Acute Intravenous Tissue Plasminogen Activator Therapy does not Impact Community Discharge after Inpatient Rehabilitation

Copyright: © 2015 Ifejika NL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

In comparison to Vascular Neurologists, rehabilitation professionals such as physiatrists, physical therapists, occupational therapists and speech and language pathologists use separate and distinct outcome measures to determine community discharge in stroke patients. Measures of rehabilitation success and quality include discharge status, rates of re-hospitalization and improvement in FIM (functional independence measure) score. Consisting of eighteen items in seven domains, the FIM score provides a uniform assessment of the severity of disability based on the level of independence [4,5]. During the rehabilitation hospitalization, FIM scores provide objective data that is used to track improvements and decompensations on a daily basis [6]; this data is used to facilitate discharge planning in those with high FIM scores and preparation for placement in a skilled nursing facility for those with low FIM scores [7].
FIM values in the inpatient rehabilitation setting can be detrimentally impacted by HAIs (healthcare associated infections) [8]. HAIs in the acute stroke patient have been associated with poor outcomes due to both prolonged hospitalization for antibiotic treatment and suboptimal participation in acute rehabilitation [8][9][10]. The most prevalent, SUTI (symptomatic urinary tract infection), accounts for over 21% of HAI incidence; studies have found that UTI [urinary tract infection] is one of the most frequent complications of stroke, with rates of 1 to 24% within the first month [11][12][13]. Sien Ng et al. [14] noted that higher discharge FIM score was associated the absence of HAI's. Furthermore, patients with medical complications during inpatient rehabilitation are at a higher risk for poorer functional outcomes at 1 year. Therefore, the identification and treatment of modifiable factors, such as SUTI, allow for optimal stroke rehabilitation [14,15].
The primary outcome of acute thrombolysis trials has focused on a clinical endpoint of ninety day mRS (modified Rankin Scale) value [16]. However, patients and their families are interested in the events that occur during those three months that lead to the end result, namely, the process of rehabilitation care.
The purpose of this study is to determine whether intravenous thrombolysis with t-PA and the subsequent improvement in NIHSS can predict community discharge after inpatient rehabilitation. Discharge FIM value will serve as the reference standard for return to the community. Furthermore, we will evaluate the impact of SUTI as a healthcare associated infection on discharge FIM values.

Subjects and Methods
This is a CQI (continuous quality improvement) project initiated as a part of the Neurorehabilitation Subcommittee of our TJC (The Joint Commission) certified CSC (Comprehensive Stroke Center), MHH-TMC (Memorial Hermann Hospital -Texas Medical Center). Quality improvement projects are integral to establishing safety guidelines, decreasing the costs of care and evaluating root-cause analyses. MHH-TMC is a tertiary care center with an in-house inpatient rehabilitation unit; all patients who meet admission criteria to inpatient Neurorehabilitation are accepted regardless of insurance type or ability to pay for services rendered. Therefore, our data set is characterized as census data, an official survey of all eligible participants.
For this project, we merged two prospectively collected quality assured databases. We performed a data query of the fields of interest from our university-based UT-Houston Medical School Stroke Registry, a collection of 200 variables collected prospectively on each patient admitted to the stroke service [17]. The registry was maintained by the SPOTRIAS (Specialized Programs of Translational Research in Acute Stroke) Data Core, a national network of 8 centers that perform early phase clinical projects, share data, and promote new approaches to therapy for acute stroke. Demographic information, SUTI on the Stroke service and NIHSS values were abstracted from the UT-Houston Stroke Registry. Cardiovascular Disease, Diabetes Mellitus, Hypertension, and History of Stroke did not show a significant impact on admission to inpatient rehabilitation in our previous studies [15,18]; instead, the patient's ability to tolerate three hours of therapy daily was used as the physical standard for inpatient rehabilitation admission [9]. Therefore, these medical comorbidities were excluded.
From the rehabilitation database, we collected length of stay, FIM score on admission and discharge, SUTI while on the Neurorehabilitation service and post-rehabilitation discharge disposition. The registries were matched by discharge date from the Stroke service and admission date to the Neurorehabilitation service, accounting for greater than 57% of the data. The remaining records required the use of a data abstractor, who manually matched cases.
Post Inpatient Rehabilitation Discharge Dispositions were defined as follows: • Community -A private, community-based dwelling (a house, apartment, mobile home, etc.) that houses the patient, family or friends.
• SNF (Skilled Nursing Facility) -A setting that provides skilled services, including physical, occupational and speech therapy for an average of 1.5 hours daily. Care is ordered by a physician, a medical record is maintained and nursing services are present 24 hours a day.
• AC (Acute Care) -An acute medical/surgical care unit where patients receive treatment by a physician and their team.
Our primary objective was to determine whether t-PA therapy is associated with post-rehabilitation discharge disposition. We hypothesized that the presence of SUTI and/or advanced age would negatively impact the stroke rehabilitation hospital course, and ultimately decrease the likelihood of community discharge. The primary dependent variable was post-inpatient rehabilitation discharge disposition, which served as the proxy for functional status [2,16].

Statistical Methods
All statistical analyses were performed using STATA 13 (College Station, Texas). Continuous variables were summarized as mean ± standard deviation, or as median with interquartile range based on their distribution. Categorical variables were reported as frequencies and proportions. Univariate comparisons for demographic and clinical variables were completed between patients with community discharge and patients who were discharged to AC or SNF. The independent variables were NIHSS score, t-PA therapy, Age, FIM score at discharge and FIM Efficiency (FIM score at admission minus FIM score at discharge divided by rehabilitation length of stay). SUTI can impact community discharge after inpatient rehabilitation, it was included to evaluate for potential effects.
Two separate logistic regression models were fit to assess the factors associated with a favorable discharge disposition (community discharge vs. AC, and community discharge vs. SNF). Factors that were clinically relevant or statistically significant at 10% level in the univariate analysis were included in the multivariate model. Likelihood ratio test was performed to assess for significance of a parsimonious model vs. the full model. Regression diagnostics were performed on the final model along with testing for the fit of the model using Hosmer and Lemeshow goodness of fit test. Level of significance for all hypothesis testing was set at 0.05.
We created a diagram that details t-PA treatment rates in the community, AC and SNF groups to address concerns regarding intergroup differences. We also analyzed the effects of t-PA therapy on median NIHSS values and admission FIM score.

Results
Between January 2011 and November 2013, we identified 346

Effect of IV t-PA therapy and NIHSS value on postrehabilitation discharge disposition
Of 346 acute ischemic stroke patients, 274 returned to the community, 47 were transferred to a SNF, and 25 were readmitted to AC from the inpatient Neurorehabilitation service (Table 1 and 2). Our comprehensive stroke center treated 31.8% of ischemic stroke patients with intravenous t-PA in the community discharge group, 23.4% in the SNF discharge group and 24% in the AC readmission group. The proportion of patients treated with IV t-PA in the three disposition groups were not statistically different ( Figure 1).
Median NIHSS values were 8 in the community discharge group, 9.5 in the AC readmission group and 11 in the SNF group. The median NIHSS scores of IV t-PA treated patients for the three disposition groups were not statistically different ( Figure 1). IV t-PA treated patients who were discharged the community had significantly higher admission FIM values as compared to those who were discharged to SNF (p=0.03) (Figure 1).

Univariate analysis: Community versus SNF -Postrehabilitation discharge disposition
Patients in the community discharge group were 9.7 years younger than the SNF group. For a one year increase in age, there were 5% increased odds of SNF admission (Table 1).
Admission FIM score was significantly higher in the community group (56. 8

Univariate analysis: Community versus AC -Postrehabilitation discharge disposition
Patients who returned to AC had a shortened length of rehabilitation stay by 6.52 days compared to the community discharge group (P<0.0001). For a one day increase in rehabilitation length of stay, there were 21 percent decreased odds of AC readmission ( Table 2).
Admission FIM score was significantly higher in the community discharge group (56.8) than the SNF group (45.9; P=0.001). For a one unit increase in admission FIM, there were six percent decreased odds of SNF admission (

Discussion
This study provides new information on the impact of acute thrombolysis for ischemic stroke during inpatient rehabilitation. The administration of t-PA therapy within 3 hours of symptom onset has been shown to increase community discharge rates after the acute hospitalization [3]. However, the five day duration of the acute stroke stay provides limited data on rehabilitation expectations. This study extends out the time window, establishing the impact of t-PA therapy on rehabilitation outcomes during the first 2.5 weeks post-stroke, a time of significant adjustment, anxiety and stress among stroke patients and their families.    By analyzing all ischemic stroke patients who received rehabilitation care, we have created "census data", an official enumeration of the population without the influence of health insurance, a barrier that can block access to inpatient rehabilitation services.
Although IV t-PA therapy rates averaged 30% across the community, SNF and AC groups, the administration of t-PA therapy had no impact on community discharge. NIHSS values varied between the community, SNF and AC groups; however, there were no statistically significant differences. These findings reinforce the importance of inpatient rehabilitation and highlight a new finding -three hours of daily inpatient therapy can serve as an equalizer among patients with mild to moderate stroke who did not receive intravenous thrombolysis.
A secondary goal of stroke rehabilitation is to facilitate an appropriate change in FIM to improve a stroke survivor's functional mobility. This improvement in functional mobility leads to a decreased risk of debility related complications (falls, pressure ulcers, deep venous thrombosis). Therefore, the lower admission FIM scores in the t-PA treated group who were discharged to SNF are a function of preparing these patients for another level of post-acute care.
The diagnosis of SUTI had no significant impact on AC readmission rates from inpatient rehabilitation. This new information contrasts with AC studies, where the presence of SUTI was predictive of rehabilitation care in a SNF, a level of care suggestive of lower functional status and worse outcomes [12,15]. The obviated impact of UTI on community discharge is due to the standard protocol of collecting a urine sample within 24 hours of rehabilitation admission. Early detection of genitourinary infections facilitates rapid treatment, decreasing urosepsis rates.
Forty percent of stroke survivors experience moderate to severe neurologic impairments, requiring specialized rehabilitation care [19]. Since peak neurologic recovery occurs within the first three months of a cerebrovascular event [20], the provision of an evidencebased rehabilitation pathway throughout those three months is of critical importance. The presence of Neurorehabilitation services in comprehensive stroke centers provides continuity of care from Vascular Neurologists and Physiatrists as leaders of the multidisciplinary team -leading to a systematic and integrated assessment of neurologic improvement.
Large numbers of stroke survivors benefit from inpatient rehabilitation at centers that provide the full range of acute services, such as physical and occupational therapy, speech and language pathology, neuropsychology rehabilitation nursing, case management and social work [21]. Unfortunately, there are financial barriers to admission in a number of Neurorehabilitation centers. Lack of insurance or underinsurance can preclude inpatient rehabilitation, and in some cases, stroke survivors return home with only minimal caregiver services. This study was conducted at a tertiary care center with an in-hospital inpatient rehabilitation facility; therefore, all patients who meet criteria for admission to inpatient rehabilitation were accepted.
We cannot comment on the provision of caregiver services -if patient needs supervision for safety, has cognitive impairments or physical limitations, the identification of a caregiver is recommended before returning home. As an alternative to home, these patients may be admitted to an SNF or a personal care home, particularly in patients with advanced age, until a caregiver becomes available. This may account for our findings of skilled nursing facility placement rates of 13.6 percent, compared to an average of ten percent [22], as well as a four percent increased odds of SNF admission for a one year increase in age. This analysis is retrospective; we endeavoured to stratify the data for age, stroke severity and known risk factors that suggest lower FIM scores and worse outcomes, such as SUTI. Our study did not define SUTI based on the Centers for Disease Control and Prevention guidelines. The reliability of using patient report of dysuria and suprapubic tenderness is attenuated, because many stroke patients cannot express symptoms due to aphasia or to the presence of indwelling urinary catheters.

Summary/Conclusions
Intense and sustained inpatient rehabilitation enhances the poststroke recovery process, particularly in patients who did not receive IV t-PA. Acute ischemic stroke patients who received acute intravenous thrombolysis with t-PA had no difference in post-rehabilitation community discharge. All patients had mild to moderate strokes and were able to tolerate three hours of daily physical, occupational and speech therapy. Unlike the acute stroke hospitalization, symptomatic urinary tract infection had no impact on community discharge. A better understanding of the scientific process of Neurorehabilitation care during the first 3 months post-stroke can further improve the impact of this specialty.