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The COVID-19 pandemic is having a profound impact on the provision of medical care. As the curve progresses and patients are discharged the rehabilitation wave brings a high number of post-acute 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 ICU 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/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., Highlights • Rehabilitation care of COVID-19 recovering patient can be safely provided starting in the ICU. • 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 of the rehabilitation unit. COVID-19 patients were able to receive ACIR level of care while still recovering from the acute infection.

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.

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 α: 0.82, 95% confidence interval: 0.76-0.85), with weaker internal consistency for all subscales (Cronbach α: 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 PMABS-ICU may be valuable in assisting to identify specific perceived barriers for consideration in designing mobility interventions for the ICU setting.

Key Points Question Are patient ambulation profiles predictive of hospital readmission, discharge location, and length of stay? Findings In this prognostic cohort study of 100 adults in a cardiac surgery progressive care unit, patient ambulation profiles were predictive of 30-day readmission (C statistic, 0.925), discharge location (C statistic, 0.930), and length of stay (correlation coefficient, 0.927). Meaning Patient ambulation profiles from a real-time location system enable prediction of clinically relevant outcomes., This prognostic cohort study evaluates novel ambulation metrics in predicting 30-day readmission rates, discharge location, and length of stay using a real-time location system to continuously monitor the voluntary ambulations of postoperative cardiac surgery patients., Importance Promoting patient mobility during hospitalization is associated with improved outcomes and reduced risk of hospitalization-associated functional decline. Therefore, accurate measurement of mobility with high–information content data may be key to improved risk prediction models, identification of at-risk patients, and the development of interventions to improve outcomes. Remote monitoring enables measurement of multiple ambulation metrics incorporating both distance and speed. Objective To evaluate novel ambulation metrics in predicting 30-day readmission rates, discharge location, and length of stay using a real-time location system to continuously monitor the voluntary ambulations of postoperative cardiac surgery patients. Design, Setting, and Participants This prognostic cohort study of the mobility of 100 patients after cardiac surgery in a progressive care unit at Johns Hopkins Hospital was performed using a real-time location system. Enrollment occurred between August 29, 2016, and April 4, 2018. Data analysis was performed from June 2018 to December 2019. Main Outcomes and Measures Outcome measures included 30-day readmission, discharge location, and length of stay. Digital records of all voluntary ambulations were created where each ambulation consisted of multiple segments defined by distance and speed. Ambulation profiles consisted of 19 parameters derived from the digital ambulation records. Results A total of 100 patients (81 men [81%]; mean [SD] age, 63.1 [11.6] years) were evaluated. Distance and speed were recorded for more than 14 000 segments in 840 voluntary ambulations, corresponding to a total of 127.8 km (79.4 miles) using a real-time location system. Patient ambulation profiles were predictive of 30-day readmission (sensitivity, 86.7%; specificity, 88.2%; C statistic, 0.925 [95% CI, 0.836-1.000]), discharge to acute rehabilitation (sensitivity, 84.6%; specificity, 86.4%; C statistic, 0.930 [95% CI, 0.855-1.000]), and length of stay (correlation coefficient, 0.927). Conclusions and Relevance Remote monitoring provides a high–information content description of mobility, incorporating elements of step count (ambulation distance and related parameters), gait speed (ambulation speed and related parameters), frequency of ambulation, and changes in parameters on successive ambulations. Ambulation profiles incorporating multiple aspects of mobility enables accurate prediction of clinically relevant outcomes.

Background The Johns Hopkins Highest Level of Mobility (JH-HLM) scale is used to document the observed mobility of hospitalized patients, including those patients in the intensive care unit (ICU) setting. Objective To evaluate the inter-rater reliability of the JH-HLM, completed by physical therapists, across medical, surgical, and neurological adult ICUs at a single large academic hospital. Methods The JH-HLM is an ordinal scale for documenting a patient’s highest observed level of activity, ranging from lying in bed (score = 1) to ambulating > 250 feet (score = 8). Eighty-one rehabilitation sessions were conducted by eight physical therapists, with 1 of 2 reference physical therapist rater simultaneously observing the session and independently scoring the JH-HLM. The intraclass correlation coefficient was used to determine the inter-rater reliability. Results A total of 77 (95%) of 81 assessments had perfect agreement. The overall intraclass correlation coefficient for inter-rater reliability was 0.98 (95% confidence interval: 0.96, 0.99), with similar scores in the medical, surgical, and neurological ICUs. A Bland–Altman plot revealed a mean difference in JH-HLM scoring of 0 (limits of agreement: −0.54 to 0.61). Conclusion The JH-HLM has excellent inter-rater reliability as part of routine physical therapy practice, across different types of adult ICUs.

Objective To expand an existing validated measure of basic mobility (Activity Measure for Post-Acute Care [AM-PAC]) for patients at the lowest levels of function. Design Item replenishment for existing item response theory (IRT) derived measure via (1) idea generation and creation of potential new items, (2) item calibration and field testing, and (3) longitudinal pilot test. Setting Two tertiary acute care hospitals. Participants Consecutive inpatients (N=502) ≥18 years old, with an AM-PAC Inpatient Mobility Short Form (IMSF) raw score ≤15. For the longitudinal pilot test, 8 inpatients were evaluated. Results Fifteen new AM-PAC items were developed, 2 of which improved mobility measurement at the lower levels of functioning. Specifically, with the 2 new items, the floor effect of the AM-PAC IMSF was reduced by 19%, statistical power and measurement breadth were greater, and there was greater measurement sensitivity in longitudinal pilot testing. Conclusion Adding 2 new items to the AM-PAC IMSF lowered the floor and increased statistical power, measurement breadth, and sensitivity.

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 = 805) 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.

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.

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.Criterion standard validation study.Inpatient, university hospital.Patients (N=25) in an adult neuroscience/brain rescue unit.Not applicable.RTLS and clinician-reported ambulation distance in feet, and JH-HLM score on an 8-point ordinal scale.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.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.

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.A cross-sectional, self-administered survey in two different hospital settings was completed by 120 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.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 (P0.001).The survey identified specific barriers common to both nurses and rehabilitation therapists and other barriers that were discipline specific.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.

Objective To determine whether functional status on admission to a Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP) is associated with unplanned readmission to acute care. Design Retrospective cohort study. Setting Academic hospital-based CIIRP. Participants Consecutive patients (N=1515) admitted to a CIIRP between January 2009 and June 2012. Interventions Patients' functional status, the primary exposure variable, was assessed using tertiles of the total FIM score at CIIRP admission, with secondary analyses using the FIM motor and cognitive domains. A propensity score, consisting of 25 relevant clinical and demographic variables, was used to adjust for confounding in the analysis. Main Outcome Measures Readmission to acute care was categorized as (1) readmission before planned discharge from the CIIRP, (2) readmission within 30 days of discharge from the CIIRP, and (3) total readmissions from both groups, with total readmissions being the a priori primary outcome. Results Among the 1515 patients, there were 347 total readmissions. Total readmissions were significantly associated with FIM scores, with adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the lowest and middle FIM tertiles versus the highest tertile (AOR=2.6; 95% CI, 1.9–3.7; P P =.002, respectively). There were similar findings for secondary analyses of readmission before planned discharge from the CIIRP (AOR=3.5; 95% CI, 2.2–5.8; P P =.002, respectively), and a weaker association for readmissions after discharge from the CIIRP (AOR=1.6; 95% CI, 1.0–2.4; P =.047 and AOR=1.3; 95% CI, 0.8–1.9; P =.28, respectively). The FIM motor domain score was more strongly associated with readmissions than the FIM cognitive score. Conclusions Functional status on admission to the CIIRP is strongly associated with readmission to acute care, particularly for motor aspects of functional status and readmission before planned discharge from the CIIRP. Efforts to reduce hospital readmissions should consider patient functional status as an important and potentially modifiable risk factor.

Lean Six Sigma (LSS) process analysis can be used to increase completeness of discharge summary reports used as a critical communication tool when a patient transitions between levels of care. The authors used the LSS methodology as an intervention to improve systems process. Over the course of the project, 8 required elements were analyzed in the discharge paperwork. The authors analyzed the discharge paperwork of patients (42 patients preintervention and 143 patients postintervention) of a comprehensive integrated inpatient rehabilitation program (CIIRP). Prior to this LSS project, 61.8% of required discharge elements were present. The intervention improved the completeness to 94.2% of the required elements. The percentage of charts that were 100% complete increased from 11.9% to 67.8%. LSS is a well-established process improvement methodology that can be used to make significant improvements in complex health care workflow issues. Specifically, the completeness of discharge documentation required for transition of care to CIIRP can be improved.