ORIGINAL ARTICLE

Medical complications and outcomes at an onsite rehabilitationunit for older people

M. Mulroy • L. O’Keeffe • D. Byrne •

D. Coakley • M. Casey • B. Walsh • J. Harbison •

C. Cunningham

Received: 10 March 2012 / Accepted: 11 February 2013 / Published online: 1 March 2013

� Royal Academy of Medicine in Ireland 2013

Abstract

Background The rehabilitation of older patients in

Ireland after an acute medical event occurs at dedicated

onsite hospital units or at offsite centres. Information on

medical complications and outcomes is inadequate.

Aims Enumeration of medical complications of patients

admitted to a dedicated onsite rehabilitation unit for older

people, and the extent of co-morbidity in the population

with the effects that this had on the evolution of medical

complications.

Methods A retrospective analysis of patients admitted to

a 58-bed onsite unit over a 1-year period was performed.

Information collating co-morbidities, medical complica-

tions and functional outcomes was recorded.

Results Medical complications occurred in almost 95 %

of patients, where full data were available. Over one-third

required intravenous therapy.

Conclusion Twenty-four hour medical cover is required

for older patients managed at onsite rehabilitation units.

Further studies on offsite medical rehabilitation facilities

for older patients are required.

Keywords Onsite rehabilitation � Offsite rehabilitation �Complications � Outcomes

Methods

A retrospective chart review of all patients admitted to a

58-bed rehabilitation facility on the general hospital

campus of St James’s Hospital took place over a 12-month

period (July 2004–June 2005) following examination of the

admission and discharge dates from the Hospital In Patient

(HIPE) records. The catchment area for the hospital has

approximately 25,000 people aged 65 and over reflecting

approximately 2.3 rehabilitation beds per thousand, but up

to 25 % of beds can be occupied by patients awaiting

transfer to nursing homes so the actual rate available for

rehabilitation is closer to 1.75 beds per thousand [1]. A

proforma which detailed the patients age, date of admission

to the rehabilitation unit, time pending rehabilitation bed,

length of stay, source of referral, and discharge location

was recorded. Activities of Daily Living (ADL’s) were

noted pre- and post-admission to the unit. The Cumulative

Illness Rating Scale for Geriatrics (CIRSG) was used to

measure co-morbidities and severity of chronic medical

disease burden prior to transfer to rehabilitation. The

CIRSG has been validated as a measure of complexity in

frail older patients [2]. Thirteen organ systems were scored,

each between 0 and 4, which graded the severity of illness

from none (0) to critical (4) [3]. The classes of medications

that patients were admitted with were detailed, but limited

to eleven categories. Complications were defined as

requiring medical attention by a Non-Consultant Hospital

Doctor (NCHD) or a consultant and required an entry into

the medical notes. The time to first complication and the

number of complications were recorded in organ-based

categories which also included falls, new fractures, bio-

chemical abnormalities and psychiatry of old age inter-

vention. If patients required transfer to the main hospital

for further medical care or radiological investigations;

this was noted. The use of intravenous drug therapy fol-

lowing complications was recorded. The discharge desti-

nation of the patient, documented overnight stays for

graded discharge, documented family meetings, number of

M. Mulroy (&) � L. O’Keeffe � D. Byrne � D. Coakley �M. Casey � B. Walsh � J. Harbison � C. Cunningham

Medel Directorate, St James Hospital, Dublin 8, Ireland

e-mail: martinmulroy@yahoo.com

123

Ir J Med Sci (2013) 182:499–502

DOI 10.1007/s11845-013-0922-1

medications and selected ADL’s were noted. Six NCHD’s

were recruited to complete the proforma and each had to

score a minimum number of charts for the CIRSG to

minimise interrater variability. All reviewers had training

from the principal author in the use of scoring guidelines

and a pilot score of 10 charts (not included in the study)

from the acute geriatric ward was used per reviewer.

Spearman’s correlation coefficient between the principal

authors’ scores and the other reviewers was 0.72.

Data were stored using a Microsoft Excel spreadsheet

and statistics were performed using Datadesk statistical

software (version 6 Ithaca, NY).

Results

One hundred and fifty-five patients were admitted to the

rehabilitation unit over 12 months (July 2004–June 2005).

Hospital charts were available for 140/155 (90.3 %) of

patients and full clinical data were available for 112/155

(72.2 %) of patients. Computer records were available for

155/155 (100 %). 89/155 were females (59 %). The mean

age of patients on admission was 80.16 years (range

62–97 years). The mean waiting time for a rehabilitation

bed was 38.5 days (range 0–196 days). The median length

of stay on the rehabilitation unit for patients was 83 days

(range 2–460 days). 79/155 (51 %) of patients were refer-

red from the General Physicians, 46/155 (30 %) were

referred from the Geriatricians, 20/155 (13 %) were refer-

red from the Orthopaedic Surgeons, 8/155 (5 %) were

referred from the General Surgeons and 2/155 (1 %) were

referred from the community. The indication for referral is

illustrated in Fig. 1. 125/155 (80.6 %) had one rehabilita-

tion admission, 24/155 (15.5 %) had two rehabilitation

admissions, 5/155 (3 %) had three rehabilitation admissions

and 1/155 (0.6 %) had four rehabilitation admissions over

12-month period.

The mean CIRSG was 8.1 (range 0–20). The mean Mini

Mental State Score was 22.9 prior to the patients’ transfer.

Of the patients with full data available, medical compli-

cations were found in 106/112 (94.6 %) of patients. The

median time to first medical complication was 7 days

(range 0–65 days). 13 % of all admissions required a

medical review within 48 h of admission. The total number

of discrete unscheduled medical reviews was 1,605 (mean

11.5 medical reviews per patient). A breakdown of organ-

specific complications is illustrated in Fig. 2.

Forty-two of 112 (38 %) required intravenous therapy

during their stay. 4/112 (3.6 %) patients had cardiorespi-

ratory arrests. 60/112 (53.5 %) required transfer for

radiological investigations. 20/112 (17.8 %) were trans-

ferred following an acute medical deterioration to the acute

geriatric ward. No patients required transfer to the emer-

gency department. In a multiple logistic regression looking

at age, gender, co-morbidity score, in-patient time waiting

for rehabilitation and in-patient mobility status prior to

transfer to rehabilitation only co-morbidity score was sig-

nificantly associated with subsequent use of intravenous

therapy (odds ratio 1.14 [95 % CI 1.03–1.27] for each point

increase in the CIRSG scale. Co-morbidity score was not

associated with inpatient mortality (odds ratio 1.07

[0.94–1.21] unadjusted and 1.08 [0.95–1.23] adjusted) or

rehabilitation length of stay (beta coefficient (s.e.) 1.48

(2.31) p = 0.52 unadjusted and 1.81 (2.28) p = 0.43

adjusted).

Fourteen of the 42 patients (33 %), who required

intravenous therapy died, 13(31 %) went to a nursing home

Stroke

Orthogeriatrics

Falls

Cardio/Chest

Others

Fig. 1 Indication for rehabilitation from source of referral: 17/112

(15 %) were stroke, 20/112 (17.8 %) were orthogeriatric/orthopaedic,

24/112 (21.4 %) were Falls, 9/112 (8 %) were cardio-respiratory,

42/112 (37.5 %) were combinations of the previous categories and

others

0

100

200

300

400

500

1

GIT/GUT

Skin

CVS

RS

Psych

RheumBiochem

Neuro

Fluid Imbalance

Injurious Fall

New Fracture

Fig. 2 Total cumulative complications recorded for 112/155 patients.

The most common complication involved gastrointestinal/genitour-

inary system 402/1,605, followed by skin 280/1,605, cardiovascular

188/1,605, respiratory 182/1,605, psychiatry 152/1,605, rheumato-

logical 101/1,605, biochemical 100/1,605, neurological 100/1,605,

fluid imbalance 49/1,605, injurious fall 44/1,605, and new fracture

7/1,605

500 Ir J Med Sci

123

and 15 (36 %) were discharged to the community. These

outcomes were significantly different (v2 = 32, 2df,

p \ 0.0001) for the 70 patients who did not require intra-

venous therapy during their stay: no deaths (0 %),

15(21 %) discharged to nursing homes and 55(79 %) dis-

charged to the community.

With regard to outcomes, computerised records of dis-

charge destination in all patients admitted were available.

96/155 (62.2 %) were discharged home, 33/155 (21 %)

were discharged to a long-term care facility, 6/155

(4 %) were transferred to another hospital, and 20/155

(12.6 %) died. Of the 96 patients discharged home, 37

(39 %) had documented overnight stays prior to discharge,

and 44 (45 %) had documented family meetings to facilitate

this with the multidisciplinary team. The median quantity of

medications following discharge increased from eight

medications (range 2–20) prior to admission to 11 medica-

tions (range 2–20) following discharge. Table 1 illustrates

selected groups of medications prescribed pre- and post-

rehabilitation.

Of those patients discharged from rehabilitation, 74/92

(80.4 %) were continent, 15/92 (16.3 %) were incontinent

with 3/92 (3.2 %) requiring long-term catheterisation.

Prior to admission to the acute hospital 89/112 (79 %)

were independent mobile (with or without an appliance),

but this had fallen to only 34/112 (30 %) preceding transfer

to the rehabilitation unit. At discharge, 79/112 (70 %) were

independently mobile (with or without an appliance).

Discussion

This represents the first data from an Irish onsite rehabili-

tation unit for older people which demonstrated that

patients had significant medical co-morbidity but most

returned home. Following listing for rehabilitation, patients

waited almost a month prior to transfer, reflecting a lack of

appropriate beds.

The management of older patients requiring rehabilita-

tion after an acute medical illness can be complex due to

the nature of the acute medical problem and the presence of

co-morbidities. There has been significant debate where

older patients requiring such rehabilitation should take

place. A recent review and meta-analysis of inpatient

rehabilitation has shown an increased level of function and

reduced mortality and admissions to nursing homes in such

patients [4]. In North America, the term ‘‘prehab’’ has been

used to describe intensive rehabilitation at the front door

when older patients are admitted to acute geriatric care

units. These units report similar findings to the inpatient

rehabilitation model with improved outcomes and reduced

placement into long-term care facilities [5]. The effect of

an acute geriatric unit, as well as standard management

units in Europe, has also reported similar outcomes [6, 7].

The models for providing rehabilitation for older people

in community or at off-campus sites are established in

Ireland. In the United Kingdom, nurse-led intermediate

care rehabilitation units have reported no significant

adverse outcomes to patients and comparable levels of

physical function [8]. In 2008, a Cochrane database review

found insufficient evidence of overall outcomes when

comparing rehabilitation of older patients in either their

own home, nursing home or in hospital [9]. The cost of

providing such diverse rehabilitation given the differing

casemix of pathologies treated is difficult to enumerate.

Where the sole provision of rehabilitation is for example

stroke, early discharge from the acute setting to provide

rehabilitation in the home setting can be cost-effective

without any adverse changes in mortality [10].

Almost all patients admitted to the inpatient rehabilita-

tion service at our hospital developed a medical compli-

cation requiring the minimum intervention of a medical

review, 13 % of which was required within 48 h of

admission. The nature of these complications was multi-

organ, and were treated by Geriatricians. Over the half of

the patients reviewed required radiological investigations

and 38 % required intravenous intervention for either fluids

or medications. Requiring intravenous treatment was

associated with significantly worse outcomes. The number

of medications prescribed increased by about three per

patient. Although the use of bone protection medications

and statins increased, the number being prescribed ben-

zodiazeopines failed to reduce and indeed increased (albeit

in 4 patients). Our unit’s failure to reduce the use of

sleeping tablets reflects the difficulty of implementing

guidelines into practice and may indicate a difficulty in

addressing this topic in older inpatients that proceed to

rehabilitation. Further research should address this area.

The average length of stay of almost 3 months, the sig-

nificant use of intravenous medications and radiological

investigations on the unit may reflect the experiences of

other onsite or offsite centres or may be profoundly dif-

ferent. It is important that other units publish their expe-

riences to inform a debate about the most efficient use of

scarce resources.

This study highlights the importance of patients having

access to medical care in a rehabilitation facility due to the

Table 1 Selected classes of prescribed medications pre and post

admission to rehabilitation

Medications Pre-admission (%) Post-rehabilitation (%)

Statin 36/112 (32) 52/92 (56.5)

Bone protection 30/112 (26) 63/92 (68.4)

Benzodiazepenes 22/112 (19.6) 26/92 (28.2)

Ir J Med Sci 501

123

incidence of medical complications. Patrick et al. [11]

previously described medical co-morbidities as a predictor

of rehabilitation efficiency whereby scores [5 were likely

to result in a poorer outcome from rehabilitation. It is likely

that our patients would have required medical care if it was

provided at an offsite location given that the mean CIRSG

was 8.1. It also highlights the amount of bed days lost by

not having timely access to rehabilitation beds (5,503 bed

days per annum in this sample). With a higher burden of

co-morbidities, rapid transfer to the acute care unit within

the hospital, with access to radiological investigations is

essential to avoid busy emergency departments. This model

works well for onsite campus rehabilitation where patient

complexity at a tertiary hospital level is high, however,

further Irish studies comparing this to an offsite rehabili-

tation unit will be required for the future. It is noteworthy

that while patients significantly increased their mobility

while on the rehabilitation ward that most failed to attain

their pre-hospital admission mobility. Further research into

rehabilitation in this frail inpatient group is warranted.

There were some limitations to the study. The study

refers to a period of 8 years ago although the unit remains

similar in terms of size, therapy staff numbers and

assessment practices. Several patients had more than one

medical chart and some charts were unavailable. Full

clinical data were found on 112/155 patients with limited

data on a further 28/155. Computerised data on all patients

located admission to different departments and their dis-

charge destination; however, discharge summaries would

give insufficient data to score CIRSG in these patients,

let alone individual complications given the median length

of stay of 83 days. Barthel scores were not collated as the

study examined medical complications only. The Func-

tional Independent Scale was not used as an outcome

measure and further studies should consider use of such

standardised scales. A full admission list of medications

was available, but only classes of medications on discharge

were recorded during this study.

Conclusion

Irish data on inpatient rehabilitation of older people’s

complications and outcomes are scarce. Onsite campus

rehabilitation of older patients requires 24 h medical cover

to diagnose and treat potential complications. Access to

diagnostics and the ability to treat with intravenous fluids

and medications are essential. Further studies are required

to compare the incidence of complications and outcomes at

rehabilitation facilities that are offsite. Economic evalua-

tive techniques need to explore which site offers the best

cost–benefit valuation although this would be limited given

the spectrum of indications for rehabilitation as well as the

co-morbidities of patients presenting. Better and timelier

access to rehabilitation would be associated with signifi-

cant bed-day savings for acute hospitals.

Conflict of interest None.

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