Prevalence of undiagnosed urinary tract infections on admission to a rehabilitation unit

Background Through clinical observation nursing staff of an inpatient rehabilitation unit identified a link between incontinence and undiagnosed urinary tract infections (UTIs). Further, clinical observation and structured continence management led to the realisation that urinary incontinence often improved, or resolved completely, after treatment with antibiotics. In 2009 a small study found that 30% of admitted rehabilitation patients had an undiagnosed UTI, with the majority admitted post-orthopaedic fracture. We suspected that the frequent use of indwelling urinary catheters (IDCs) in the orthopaedic environment may have been a contributing factor. Therefore, a second, more thorough, study was commenced in 2010 and completed in 2011. Aim The aim of this study was to identify what proportion of patients were admitted to one rehabilitation unit with an undiagnosed UTI over a 12-month period. We wanted to identify and highlight the presence of known risk factors associated with UTI and determine whether urinary incontinence was associated with the presence of UTI. Methods Data were collected from every patient that was admitted over a 12-month period (n=140). The majority of patients were over the age of 65 and had an orthopaedic fracture (36.4%) or stroke (27.1%). Mid-stream urine (MSU) samples, routinely collected and sent for culture and sensitivity as part of standard admission procedure, were used by the treating medical officer to detect the presence of UTI. A data collection sheet was developed, reviewed and trialled, before official data collection commenced. Data were collected as part of usual practice and collated by a research assistant. Inferential statistics were used to analyse the data. Results This study found that 25 (17.9%) of the 140 patients admitted to rehabilitation had an undiagnosed UTI, with a statistically significant association between prior presence of an IDC and the diagnosis of UTI. Urinary incontinence improved after the completion of treatment with antibiotics. Results further demonstrated a significant association between the confirmation of a UTI on culture and sensitivity and the absence of symptoms usually associated with UTI, such as burning or stinging on urination. Overall, this study suggests careful monitoring of urinary symptoms in patients admitted to rehabilitation, especially in patients with a prior IDC, is warranted.

Demographics and discharge outcomes of dysvascular and non-vascular lower limb amputees at a subacute rehabilitation unit: A 7-year series

Objective To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees. Methods In total, 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission and discharge descriptive statistics (frequency, percentages) were calculated and compared by aetiology. Results Participants were male (74%), aged 65 years (s.d. 14), born in Australia (72%), had predominantly dysvascular aetiology (80%) and a median length of stay 48 days (interquartile range (IQR): 25–76). Following amputation, 56% received prostheses for mobility, 21% (n = 89) changed residence and 28% (n = 116) required community services. Dysvascular amputees were older (mean 67 years, s.d. 12 vs 54 years, s.d. 16; P < 0.001) and recorded lower functional independence measure – motor scores at admission (z = 3.61, P < 0.001) and discharge (z = 4.52, P < 0.001). More nonvascular amputees worked before amputation (43% vs 11%; P < 0.001), were prescribed a prosthesis by discharge (73% vs 52%; P < 0.001) and had a shorter length of stay (7 days, 95% confidence interval: –3 to 17), although this was not statistically significant. Conclusions Differences exist in social and demographic outcomes between dysvascular and non-vascular lower limb amputees.

Patients undergoing subacute rehabilitation have accurate expectations of their health-related quality of life at discharge

Background Expectations held by patients and health professionals may affect treatment choices and participation (by both patients and health professionals) in therapeutic interventions in contemporary patient-centered healthcare environments. If patients in rehabilitation settings overestimate their discharge health-related quality of life, they may become despondent as their progress falls short of their expectations. On the other hand, underestimating their discharge health-related quality of life may lead to a lack of motivation to participate in therapies if they do not perceive likely benefit. There is a scarcity of empirical evidence evaluating whether patients' expectations of future health states are accurate. The purpose of this study is to evaluate the accuracy with which older patients admitted for subacute in-hospital rehabilitation can anticipate their discharge health-related quality of life. Methods A prospective longitudinal cohort investigation of agreement between patients' anticipated discharge health-related quality of life (as reported on the EQ-5D instrument at admission to a rehabilitation unit) and their actual self-reported health-related quality of life at the time of discharge from this unit was undertaken. The mini-mental state examination was used as an indicator of patients' cognitive ability. Results Overall, 232(85%) patients had all assessment data completed and were included in analysis. Kappa scores ranged from 0.42-0.68 across the five EQ-5D domains and two patient cognition groups. The percentage of exact correct matches within each domain ranged from 69% to 85% across domains and cognition groups. Overall 40% of participants in each cognition group correctly anticipated all of their self-reported discharge EQ-5D domain responses. Conclusions Patients admitted for subacute in-hospital rehabilitation were able to anticipate the discharge health-related quality of life on the EQ-5D instrument with a moderate level of accuracy. This finding adds to the foundational empirical work supporting joint treatment decision making and patient-centered models of care during rehabilitation following acute illness or injury. Accurate patient expectations of the impact of treatment (or disease progression) on future health-related related quality of life is likely to allow patients and health professionals to successfully target interventions to priority areas where meaningful gains can be achieved.

Outcomes following inpatient rehabilitation : a seven year perspective

Introduction: Improving physical and cognitive functioning is a key objective of multi-disciplinary inpatient geriatric rehabilitation. Outcomes relevant to minimum functional ability required for older adults to successfully participate in the community have been reported. However, there has been little investigation reporting outcomes of older inpatients receiving multi-disciplinary rehabilitation being discharged home from geriatric rehabilitation units. This study aims to investigate characteristics and physical and cognitive outcomes of this cohort. Method: The Princess Alexandra Hospital Geriatric and Rehabilitation Unit is the largest rehabilitation unit in Queensland. Multidisciplinary health professionals enter admission and discharge functional and clinical outcomes along with demographic information into a purpose designed database for all patients. Data collected between 2005 and 2011 was analysed using descriptive statistics. Results: During the seven-year period, 4120 patients were admitted for rehabilitation; 2126 (52%) were female, mean age of 74 years (Standard Deviation 14). Primary reasons for admission were for reconditioning post medical illness or surgical admission (n = 1285, 31%), and 30% (n = 1233) admitted for orthopaedic reasons. Of these orthopaedic admissions, 6.6% (n = 82) were for elective surgery, and 46% (n = 565) were for fractured neck-of-femurs. 76% (n = 3130) of patients were discharged home, 13% (n = 552) to residential care facilities and 10% (n = 430) were discharged to an alternative hospital setting or passed away during their admission. Mean length of stay was 44 days (SD 39) Preliminary analysis of FIM outcomes shows a mean motor score of 53 (SD = 19) on admission which significantly improved to 71 (SD = 18) by discharge. There was no change on FIM cognitive score (28 (SD7) vs 29 (SD 6). Conclusion: Geriatric patients have significant functional limitations even on discharge from inpatient rehabilitation; though overall cognition is relatively intact. Orthopaedic conditions and general deconditioning from medical/surgical admissions are the main reasons for admission. The majority of people receiving rehabilitation are discharged home.

Outcomes following inpatient rehabilitation of lower limb amputees

Introduction: Lower-limb amputations are a serious adverse consequence of lifestyle related chronic conditions and a serious concern among the aging population in Australia. Lower limb amputations have severe personal, social and economic impacts on the individual, healthcare system and broader community. This study aimed to address a critical gap in the research literature by investigating the physical functioning and social characteristics of lower limb amputees at discharge from tertiary hospital inpatient rehabilitation. Method: A cohort study was implemented among patients with lower limb amputations admitted to a Geriatric Assessment and Rehabilitation Unit for rehabilitation at a tertiary hospital. Conventional descriptive statistics were used to examine patient demographic, physical functioning and social living outcomes recorded for patients admitted between 2005 and 2011. Results: A total of 423 admissions occurred during the study period, 313 (74%) were male. This sample included admissions for left (n = 189, 45%), right (n = 220, 52%) and bilateral (n = 14, 3%) lower limb amputations, with 15 (3%) patients dying whilst an inpatient. The mean (standard deviation) age was 65 (13.9) years. Amputations attributed to vascular causes accounted for 333 (78%) admissions; 65 (15%) of these had previously had an amputation. The mean (SD) length of stay in the rehabilitation unit was 56 (42) days. Prior to this admission, 123 (29%) patients were living alone, 289 (68%) were living with another and 3 (0.7%) were living in residential care. Following this amputation related admission, 89 (21%) patients did not return to their prior living situation. Of those admitted, 187 (44%) patients were discharged with a lower limb prosthesis. Conclusion: The clinical group is predominately older adults. The ratio of males to females was approximately 3:1. Over half did not return to walking and many were not able to return to their prior accommodation. However, few patients died during their admission.

Functional independence following subacute inpatient rehabilitation was not affected by age among older patients recovering from cardiac-related hospital admissions

Introduction Older people recovering from cardiac events requiring an acute hospital admission may experience a decline in physical function limiting their ability to return home to their previous accommodation. Subacute inpatient rehabilitation therapies have potential to assist recovery of physical functioning. However, it is unknown whether age influences the length of stay or physical functioning at discharge from subacute inpatient rehabilitation for this population. Objectives This study examined the outcomes of a cohort of older patients recovering from a cardiac event requiring hospitalisation to investigate the association between age and physical function at discharge, as well as age and length of rehabilitation stay. Methods Participants included 145 consecutive inpatient admissions to a subacute geriatric assessment and rehabilitation unit with a cardiac condition as their primary reason for hospital admission. Participants were required to complete a multi-disciplinary physical functioning assessment within 72 hours of admission to the unit, and again within 72 hours prior to discharge from the unit. The primary outcome measure was the Functional Independence Measure motor score. Demographic and clinical information, including length of stay and discharge destination, were also recorded. Results A total n=126 (87%) participants, with a mean (standard deviation) age of 79 (10) years, had both assessments completed and were included in analyses. Participants who had passed away (n=4, 3%), or did not have both assessments completed per protocol were excluded from analyses. Discharge destinations included home (n=101, 80%), residential aged care (n=17, 13%) and another hospital (n=8, 6%). The (median, interquartile range) Functional Independence Measure motor score was higher at discharge (79, 71 to 84) than admission (61, 48 to 71); z=7.75 p<0.001. Age was not associated with Functional Independence Measure motor score at discharge (t= -0.18, p=0.86), or length of stay in the rehabilitation unit (t= -0.52, 0.60). Conclusion Any perception that age may be associated with longer lengths of stay and reduced physical function outcomes among patients with cardiac conditions admitted for subacute inpatient rehabilitation for older adults is not supported data from this investigation. Older age should not be considered a disincentive when considering the suitability of patients with cardiac diagnoses for this type of inpatient rehabilitation or their potential physical functioning outcome.

Developing a quick and practical screen to improve the identification of poor hydration in geriatric and rehabilitative care

Dehydration has been associated with increased morbidity and mortality. Dehydration risk increases with advancing age, and will progressively become an issue as the aging population increases. Worldwide, those aged 60 years and over are the fastest growing segment of the population. The study aimed to develop a clinically practical means to identify dehydration amongst older people in the clinical care setting. Older people aged 60 years or over admitted to the Geriatric and Rehabilitation Unit (GARU) of two tertiary teaching hospitals were eligible for participation in the study. Ninety potential screening questions and 38 clinical parameters were initially tested on a single sample (n=33) with the most promising 11 parameters selected to undergo further testing in an independent group (n=86). Of the almost 130 variables explored, tongue dryness was most strongly associated with poor hydration status, demonstrating 64% sensitivity and 62% specificity within the study participants. The result was not confounded by age, gender or body mass index. With minimal training, inter-rater repeatability was over 90%. This study identified tongue dryness as a potentially practical tool to identify dehydration risk amongst older people in the clinical care setting. Further studies to validate the potential screen in larger and varied populations of older people are required

Patient preference for falls prevention in hospitals revealed through willingness-to-pay, contingent valuation survey

Rationale, aims and objectives: Patient preference for interventions aimed at preventing in-hospital falls has not previously been investigated. This study aims to contrast the amount patients are willing to pay to prevent falls through six intervention approaches. ----- ----- Methods: This was a cross-sectional willingness-to-pay (WTP), contingent valuation survey conducted among hospital inpatients (n = 125) during their first week on a geriatric rehabilitation unit in Queensland, Australia. Contingent valuation scenarios were constructed for six falls prevention interventions: a falls consultation, an exercise programme, a face-to-face education programme, a booklet and video education programme, hip protectors and a targeted, multifactorial intervention programme. The benefit to participants in terms of reduction in risk of falls was held constant (30% risk reduction) within each scenario. ----- ----- Results: Participants valued the targeted, multifactorial intervention programme the highest [mean WTP (95% CI): $(AUD)268 ($240, $296)], followed by the falls consultation [$215 ($196, $234)], exercise [$174 ($156, $191)], face-to-face education [$164 ($146, $182)], hip protector [$74 ($62, $87)] and booklet and video education interventions [$68 ($57, $80)]. A ‘cost of provision’ bias was identified, which adversely affected the valuation of the booklet and video education intervention. ----- ----- Conclusion: There may be considerable indirect and intangible costs associated with interventions to prevent falls in hospitals that can substantially affect patient preferences. These costs could substantially influence the ability of these interventions to generate a net benefit in a cost–benefit analysis.

Flight-training effect on the cervical muscle isometric strength of trainee pilots

External stimulus/loading initiates adaptations within skeletal muscle. It has been previously found that the cervical area has the highest loading while performing flying maneuvers under +Gz. The first purpose of this study was to examine the neck muscle response to the physical environment associated with flight training, incorporating limited exposure to +Gz force, in a Pilatus PC-9 aircraft. The second purpose was to examine the short-term range of movement (ROM) response to flight training. Isometric cervical muscle strength and ROM was monitored in 9 RAAF pilots completing an 8-mo flight-training course at Pearce Airbase in Western Australia, and in 10 controls matched for gender, age, height, and weight. Isometric cervical muscle strength and ROM were measured at baseline and at 8 mo using the multi-cervical rehabilitation unit (Hanoun Medical, Downsview, Ontario, Canada). Results indicated that an increase in pilot neck strength was limited to flexion while in a neutral position. No strength changes were recorded in any other site in the pilots or for the controls. These findings suggest that short-term exposure to the physical environment associated with flight training had a limited significant effect on increasing isometric cervical muscle strength. No significant changes were observed in pilot ROM, indicating that short-term exposure to flight does not effect ROM.

Predicting final disposition after stroke using the Orpington Prognostic Score

Background: Prediction of outcome after stroke is important for triage decisions, prognostic estimates for family and for appropriate resource utilization. Prognostication must be timely and simply applied. Several scales have shown good prognostic value. In Calgary, the Orpington Prognostic Score (OPS) has been used to predict outcome as an aid to rehabilitation triage. However, the OPS has not been assessed at one week for predictive capability. Methods: Among patients admitted to a sub-acute stroke unit, OPS from the first week were examined to determine if any correlation existed between final disposition after rehabilitation and first week score. The predictive validity of the OPS at one week was compared to National Institute of Health Stroke Scale (NIHSS) score at 24 hours using logistic regression and receiver operator characteristics analysis. The primary outcome was final disposition after discharge from the stroke unit if the patient went directly home, or died, or from the inpatient rehabilitation unit. Results: The first week OPS was highly predictive of final disposition. However, no major advantage in using the first week OPS was observed when compared to 24h NIHSS score. Both scales were equally predictive of final disposition of stroke patients, post rehabilitation. Conclusion: The first week OPS can be used to predict final outcome. The NIHSS at 24h provides the same prognostic information.

Report : development of a methodology for assessing variation in maintenance and rehabilitation costs

In the previous research CRC CI 2001-010-C “Investment Decision Framework for Infrastructure Asset Management”, a method for assessing variation in cost estimates for road maintenance and rehabilitation was developed. The variability of pavement strength collected from a 92km national highway was used in the analysis to demonstrate the concept. Further analysis was conducted to identify critical input parameters that significantly affect the prediction of road deterioration. In addition to pavement strength, rut depth, annual traffic loading and initial roughness were found to be critical input parameters for road deterioration. This report presents a method developed to incorporate other critical parameters in the analysis, such as unit costs, which are suspected to contribute to a certain degree to cost estimate variation. Thus, the variability of unit costs will be incorporated in this analysis. Bruce Highway located in the tropical east coast of Queensland has been identified to be the network for the analysis. This report presents a step by step methodology for assessing variation in road maintenance and rehabilitation cost estimates.

A Sexual Health Programme Implemented in a Psychiatric Inpatient Unit

Research has shown that people with a mental illness are an at-risk group for sexually transmitted infections. A programme for preventing risk behaviours for sexually transmitted infections among people with psychiatric disorder was designed and implemented by mental health occupational therapists. This programme used an interactive didactic approach to provide education and awareness of sexual health issues to acute psychiatric inpatients. Twenty-four participants completed a sexual health questionnaire, which was designed for this study, both before and after attending the programme. They had a higher than expected knowledge of sexually transmitted infections and safe sex practices at pre-test. The education programme resulted in a statistically significant but modest increase in sexual health knowledge. These findings indicate that there are benefits in providing sexual health education to clients with a mental illness. Further programme development should be directed towards sexual health decision-making and behaviour change.

A stepped-wedge cluster randomised controlled trial for evaluating rates of falls among inpatients in aged care rehabilitation units receiving tailored multimedia education in addition to usual care : a trial protocol

Introduction Falls are the most frequent adverse event reported in hospitals. Approximately 30% of in-hospital falls lead to an injury and up to 2% result in a fracture. A large randomised trial found that a trained health professional providing individualised falls prevention education to older inpatients reduced falls in a cognitively intact subgroup. This study aims to investigate whether this efficacious intervention can reduce falls and be clinically useful and cost-effective when delivered in the real-life clinical environment. Methods A stepped-wedge cluster randomised trial will be used across eight subacute units (clusters) which will be randomised to one of four dates to start the intervention. Usual care on these units includes patient's screening, assessment and implementation of individualised falls prevention strategies, ongoing staff training and environmental strategies. Patients with better levels of cognition (Mini-Mental State Examination >23/30) will receive the individualised education from a trained health professional in addition to usual care while patient's feedback received during education sessions will be provided to unit staff. Unit staff will receive training to assist in intervention delivery and to enhance uptake of strategies by patients. Falls data will be collected by two methods: case note audit by research assistants and the hospital falls reporting system. Cluster-level data including patient's admissions, length of stay and diagnosis will be collected from hospital systems. Data will be analysed allowing for correlation of outcomes (clustering) within units. An economic analysis will be undertaken which includes an incremental cost-effectiveness analysis. Ethics and dissemination The study was approved by The University of Notre Dame Australia Human Research Ethics Committee and local hospital ethics committees. Results The results will be disseminated through local site networks, and future funding and delivery of falls prevention programmes within WA Health will be informed. Results will also be disseminated through peer-reviewed publications and medical conferences.

Fall rates in hospital rehabilitation units after individualised patient and staff education programmes: A pragmatic, stepped-wedge, cluster-randomised controlled trial

- Background Falls are the most frequent adverse events that are reported in hospitals. We examined the effectiveness of individualised falls-prevention education for patients, supported by training and feedback for staff, delivered as a ward-level programme. - Methods Eight rehabilitation units in general hospitals in Australia participated in this stepped-wedge, cluster-randomised study, undertaken during a 50 week period. Units were randomly assigned to intervention or control groups by use of computer-generated, random allocation sequences. We included patients admitted to the unit during the study with a Mini-Mental State Examination (MMSE) score of more than 23/30 to receive individualised education that was based on principles of changes in health behaviour from a trained health professional, in addition to usual care. We provided information about patients' goals, feedback about the ward environment, and perceived barriers to engagement in falls-prevention strategies to staff who were trained to support the uptake of strategies by patients. The coprimary outcome measures were patient rate of falls per 1000 patient-days and the proportion of patients who were fallers. All analyses were by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials registry, number ACTRN12612000877886). - Findings Between Jan 13, and Dec 27, 2013, 3606 patients were admitted to the eight units (n=1983 control period; n=1623 intervention period). There were fewer falls (n=196, 7·80/1000 patient-days vs n=380, 13·78/1000 patient-days, adjusted rate ratio 0·60 [robust 95% CI 0·42–0·94], p=0·003), injurious falls (n=66, 2·63/1000 patient-days vs 131, 4·75/1000 patient-days, 0·65 [robust 95% CI 0·42–0·88], p=0·006), and fallers (n=136 [8·38%] vs n=248 [12·51%] adjusted odds ratio 0·55 [robust 95% CI 0·38 to 0·81], p=0·003) in the intervention compared with the control group. There was no significant difference in length of stay (intervention median 11 days [IQR 7–19], control 10 days [6–18]). - Interpretation Individualised patient education programmes combined with training and feedback to staff added to usual care reduces the rates of falls and injurious falls in older patients in rehabilitation hospital-units.