Impact of early mobilization on discharge disposition and functional status in patients with subarachnoid hemorrhage

Introduction: Deep vein thrombosis (DVT) is reported in 23% to 50% of hemiplegic stroke survivors and the highest rate of incidence occurs within one week of stroke onset. Pulmonary embolism (PE) is reported in up to 5% of stroke patients. There is limited data about the relationship of ambulatory status and the rate of venous thromboembolism (VTE) following a stroke. Hypothesis: The goal of our retrospective cohort study was to understand the relationship between VTE and a patient’s ambulatory status, adjusting for age, gender, and stroke type (ischemic, intracerebral hemorrhage, or subarachnoid hemorrhage). We assessed the hypothesis that the stroke patients who are able to ambulate during hospitalization would have lower rates of DVT and PE. Methods: We retrospectively analyzed 1670 acute stroke patients who were admitted to an academic comprehensive stroke center between Feb 2006 and May 2014. “Get with the guideline data” was used to identify stroke patients and their ambulatory status (yes/no). VTE was identified using discharge diagnosis. Chi square test and logistic regression methods were used for statistical analysis. Results: Mean age was 64.9 ± 14.6 years with 51% men. 1138 (68%) patients were classified as having ischemic stroke; 291 (17.5%) patients had intracerebral hemorrhage; and 241 (14.5%) patients had subarachnoid hemorrhage. During hospitalization, 444 (27%) were ambulatory. Patients able to ambulate during hospitalization had less rate of DVT (6.3% vs 15.3%; p<0.0001) and PE (2.9% vs 5.3%; p=0.04), when compared to non-ambulating patients. After adjusting for age, gender, and stroke type; patients who were able to ambulate still had lower rates of DVT (OR: 0.42, 95% CI 0.27-0.63) and PE (OR: 0.49, 95% CI 0.25-0.88). Conclusion: In conclusion, our findings suggest that the patient’s ambulatory status during hospitalization is an independent predictor of VTE. Further research is needed to understand if early mobilization in non-ambulatory stroke patients would have similar protective effect against VTE or not.

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Geriatric Trauma Screening Tool: Preinjury Functional Status Dictates Intensive Care Unit Discharge Disposition

The American Surgeon ◽

10.1177/000313481908500828 ◽

2019 ◽

Vol 85 (8) ◽

pp. 800-805

Author(s):

Lindsey C. Bridges ◽

Amy B. Christie ◽

Hamza H. Awad ◽

Erika J. Sigman ◽

D. Benjamin Christie ◽

...

Keyword(s):

Older Adults ◽

Functional Status ◽

Screening Tool ◽

Intensive Care Unit Discharge ◽

Hospital Length ◽

Transitions Of Care ◽

Geriatric Trauma ◽

Trauma Patients ◽

Discharge Disposition ◽

Hospital Resources

Older adults account for an increasing percentage of trauma patients and have worse outcomes when compared with younger populations. Simple prediction tools are needed to designate risk categories among these patients. The Geriatric Trauma Screening Tool (GTST) was developed to risk stratify older adults admitted to the ICU at a Level 1 trauma center. One hundred fifty patients aged ≥ 65 years were prospectively screened for high-risk (HR) injuries, comorbidities, and pre-hospital function using the GTST. Patients who screened for HR were more likely to have an unfavorable disposition than non-HR patients. HR patients had significantly longer ICU and hospital length of stays when compared with non-HR patients. In addition, patients with prior functional impairment were at higher risk for an unfavorable discharge disposition than their counterparts. Implementation of the GTST predicted discharge disposition in geriatric trauma patients admitted to the ICU. Pre-injury functional status was a better predictor of discharge disposition than either the types of HR injuries or the presence of comorbidities. Risk stratification of geriatric trauma patients allows for early engagement of patients and caregivers regarding transitions of care as well as more efficient utilization of hospital resources.

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Functional Status Is an Independent Predictor of Poor Discharge Disposition and Mortality after Bariatric Surgery

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2018.07.021 ◽

2018 ◽

Vol 227 (4) ◽

pp. S20

Author(s):

Sara A. Hennessy ◽

Rui-Min D. Mao ◽

Nancy Puzziferri ◽

Amarita S. Klar ◽

Daniel J. Scott ◽

...

Keyword(s):

Bariatric Surgery ◽

Functional Status ◽

Independent Predictor ◽

Discharge Disposition

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VENTRICULOPERITONEAL SHUNTING AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000317310.62073.b2 ◽

2008 ◽

Vol 62 (3) ◽

pp. 618-627 ◽

Cited By ~ 38

Author(s):

Andrew S. Little ◽

Joseph M. Zabramski ◽

Madelon Peterson ◽

Pamela W. Goslar ◽

Scott D. Wait ◽

...

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Functional Status ◽

Posthemorrhagic Hydrocephalus ◽

Ventriculoperitoneal Shunting ◽

Group 3 ◽

Group 2 ◽

Ventricle Size ◽

Group 1

Abstract OBJECTIVE The goals of this study were to investigate the risk factors, indications, complications, and outcome for patients with ventriculoperitoneal shunts (VPSs) after subarachnoid hemorrhage and to define a subgroup eligible for future prospective studies designed to clarify indications for placement of a VPS. METHODS Clinical characteristics of 236 prospectively evaluated patients with subarachnoid hemorrhage and 6 months of follow-up were analyzed. Hydrocephalus was estimated by the relative bicaudate index (RBCI) measured on computed tomographic scans at the time of shunting. Patients were divided into three groups by ventricle size: Group 1 included 121 patients with small ventricles (RBCI <1.0), Group 2 included 88 patients with borderline ventricle size (RBCI 1.0–1.4), and Group 3 included 27 patients with markedly enlarged ventricles (RBCI >1.4). RESULTS Initially, 86 patients (36%) underwent ventriculoperitoneal shunting: 19 in Group 1 (16%), 43 in Group 2 (49%), and 24 in Group 3 (90%). Indications for placement of a VPS, risk factors, and outcome differed markedly by group. Four patients (3% of those not initially shunted) developed delayed hydrocephalus requiring a VPS, including one in Group 2 (2%). The 6-month shunt complication rate was 13%. Evaluation of patients in Group 2 indicated that functional status was an important factor in selecting candidates for shunting, and that patients receiving shunts and shunt-free patients demonstrated improvement in functional status during follow-up. CONCLUSION Although we currently use a proactive shunting paradigm for posthemorrhagic hydrocephalus, this report demonstrates that a conservative approach to patients with borderline ventricle size (i.e., RBCI of 1.0–1.4) and normal intracranial pressure should be evaluated in a prospective randomized trial.

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Safety and Feasibility of an Early Mobilization Program for Patients With Aneurysmal Subarachnoid Hemorrhage

Physical Therapy ◽

10.2522/ptj.20110334 ◽

2013 ◽

Vol 93 (2) ◽

pp. 208-215 ◽

Cited By ~ 38

Author(s):

Brian F. Olkowski ◽

Mary Ann Devine ◽

Laurie E. Slotnick ◽

Erol Veznedaroglu ◽

Kenneth M. Liebman ◽

...

Keyword(s):

Heart Rate ◽

Subarachnoid Hemorrhage ◽

Physical Therapist ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Early Mobilization ◽

Therapeutic Exercise ◽

Mean Flow ◽

Functional Training ◽

Prolonged Monitoring ◽

Mean Flow Velocity

BackgroundSurvivors of aneurysmal subarachnoid hemorrhage (SAH) are faced with a complicated recovery, which typically includes surgery, prolonged monitoring in the intensive care unit, and treatment focusing on the prevention of complications.ObjectiveThe purpose of this study was to determine the safety and feasibility of an early mobilization program for patients with aneurysmal SAH.DesignThis study was a retrospective analysis.MethodsTwenty-five patients received early mobilization by a physical therapist or an occupational therapist, or both, which focused on functional training and therapeutic exercise in more progressively upright positions. Participation criteria focused on neurologic and physiologic stability prior to the initiation of early mobilization program sessions.ResultsPatients met the criteria for participation in 86.1% of the early mobilization program sessions attempted. Patients did not meet criteria for the following reasons: Lindegaard ratio >3.0 or middle cerebral artery (MCA) mean flow velocity (MFV) >120 cm/s (8.1%), mean arterial pressure (MAP) <80 mm Hg (1.8%), intracranial pressure (ICP) >15 mm Hg (1.8%), unable to open eyes in response to voice (0.9%), respiratory rate >40 breaths/min (0.6%), MAP >110 mm Hg (0.3%), and heart rate <40 bpm (0.3%). Adverse events occurred in 5.9% of early mobilization program sessions for the following reasons: MAP <70 mm Hg (3.1%) or >120 mm Hg (2.4%) and heart rate >130 bpm (0.3%). The 30-day mortality rate for all patients was 0%. Participation in the early mobilization program began a mean of 3.2 days (SD=1.3) after aneurysmal SAH, and patients received an average of 11.4 sessions (SD=4.3). Patients required a mean of 5.4 days (SD=4.2) to participate in out-of-bed activity and a mean of 10.7 days (SD=6.2) to walk ≥15.24 m (50 ft).ConclusionsThe results of this study suggest that an early mobilization program for patients with aneurysmal SAH is safe and feasible.

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PT Achievement in Public Hospitals and Its Effect on Outcomes

Geriatrics ◽

10.3390/geriatrics4040058 ◽

2019 ◽

Vol 4 (4) ◽

pp. 58

Author(s):

Jessica S. Morton ◽

Alex Tang ◽

Michael J. Moses ◽

Dustin Hamilton ◽

Neville Crick ◽

...

Keyword(s):

Physical Therapy ◽

Length Of Stay ◽

Medical Center ◽

Therapy Group ◽

Academic Medical Center ◽

Early Mobilization ◽

The United States ◽

Public Hospitals ◽

Hospital Length Of Stay ◽

Discharge Disposition

The demand for TKA continues to rise within the United States, while increasing quality measures and cost containment became the basis of reimbursement for hospital systems. Length of stay is a major driver in the cost of TKA. Early mobilization with physical therapy has been shown to increase range of motion and decrease complications, but with mixed results in regards to length of stay. We postulate that initiating physical therapy on post-operative day zero will decrease length of stay in an urban public hospital. Retrospective chart review was performed at a large, urban, public academic medical center to identify patients who have had a primary TKA over the course of a 3-year period. Groups who underwent post-operative day zero therapy were compared with those who initiated physical therapy on post-operative day one. Length of stay was the primary outcome. Patient demographic characteristics and discharge disposition were also collected. There were 98 patients in the post-operative day-one physical therapy cohort and 58 in the post-operative day zero physical therapy group. Hospital length of stay was significantly decreased in the post-operative day zero physical therapy group. (p < 0.01) There was no difference in discharge disposition between the two groups.

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A troponin study on patients with ischemic stroke, intracerebral hemorrhage and subarachnoid hemorrhage: Type II myocardial infarction is significantly associated with stroke severity, discharge disposition and mortality

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2019.04.005 ◽

2019 ◽

Vol 64 ◽

pp. 83-88 ◽

Cited By ~ 2

Author(s):

Ayham M. Alkhachroum ◽

Benjamin Miller ◽

Tarek Chami ◽

Curtis Tatsuoka ◽

Cathy Sila

Keyword(s):

Myocardial Infarction ◽

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Intracerebral Hemorrhage ◽

Stroke Severity ◽

Type Ii ◽

Discharge Disposition

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Abstract P50: IV Alteplase Use Predicts Favorable Discharge Disposition in Patients With Acute Ischemic Stroke: Insights From the UTHSC Houston Stroke Registry

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.ap50 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Nneka Ifejika-Jones ◽

Nusrat Harun ◽

Elizabeth Noser ◽

James Grotta

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Status ◽

Inpatient Rehabilitation ◽

Level Of Care ◽

Stroke Patients ◽

Short Term ◽

Post Stroke ◽

Discharge Disposition

Introduction: Acute ischemic stroke patients receiving IV alteplase (t-PA) within 4.5 hours of symptom onset are 30% more likely to have minimal or no disability at 3 months. During hospitalization, short-term disability is subjectively measured by discharge disposition, whether to home or Inpatient Rehabilitation (IR), Skilled Nursing Facility (SNF) or Sub-acute Care (Sub). There are no studies assessing the role of IV t-PA as a predictor of short-term disability, evidenced by post-stroke disposition. Hypothesis: Low NIHSS is a predictor of high functional status. We assessed the hypothesis that similar to low NIHSS, t-PA predicts post-stroke disposition to a level of care suggestive of high functional status. Methods: All patients with acute ischemic stroke admitted to the UT Service between January 2004 and October 2009 were included. Stratification occurred for age>65, NIHSS and stroke risk factors. Using multivariate logistic regression, the data was analyzed to determine whether there were differences in post-stroke disposition among patients who received t-PA. Results: Patients with mild (NIHSS<8) and moderate (NIHSS 8 to 16) stroke were discharged to the highest level of care in each analysis. Home vs. Other Level of Care Of 2261 patients, 1032 were discharged home, 1229 to another level of care. Patients who received t-PA were 1.7 times more likely to be discharged home (P = <.0001, OR 1.663, 95% CI 1.326 to 2.085). IR vs. SNF Of 1111 patients, 731 patients were discharged to acute IR, 380 to SNF. There were no statistically significant differences in disposition between patients who received t-PA. (P = .0638, OR 1.338, 95% CI 0.983 to 1.822). SNF vs. Sub Of 498 patients, 380 were discharged to SNF, 118 to Sub. There were no significant differences in disposition between patients who received t-PA. Conclusion: Acute stroke patients who receive IV t-PA are more 1.7 times more likely to be discharged home. If post-stroke care is necessary, there is a trend toward rehabilitation at a level reflective of improved functional status (IR vs. SNF). This study is limited by its retrospective nature and the undetermined role of psychosocial factors related to discharge. Prospective studies of time to t-PA therapy in relation to post-stroke disposition are warranted.

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Impact of admission month and hospital teaching status on outcomes in subarachnoid hemorrhage: evidence against the July effect

Journal of Neurosurgery ◽

10.3171/2011.8.jns11324 ◽

2012 ◽

Vol 116 (1) ◽

pp. 157-163 ◽

Cited By ~ 35

Author(s):

Robert J. McDonald ◽

Harry J. Cloft ◽

David F. Kallmes

Keyword(s):

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Hospital Admissions ◽

Adverse Outcomes ◽

Discharge Disposition ◽

July Effect ◽

Teaching Status ◽

Discharge Status ◽

The Impact ◽

Hospital Characteristics

Object The authors sought to identify the presence of a “July effect,” a transient increase in adverse outcomes during July, among a cohort of spontaneous subarachnoid hemorrhage (SAH) admissions recorded in the National Inpatient Sample (NIS). Methods The discharge status, admission month, patient demographics, treatment parameters, and hospital characteristics among spontaneous SAH admissions were extracted from the 2001–2008 NIS. Multivariate regression was used to determine whether an unfavorable discharge status and/or in-hospital mortality significantly increased in summer months in a pattern suggestive of a July effect. Additional models were generated to assess the impact of hospital teaching status on these outcomes. Results Among 57,663,486 hospital admissions from the 2001–2008 NIS, 52,879 cases of spontaneous SAH (ICD-9-CM 430) were treated at teaching (36,914 cases [70%]) and nonteaching (15,965 cases [30%]) facilities. Regression models failed to reveal a July effect for in-hospital mortality (χ2 = 0.75, p = 1.000) or unfavorable discharges (χ2 = 1.69, p = 0.999) among monthly SAH admissions, although they did suggest a significant reduction in these outcomes (in-hospital mortality, OR = 0.89, p < 0.001; unfavorable discharges, OR = 0.88, p < 0.001) among teaching hospitals as compared with nonteaching hospitals after adjustment for disparities in demographic, treatment, and hospital characteristics. Conclusions The discharge disposition among SAH admissions within the NIS was not suggestive of a July effect but did reveal that teaching institutions have significantly lower rates of adverse outcomes when compared with nonteaching hospitals. Note, however, that the origins of this difference related to teaching status remain unclear.

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