Domenico Intiso1, Andrea Fontana2, Giuseppe Maruzzi3, Maurizio Tolfa3, Massimiliano Copetti2, Filomena DI Rienzo3. 1. Unit of Physical Medicine and Rehabilitation, Section of Neurorehabilitation, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy - d.intiso@operapadrepio.it. 2. Unit of Biostatistics, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy. 3. Unit of Physical Medicine and Rehabilitation, Section of Neurorehabilitation, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy.
Abstract
BACKGROUND: Medical and surgical complications are common after brain lesions and may require acute care unit readmission (ACUR) during the rehabilitation stay. This clinical phenomenon has not been explored in subjects with severe brain injury (sBI). AIM: Because sBI patients come from the intensive care unit (ICU), patients may be transferred to rehabilitation before complete clinical stabilization. We investigated ACUR and causes as well as whether those who required ACUR had different functional outcomes. DESIGN: Prospective cohort study. SETTING: Dedicated rehabilitation setting. PARTICIPANTS: Adult subjects with sBI causing a disorder of consciousness graded 3-8 on the Glasgow Coma Scale admitted to a dedicated rehabilitative setting were prospectively enrolled from January 2014 to December 2015. METHODS: Functional outcome was investigated using the Rancho Los Amigos Levels of Cognitive Functioning (LCF), Disability Rating Scale (DRS), Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), in subjects with and without ACUR, at admission and discharge. Mortality and length of stay (LOS) were recorded. RESULTS: One hundred-thirty (53 F, 77 M; mean age: 55.7±17.8) subjects were admitted to the rehabilitation setting, and 97 were enrolled (43 F, 54 M; mean age: 54.7±18.2). Thirty-six ACUR were detected that involved 29 (29.8%) patients. There were 20 and 16 referrals to acute medical and surgical care, respectively. Significant functional outcomes in all assessment measures were observed after rehabilitation, but subjects without ACUR showed significant improvement in all measurements: LCF (P=0.001), DRS (P<0.001), GOS (P=0.003), and mRS (P<0.001), compared to those who required ACUR. At baseline, patients with ACUR were more disabled than those without ACUR, and they had significant lower LCF scores: 2.60 (95% CI: 2.15-3.14) and 3.47 (95% CI: 3.07-3.91) (P=0.013), respectively. Significant longer LOS was observed in subjects with ACUR as compared to those without ACUR: 120 (q1-q3:93-165) vs. 63 (q1-q3: 38-93) days (P<0.001), respectively. The intra-hospital mortality rate was higher in patients who required ACUR (8.1 events per 100 person-months) as compared to those who did not require ACUR (2.8 events per 100 person-months). CONCLUSIONS: Readmission to acute care was common in subjects with sBI during rehabilitation. Subjects who required ACUR had poorer functional outcomes, higher risk of mortality and longer LOS than subjects without ACUR. CLINICAL REHABILITATION IMPACT: Careful control of these subjects and more strict collaboration and communication among physicians on the rehabilitative team are required to plan proper care pathways.
BACKGROUND: Medical and surgical complications are common after brain lesions and may require acute care unit readmission (ACUR) during the rehabilitation stay. This clinical phenomenon has not been explored in subjects with severe brain injury (sBI). AIM: Because sBI patients come from the intensive care unit (ICU), patients may be transferred to rehabilitation before complete clinical stabilization. We investigated ACUR and causes as well as whether those who required ACUR had different functional outcomes. DESIGN: Prospective cohort study. SETTING: Dedicated rehabilitation setting. PARTICIPANTS: Adult subjects with sBI causing a disorder of consciousness graded 3-8 on the Glasgow Coma Scale admitted to a dedicated rehabilitative setting were prospectively enrolled from January 2014 to December 2015. METHODS: Functional outcome was investigated using the Rancho Los Amigos Levels of Cognitive Functioning (LCF), Disability Rating Scale (DRS), Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS), in subjects with and without ACUR, at admission and discharge. Mortality and length of stay (LOS) were recorded. RESULTS: One hundred-thirty (53 F, 77 M; mean age: 55.7±17.8) subjects were admitted to the rehabilitation setting, and 97 were enrolled (43 F, 54 M; mean age: 54.7±18.2). Thirty-six ACUR were detected that involved 29 (29.8%) patients. There were 20 and 16 referrals to acute medical and surgical care, respectively. Significant functional outcomes in all assessment measures were observed after rehabilitation, but subjects without ACUR showed significant improvement in all measurements: LCF (P=0.001), DRS (P<0.001), GOS (P=0.003), and mRS (P<0.001), compared to those who required ACUR. At baseline, patients with ACUR were more disabled than those without ACUR, and they had significant lower LCF scores: 2.60 (95% CI: 2.15-3.14) and 3.47 (95% CI: 3.07-3.91) (P=0.013), respectively. Significant longer LOS was observed in subjects with ACUR as compared to those without ACUR: 120 (q1-q3:93-165) vs. 63 (q1-q3: 38-93) days (P<0.001), respectively. The intra-hospital mortality rate was higher in patients who required ACUR (8.1 events per 100 person-months) as compared to those who did not require ACUR (2.8 events per 100 person-months). CONCLUSIONS: Readmission to acute care was common in subjects with sBI during rehabilitation. Subjects who required ACUR had poorer functional outcomes, higher risk of mortality and longer LOS than subjects without ACUR. CLINICAL REHABILITATION IMPACT: Careful control of these subjects and more strict collaboration and communication among physicians on the rehabilitative team are required to plan proper care pathways.