the psychosocial determinants of condom use were assessed, using a pre-test post-test quasi-experimental design. A total of 296 adolescents participated in the program (experimental group) while 240 adolescents did not receive the intervention (control group). The program led to positive outcomes among participants with respect to several of the main psychosocial determinants of condom use for sexual intercourse with a new partner. The results suggest that interventions that draw upon a combination of theoretical knowledge and consideration of the specific characteristics of the milieu could be efficient in promoting safer sexual practices among adolescents in juvenile rehabilitation centers.