- Email: [email protected]
Reducing Post-Hospital Syndrome: A Quality Improvement (QI) Project
PM&R
Furthermore, the event had a positive impact on individuals at each level of amputation along all metrics evaluated using PIADS with the upper extremity level showing the largest increase in competence, adaptability and self esteem. Conclusions: There is no scientific literature on amputees participating in adaptive motor sports in rehabilitation, despite their ability to participate using assistive technology. We showed that using appropriate safety measures, training and assistive technology, amputees can participate in adaptive motor sports with profound effects. This provides a unique perspective to addressing psychological issues using assistive technology. Further study is needed to better understand adaptive motor sports in rehabilitation following amputation. Poster 16 Use of Botulinum Toxin Type A to Improve Severe Cervical Dystonia Prior to Replacement of Broken Cervical Fixation Hardware: A Case Report. Ryan K. Murphy, DO (Sinai Hospital, Baltimore, MD, United States); Michael D. Stubblefield, MD. Disclosures: R. K. Murphy, No Disclosures: I Have Nothing To Disclose. Case Description: Cervical chordoma originally resected 10/97. Recurrence re-resected in 10/2001 and stabilized with occipital to cervical fusion followed by 4600 cGy of radiation. Third recurrence in 2005 resected and radiated with proton beams. Fourth recurrence resected in 3/2008. Fifth recurrence treated with single fraction radiation from C1 to C4 with 2400cGy in 4/2009. She developed multiple complications of disease, surgery, and radiation including dysphonia, dysphagia requiring PEG tube, and multiple cranial neuropathies (CN VII, IX, XI, XII) with severe cervical dystonia with chin on chest deformity and torticollis to the right. In 4/2012 she broke her cervical instrumentation hardware requiring surgical replacement. Rehabilitation medicine was asked to utilize botulinum toxin injections prior to surgery to facilitate head positioning and successful fixation. Setting: Outpatient cancer rehabilitation clinic. Results or Clinical Course: The bilateral scalene and sternocleidomastoid muscles were injected with a total of 200 units of botulinum toxin type A (100 units each side). Nine days later the patient improved markedly and successfully underwent re-instrumentation from occiput to T4 with realignment of sagittal and coronal balance. Patient was later discharged without complication. Discussion: An exhaustive literature search could find no documented cases of the use of botulinum toxin to facilitate surgical instrumentation in patients with severe cervical dystonia. The severity of this patient’s cervical dystonia is likely due to radiation fibrosis syndrome, her cervical chordoma, and scar tissue formation secondary to multiple surgeries for the recurrent chordoma. Conclusions: Botulinum toxin injections can be used to acutely mitigate the effects of radiation-induced cervical dystonia prior to surgery in selected cases. Poster 19 Reducing Post-Hospital Syndrome: A Quality Improvement (QI) Project. Levan Atanelov, MD, MS (Hopkins, Baltimore, MD, United States); Michael Friedman, PT, MBA; R. Samuel Mayer, MD; Erik Hoyer, MD.
Vol. 5, Iss. 9S, 2013
S145
Disclosures: L. Atanelov, No Disclosures: I Have Nothing To Disclose. Objective: To implement an interdisciplinary early activity and mobility QI program for patients during the hospital stay. Design: Prospective, observational study. Setting: 2 inpatient general internal medical units in a large academic center Participants: An interdisciplinary team of administration, physicians, nurses, and rehabilitation therapists. Interventions: The Johns Hopkins Translating Research into Practice QI model was used to: a) Assess provider knowledge, attitudes, behaviors, and barriers towards patient mobility, and cultural change over time; b) Mobilize patients to out-of-bed or ambulating 3 times daily; c) Develop a method for nurses to document 3 times daily the highest level of activity patients achieved; d) Develop training sessions to create nursing super-users to safely mobilize patients and, later, nurse-to-nurse training; e) Implement daily huddles between rehabilitation therapists and nurses to discuss 3 points on each patient: i) what activity did the patient do?; ii) what barriers does the patient have to be mobilized?; iii) How can activity with patient continue to progress?; f) Educate physicians, nursing, and therapists to engage patient/family in mobility. Main Outcome Measures: Survey results at baseline and 12 months into project. Compliance rates with documenting highest level of activity for patients 3 times daily. Longitudinal assessment of highest level of activity scores for patients on the unit. Results or Clinical Course: Baseline survey showed that 90% of nurses believe mobilizing their patients at least 3 times daily will improve their outcomes. Barriers identified by survey included deficiencies in prior nursing training to safely mobilize patients (45%), lack of furnishings/equipment to safely mobilize patients (78%), and perception that patients will be resistant to mobility (86%). 3 weeks into project implementation, nurses were documenting the highest level of activity for 95-100% of patients. Conclusions: Active prevention of deconditioning during acute hospitalization will be a valuable tool to improve clinical outcomes and prevent avoidable complications. Using an interdisciplinary approach and well defined QI model, physical medicine and rehabilitation can take a lead role to implement an early activity and mobility program in hospitalized patients. Poster 20 Satisfaction With Botulinum Toxin Treatment in PostStroke Spasticity: Results From a Cross-Sectional Patient and Physician Survey. Djamel Bensmail (Hôpital R. Poincaré (AP-HP), Garches, France); Angelika Hanschmann. Disclosures: D. Bensmail, Consulting fees or other remuneration (payment): Merz, Allergan, Ipsen, Medtronic, Almirall Objective: To evaluate patient and physician satisfaction with botulinum toxin treatment in patients with post-stroke spasticity. Design: International, cross-sectional structured survey conducted in Germany, France, the USA, and Canada. Setting: Clinical practice. Participants: Adult patients (18 years) with post-stroke spasticity treated with 2 injection cycles of onabotulinumtoxinA (BotoxÒ) or abobotulinumtoxinA (DysportÒ), and the physicians who treated them. Interventions: Patient and physician questionnaire.
Furthermore, the event had a positive impact on individuals at each level of amputation along all metrics evaluated using PIADS with the upper extremity level showing the largest increase in competence, adaptability and self esteem. Conclusions: There is no scientific literature on amputees participating in adaptive motor sports in rehabilitation, despite their ability to participate using assistive technology. We showed that using appropriate safety measures, training and assistive technology, amputees can participate in adaptive motor sports with profound effects. This provides a unique perspective to addressing psychological issues using assistive technology. Further study is needed to better understand adaptive motor sports in rehabilitation following amputation. Poster 16 Use of Botulinum Toxin Type A to Improve Severe Cervical Dystonia Prior to Replacement of Broken Cervical Fixation Hardware: A Case Report. Ryan K. Murphy, DO (Sinai Hospital, Baltimore, MD, United States); Michael D. Stubblefield, MD. Disclosures: R. K. Murphy, No Disclosures: I Have Nothing To Disclose. Case Description: Cervical chordoma originally resected 10/97. Recurrence re-resected in 10/2001 and stabilized with occipital to cervical fusion followed by 4600 cGy of radiation. Third recurrence in 2005 resected and radiated with proton beams. Fourth recurrence resected in 3/2008. Fifth recurrence treated with single fraction radiation from C1 to C4 with 2400cGy in 4/2009. She developed multiple complications of disease, surgery, and radiation including dysphonia, dysphagia requiring PEG tube, and multiple cranial neuropathies (CN VII, IX, XI, XII) with severe cervical dystonia with chin on chest deformity and torticollis to the right. In 4/2012 she broke her cervical instrumentation hardware requiring surgical replacement. Rehabilitation medicine was asked to utilize botulinum toxin injections prior to surgery to facilitate head positioning and successful fixation. Setting: Outpatient cancer rehabilitation clinic. Results or Clinical Course: The bilateral scalene and sternocleidomastoid muscles were injected with a total of 200 units of botulinum toxin type A (100 units each side). Nine days later the patient improved markedly and successfully underwent re-instrumentation from occiput to T4 with realignment of sagittal and coronal balance. Patient was later discharged without complication. Discussion: An exhaustive literature search could find no documented cases of the use of botulinum toxin to facilitate surgical instrumentation in patients with severe cervical dystonia. The severity of this patient’s cervical dystonia is likely due to radiation fibrosis syndrome, her cervical chordoma, and scar tissue formation secondary to multiple surgeries for the recurrent chordoma. Conclusions: Botulinum toxin injections can be used to acutely mitigate the effects of radiation-induced cervical dystonia prior to surgery in selected cases. Poster 19 Reducing Post-Hospital Syndrome: A Quality Improvement (QI) Project. Levan Atanelov, MD, MS (Hopkins, Baltimore, MD, United States); Michael Friedman, PT, MBA; R. Samuel Mayer, MD; Erik Hoyer, MD.
Vol. 5, Iss. 9S, 2013
S145
Disclosures: L. Atanelov, No Disclosures: I Have Nothing To Disclose. Objective: To implement an interdisciplinary early activity and mobility QI program for patients during the hospital stay. Design: Prospective, observational study. Setting: 2 inpatient general internal medical units in a large academic center Participants: An interdisciplinary team of administration, physicians, nurses, and rehabilitation therapists. Interventions: The Johns Hopkins Translating Research into Practice QI model was used to: a) Assess provider knowledge, attitudes, behaviors, and barriers towards patient mobility, and cultural change over time; b) Mobilize patients to out-of-bed or ambulating 3 times daily; c) Develop a method for nurses to document 3 times daily the highest level of activity patients achieved; d) Develop training sessions to create nursing super-users to safely mobilize patients and, later, nurse-to-nurse training; e) Implement daily huddles between rehabilitation therapists and nurses to discuss 3 points on each patient: i) what activity did the patient do?; ii) what barriers does the patient have to be mobilized?; iii) How can activity with patient continue to progress?; f) Educate physicians, nursing, and therapists to engage patient/family in mobility. Main Outcome Measures: Survey results at baseline and 12 months into project. Compliance rates with documenting highest level of activity for patients 3 times daily. Longitudinal assessment of highest level of activity scores for patients on the unit. Results or Clinical Course: Baseline survey showed that 90% of nurses believe mobilizing their patients at least 3 times daily will improve their outcomes. Barriers identified by survey included deficiencies in prior nursing training to safely mobilize patients (45%), lack of furnishings/equipment to safely mobilize patients (78%), and perception that patients will be resistant to mobility (86%). 3 weeks into project implementation, nurses were documenting the highest level of activity for 95-100% of patients. Conclusions: Active prevention of deconditioning during acute hospitalization will be a valuable tool to improve clinical outcomes and prevent avoidable complications. Using an interdisciplinary approach and well defined QI model, physical medicine and rehabilitation can take a lead role to implement an early activity and mobility program in hospitalized patients. Poster 20 Satisfaction With Botulinum Toxin Treatment in PostStroke Spasticity: Results From a Cross-Sectional Patient and Physician Survey. Djamel Bensmail (Hôpital R. Poincaré (AP-HP), Garches, France); Angelika Hanschmann. Disclosures: D. Bensmail, Consulting fees or other remuneration (payment): Merz, Allergan, Ipsen, Medtronic, Almirall Objective: To evaluate patient and physician satisfaction with botulinum toxin treatment in patients with post-stroke spasticity. Design: International, cross-sectional structured survey conducted in Germany, France, the USA, and Canada. Setting: Clinical practice. Participants: Adult patients (18 years) with post-stroke spasticity treated with 2 injection cycles of onabotulinumtoxinA (BotoxÒ) or abobotulinumtoxinA (DysportÒ), and the physicians who treated them. Interventions: Patient and physician questionnaire.