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Background: Using an inpatient fall risk assessment tool helps categorize patients into risk groups which can then be targeted with fall prevention strategies. While potentially important in preventing patient injury, fall risk assessment may unintentionally lead to reduced mobility among hospitalized patients. Here we examined the relationship between fall risk assessment and ambulatory status among hospitalized patients. Methods: We conducted a retrospective cohort study of consecutively admitted adult patients (n = 48,271) to a quaternary urban hospital that provides care for patients of broad socioeconomic and demographic backgrounds. Non‐ambulatory status, the primary outcome, was defined as a median Johns Hopkins Highest Level of Mobility <6 (i.e., patient walks less than 10 steps) throughout hospitalization. The primary exposure variable was the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) category (Low, Moderate, High). The capacity to ambulate was assessed using the Activity Measure for Post‐Acute Care (AM‐PAC). Multivariable regression analysis controlled for clinical demographics, JHFRAT items, AM‐PAC, comorbidity count, and length of stay. Results: 8% of patients at low risk for falls were non‐ambulatory, compared to 25% and 54% of patients at moderate and high risk for falls, respectively. Patients categorized as high risk and moderate risk for falls were 4.6 (95% CI: 3.9–5.5) and 2.6 (95% CI: 2.4–2.9) times more likely to be non‐ambulatory compared to patients categorized as low risk, respectively. For patients with high ambulatory potential (AM‐PAC 18–24), those categorized as high risk for falls were 4.3 (95% CI: 3.5–5.3) times more likely to be non‐ambulatory compared to patients categorized as low risk. Conclusions: Patients categorized into higher fall risk groups had decreased mobility throughout their hospitalization, even when they had the functional capacity to ambulate. [ABSTRACT FROM AUTHOR]

Background: Greater mobility and activity among hospitalized patients has been linked to key outcomes, including decreased length of stay, increased odds of home discharge, and fewer hospital-acquired morbidities. Systematic approaches to increasing patient mobility and activity are needed to improve patient outcomes during and following hospitalization. Problem: While studies have found the Johns Hopkins Activity and Mobility Promotion (JH-AMP) program improves patient mobility and associated outcomes, program details and implementation methods are not published. Approach: JH-AMP is a systematic approach that includes 8 steps, described in this article: (1) organizational prioritization; (2) systematic measurement and daily mobility goal; (3) barrier mitigation; (4) local interdisciplinary roles; (5) sustainable education and training; (6) workflow integration; (7) data feedback; and (8) promotion and awareness. Conclusions: Hospitals and health care systems can use this information to guide implementation of JH-AMP at their institutions. [ABSTRACT FROM AUTHOR]

Importance: Identifying cognitive impairment in adults in acute care is essential so that providers can address functional deficits and plan for safe discharge. Occupational therapy practitioners play an essential role in screening for, evaluating, and treating cognitive impairment. Objective: To test and compare the psychometrics and feasibility of three cognitive screens and select the ideal screen for use in acute care. Design: Prospective mixed methods. Setting: Acute care hospital. Participants: Fifty adults. Outcomes and Measures: We examined the interrater reliability, administration time, and usability of the Brief Cognitive Assessment Tool Short Form (BCAT–SF), the Activity Measure for Post-Acute Care "6-Clicks" Applied Cognitive Inpatient Short Form (AM-PAC ACISF), and the Montreal Cognitive Assessment (MoCA). We compared the construct validity, sensitivity, and specificity of the BCAT–SF and AM-PAC ACISF with those of the MoCA. Results: Interrater reliability was good to excellent; ICCs were.98 for the MoCA,.97 for the BCAT–SF, and.86 for the AM-PAC ACISF. The BCAT–SF and the AM-PAC ACISF both had 100% sensitivity, and specificity was 74% for the BCAT–SF and 98% for the AM-PAC ACISF. The optimal cutoff score for cognitive impairment on the AM-PAC ACISF was <22. Administration time of the AM-PAC ACISF (1.0 min) was significantly less than that of the BCAT–SF (5.0 min) and the MoCA (13.3 min; p <.001). Conclusions and Relevance: Each screen demonstrated acceptable reliability and construct validity. The AM-PAC ACISF had the optimum mix of performance and feasibility for the fast-paced acute care setting. What This Article Adds: Early identification of cognitive impairment using the AM-PAC ACISF can allow for timely occupational therapy intervention in acute care settings. This study tested and compared the psychometrics and feasibility of three cognitive screens and concludes that each tool demonstrated acceptable reliability and construct validity in acute care hospitals, with the Activity Measure for Post-Acute Care "6-Clicks" Applied Cognitive Inpatient Short Form (AM-PAC ACISF) overall having the optimum mix of performance and feasibility. [ABSTRACT FROM AUTHOR]

Individualized mobility goals created using a goal calculator have been shown to increase patient mobility on medical nursing units, but have not been studied among postoperative populations. This study aimed to examine the feasibility of an automated mobility goal calculator on a postoperative nursing unit. To examine this, we used the goal calculator to create goals for patients (N = 128) following surgery and mobilized each patient with either a nurse or physical therapist. Each patient's highest level of mobility was recorded and providers completed surveys on the appropriateness of calculated goals. Overall, 94% of patients achieved calculated goals. Patients with more pain achieved goals significantly less often than those with less pain. Those with higher mobility achieved their goals similarly with either provider. Providers reported 47% of goals were appropriate, with goals being set too low as the primary reason for goals being inappropriate. We conclude that the automated goal calculator can be used on postoperative nursing units to set realistic goals for patients after surgery. [ABSTRACT FROM AUTHOR]

Compared to the non-ARISE hospitals, patients in the ARISE hospital were younger, lived in more socioeconomically disadvantaged areas, were more often admitted from another acute facility, were more frequently admitted to the ICU or ventilated within 48 h, had higher admission SOFA scores, and had more days with delirium (Table 1). Improving hospital outcomes using an acute hospital rehabilitation intensive service (ARISE) for patients with COVID-19 Dear Editor, The initial surge of COVID-19 in 2020 placed an unprecedented strain on the hospital healthcare system [[1]]. [Extracted from the article]

Objective. Physical function is associated with important outcomes, yet there is often a lack of continuity in routine assessment. The purpose of this study was to determine data elements and instruments for longitudinal measurement of physical function in routine care among patients transitioning from acute care hospital setting to home with home health care. Methods. A 4-round modified Delphi process was conducted with 13 participants with expertise in physical therapy, health care administration, health services research, physiatry/medicine, and health informatics. Three anonymous rounds identified important and feasible data elements. A fourth in-person round finalized the recommended list of individual data elements. Next, 2 focus groups independently provided additional perspectives from other stakeholders. Results. Response rates were 100% for online rounds 1, 3, and 4 and 92% for round 2. In round 1, 9 domains were identified: physical function, participation, adverse events, behavioral/emotional health, social support, cognition, complexity of illness/disease burden, health care utilization, and demographics. Following the fourth round, 27 individual data elements were recommended. Of these, 20 (74%) are "administrative" and available from most hospital electronic medical records. Additional focus groups confirmed these selections and provided input on standardizing collection methods. A website has been developed to share these results and invite other health care systems to participate in future data sharing of these identified data elements. Conclusion. A modified Delphi consensus process was used to identify critical data elements to track changes in patient physical function in routine care as they transition from acute hospital to home with home health. Impact. Expert consensus on comprehensive and feasible measurement of physical function in routine care provides health care professionals and institutions with guidance in establishing discrete medical records data that can improve patient care, discharge decisions, and future research. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on the provision of medical care. As the curve progresses and patients are discharged, the rehabilitation wave brings a high number of postacute COVID-19 patients suffering from physical, mental, and cognitive impairments threatening their return to normal life. The complexity and severity of disease in patients recovering from severe COVID-19 infection require an approach that is implemented as early in the recovery phase as possible, in a concerted and systematic way. To address the rehabilitation wave, we describe a spectrum of interventions that start in the intensive care unit and continue through all the appropriate levels of care. This approach requires organized rehabilitation teams including physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists or neuropsychologists, and physiatrists collaborating with acute medical teams. Here, we also discuss administrative factors that influence the provision of care during the COVID-19 pandemic. The services that can be provided are described in detail to allow the reader to understand what services may be appropriate locally. We have been learning and adapting real time during this crisis and hope that sharing our experience facilitates the work of others as the pandemic evolves. It is our goal to help reduce the potentially long-lasting challenges faced by COVID-19 survivors. • Rehabilitation care of coronavirus disease 2019 (COVID-19) recovering patient can be safely provided starting in the intensive care unit. • Redeployment of outpatient therapy workforce was useful to provide rehabilitation to patients recovering from COVID-19 in the acute medical care. • Objective functional assessments allowed for a tailored rehabilitation approach based on the individual patient's needs. • Changes in Medicare regulation allowed for the provision of acute inpatient rehabilitation services outside the rehabilitation unit. COVID-19 patients were able to receive acute comprehensive inpatient rehabilitation level of care while still recovering from the acute infection. [ABSTRACT FROM AUTHOR]

Purpose: Early mobilization in the intensive care unit (ICU) can improve patient outcomes but has perceived barriers to implementation. As part of an ongoing structured quality improvement project to increase mobilization of medical ICU patients by nurses and clinical technicians, we adapted the existing, validated Patient Mobilization Attitudes & Beliefs Survey (PMABS) for the ICU setting and evaluated its performance characteristics and results. Materials and Methods: The 26-item PMABS adapted for the ICU (PMABS-ICU) was administered as an online survey to 163 nurses, clinical technicians, respiratory therapists, attending and fellow physicians, nurse practitioners, and physician assistants in one medical ICU. We evaluated the overall and subscale (knowledge, attitude, and behavior) scores and compared these scores by respondent characteristics (clinical role and years of work experience). Results: The survey response rate was 96% (155/163). The survey demonstrated acceptable discriminant validity and acceptable internal consistency for the overall scale (Cronbach a: 0.82, 95% confidence interval: 0.76-0.85), with weaker internal consistency for all subscales (Cronbach a: 0.62-0.69). Across all respondent groups, the overall barrier score (range: 1-100) was relatively low, with attending physicians perceiving the lowest barriers (median [interquartile range]: 30 [28-34]) and nurses perceiving the highest (37 [31-40]). Within the first 10 years of work experience, greater experience was associated with a lower overall barrier score (-0.8 for each additional year; P = 0.02). Conclusions: In our medical ICU, across 6 different clinical roles, there were relatively low perceived barriers to patient mobility, with greater work experience over the first 10 years being associated with lower perceived barriers. As part of a structured quality improvement project, the PMABSICU may be valuable in assisting to identify specific perceived barriers for consideration in designing mobility interventions for the ICU setting. [ABSTRACT FROM AUTHOR]

Aim: Characterize the relationship between patient ambulatory status and in‐hospital call bell use. Background: Although call bells are frequently used by patients to request help, the relationship between physical functioning and call bell use has not been evaluated. Methods: Retrospective cohort study of 944 neuroscience patients hospitalized in a large academic urban medical centre between April 1, 2014 and August 1, 2014. We conducted multiple linear regression analyses with number of daily call bells from each patient as the primary outcome and patients' average ambulation status as the primary exposure variable. Results: The mean number of daily call bell requests for all patients was 6.9 (6.1), for ambulatory patients 5.6 (4.8), and for non‐ambulatory patients, it was 7.7 (6.6). Compared with non‐ambulatory patients, ambulatory patients had a mean reduction in call bell use by 1.7 (95% CI 2.5 to −0.93, p <.001) calls per day. In a post hoc analysis, patients who could walk >250 feet had 5 fewer daily call bells than patients who were able to perform in‐bed mobility. Conclusion: Ambulatory patients use their call bells less frequently than non‐ambulatory patients. Implications for Nursing Management: Frequent use of call bells by non‐ambulatory patients can place additional demands on nursing staff; patient mobility status should be considered in nurse workload/patient assignment. [ABSTRACT FROM AUTHOR]

To describe the implementation and evaluation of an interdisciplinary quality improvement (QI) project to increase prescription of take-home naloxone (THN) to reduce risks associated with opioids for patients admitted to an acute inpatient rehabilitation unit. Prospective cohort quality improvement project. Eighteen-bed acute comprehensive inpatient rehabilitation (ACIR) unit at a large academic institution. Patients admitted to ACIR between December 2015-November 2016 (N=788). An interdisciplinary QI model comprised of planning, education, implementation, and maintenance was used to implement a THN and opioid risk-reduction program involving provider and patient education. Analyses consisted of comparisons between baseline, early, and late phases of the project. (1) The proportion of eligible patients who received a prescription for naloxone upon discharge from ACIR; (2) the proportion of patients originally admitted to ACIR on opioids that were weaned off upon discharge. The adjusted odds of eligible patients being discharged from ACIR with a naloxone prescription during the late QI period were 7 (95% confidence interval [CI]: 3-21) times higher than during the early QI period (late QI period: 43%, 95% CI: 25%-63%; early QI period: 10%, 95% CI: 3%-28%; P <.001). For patients admitted on opioids, the adjusted odds of being weaned off opioids during the late QI period were 10 (95% CI: 4-25) times higher than during baseline (late QI period: 29%, 95% CI: 17%-45%; baseline: 4%, 95% CI: 1%-10%; P <.001). Implementation of a THN and opioid risk reduction QI project in an inpatient rehabilitation setting led to significantly more eligible patients receiving naloxone and more patients weaned off schedule II opioids. [ABSTRACT FROM AUTHOR]

Aim: To characterize resources to safely mobilize different types of hospitalized patients. Background: Current approaches to determine nurse–patient ratios do not always include information regarding the specific demands of patients who require extra resources to mobilize. Workflows must be designed with knowledge of resource requirements to integrate patient mobility into the daily nursing team care plan. Methods: Nurse‐led mobility sessions were evaluated on two adult hospital units, which consisted of nurse–patient encounters focused on patient mobility only. The resources assessed for each session were time‐to‐mobilize patient, time‐to‐document, need for additional staff support, and the need for assistive devices. Mobility sessions were also categorized by patient ambulation status, level of mobility limitations (low, medium and high) and diagnosis. Results: In 212 total mobility sessions, the median time‐to‐mobilize and time‐to‐document were 7.75 and 1.27 min, respectively. Additional staff support was required for 87% and 92% of patients with medium and high mobility limitations, respectively. All patients with low mobility limitations ambulated, and only 14% required additional staff. Ambulating patients with high mobility limitations was the most time‐intensive (median 12.55 min). Ambulating stroke patients required one additional staff and an assistive device in 92% and 69% of the sessions, respectively. Conclusion: This study describes the resources associated with mobilizing inpatients with different levels of mobility impairments and diagnoses. Implications for Nursing Management: These results could assist nursing management with facilitating appropriate daily nurse–patient ratios and justify the need for assistive devices and staff support to safely mobilize patients. [ABSTRACT FROM AUTHOR]

• Unnecessary delays in hospital discharge are a problem for patients and hospitals. • Early identification of need for post-acute care might reduce discharge delays. • Mobility is the most important predictor of post-acute care need. • Accuracy of post-acute care prediction is similar across medical conditions. One-fifth of patient discharges from the acute hospital are delayed due to non-medical reasons. Prior research on small specific samples shows that patient mobility is important for predicting post-acute care (PAC) need. Our purpose was to create a disposition prediction model for PAC need in a large, clinically diverse. A random forest (RF) was constructed to analyze patient admissions at 2 hospitals. The primary outcome was discharge disposition (home or PAC). Predictors included the lowest AM-PAC '6-clicks' mobility score within 48-hours of admission (primary predictor) and demographic and clinical characteristics. A global summary tree was constructed to summarize the RF. Among 34,432 patient admissions, the most important variables for predicting PAC placement were AM-PAC, BMI, and age. The AUC was 0.80 (95% confidence interval: 0.79, 0.81). Using a predicted probability for PAC of 0.25 or higher, the sensitivity, specificity and overall accuracy was 76%, 70% and 72%, respectively. Patients 66 years or older with AM-PAC of <31 had the highest probability (0.76) for discharge to PAC. Patients with AM-PAC of >43 had the highest probability for discharge to home. Systematic assessment of inpatients admission mobility should be implemented and used for discharge planning. Electronic medical record systems should be designed to collect and facilitate availability of mobility data on all patients to providers who play key roles in discharge planning. Patient's mobility status during hospitalization has been used to predict their next level of care at discharge, but this work has been done with more limited methods and focused on select patient groups. Using a machine learning technique on thousands of patients with very different medical problems, this study shows that mobility status very early in hospitalization predicts post-acute care (PAC) needs. Based on this study we recommend that early assessment of patient mobility in the hospital should occur for all patients as it can facilitate more effective discharge planning. [ABSTRACT FROM AUTHOR]

Background Hospital-acquired functional decline due to decreased mobility has negative impacts on patient outcomes. Current nurse-directed mobility programs lack a standardized approach to set achievable mobility goals. Purpose We aimed to describe implementation and outcomes from a nurse-directed patient mobility program. Method The quality improvement mobility program on the project unit was compared to a similar control unit providing usual care. The Johns Hopkins Mobility Goal Calculator was created to guide a daily patient mobility goal based on the level of mobility impairment. Findings On the project unit, patient mobility increased from 5.2 to 5.8 on the Johns Hopkins Highest Level of Mobility score, mobility goal attainment went from 54.2% to 64.2%, and patients exceeding the goal went from 23.3% to 33.5%. All results were significantly higher than the control unit. Discussion An individualized, nurse-directed, patient mobility program using daily mobility goals is a successful strategy to improve daily patient mobility in the hospital. [ABSTRACT FROM AUTHOR]

Background. The lack of common language among interprofessional inpatient clinical teams is an important barrier to achieving inpatient mobilization. In The Johns Hopkins Hospital, the Activity Measure for Post-Acute Care (AM-PAC) Inpatient Mobility Short Form (IMSF), also called "6-Clicks," and the Johns Hopkins Highest Level of Mobility (JH-HLM) are part of routine clinical practice. The measurement characteristics of these tools when used by both nurses and physical therapists for interprofessional communication or assessment are unknown. Objective. The purposes of this study were to evaluate the reliability and minimal detectable change of AM-PAC IMSF and JH-HLM when completed by nurses and physical therapists and to evaluate the construct validity of both measures when used by nurses. Design. A prospective evaluation of a convenience sample was used. Methods. The test-retest reliability and the interrater reliability of AM-PAC IMSF and JH-HLM for inpatients in the neuroscience department (n = 118) of an academic medical center were evaluated. Each participant was independently scored twice by a team of 2 nurses and 1 physical therapist; a total of 4 physical therapists and 8 nurses participated in reliability testing. In a separate inpatient study protocol (n = 69), construct validity was evaluated via an assessment of convergent validity with other measures of function (grip strength, Katz Activities of Daily Living Scale, 2-minute walk test, 5-times sit-to-stand test) used by 5 nurses. Results. The test-retest reliability values (intraclass correlation coefficients) for physical therapists and nurses were 0.91 and 0.97, respectively, for AM-PAC IMSF and 0.94 and 0.95, respectively, for JH-HLM. The interrater reliability values (intraclass correlation coef- ficients) between physical therapists and nurses were 0.96 for AM-PAC IMSF and 0.99 for JH-HLM. Construct validity (Spearman correlations) ranged from 0.25 between JH-HLM and right-hand grip strength to 0.80 between AM-PAC IMSF and the Katz Activities of Daily Living Scale. Limitations. The results were obtained from inpatients in the neuroscience department of a single hospital. Conclusions. The AM-PAC IMSF and JH-HLM had excellent interrater reliability and test-retest reliability for both physical therapists and nurses. The evaluation of convergent validity suggested that AM-PAC IMSF and JH-HLM measured constructs of patient mobility and physical functioning. [ABSTRACT FROM AUTHOR]

Background: Hospital performance on the 30-day hospital-wide readmission (HWR) metric as calculated by the Centers for Medicare and Medicaid Services (CMS) is currently reported as a quality measure. Focusing on patient-level factors may provide an incomplete picture of readmission risk at the hospital level to explain variations in hospital readmission rates.Objective: To evaluate and quantify hospital-level characteristics that track with hospital performance on the current HWR metric.Design: Retrospective cohort study.Setting/patients: A total of 4785 US hospitals.Metrics: We linked publically available data on individual hospitals published by CMS on patient-level adjusted 30-day HWR rates from July 1, 2011, through June 30, 2014, to the 2014 American Hospital Association annual survey. Primary outcome was performance in the worst CMS-calculated HWR quartile. Primary hospital-level exposure variables were defined as: size (total number of beds), safety net status (top quartile of disproportionate share), academic status [member of the Association of American Medical Colleges (AAMC)], National Cancer Institute Comprehensive Cancer Center (NCI-CCC) status, and hospital services offered (e.g., transplant, hospice, emergency department). Multilevel regression was used to evaluate the association between 30-day HWR and the hospital-level factors.Results: Hospital-level characteristics significantly associated with performing in the worst CMS-calculated HWR quartile included: safety net status [adjusted odds ratio (aOR) 1.99, 95% confidence interval (95% CI) 1.61-2.45, p < 0.001], large size (> 400 beds, aOR 1.42, 95% CI 1.07-1.90, p = 0.016), AAMC alone status (aOR 1.95, 95% CI 1.35-2.83, p < 0.001), and AAMC plus NCI-CCC status (aOR 5.16, 95% CI 2.58-10.31, p < 0.001). Hospitals with more critical care beds (aOR 1.26, 95% CI 1.02-1.56, p = 0.033), those with transplant services (aOR 2.80, 95% CI 1.48-5.31,p = 0.001), and those with emergency room services (aOR 3.37, 95% CI 1.12-10.15, p = 0.031) demonstrated significantly worse HWR performance. Hospice service (aOR 0.64, 95% CI 0.50-0.82, p < 0.001) and having a higher proportion of total discharges being surgical cases (aOR 0.62, 95% CI 0.50-0.76, p < 0.001) were associated with better performance.Limitation: The study approach was not intended to be an alternate readmission metric to compete with the existing CMS metric, which would require a re-examination of patient-level data combined with hospital-level data.Conclusion: A number of hospital-level characteristics (such as academic tertiary care center status) were significantly associated with worse performance on the CMS-calculated HWR metric, which may have important health policy implications. Until the reasons for readmission variability can be addressed, reporting the current HWR metric as an indicator of hospital quality should be reevaluated. [ABSTRACT FROM AUTHOR]

Hoyer EH, Brotman DJ, Chan KS, Needham DM: Barriers to early mobility of hospitalized general medicine patients: survey development and results. Am J Phys Med Rehabil 201 5 ;94 :3 0 4 -3 1 2. Objective: Functional status decline commonly accompanies hospitalization making patients vulnerable to complications. Such decline can be mitigated through hospital-based early mobility programs. Success in implementing patient mobility quality improvement processes requires evaluating providers' knowledge, attitudes, and behaviors. Design: A cross-sectional, self-administered survey in two different hospital settings was completed by 1 20 nurses and physical and occupational therapists (rehabilitation therapists, 38; nurses, 82) from six general medicine units. The survey was developed using published guidelines, literature review, and provider meetings and refined through pilot testing. Psychometric properties were assessed, and regression analyses were conducted to examine barriers to early mobility by hospital site, provider discipline, and years of experience. Results: Internal consistency reliability, item consistency, and discriminant validity psychometric characteristics were acceptable. In multivariable regression analysis, overall perceived barriers were similar between the two hospitals (P = 0.25) and significantly higher for staff with less experience (P = 0.02) and for nurses vs. rehabilitation therapists (P < 0.001 ).The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific. Conclusions: This novel survey identified important barriers to mobilizing medical inpatients that were similar across two hospital settings. These results can assist with the implementation of quality improvement projects for increasing early hospital-based patient mobility. [ABSTRACT FROM AUTHOR]

Stroke is the leading cause of long-term disability. Understanding how people recover from stroke and other brain lesions remain one of the biggest conundrums in neuroscience. As a result, concerted efforts in recent years have focused on investigating the neurophysiological changes that occur in the brain after stroke, and in developing novel strategies to enhance motor recovery. In particular, transcranial magnetic stimulation (TMS) is a non-invasive tool that has been used to investigate the brain plasticity changes resulting from stroke and as a therapeutic modality to safely improve motor function. In this review, we discuss the contributions of TMS to understand how different motor areas, such as the ipsilesional hemisphere, secondary motor areas, and contralesional hemisphere are involved in motor recovery. We also consider recent studies using repetitive TMS (rTMS) in stroke patients to enhance upper extremity function. Although further studies are needed, these investigations provide an important starting point to understand the stimulation parameters and patient characteristics that may influence the optimal response to non-invasive brain stimulation. Future directions of rTMS are discussed in the context of post-stroke motor recovery. [ABSTRACT FROM AUTHOR]

Aims Design Results Conclusion Implication for the Profession and/or Patient Care Reporting Method Patient or Public Contribution Our study aimed to (1) validate the accuracy of nursing mobility documentation and (2) identify the most effective timings for behavioural mapping.We monitored the mobility of 55 inpatients using behavioural mapping throughout a nursing day shift, comparing the observed mobility levels with the nursing charting in the electronic health record during the same period.Our results showed a high level of agreement between nursing records and observed mobility, with improved accuracy observed particularly when documentation was at 12 PM or later. Behavioural mapping observations revealed that the most effective timeframe to observe the highest levels of patient mobility was between 10 AM AND 2 PM.To truly understand patient mobility, comparing nursing charting with methods like behavioural mapping is beneficial. This comparison helps evaluate how well nursing records reflect actual patient mobility and offers insights into the best times for charting to capture peak mobility. While behavioural mapping is a valuable tool for auditing patient mobility, its high resource demands limit its regular use. Thus, determining the most effective times and durations for observations is key for practical implementation in hospital mobility audits.Nurses are pivotal in ensuring patient mobility in hospitals, an essential element of quality care. Their role involves safely mobilizing patients and accurately charting their mobility levels during each shift. For nursing practice, this research underscores that nurse charting can accurately reflect patient mobility, and highlights that recording the patient's highest level of mobility later in the shift offers a more precise representation of their actual mobility.Strobe.No Patient or Public Contribution. [ABSTRACT FROM AUTHOR]

Background Purpose Method Findings Discussion Nurses routinely perform multiple risk assessments related to patient mobility in the hospital. Use of a single mobility assessment for multiple risk assessment tools could improve clinical documentation efficiency, accuracy and lay the groundwork for automated risk evaluation tools.We tested how accurately Activity Measure for Post‐Acute Care (AM‐PAC) mobility scores predicted the mobility components of various fall and pressure injury risk assessment tools.AM‐PAC scores along with mobility and physical activity components on risk assessments (Braden Scale, Get Up and Go used within the Hendrich II Fall Risk Model®, Johns Hopkins Fall Risk Assessment Tool (JHFRAT) and Morse Fall Scale) were collected on a cohort of hospitalised patients. We predicted scores of risk assessments based on AM‐PAC scores by fitting of ordinal logistic regressions between AM‐PAC scores and risk assessments. STROBE checklist was used to report the present study.AM‐PAC scores predicted the observed mobility components of Braden, Get Up and Go and JHFRAT with high accuracy (≥85%), but with lower accuracy for the Morse Fall Scale (40%).These findings suggest that a single mobility assessment has the potential to be a good solution for the mobility components of several fall and pressure injury risk assessments. [ABSTRACT FROM AUTHOR]

Objective To assess the feasibility of using an infrared-based Real-Time Location System (RTLS) for measuring patient ambulation in a 2-minute walk test (2MWT) by comparing the distance walked and the Johns Hopkins Highest Level of Mobility (JH-HLM) score to clinician observation as a criterion standard. Design Criterion standard validation study. Setting Inpatient, university hospital. Participants Patients (N=25) in an adult neuroscience/brain rescue unit. Interventions Not applicable. Main Outcome Measures RTLS and clinician-reported ambulation distance in feet, and JH-HLM score on an 8-point ordinal scale. Results The RTLS ambulation distance for the 25 patients in the 2MWT was between 68 and 516ft. The mean difference between clinician-reported and RTLS ambulation distance was 8.4±11.7ft (2.7%±4.6%). The correlation between clinician-reported and RTLS ambulation distance was 97.9% ( P <.01). The clinician-reported ambulation distance for 2 patients was +100ft and −99ft compared with the RTLS distance, implying clinician error in counting the number of laps (98ft). The correlation between the RTLS distance and clinician-reported distance excluding these 2 patients is 99.8% ( P <.01). The accuracy of the RTLS for assessment of JH-HLM score for all 25 patients was 96%. The average patient speed obtained from RTLS data varied between 0.4 and 3.0mph. Conclusions The RTLS is able to accurately measure patient ambulation and calculate JH-HLM for a 2MWT when compared with clinician observation as the criterion standard. [ABSTRACT FROM AUTHOR]

Objectives: A decline in functional status is common during acute care hospitalization and may make patients vulnerable to further complications. This decline can be mitigated through hospital-based early activity and mobility programs. An important component of successful activity and mobility programs is systematic documentation of patient function, which can be an important barrier to program implementation in the acute care setting. Herein, we present a new nursing-based documentation system created as part of an early activity and mobility quality improvement (QI) project. Design: This project was undertaken, using a structured QI process, on two 24-bed general medicine units in an academic hospital. Our performance measure was based on a mobility scale currently-used in the ICU setting, known as "highest level of mobility" (HLM). HLM served as a daily "vital sign" and is an ordinal scale ranging from 1 to 8 (example scores: 1 = bed rest, 6 = ambulating >10 steps, 8 = ambulating >250 feet). We present prospective data on 440 consecutive patients with a length of stay (LOS) >2 days, admitted between 3/1/2013 and 6/7/2013. We analyzed the association between the average HLM during the first 2 days of admission for each patient and our two primary outcomes, hospital LOS and discharge to home. After logarithmic transformation, LOS was analyzed using linear regression. Discharge to home was analyzed using logistic regression. These models were adjusted for 7 relevant variables (age, gender, race, marital status, payer, expected LOS, and the AHRQ comorbidity index). Results: Mean (T standard deviation) LOS was 6.9 (±5.1), with 385 (88%) patients discharged home. Compared to non-ambulatory patients (HLM <6), patients who were able to ambulate >10 steps or more (HLM ≥6) during their first two days on admission had significantly shorter mean hospital LOS (6.4 (±5.3) versus 7.4 (±4.9) days, p=0.03), and higher rates of discharge home (98% versus 77%, p<0.001). In our adjusted analysis, a 1 point increase in HML was associated with a significantly shorter LOS by 0.6 (95% CI 0.3-0.8, p<0.001) days and an increased odds of discharge to home (OR 1.8, 95% CI 1.5-2.2, p<0.001). Conclusions: When implemented within a structured QI project, nursing-based documentation of patients' physical function shortly after acute care hospital admission may be helpful in identifying general medicine patients requiring a longer length of stay and institutionalization at discharge. [ABSTRACT FROM AUTHOR]

Delayed hospital discharges for patients needing rehabilitation in a postacute setting can exacerbate hospital-acquired mobility loss, prolong functional recovery, and increase costs. Systematic measurement of patient mobility by nurses early during hospitalization has the potential to help identify which patients are likely to be discharged to a postacute care facility versus home. To test the predictive ability of this approach, a machine learning classification tree method was applied retrospectively to a diverse sample of hospitalized patients (N = 761) using training and validation sets. Compared with patients discharged to home, patients discharged to a postacute facility were older (median, 64 vs 56 years old) and had lower mobility scores at hospital admission (median, 32 vs 41). The final decision tree accurately classified the discharge location for 73% (95% CI, 67%-78%) of patients. This study emphasizes the value of systematically measuring mobility in the hospital and provides a simple decision tree to facilitate early discharge planning.

Interventions to prevent readmissions often rely upon patient participation to be successful. We surveyed 895 general medicine patients slated for hospital discharge to (1) assess patient attitudes surrounding readmission, (2) ascertain whether these attitudes were associated with actual readmission, and (3) determine whether patients can estimate their own readmission risk. Actual readmissions and other clinical variables were captured from administrative data and linked to individual survey responses. We found that actual readmissions were not correlated with patients' interest in preventing readmission, sense of control over readmission, or intent to follow discharge instructions. However, patients were able to predict their own readmissions (P = .005) even after adjusting for predicted readmission rate, race, sex, age, and payer. Reassuringly, over 80% of respondents reported that they would be frustrated or disappointed to be readmitted and almost 90% indicated that they planned to follow all of their discharge instructions. Whether assessing patient-perceived readmission risk might help to target preventive interventions warrants further study., (© 2018 Society of Hospital Medicine.)

Background: Although many hospitalized neuroscience patients have physical and occupational therapy (rehabilitation) needs, patients with none or minimal physical impairments frequently receive rehabilitation consultation, diverting from patients with greatest need., Methods: A multidisciplinary team on the general and cerebrovascular neurology acute inpatient services mapped the rehabilitation consultation process, resulting in multiple implemented interventions including physician education on appropriate acute rehabilitation consultations, modification of multidisciplinary rounds, and discussion of patient rehabilitation needs throughout hospitalization. Nurses used the same functional impairment measurement tool used by physical and occupational therapists, the Activity Measure for Post-Acute Care Inpatient Short Forms (Basic Mobility and Activity domains)., Results: The rate for initial rehabilitation consults for patients with no limitations in mobility or activity during the 6-month baseline period was 12%, which was decreased to 7% and 10% during the 6-month intervention and sustain periods, respectively ( P < .001). The baseline rate for patients with no limitations receiving both physical therapy and occupational therapy consultations was 62% and was decreased to 21% and 39% in the intervention and sustain periods, respectively ( P < .001). Rehabilitation sessions per hospital day increased for patients with high functional impairments, from 0.52 at baseline to 0.64 in the intervention and 0.66 in the sustain periods ( P = .02), which equated to 1 more rehabilitation visit per patient hospitalization., Conclusions: A multifaceted intervention led to improved utilization of acute inpatient rehabilitation consultation while increasing the frequency of rehabilitation treatment for patients with highest functional impairment., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Hospital discharge summaries can provide valuable information to future providers and may help to prevent hospital readmissions. We sought to examine whether the number of days to complete hospital discharge summaries is associated with 30-day readmission rate., Patients and Methods: This was a retrospective cohort study conducted on 87,994 consecutive discharges between January 1, 2013 and December 31, 2014, in a large urban academic hospital. We used multivariable logistic regression models to examine the association between days to complete the discharge summary and hospital readmissions while controlling for age, gender, race, payer, hospital service (gynecology-obstetrics, medicine, neurosciences, oncology, pediatrics, and surgical sciences), discharge location, length of stay, expected readmission rate in Maryland based on diagnosis and illness severity, and the Agency for Healthcare Research and Quality Comorbidity Index. Days to complete the hospital discharge summary-the primary exposure variable-was assessed using the 20th percentile (>3 vs ≤3 days) and as a continuous variable (odds ratio expressed per 3-day increase). The main outcome was all-cause readmission to any acute care hospital in Maryland within 30 days., Results: Among the 87,994 patients, there were 14,248 (16.2%) total readmissions. Discharge summary completion >3 days was significantly associated with readmission, with adjusted odds ratio (OR) (95% confidence interval [CI]) of 1.09 (1.04 to 1.13, P = 0.001). We also found that every additional 3 days to complete the discharge summary was associated with an increased adjusted odds of readmission by 1% (OR: 1.01, 95% CI: 1.00 to 1.01, P < 0.001)., Conclusion: Longer days to complete discharge summaries were associated with higher rates of all-cause hospital readmissions. Timely discharge summary completion time may be a quality indicator to evaluate current practice and as a potential strategy to improve patient outcomes. Journal of Hospital Medicine 2016;11:393-400. 2016 Society of Hospital Medicine., (© 2016 Society of Hospital Medicine.)

Stroke is the leading cause of long-term disability. Understanding how people recover from stroke and other brain lesions remain one of the biggest conundrums in neuroscience. As a result, concerted efforts in recent years have focused on investigating the neurophysiological changes that occur in the brain after stroke, and in developing novel strategies to enhance motor recovery. In particular, transcranial magnetic stimulation (TMS) is a non-invasive tool that has been used to investigate the brain plasticity changes resulting from stroke and as a therapeutic modality to safely improve motor function. In this review, we discuss the contributions of TMS to understand how different motor areas, such as the ipsilesional hemisphere, secondary motor areas, and contralesional hemisphere are involved in motor recovery. We also consider recent studies using repetitive TMS (rTMS) in stroke patients to enhance upper extremity function. Although further studies are needed, these investigations provide an important starting point to understand the stimulation parameters and patient characteristics that may influence the optimal response to non-invasive brain stimulation. Future directions of rTMS are discussed in the context of post-stroke motor recovery.