COMPARISON OF INPATIENT AND OUTPATIENT REHABILITATION ENGINEERING SERVICES IN AN ACUTE REHABILITATION SETTING

Yuichi Tamano, B.S., Glen Ashlock, M.S., Donn F. Hilker, M.S, and Simon P. Levine, Ph.D. Rehabilitation Engineering Program, Department of Physical Medicine and Rehabilitation University of Michigan

ABSTRACT

A comparison is made of rehabilitation engineering services provided to inpatient and outpatients in an acute rehabilitation setting. Data is collected from inpatient and outpatient records on the types of patients and the amounts and types of services received. Implications to the model of rehabilitation engineering in the acute rehabilitation setting are discussed.

BACKGROUND

Rehabilitation engineering services are provided in a number of medical centers as part of an acute, comprehensive rehabilitation program. It has been postulated that early intervention in such a setting may lead to improved patient independence and efficiency of service delivery (1). However, the proportion of medical centers which employ rehabilitation engineers remains small (2). In order to justify the existence of rehabilitation engineers in this setting, it is critical to provide evidence of improved patient outcomes as a result of service in the acute setting. As an underlying component, the characteristics of service delivery should be helpful in determining why this particular model is or is not successful. This information should then be useful in justification of service delivery in the acute-care environment, and would also provide valuable feedback to the service providers. The rehabilitation engineering program (REP) analyzed in this paper is part of a university-based regional medical center. It provides services to patients throughout their hospital stay and may continue to follow them after discharge. Clients are also referred as outpatients. A large proportion of service is geared towards environmental control, computer access (including both interface and computer literacy issues), and augmentative and alternative communications. A wheelchair mobility and seating service at an offsite location sees clients primarily on an outpatient basis. Detailed descriptions of these programs can be found in previous papers (1,3).

OBJECTIVE

The objective of this paper is to quantitatively compare certain aspects of the service provided to a group of inpatients and a group of outpatients at an acute rehabilitation center. The two groups will represent the acute rehabilitation model and the outpatient rehabilitation model, respectively. Comparison of the two groups will hopefully improve our understanding of the manner in which an acute-care rehabilitation engineering program differs from other models. Although patient outcomes were not measured, quantitative data on the service delivery of our program can provide insights into strengths and weaknesses of the program and validate (or invalidate) previous assumptions about the service delivery model. Specific questions which will be considered are: is this model effective in providing access to assistive technology services? Does this lead to increased evaluation and training time?

METHODS

Data was collected from all inpatients and outpatients who met two criteria: (a) equipment had been ordered for the patient within the last two years; and (b) the patient had had their initial contact with the rehabilitation engineering program within the last three years. Patients for whom no equipment had been ordered were excluded in order to obtain a better match of services provided to the inpatient and outpatient groups. This excluded a large number of inpatients who were provided with access to nurse-call controls and/or varying levels of orientation and evaluation as part of their inpatient service. Patients who had been initially contacted more than three years ago were also excluded to reduce the number of patients who had had "re-evaluations" and thus would have inflated statistics. Patients from the off-site seating service were not included in this study. All data was collected retrospectively from patient charts. Data was collected from 45 patients, including 5 with incomplete records (one or more data values not available). The following data was collected: age of patient type of disability source of initial referral (inpatient or outpatient) length of initial inpatient rehabilitation (if the disability was recently incurred) amount of time spent in evaluation or in training as an inpatient for the various types of services amount of time spent on environmental control for use during a hospital stay amount of time spent in evaluation or training as an outpatient cost of equipment type of equipment Amount of time spent on environmental control for use during a hospital stay indicates time spent in providing access to the nurse-call, TV, hospital bed, and other devices. This was separated from inpatient ECU evaluation because inpatient evaluations focus on the patient's needs following discharge as opposed to the patient's needs while in the hospital.

RESULTS

Tables 1 and 2 summarize the ages and types of disabilities seen for all patients included in the study. Thirty-one of the patients were initially contacted during an inpatient hospital visit, while twelve patients were initially contacted as outpatients.

Table 1. Summary of Patient Ages

Average Age: 40 yrs.

Table 2. Types of Disabilities Seen

Tables 3-5 summarize the service-delivery statistics for AAC, environmental controls, and computer access. Only patients for whom equipment had been ordered relevant to the type of service are included. For example, a patient who had an AAC evaluation but had no AAC equipment would not be included. In the tables, "Eval Time" is the average time per patient spent on evaluation and/or training. "In-hospital ECU Time" is the average time spent on evaluating and training a patient for environmental control to use while in the hospital. "Equip Cost" is the hardware cost per environmental control system. "Length of Rehab Visit" is the time from admission to the rehabilitation unit to the time of discharge. In general, equipment was provided on an outpatient basis, even for those who had been evaluated as inpatients. The exception to this is in environmental controls. A significant number of patients were provided with equipment from the REP's stock during their hospital stay. For the other services, patients had to wait for insurance approval and shipping time. One patient received ECU equipment as both an inpatient and an outpatient.

Table 3. Summary of AAC Service

Table 4. Summary of Computer Access Service

Table 5. Summary of Environmental Control Service

* Inpatients who were provided with ECU equipment during their inpatient (IP) stay ** Inpatients who were provided with ECU equipment as outpatient after discharge

DISCUSSION

The first issue to be addressed is to determine the relative frequency of service provision between the inpatient and outpatient settings. This will be discussed separately for each of the three assistive technology service areas. For AAC, five out of six patients who received equipment were referred as outpatients. The acute-service model was not a critical component in providing access to services in this case. This may be because the majority of AAC users have long-standing disabilities which would not be appropriate for treatment in an acute rehabilitation setting. For computer access, the number of patients who received equipment is fairly evenly distributed between inpatient and outpatient referrals. This implies that both the inpatient and outpatient models were important components of service provision in this area. However, whether access to services provided in the inpatient setting can effectively be replaced in the outpatient setting remains an unanswered question. The level of access to services for environmental controls was high in the acute setting. Twenty-six of twenty-nine patients who received environmental controls equipment were initially referred as inpatients. The provision of simple environmental control for nurse-call and TV controls as a standard service may be largely responsible for this. Another factor may be that the time required for evaluation is relatively short, and in many cases some equipment was provided from REP stock. Finally, the need for environmental controls may be most apparent to patients with newly acquired disabilities, while outpatients may have become accustomed to doing without. The next issue is whether the acute-service model results in increased evaluation and training times? The data here for AAC is inconclusive, since only one patient received AAC services as an inpatient. The data for environmental controls is also inconclusive; only three outpatients received equipment, and for one of these, the evaluation/training times were not available. However, the evaluation and training time for computer access is much greater for inpatients than for outpatients (about four times greater). As an acute-rehabilitation service, the REP is able to see clients several times a week to allow to them to try many different types of computer systems and to give in-depth training on a particular software package. This type of evaluation and training would be difficult to arrange in an outpatient facility. No measures were taken to see if this increased training time resulted in improved outcomes. It could be expected that increased training time will lead to more efficient and frequent equipment use. In addition to this, training may be therapeutic. It can increase self-esteem and provide recreational release while in the hospital. It may also stimulate the patient to pursue new interests and may even lead to career options. On the other hand, patients in rehabilitation may be adjusting to a new disability and may not have developed clear goals beyond discharge. Their functional status may be changing during the hospital stay, requiring changing methods of computer use. The effectiveness of increased training may be reduced in these situations. A significant statistic is that fact that 20 of the 31 inpatient-contacts had spinal-cord injuries. The medical center in which the REP is based contains a Model Spinal Cord Injury Program. This influences the types of services that are provided. This is particularly obvious in computer access and environmental controls.

CONCLUSION

Only a small number of the factors that influence the effectiveness of assistive technology provision have been examined in this paper. However, the data collected does support the idea that an acute-service model can lead to increased access to services for environmental controls and increased evaluation and training time for computer access. To properly justify the placement of rehabilitation engineering services within an acute rehabilitation setting, much more work is needed. Measures of patient outcomes, in terms of functional, economic, and emotional benefits, will be at the heart of this process.

REFERENCES

1. D.F. Hilker, S.P. Levine, W. Waring. "A Model of Rehabilitation Engineering Services in an Acute Rehabilitation Setting", Proceedings of the 16th Annual RESNA Conference, RESNA, pp20-22, June 1993. 2. L.S. Gaster, J.C. Gaster. "Acceptance of Rehabilitation Engineering: A Survey of Healthcare Administrators", Proceedings of the 15th Annual RESNA Conference, RESNA, pp196-198, June 1992. 3. P. Zuba, G. Ashlock. "A Computer Literacy Program in an Acute Rehabilitation Setting", Proceedings of the 18th Annual RESNA Conference, RESNA, pp428-430, June 1995. 4. C.G. Warren. "Cost Effectiveness and Efficiency in Assistive Technology Service Delivery", Assistive Technology Journal, RESNA, v.5, pp.61-65, 1993.

ACKNOWLEDGMENTS

The authors would like to acknowledge Shana Burke for her assistance in compiling the data and Rick Nelson for his valuable feedback.