- Email: [email protected]
Poster 309 Implementing the Siebens Domain Management Model During Inpatient Rehabilitation to Increase Functional Independence and Discharge Rates to Home from an Inpatient Rehabilitation Facility in Stroke Patients and Minimize Acute Discharges: IRB Approved Study
S260
Abstracts / PM R 8 (2016) S151-S332
Poster 306 Rehabilitation of Patients Undergoing Sacrectomies: A Case Report George Francis, MD (University of Alberta, Calgary, Alberta, Canada), An Ngo-Huang, DO, Eduardo Bruera, MD Disclosures: George Francis: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Sacral neoplasms often present as large masses refractory to chemotherapy and radiation, requiring a sacrectomy. Multiple sacral nerve roots and vessels may be compromised, resulting in immobility, pressure ulcers, orthostasis, and neurogenic bowel and bladder. Our goal is to review the rehabilitative needs and outcomes post-sacrectomy via two inpatient case presentations. A 58-year-old woman with a solitary fibrous tumor underwent an en bloc resection involving a subtotal sacrectomy from S2 to coccyx, an L5-S1 laminectomy, ligation of her bilateral S2-5 nerve roots, neurolysis of bilateral S1 and sciatic nerve roots, and bilateral gluteal flap closures. Post-operatively, activity precautions included no walking initially and no hip flexion for two weeks. She required tilt table treatments and was ambulating at post-op Day 8. The rehabilitation challenges included: training on the management of her neurogenic bowel and bladder, controlling her neuropathic and somatic pain, and mobilizing her despite the hip restrictions. The second case includes a 67-year-old male with a sacral chordoma who underwent a two-stage surgery. Stage one involved preparation for the en bloc resection of the sacral tumor. One day later, stage two involved an L5-S1 laminectomy, ligation of the S2-5 nerve roots, en bloc resection of the sacral, bilateral S1 root and sciatic neurolysis, and bilateral gluteus muscle flaps for closure. His rehabilitation challenges included: severe protein malnutrition, orthostatic hypotension, delayed wound healing, fluid collection, uncontrolled pain, and neurogenic bowel and bladder. Setting: Tertiary cancer center. Results: Highly functional outcomes are seen in these patients, including independent bowel and bladder management and return to pre-operative ambulatory status. Discussion: Rehabilitation interventions for these patients include: medical stabilization, pain management, wound healing, transfers, mobility, and neurogenic bowel and bladder management. Conclusions: These are highly complex surgical patients with extensive rehabilitation needs that require the management by a physiatrist. Level of Evidence: Level V Poster 308 Improvement of Spasticity, Active Movements and Active Function after Repeated Injections of AbobotulinumtoxinA (Dysport) in Adults with Spastic Paresis in the Upper Limb: Results of a Phase III Open-Label Extension Study Christina Marciniak, MD (Northwestern University and the Rehabilitation Institute of Chicago, Chicago, Illinois, USA), Fatma Gul, MD, Ziyad Ayyoub, MD, David M. Simpson, MD, Heather W. Walker, Michael Wimmer, MD, Claire Vilain, MD, Jean-Michel Gracie`s Disclosures: Research Grants - Allergan, Ipsen, Advisory Board - Merz Objective: Assessment of long term efficacy on spasticity, active movements, active function and safety of abobotulinumtoxinA over repeated treatment cycles in hemiparetic patients with upper limb spasticity due to stroke/traumatic brain injury. Design: Open-label extension to a double-blind study. Setting: Phase III, international, multicenter.
Participants: 258 patients consisting of 227 rollover patients who completed a double-blind study (Gracies, et al. Lancet Neurol. 2015) and 31 de novo patients. Interventions: AbobotulinumtoxinA 500U, 1000U or 1500U (selected and adapted by investigator) for up to 4/5 cycles. Main Outcome Measures: Spasticity (Tardieu Scale: passive range of motion [XV1] and angle of catch [XV3]), active range of motion in the primary target muscle group (PTMG: finger, wrist or elbow flexors), active function (Modified Frenchay Scale, MFS [assessed by videotaping patients’ performance of ten tasks using the upper limb, scored by independent observer) and safety assessments. Results (mean change (SD) from baseline) are provided irrespective of dose (500U, 1000U, 1500U) administered. Results: Passive range of motion and angle of catch improved over repeated cycles in the three PTMGs. The increase of active finger extension of +19.8 (28.8) seen at Week 4 in the double-blind phase nearly doubled to +38.0 (53.4) in cycle 4 of the open-label phase. A progressive improvement over cycles was also broadly observed for wrist and elbow extension. Upper limb active function (MFS) improved progressively over cycles: the increase of +0.21 (0.53) observed at Week 4 of the double-blind phase reached +0.40 (0.75) at Week 4 of cycle 4. The incidence of treatment emergent adverse events decreased over repeated cycles from 41.5% in the double-blind study to 13.6% in cycle 4 of the open-label phase. Conclusions: Over repeated cycles of abobotulinumtoxinA injections, improvements of spasticity and active movements were observed; this was associated with a progressive improvement in active function. The safety profile was consistent with previously reported data on abobotulinumtoxinA. Disclosure: AbobotulinumtoxinA has received approval by the FDA for the treatment of adult upper limb spasticity. Level of Evidence: Level I Poster 309 Implementing the Siebens Domain Management Model During Inpatient Rehabilitation to Increase Functional Independence and Discharge Rates to Home from an Inpatient Rehabilitation Facility in Stroke Patients and Minimize Acute Discharges: IRB Approved Study Kirill Alekseyev, MD, EMBA (Kingsbrook Jewish Med Center, Brooklyn, NY, United States), Jemmry Pantin, Calvin R. Spott, MD, Sangita T. Bajpayee, MD, Blair E. Conard III, MS, Marc Ross, MD Disclosures: Kirill Alekseyev: I Have No Relevant Financial Relationships To Disclose Objective: To utilize the Siebens Domain Management Model (SDMM) during the inpatient rehabilitation period of stroke patients to increase functional independence measure (FIM) scores, thereby increasing the discharge rate from the inpatient rehabilitation facility (IRF) to home and minimizing acute discharges. Design: Retrospective and Prospective Study. Setting: Inpatient Rehabilitation Facility (IRF) in an inner city hospital. Participants: CVA IRF patients excluding prisoners. Interventions: Following the SDMM, a team conference approach was utilized to discuss CVA patients’ FIM items and scores in a team setting. Team members included the following: Physician, Resident, Case Manager, Nurse, Physical Therapist, Occupational Therapist, Social Worker, Speech Pathologist, Psychologist, and Vocational Rehabilitation Specialist. A team conference checklist (TCC) was designed and applied to weekly team conference meetings. The TCC included information regarding patient demographics, team care members present, length of stay, FIM items with most recent FIM Scores, and updating of the treatment plan. In the event that any item was not discussed during the conference, interventions would be made to address the issue. Major FIM items assessed were the patients’: SelfCare, Sphincter Control, Mobility and Ambulation, Locomotion,
Abstracts / PM R 8 (2016) S151-S332 Communication, and Social Cognition. The TCC included a retrospective period of 6 months and prospective period of 6-months for a total of one year. Main Outcome Measures: Comparison between retrospective, transition and prospective data of Functional Independence Measure (FIM) scores during weekly team conferences to identify barriers to discharge. Results: The SDMM included a 6-month retrospective analysis, a 1-month transition period and a 6-month prospective analysis. The retrospective study consisted of 73 post-cerebrovascular accident (CVA)-IRF patients, admitted between the months of February 2015 to July 2015. During this period, the total, on-admission FIM score averaged 48.5 and the total, discharge FIM score averaged 66.7, which correlates to an improvement of 18.2 points during their admission. Changes in each FIM score subcategory from on-admission to discharge are as follows, respectively: Self-Care: Eating: 4.06 to 4.92 a change of 0.86 Grooming: 2.28 to 3.86 a change of 1.58, Bathing: 1.82 to 2.76 a change of 0.94, Dressing Upper: 2.92 to 3.68 a change of 0.76, Dressing Lower: 2.00 to 3.04 a change of 1.04, Toileting: 1.83 to 2.88 a change of 1.05. Sphincter: Bladder: 2.42 to 3.01 a change of 0.59, Bowel: 3.29 to 3.62 a change of 0.33. Mobility and Ambulation: Bed Chair/Wheelchair Transfer: 2.02 to 3.28 a change of 1.26, Toilet Transfer: 2.21 to 3.24 a change of 1.03, Tub Shower Transfer: 1.97 to 2.03 a change of 0.06. Locomotion: Walk/Wheelchair Mobility: 0.96 to 2.81 a change of 1.85, Stairs: 0.51 to 2.56 a change of 2.05. Communication: Comprehension: 3.84 to 5.16 a change of 1.32, Expression: 3.85 to 5.03 a change of 1.18. Social Cognition: Social Interaction: 4.60 to 5.68 a change of 1.08, Problem Solving: 3.15 to 4.50 a change of 1.35, Memory: 3.41 to 4.63 a change of 1.22. The averaged, actual length of stay was 18.6 days. Out of 73 patients, 11 were acutely discharged representing 15.1%, 26 were sent to a skilled nursing facility (SNF) representing 35.6%, and 36 were sent home representing 49.3%. During the transition period, which allowed for the implementation of the SDMM team approach and utilization of the TCC, the month of August 2015 included 10 patients. The averaged, total, on-admission FIM score was 60.4 and the averaged, total, discharged FIM score was 78.1, which correlates to an improvement of 17.7 points during this period. Changes in each FIM score subcategory from on-admission to discharge are as follows, respectively: Self-Care: Eating: 4.7 to 5.2 a change of 0.50, Grooming: 3.7 to 3.8 a change of 0.10, Bathing: 2.5 to 3.5 a change of 1.0, Dressing Upper: 3.6 to 4.7 a change of 1.1, Dressing Lower: 2.8 to 3.9 a change of 1.1, Toileting: 2.5 to 4.1 a change of 1.6. Sphincter: Bladder: 3.3 to 4.6 a change of 1.3, Bowel: 4.2 to 5.1 a change of 0.9. Mobility and Ambulation: Bed Chair/Wheelchair Transfer: 3.1 to 4.2 a change of 1.1, Toilet Transfer: 3.2 to 4.7 a change of 1.5, Tub Shower Transfer: 2.7 to 1.8 a decreased change of 0.9. Locomotion: Walk/Wheelchair Mobility: 1.5 to 3.1 a change of 1.6, Stairs: 1.1 to 3.2 a change of 2.1. Communication: Comprehension: 4.2 to 5.2 a change of 1.0, Expression: 4.3 to 5.3 a change of 1.0. Social Cognition: Social Interaction: 5.1 to 5.8 a change of 0.7, Problem Solving: 3.4 to 4.9 a change of 1.5, Memory: 3.8 to 5.0 a change of 1.2. The averaged, actual length of stay was 12.6 days. Out of 10 patients, 3 were acutely discharged representing 30.0%, 3 were sent to a SNF representing 30.0%, and 4 were sent home representing 40.0%. The prospective months incorporated the SDMM team approach to every patient care conference along with the application of the TCC, for the months of September 2015 to February 2016. This period consisted of 82 patients. The averaged, total, onadmission FIM score was 54.7 and the average, total discharged FIM score was 75.1, which correlates to an improvement of 20.4 points during this period. Changes in each FIM score subcategory from onadmission to discharge are as follows, respectively: Self-Care: Eating: 4.36 to 5.30 a change of 0.94, Grooming: 2.38 to 4.06 a change of 1.68, Bathing: 2.09 to 3.30 a change of 1.21, Dressing Upper: 2.89 to 4.19 a change of 1.3, Dressing Lower: 2.19 to 3.79 a
S261
change of 1.6, Toileting: 2.06 to 3.55 a change of 1.49. Sphincter: Bladder: 3.29 to 4.06 a change of 0.77, Bowel: 3.71 to 4.03 a change of 0.32. Mobility and Ambulation: Bed Chair/Wheelchair Transfer: 2.35 to 3.83 a change of 1.48, Toilet Transfer: 2.20 to 3.95 a change of 1.75, Tub Shower Transfer: 1.88 to 2.15 a change of 0.27. Locomotion: Walk/Wheelchair Mobility: 1.07 to 3.24 a change of 1.48, Stairs: 0.65 to 3.17 a change of 2.52. Communication: Comprehension: 4.68 to 5.47 a change of 0.79, Expression: 4.61 to 5.56 a change of 0.95. Social Cognition: Social Interaction: 5.21 to 5.78a change of 0.57, Problem Solving: 3.89 to 4.77 a change of 0.88, Memory: 3.86 to 4.84 a change of 0.98. The averaged, length of stay was 19.3 days. From our patient population 3 were acutely discharged representing 4.5%, 23 were sent to a SNF representing 34.8%, and 40 were sent home representing 60.6%. Conclusions: In this IRB study, utilizing the SDMM to improve FIM scores and increase the discharge rates to home was demonstrated in our target population of CVA, IRF patients. In this study, we showed an improvement for the averaged, discharged, total FIM scores (retrospective value of 66.7 compared to a prospective value of 75.1 representing an increase of 8.4). We may extrapolate that the team approach to patient care ultimately leads to an improvement of patient functional independence measures. Implementing the team approach we were also able to demonstrate a significant decrease in acute discharges; a retrospective value of 15.1% (11 out of 73 patients) compared to a prospective value of 4.5% (3 out of 66 patients). In our study we were also able to significantly increase the rate of discharges to home; a retrospective value of 49.3% (36 out of 73 patients) compared to a prospective value of 60.6% (40 out of 66 patients) an increase of 11.3%. These increases in the averaged, overall FIM scores (increase of 8.4) and an increase of 11.3% in those being discharged to home, demonstrates the advantage of a team approach for improving patient care. The recommendation of a team approach will be suggested with the team consisting of an attending physician, resident physician, case manager, nurse, physical therapist, occupational therapist, social worker, speech pathologist, neuropsychologist, and a vocational rehabilitation specialist. Level of Evidence: Level I Poster 310 EMG Guided Botulinum Toxin Type A Injections for Functional Problems Associated to Congenital Facial Palsy: A Case Report Isabel M. Rutzen, MD (VA Caribbean Healthcare System San Juan, San Juan, Puerto Rico), David Q. Atkins, MD, Keryl Motta, MD Disclosures: Isabel Rutzen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 46-year-old man with congenital right facial palsy who was evaluated by physiatry service since aside from the cosmetic impact of his facial asymmetry, he was experiencing late onset functional problems. He complained of progressive lip inversion causing recurrent biting and discomfort. Physical exam was remarkable for right lip inversion and hypertrophy of the contralateral facial muscles. Decision was made to infiltrate selected left facial muscles with incobotulinum toxin type A to reduce muscle pull on the weaker right side, with functional outcome goals of reducing biting as well as improving facial symmetry. The botulinum toxin was reconstituted with 0.9% normal saline to a concentration of 4U/ 0.1cc. A total of 45U were distributed among selected muscles under EMG guidance. Setting: Tertiary Care Hospital. Results: At 6 weeks post-injection the patient reported favorable outcomes, referring resolution of lip biting and overall satisfaction with improvement in facial symmetry. The patient denied adverse reactions from procedure. Physical exam was pertinent for significant
Abstracts / PM R 8 (2016) S151-S332
Poster 306 Rehabilitation of Patients Undergoing Sacrectomies: A Case Report George Francis, MD (University of Alberta, Calgary, Alberta, Canada), An Ngo-Huang, DO, Eduardo Bruera, MD Disclosures: George Francis: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Sacral neoplasms often present as large masses refractory to chemotherapy and radiation, requiring a sacrectomy. Multiple sacral nerve roots and vessels may be compromised, resulting in immobility, pressure ulcers, orthostasis, and neurogenic bowel and bladder. Our goal is to review the rehabilitative needs and outcomes post-sacrectomy via two inpatient case presentations. A 58-year-old woman with a solitary fibrous tumor underwent an en bloc resection involving a subtotal sacrectomy from S2 to coccyx, an L5-S1 laminectomy, ligation of her bilateral S2-5 nerve roots, neurolysis of bilateral S1 and sciatic nerve roots, and bilateral gluteal flap closures. Post-operatively, activity precautions included no walking initially and no hip flexion for two weeks. She required tilt table treatments and was ambulating at post-op Day 8. The rehabilitation challenges included: training on the management of her neurogenic bowel and bladder, controlling her neuropathic and somatic pain, and mobilizing her despite the hip restrictions. The second case includes a 67-year-old male with a sacral chordoma who underwent a two-stage surgery. Stage one involved preparation for the en bloc resection of the sacral tumor. One day later, stage two involved an L5-S1 laminectomy, ligation of the S2-5 nerve roots, en bloc resection of the sacral, bilateral S1 root and sciatic neurolysis, and bilateral gluteus muscle flaps for closure. His rehabilitation challenges included: severe protein malnutrition, orthostatic hypotension, delayed wound healing, fluid collection, uncontrolled pain, and neurogenic bowel and bladder. Setting: Tertiary cancer center. Results: Highly functional outcomes are seen in these patients, including independent bowel and bladder management and return to pre-operative ambulatory status. Discussion: Rehabilitation interventions for these patients include: medical stabilization, pain management, wound healing, transfers, mobility, and neurogenic bowel and bladder management. Conclusions: These are highly complex surgical patients with extensive rehabilitation needs that require the management by a physiatrist. Level of Evidence: Level V Poster 308 Improvement of Spasticity, Active Movements and Active Function after Repeated Injections of AbobotulinumtoxinA (Dysport) in Adults with Spastic Paresis in the Upper Limb: Results of a Phase III Open-Label Extension Study Christina Marciniak, MD (Northwestern University and the Rehabilitation Institute of Chicago, Chicago, Illinois, USA), Fatma Gul, MD, Ziyad Ayyoub, MD, David M. Simpson, MD, Heather W. Walker, Michael Wimmer, MD, Claire Vilain, MD, Jean-Michel Gracie`s Disclosures: Research Grants - Allergan, Ipsen, Advisory Board - Merz Objective: Assessment of long term efficacy on spasticity, active movements, active function and safety of abobotulinumtoxinA over repeated treatment cycles in hemiparetic patients with upper limb spasticity due to stroke/traumatic brain injury. Design: Open-label extension to a double-blind study. Setting: Phase III, international, multicenter.
Participants: 258 patients consisting of 227 rollover patients who completed a double-blind study (Gracies, et al. Lancet Neurol. 2015) and 31 de novo patients. Interventions: AbobotulinumtoxinA 500U, 1000U or 1500U (selected and adapted by investigator) for up to 4/5 cycles. Main Outcome Measures: Spasticity (Tardieu Scale: passive range of motion [XV1] and angle of catch [XV3]), active range of motion in the primary target muscle group (PTMG: finger, wrist or elbow flexors), active function (Modified Frenchay Scale, MFS [assessed by videotaping patients’ performance of ten tasks using the upper limb, scored by independent observer) and safety assessments. Results (mean change (SD) from baseline) are provided irrespective of dose (500U, 1000U, 1500U) administered. Results: Passive range of motion and angle of catch improved over repeated cycles in the three PTMGs. The increase of active finger extension of +19.8 (28.8) seen at Week 4 in the double-blind phase nearly doubled to +38.0 (53.4) in cycle 4 of the open-label phase. A progressive improvement over cycles was also broadly observed for wrist and elbow extension. Upper limb active function (MFS) improved progressively over cycles: the increase of +0.21 (0.53) observed at Week 4 of the double-blind phase reached +0.40 (0.75) at Week 4 of cycle 4. The incidence of treatment emergent adverse events decreased over repeated cycles from 41.5% in the double-blind study to 13.6% in cycle 4 of the open-label phase. Conclusions: Over repeated cycles of abobotulinumtoxinA injections, improvements of spasticity and active movements were observed; this was associated with a progressive improvement in active function. The safety profile was consistent with previously reported data on abobotulinumtoxinA. Disclosure: AbobotulinumtoxinA has received approval by the FDA for the treatment of adult upper limb spasticity. Level of Evidence: Level I Poster 309 Implementing the Siebens Domain Management Model During Inpatient Rehabilitation to Increase Functional Independence and Discharge Rates to Home from an Inpatient Rehabilitation Facility in Stroke Patients and Minimize Acute Discharges: IRB Approved Study Kirill Alekseyev, MD, EMBA (Kingsbrook Jewish Med Center, Brooklyn, NY, United States), Jemmry Pantin, Calvin R. Spott, MD, Sangita T. Bajpayee, MD, Blair E. Conard III, MS, Marc Ross, MD Disclosures: Kirill Alekseyev: I Have No Relevant Financial Relationships To Disclose Objective: To utilize the Siebens Domain Management Model (SDMM) during the inpatient rehabilitation period of stroke patients to increase functional independence measure (FIM) scores, thereby increasing the discharge rate from the inpatient rehabilitation facility (IRF) to home and minimizing acute discharges. Design: Retrospective and Prospective Study. Setting: Inpatient Rehabilitation Facility (IRF) in an inner city hospital. Participants: CVA IRF patients excluding prisoners. Interventions: Following the SDMM, a team conference approach was utilized to discuss CVA patients’ FIM items and scores in a team setting. Team members included the following: Physician, Resident, Case Manager, Nurse, Physical Therapist, Occupational Therapist, Social Worker, Speech Pathologist, Psychologist, and Vocational Rehabilitation Specialist. A team conference checklist (TCC) was designed and applied to weekly team conference meetings. The TCC included information regarding patient demographics, team care members present, length of stay, FIM items with most recent FIM Scores, and updating of the treatment plan. In the event that any item was not discussed during the conference, interventions would be made to address the issue. Major FIM items assessed were the patients’: SelfCare, Sphincter Control, Mobility and Ambulation, Locomotion,
Abstracts / PM R 8 (2016) S151-S332 Communication, and Social Cognition. The TCC included a retrospective period of 6 months and prospective period of 6-months for a total of one year. Main Outcome Measures: Comparison between retrospective, transition and prospective data of Functional Independence Measure (FIM) scores during weekly team conferences to identify barriers to discharge. Results: The SDMM included a 6-month retrospective analysis, a 1-month transition period and a 6-month prospective analysis. The retrospective study consisted of 73 post-cerebrovascular accident (CVA)-IRF patients, admitted between the months of February 2015 to July 2015. During this period, the total, on-admission FIM score averaged 48.5 and the total, discharge FIM score averaged 66.7, which correlates to an improvement of 18.2 points during their admission. Changes in each FIM score subcategory from on-admission to discharge are as follows, respectively: Self-Care: Eating: 4.06 to 4.92 a change of 0.86 Grooming: 2.28 to 3.86 a change of 1.58, Bathing: 1.82 to 2.76 a change of 0.94, Dressing Upper: 2.92 to 3.68 a change of 0.76, Dressing Lower: 2.00 to 3.04 a change of 1.04, Toileting: 1.83 to 2.88 a change of 1.05. Sphincter: Bladder: 2.42 to 3.01 a change of 0.59, Bowel: 3.29 to 3.62 a change of 0.33. Mobility and Ambulation: Bed Chair/Wheelchair Transfer: 2.02 to 3.28 a change of 1.26, Toilet Transfer: 2.21 to 3.24 a change of 1.03, Tub Shower Transfer: 1.97 to 2.03 a change of 0.06. Locomotion: Walk/Wheelchair Mobility: 0.96 to 2.81 a change of 1.85, Stairs: 0.51 to 2.56 a change of 2.05. Communication: Comprehension: 3.84 to 5.16 a change of 1.32, Expression: 3.85 to 5.03 a change of 1.18. Social Cognition: Social Interaction: 4.60 to 5.68 a change of 1.08, Problem Solving: 3.15 to 4.50 a change of 1.35, Memory: 3.41 to 4.63 a change of 1.22. The averaged, actual length of stay was 18.6 days. Out of 73 patients, 11 were acutely discharged representing 15.1%, 26 were sent to a skilled nursing facility (SNF) representing 35.6%, and 36 were sent home representing 49.3%. During the transition period, which allowed for the implementation of the SDMM team approach and utilization of the TCC, the month of August 2015 included 10 patients. The averaged, total, on-admission FIM score was 60.4 and the averaged, total, discharged FIM score was 78.1, which correlates to an improvement of 17.7 points during this period. Changes in each FIM score subcategory from on-admission to discharge are as follows, respectively: Self-Care: Eating: 4.7 to 5.2 a change of 0.50, Grooming: 3.7 to 3.8 a change of 0.10, Bathing: 2.5 to 3.5 a change of 1.0, Dressing Upper: 3.6 to 4.7 a change of 1.1, Dressing Lower: 2.8 to 3.9 a change of 1.1, Toileting: 2.5 to 4.1 a change of 1.6. Sphincter: Bladder: 3.3 to 4.6 a change of 1.3, Bowel: 4.2 to 5.1 a change of 0.9. Mobility and Ambulation: Bed Chair/Wheelchair Transfer: 3.1 to 4.2 a change of 1.1, Toilet Transfer: 3.2 to 4.7 a change of 1.5, Tub Shower Transfer: 2.7 to 1.8 a decreased change of 0.9. Locomotion: Walk/Wheelchair Mobility: 1.5 to 3.1 a change of 1.6, Stairs: 1.1 to 3.2 a change of 2.1. Communication: Comprehension: 4.2 to 5.2 a change of 1.0, Expression: 4.3 to 5.3 a change of 1.0. Social Cognition: Social Interaction: 5.1 to 5.8 a change of 0.7, Problem Solving: 3.4 to 4.9 a change of 1.5, Memory: 3.8 to 5.0 a change of 1.2. The averaged, actual length of stay was 12.6 days. Out of 10 patients, 3 were acutely discharged representing 30.0%, 3 were sent to a SNF representing 30.0%, and 4 were sent home representing 40.0%. The prospective months incorporated the SDMM team approach to every patient care conference along with the application of the TCC, for the months of September 2015 to February 2016. This period consisted of 82 patients. The averaged, total, onadmission FIM score was 54.7 and the average, total discharged FIM score was 75.1, which correlates to an improvement of 20.4 points during this period. Changes in each FIM score subcategory from onadmission to discharge are as follows, respectively: Self-Care: Eating: 4.36 to 5.30 a change of 0.94, Grooming: 2.38 to 4.06 a change of 1.68, Bathing: 2.09 to 3.30 a change of 1.21, Dressing Upper: 2.89 to 4.19 a change of 1.3, Dressing Lower: 2.19 to 3.79 a
S261
change of 1.6, Toileting: 2.06 to 3.55 a change of 1.49. Sphincter: Bladder: 3.29 to 4.06 a change of 0.77, Bowel: 3.71 to 4.03 a change of 0.32. Mobility and Ambulation: Bed Chair/Wheelchair Transfer: 2.35 to 3.83 a change of 1.48, Toilet Transfer: 2.20 to 3.95 a change of 1.75, Tub Shower Transfer: 1.88 to 2.15 a change of 0.27. Locomotion: Walk/Wheelchair Mobility: 1.07 to 3.24 a change of 1.48, Stairs: 0.65 to 3.17 a change of 2.52. Communication: Comprehension: 4.68 to 5.47 a change of 0.79, Expression: 4.61 to 5.56 a change of 0.95. Social Cognition: Social Interaction: 5.21 to 5.78a change of 0.57, Problem Solving: 3.89 to 4.77 a change of 0.88, Memory: 3.86 to 4.84 a change of 0.98. The averaged, length of stay was 19.3 days. From our patient population 3 were acutely discharged representing 4.5%, 23 were sent to a SNF representing 34.8%, and 40 were sent home representing 60.6%. Conclusions: In this IRB study, utilizing the SDMM to improve FIM scores and increase the discharge rates to home was demonstrated in our target population of CVA, IRF patients. In this study, we showed an improvement for the averaged, discharged, total FIM scores (retrospective value of 66.7 compared to a prospective value of 75.1 representing an increase of 8.4). We may extrapolate that the team approach to patient care ultimately leads to an improvement of patient functional independence measures. Implementing the team approach we were also able to demonstrate a significant decrease in acute discharges; a retrospective value of 15.1% (11 out of 73 patients) compared to a prospective value of 4.5% (3 out of 66 patients). In our study we were also able to significantly increase the rate of discharges to home; a retrospective value of 49.3% (36 out of 73 patients) compared to a prospective value of 60.6% (40 out of 66 patients) an increase of 11.3%. These increases in the averaged, overall FIM scores (increase of 8.4) and an increase of 11.3% in those being discharged to home, demonstrates the advantage of a team approach for improving patient care. The recommendation of a team approach will be suggested with the team consisting of an attending physician, resident physician, case manager, nurse, physical therapist, occupational therapist, social worker, speech pathologist, neuropsychologist, and a vocational rehabilitation specialist. Level of Evidence: Level I Poster 310 EMG Guided Botulinum Toxin Type A Injections for Functional Problems Associated to Congenital Facial Palsy: A Case Report Isabel M. Rutzen, MD (VA Caribbean Healthcare System San Juan, San Juan, Puerto Rico), David Q. Atkins, MD, Keryl Motta, MD Disclosures: Isabel Rutzen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 46-year-old man with congenital right facial palsy who was evaluated by physiatry service since aside from the cosmetic impact of his facial asymmetry, he was experiencing late onset functional problems. He complained of progressive lip inversion causing recurrent biting and discomfort. Physical exam was remarkable for right lip inversion and hypertrophy of the contralateral facial muscles. Decision was made to infiltrate selected left facial muscles with incobotulinum toxin type A to reduce muscle pull on the weaker right side, with functional outcome goals of reducing biting as well as improving facial symmetry. The botulinum toxin was reconstituted with 0.9% normal saline to a concentration of 4U/ 0.1cc. A total of 45U were distributed among selected muscles under EMG guidance. Setting: Tertiary Care Hospital. Results: At 6 weeks post-injection the patient reported favorable outcomes, referring resolution of lip biting and overall satisfaction with improvement in facial symmetry. The patient denied adverse reactions from procedure. Physical exam was pertinent for significant