Brain Injury

ISSN: 0269-9052 (Print) 1362-301X (Online) Journal homepage: http://www.tandfonline.com/loi/ibij20

Intensity of rehabilitation and length of stay W. F. Blackerby To cite this article: W. F. Blackerby (1990) Intensity of rehabilitation and length of stay, Brain Injury, 4:2, 167-173, DOI: 10.3109/02699059009026162 To link to this article: http://dx.doi.org/10.3109/02699059009026162

Published online: 03 Jul 2009.

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Date: 08 March 2016, At: 06:52

BRAIN INJURY,

1990, VOL. 4, NO. 2, 167-173

Intensity of rehabilitation and length of stay W. F. B L A C K E R B Y W. F. Blackerby & Associates, Hendersonville, Tennessee, USA

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(Received t5 September 1989; accepted 1 1 October 7989) This study investigated the effects of different levels ofbrain injury rchabilitation intensity on length of stay in two hospital-based coma and acute rehabilitation populations. In two hospitals, in separate areas of the USA, rehabilitation intensity was increased from 5 h per day to 8 h per day, 7 days per wcck. Patients were studied retrospectively both before and after the change in intensity. There were n o significant differences among subjects in age, education, time since injury or level offunctioning on admission either across hospitals or from pre- to post-change-in-intensity. Results show that the length of stay significantly decreased 31% for both coma and acute groups in both hospitals. Implications of these findings for clinical treatment and social policy are discussed.

Introduction T h e focus of this study was t o investigate whether varying intensity of rehabilitation treatment results i n differential effects o n functional progress made by patients. There has been a general trend in rehabilitation over the past several years t o intensify rchabilitation programming and t o extend therapy activities into evening and weekend hours. M a n y head-injury rehabilitation programmes systematically involve patients in therapeutic activities as much as 10 h per day. T h e r e is also a trend in coma treatment programmes for active intermittent stimulation of patients for 8 h o r more per day. Although there currently is little supporting empirical evidence, the concept is that increases in intensity of treatment should result in m o r e rapid patient improvement [1,2,3]. Within this concept, systematic, individually tailored stimulation and rehabilitation training should improve the patient’s ability t o modulate the level of arousal and t o interact effectively with the environment [4].An associated issue is whether such treatment can be justified in terms of the time, effort and cost expended. T h e r e is some evidence that high-intensity treatment, whether rehabilitative o r some other type of training, produces greater functional gains than lower intensity treatment [5,6].For example, total immersion language training has been found t o improve the speed and fluency offoreign language acquisition [7,8,9].In the arena ofeducation, academic skill development is enhanced in intensive education programmes [ l o , 11,121. Research in mental health shows that highly intensive treatment programmes can produce rapid results [13]. T h e r e is also a variety of research in rehabilitation that indicates that functional gains occur m o r e rapidly with intensive treatment [3,14,15,16,17,18,19,20,21]. O n e study found a 28% reduction in length of stay of both coma and acute brain-injury patients in high-intensity rehabilitation [22]. Nevertheless, there has been some research that did n o t find improvements in patient functioning w i t h m o r e intensive rehabilitation [23].

Address correspondence to: Dr W. F. Blackerby, W. F. Blackerby & Associates, 113 Hickory Heights Drive, Hendersonville, Tennessee 37075, USA. 026%9052/YO L3.W

0 1990 Taylor & Francis Ltd

W. F. Blackerby

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168

It is well known that head injury patients in rehabilitation often lack the strength and stamina to participate in a rigorous rehabilitation programme. This is particularly true when a multidisciplinary team attempts to provide active treatment during the usual working hours in which the therapists are available. However, if the treatment activities are naturalistic for the individual patient, and ifthe treatment day is extended into the evenings and weekends (with intermittent rest periods), patients may be ablc to benefit from increased treatment intensity. Naturalistic therapeutic activities would involve adaptations of those activities that were of interest to the individual before the head injury, and are more likely to be inherently meaningful and motivating for the patient. This investigation focused on determining whether such treatment resulted in differences in functional gains in head-injury rehabilitation patients. The expectation was that higher-intensity treatment should reduce the length ofstay of patients with functional levels at discharge remaining the same. That is, that patients would achieve functional discharge criteria more rapidly under high-intensity than lower-intensity treatment. In 1986, Rebound Inc., a major provider of head-injury rehabilitation services, substantially altered the structure of their rehabilitation service delivery system. The changes consisted of the addition of internal case-management services and the increase in intensity of rehabilitation treatment from an average of 5-5h per day in hospital-based, acute rehabilitation programmes, to an average of 8 h per day following the naturalistic activity, total therapeutic day model described above. A pilot study was conducted to investigate the effects of this model change in two populations. Both sites were 22-bed hospital-based coma and acute brain-injury rehabilitation units, one in Missouri and the other in Tennessee. Both units had been in operation for at least 8 months before the clinical model changes. The clinical model change took place in both units at approximately the same time in 1986.

Method Subjects The subjects used in the pilot study consisted of all clients in the rehabilitation programmes noted above from 1986 to 1988, including patients treated before and after the clinical model changes. Staff in both facilities were unaware of this project. Table 1 shows the distribution of subjects in each treatment programme in each facility and for the combined groups. As can be seen from this table, there is considerable variability in each cell of this table; this variability reflects the referral pattern in each facility. The number of subjects in the post-change groups is smaller than in the pre-change groups. This is a function of the amount of time and number of discharges that have occurred from the point of change in each programme until September 1988, when these data were collected. Most subjects (97%) were admitted with diagnoses of traumatic brain injury. The remainder had diagnoses of anoxic encephalopathy, anterior communicating artery aneurysm, anterior cerebral artery infarction and post-surgical astrocytoma. Subjects ranged in age from 3 to 62 years and in educational stage from pre-school to college graduate, with n o significant differences between subjects in the two facilities. Level of functioning on admission was also not significantly different, either across the two hospitals or from pre- to post-intensity-change. Time post-injury at admission ranged from 14 to 84 days, and was not significantly different across the two facilities.

169

Rehabilitation intensity and length of stay Table 1.

Distribution of subjects b y site.

Coma treatment programme

treatment programme

(4

(n)

48 6 54

38 6 44

8 6 14

27 10 37

Acute

Pie-change

Hospital 1 Hospital 2 Combined pre-change group

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Post-change

Hospital 1 Hospital 2 Combined post-change group

Procedure Both coma and acute rehabilitation patients were studied retrospectively before and after the organizational and programmatic changes occurred. The only variable examined in this study was the length of stay in the before and after conditions for each group. Patients who were admitted, treated and discharged before the implementation of the model changes were compared with patients admitted, treated and discharged after the changes were implemented. Data were only collected on length of stay for the pilot study as that was the primary variable of interest.

Results The results for Hospital 1, before and after the programmatic change are shown in Table 2. As can be seen from these data, the average length of stay (LOS) in both the coma and acute treatment programmes dropped considerably following the programmatic changes. In addition, the variability of the LOS also decreased considerably in both programmes following the changes. For Hospital 2, Table 3 shows the pre- and post-change average LOS. As in the previous data, the average LOS decreased considerably following the programme changes as did the variability of LOS. An unexpected finding was that the degree of change in LOS and variability of LOS was approximately the same in each facility. For the combined group, shown in Table 4, the results are similar. For both the coma patients and the acute patients, the length of stay and the variability of length of stay have Table 2.

Length of stay pie- and post-change for Hospital 1 .

Days in coma treatment programme

treatment programme

Days in acute

Pre-change

Mean LOS SD

14590 136.07

177.11 130.66

Post-change

Mean LOS

101.75 86.36 44.15

122.93 109.88 54.18

SD Average change in LOS

W . F. Blackerby

170 Table 3. Length of stay pre- and post-change for Hospital 2.

Days in acute treatment programme

Pre-change

Mean LOS SD

199.83 144.29

90.50 36.93

Post-change

Mean LOS SD

107.83 107.96

84.10 87.14 6.4

Average change in LOS

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Days in coma treatment programme

92.0

decreased. After the programmatic changes, length of stay for the coma group was reduced by 48.43 days. The average change in length of stay for the acute group was 52.87 days.

Discussion The difference in average change ofLOS between the two hospitals may be related to at least two factors. First, the much lower number of patients available for inclusion in this study from Hospital 2 may have produced this difference. Secondly, Hospital 2 had only been operating for 8 months at the time of this study and the less experienced staff and general newness of the programme may have contributed to the difference. As can be seen in Table 4, the difference in average length of stay is statistically significant. More importantly, it is clinically significant. These results imply that, following the changes made in the programmes in these two hospitals, patients were able to be discharged an average of 1.5 months earlier than before the changes. Since the criteria for discharge from these programmes did not change during this period, the patients must have achieved the discharge criteria more rapidly after the programme changes than before the changes. The results for the coma patients are particularly noteworthy. There is considerable discussion in rehabilitation circles regarding the benefits of active stimulation programmes for coma patients. These data suggest that active stimulation programmes may result in earlier discharge of coma patients. O f course, these results are but ‘one stone in the foundation’ of such an argument for coma stimulation. Considerable additional research is needed in this arena to define further the efficacy of coma stimulation programmes. An additional implication for these results is in the area ofcost containment. It is useful to consider the cost of rehabilitation in four categories: therapies, ancillaries, physician charges Table 4.

Length of

stay

pre- and post-change for the combined group.

Days in coma treatment programme

treatment programme

Days in acute

Pre-change

Mean LOS SD

152.79 133.60

165.30 125.51

Post-change

Mean LOS SD

104.36 92.24 48.43* (31.7%)

1 12.43 104.52 52.87* (31.9%)

Average change in LOS

* p

Intensity of rehabilitation and length of stay.

This study investigated the effects of different levels of brain injury rehabilitation intensity on length of stay in two hospital-based coma and acut...
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