Assessing Clinically Important Differences During Rehabilitation for Stroke: A Pilot Study Evaluating Anchor and Distribution Derived Estimates of Physical Function Change in Classically Summed and Rasch Models of Section GG of the Inpatient Rehabilitation Facility Patient Assessment Instrument.

OBJECTIVE: To determine clinically important differences (CIDs) on Section GG physical functioning scores on the Centers for Medicare and Medicaid Services (CMS) Inpatient Rehabilitation Facility Assessment Instrument (IRF-PAI) for patients with stroke, using anchor and distribution-based approaches. DESIGN: Pilot prospective observational cohort study. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: Patients with stroke (N=208). INTERVENTIONS: Physicians assessed improvements during rehabilitation using the modified Rankin scale (mRS). Improvements (≥1 point) on the mRS were used as the anchor for establishing CIDs. MAIN OUTCOME MEASURES: Classically summed and Rasch transformed Section GG change scores associated with clinically important improvements on the mRS. RESULTS: A total of 166 patients (79.8%) improved ≥1 point on the mRS. Change scores of 27, 9, and 16 on Section GG total physical functioning (self-care + mobility), self-care, and mobility/walk scales, respectively, had high sensitivity (0.82-0.85) but low specificity (0.52-0.69) in identifying patients improving on the mRS. Positive predictive values ranged from 0.87 to 0.91, and negative predictive values ranged from 0.42 to 0.52. Total physical functioning and selfcare anchor-derived change scores were similar to the reliable change index (RCI [2.77 × SEM]), calculated as 28 and 10 points, respectively, whereas anchor-derived mobility/walk scale change scores were equivalent to 1.96 × SEM. Exploratory Rasch modeling identified 3 Section GG subscales (R-Self-Care, R-Mobility, and R-Walking). Improvements on the R-Walking subscale were most correlated with mRS improvements (ρ=-0.47); however, accuracy of CID estimates was not improved. CONCLUSIONS: Cut-off scores obtained using the mRS anchor aligned with more robust estimates of change, as estimated by distribution-based measures. While patients achieving anchor-derived cut-offs have a high probability of mRS improvement, change scores may fail to detect clinically meaningful improvements at these same thresholds. Alternative criteria for determining MCID/CIDs, should be explored. Rasch models require further validation.

Effects of an acute care brain injury medicine continuity consultation service on health care utilization and rehabilitation outcomes.

INTRODUCTION: Although general physiatry acute-care consultation services are commonplace and improve length of stay (LOS), the benefits of a subspecialty physiatric continuity consultation service targeting patients with severe brain injury have not been reported. OBJECTIVES: Our primary objective was to characterize patient care recommendations from a Brain Injury Medicine (BIM) Continuity Consult Service, and to investigate the effects on acute-care LOS relative to brain injury patients receiving General Physical Medicine & Rehabilitation (PM&R) Consult Services. Our secondary objectives were to examine inpatient rehabilitation (IPR) health care utilization metrics and costs between groups and evaluate clinical improvements during IPR and discharge disposition. DESIGN: Retrospective cohort comparison study. SETTING: Academic medical center with level 1 trauma center. PARTICIPANTS: Adults with severe brain injury admitted to a single-site acute-care facility and subsequently admitted to a single inpatient brain injury rehabilitation unit over the same time period. PHYSIATRIC CARE MODELS: BIM Continuity Consult Service versus General PM&R Consult Service. MAIN OUTCOME MEASURES: Acute-care LOS; unplanned discharges to acute-care. RESULTS: Despite no major demographic or clinical group differences, the BIM Consult Service had more patient comorbidities than General PM&R Consult Service (17.5±5.3 versus 16±5.1;P = .04). BIM Consult Service patients spent fewer days in acute care (30±11.8 versus 36±22.8; P = .008), and early BIM consult (≤7 days after admission) was associated with shorter acute-care LOS (P < .002). IPR LOS was similar between groups when considering unplanned transfers. Unplanned transfers among General PM&R Consult Service patients occurred twice as frequently as in BIM Consult Service patients; average readmission costs were $2778 per patient on the BIM Consult Service and $6702 per patient on the General PM&R Consult Service. More BIM Consult Service (85.7%) than General PM&R Consult Service (27.3%) patients emerged from disorders of consciousness during IPR (P = .02). CONCLUSIONS: BIM Continuity Consultation Services were associated with shorter acute-care LOS, fewer unplanned acute-care transfers, and an increased likelihood of emerging from a minimally conscious state during IPR.

Clostridium difficile Infection Reservoirs Within an Acute Rehabilitation Environment.

OBJECTIVE: Clostridium difficile infection is a common hospital-associated infection spread via patient contact or contaminated environments. The risk for spread of C difficile may be greater in inpatient rehabilitation units than in some hospital units as patients are not confined to their rooms and often share equipment. Environmental disinfection is challenging in shared medical equipment, especially in equipment with complex designs. The study aimed to examine the presence of C difficile spores within an acute rehabilitation environment and to evaluate disinfection effectiveness. DESIGN: Cultures were performed on 28 rehabilitation rooms, 28 rehabilitation floor surfaces, and 80 shared devices and equipment. Two disinfection interventions were implemented, and environmental cultures then were repeated postintervention. RESULTS: Environmental cultures positive for CD spores were rehabilitation rooms (1/28), rehabilitation floors (13/28), and wheelchairs (3/20). After the implementation of new disinfection methods, repeat cultures were obtained and produced negative results. CONCLUSIONS: Nonsporicidal disinfectant was not effective on hospital floors. Sporicidal disinfection of the floor is important when rates of C difficile infection are increased. Wheelchairs are complex devices and difficult to properly clean. The hospital purchased an ultraviolent device for wheelchair cleaning with a subsequent reduction in spores on repeat cultures. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the impact of Clostridium difficile infections on the healthcare system; (2) Describe potential reservoirs of Clostridium difficile in the inpatient rehabilitation environment; and (3) Discuss interventions that may be implemented to reduce the reservoirs of Clostridium difficile on the rehabilitation unit. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Impact of annual urodynamic evaluations on guiding bladder management in individuals with spinal cord injuries.

STUDY DESIGN: A single-center institutional review board-approved prospective cross-sectional observational study. CONTEXT: Urodynamic studies are essential to accurately direct bladder management following spinal cord injury (SCI). There is no consensus on how often testing should be performed. OBJECTIVE: To determine the impact of annual urodynamic studies on guiding bladder management following SCI. METHODS: Individuals with traumatic SCI undergoing annual urological evaluations were enrolled in this study. They had to be injured for at least 2 years so that urodynamic changes could be compared with their previous annual urodynamic evaluation. Changes in the urodynamic parameters and autonomic dysreflexia were determined by comparing this study with the previous year's study. All studies were done with the same physician and nursing staff. Demographic data, bladder management, urodynamic parameters, and the need and type of interventions based on the urodynamic study were obtained. The main outcome measure was whether or not there was a need for an intervention based on the urodynamics. Interventions were classified as urological intervention, non-urological intervention, or a combination of urological and non-urological intervention. The impact of the type of bladder management, length of injury, and level of injury was also evaluated. RESULTS: Ninety-six consecutive individuals with SCI undergoing annual urodynamic evaluations were enrolled over a 5-month period. Overall, 47.9% of individuals required at least one type of intervention based on urodynamic studies: 82.6% were urological interventions (medication changes were most common, comprising 54.3% of urological interventions); 13.0% were non-urological interventions; and 4.3% were a combination of non-urological and urological interventions. The need for interventions did not appear to be influenced by the type of bladder management, the length of time post-injury or level of injury. CONCLUSION: Annual urodynamic evaluation plays an important role in guiding bladder management following SCI.

Accuracy of predicting bladder stones based on catheter encrustation in individuals with spinal cord injury.

BACKGROUND: Bladder calculi are the second most common urological complication in those with spinal cord injury (SCI). Detection and removal of bladder stones are important to prevent possible complications. OBJECTIVE: To determine the accuracy of bladder stone detection based on catheter encrustation in asymptomatic individuals with SCI. DESIGN: Prospective cohort study. METHODS: Cystoscopy findings in persons with SCI who were noted to have catheter encrustation at the time of catheter removal for their scheduled cystoscopy were used in this prospective study. Indwelling catheters were examined for encrustation at the time of removal as they were being prepared for cystoscopy. Cystoscopy was performed, and the presence or absence of bladder stones was noted. MAIN OUTCOME MEASURES: Presence or absence of bladder stones detected with cystoscopy in those with precystoscopy catheter encrustation. RESULTS: Forty-nine individuals with indwelling catheters were evaluated. Overall, 17/49 (35%) individuals in this study had bladder stones. Catheter encrustation was noted in 13 patients. Of these 13 patients, 11 also had bladder stones. In other words, a positive result for catheter encrustation had a positive result for bladder stones 85% of the time. Thirty-six individuals had no catheter encrustation. Of these, 6 (16%) were found to have bladder stones. CONCLUSIONS: Encrustation of a catheter is highly predictive of the presence of bladder stones. This suggests that cystoscopy should be scheduled in a person undergoing a catheter change if catheter encrustation is noted.

Accuracy of bladder stone detection using abdominal x-ray after spinal cord injury.

BACKGROUND: Bladder calculi are a common problem in those with spinal cord injury (SCI). Detection is important to prevent complications. OBJECTIVE: To determine the accuracy of bladder stone detection by abdominal x-rays. METHODS: X-ray reports from individuals with SCI with known bladder stones detected by cystoscopy were reviewed. MAIN OUTCOME MEASURES: X-ray reports noted the presence or absence of bladder stones. The stone variables evaluated were stone composition (crystallographic analysis), widest dimension of the largest stone (during cystoscopy), and the total volume (cm3) of the stone mass removed. RESULTS: Sixty-two consecutive x-ray reports from individuals with bladder stones were reviewed. The majority of stones were calcium phosphate (46.8%) or struvite (26.7%). Regarding stone composition, the detection by x-ray was 28.6% for struvite stones and 41.9% for calcium phosphate stones. Regarding diameter of largest stone, the detection by x-ray was 14% for stones < 0.5 cm, 0% for stones 0.5 cm to 0.9 cm, 33% for stones 1.0 cm to 1.49 cm, 33% for stones 1.5 cm to 1.9 cm, and 54% for stones > or = 2.0 cm. Regarding total volume of stones, the detection by x-ray was 0% for volumes < 0.2 cm3, 33% for volumes 0.2 cm3 to 0.39 cm3, 60% for volumes 0.40 cm3 to 0.59 cm3, 40% for volumes of 0.60 cm3 to 0.79 cm3, 0% for stones from 0.8 cm3 to 0.99 cm3, and 57% for volumes > or = 1.0 cm3. Overall, 13/62 (20.97%) of stones found during cystoscopy were detected by the x-ray. CONCLUSION: Abdominal x-ray is not a reliable method to detect bladder stones in individuals with SCI.