So just to get started, we'll poll the audience. So you can see a poll that shows up that asks, are you an attending physician, a resident physician or a fellow, a medical student, or other healthcare professional? So for each of our polls, we'll give about 15 seconds for everybody to answer, and then we'll be able to review the results together. So great, it looks like we have about 76% of the people who are attending physicians and 14% who are resident physicians. Thank you so much for joining us. All right, so moving to our first question, just to get a sense of the policies within all the facilities that are represented within our session. Does your inpatient rehab facility accept patients with mechanical ventilation? Yes, without limitations, and we will wean into the facility if appropriate. Yes, but only if they're going home on the mechanical ventilation. Or no, not at all. Thank you so much again for your participation. And if you have questions along the way, please feel free to use the chat along the side, and our AAPMNR faculty and staff will be able to assist us with that too. So it sounds like the majority of the people in the audience do not accept mechanical ventilation, but there are a few who do, so that's good to know. Let's go to the next one. What about tracheostomies? Do you accept patients in your inpatient rehab facility with tracheostomies? Yes, no, or decided on a case-by-case basis? Great, so it looks like the majority of people do accept tracheostomies in their facilities. A couple of people do not, and there's one that's decided on a case-by-case basis. So that's a good, we do have a couple of cases to discuss further down the road, so that'll be important to note. So the next question, does your inpatient rehab facility accept patients with chest tubes? Yes, without limitations, even if it's with a water-sealed drain. Yes, but only if a tube is there that it can be discharged with, like a Plorex tube. Yes, but only if it's a mini dry-sealed drain, or no, not at all. Great, so this one's a little bit more split. It looks like about half of the people do not allow the chest tubes at all, but some people do allow chest tubes as long as they can be discharged with them, such as the Plorex tube. All right, next one. What about high flow oxygen? Does your inpatient rehab facility accept patients with high flow oxygen, yes or no? And if you have specific parameters or limits that you use in your facility as guidelines, please add them to the chat so we can share that with the group. Okay, so the majority do not allow high flow oxygen. Okay. The next one. No renown drips. Do you allow patients in your inpatient rehab facility with no renown drips, yes, no, or decided on a case-by-case basis? Great, so I'm hearing a lot of no there. Looks like one yes. Okay. How about the next one? Hemodialysis, intermittent hemodialysis, or yes, any frequency of hemodialysis? Yes, but no more than three times a week. Yes, but only if they are on a pre-hospitalization regimen so there is no plan for weaning or further adjustments. Or no, not at all. Very interesting. So it sounds like, it looks like everybody has an availability of hemodialysis except sometimes only three times a week and then sometimes regardless of frequency. Very interesting. So let's move to the next one. All right, our next. Oh, sorry, go ahead. Our next poll, does your IRF accept patients with no need for frequent transfusion of blood products? Yes, regardless of frequency, yes, but with limitations, or no? Okay. So it looks like about 20% say yes, regardless of frequency and about 70% say yes, but with limitations, with 10% saying no. And our next poll, does your IRF accept patients with need for radiation therapy during their rehab stay? Yes or no? So about 65% are saying yes and 35% saying no. We have just a few more polls here. Does your IRF accept patients with the need for chemotherapy? Yes, any chemotherapy. Yes, only maintenance, even if IV infusion. Yes, but only if it's oral or no. So, about 30% provide any chemotherapy, 4% only if it's maintenance, 48% only if oral, and 17% no. And our next poll. Almost done. Does your IRF accept patients with ventricular assist devices, yes or no? So, we're about 50-50 here with 46% saying yes and 54% saying no. And last but not least, does your IRF accept patients with known COVID positivity without a negative follow-up test? Yes, even if symptomatic, yes if there are no signs or symptoms for 72 hours, yes if no signs or symptoms for 7 days, yes if no signs or symptoms for 10 days, or no. And we're very split here, which we kind of expected. So 16% even if symptomatic, 11% if no signs or symptoms for 72 hours, 5% if no signs or symptoms for seven days, 26% if no signs or symptoms for 10 days, and no 42%. So we've seen a lot of variety in answers today, which is good. And I think we'll see a lot of different responses to our discussion cases, which are coming up next. But first, we'd like our panelists to introduce themselves and describe a little bit about their practice environment, starting with Dr. Brunetta. Yeah, hi, thank you. I am a medical director of a community-based hospital, IRF, in Northeast Philadelphia. It's a 20-bed unit at Nazareth Hospital. I'm also the medical director of Our Lady of Fatima Home Health Care. I'm a member of the AAPMNR Reimbursement and Policy Review Committee. And I'm co-chair of the AAPMNR BOLD Initiative Committee for Rehabilitation Continuing Care. Great. And next, we have Dr. Karana. My name is Seema Karana. I've worked at the University of Miami and Jackson Memorial Hospital for 14 years. We actually just moved to a new rehab building. Luckily, the building is still adjacent to the acute hospital, which makes it very convenient. And that's about it. Thank you. And next, we have Dr. McNary. Hi, I'm Lennox McNary. And I was the medical director of a 33-bed inpatient rehab unit until July, and now I'm a COO of a tech startup, so it's a little bit of a pivot. But our main hospital is a level one trauma center, and it has a primary stroke center. But our rehab unit was actually about a mile down the road, and it was an old hospital that was converted mostly into education classrooms. So we didn't have labs or imaging or anything like that, so a little different. We're also in rural southwest Virginia, so my perspective may be a little different than my colleagues who are going to be in the middle of larger cities. And last but not least, Dr. Strasser. Hi, I'm Dale Strasser, and for this purpose, I'm the director of our general rehab program. This is a floor at the Emory Rehab Hospital where we take a significant number of very medically complex patients, LVAD, solid organ transplants, multiple trauma, even some quadriplegics and Guillain-Barre type. I've been in academic medicine for about 32 years, and at least well over half of that has been primarily in inpatient rehab, along with some research into the VA and other administrative roles. Great. Thanks, everyone. We're going to move on to our first discussion case. So we have an 85-year-old woman with a history of hypertension, diabetes, AFib, and prior stroke without residual deficits. She had a left MCA stroke about five days prior to her referral to the IRF. She has global aphasia, severe oropharyngeal dysphagia, and dense right hemiplegia. The issues are primarily her medical conditions are optimized, but the acute care speech therapist has recommended keeping her NPO. The family reportedly refused placement of an NG tube or PEG because her swallowing quote unquote got better last time she had a stroke. The stroke service put her on a puree diet with honey-thickened liquids given by spoon. Team reports a wet voice after she swallows. Premorbidly, she walked with a cane and was independent with self-care, now moderate assistance with transfers and to walk a few steps, and she requires Montemax assist with basic ADLs. She has good support from her adult children, and her home is accessible. So we'd like to poll the audience, and then we'll go through with our panelists as well. So is this a patient that you would accept to IRF, yes or no, and if you could also respond if your answer would be different if she had been on Coumadin or Plavix, which may need to be held for several days before PEG placement rather than Eloquus, which only needs to be held a short period of time. All right, and while we're waiting for the poll to come up, poll results to come up, we'll start with Dr. Brunetta. Yes, I think I would accept this patient, and I think it's the basic issue here is the I think the swallowing and the concern is the swallowing and the safety of such, and I think that would be something we would have to intervene with the family in a large way and try to press upon them if she could not achieve safe swallowing, convince them potentially of getting a tube placed and accepting that, and in the meantime, working on the other areas of therapy for her. And next, Dr. Karana. So yes, we would accept her, but initially I would, or before she came, I would like to see if she can have a chest x-ray to rule out any aspiration, and then also I would want a family or friend to maybe provide her diet consistently for 24 hours and ensure there's no aspiration and adequate intake is possible. If this is possible, then she could come to rehab, but in the meanwhile, I would try to convince the family to place an NG tube as this can be easily removed as soon as she's able to take in adequate nutrition. And Dr. McNary. I would take her, and I think, you know, I'm not sure how many residents we are, med students we have here, but I think the things for me that really, at 85, that make it a definite yes also are the fact that she was actually doing so well beforehand and that she has such good support and the accessible home in addition to what my colleagues have already said. And Dr. Strasser. I share the concerns that other people expressed in terms of the aspiration risk and the nutrition. And it said that I think the rationale given to admit her or acceptable and I would accept her. Great. And we have a comment in the chat that the gentleman would attempt to get peg place put in prior to transfer possible, which is certainly very reasonable. And I could add that this was based on a patient that I recently had on my service. And we did in fact have to place the peg while she was on rehab. But fortunately, that's something that's relatively easy for us to do. Again, on Eloquus, I think if she had been on Coumadin or Plavix, I would have held off until the peg was placed. So let's look at our poll results. So 62% said they would accept to IRF with 38% saying no, and 43% said it would potentially be different if they had if she had been on Coumadin or Plavix rather than Eloquus. Great. And our next case. So our next case is a 59-year-old male with a past medical history of tobacco and alcohol dependence who presented to the emergency room with bilateral lower extremity numbness and paresthesias, which he had had for over the last month progressively with slight hand weakness noted as well. There was also urinary retention that started on admission to the hospital with a Foley catheter placed. Hemoglobin A1c was 7.0. The patient was started on insulin. A CT lumbar spine showed degenerative joint disease with spinal canal narrowing. And an MRI of the cervical and thoracic spine were normal. The patient was ultimately diagnosed with a B12 neuropathy and started on supplementation. Neurology has signed off, recommended outpatient EMG and nerve conduction studies, if not improving within two weeks. The issue was that the patient was medically stable, and as you all are aware, I'm sure, there's a push in general in acute care hospitals to decrease length of stay and get the patient to their next disposition. So we, when we're consulted in the hospital, we are frequently asked if we will accept the patient, although it's felt that there might need to be further workup. If the further workup is requested now by PM&R, the patient's likely to be transferred to our competitors or to a sub-acute rehab. Functionally and socially, social history, the patient pre-morbidly was independent, working full-time as a traffic planner, but now he's been assisted for transfers and ambulating 20 feet with a rolling walker. He lives alone in an apartment with two steps to enter, but family lives in the area and is able to support as needed. So would you have accepted this patient to the inpatient rehab facility, yes or no? And or would you also have insisted on further workup anyway, such as an EMG nerve conduction study or a lumbar puncture? So we'll start our discussion, as you're answering the poll, we'll start our discussion with Dr. Karana. So I do feel that he should be able to come. I did have some questions or concerns that I would like, if possible, answered before he came. I guess changes in bowel habits, any saddle anesthesia. Maybe if there was a reason why he didn't have an MRI of the lumbar spine, since he had one of the cervical and thoracic area. Also was neurosurgery orthospine consulted on the case? And was cauda equina syndrome or any other spinal cord compression ruled out? If he is coming, which I would think he would benefit, maybe if the Foley could be discontinued and we're able to do intermittent catheterization. And then finally, I would, for his disposition, want to find out if the steps have railing and if there's any other issues at home that he wouldn't be able to enter or exit his house. Those are great questions. So the patient was ruled out for cauda equina syndrome. The MRI was difficult to get because he had anxiety and was not willing to do an MRI. So he had to be done under sedation in the OR, actually. And so it was difficult to get the MRI to begin with. And so that delayed the length of stay already a few days. So to push for anything further was difficult. And in terms of saddle anesthesia, that was not seen. But we'll move forward with Dr. McNary for the discussion. This case always makes me laugh a little bit just because it was a very common threat at our hospital. If you don't take him, we're just going to send him home or we're just going to send him to subacute. And I hate getting bullied by the other specialties or case management and social work. But I think ultimately, it's trying to do what's the best for the patient. And I always tried to keep that in mind and always looking at what badness could happen at a lower level of care. And so I agree with all of Dr. Karana's concerns that she had mentioned earlier. And I think for me, the bowel and bladder piece, or at least the bladder management, that's something that our subacutes here cannot handle well. They're just not equipped with the staffing to be able to manage intermittent calf or bladder scans. And so for that reason, and the fact that he's young and making some progress at least and has support, I would want to bring him. Great. Dr. Strasser? Well, I too would have admitted for many of the same reasons. We have these situations where we suspect that the workup has not been comprehensive and we'll make suggestions that this workup be done, but that can only go so far. And also, I do appreciate the comments about the bladder incontinence, which is a very important task and it's hard to initiate an effective bladder program in a SNF. Dr. Burnetta? Well, first I have to thank Dr. McNeary for referring to this 59-year-old as young. I appreciate that. And I had to say, based on his functional status prior to admission, working full-time, et cetera, and he used Minisys to transfer his ambulance 20 feet, definitely would admit him. And I concur with the medical piece as well of working that up. It seems like that would be pretty straightforward. And I also concur with the fact that being pressured based on we're going to transfer out to a different unit is not the best way to handle patient care. Thank you. I would agree. And I do appreciate all of you and your support of not being bullied. So we did want to provide the best care for this patient and we did feel that they would not receive all that workup that needs to be done or the follow-up with bladder program and all of the things that you have mentioned. This was a case that I had. We did end up taking the patient in our inpatient rehab facility. And we are lucky enough that one of our rehab physiatrists does do EMGs on our unit. So she was able to complete the EMG. Patient ended up getting sent for a lumbar puncture anyway. And it did show consistency with Guillain-Barre. So the patient was ultimately transferred back to the acute care hospital, had five rounds of IVIG and did very well and came back to our acute inpatient rehab, which I feel was probably the best for this patient. He ultimately did get discharged home and did well. So looking at the poll, it looks like 95% of you would agree that the patient should be accepted to the inpatient rehab facility. And we're all sitting there about 50-50 whether we should really insist on that further workup at that time before taking the patient in. So I appreciate all of you, your responses on that. We'll go to the next case. All right. Our next case is a 58-year-old man with chronic progressively worsening non-ischemic heart failure, referred to IRF three months following placement of an LVAD with a course complicated by respiratory failure, septic shock due to bacteremia, and an acute kidney injury for which he required hemodialysis. He's now been medically stabilized, but his INR is sub-therapeutic at 1.5 with a goal of 1.8 to 2.5 for the LVAD team. However, there are no plans for heparin or lovonotz bridge. His last hemodialysis session was two days prior. There's been some recovery of renal function, and the creatinine is now 2.2 with good urine output. Nephrology wants to hold off on dialysis and monitor labs and urine output daily and just give dialysis as needed. And of note, he still has a Quentin catheter in place for access. Premorbidly, he was modified independent but had very poor endurance, now requires meniscus with most household mobility and self-care with need for frequent rest breaks. His spouse will be a caregiver and has begun LVAD care training. So is this a patient that you would accept to IRF as is or potentially hold off on? So if you could answer yes, no, and we accept patients with LVADs, or no, and we don't accept patients with LVADs because it looked like only about half of us accept patients with VADs. All right. And then we will pull our panelists, starting with Dr. McNeary. Thanks, Lauren. So we did take LVADs at our hospital, and this is somebody, yeah, I think depending on where you are, I'm curious to hear the other panelists. I think you could make the argument either way. Given his endurance, I would worry about his ability to tolerate three hours of therapy a day, but I also know in our area, the subacutes would really have trouble with that medical complexity, and so I think I would rather just bring him for a short stay and then get him home. All right. And Dr. Strasser? I, too, would likely admit this patient. Prior to the admission, I'd want to have a dialogue with the LVAD service, make sure we were on the same page in terms of the anticoagulation status along with the kidney status. And just to make the broader statement, for patients like this, it's vital that the admitting inpatient service have a good relationship with the LVAD service and a good give and take and some resources. It's also critically important that the nursing staff has been adequately trained in terms of monitoring the LVAD and have access to experts in the area if and when situations occur. And Dr. Burnetta? Well, I actually feel like this patient kind of represents kind of a very deconditioned patient. I know that terminology is kind of dangerous to use in the IRF environment, but my thought would be he might be more appropriately sent to an LTACH and have them manage him in the LTACH and progress him through a less than three-hour-a-day therapy regime. And if he's making progress there, there's the potential for transfer back to the IRF if he needs to kind of finalize his functional status prior to going home. But I would probably say no and likely send him to an LTACH where they can really manage a majority of these things. And Dr. Karana? Since we work so closely with the LVAD team and they're able to come and round almost daily if we need it or any other time if there's any problems, I would bring the patient and have them continue to follow the patient. Something I would also like to add is that I think if the patient is to need dialysis, to start working on that, or if the patient's not to need dialysis and the catheter has to be removed, know what the plan is for catheter removal. Who's going to do it? Is it going to be done on our service? Is it going to be done as an outpatient? And then the disposition, I was happy to hear that the spouse is already being trained. All right. There were a couple of questions that came up in the chat. So with regards to his potential transplant status, you know, potentially at the time he was not yet listed. And yes, the service was asking for us to provide the PRN dialysis with their ongoing input, which is pretty common here. Nephrology will like potentially just stop dialysis and monitor them here. Of course, it does make it hard to schedule therapies if you're not sure if the patient's going to dialysis or not. And I will just kind of while we're waiting for the poll results to show up, I will say this is a patient that we did, in fact, take. I mean, he did ultimately go home and did well, but we did have a number of extra days at the end, solely for the purpose of medical management of his Coumadin, because it had to be held for several days while we arranged to have the Quentin catheter removed. They didn't want to remove it with a high INR. And then we had to resume the Coumadin. So it looks like most people who accept LVADs would have accepted the patient. And then 44 percent said no because they don't accept LVADs. So thank you. And our next case. So our next case is a 40-year-old obese male healthcare worker who survived a severe COVID-19 infection for which he required ECMO. He developed necrosis of all the fingertips and severe critical illness myopathy with a zero out of five strength in the lower limbs, as well as a stage four pressure sore. Three months later, he was transferred to a skilled nursing facility, but he was readmitted a short time later for wound drainage. The wound now improved in appearance and no plans for surgical intervention. The issues are that he's extremely motivated, but very poor out-of-bed tolerance. And he has no LTAC benefit. Functional and social history, pre-morbidly he was independent. And now he's mod-assist with bed mobility and feeding. He's total assist with transfers and all other ADLs. He lives with young children and an elderly parent. Adult siblings can provide some. but not 24 hour assistance. And he has the first floor set up and can add a ramp at the entrance. So as we have the poll going for whether you would accept the patient to the IRF, we'll start at the discussion with Dr. Strasser. Okay. So this is a very challenging and very contemporary case. What I would do is, I see him as sort of at a loss of where he really should go. Ideally, a lower intense rehab setting than an IRF would accommodate his needs. He's basically a quadriplegic. However, he basically failed the skilled nursing. Let's say he's developed a terrible pressure sore. Likewise, he doesn't have LTAC benefits. So that's also not an option. So we're at the place where the best option available would be IRF. And then frankly, not that this is a primary reason, but this is a coworker. This is another health professional who has survived COVID. So yes, I would accept him. Dr. Burnetta. Yeah, I think Dr. Strasser stated most of the issues very, very well. You're sort of hemmed in with this patient. I think the issue would become how your FIM efficiency scores, et cetera, on the acute rehab unit, I think would be problematic with this patient. And I think your average length of stay obviously would be affected. So considering those areas, I don't know whether an alternative skilled facility that may have better wound care management, better scores might be worthwhile considering from this perspective and see whether he'd be able to tolerate that therapy at least first prior to coming to the IRF. Thank you. Dr. Karana. I would accept him to our facility as I think we've seen great improvement with a lot of the COVID patients. Also, my concern as stated before would be that he would have the same issues with his wound and maybe other issues at the SNF. So that's it. Okay, Dr. McNary. Yeah, I would bring him also. And I've seen so many of the critical, the severe critical illness myopathy patients really do beautifully in rehab, especially when we can start using things like overhead lifts and that sort of technology and highly motivated therapists. And I agree the fact that this is a colleague, I would have a conversation with our administrators and just say, hey, we're bringing this person just so you know, this is gonna be a longer length of stay, but I think that's the right thing to do right now. Right, I think this is a complicated case and it looks like our poll tells us that about 65% of the people in the audience would have accepted a patient to IRF. And I do see in the chat, there is a mention about medical complexity of the patient, which requires very close monitoring, which isn't always possible in SNF, which is some of the same things that you had been saying, that our panel had been saying. And a question that goes beyond this is whether it seems likely that the SNF could manage the complexity of the patient and whether the three hour rule, whether the patient really could tolerate three hours of therapy. So great points. Thank you for bringing that up in the chat. Lauren, did you wanna add to the conversation? Yes, no, I mean, I think it's a really interesting discussion. This is a patient that I advocated for and ultimately got accepted to my service where this patient has been for three months, however, making slow, steady progress. Although workers' comp initially denied this case, we were ultimately able to get workers' comp benefits, which has allowed us to keep this patient a longer period of time. So it's been a little over three months. The patient is now walking 175 feet with about min assist and the family's been trained and we're hopefully going to be able to discharge home within the next week or two. Wonderful. And it looks like there's one more comment on the chat that says, at my institution, the scenario is not uncommon and we accept a limited number of these patients at a time knowing we will need to place them on an alternative plan of care and they will have a longer length of stay. So great job, Dr. Shapiro. All right. Our next case is a 19-year-old man with severe multifocal traumatic brain injury following a car crash who was incidentally found to be COVID positive on presentation to the emergency room, reportedly previously asymptomatic. While still hospitalized two weeks later, he had bacterial pneumonia. Repeat COVID testing at that time was done and was negative, but when repeated again one week later, SARS-CoV-2 was detected again. He is referred to IRF four weeks out from the initial injury and the initial positive test. He is globally aphasic, making it hard to ask with regards to symptoms, but he's awake and alert, responding to visual and tactile cues and not requiring any oxygen. He's on a pureed diet with honey-thickened liquids for dysphagia. Y-count is slightly elevated at 12.5 and a chest X-rays without infiltrate. So it's now been one week since the last positive COVID PCR test and there's been no repeat tests done. Pre-morbidly independent, but now modicest with significant cueing for most mobility and self-care. Parents and sibling able to provide physical assistance 24 seven in an accessible home. So we'll poll you. The audience, would you have accepted to IRF? And I should specify, would you accept to IRF now without the additional testing, yes or no? And while we're waiting for our poll results, we'll start with Dr. Brunetta. I mean, I think the obvious answer would be you want to get a COVID test checked prior to him coming up to the IRF. But yes, and with that in mind, like once that is complete and negative, I think that would be fine to bring him up and work on his recovery. I think the age, the family support, pre-morbidly independent, I don't see, it seems to me that it'd be entirely appropriate to bring him up at that stage. Dr. Karana. I agree with what he had said. Maybe looking at the trend for the WBCs just to make sure nothing else is going on and how new that is. And then if we bring him, maybe just keeping him in one of the negative pressure rooms just in case something was to worsen. Okay, and Dr. McNary. I agree with Dr. Karana on wanting to keep an eye on that white count and make sure there's nothing else going on. We did not have negative pressure rooms. I definitely would have wanted that extra COVID test first. And Dr. Strasser. I would have also pushed for the follow-up COVID test. It does occur in the context where we have a changing knowledge base. And more recent information is shared that you can be COVID positive, test positive for some time afterwards, even though you're not considered infectious. So if he still tested positive, I would want sort of more assurance from infectious disease individuals that he wasn't infectious. We do have an obligation to keep our staff and other patients safe. Otherwise, outside of the COVID issue, he obviously would merit acute inpatient rehab. All right. Well, thanks everyone. This is in fact a patient that we accepted and it was probably an error because at the time the thinking was once someone was 10 days out, they were probably okay. But we know some people continue to shed longer. And because the patient was aphasic, it was very different. And he had a white count and tachycardia. It's very hard to really evaluate clinically. And he in fact tested positive on admission to inpatient rehab. We were very fortunate in that we do have negative pressure rooms in our new building. And we were able to keep him there and provide therapy in the room. And I think he did well during that period of time until he tested negative. He still benefited from our service, but we had to take every precaution not to spread the virus. So looking at our poll results, it looks like we're pretty split. 54% would have accepted to IRF, 46% said no. And there are some comments in the chat regarding current CDC guidelines. And yes, they do say no need to retest, particularly after 20 days. I think the challenge is really with those with significant cognitive and or communicative impairments, where it is particularly hard to judge whether or not they may have symptoms of ongoing infection. But thank you. We'll move on to the next case. The next case is a 78-year-old female with coronary artery disease who presented to emergency room with impaired cognition and balance after a fall. Patient was found to have a right subdural hematoma, which is managed conservatively. Serial CAT scans have been stable. There was a negative COVID swab on admission to acute care, but the patient did have known close household contacts that did test positive. There are no signs or symptoms of COVID, but mental status waxes and wanes. The patient was referred for inpatient rehab facility admission on hospital day number three. The issue is the patient, the recent contact with the COVID positive individuals. Both planned family caregivers are also COVID positive. Functionally, the pre-morbidly, the patient walked with a walker and had mild cognitive impairment. And a family did assist with meds and finances, but now the patient is modest with most mobility and self-care. Lives with a sister and an adult niece who would serve as the caregivers. So again, would you have accepted this patient into the inpatient rehab facility? Yes or no. And we'll start our discussion with Dr. Corona. So I guess I would like some things again answered. Upon discharge, will the patient, I think the patient will require 24-hour supervision and some assistance, so it's important to clarify if she has any other places to go as the main caretakers had COVID or have COVID and may continue to have it and may be symptomatic. Also if she remains COVID-free, will they be willing to let her, if needed, go to a SNF for a short amount of time, and so therefore does she have SNF benefits if needed? Also I just would want a little bit of background with the sister and the niece, how long, when they were tested and when was her last positive test. And then finally I'd also want to know if there are other scans or tests that they will be requiring for her, and if they know the dates for them, because sometimes we've had where they want a CT scan the day that they arrive or the next day, so if that's the case then maybe they can get it on the other side so it won't interrupt her therapy anymore. Dr. McNary? I agree with all those questions. That was one of my questions was at what point did her family test positive and were they symptomatic or not, because I think that makes a difference in terms of my wanting COVID-positive people to be taken care of this little lady. She would be high-risk for me. She's somebody I would be a little more inclined to send to subacute. Dr. Strasser? I would like clarification on the COVID history also, and again I would involve the local infectious disease people. I think one of the differences at an academic medical center is if you ask for it, you can get input from specialists, so I would probably accept her with that caveat. I think the concerns about social support following the hospitalization are equally valid, and then whether or not she had SNF benefits. Dr. Bernetta? Yes, I would accept her. The diagnosis of dual hematoma is in the 70-30 range for admission to an IRF. Given her age and her prior functional level, it seems it would be appropriate for her to come and have her three hours a day of therapy. Obviously, you'd want to get a COVID test, repeat COVID test prior to her coming up. Excellent. Lauren, did you want to add anything for this one? It looks like our poll shows 65% of the audience would accept the patient to an inpatient rehab facility and 35% would not. Yeah, this was based on a patient that was accepted to our facility. The information regarding the COVID positive caregivers was actually not provided to us at the time. Once we found out after admission, we did swab the patient, and the patient was negative, but unfortunately eventually had worsening subdural hematoma and had to go back for surgery. Again, had a negative swab, but immediately post-op spiked a fever and had some changes on chest X-ray and was in fact COVID positive. Despite adequate PPE, several healthcare workers in acute care who took care of the patient post-operatively unfortunately got COVID, but now are recovered. All right. Our next case. This is a 66-year-old man with no significant past medical history who presents with cryptogenic left MCA stroke, is monitored on telemetry for two days without events. Loop recorder was implanted. There are no episodes of hypertension. A1C is within normal limits. RPR is non-reactive. Only medications are aspirin, statin, and sub-Q heparin for DVT prophylaxis. He now has right flaccid hemiplegia, dysarthria, non-fluent aphasia, and requires pureed diet with nectar thickened liquids for dysphagia. So the issue here is no chronic medical problems, and this was actually based on a case that someone posted in FIS forum several months back where you have a stroke patient who clearly needs a lot of rehab but has no really significant chronic medical problems. Premorbidly independent, worked full-time, drove, worked out in a gym, now moderate assistance with most bed mobility and self-care, lives with spouse in an apartment with an elevator, and the spouse can assist on discharge. So is this a patient that you would accept to your IRF? Yes or no? And while we're waiting for the poll results to come in, we'll start with Dr. McNary. I would absolutely bring him just because he doesn't have chronic medical issues. I mean, he's had a new extensive stroke, and so I think you could justify it if you're worried about the medical complexity piece. This is somebody who's going to be at high risk for aspiration pneumonia, potential for spasticity, which you would need to manage, and you could talk about needing to monitor blood pressure closely. Even though he doesn't have hypertension, you, of course, wouldn't want his blood pressure to drop while he's down in therapy. So I think there's the risk of, as we always talked about, the risk of potential badness at a lower level of care if they're not monitoring these things. All right. And Dr. Strasser? I would accept this patient. He's got a lot of potential. You do want to minimize stroke risk factors and things like that, but I would definitely accept him. There's a lot to work on. Dr. Burnetta? Yes, absolutely. We'd accept him. I think it's a complex for speech therapy in terms of his non-fluent aphasia as well as the oropharyngeal dysphagia. It appears dysarthria as well. And given his functional status, and he has an excellent disposition to home with the elevator and the stow, so absolutely would accept him to IRF. All right. And Dr. Karana? Yes, we would accept him, and I think everything was already said. All right. So let's see our poll results. Yay! Finally, it's unanimous. Very good. All right. So we'll move on to our next case. All right. So our next case is an 86-year-old man with a past medical history of COPD, mantle cell cancer, and lymphoma, recently had a six-week course of ibuprofen for bacteremia, and then was on home oxygen with worsened dyspnea and cough and oxygen desaturation, and was taken back to the acute care hospital. COVID was negative. He was found to have new bacteremia with cenotrophomonas, started on IV steroids. Infectious disease was consulted, and now the patient's on minocycline, which they will switch to oral, but also a newer, expensive IV antibiotic, cefaziracol, which he'll need for seven more days. The issue? Rehab diagnosis is stability with COPD exacerbation. Administration asks you to take the patient because the IV antibiotic is very expensive and hard to get, and the pharmacy has made a deal with the pharmaceutical company to obtain the drug. The antibiotic takes three hours to run each time and is run three times a day. Functionally, the patient was independent premorbidly with ambulation and intermittently assisted with ADLs. Now, the patient's supervised for transfers, contact guard for ambulating 20 feet with a rolling walker, meniscus for most ADLs. He lives alone, but his daughter can stay with him. So, would you have accepted this patient to the inpatient rehab facility, yes or no? We'll start the discussion with Dr. Strasser. Okay. Boy, this is a challenging one. The short answer is yes, I probably would have accepted the patient. Prior to accepting, I would informally discuss both with nursing and therapy services. It's going to be awkward. He's got, as I calculate, nine hours a day of treatments. So, how will the three-hour day of therapy and other issues be factored in? The medical complexity certainly merits an IRF-level services, and there seems to be goals to work on. Okay. Dr. Burnett? Yeah. I don't think I would accept this patient based on the fact that he's had an extended course, six-week course of antibiotics, and he was still kind of on home oxygen worsening dyspnea prior to this most recent admission. And, you know, as pointed out by Dr. Strasser, that's sort of problematic in terms of the timing factor. And I don't see – I mean, I think a rehab diagnosis of debility and COPD exacerbation is not in and of itself something that would keep someone from coming up to the unit, but I believe the ability to tolerate and benefit from three hours a day of therapy would be an issue with this particular patient. So, I likely would suggest a SNF placement for this type of patient. Dr. Carrano? I think that, especially if the administration's asking for it and we're able – and they understand that we're going to try to fit the therapy in between the antibiotics, we would bring him for a short stay automatically. And I would have therapists work with him towards modifying independence's supervision as he was independent with ambulation and intermittently needed assistance with ADLs, but he's still not at his goals for maybe some of his transfers and ambulation. So, maybe we can work with him while he's finishing his antibiotics. Dr. McNary? Like Dr. Strasser, I thought this one was a little – is tricky and a little iffy. I find that our patients with COPD tend to not do as well as a lot of other conditions that, at least in our unit, the endurance always was an issue. Do we know what his oxygen requirement was? I believe he was on two or three liters. Okay. Yeah, my gut would have been subacute, but I think if that really wasn't an option because of the antibiotics, then I would have been willing to take him. Yeah, I mean, this is definitely one of those not-so-clear-cut cases. Our poll looks like 74 percent would accept patients to the inpatient rehab facility and 26 percent would not. And to answer the question in the chat, if there was an oncology consult, yes, there was an oncology consult during acute care. They felt that the lymphoma was stable and not currently something that needed to be treated acutely, so that was not an issue for that patient at this time. This was a patient we did accept into the inpatient rehab facility ultimately. He did complete his course of seven days of the antibiotic, and we managed to get in the three hours of therapy a day, which he tolerated well. He was sent home. Unfortunately, about a week later, he continued to have oxygen desaturation and ended up back into the acute care hospital. And then he needed the antibiotic again for a longer period of time, and he ultimately was discharged to a subacute facility at that point. So it's difficult. It's a difficult case. I appreciate all your insight. Next case. All right, this is going to be our last case before we take a five-minute break, and then when we come back, we're going to discuss trans-route-type cases. So this is a 70-year-old right-hand dominant man admitted following a fall off a ladder. He sustained multiple fractures of the right hand and fingers, which are splinted, and underwent posterior laminectomies and an instrumented cervical fusion for C7 and T1 fractures with severe subluxation. He must remain in a hard cervical collar. He's an insulin-dependent diabetic. So the primary issue with him is disposition. He'll likely need assistance with administration of insulin, and he was independent before, but now he's meniscus with basic ADLs and mobility, and, again, limited use of his dominant hand because of the fractures. And, unfortunately, he resides at the Salvation Army with no local family to assist. So is this a patient that you would accept for inpatient rehab, yes or no? And while we're waiting for poll results to come in, we'll start with Dr. Burnetta. I would say no. I think for him, you probably want his management, the diabetes, to be supervised and assisted in a skilled facility prior to, you know, going back to the Salvation Army. I think a short stay on the IRF probably wouldn't benefit him as much as the relative safety of being in a SNF and having a prolonged admission there. Someone's asking if he had significant polyneuropathy. Just very mild. So we'll go to Dr. Carano. If he does have SIF benefits, there may be a reason maybe actually to bring him to see what type of progress he can make, and if needed, he may need to go to a SNF for a short time afterwards. If he does go back to the shelter, I would want to make sure that if he has insurance, that they will ensure that he has nursing and aid to assist him. So even if he does end up going back, somebody will be working with him at the shelter, which we've done before. Dr. McNeary. I would have liked to have seen him go to subacute so he'd have that nursing care to manage his diabetes. This is a fairly typical sort of story for us, but it would be a patient who was just enough younger that they wouldn't have Medicare and wouldn't have any insurance, and so we would usually bring someone like this and then coordinate with the medical unit at our rescue mission, which is like Salvation Army, and they did a fantastic job of taking care of patients like this. We would just try to make sure we got everything tucked in and then hand them off to the medical unit there. Great, and Dr. Strasser. In an ideal world, he could go to a SNF, get the longer course of both medical management and rehab management, and then something to consider if after that and after some of the restrictions on his hand are lifted and he still has some deficits, you could consider a shorter length of stay back to IRF. This is something we don't do very often, but I think there is a niche here for people coming to IRF after they have stabilized, and I assume that there was no myelopathy. Correct. All right, so let's see our poll results. So we were pretty split, and I kind of agree with Dr. Strasser. Ideally, he would go somewhere else first and then to IRF potentially. Because of some social limitations with him being uninsured, we did accept for inpatient rehab but set up some nursing for him at the Salvation Army for insulin administration. Still felt fairly uncomfortable discharging him to that setting, but unfortunately, it was necessary. So thank you, everyone, for your attention thus far. We're going to take about a five-minute break so everyone can have a nice stretch, get something to drink, go to the restroom. We'll monitor the chat in the interim, and we have a five-minute countdown that we're going to start now. All right, everyone. Welcome back. Thank you for making it this far. So our next section is going to be about should they stay or should they go when they're already a patient in the inpatient rehab and whether they need to be sent back to the acute care hospital. Over the break, there was a question that came up on the chat, so I'll just open that real quick to our panel. Can anyone on the panel please comment on the appropriateness of admitting observation patients with Medicare insurance to the inpatient rehab facility? I feel that the majority do not meet IRF criteria. A colleague of mine that works at a different health system has a blanket policy of not accepting any Medicare OBS patients. I have also seen competitor IRFs take a significant number of Medicare OBS patients that I did not always agree with. So at my facility, we find that there are often patients that are appropriate from OBS, not always, but as Dr. Shapiro also mentioned, they don't need a three-day length of stay to qualify, a three-day hospital stay to qualify for acute rehab, and sometimes they do meet the appropriate criteria. Not always, though. I would agree with you there. Yeah, an important thing to mention there as well is that during this COVID emergency, they've waived the three-day rule for SNFs so that an OBS patient who's been there for a day or two, you know, it's not like you have to wait it out to get admitted to the IRF, and or in the current environment, the SNF as well can bring the patient. The patient can go to a SNF after an OBS admission, and they don't have to wait for the three-day rule either. So it's a somewhat antiquated rule from quite some time ago, and the hope is, and AAP Menard sent in a letter saying that, you know, if the possibility is to rid that rule forever, it would not be a bad thing. Lauren, we used to get a ton of consults on OBS patients, and I started working with the complex care team on a lot of these patients because we found that they really were very frail patients, and we actually started using the frailty scale or frailty score, and were able to get a lot of these patients to meet criteria for admission to the hospital back when we did have to worry about the three-midnight rule. But for patients that we didn't feel like were appropriate for rehab, a lot of times that was the way to get them admitted and actually get them a good workup and get them where they needed to go. I find a lot of times some of these referrals are patients for whom acute rehab was actually recommended, and then they go home and they realize they can't handle things, and they wind up back in the emergency room and wind up as observation. The other category are people who maybe had strokes, and they come in a little late, and they're able to do the workup relatively quickly, sometimes within 24 hours. So there's no reason not to take them if they're otherwise appropriate. And I would say some other forms of trauma, like nonoperative fractures, for example, are another good example where, you know, if they're not going for surgery and their pain is reasonably controlled on oral agents and they're able to do therapy and require the level of care you're providing, I think it's certainly reasonable to admit them. Right. In our facility, this is a common thing because we have an elderly population in the area, and they're constantly falling and having a fracture of some sort that's nonoperative. So in the OB, that's where we find those patients. And a lot of the times they do seem appropriate. Okay. So moving forward so that we don't get too far behind, we're going to move to the first case. All right. So we have a 75-year-old woman who's on rehab following an ORIF of a left intratrochanteric femur fracture. She's progressing well in rehab but is very anxious about returning home independently. Her adult children live in New York, and due to isolation orders at the time, they are unable to come to Florida to help care for her. She has selected a local subacute rehab facility, and she has a COVID PCR swab ordered, which was at the time mandated for transfer. The PCR test unexpectedly returns positive. She is completely asymptomatic. So is this – obviously we can't – at the time we were unable to transfer to subacute rehab facilities. So is this a patient that would you keep in inpatient rehab or transfer to acute care? So we'll wait for our poll to pop up, and we will throw this to our panel beginning with Dr. Strasser. So if the staff has gone through – the rehab staff has gone through all the appropriate precautions on how to use protective equipment and everything, yes, I would keep her on acute inpatient rehab. Dr. Carano? I agree we would keep her on inpatient rehab and place her in a negative pressure room. In the meanwhile, we would try to increase her confidence and independence and possibly try to get her home where by that time family would be able to come and assist her. And hopefully then she won't need to go to a SNF in the meanwhile. Dr. Burnetto? I mean, I would keep her on the unit, but I would definitely try to repeat the test like the next day and see whether you're getting a negative test at that stage. And at that point, you know, allow her to go to a local subacute rehab. I'm kind of surprised a patient like this would be admitted to IRF. Like in Philadelphia, we wouldn't really probably get the insurance approval for an admission without comorbidities of a 75-year-old ORIF. That's interesting. We usually do get authorization even when they're in Medicare Advantage plans just because of their risk for complications. Dr. McNeary? I don't have anything to add. I think everybody else hit the highlights. All right. So obviously I think facilities' rules regarding COVID positivity have changed a lot throughout the pandemic. At the time, we did have to transfer her to acute care, although we subsequently had cases that we kept at our facility. And it looks like we're pretty split here with 59% saying they would transfer to acute care and 41% saying no. All right. Our next case? So our next case is an 83-year-old gentleman with a past medical history of hypertension, hyperlipidemia, and chronic low-vaccine status post-priorospinal fusion, but also with three prior strokes and residual mild cognitive deficits. He was transferred to the inpatient rehab facility three days after his recent new right posterior parietal acute stroke with only left-hand grip weakness. He had been discharged to acute inpatient rehab with Agrinox twice daily. He arrived on a Friday night. He was ambulating contact guard in the room to the bathroom. And throughout the day on Sunday, which was day three in the IRF or day six after his stroke, he was noted to have slight increases in weakness and facial droop through the day. A stat CT was negative for bleed on Sunday. And by Monday morning, he now is at max assist for transfers. And there's no other changes in mental status, and his vitals remain stable, just a change in transfers. Would you have transferred this patient to acute care at this time? We'll start this discussion with Dr. Karana. Well, initially, I would try to keep the patient and start the workup of the patient while the patient was on rehab, considering repeating a CT and possible MRI and consulting neurology. If neurology felt that there was further workup or interventions needed or they felt uncomfortable with the patient staying with us, then I would transfer the patient to acute. But initially, I would start the workup on our floor. Dr. Bernetta? I would transfer her off the floor based on the fact that you have an acute decrement in function and you really don't have an etiology on the unit. So to me, I think this would be basically an acute transfer likely to the ER on like a neuro protocol for this patient to be evaluated. Dr. McNary? I think this is one I probably would have sent back to. I'd be worried about some underlying infection, possibly a new stroke, and I think I would have sent him back for workup. And Dr. Strasser? More than likely, I would have sent the patient back for workup. There's been a significant change in function, and we don't have a good understanding of what it is. So I concur with what other people were saying. Okay, and looking at our poll, it looks like 65% would have transferred to acute care and 35% wouldn't have. This was a difficult case on our inpatient rehab unit patient. We have a pretty close relationship with the neurologist, so we were able to work with them. They felt that the patient was stable, and this was just an extension probably of their first stroke. An MRI was eventually done. But the patient remained medically stable. However, because of his back pain that flared up, he also began having some mental status changes later in the week. So by the next weekend, he was transferred to acute care to rule out any changes neurologically. He had a repeat MRI, which showed no changes, and he ended up back in our acute inpatient rehab facility. So I think this was a difficult case and very uncomfortable for some of our staff members as there were changes in some of the functions. So not always so clear cut, but thank you. All right. Our next case is a 72-year-old man with myelodysplastic syndrome who had been receiving frequent outpatient platelet transfusions, who then presented to the hospital with small bilateral subdural hematomas. Neurosurgery consultant recommended no surgical intervention but requested his platelets be kept above 100,000. Nevertheless, he was transferred to IRF with a platelet count of 13,000. Despite receiving two units of platelets, the count drops to 8,000 two days later. A CT brain is repeated and is stable. His mental status waxes and wanes, and he participates poorly in rehabilitation. And at the same time, we're somewhat limited in our ability to get him out of bed due to the low platelet count. The family understands his poor medical prognosis, and they're contemplating DNR status, but haven't yet committed to that yet. They are, however, committed to providing him care at home. So is this a patient that you would transfer to acute care? Yes or no? And we will start off with Dr. Burnetta. Oh, that's a tough case. I think obviously you want oncology consulted to follow this patient up on the unit. Man, I think this patient probably may need hospice consult as well. And I don't know how much we would be doing for him on the IRF. I probably would transfer him back for those reasons. Dr. McNary? I would be, with somebody like this whose mental status is waxing and waning, I would try to avoid transferring him back, I think, if the goal really was to get the family to take him home. And we were lucky to have an awesome palliative care team at our hospital. So I think, you know, as was mentioned, I would probably have them come over and have some discussions with them and the family about goals of care, and really probably pivot to focusing more on family training and really try to get him home as quickly as possible and not have to put him in a different setting to be more stressful on him and the family. Dr. Strasser? I concur, primarily with the rationale of keeping, I would work in conjunction with hematology and make sure we're all on board. But having said that, I would concur with the rationale of keeping him on the unit, almost as like a pre-hospice type of planning care coordination role. I would be concerned about just the upheaval of a transfer, but again, I would do it in consultation with hematology. All right, and Dr. Carano? I would keep the patient, and I agree with everything that was said. Great. And we, in fact, did keep the patient. Hematology rounded daily. We did get palliative care involved, and we focused primarily on just caregiver training for his family to enable a safe transition home. So about two-thirds said they would, however, transfer to acute care. I was certainly tempted to on several occasions, and one-third said they would not. So we will move on to the next case. The next case is a 71-year-old female with a past medical history of hypertension, hyperlipidemia, and seizures, now with a new hospitalization for exacerbation of multiple sclerosis, treated with IV steroids and acute care. MRI of the brain and C-spine also showed right parietal lobe stroke, now with a left upper extremity in coordination and weakness in addition to the baseline right hemiparesis. On the day after admission to the inpatient rehab facility, the patient was found to have seizure-like activity during the occupational therapy session, with truncal extension and eyes rolled back, foaming at the mouth for one minute and unresponsive. It spontaneously resolved in little over a minute. The patient is already on Tegretol for seizures. I guess my first question would be, would you transfer the patient at this point? But then neurology was consulted, Tegretol was increased, and two days later had another seizure, a similar seizure episode, and Kepra was started. Would you transfer the patient at this point to the acute facility, the acute care hospital? Dr. McNary, could we start the discussion with you? Seizures always make me nervous. So I think I would not have transferred out after the first one. The second one makes me a little nervous. But I think, you know, they started Kepra. I would have probably kept the patient, I think, number three, and they would have been out, though. And I would have talked to neurology about maybe doing a 24-hour EEG or something like that. Sure. Dr. Strasser? I would work in close coordination with neurology, make sure that they were on the same page. Assuming the decision was made to keep the patient on the unit, adding the Kepra, this is going to be a very complex discharge issue, and you probably will uncover even further deficits. She's had a new right brain stroke. Many of us have had experiences with multiple sclerosis patients. As it gets farther on, some judgment and other issues come to play. So I would have worked with neurology like I would have kept the patient. Dr. Karana? At least initially I'd keep the patient, like we were talking about, working with neurology and getting further testing if it can be done on our service. If they want other tests done that cannot be done on our service and are going to interfere for a prolonged period of time, then I would consider transferring the patient off because they won't be able to participate. Good point. Dr. Bernetta? Yeah, I think I would keep this patient. I wouldn't transfer them off the IRF. I think the exacerbation of multiple sclerosis concomitant with a stroke, I mean, I think that type of individual really would benefit from therapy, and I kind of feel like as long as neurology is involved in keeping an eye on things and there's no ‑‑ I think that would be reason enough to keep the patient on IRF and hopefully get them back to where they can get home and function as they were previously. Sure. And looking at our poll, it looks like 68% would have transferred to acute care, but 32% would have not. I think I would echo a lot of what was said by the panel, and it really depends on the level of coordination with neurology and what they're looking to do. So neurology had been involved in the switches of the seizure medication. The patient luckily did not have a third seizure. We did keep the patient on the unit, and the patient did okay and was discharged. So again, it's interesting to see the 68% that would have transferred to acute care because we certainly thought about it. Okay, moving to the next piece. All right. We have a 60‑year‑old man who sustained a concussion, bilateral pubic rami fractures, multiple rib fractures, and a left femur fracture, now status post I am now, and a jet ski accident. He's progressing well in rehab and normally sats in the mid to high 90s on room air, and he's receiving Lovenox, 30-milligram subcu BID for DBT prophylaxis. Late at night on rehab day five, he developed some chest pressure, and O2 sat dropped to 88%. The on‑call MD placed him on supplemental oxygen, which helped, and ordered a CTA of the chest. Two hours later, the patient is completely without any chest pain or chest pressure, and he's sat in 94% on room air. At that time, the radiologist calls to report a small subsegmental PE, and EKG is without any evidence of right heart strain. So is this a patient that you would transfer out? We will start the poll, and then we will ask Dr. Strasser. I want to congratulate Sue-Ann and Lauren. These are very challenging cases and quite illustrative. We at Emory, we were fortunate. There's actually a PE team. So the patient sounds like male, sounds like he's relatively stable. EKG doesn't show any evidence of a right heart strain. He can be treated with a therapeutic Lovenox. So with the involvement of a pulmonary embolus team or comparable professionals, I would probably keep him. Dr. Carano? Actually, he said everything I was gonna say. Because he's stable right now and he looks relatively good, I would start the therapeutic dose of Lovenox. And as long as he continues to be stable, keep him on the floor. Dr. Burnetta? Yeah, likewise. I mean, he's multiple fractures. He's an excellent candidate given that he's 60 years of age and he was a jet ski, I'm pretty impressed. And I think you might want to consider if he's on that Lovenox for DVT prophylaxis and he has his PE, you might want to consider a hematology or neurology consult regarding thrombotic therapy for him, whether that's enough or whether you need to alter that. But definitely would keep him on the earth. And Dr. McNeary? I think this case is a great illustration of how our practice patterns change over time. Because I know when I started 12 years ago, out the door, would have been back over at the main hospital for telemetry, no questions asked. And this is somebody I would keep. I love that they got the EKG. That would have made me feel more comfortable about keeping him. Great, thanks. Yeah, I like this case for the exact same reason because 10 years ago, we would have transferred this patient out, but we in fact did keep him and he did great. And it looks like 41% would transfer to acute care and 59% said they would keep. So we'll move on to our next case. The next case is an 86 year old female with past medical history of COPD, hypertension, hyperlipidemia, triple A repair, MI two years prior with without sensing in a prior stroke, transitional cell cancer of the right kidney since 2009 status post nephrectomy, now admitted for hospitalization for COPD exacerbation. Currently on two liters, O2 via nasal cannula, has a history of CKD4 due to solitary kidney with a baseline creatinine of 2.5 to 2.8. While in acute care, the creatinine had gone up to 4.1, but the patient and the family refused hemodialysis. So after a few days, the creatinine remained stable at 4.1 and a nephrologist and internal med physicians felt that the patient was medically stable to be transferred to a patient rehab facility. Nephrology has been following the patient closely while in IRF, but by day four in the IRF, creatinine had continued to go up now to 4.7, but now the patients and the family were agreeable to starting hemodialysis. So is this a patient you would have transferred to acute care at this point? Yes or no, we'll start the poll and we'll start our discussion with Dr. Karana. So in this case, we've had several of these types of patients where they didn't, they were not started on dialysis for whatever reason and needed dialysis when they were on inpatient. So we normally just work with nephrology and IR and have the catheter placed for dialysis and then start dialysis as needed or three times a week or whatever is required and make sure it's just scheduled after therapy. So after 3 p.m. so they can continue receiving all of their therapy. Interesting, Dr. Burnetta. Yeah, I mean, our IRF is in an acute hospital setting. So I believe we could achieve the institution of the hemodialysis and get it started in house and keep the patient on IRF and continue with the therapy program, timing the interventions to the dialysis. Dr. McNary. If this patient were 50, I would keep them but the fact that it's an 86 year old, I would send them back to the main hospital. I think there's so much risk for bad outcomes when starting dialysis in a patient that age especially with the prior MI, the prior stroke, they're gonna need really close monitoring and I would worry about their ability to tolerate dialysis at their age and then try to do three hours of therapy a day. So I would send them back. And Dr. Strasser. Well, I'm gonna side with Dr. McNary on this one. This person has a lot of comorbidities and it's quite delicate. And I would of course wanna work closely with the nephrology service but I'd likely would push for transfer. There's also a practical issue here. The RAND date clock might be reset when they came back and they could deal with any peri-procedure delirium. Sure. So the poll I'm surprised is 29% would transfer to acute care and 71% would not. This was a patient we did end up sending to acute care to have the catheter replaced and to have the start of hemodialysis to be done over in acute care. It is one of those cases where unfortunately the patient did end up in acute care and refused the hemodialysis again. Patient refused again and the family refused again. Ultimately this patient, they ended up going into palliative care and hospice and passed away shortly after. And we'll move on to our next case, Lauren. All right. Our next case is an 80 year old woman with a history of high blood pressure receiving inpatient rehab following an ischemic stroke. She had no arrhythmias captured on two days of telemetry before transferring to rehab, nor any known history of AFib. On rehab day number seven, she complains of some palpitations and her heart rate is noted to be 130 beats per minute. Her respiratory rate and oxygen stats are normal and EKG is obtained and confirms AFib with RVR. While waiting for the physician on call to arrive, the RN administers the patient's usual evening dose of metoprolol by mouth for hypertension. Within a few minutes of the physician's arrival, her palpitations have resolved and her heart rate remains in the 90s. So is this a patient that you would transfer out? We'll poll the audience and we'll start with Dr. Bernetta. Now, again, I think medically, at least right now she's stable. And I think this could be tracked by cardiology consult on the IRF unit. She's a stroke patient. I think that it's appropriate for her to remain on the IRF. Obviously, if symptoms persist or worsen, that would be a cause for transfer. But this patient, I would keep on the unit. Dr. McNary. Yeah, I would keep him. I would consult cardiology, probably get, or at least have a phone call with them and probably get her set up with a ultra monitor and then talk with the therapist about just watching vitals and when to be concerned. Dr. Strasser. I would like to be able to keep this patient on the inpatient unit. I would, this would necessitate close collaboration with cardiology and I like the point about educating the other rehab professionals. All right, Dr. Corona. I would keep her on the unit. Since we, in our new rehab hospital, we have telemetry beds. I would move her to one of the telemetry beds and work with cardiology closely. And if it recurs, probably send her to acute. All right, and that's basically what we did. We did use telemetry and we monitored her heart rate and she did quite well. So only 4% would have transferred to acute care. 96% said they would keep. I would say this is another case where 10 years ago, I would have definitely transferred the patient out and it kind of shows you how practice patterns have changed over time. So we'll move on to our next case. And regarding that last case, Dr. Shapiro, I would say, maybe this is something we should have told in the beginning too, whether you do telemetry on your inpatient rehab, because I have a feeling that a good number don't. I know we don't, yeah. So, okay, moving on to the next case. So the next case is a 50-year-old obese female without significant prior medical history, initially hospitalized with COVID-19 pneumonia, had a prolonged complicated course, which included an empyema for which a pigtail catheter was placed. And then she was discharged to the IRF with it, has had two negative nasopharyngeal swabs. From rehab day number five to number eight, she had worsening leukocytosis from 11.7 to 20.2, worsening drain output and anemia with a hemoglobin going from 8.1 to 6.7. She's awake and alert with poor activity tolerance and resting tachycardia with a heart rate of 120. Oxygen saturations are in the mid 90s on with two liters of O2. So would you have transferred this patient to acute care at this time? We'll start the poll of yes or no, and we'll start the discussion with Dr. McNeary. Sorry, the poll keeps popping up in front of my mute button. When I first read this, I missed the anemia and the hemoglobin dropping to 6.7. My initial gut would be to repeat the imaging on her and that she might need transfer back to initially, I mean, ultimately, but I wonder if IR intervention, if we saw something in IR could intervene, if we could really keep her on the unit. But now that I'm seeing the drop in hemoglobin too, that makes me a little more nervous. I think I'd start the work up, but low threshold to transfer back. And Dr. Strasser? I agree with that. Start the work up with a low threshold to transfer back. Dr. Karana? I really feel like she needs a complete work up done. And because she's unable to participate in therapy in the meanwhile, I would plan on transferring her back. And Dr. Burnetta? Yeah, I agree with all my colleagues. I would transfer to the acute hospital. The coagulopathy associated with COVID-19 can be quite significant. So I think given that you'd have to transfer from the unit. And our poll shows that 89% would also transfer to acute care, 11% would not. I wanted to also mention that on our unit, our nurses would be very uncomfortable with this patient, and they would probably not stop bothering us to transfer the patient out. They use an early warning score based on the parameters of the vitals and some of the lab parameters. And if it meets a certain threshold, then they automatically call rapid response and send the patient out from, or have internal medicine decide whether the patient should be sent out anyway. So this would be right on the border for us. Lauren, do you have anything to add with this patient? Oh, we transferred this patient out. They probably re-referred to readmit to IRF right away, but they did require several days in the hospital for stabilization. Right, all righty. And our very last discussion case is an 80-year-old man with end-stage renal disease who recently started hemodialysis as an outpatient. He presented with a small subdural hematoma that was managed conservatively and a large leg hematoma without any fractures. He was noted to have some improvement in renal function and hemodialysis was discontinued by nephrology who planned to monitor in IRF. He progressed to a supervision level and was anticipated to discharge on rehab day eight, but on the planned day of discharge, awoke feeling short of breath and oxygen saturations were in the high 80s, but they did respond to two liters of oxygen via nasal cannula. Chest X-ray revealed pulmonary edema. The medical consultant recommends IV Lasix, which we don't typically do on our floor. So is this a patient that you would transfer out? Yes or no? We will poll the audience and we will start with Dr. Strasser. Well, I would likely transfer this patient out simply because of the drop in the oxygen in the pulmonary edema and 80 years old, multiple risk factors and the question of the kidney function. Dr. Karana? Even though we don't like to give the IV Lasix on our floor, I know that we can do that. So I would give the dose of IV Lasix and if the patient's clearly improving, possibly consider keeping the patient, but if not, transfer the patient out and start any other workup on our floor in the meanwhile. Dr. Burnetta? I would transfer her off. I think you've completed the therapy functional component of his admission and there's a lot going on there with the hematoma and the subdural and now he has a desaturation. I'd be worried about from a coagulopathy standpoint or it seems like he has a bleeding diathesis. Something's going on there that probably needs to be at least evaluated on the acute side prior to being discharged to home. And Dr. McNary? He's so close to going home. I would try to see if we could tuck him in and just keep him a few more days and then send him home. So like Dr. Karana, I would give the IV Lasix and see how he does. If he doesn't respond, I would send him back. And I would just like to say, I love the fact that both in the polls and our discussion, we are not all agreeing on every case and that's some justification or vindication, I think from years of on consults hearing, well, y'all aren't consistent in how you make your decisions. And this just makes me feel better that we're all looking at the same cases and coming up with some different takes on them. Yeah, well, thank you. I agree, it's always interesting how divergent our decisions would be. And here in the poll, 66% said they would discharge or transfer to acute care and 34% said they would not. I will say that this is a patient that I tried to transfer to acute care, but unfortunately it happened during our COVID surge here in Miami and beds were very short. So for that reason, I did wind up keeping the patient very closely monitored. I did give the IV Lasix on the floor, again, which is outside our norm, that's something we technically can do in an emergency. And we were ultimately able to transfer that patient home a few days later. So I think all of our panelists for their sharing their expertise, I think it was very illuminating. And we just wanted to open up the session to hear from our member community. We know that this year has been a very interesting one and challenging one for inpatient rehab doctors across the country. So I thank everyone for participating and we're gonna open it up to questions in just a few minutes. We'd also like to hear from anyone with any ideas as to what issues or topics you'd like us to address with next year's inpatient member community, which hopefully will be in person. But please, this is meant to be as interactive as possible. And we will be unmuting people to speak in just a minute. Before we do that, though, I just wanted to highlight our member community. We are on PhysForum. This is a great way to get input from a lot of rehabilitation physicians across the country. So please look for our member community there on PhysForum and share any new information that you find interesting or any questions or concerns you have there as well. Joanne, you want to take it away? All right. So we just want to thank everybody for attending and we wanted to see if anybody had any questions or concerns or any topics that they would like to bring to the whole session. We appreciate your comments in the chat and for all of your participation. One person did say, I think the support staff available and the relationship with other services influences our decision to keep versus transfer. And I think that goes right with what Dr. McNary was saying that we do have different opinions and different answers to these questions based on a lot of what resources we have available to us. So I think PhysForum is a great location to also discuss what other people would want to do for certain cases as well. So please take advantage of that and any other topics that might be of interest to you. Any other topics that might be concerning. So does anyone have any issues or topics that they would like to discuss? We can unmute the community. I'm looking at the chat and I thank everyone for their comments. I see one comment about any interest in doing such sessions on a regular basis. And I think if people feel like it would be helpful, I'm certainly happy to participate and help facilitate in any way. I think we have no shortage of difficult cases for discussion. Absolutely. Oh, what is my secret to getting hip fracture patients with Medicare Advantage insurance? I want to know that, too. I'm not afraid to call for peer-to-peers. I feel like being a native New Yorker comes with an advantage. I kind of go in and I don't take no for an answer, and I think they just agree to shut me up. But I do highlight, you know, most of them have some post-operative anemia, some constipation. You know, maybe they have one or two, like, controlled medical problems. Highlight their pain medication needs. And then their functional status and their Dyspo. We're very fortunate in that many of our admissions are seen first by our consult service, particularly at Jackson Memorial Hospital. And they do a really nice job trying to capture those conditions, because I find too often, especially for patients who wind up on hospitalist services, they're not really good about documenting the comorbid conditions. And often they come and then, like, within, you know, an hour, I have, like, a list of, like, 20 other conditions that should have been listed in the medical record. So I think, you know, if you do have a consult service, it's excellent. I'll put in a plug for my colleague, Dr. Val Buena, just started a consult physiatrist, for our community group. So for those of you who do acute care hospitalists, hospital consults, I think it would be great to join that community as well. So I'm looking at Anup's comment again. Sorry, Dr. Shapiro, so just to add to that, you know, we just wanted to say that we had talked about earlier, when this community session was supposed to be in person, about doing a whole other section about peer-to-peers and the denials we get and how to really approach those. So we can do that in the future, too. And I think peer-to-peers is a whole other topic that's changing as well. And we instituted our consult service not too long ago and have made a real big difference in those peer-to-peers. And I specifically remember one case that recently, we know that if we had been the ones to do the peer-to-peer, we would have won that peer-to-peer because we could fight those harder. Instead, it was an internal medicine resident who tried to do the peer-to-peer, an intern. I think it was her, you know, third month. And she tried to do the peer-to-peer, and it was too late by that time. So I think we have more in our pocket to try to fight those. Agreed. Agreed. It was also a little bit easier to get those types of patients in during the COVID surge because there weren't great options for many of them. That's interesting. I'm seeing another comment that they have luck at their institution bypassing the peer-to-peer and going straight to family appeal. And that's another great point. You know, definitely engage the family. I recently had a patient who went on CNN with her family and advocated for herself. We've been actually instituting appeal letters, advocacy letters that we send directly to the insurance company as well, and that has overturned some for us as well. Yeah. You know, and Dr. Balbuena is commenting in the chat that she educates the insurance medical directors about femur fractures being a CMS-13 diagnosis. I think that's a great point. Well, I mean, but then you have, I mean, that's kind of comparable to bilateral knee replacements. Yeah, they're their CMS-13 diagnosis, but the managed Medicare insurances do not really accept them without comorbidities. So someone is asking if we could comment about DBT prophylaxis for patients with chronic anemia and then leukemia. I don't know if anyone wants to take that. You know, I find if their anemia is stable, I'm usually going to give them appropriate DBT prophylaxis. If they have a dropping hemoglobin, I'm certainly concerned, and I need to evaluate that before I give them chemical prophylaxis. We have a close relationship with hematology oncology, so if there was that case, we would get them involved and get clearance from their perspective as well. Any other comments, or? Oh, that's interesting. How many take patients with traits which have never been downsized? Interesting. I do. We probably would, too, but it would be very case-by-case. Would the rest of the panel like the traits? Same. Prefer downsized, inadvertently sometimes get them not. Same at Emory. It seems like a lot of the traits get directed to LTACHs. I would say, though, because we primarily keep Shiley number sixes on our floors, if they have any other size, I make sure I have a supply on the unit before I accept them. Great question. Any others? That's another great question from Joseph Collins. Have any of your IRFs been accepting patients pending preauthorization? Dr. Strasser? In accepting patients pending preauthorization, I think all our patients, we have recommended IRF admission and been denied. So I think everyone gets preauthorization. I think what they're saying is admitting a patient prior to getting the prior authorization, assuming that you're going to get the prior authorization as they get admitted to the IRF. That would be an administrative decision above my pay grade. Dr. Bernetta? Likewise. I haven't done that. I'd be apprehensive about that. They probably wouldn't like patients on the unit that aren't being paid for. Dr. Chen? We would never take someone that we did not have an authorization for. However, on the weekends, we don't have our financial clearance people to verify. So if we're hearing from the acute care side and we're hearing from the ICU side, we're hearing from their social workers or case managers that there is an off, we'll go with that. So we haven't verified it yet, but we're going with what the insurance, the acute care side has said. Dr. McNary? Dr. Chen really must trust hers because I could see that going. I'm sure we've got the off. We have admitted a few, but the insurance hasn't been correct. So we didn't know they needed a pre-auth, and we thought they had no insurance, and it turns out they did, but never intentionally taking someone without a pre-auth. And Dr. Carana and I work at the same place, but we actually do on occasion, but very, very carefully. And we consider what insurance they take. It's ultimately the administration's, you know, their decision whether or not to do it. The physicians don't get involved in that decision in any way, but they do on occasion if it's kind of like a slam dunk case. But we as physicians have kind of advised them over the years, like, hey, this is not a slam dunk. I would not take this patient without authorization. But unfortunately, some of them do come back and then they appear to appear later on and they stay with us because they didn't get the right authorization. And then they're able to be accepted, but you have to go through all of that as an inpatient physician. And I see a comment here. Usually goes through admin for our health system, has been used at times to help unload the acute care hospital during surge times. And I would agree with that, particularly during our surge, we actually didn't have to get authorization for a number of insurances. And we, you know, kind of let the floodgates open a little bit. And we have fallen hurricanes in the past as well. And another interesting question came in. Patients that leave AMA, do you give scripts or just send to PCP? That's an excellent question. Our hospital, our IRF has a protocol in place for that. And we do give prescriptions and we do a discharge summary on these patients. I think the medical legal people looked at this as well. And at least in my facility, the go-to is writing prescriptions and giving a discharge summary, even if the patient's going off AMA. In our facility, we try very hard to switch that AMA to at least a discharge. We're all, it might be early and it might be soon, but at least something where we can get them comfortably sent home. If we can do training, family training with the family earlier, like that day, or get the script tucked in and things like that. So we try to convert the AMA to an early discharge. It's not always successful. I would concur with that. If you could convert it to a less than an AMA. At the end of the day, you do what is going to, you think is most indicated for the patient. The necessary scripts for basic stability like to be given. Yeah. And we try to tuck in as much as we can in terms of equipment and follow-ups and everything. Even if the patient really truly leaves AMA over the weekend or something, I would have, which fortunately didn't happen often, but I would have our care management team and social workers try to tuck in follow-ups and everything we could just to make sure that the patient was as safe as possible. Yeah, I think it very much depends on the situation that's causing them to leave AMA. Typically, I would give any like medically necessary medications and therapy referrals if I thought they would actually go for therapy. However, things like pain medication and benzodiazepines, I usually won't give unless they're at risk for benzo withdrawal. In which case, I have to check our state kind of prescription drug management program. Any other questions or issues anyone wants to bring up, including topics they'd like addressed in future sessions? I'm kind of curious as to how everyone, in general, how everyone's census has been, both when they're going through the COVID surges and when things have normalized somewhat. In 2020, has your census been affected on the earth in your buildings? That's a great question. We're in New Jersey, which is not right. We're not right next to New York City, but we are fairly close. We did get a surge of COVID, but we luckily in this hospital did not get a surge where we had to convert units and things like that. Our sister hospital, JFK, did have to convert entire rehab units to COVID ICU units. They did try to unload some of those patients onto us. We did have that issue. We were lucky to only be able to accept patients who were COVID negative. During that time, it was getting so crazy trying to figure out who was going to be roomed with who, especially if we're full, and then something comes up. We were checking temperatures that if they were 99.5, we were really keeping an eye on that patient and trying to test them if we can. At some point in March and April, for about a month, we kept all of our patients. We normally have 40 beds. Eight of them are private, but the rest are semi-private. We kept our patients only in – every room was a private room during that time. Our census was down, but that was understood with our administration, and they were very accepting of that, luckily. What are you seeing over there, Dr. Shafir and Dr. Karana? We were in a very unique situation. You can read about our experience. We actually just published an article. We were in the process of opening a brand-new rehab hospital, and we were previously taking up two units within the acute care hospital with plans to move actually in April. Then there were some delays, but they needed us out of the hospital to get ready for surge. We very quickly moved into a building that was not quite ready for us, but is now. This building has 72 beds, whereas previously we were capped at 52. We've been maintaining a pretty good census throughout. Every once in a while, there'll be a little bit of a blip and we'll go down, but it usually pops right back up. Most of the time right now, we have a pretty good wait list for beds over here. Of course, this was a very interesting, kind of unique circumstance. What are you seeing, Dr. Shafir? At Emory, we had a surprisingly stable. We had a slight dip in, I guess, March or April, but it has remained surprisingly stable. I think we certainly had a surge, but not at the level of either Miami or New York. All right. I see one more question, and I think it's a good one that we could cover quickly. Do you accept patients directly from the ICU? Some of the cardiac surgeons in our facility like to transfer patients to rehab rather than the regular medical units. That's an excellent question. Just to mention, Dr. At Hopkins, they actually did a project on this where they had physiatry consults going on in the ICU. Kind of like a prehab consults early in the admission and found that that did lead to greater degrees of patients being transferred directly from ICU to the rehab unit. Dr. Marlies Gonzalez, I think she's going to have a paper out on that soon, a physiatrist in our specialty. That's a good point. Yes, I would accept someone from ICU if they've been seen by a cardiologist. Yes, I would accept someone from ICU if they've been seen by the therapies in the unit and are functionally ready to come up to the ER. I think similarly, a question would be if you accept patients from the ER. We're getting a lot of those too. We fairly routinely took patients from the ICU a lot of times from trauma, and sometimes it was because they just couldn't get them out of the ICU to a regular bed. Rather than waiting for a regular medical bed, it just made more sense to bring them to rehab. But as long as they were stable, we would do that. We did bring patients from the ER, not frequently, but probably one or two a month we would bring from the ER. This was true, especially on the pediatric unit and the pediatric ICU. They felt a lot more comfortable bringing the pediatric patients from PICU to rehab instead of introducing, putting them on the floors for a very short time normally. We would send them directly to us. Dr. McGarry, Dr. Chen, would this be, you would want a physiatry consult in the ER, and then you get physical and occupational therapy evaluations in the ER as well? Or how would you generally work that process? Yeah, we would get consults in the ER or referrals from the ER. If we got just a referral, I would insist on a consult, on a PM&R consult. And yeah, we have to insist on PP and OT eval in the ER as well. And for us, as Dr. Shapiro was saying, a lot of them were patients who had gone home, maybe a TBI or something, and they're like, oh, no, no, we're fine. They'd go home and then they weren't fine. So we might be familiar with them. And a lot of the ACPs who used to work on our unit were over running our POBS unit over in the ER. And so they actually had a really great sense for who were good rehab candidates. And so that was, we would sometimes send one of our ER, I mean, our PM&R team over to see them. But getting a heads up from that crew was usually about 95% of my decision. They were almost always right. Well, again, it's just about 5 o'clock Eastern Time. Thank you, everyone, for participating today. We look forward to interacting with you all on PhysForum. I put my email here in the chat for anyone who has another question or idea, you know, after the session ends. And thanks again. If you live here in Florida or along the Gulf, stay safe. I guess everyone else, too. But a storm's coming. Have a good night. Good night. Thank you. Great job. Great job. Thanks, everyone.

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