Poster 412 Paraneoplastic Syndrome Masked by a History of Chronic Alcoholic Neuropathy: A Case Report

PM&R

stimulator leads can achieve successful neuromodulation of the sensory afferents and provide clinically significant reduction in pain and improvement in quality of life.

PRACTICE MANAGEMENT Poster 410 Rehabilitation in Neuroacanthocytosis: A Case Report. Kathya E. Ramos-Vargas (University of Puerto RicoMedical Sciences Campus, San Juan, Puerto Rico); , Edwardo Ramos, MD. Disclosures: K. E. Ramos-Vargas, none. Program Description: A 46-year-old Puerto Rican man with a history of diabetes mellitus type 2, and a family history of neuroacanthocytosis (brother), who, in July 2005, presented with left hemiparesis. Imaging studies, at that time, revealed right basal ganglia ischemic infarction. On September 2007, he presented with new onset seizures that required hospitalization due to status epilepticus for which antiepileptic treatment was given. Soon after, the patient developed progressive choreoathetoid movements in his trunk, with associated poor neck and trunk control. In September 2008, he was admitted to an inpatient rehabilitation center with the diagnosis of neuroacanthocytosis. Setting: Inpatient rehabilitation facility. Results: The patient’s clinical improvement after receiving therapies in an inpatient rehabilitation facility was assessed. The Functional Independence Measurement (FIM) scores on admission and discharge were compared. On admission, the patient was totally dependent in activities of daily living and was not able to ambulate or to use a wheelchair to move across areas. FIM assessment upon discharge (change in FIM scores from admission to discharge date) showed progress in wheelchair mobility (FIM change, 2-5), transfers (FIM change, 3-4), toileting (FIM change, 2-5), eating (FIM change, 2-3), grooming (FIM change, 3-4), dressing (FIM change, 4-5), and bladder control (FIM change, 3-4). Discussion: A description of a specific regimen of therapies in a patient with neuroacanthocytosis has not been made. After receiving a combination of physical, occupational, and speech therapies in an inpatient setting, this patient was able to improve toward his independence in some areas and to maintain a steady state in others. Conclusions: Little is known about neuroacanthocytosis treatment and its rehabilitation process. New studies are still needed to continue expanding our knowledge in neuroacanthocytosis pathophysiology, treatment, and rehabilitation process.

Poster 411 Pre- and Postanalysis of a Lean Six Sigma Quality Improvement Project to Increase Discharge Paperwork Completeness to a Comprehensive Integrated Inpatient Rehabilitation Program. Nathan J. Neufeld, DO (Johns Hopkins University School of Medicine, Baltimore, MD, United States); , Phillippines Cabahug, MD, Marlís González Fernández, MD, PhD, R. Samuel Mayer, MD, Megha Mehta, MHA, Richard L. Powers, BSEE, MBA, Nathaniel Walker. Disclosures: N. J. Neufeld, none. Objective: To determine if implementation of Lean Six Sigma

Vol. 3, Iss. 10S1, 2011

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(LSS) methodology in the health care setting can improve completeness of discharge reports generated for admission to an Comprehensive Integrated Inpatient Rehabilitation Program (CIIRP). We propose that, by using LSS, we will improve the percentage of required elements present in the discharge paperwork before admission to CIIRP. Design: We used LSS methodology (define, measure, analyze, improve, and control [DMAIC]) to improve our discharge paperwork process. Standardized LSS tools SIPOC (suppliers, inputs, process, outputs, and customers) and VOC (voice of the customer) were used. During the standardized improvement phase of LSS, various interventions occurred: education, policy change, and information technology improvements. By using an interdisciplinary team, we defined 8 critical elements necessary in a discharge summary. The presence of these elements in the discharge paperwork was audited at baseline and after implementation of the interventions. We compared the mean proportion of completed elements before and after intervention by using general linear models with marginal effects to account for the range of the data (limited by 0 and 1). Setting: Tertiary care medical center. Participants: 185 charts were audited (42 before intervention and 143 after intervention). Interventions: LSS quality improvement project. Main Outcome Measures: A proportion of elements present in the discharge paperwork. Results: In the preintervention period, on average, 59.6% of required elements were present. After implementation of the LSS project, 94.2% of elements were present. This difference was statistically significant (P⬍.001). Conclusions: By using the systematic approach of the LSS methodology, we improved the proportion of critical elements present in the discharge documentation required before admission to CIIRP by approximately 35%. The use of LSS, a standardized and wellestablished process improvement methodology, can result in significant process improvement in the health care setting.

Poster 412 Paraneoplastic Syndrome Masked by a History of Chronic Alcoholic Neuropathy: A Case Report. Bret L. Burlingame, DO (William Beaumont Hospital, Royal Oak, MI, United States); , Ronald S. Taylor, MD. Disclosures: B. L. Burlingame, none. Patients or Programs: A 69-year-old man with chronic alcoholic neuropathy with superimposed acute inability to ambulate. Program Description: The patient presented with progressive gait instability over 2 months and an inability to ambulate for several days before admission. He was walking independently until 2 months before admission, at which point, he required the use of a rolling walker. He experienced paresthesias below the knees and in bilateral hands. He has a history of alcohol and tobacco abuse. Results of his examination revealed symmetrical decreased sensation below knees and both hands, marked ataxia, no long tract signs, and essentially preserved strength. Setting: Tertiary care hospital, inpatient rehabilitation unit. Results: The diagnosis upon admission to the inpatient rehabilitation unit was alcoholic neuropathy. The rapid onset of weakness was not consistent with alcoholic changes, therefore, a search for an alternate etiology of the weakness ensued. A workup revealed the

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presence of serum anti-Hu antibody. Imaging revealed an enlarged hilar lymph node that was too small to biopsy. Recommended follow-up imaging 3 months later demonstrated a significant increase in the size of the lesion. He was found to have poorly differentiated squamous cell lung carcinoma and subsequently underwent radiation therapy. A follow-up positron emission tomography suggested resolution of the tumor. He is currently able to ambulate well with a walker and is independent with all activities of daily living. Discussion: This is a case of a patient with chronic symptomatic alcoholic neuropathy who presented with acute worsening of neuropathic symptoms secondary to a paraneoplastic syndrome from an occult cancer. A diagnosis of paraneoplastic syndrome facilitated the early treatment of the tumor and resulted in resolution of the paraneoplastic symptoms. Conclusions: This case demonstrates the importance of considering alternate diagnoses when a patient with a preexisting neuropathic condition presents with changes not consistent with the underlying neuropathy.

Poster 413 Human Factors Research to Improve Programming and Variable Drug Dosing for an Intrathecal Drug Delivery System. Sarah Alme, BS (Medtronic Inc, Fridley, MN, United States); , Ajinkya Joglekar, MSBME. Disclosures: S. Alme, none. Objective: The goal was to use Human Factors principles to generate a variable infusion rate (dose) feature while preventing use error for an implanted drug delivery system. Design: Interviews were conducted to identify user needs followed by multiple rounds of usability testing with clinicians. Patients or Programs: Not applicable. Program Description: Not applicable. Setting: Offices (interviews) and simulated clinical environments (usability testing). Participants: Clinicians who implanted and/or managed patients with programmable drug pumps. Interventions: Not applicable. Main Outcome Measures: For critical tasks, the criterion for success was that 100% of the participants must have successfully completed the task after the first attempt. Results: Interviews with 128 clinicians revealed how users think when programming variable infusion rates to manage daily fluctuating therapy needs. Follow-up interviews with 10 clinicians confirmed areas for improvement. During 3 rounds of usability testing with 20 clinicians, the users successfully mapped their infusion plan to a graphic display and established the following capabilities: (1) identify and correct numeric entry errors, (2) proportionally evaluate and visually confirm the infusion pattern, (3) effectively edit individual doses via numeric entry and graphic modification, (4) readily identify the total 24-hour dose for each drug in the reservoir, (5) quickly discern elements of the infusion pattern through color differentiation, and (6) experience greater confidence with the redesigned system. Discussion: Not applicable. Conclusions: Using Human Factors principles, we designed an infusion setup feature that aligns with the way clinicians comprehend and apply varying infusion therapy. Clinicians expressed

PRESENTATIONS

greater confidence in their ability to set up infusion programs, supervise mid level professionals performing infusion setup, and tailor therapy to patients’ variable prescription needs.

Poster 414 The Impact of an Acute Care Hospital’s Active Surveillance Program for Methicillin-resistant Staphylococcus aureus (MRSA) on Clinical Infections With MRSA in an Associated Inpatient Rehabilitation Facility. Aimee Widner, MD (East Carolina University, Greenville, NC, United States); , Clinton E. Faulk, MD, Delores L. Nobles, MT, MPH, Keith M. Ramsey, MD, Paul Vos. Disclosures: A. Widner, none. Objective: To determine how the implementation of a methicillin-resistant Staphylococcus aureus (MRSA) admission screening and decolonization program in an acute care hospital impacted the inpatient rehabilitation facility (IRF) investigated in this study. Design: Retrospective chart review. Setting: Adult IRF located in a tertiary teaching hospital. Participants: Adult patients in the IRF who developed a health care–associated MRSA infection from February 2006 through January 2011. Interventions: In February 2007, the affiliated hospital, Pitt County Memorial Hospital, began screening 100% of admissions for MRSA, with the implementation of decolonization therapy for those who tested positive. Main Outcome Measures: Comparison of monthly MRSA infection rates per 1000 patient days before and after the intervention. Results: The infection rate was lower in the 4 years after the intervention. The mean monthly infection rate before the intervention (February 2006 through January 2007) was 1.2520 per 1000 patient days compared with 0.6772 per 1000 patient days during the years following (February 2007 through January 2011). The decrease in infection rates for health care–associated MRSA after the intervention was statistically significant (P⫽.0255). Conclusions: Based on this study, implementation of an alladmissions MRSA screening and decolonization program of an affiliated hospital resulted in decreased MRSA infection rates in the IRF. Because MRSA infections often have a significantly negative impact on rehabilitation goals, IRFs should not only be cognizant of infection rate trends but also of the affiliated hospital’s scope of policies and practices for infection prevention control.

Poster 415 Introducing the Siebens Domain Management Model in a Physical Medicine and Rehabilitation Residency Program. Mary G. Bryant, MD (University of Virginia Health System, Charlottesville, VA, United States); , Alan Alfano, MD, Hilary C. Siebens, MD. Disclosures: M. G. Bryant, none. Objective: To conduct a pilot study on introducing the Siebens Domain Management Model (SDMM) in a residency program and including it in documentation templates. Design: Programmatic quality improvement project from 2005 through 2007. The SDMM is a conceptual framework for clinical