- Email: [email protected]
Rate of Return to Acute Care Hospital Based on Day and Time of Rehabilitation Admission
Original Research
Rate of Return to Acute Care Hospital Based on Day and Time of Rehabilitation Admission Clinton E. Faulk, MD, Natalie R. Cooper, MD, Judit A. Staneata, MD, Michael P. Bunch, MD, Enrique Galang, MD, Xiangming Fang, PhD, Keith J. Foster, MD Objective: To determine if a patient’s return to the acute care hospital (RTACH) from an inpatient rehabilitation facility (IRF) because of medical acuity is affected by the day of the week and time of rehabilitation admission. Design: Retrospective chart review. Setting: Inpatient rehabilitation facility. Participants: All adult patients admitted to the IRF from January 1, 2009, to June 30, 2011. RTACH was defined as an interruption in the patients’ rehabilitation course as a result of medical and/or surgical complications requiring a higher level of care. The control group was defined as patients who completed an uninterrupted rehabilitation course. The study included 2282 patients (2026 control patients and 256 case patients). Main Outcome Measures: We compared patient demographics, admission impairment groups, discharge diagnosis, admission and discharge Functional Independent Measure (FIM) scores, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. Results: Out of 2282 patients admitted to the IRF over a 30-month period, 256 patients (10.85%) required an RTACH for a higher level of care not available in the IRF. Two statistically significant results were found for RTACH, including rehabilitation admission time and FIM scores (admission motor and cognition scores). Day of the week for inpatient rehabilitation admission was not statistically significant. Conclusion: This study found that the later in the day a patient was admitted to the IRF, the higher the rate of RTACH. In addition, a lower Motor FIM score was found to be correlated with a higher rate of RTACH. Admission day of the week was not found to be statistically significant with regard to the rate of RTACH. Further research is needed to determine the underlying contributing factors that would help decrease the rate of RTACH. PM R 2013;5:757-762
Acute inpatient rehabilitation hospital personnel have experienced an increase in the admissions of medically complex patients in recent years. In addition, pressure is increasing for patients to be admitted to inpatient rehabilitation facilities (IRFs) earlier in the course of their acute hospitalization to help decrease length of stay and reduce hospital costs. Despite prescreening for medical problems that would limit a patient’s ability to fully participate in a comprehensive rehabilitation program, complications still arise during the course of an inpatient rehabilitation stay. When complications are severe enough to warrant an unplanned transfer back to an acute care hospital, this transfer can delay the patient’s overall rehabilitation progress and functional gains. Thus an increasing amount of attention is being devoted to identifying patient factors that may increase the likelihood of a return to the acute care hospital (RTACH). Several studies have documented the rates of RTACH in the general inpatient rehabilitation populations. In a 9-year retrospective study by Carney et al [1], an 8% rate of transfer back to the acute care hospital was found, with the most common reasons for
1934-1482/13/$36.00 Printed in U.S.A.
N.R.C. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose J.A.S. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose M.P.B. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose
INTRODUCTION
PM&R
C.E.F. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC. Address correspondence to: C.E.F.; East Carolina University Department of PM&R, 600 Moye Blvd, Greenville, NC 27834; e-mail: [email protected] Disclosure: nothing to disclose
E.G. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose X.F. East Carolina University, Greenville, NC Disclosure: nothing to disclose K.J.F. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose Peer reviewers and all others who control content have no relevant financial relationships to disclose. Submitted for publication December 12, 2011; revised June 4, 2013; accepted June 6, 2013.
ª 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 757-762, September 2013 http://dx.doi.org/10.1016/j.pmrj.2013.06.002
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transfer being infection and pulmonary complications. Factors that put patients at risk for an acute care transfer were age greater than 64 years, spinal cord injury (SCI), or amputation. Wright et al [2] found an 11.6% rate of emergency transfer to acute care and also found that patients who were judged to have unstable comorbid conditions were at an 81% greater risk for adverse events compared with stable patients. In an earlier study, Siegler et al [3] reported a 14% unplanned transfer to acute care rate, with surgical cases, infection, fever, and thromboembolic events being the most common reasons for transfer. In this study, major risk factors for acute care transfer were a primary diagnosis of deconditioning or nontraumatic SCI, as well as the severity of the initial disability and the number of comorbid conditions. Other studies have focused on specific patient populations within IRFs, with patients who have had a stroke being one of the groups most extensively studied. In a large study, Stineman et al [4] reported an overall 9.1% transfer to acute care rate for patients who had a stroke, with cardiopulmonary arrest and chest pain being the 2 conditions most associated with risk for transfer. In a study by Deshpande et al [5] that looked at patients with traumatic brain injury, it was found that a history of pneumonia or recent surgery during the acute care hospital stay were both significantly associated with unplanned transfer. Alam et al [6] studied patients with a neoplasm and found a significantly higher rate of transfer to the acute care hospital (21%) compared with control patients without a neoplasm in the same rehabilitation facility (9.7%). Infection was the most common reason for transfer to the acute care hospital in the neoplasm group compared with cardiopulmonary factors in the non-neoplasm group. Taken together, these studies indicate that the rate of transfer to the acute care hospital, as well as the reason for the transfer, differs significantly depending on the specific subpopulation of patients undergoing inpatient rehabilitation. Several studies have also looked at the duration of stay before transfer to the acute care hospital from the rehabilitation unit. In the previously cited study by Carney et al [1], it was reported that 22% of all transfers to the acute care hospital occurred within the first 3 days of admission. In an earlier study by Yap et al [7] in a community rehabilitation hospital, it was found that 54% of unplanned transfers to the acute care hospital took place within 3 days of initial admission. In another study performed by Pitts [8], it was found that admitted patients who arrived at the inpatient rehabilitation facility after 4 PM were associated with a higher incidence of medication errors and longer lengths of stay. The primary objective of this study was to investigate whether the day of rehabilitation admission or the specific time of admission predisposes patients to unplanned transfer to the acute care hospital. A secondary objective was to identify demographic, medical, and functional factors that
place patients at increased risk for RTACH. Our study hypothesized that patients admitted to the IRF later in the day would have a greater risk of RTACH when compared with patients admitted earlier in the day. We also hypothesized that patients who were admitted on weekends would have a higher rate of RTACH compared with patients admitted on weekdays. Finally, we hypothesized that patients with lower admission Functional Independent Measure (FIM) scores would have a higher rate of RTACH.
METHODS Retrospective charts were reviewed for all adult admissions to the IRF for a 30-month period (January 2009-June 2011). The inclusion criteria were as follows: all patients older than 18 years admitted to the IRF, including patients admitted from the attached Vidant Medical Center (formerly Pitt County Memorial Hospital) and outside admitted patients from multiple area and regional hospitals. Patients were then classified as RTACH or control based on whether they required transfer to the acute care hospital from the IRF before their planned discharge date. A duration of stay in the IRF that was less than 72 hours from admission prior to RTACH also was noted. For statistical analysis of the study variables, the RTACH rate was calculated by dividing the number of patients who returned to the acute care hospital during a certain day of the week or time of the day by the total number of patients admitted during that same period. The RTACH rate used by eRehabData* is calculated by dividing the number of patients who returned to the acute care hospital by the total number of patients who completed an uninterrupted rehabilitation stay. This calculation was used for the overall RTACH rate during the 30-month period of our study for comparison, with the average weighted RTACH rates provided by eRehabData. RTACH patients were compared with regard to gender, age, day and time of admission, length of stay, admissions from our attached acute care hospital versus admissions from area or regional hospitals, admission impairment groups, discharge diagnosis, and admission and discharge FIM scores (Table 1). The c2 test was used for comparing categorical variables and the t-test or multiple regression analysis was used for comparing continuous variables as appropriate. To further study the effect of admission time on whether a patient returns to an acute care hospital, we fitted a logistic regression model with RTACH (yes/no) as the response and the military time of admission as a continuous predictor. To control for possible confounders, we also included gender, *
eRehabData is an inpatient rehabilitation outcomes system offered to inpatient rehabilitation providers by the American Medical Rehabilitation Providers Association. eRehabData serves as a complete online patient assessment system to assist inpatient rehabilitation facilities in complying with the regulations of the Centers for Medicare and Medicaid Services under the inpatient rehabilitation facility prospective payment system, based on the inpatient rehabilitation facility patient assessment instrument.
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Table 1. Descriptive statistics by patient group
Continuous variables, mean (SD) Age (y) Length of stay (d) Admission FIM Total motor Total cognition Discharge FIM Total motor Total cognition Categorical variables, N (%) Group Gender Female Male Impairment group Brain dysfunction Debility Orthopedic SCI Stroke Other Admission source Inside hospital Outside hospital
Return to Acute Care Hospital
Control
P Value
60.68 (14.10) 10.31 (8.96)
60.00 (17.50) 17.07 (11.89)
.48*
29.14 (10.34) 22.24 (8.54)
35.29 (11.53) <.0001y 24.29 (7.93) .0001y
31.61 (14.13) 22.52 (9.35)
53.54 (13.67) <.0001y 28.54 (6.46) <.0001y
256 (11.22)
2026 (88.78)
125 (11.05) 131 (11.38)
1006 (88.95) 1020 (88.62)
30 52 63 34 39 38
(10.71) (11.40) (11.19) (13.93) (11.82) (9.29)
198 (11.17) 58 (11.39)
.80z
(89.29) (88.60) (88.81) (86.07) (88.18) (90.71)
.62z
1575 (88.83) 451 (88.61)
.89z
250 404 500 210 291 371
SD ¼ standard deviation; FIM ¼ Functional Independent Measure; SCI ¼ spinal cord injury. *Two-sample t-test. y Multiple regression with control for gender and age effects. z 2 c test.
age at admission, day of admission, admission impairment group code, total FIM scores at admission, length of stay, and whether the patient was admitted from our attached acute care hospital (inside admission) or from an area/ regional hospital (outside admission) as predictors (Table 2). All data analysis was carried out using SAS 9.3 (SAS Institute, Cary, NC), and a significance level of .05 was adopted for all statistical tests.
RESULTS Out of 2282 patients admitted to the IRF during a 30-month period, 256 patients required RTACH for a higher level of care and medical management that was not available in the IRF. The RTACH rate for our institution was 10.85%, and the national average RTACH rate was 10.91% (weighted) during this same 30-month period (eRehabData) [9]. The average length of stay for the RTACH group was 10.31 days, and of this group, 57 patients returned in less than 72 hours from rehabilitation admission (22.3%). No statistically significant difference with regard to the day of admission was found among the patients who returned within 72 hours.
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The descriptive statistics by group are shown in Table 1. The 256 patients in the RTACH group were found to be slightly older (60.7 versus 60.0 years old; P ¼ .4830), and they had significantly lower admission and discharge motor and cognition FIM scores when compared with the control group. No significant difference in RTACH rate was found between men and women (11.38% versus 11.05%; P ¼ .8032) or between admissions from our attached acute care hospital (inside hospital) and area/regional hospital admissions (outside hospital) (11.17% versus 11.39%; P ¼ .8861). Discharge diagnoses for RTACH patients were categorized in the following groups: cardiac, electrolyte abnormalities, gastrointestinal, hematology/oncology, infectious, orthopedic, neurologic, respiratory, surgical, vascular, renal, and all other (ie, other medical and surgical complications not previously listed). The top 5 discharge diagnosis categories were respiratory (26.72%), infectious (22.27%), cardiac (10.93%), all other (10.53), and neurologic (8.91). Out of the Prospective Payment System admission impairment group codes, the top 5 impairment groups for RTACH patients were SCI (13.93%), stroke (11.82%), debility (11.40%), orthopedic (11.19%), and brain dysfunction (10.71%). All other remaining impairment groups were included in a sixth category labeled as “other.” No significant differences were found between the RTACH and control groups with regard to impairment groups (P ¼ .6174). Although patients admitted on Fridays and Sundays were noted to have the highest RTACH rates (Figure 1), overall, no statistically significant difference was found regarding admission day of the week (see Table 3). Results from the logistic regression analysis showed that only admission time and total FIM motor score were statistically significant predictors of RTACH (Table 2). A reduced model analysis was then performed by removing the insignificant predictors one at a time from the full regression model. The results of this reduced model showed the same two predictors of RTACH: admission time and total FIM Motor score. The regression coefficient for admission time is positive, suggesting that patients admitted later in the day are more likely to RTACH than are patients admitted earlier in the day. The negative coefficients for the total FIM Motor score may indicate that patients with lower FIM scores at admission are more likely to RTACH.
DISCUSSION This study examined the rates of RTACH from an IRF by analyzing a variety of demographic, logistical, and functional factors, including age, gender, admission impairment groups, discharge diagnosis, admission and discharge FIM scores, admission day of the week, time of admission, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. Although several studies have examined this concept in a similar fashion, they focused on specific populations within
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Table 2. Logistic regression models Full Model Predictor Intercept Gender Female (vs male) Day of admission Tuesday (vs Monday) Wednesday (vs Monday) Thursday (vs Monday) Friday (vs Monday) Saturday (vs Monday) Sunday (vs Monday) Impairment group Brain dysfunction (vs orthopedic) Debility (vs orthopedic) Other (vs orthopedic) SCI (vs orthopedic) Stroke (vs orthopedic) Admission source Inside (vs outside) Time of admission Age at admission Admit FIM total motor Admit FIM total cognition
Regression Coefficient (b) 1.8127 0.0008 0.2209 0.1399 0.2053 0.0372 0.0640 0.8059 0.0929 0.0304 0.2254 0.2385 0.0955 0.0098 0.000026 0.0031 0.0472 0.0070
Reduced Model P Value .0013 .9909 .9909 .4475 .1744 .3784 .2067 .8075 .7980 .0508 .5716 .5977 .8304 .1535 .1590 .5477 .9074 .9074 .0017* .4473 <.0001* .4370
Regression Coefficient (b) 1.8030
P Value .0001
—
—
— — — — — —
— — — — — —
— — — —
— — — —
—
—
0.000025 — 0.0482 —
.0024* — <.0001* —
SCI ¼ spinal cord injury; FIM ¼ Functional Independent Measure. *Significant at .05 level.
an inpatient rehabilitation facility (eg, stroke [4], traumatic brain injury [5], and cancer rehabilitation [6]), whereas this study is unique in its evaluation of a patient population with diverse impairment group codes. Our end points were also different than other studies such as that by Pitts [8], which focused on medication errors and longer lengths of stay in patients admitted after 4 PM. The bivariant analysis found a statistically significant difference in motor and cognition FIM scores of the RTACH group when compared with the control group (Table 1). Further discussion of the significance of FIM scores will be discussed later with the multivariant analysis. No statistically significant differences were found relating to age, gender, impairment group, and admission source (area/regional facility versus our attached acute care hospital). The multivariant analysis showed that admission motor FIM scores was a statistically significant predictor of RTACH (Table 2). Similarly, Chung et al [10] found that lower FIM scores on admission (motor and cognition) were predictive of higher rates of return to the acute care hospital from inpatient rehabilitation in patients who had a stroke. Another negative outcome associated with lower FIM scores was found by Whiting et al [11], with higher FIM scores in patients who had a stroke being a significant positive predictor of survival at 5 years. In light of these findings, we believe that more emphasis should be placed on functional status at the time of rehabilitation consultation, because low admission FIM scores could be a predictor of return to acute rate in our study. In our facility,
functional assessments performed in the acute hospital are not as comprehensive as those performed within our IRF, most likely because of differences in medical acuity and therapy goals, as well as time constraints for acute therapy staff. Thus a future direction for our facility may be to make the acute care functional assessment more equivalent to that performed in the IRF. Our multivariant analysis also showed that admission time was a statistically significant predictor of RTACH. In
Figure 1. Return to acute care hospital (RTACH) rate by time of admission.
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Table 3. Return to acute care hospital rate by day of the week Day of the Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Total Admissions
No. RTACH Admissions RTACH Rate (%)
263 456 467 443 483 140 30
26 48 52 48 60 16 6
9.89 10.53 11.13 10.84 12.42 11.43 20.00
RTACH ¼ return to acute care hospital.
other words, the later in the day that patients were admitted to inpatient rehabilitation, the higher the likelihood of RTACH. This increased likelihood of RTACH for admitted patients who arrive later in the day could have a variety of underlying factors. Although these factors were not specifically measured or analyzed in this pilot study, they may include but are not limited to fatigue of medical staff, reduced number of rehabilitation medical staff on the evening/night shift, transfer of appropriate information (eg, accurate and current discharge summary and medication reconciliation), and inability to obtain information from the discharging team late in the day. The rate of RTACH itself does not appear to be a factor, because our institution’s RTACH rate (10.85%) during this 30-month period was almost identical to the national average (10.91%) (eRehabData) [9]. The multivariant analysis did not show any statistically significant differences regarding age, gender, impairment group, and admission source (area/regional facility versus our attached acute care hospital). The finding that admission time is a predictor for RTACH raises the question of why patients are being admitted later in the day to inpatient rehabilitation, particularly in light of recent research by Pitts [8] that showed increased medication errors and longer lengths of stay in patients admitted after 4 PM. Our analysis showed that 21.9% of all admissions arrived at the IRF after 4 PM (see Figure 1). The time a patient is admitted to the IRF is dependent on multiple factors. These factors include the time required to complete medical and insurance clearance, availability of transport service (for both in-hospital and outside-hospital admissions), room turnover (ie, the time required to clean and prepare a room for a new patient after discharge of another patient), and time delay for the acute hospital team to discharge patients. Thus a future direction for our facility would be to modify factors that may contribute to admissions arriving later in the day. Our study did not show a significant difference in RTACH rate when analyzing for admission day of the week using a logistic regression analysis (Table 2). However, the rate of RTACH was highest for patients admitted on Fridays and Sundays (Table 3). The higher rate of RTACH for patients admitted on Fridays could be related to the fact that our IRF has a higher number of admissions on Fridays. Our attached acute care hospital is classified as a level I trauma center* with a
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high patient census, which could create an increasing need for rehabilitation admissions on Fridays to decrease length of stay in the acute care hospital and off-load many of the acute care services prior to the weekend. The higher RTACH rate for patients admitted on Sundays could be related to some of the aforementioned factors, but it should also be noted that the overall number of Sunday admissions was substantially lower compared with the other days of the week. Other studies have been performed regarding the day and time of acute care hospital admission, with differing results. In a study by Bell and Redelmeier [12], it was discovered that mortality was higher for patients admitted to the acute care hospital on weekends compared with weekdays. However, Khanna et al [13] did not find worse hospitalization-relevant outcomes for admission to medical services on nights or weekends. We also evaluated other variables in our study, including the RTACH rate within 72 hours of admission and discharge diagnosis. Our RTACH rate within 72 hours of admission was 22%, and the two most common discharge diagnosis categories for RTACH patients were respiratory and infectious. Similarly, Carney et al [1] found a 22% rate of transfer within 72 hours and that the most common reasons for early transfers were infection and pulmonary complications. The main limitation of this study is the lack of generalizability. However, to our knowledge, no study has been performed to date to look specifically at how the day and time of admission to inpatient rehabilitation affects a patient’s risk of returning to the acute hospital. In addition, this investigation was an initial pilot study with a data collection period that was limited to a 30-month time frame. Subsequently, the sample sizes are relatively small. A future direction could be to perform a multicenter study with a longer data collection period, which would allow for more robust sample sizes. This approach would also allow us to see if these results are replicable in other inpatient rehabilitation facilities. If the results are replicable, further analysis would be warranted to determine which factors are common across different centers (eg, staffing ratio and differences in the admissions process). Another limitation of this study is that we did not include comorbidities or other measures of medical severity in our data collection or analysis. For the purpose of this pilot study, we elected to start with a broad analysis of age, gender, admission impairment groups, discharge diagnosis, admission and discharge FIM scores, admission day of the week, time of admission, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. A future study as previously described could include collection of additional patient information such as comorbidities to further examine the relationship between time of admission and risk of return to the acute care hospital. *
Vidant Medical Center is designated by the state of North Carolina and verified by the American College of Surgeons as a level I trauma center.
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Although we hypothesize that reduced staffing in the evening and weekend hours may be one factor that contributed to the increased RTACH rate for admissions later in the day, we have not yet been able to collect data to examine this concept. Given that many inpatient rehabilitation hospitals are facing increased pressure to admit patients on a 24-hours-a-day/7-days-a-week basis, further analysis of traditional nursing and physician staffing models may be warranted if our research is replicated in other inpatient rehabilitation facilities.
CONCLUSIONS This study showed statistically significant results with regard to the time of inpatient rehabilitation admission and admission FIM motor score in relation to the likelihood of RTACH. Because these findings may be specific to our institution, additional studies may be warranted to examine these elements at other institutions to determine if these study findings are replicable, as well as to help determine the underlying contributing factors at each institution. However, based on our findings, we recommend consideration of admitting patients earlier in the day to inpatient rehabilitation at our institution, which may also apply to other similar IRFs. It also may be helpful to monitor the number of admissions on certain days of the week, which could be institution-specific with regard to RTACH. One solution may be to distribute the inpatient rehabilitation admissions as evenly as possible throughout the week. Finally, we recommend that emphasis be placed on completion of a more comprehensive assessment of functional status during the rehabilitation consult process in our institution.
ACKNOWLEDGMENTS We thank Paul Heath, Technical Analyst, Rehabilitation Administration, Pitt County Memorial Hospital/Vidant Medical Center, Greenville, NC, for his assistance.
REFERENCES 1. Carney ML, Ullrich P, Esselman P. Early unplanned transfers from inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:453-460; quiz 461-463. 2. Wright RE, Rao N, Smith RM, Harvey RF. Risk factors for death and emergency transfer in acute and subacute inpatient rehabilitation. Arch Phys Med Rehabil 1996;77:1049-1055. 3. Siegler EL, Stineman MG, Maislin G. Development of complications during rehabilitation. Arch Intern Med 1994;154:2185-2190. 4. Stineman MG, Ross R, Maislin G, Fiedler RC, Granger CV. Risks of acute hospital transfer and mortality during stroke rehabilitation. Arch Phys Med Rehabil 2003;84:712-718. 5. Deshpande AA, Millis SR, Zafonte RD, Hammond FM, Wood DL. Risk factors for acute care transfer among traumatic brain injury patients. Arch Phys Med Rehabil 1997;78:350-352. 6. Alam E, Wilson RD, Vargo MM. Inpatient cancer rehabilitation: A retrospective comparison of transfer back to acute care between patients with neoplasm and other rehabilitation patients. Arch Phys Med Rehabil 2008;89:1284-1289. 7. Yap LK, Ow KH, Hui JY, Pang WS. Premature discharge in a community hospital. Singapore Med J 2002;43:470-475. 8. Pitts EP. Medication errors versus time of admission in a subpopulation of stroke patients undergoing inpatient rehabilitation complications and considerations. Top Stroke Rehabil 2011;18:151-153. 9. American Medical Rehabilitation Providers Association. eRehabData. Available at http://erehabdata.com. Accessed June 18, 2013. 10. Chung D, Niewczyk P, DiVita M, Markello S, Granger C. Predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients. Am J Phys Med Rehabil 2012;91:387-392. 11. Whiting R, Shen Q, Hung WT, Cordato D, Chan DK. Predictors for 5year survival in a prospective cohort of elderly stroke patients. Acta Neurol Scand 2011;124:309-316. 12. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001; 345:663-668. 13. Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. The association between night or weekend admission and hospitalization-relevant patient outcomes. J Hosp Med 2011;6:10-14.
This CME activity is designated for 1.0 AMA PRA Category 1 Credit and can be completed online at me.aapmr.org. Log on to www.me.aapmr.org, go to Lifelong Learning (CME) and select Journal-based CME from the drop down menu. This activity is FREE to AAPM&R members and $25 for non-members.
CME Question Which one of the following factors was significantly associated with return to acute care hospital (RTACH) in this study? a. b. c. d.
time of admission diagnostic related group day of the week source of admission
Answer online at me.aapmr.org
Rate of Return to Acute Care Hospital Based on Day and Time of Rehabilitation Admission Clinton E. Faulk, MD, Natalie R. Cooper, MD, Judit A. Staneata, MD, Michael P. Bunch, MD, Enrique Galang, MD, Xiangming Fang, PhD, Keith J. Foster, MD Objective: To determine if a patient’s return to the acute care hospital (RTACH) from an inpatient rehabilitation facility (IRF) because of medical acuity is affected by the day of the week and time of rehabilitation admission. Design: Retrospective chart review. Setting: Inpatient rehabilitation facility. Participants: All adult patients admitted to the IRF from January 1, 2009, to June 30, 2011. RTACH was defined as an interruption in the patients’ rehabilitation course as a result of medical and/or surgical complications requiring a higher level of care. The control group was defined as patients who completed an uninterrupted rehabilitation course. The study included 2282 patients (2026 control patients and 256 case patients). Main Outcome Measures: We compared patient demographics, admission impairment groups, discharge diagnosis, admission and discharge Functional Independent Measure (FIM) scores, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. Results: Out of 2282 patients admitted to the IRF over a 30-month period, 256 patients (10.85%) required an RTACH for a higher level of care not available in the IRF. Two statistically significant results were found for RTACH, including rehabilitation admission time and FIM scores (admission motor and cognition scores). Day of the week for inpatient rehabilitation admission was not statistically significant. Conclusion: This study found that the later in the day a patient was admitted to the IRF, the higher the rate of RTACH. In addition, a lower Motor FIM score was found to be correlated with a higher rate of RTACH. Admission day of the week was not found to be statistically significant with regard to the rate of RTACH. Further research is needed to determine the underlying contributing factors that would help decrease the rate of RTACH. PM R 2013;5:757-762
Acute inpatient rehabilitation hospital personnel have experienced an increase in the admissions of medically complex patients in recent years. In addition, pressure is increasing for patients to be admitted to inpatient rehabilitation facilities (IRFs) earlier in the course of their acute hospitalization to help decrease length of stay and reduce hospital costs. Despite prescreening for medical problems that would limit a patient’s ability to fully participate in a comprehensive rehabilitation program, complications still arise during the course of an inpatient rehabilitation stay. When complications are severe enough to warrant an unplanned transfer back to an acute care hospital, this transfer can delay the patient’s overall rehabilitation progress and functional gains. Thus an increasing amount of attention is being devoted to identifying patient factors that may increase the likelihood of a return to the acute care hospital (RTACH). Several studies have documented the rates of RTACH in the general inpatient rehabilitation populations. In a 9-year retrospective study by Carney et al [1], an 8% rate of transfer back to the acute care hospital was found, with the most common reasons for
1934-1482/13/$36.00 Printed in U.S.A.
N.R.C. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose J.A.S. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose M.P.B. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose
INTRODUCTION
PM&R
C.E.F. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC. Address correspondence to: C.E.F.; East Carolina University Department of PM&R, 600 Moye Blvd, Greenville, NC 27834; e-mail: [email protected] Disclosure: nothing to disclose
E.G. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose X.F. East Carolina University, Greenville, NC Disclosure: nothing to disclose K.J.F. East Carolina University and Pitt County Memorial Hospital / Vidant Medical Center, Greenville, NC Disclosure: nothing to disclose Peer reviewers and all others who control content have no relevant financial relationships to disclose. Submitted for publication December 12, 2011; revised June 4, 2013; accepted June 6, 2013.
ª 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 757-762, September 2013 http://dx.doi.org/10.1016/j.pmrj.2013.06.002
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transfer being infection and pulmonary complications. Factors that put patients at risk for an acute care transfer were age greater than 64 years, spinal cord injury (SCI), or amputation. Wright et al [2] found an 11.6% rate of emergency transfer to acute care and also found that patients who were judged to have unstable comorbid conditions were at an 81% greater risk for adverse events compared with stable patients. In an earlier study, Siegler et al [3] reported a 14% unplanned transfer to acute care rate, with surgical cases, infection, fever, and thromboembolic events being the most common reasons for transfer. In this study, major risk factors for acute care transfer were a primary diagnosis of deconditioning or nontraumatic SCI, as well as the severity of the initial disability and the number of comorbid conditions. Other studies have focused on specific patient populations within IRFs, with patients who have had a stroke being one of the groups most extensively studied. In a large study, Stineman et al [4] reported an overall 9.1% transfer to acute care rate for patients who had a stroke, with cardiopulmonary arrest and chest pain being the 2 conditions most associated with risk for transfer. In a study by Deshpande et al [5] that looked at patients with traumatic brain injury, it was found that a history of pneumonia or recent surgery during the acute care hospital stay were both significantly associated with unplanned transfer. Alam et al [6] studied patients with a neoplasm and found a significantly higher rate of transfer to the acute care hospital (21%) compared with control patients without a neoplasm in the same rehabilitation facility (9.7%). Infection was the most common reason for transfer to the acute care hospital in the neoplasm group compared with cardiopulmonary factors in the non-neoplasm group. Taken together, these studies indicate that the rate of transfer to the acute care hospital, as well as the reason for the transfer, differs significantly depending on the specific subpopulation of patients undergoing inpatient rehabilitation. Several studies have also looked at the duration of stay before transfer to the acute care hospital from the rehabilitation unit. In the previously cited study by Carney et al [1], it was reported that 22% of all transfers to the acute care hospital occurred within the first 3 days of admission. In an earlier study by Yap et al [7] in a community rehabilitation hospital, it was found that 54% of unplanned transfers to the acute care hospital took place within 3 days of initial admission. In another study performed by Pitts [8], it was found that admitted patients who arrived at the inpatient rehabilitation facility after 4 PM were associated with a higher incidence of medication errors and longer lengths of stay. The primary objective of this study was to investigate whether the day of rehabilitation admission or the specific time of admission predisposes patients to unplanned transfer to the acute care hospital. A secondary objective was to identify demographic, medical, and functional factors that
place patients at increased risk for RTACH. Our study hypothesized that patients admitted to the IRF later in the day would have a greater risk of RTACH when compared with patients admitted earlier in the day. We also hypothesized that patients who were admitted on weekends would have a higher rate of RTACH compared with patients admitted on weekdays. Finally, we hypothesized that patients with lower admission Functional Independent Measure (FIM) scores would have a higher rate of RTACH.
METHODS Retrospective charts were reviewed for all adult admissions to the IRF for a 30-month period (January 2009-June 2011). The inclusion criteria were as follows: all patients older than 18 years admitted to the IRF, including patients admitted from the attached Vidant Medical Center (formerly Pitt County Memorial Hospital) and outside admitted patients from multiple area and regional hospitals. Patients were then classified as RTACH or control based on whether they required transfer to the acute care hospital from the IRF before their planned discharge date. A duration of stay in the IRF that was less than 72 hours from admission prior to RTACH also was noted. For statistical analysis of the study variables, the RTACH rate was calculated by dividing the number of patients who returned to the acute care hospital during a certain day of the week or time of the day by the total number of patients admitted during that same period. The RTACH rate used by eRehabData* is calculated by dividing the number of patients who returned to the acute care hospital by the total number of patients who completed an uninterrupted rehabilitation stay. This calculation was used for the overall RTACH rate during the 30-month period of our study for comparison, with the average weighted RTACH rates provided by eRehabData. RTACH patients were compared with regard to gender, age, day and time of admission, length of stay, admissions from our attached acute care hospital versus admissions from area or regional hospitals, admission impairment groups, discharge diagnosis, and admission and discharge FIM scores (Table 1). The c2 test was used for comparing categorical variables and the t-test or multiple regression analysis was used for comparing continuous variables as appropriate. To further study the effect of admission time on whether a patient returns to an acute care hospital, we fitted a logistic regression model with RTACH (yes/no) as the response and the military time of admission as a continuous predictor. To control for possible confounders, we also included gender, *
eRehabData is an inpatient rehabilitation outcomes system offered to inpatient rehabilitation providers by the American Medical Rehabilitation Providers Association. eRehabData serves as a complete online patient assessment system to assist inpatient rehabilitation facilities in complying with the regulations of the Centers for Medicare and Medicaid Services under the inpatient rehabilitation facility prospective payment system, based on the inpatient rehabilitation facility patient assessment instrument.
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Table 1. Descriptive statistics by patient group
Continuous variables, mean (SD) Age (y) Length of stay (d) Admission FIM Total motor Total cognition Discharge FIM Total motor Total cognition Categorical variables, N (%) Group Gender Female Male Impairment group Brain dysfunction Debility Orthopedic SCI Stroke Other Admission source Inside hospital Outside hospital
Return to Acute Care Hospital
Control
P Value
60.68 (14.10) 10.31 (8.96)
60.00 (17.50) 17.07 (11.89)
.48*
29.14 (10.34) 22.24 (8.54)
35.29 (11.53) <.0001y 24.29 (7.93) .0001y
31.61 (14.13) 22.52 (9.35)
53.54 (13.67) <.0001y 28.54 (6.46) <.0001y
256 (11.22)
2026 (88.78)
125 (11.05) 131 (11.38)
1006 (88.95) 1020 (88.62)
30 52 63 34 39 38
(10.71) (11.40) (11.19) (13.93) (11.82) (9.29)
198 (11.17) 58 (11.39)
.80z
(89.29) (88.60) (88.81) (86.07) (88.18) (90.71)
.62z
1575 (88.83) 451 (88.61)
.89z
250 404 500 210 291 371
SD ¼ standard deviation; FIM ¼ Functional Independent Measure; SCI ¼ spinal cord injury. *Two-sample t-test. y Multiple regression with control for gender and age effects. z 2 c test.
age at admission, day of admission, admission impairment group code, total FIM scores at admission, length of stay, and whether the patient was admitted from our attached acute care hospital (inside admission) or from an area/ regional hospital (outside admission) as predictors (Table 2). All data analysis was carried out using SAS 9.3 (SAS Institute, Cary, NC), and a significance level of .05 was adopted for all statistical tests.
RESULTS Out of 2282 patients admitted to the IRF during a 30-month period, 256 patients required RTACH for a higher level of care and medical management that was not available in the IRF. The RTACH rate for our institution was 10.85%, and the national average RTACH rate was 10.91% (weighted) during this same 30-month period (eRehabData) [9]. The average length of stay for the RTACH group was 10.31 days, and of this group, 57 patients returned in less than 72 hours from rehabilitation admission (22.3%). No statistically significant difference with regard to the day of admission was found among the patients who returned within 72 hours.
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The descriptive statistics by group are shown in Table 1. The 256 patients in the RTACH group were found to be slightly older (60.7 versus 60.0 years old; P ¼ .4830), and they had significantly lower admission and discharge motor and cognition FIM scores when compared with the control group. No significant difference in RTACH rate was found between men and women (11.38% versus 11.05%; P ¼ .8032) or between admissions from our attached acute care hospital (inside hospital) and area/regional hospital admissions (outside hospital) (11.17% versus 11.39%; P ¼ .8861). Discharge diagnoses for RTACH patients were categorized in the following groups: cardiac, electrolyte abnormalities, gastrointestinal, hematology/oncology, infectious, orthopedic, neurologic, respiratory, surgical, vascular, renal, and all other (ie, other medical and surgical complications not previously listed). The top 5 discharge diagnosis categories were respiratory (26.72%), infectious (22.27%), cardiac (10.93%), all other (10.53), and neurologic (8.91). Out of the Prospective Payment System admission impairment group codes, the top 5 impairment groups for RTACH patients were SCI (13.93%), stroke (11.82%), debility (11.40%), orthopedic (11.19%), and brain dysfunction (10.71%). All other remaining impairment groups were included in a sixth category labeled as “other.” No significant differences were found between the RTACH and control groups with regard to impairment groups (P ¼ .6174). Although patients admitted on Fridays and Sundays were noted to have the highest RTACH rates (Figure 1), overall, no statistically significant difference was found regarding admission day of the week (see Table 3). Results from the logistic regression analysis showed that only admission time and total FIM motor score were statistically significant predictors of RTACH (Table 2). A reduced model analysis was then performed by removing the insignificant predictors one at a time from the full regression model. The results of this reduced model showed the same two predictors of RTACH: admission time and total FIM Motor score. The regression coefficient for admission time is positive, suggesting that patients admitted later in the day are more likely to RTACH than are patients admitted earlier in the day. The negative coefficients for the total FIM Motor score may indicate that patients with lower FIM scores at admission are more likely to RTACH.
DISCUSSION This study examined the rates of RTACH from an IRF by analyzing a variety of demographic, logistical, and functional factors, including age, gender, admission impairment groups, discharge diagnosis, admission and discharge FIM scores, admission day of the week, time of admission, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. Although several studies have examined this concept in a similar fashion, they focused on specific populations within
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Table 2. Logistic regression models Full Model Predictor Intercept Gender Female (vs male) Day of admission Tuesday (vs Monday) Wednesday (vs Monday) Thursday (vs Monday) Friday (vs Monday) Saturday (vs Monday) Sunday (vs Monday) Impairment group Brain dysfunction (vs orthopedic) Debility (vs orthopedic) Other (vs orthopedic) SCI (vs orthopedic) Stroke (vs orthopedic) Admission source Inside (vs outside) Time of admission Age at admission Admit FIM total motor Admit FIM total cognition
Regression Coefficient (b) 1.8127 0.0008 0.2209 0.1399 0.2053 0.0372 0.0640 0.8059 0.0929 0.0304 0.2254 0.2385 0.0955 0.0098 0.000026 0.0031 0.0472 0.0070
Reduced Model P Value .0013 .9909 .9909 .4475 .1744 .3784 .2067 .8075 .7980 .0508 .5716 .5977 .8304 .1535 .1590 .5477 .9074 .9074 .0017* .4473 <.0001* .4370
Regression Coefficient (b) 1.8030
P Value .0001
—
—
— — — — — —
— — — — — —
— — — —
— — — —
—
—
0.000025 — 0.0482 —
.0024* — <.0001* —
SCI ¼ spinal cord injury; FIM ¼ Functional Independent Measure. *Significant at .05 level.
an inpatient rehabilitation facility (eg, stroke [4], traumatic brain injury [5], and cancer rehabilitation [6]), whereas this study is unique in its evaluation of a patient population with diverse impairment group codes. Our end points were also different than other studies such as that by Pitts [8], which focused on medication errors and longer lengths of stay in patients admitted after 4 PM. The bivariant analysis found a statistically significant difference in motor and cognition FIM scores of the RTACH group when compared with the control group (Table 1). Further discussion of the significance of FIM scores will be discussed later with the multivariant analysis. No statistically significant differences were found relating to age, gender, impairment group, and admission source (area/regional facility versus our attached acute care hospital). The multivariant analysis showed that admission motor FIM scores was a statistically significant predictor of RTACH (Table 2). Similarly, Chung et al [10] found that lower FIM scores on admission (motor and cognition) were predictive of higher rates of return to the acute care hospital from inpatient rehabilitation in patients who had a stroke. Another negative outcome associated with lower FIM scores was found by Whiting et al [11], with higher FIM scores in patients who had a stroke being a significant positive predictor of survival at 5 years. In light of these findings, we believe that more emphasis should be placed on functional status at the time of rehabilitation consultation, because low admission FIM scores could be a predictor of return to acute rate in our study. In our facility,
functional assessments performed in the acute hospital are not as comprehensive as those performed within our IRF, most likely because of differences in medical acuity and therapy goals, as well as time constraints for acute therapy staff. Thus a future direction for our facility may be to make the acute care functional assessment more equivalent to that performed in the IRF. Our multivariant analysis also showed that admission time was a statistically significant predictor of RTACH. In
Figure 1. Return to acute care hospital (RTACH) rate by time of admission.
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Table 3. Return to acute care hospital rate by day of the week Day of the Week Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Total Admissions
No. RTACH Admissions RTACH Rate (%)
263 456 467 443 483 140 30
26 48 52 48 60 16 6
9.89 10.53 11.13 10.84 12.42 11.43 20.00
RTACH ¼ return to acute care hospital.
other words, the later in the day that patients were admitted to inpatient rehabilitation, the higher the likelihood of RTACH. This increased likelihood of RTACH for admitted patients who arrive later in the day could have a variety of underlying factors. Although these factors were not specifically measured or analyzed in this pilot study, they may include but are not limited to fatigue of medical staff, reduced number of rehabilitation medical staff on the evening/night shift, transfer of appropriate information (eg, accurate and current discharge summary and medication reconciliation), and inability to obtain information from the discharging team late in the day. The rate of RTACH itself does not appear to be a factor, because our institution’s RTACH rate (10.85%) during this 30-month period was almost identical to the national average (10.91%) (eRehabData) [9]. The multivariant analysis did not show any statistically significant differences regarding age, gender, impairment group, and admission source (area/regional facility versus our attached acute care hospital). The finding that admission time is a predictor for RTACH raises the question of why patients are being admitted later in the day to inpatient rehabilitation, particularly in light of recent research by Pitts [8] that showed increased medication errors and longer lengths of stay in patients admitted after 4 PM. Our analysis showed that 21.9% of all admissions arrived at the IRF after 4 PM (see Figure 1). The time a patient is admitted to the IRF is dependent on multiple factors. These factors include the time required to complete medical and insurance clearance, availability of transport service (for both in-hospital and outside-hospital admissions), room turnover (ie, the time required to clean and prepare a room for a new patient after discharge of another patient), and time delay for the acute hospital team to discharge patients. Thus a future direction for our facility would be to modify factors that may contribute to admissions arriving later in the day. Our study did not show a significant difference in RTACH rate when analyzing for admission day of the week using a logistic regression analysis (Table 2). However, the rate of RTACH was highest for patients admitted on Fridays and Sundays (Table 3). The higher rate of RTACH for patients admitted on Fridays could be related to the fact that our IRF has a higher number of admissions on Fridays. Our attached acute care hospital is classified as a level I trauma center* with a
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high patient census, which could create an increasing need for rehabilitation admissions on Fridays to decrease length of stay in the acute care hospital and off-load many of the acute care services prior to the weekend. The higher RTACH rate for patients admitted on Sundays could be related to some of the aforementioned factors, but it should also be noted that the overall number of Sunday admissions was substantially lower compared with the other days of the week. Other studies have been performed regarding the day and time of acute care hospital admission, with differing results. In a study by Bell and Redelmeier [12], it was discovered that mortality was higher for patients admitted to the acute care hospital on weekends compared with weekdays. However, Khanna et al [13] did not find worse hospitalization-relevant outcomes for admission to medical services on nights or weekends. We also evaluated other variables in our study, including the RTACH rate within 72 hours of admission and discharge diagnosis. Our RTACH rate within 72 hours of admission was 22%, and the two most common discharge diagnosis categories for RTACH patients were respiratory and infectious. Similarly, Carney et al [1] found a 22% rate of transfer within 72 hours and that the most common reasons for early transfers were infection and pulmonary complications. The main limitation of this study is the lack of generalizability. However, to our knowledge, no study has been performed to date to look specifically at how the day and time of admission to inpatient rehabilitation affects a patient’s risk of returning to the acute hospital. In addition, this investigation was an initial pilot study with a data collection period that was limited to a 30-month time frame. Subsequently, the sample sizes are relatively small. A future direction could be to perform a multicenter study with a longer data collection period, which would allow for more robust sample sizes. This approach would also allow us to see if these results are replicable in other inpatient rehabilitation facilities. If the results are replicable, further analysis would be warranted to determine which factors are common across different centers (eg, staffing ratio and differences in the admissions process). Another limitation of this study is that we did not include comorbidities or other measures of medical severity in our data collection or analysis. For the purpose of this pilot study, we elected to start with a broad analysis of age, gender, admission impairment groups, discharge diagnosis, admission and discharge FIM scores, admission day of the week, time of admission, length of stay, attached hospital versus outside hospital admissions, and RTACH rates between case patients and control patients. A future study as previously described could include collection of additional patient information such as comorbidities to further examine the relationship between time of admission and risk of return to the acute care hospital. *
Vidant Medical Center is designated by the state of North Carolina and verified by the American College of Surgeons as a level I trauma center.
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Although we hypothesize that reduced staffing in the evening and weekend hours may be one factor that contributed to the increased RTACH rate for admissions later in the day, we have not yet been able to collect data to examine this concept. Given that many inpatient rehabilitation hospitals are facing increased pressure to admit patients on a 24-hours-a-day/7-days-a-week basis, further analysis of traditional nursing and physician staffing models may be warranted if our research is replicated in other inpatient rehabilitation facilities.
CONCLUSIONS This study showed statistically significant results with regard to the time of inpatient rehabilitation admission and admission FIM motor score in relation to the likelihood of RTACH. Because these findings may be specific to our institution, additional studies may be warranted to examine these elements at other institutions to determine if these study findings are replicable, as well as to help determine the underlying contributing factors at each institution. However, based on our findings, we recommend consideration of admitting patients earlier in the day to inpatient rehabilitation at our institution, which may also apply to other similar IRFs. It also may be helpful to monitor the number of admissions on certain days of the week, which could be institution-specific with regard to RTACH. One solution may be to distribute the inpatient rehabilitation admissions as evenly as possible throughout the week. Finally, we recommend that emphasis be placed on completion of a more comprehensive assessment of functional status during the rehabilitation consult process in our institution.
ACKNOWLEDGMENTS We thank Paul Heath, Technical Analyst, Rehabilitation Administration, Pitt County Memorial Hospital/Vidant Medical Center, Greenville, NC, for his assistance.
REFERENCES 1. Carney ML, Ullrich P, Esselman P. Early unplanned transfers from inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:453-460; quiz 461-463. 2. Wright RE, Rao N, Smith RM, Harvey RF. Risk factors for death and emergency transfer in acute and subacute inpatient rehabilitation. Arch Phys Med Rehabil 1996;77:1049-1055. 3. Siegler EL, Stineman MG, Maislin G. Development of complications during rehabilitation. Arch Intern Med 1994;154:2185-2190. 4. Stineman MG, Ross R, Maislin G, Fiedler RC, Granger CV. Risks of acute hospital transfer and mortality during stroke rehabilitation. Arch Phys Med Rehabil 2003;84:712-718. 5. Deshpande AA, Millis SR, Zafonte RD, Hammond FM, Wood DL. Risk factors for acute care transfer among traumatic brain injury patients. Arch Phys Med Rehabil 1997;78:350-352. 6. Alam E, Wilson RD, Vargo MM. Inpatient cancer rehabilitation: A retrospective comparison of transfer back to acute care between patients with neoplasm and other rehabilitation patients. Arch Phys Med Rehabil 2008;89:1284-1289. 7. Yap LK, Ow KH, Hui JY, Pang WS. Premature discharge in a community hospital. Singapore Med J 2002;43:470-475. 8. Pitts EP. Medication errors versus time of admission in a subpopulation of stroke patients undergoing inpatient rehabilitation complications and considerations. Top Stroke Rehabil 2011;18:151-153. 9. American Medical Rehabilitation Providers Association. eRehabData. Available at http://erehabdata.com. Accessed June 18, 2013. 10. Chung D, Niewczyk P, DiVita M, Markello S, Granger C. Predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients. Am J Phys Med Rehabil 2012;91:387-392. 11. Whiting R, Shen Q, Hung WT, Cordato D, Chan DK. Predictors for 5year survival in a prospective cohort of elderly stroke patients. Acta Neurol Scand 2011;124:309-316. 12. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001; 345:663-668. 13. Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. The association between night or weekend admission and hospitalization-relevant patient outcomes. J Hosp Med 2011;6:10-14.
This CME activity is designated for 1.0 AMA PRA Category 1 Credit and can be completed online at me.aapmr.org. Log on to www.me.aapmr.org, go to Lifelong Learning (CME) and select Journal-based CME from the drop down menu. This activity is FREE to AAPM&R members and $25 for non-members.
CME Question Which one of the following factors was significantly associated with return to acute care hospital (RTACH) in this study? a. b. c. d.
time of admission diagnostic related group day of the week source of admission
Answer online at me.aapmr.org