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Objectives: Manufacturer recalls and altered supply chains during the coronavirus disease 2019 (COVID-19) pandemic caused a nationwide shortage of blue-top tubes (BTTs). Most non-point-of-care coagulation tests use these tubes, leaving laboratories and health care facilities in short supply. The Department of Pathology and Laboratory Medicine at Cedars-Sinai Medical Center implemented interventions to conserve supply without sacrificing patient safety., Methods: In a retrospective quality improvement analysis, we examined coagulation testing and BTT utilization over the 3-month interval during which our interventions were applied. Our study assessed the interventions' effectiveness by evaluating changes in BTT utilization, coagulation testing volume, and patient impact., Results: Average daily use (ADU) of BTT before and after the intervention were 476 and 403, respectively-a 15.2% reduction. Notably, the Emergency Department had a reduction in ADU of 43.3%. Average daily volumes of coagulation assays performed decreased from 949 to 783-a 17.5% reduction. No adverse events from the Pharmacy Department were identified during the study period., Conclusions: Interventions resulting in significant reductions were in divisions with effective management and supervision. Success in navigating the BTT shortage stemmed from timely announcements, action, and effective communication. Our recommendations established more effective coagulation assay utilization, decreased overall BTT use, and prevented patients with coagulopathic disorders from experiencing adverse consequences., (© The Author(s) 2022. Published by Oxford University Press on behalf of American Society for Clinical Pathology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: We sought to determine the extent of SARS-CoV-2 seroprevalence and the factors associated with seroprevalence across a diverse cohort of healthcare workers., Design: Observational cohort study of healthcare workers, including SARS-CoV-2 serology testing and participant questionnaires., Settings: A multisite healthcare delivery system located in Los Angeles County., Participants: A diverse and unselected population of adults (n=6062) employed in a multisite healthcare delivery system located in Los Angeles County, including individuals with direct patient contact and others with non-patient-oriented work functions., Main Outcomes: Using Bayesian and multivariate analyses, we estimated seroprevalence and factors associated with seropositivity and antibody levels, including pre-existing demographic and clinical characteristics; potential COVID-19 illness-related exposures; and symptoms consistent with COVID-19 infection., Results: We observed a seroprevalence rate of 4.1%, with anosmia as the most prominently associated self-reported symptom (OR 11.04, p<0.001) in addition to fever (OR 2.02, p=0.002) and myalgias (OR 1.65, p=0.035). After adjusting for potential confounders, seroprevalence was also associated with Hispanic ethnicity (OR 1.98, p=0.001) and African-American race (OR 2.02, p=0.027) as well as contact with a COVID-19-diagnosed individual in the household (OR 5.73, p<0.001) or clinical work setting (OR 1.76, p=0.002). Importantly, African-American race and Hispanic ethnicity were associated with antibody positivity even after adjusting for personal COVID-19 diagnosis status, suggesting the contribution of unmeasured structural or societal factors., Conclusion and Relevance: The demographic factors associated with SARS-CoV-2 seroprevalence among our healthcare workers underscore the importance of exposure sources beyond the workplace. The size and diversity of our study population, combined with robust survey and modelling techniques, provide a vibrant picture of the demographic factors, exposures and symptoms that can identify individuals with susceptibility as well as potential to mount an immune response to COVID-19., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Provider organizations increasingly allow incorporation of patient-generated data into electronic health records (EHRs). In 2015, we began allowing patients to upload data to our EHR without physician orders, which we henceforth call patient-initiated data (PAIDA). Syncing wearable heart rate monitors to our EHR allows for uploading of thousands of heart rates per patient per week, including many abnormally low and high rates. Physician informaticists expressed concern that physicians and their patients might be unaware of abnormal heart rates, including those caused by treatable pathology., Objective: This study aimed to develop a protocol to address millions of unreviewed heart rates., Methods: As a quality improvement initiative, we assembled a physician informaticist team to meet monthly for review of abnormally low and high heart rates. By incorporating other data already present in the EHR, lessons learned from reviewing records over time, and from contacting physicians, we iteratively refined our protocol., Results: We developed (1) a heart rate visualization dashboard to identify concerning heart rates; (2) experience regarding which combinations of heart rates and EHR data were most clinically worrisome, as opposed to representing artifact; (3) a protocol whereby only concerning heart rates would trigger a cardiologist review revealing protected health information; and (4) a generalizable framework for addressing other PAIDA., Conclusion: We expect most PAIDA to eventually require systematic integration and oversight. Our governance framework can help guide future efforts, especially for cases with large amounts of data and where abnormal values may represent concerning but treatable pathology., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: In response to the global aging population, there has been increasing research on frailty. How frailty is conceptualized is shifting with the development of frailty models, especially in the acute care arena., Objective: To explore frailty/vulnerability risk factors available at admission that were associated with salient patient outcomes within the context of inpatient rehabilitation., Design: Methodologies in acute care are not easily adapted for a typical admission evaluation or a rehabilitation patient. In this study, the concept of frailty among patients admitted to rehabilitation was developed from risk factors available at admission that were associated with two patient outcomes, adverse hospital outcomes and 30-day hospital readmissions., Setting: Inpatient rehabilitation., Patients: Data were included on all patients (n = 768) discharged from an inpatient rehabilitation unit of an academic medical center from 1 January 2012 through 31 December 2012., Interventions: Not applicable., Main Outcome Measure: Adverse events within the inpatient rehabilitation stay and 30-day hospital readmissions., Results: Significant independent factors associated with adverse events in the rehabilitation unit included African American (1.77 OR; 95% CI 1.06-2.96), Hispanic (3.17 OR; 95% CI 1.13-8.94), having >9 total comorbid conditions (1.44 OR; 95% CI 1.244-1.66), and sphincter control domain (including bladder and bowel management) ≤ 9 FIM (0.92 OR; 95% CI 0.86-0.98). For 30-day readmission three variables were found to be significant: onset ≥7 days (2.31 OR; 95% CI 1.28-4.22), requiring a tube for feeding (3.45 OR; 95% CI 1.433-11.12), and being obese (4.72 OR; 95% CI 1.433-15.58)., Conclusions: The findings highlight the need for early admission screening and identification of risk factors which can provide the time in the rehabilitation setting for the clinical team to treat and prevent the potential for poor outcomes., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

To demonstrate a process of calculating the maximum potential morphine milligram equivalent daily dose (MEDD) based on the prescription Sig for use in quality improvement initiatives. To calculate an opioid prescription's maximum potential Sig-MEDD, we developed SQL code to determine a prescription's maximum units/day using discrete field data and text-parsing in the prescription instructions. We validated the derived units/day calculation using 3000 Sigs, then compared the Sig-MEDD calculation against the Epic-MEDD calculator. Of the 101 782 outpatient opioid prescriptions ordered over 1 year, 80% used discrete-field Sigs, 7% used free-text Sigs, and 3% used both types. We determined units/day and calculated a Sig-MEDD for 98.3% of all the prescriptions, 99.99% of discrete-Sig prescriptions, and 81.5% of free-text-Sig prescriptions. Analyzing opioid prescription Sigs to determine a maximum potential Sig-MEDD provides greater insight into a patient's risk for opioid exposure., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Frailty is a complex and growing phenomenon facing health care providers throughout the continuum of care. Frailty is not well understood in post-acute care (PAC) settings. The purpose of this scoping review was to summarize current evidence of frailty impact on outcomes and frailty mitigation initiatives in PAC. Three major publication databases were searched from January 2000 to June 2017 that identified 18 articles specifically addressing frailty in PAC. Three themes were identified: scales used to measure frailty, factors that led to an adverse outcome or diagnosis of frailty, and interventions to address frailty in PAC. Scales used to measure frailty were dominated by physical factors and scarce on nutrition and social support. Functional decline, grip strength, gait speed, polypharmacy, and nutrition were identified in the studies as factors that identify frailty and are associated with poor outcomes. All these frailty characteristics compromise patients' ability to benefit from rehabilitation, which further establishes the importance of PAC providers to identify, prevent, and treat frailty. Intervention studies had mixed outcomes, suggesting a need for further development in this area. The findings of this scoping review highlight the need for a comprehensive multidimensional assessment of frailty risks in PAC. LEVEL OF EVIDENCE: IV., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine whether functional status, as measured by the AcuteFIM instrument, can be used to predict discharge destination of stroke patients from the acute hospital setting., Design: A retrospective cohort study was carried out in an urban academic medical center. Data were collected on 481 new-onset stroke patients 18 yrs or older in an acute hospital between January 1 and September 30, 2013. Functional Independence Measure (FIM) instrument data were linked to a subset of 54 patients who received additional services at an inpatient rehabilitation facility. A receiver operator characteristic curve was constructed to validate the predictive ability of the AcuteFIM instrument and to determine the optimal cutoff score associated with discharge to a community setting., Results: All AcuteFIM items in stroke patients at admission demonstrated strong interitem correlation coefficients (all above 0.6) and high internal consistency (Cronbach α = 0.94). The AcuteFIM total score was positively associated with discharge to the community from the acute hospital (odds ratio, 1.06; 95% confidence interval, 1.05-1.07). Receiver operator characteristic curve analysis generated a c statistic of 0.89 (95% confidence interval, 0.87-0.92), indicating that the AcuteFIM instrument is predictive of patient discharge to the community setting., Conclusion: This study suggests that the AcuteFIM instrument is a reliable tool that can be used to predict discharge destination from the acute hospital among stroke patients.

Objective: To determine predictive factors for TRansferring Inpatient rehabilitation facility (IRF) cancer Patients Back to Acute Care (TRIPBAC)., Design: A retrospective chart review of patients with cancer admitted to an IRF from 2009 to 2010 because of a functional impairment that developed as a direct consequence of their cancer or its treatment., Setting: IRF of a community-based, academic, tertiary care facility., Methods: The characterization of patients with cancer in the IRF was primarily based on analysis of the IRF Patient Assessment Instrument and other internal IRF data logs., Main Outcome Measurement: Frequency and reasons for TRIPBAC., Results: The TRIPBAC rate in our IRF was 17.4%. The most common reasons for TRIPBAC were postneurosurgical complications (31%). Factors associated with TRIPBAC were a motor Functional Independence Measure score of 35 points or lower on admission (odds ratio 4.01, 95% confidence interval 1.79-8.98; P = .001) and the presence of a feeding tube or a modified diet (odds ratio 3.18, 95% confidence interval 1.44-7.04; P = .004)., Conclusions: Motor Functional Independence Measure score on admission is the best predictor for TRIPBAC in patients with cancer admitted to our IRF, followed by the presence of a feeding tube or a modified diet., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the impact of an inpatient rehabilitation program on functional improvement and survival among patients with newly diagnosed glioblastoma multiforme (GBM) who underwent surgical resection of the brain tumor., Design: A retrospective cohort study of newly diagnosed patients with GBM between 2003 and 2010, with survival data updated through January 23, 2013., Setting: An urban academic nonprofit medical center that included acute medical and inpatient rehabilitation., Participants: Data for newly diagnosed patients with GBM were examined; of these patients, 100 underwent inpatient rehabilitation after resection, and 312 did not undergo inpatient rehabilitation., Main Outcome Measurements: Overall functional improvement and survival time for patients who participated in the inpatient rehabilitation program., Results: A total of 89 patients (93.7%) who underwent inpatient rehabilitation improved in functional status from admission to discharge, with the highest gain observed in mobility (96.8%), followed by self-care (88.4%), communication/social cognition (75.8%), and sphincter control (50.5%). The median overall survival among inpatient rehabilitation patients was 14.3 versus 17.9 months for patients who did not undergo inpatient rehabilitation (P = .03). However, after we adjusted for age, extent of resection, and Karnofsky Performance Status Scale scores, we found no statistical difference in the survival rate between patients who did and did not undergo inpatient rehabilitation (hazard ratio [HR], 0.84; P = .16). Among the patients who underwent inpatient rehabilitation, older age (HR, 2.24; P = .0006), a low degree of resection (HR, 1.67; P = .02), and lack of a Stupp regimen (HR, 1.71; P = .05) were associated with greater hazard of mortality., Conclusions: Patients who undergo inpatient rehabilitation demonstrate significant functional improvements, primarily in the mobility domain. Confounder adjusted multivariate analysis showed no survival difference between patients who did and did not undergo inpatient rehabilitation; this finding suggests that a structured inpatient rehabilitation program may level the survival field in lower-functioning patients who otherwise may be faced with a dismal prognosis., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: To identify medical and functional health risk factors for being discharged directly to an acute-care hospital from an inpatient rehabilitation facility among patients who have had a stroke., Design: Retrospective cohort study., Setting: Academic medical center., Participants: A total of 783 patients with a primary diagnosis of stroke seen from 2008 to 2012; 60 were discharged directly to an acute-care hospital and 723 were discharged to other settings, including community and other institutional settings., Methods or Interventions: Logistic regression analysis., Main Outcome Measurements: Direct discharge to an acute care hospital compared with other discharge settings from the inpatient rehabilitation unit., Results: No significant differences in demographic characteristics were found between the 2 groups. The adjusted logistic regression model revealed 2 significant risk factors for being discharged to an acute care hospital: admission motor Functional Independence Measure total score (odds ratio 0.97, 95% confidence interval 0.95-0.99) and enteral feeding at admission (odds ratio 2.87, 95% confidence interval 1.34-6.13). The presence of a Centers for Medicare and Medicaid-tiered comorbidity trended toward significance., Conclusion: Based on this research, we identified specific medical and functional health risk factors in the stroke population that affect the rate of discharge to an acute-care hospital. With active medical and functional management, early identification of these critical components may lead to the prevention of stroke patients from being discharged to an acute-care hospital from the inpatient rehabilitation setting., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare and contrast subjective perceptions with objective compliance of the impact of the 2010 Centers for Medicare and Medicaid Service updates of the Medicare Benefit Policy Manual., Design or Setting: Cross-sectional survey., Participants and Methods: An electronic survey was sent by the Uniform Data System for Medical Rehabilitation to all enrolled inpatient rehabilitation facility subscribers (n = 817). The survey was sent April 15, 2011, and responses were tabulated if they were received by May 15, 2011., Main Outcome Measurements: Comparing and contrasting of the subjective perception to objective evaluation and/or compliance with the Medicare Benefit Policy Manual on case mix index, length of stay, admissions by diagnostic category as well as perception of preadmission screening, postadmission evaluation, plan of care, and interdisciplinary conferencing., Results: Twenty-five percent of the 817 facilities responded, for a total of 209 responses. Complete data were present in 148 of the respondents. For most diagnostic categories, perception of change did not mirror reality of change; neither did the perception between change in case mix index and length of stay. Perception did match reality in stroke and multiple trauma cases; respondents perceived an increase in admissions for the 2 impairments, and there was an overall increase in reality., Conclusion: Comparison with actual data identified that gaps exist between diagnostic category perceptions and actual diagnostic category admission performance. Regulations such as the 75%-60% rule and audit focus on non-neurologic conditions as well as actual inpatient rehabilitation facility program payment reports may have influenced respondents perceptions to change associated with the Medicare Benefit Policy Manual modifications. This disparity between perception and actual data may have implications for programmatic planning, forecasting, and resource allocation., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

A perfect storm had been brewing in the last decade: Medicare payment mistakes; Medicare waste, fraud, and abuse; fuzzy medical necessity definitions; erroneous coding; and a strained national budget. The United States Congress responded by inserting Section 306 into the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Section 306 called for the correction of Medicare payment problems by establishing the Recovery Audit Contractor program as the vehicle for the Centers for Medicare & Medicaid Services to recoup Medicare overpayments as far back as 3 yrs from its healthcare providers and to return underpayments to them. The legislation allowed for Medicare to contract with private firms to follow the money and earn a cut. Caught in the eye of the storm, Medicare providers combined are giving back more than they get back. Inpatient Rehabilitation Facilities are taking back takebacks-but enough to remain viable?

Objective: To determine if discharge destination after hospitalization for hip replacement or repair influences the hospital readmission rate., Design: A retrospective cohort study that included consecutive patients with a primary diagnosis of hip replacement or repair who were discharged from the acute hospital in a 3-year period., Setting: Urban academic nonprofit hospital., Patients: Data for 606 orthopedic patients discharged alive from the acute hospital between January 2004 and September 2006 were abstracted from the University Health-System Consortium (UHC) Clinical DataBase/Resource Manager clinical database for the study hospital., Main Outcome Measures: Unplanned readmission rate to the study-site hospital within 180 days after discharge after hip replacement or repair., Results: Unplanned readmission within 180 days occurred at a rate of 8.3% and varied significantly by discharge destination: home 5.1%, home with home health care services 10.5%, skilled nursing facility 12.3%, inpatient rehabilitation 4.2%, and other 42.9%. Variables from the surgical admission that were significantly associated with higher risk of readmission included admission severity, burden of comorbidities, any days in the intensive care unit, long length of stay, and cost. When controlling for multiple independent risk factors, discharge to inpatient rehabilitation (P = .015) remained a significant independent predictor of lower risk of readmission within 180 days., Conclusion: Discharge to acute inpatient rehabilitation was associated with a lower risk of hospital readmission. Identification of patients with orthopedic procedures who may benefit from inpatient rehabilitation and further medical management before discharge from the acute hospital may be an important strategy in prevention of hospital readmission., (Copyright © 2010 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Visual deficits after cerebral injury are common. The variability in the types of injury sustained as well as their impact on function in the environment have produced multiple approaches at corrective intervention. To assess the effectiveness of these vision interventions, an extensive literature search was completed. The analysis of this review revealed some success with visual neglect disorders, but not enough evidence to comment definitively on interventions for hemianopsia, quadrantonopsia, diplopia, or convergence insufficiency. A lack of follow-up also limited efforts to assess the durability of documented gains. Additional research is necessary to clarify, quantify, and measure treatment outcomes for acquired visual dysfunction as well as to link laboratory testing to improvement in actual functioning for individuals in their environment.

Constraint-induced therapy (CIT) is a rehabilitation intervention designed to promote increased use of a weak or paralyzed arm, most commonly in patients who sustained a stroke. CIT involves constraining the unaffected arm in a sling or mitt, forcing the use of the weaker or paralyzed arm in daily activities. The aim of this study was to determine whether immobilizing the uninvolved arm of persons who experienced a stroke while participating in meaningful activities of daily living would increase their satisfaction and performance in life roles. Nine clients participated in a pilot study consisting of 2 weeks of individualized occupation-based CIT. This pilot study combined therapy in the clinic with therapy in the individual's home environment and incorporated meaningful daily activities chosen by the client into treatment. Results revealed a significant change in reported satisfaction and performance postintervention; however, a decline in satisfaction at follow-up despite continued motor improvement. Even though voluntary movements demonstrated improvement, participants were not satisfied with their performance in functional goal-related activities in their natural environment. Motor improvement can be repeated; however, at follow-up, participants were not satisfied with the improvement in meaningful activities that they identified. This may have to do with participants wanting or expecting their affected upper extremity to function better despite the deficits. It is also possible that participants expected their function to improve at the rate that it did during treatment. Further investigation using meaningful activity is needed to identify integration of the affected upper extremity into individuals' own environments and determine how it affects overall life roles and satisfaction over time.

Objective: To assess the effects of multidisciplinary rehabilitation interventions and use of bromocriptine on outcome in patients with traumatic brain injury-vegetative state (TBI-VS)., Design: Retrospective review of clinical cases., Setting: Free-standing rehabilitation hospital; Acute and extended rehabilitation hospital., Participants: Five consecutive TBI-VS patients, as well as 33 TBI-VS patients and 37 traumatic brain injury-minimally conscious state (TBI-MCS) patients reported in the literature., Interventions: Bromocriptine administration, systematic neuropsychologic testing, sensory stimulation, and traditional comprehensive rehabilitation with physical therapy, occupational therapy, and speech therapy., Main Outcome Measures: Disability Rating Scale (DRS) at 1, 3, 6, and 12 months postinjury and FIM instrument scores at 1 month and 12 months postinjury, Coma Recovery Scale, and Barry Rehabilitation Inpatient Screening of Cognition., Results: The 5 TBI-VS patients emerged from a VS into a MCS and regained functional status. Their recovery of physical and cognitive functioning, as rated by the DRS, was greater than previously reported in the literature for patients in a VS or MCS at 3, 6, and 12 months postinjury., Conclusion: Bromocriptine administration, systematic neuropsychologic testing, sensory stimulation, a comprehensive rehabilitation program, or a combination of these treatments may enhance functional recovery in this TBI-VS patient group. Further systematic study to quantify the contribution of these variables and to reproduce this data in a larger patient population should be performed.

Since 1981, the epidemic of acquired immunodeficiency syndrome (AIDS), due to infection with human immunodeficiency virus (HIV), has grown and challenged health care providers in the United States. Although the total number of AIDS cases diagnosed each year appears to be reaching a plateau, cases attributable to heterosexual transmission are rising. With improved treatment, survival of persons with HIV infection is expected to increase; this change suggests that the prevalence of HIV-related physical disability will also increase. This article outlines the pathophysiology and systemic manifestations of HIV infection. The more common neuromuscular and neurological complications at each stage of the disease are presented, and appropriate rehabilitation interventions are discussed. The indications for aerobic exercise in persons with HIV infection and the approach to disability management in pediatric HIV infection are presented. Psychosocial considerations related to access to rehabilitations services, discrimination on the basis of HIV infection or membership in HIV risk behavior groups, and vocational rehabilitation are discussed. The review concludes that rehabilitation interventions in persons with HIV infection are based on functional deficits, rather than disease processes, suggesting that a general physiatric fund of knowledge should be adequate to manage most HIV disability.

Angiotensin II (AII) was infused into the lateral cerebral ventricle of rats given water, isotonic saline, or hypertonic saline ad libitum, or 40 ml water/day. Fluid intake, change in body weight, plasma [Na+], and plasma and pituitary arginine vasopressin (AVP) levels were measure. Isotonic saline or AII (1 micrograms/microliter saline) was infused at 1 microliter/h for 5 days using osmotic minipumps. AII increased fluid intake of rats given isotonic saline to drink; they consumed an average of 269 +/- 25 ml/day on day 5. AII infusions in rat given water or isotonic saline to drink decreased plasma [Na+] with no changes in plasma or pituitary AVP. However, in rats given hypertonic saline, plasma [Na+] remained at control levels while plasma AVP increased. In water-restricted rats, the effects of AII were intermediate: a small decrease in plasma [Na+] and a small increase in plasma AVP. From these results, it is suggested that although acute AII administration elicits AVP release, this effect diminishes during chronic AII infusion, coincident with reduced plasma [Na+].