during Acute Inpatient Rehabilitation Predict Length of Stay in Acute Inpatient Rehabilitation and Motor FIMs TM at Discharge for Patients with Traumatic Brain Injury MA Bockbrader A ID: 161941
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Slide1
Agitation Duration, Density and Intensity
during
Acute Inpatient Rehabilitation
Predict
Length
of Stay
in Acute
Inpatient Rehabilitation
and Motor FIMsTM at Discharge for Patients with Traumatic Brain Injury
MA Bockbrader, A
Nielsen,
C
Kudron
,
L
Worthen-Chaudhari
,
J Rosenthal, D Mortimer, WJ
Mysiw
, J
Bogner
, J CorriganSlide2
Objective
To examine the relationship between Traumatic Brain Injury (TBI) outcomes and duration, density
and intensity of agitation during inpatient rehabilitation (IPR).
2Slide3
Disclosures
Research supported by NIDRR TBI Model Systems grant to J Bogner and J CorriganMarcie Bockbrader has nothing to disclose
3Slide4
AGITATION
DFN: excessive
behaviors occurring during an altered state of consciousness (Bogner, Corrigan, 1995); for TBI, the altered state of consciousness is post-traumatic amnesia (PTA).
E.g., aggressive, labile, or disinhibited behaviors
Interferes with functional activityC
an affect therapy participationHypothesis
: Agitation affects recovery and outcomes after TBI
4Slide5
Agitated Behavior Scale
(Corrigan 1989)
Each item rated
1 (none) – 4 (extreme)
per 8h shift
Total score range: 14 – 56Cutoff for agitation: total score > 21
5
14
ItemsSlide6
Background
Bogner
et al. 2001
n= 340 TBI patients in IPR
Agitation as categorical variablePresence of agitation
Severity of agitation
Duration of agitation
6
Agitated: at least one 48-hr period during IPR with 3 ABS scores > 21Mean of 3 high ABS scoresMild: 22-28Moderate: 29-35Severe: >36 Days (first agitated shift in 48-hr period containing 3 ABS scores > 21) to (last shift with ABS >21)
4 groups: 0d, (1-10d), (11-25d), >26d Slide7
Presence of agitation
Patients with agitation hadLonger LOS in IPRLess frequent discharge home
Lower motor and cognitive FIMsTM at discharge
7
Agitated:
at least one 48-hr period during inpatient stay contained 3 ABS total scores > 21
“
Cognitive functioning at admission to IPR mediates the relationship between the presence of agitation and
LOS in IPR, as well as between agitation and cognitive functioning at discharge.”36% of 340 TBI patients were agitated using this definition.Slide8
Severity of agitation
8
Agitation severity: Mean 3 high ABS
None <22Mild 22 - 28
Moderate 29 - 35 Severe 36 - 56
No significant differences based on severity for
LOS in IPR
FIM
TM motor at dischargeMild and moderate groups had lower FIMTM cog at discharge than nonagitated group (difference 2.3)Severe group did not differ from nonagitated
group for
FIM
TM
cog at discharge
Bogner
et al.
2001Slide9
Duration of agitation
9
LOS in IPR
Equivalent for 0d, 1-10d agitation
~LOS +12d for 11-25d agitation
~LOS +41d for >26d agitation (& not dc to home)
FIMs
TMs
at dischargeMotor & Cog equivalent for 0d, 1-10d, 11-25d groupsFIMTM cog –3.6 for >26d agitationFIMTM motor –8.9 for >26d agitationDays (first agitated shift in 48-hr period
containing
3
ABS scores
>
21) to (last shift with ABS >21)
4 groups: 0d, (1-10d), (11-25d), >26d
Bogner
et al.
2001Slide10
Revisit effects of agitation intensity, duration and density
New sample of 284 patientsCharacterize agitation as continuous variableAgitation intensity = Bogner’s
severityAgitation duration = 3 alternative definitionsAgitation density = 4 alternative definitionsAgitated Bout = Time period over which 6 consecutive shifts had at least 3 ABS scores >21
10Slide11
Agitation Intensity
Intensity.1
11Mean of 3 highest ABS scores
Range: 14 – 56
Intensity ~ peak agitation
http://
www.peakfreaks.com/everestclimbphotos.htmSlide12
Agitation Duration
Duration.1Duration.2
Duration.3 12
Number of shifts in longest bout
Range: 0 – 3*LOS in IPR
Number of shifts from first agitated shift of first bout to last agitated shift of last boutRange: 0 – 3*LOS in IPR
Number of agitated shifts from first agitated shift of first bout to last agitated shift during IPR
Range: 0 – 3*LOS in IPR
shortestlongestSlide13
Agitation Density
Density.1Density.2
Density.3Density.4
13
Number of boutsRange: 0 – LOS in IPR/2
Number of agitated shifts within all boutsRange: 0 – 3*LOS in IPR
Number of agitated shifts during IPR
Range: 0 – 3*LOS in IPRNormalized density:
Avg number of agitated shifts per day =Density.3/LOS in IPRRange: 0 – 3shortestlongestSlide14
Methods
Design: Prospective, observationalSetting: Multidisciplinary acute inpatient rehab
Participants: 284 consecutively admitted patients meeting criteria for participation in the NIDRR-funded TBI Model Systems National
Database (10 excluded)Instruments: Agitated behavior scale (ABS) scores during each shift of IPR. Computed agitation
Density, Duration and Intensity constructsDemographic variables: Age, Gender, Race, Education level, Admission GCS, LOS acute, FIM Motor and Cognitive scores at IPR admission
Outcomes: LOS in acute IPR, FIM Motor and FIM Cognitive scores at discharge
from IPR14Slide15
MA Bockbrader
1, D Mortimer2, L Worthen-Chaudhari1, J Rosenthal
1, JD Corrigan1, WJ Mysiw1, JA Bogner1
1Physical Medicine & Rehabiitation, The Ohio State University – Columbus, OH; 2
Physical Medicine & Rehabilitation, Hennepin County Medical Center - Minneapolis, MN
Mild (GCS 13-15)
Moderate (GCS 9-12)
Severe (GCS 3-8)Uncategorizable (GCS 3T)
TBI severity, based on initial GCS
Outcome Means (SD
)
LOS IPR 20.4 (13.9) days
FIM
TM
Cog discharge 25.2 (4.2)
FIM
TM
Motor discharge 70.7 (14.2)
41% of
TBI patients (n
=112)
had at least one agitated shift.
One-third (n=85) had at least one agitated bout.
207
67
Gender
Race
Education
Sample CharacteristicsSlide16
Agitated Behavior Scale
Constructs
& Regression Analyses
Clinical bout of agitation
-
“time period over which any 6 consecutive shifts had 3 or more ABS total scores > 21”
%
v
ariance accounted for (R
2
) by
Significant*
Univariate
Predictors of:
%
v
ariance accounted for (R
2
) by
Significant*
Multivariate Predictors of:
Duration
Agitation Construct
Definition
Mean (SD)
FIM
TM
Cog discharge
FIM
TM
Motor discharge
LOS IPR (days)
FIM
TM
Cog discharge
FIM
TM
Motor discharge
LOS IPR (days)
Duration.1
# shifts in longest bout
6.8 (15.5)
7%
2%
21%
-
-
-
Duration.2
# shifts from first agitated shift of first bout to last agitated shift
of last bout
11.1 (26.8)
14%
8%
33%
-
2%
-
Duration.3
# shifts from first agitated shift of first bout to last agitated shift
14.6 (31.1)
16%
9%
37%
-
-
10%
Density
Agitation
Construct
Definition
Mean (SD)
Density.1
# bouts of agitation
0.5 (0.8)
13%
7%
28%
-
-
-
Density.2
# agitated shifts within all bouts
4.6 (10.5)
8%
2%
24%
-
-
-
Density.3
# agitated shifts during IPR
5.8 (11.3)
12%
5%
31%
-
-
-
Density.4
average # agitated shifts per day, calculated as Density.3/LOS IPR
0.2 (0.3)
11%
NS
12%--3%IntensityAgitation Construct DefinitionMean (SD)Intensity.1mean of 3 highest shift scores22.3 (8.7) 11%1%22%-3%-Demographic variablesMean (SD)Age37.2 (16.7)NS4%NS3%5%-Gender-2%NSNS1%--Race (white, nonwhite)-NSNSNS---Education level-NSNSNS---Admission GCS group-NSNSNS---FIMTM Cog admission16.4 (6.8)44%9%43%44%-2%FIMTM Motor admission39.4 (18.1)17%38%53%-38%53%LOS acute care16.4 (14.5)5%20%29%-5%5%
*p<0.05
Results
+ correlation
-
correlationSlide17
In
univariate regression analyses, Agitation Density, Duration and Intensity were significant predictors of rehab LOS and discharge FIMs
TM. As has been shown previously (
Bogner et al. 2001), the relationship between agitation and discharge Cognitive FIMTM was mediated by admission Cognitive FIMTM.
Agitation Intensity & Duration were
significant independent predictors of discharge Motor FIMTM (even after accounting for patient age, acute hospital LOS, and admission Motor FIMTM).
Agitation Duration and Density were significant independent predictors of rehab LOS (even after accounting for admission Motor and Cognitive
FIMsTM and acute hospital LOS). Agitation Duration accounted for 10% of the variability in rehab
LOS DiscussionSlide18
Conclusions
18
Constructs that take into account ABS scores over shifts yield
Duration, Density and Intensity measures of agitation. Some of these provide additional predictive power (over admission FIMsTM
and demographics) for TBI outcomes. Agitation Duration, Density, and Intensity may be important targets for intervention and relevant adjustments to case-mix groups to more accurately characterize the resources needed to achieve optimal rehabilitation outcomes.Slide19
References
19
Bogner JA, Corrigan JD, Fugate L,
Mysiw WJ, Clinchot D. Role of agitation in prediction of outcomes after traumatic brain injury. Am J Phys Med
Rehabil 2001;80:636-44.Bogner JA, Corrigan JD.
Epidemiology of agitation following brain injury. NeuroRehabilitation 1995;5(4):293-7.
Corrigan JD. Development of a scale for assessment of agitation following traumatic brain injury. J Clin Exp
Neuropsychol 1989;11:262-77.Dodds TA, Martin DP,
Stolov WC, Deyo RA. A validation of the functional independence measurement and its performance among rehabilitation inpatients. Arch Phys Med Rehab 1993;74(5):531-6.