Prevention and risk factor modification in rehabilitation

Author(s): Matthew Dounel, MD MPH, David Z. Prince, MD

Originally published:09/20/2014

Last updated:09/20/2014

1. OVERVIEW AND DESCRIPTION

Common complications in an inpatient rehabilitation setting include deep vein thrombosis (DVT), falls, polypharmacy, and pressure ulcers. Incorporation of prevention and risk factor modification in the inpatient rehabilitation setting to at-risk patients is essential to the practice of physical medicine and rehabilitation.

2. RELEVANCE TO CLINICAL PRACTICE

Deep Venous Thrombosis

A. Deep Venous Thrombosis

1. Deep Venous Thrombosis (DVT) can be a potentially serious complication in the inpatient rehabilitation setting.

2. Factors that predispose patients to venous thrombosis can be referred as Virchow’s triad, which include venous stasis, vascular endothelial damage, and hypercoagulability. The principle concern for DVT is embolization of the thrombus to the lung, which can lead to a pulmonary embolus.

3. Risk factors for DVT can be hereditary or acquired and are summarized below.

Hereditary Risk Factors Acquired Risk Factors
Protein C deficiency or Protein S deficiency Increased Age
Factor V Leiden mutation Immobility
Prothrombin gene mutation Smoking
Antithrombin deficiency Previous Thromboembolism
Elevated levels of factors VIII, IX, and XI Antiphospholipid Antibody Syndrome
Activated protein C resistance Malignancy
Hyperhomocystonemia Neurologic disease with extremity paresis
Plasminogen deficiency Spinal cord injury
Dysfibrinogemia Major trauma;
Major surgery, including orthopedic and neurosurgery
Hip or knee replacement
Presence of acute infectious disease
Fracture of the hip or knee
Traumatic Brain Injury
Burns

4. There are no routine screening guidelines for DVT for at-risk individuals in the inpatient rehabilitation setting.

  1. DVT prophylaxis should incorporate early ambulation, graduated compression stockings, intermittent pneumatic compression, and anticoagulation.
  2. Prophylactic anticoagulation can include low molecular weight heparin (LMWH), low dose unfractionated heparin (LDUH), and fondaparinux sodium. Health care providers should evaluate patients’ risk for bleeding before placing them on routine prophylactic anticoagulation.
    1. LMWH is recommended for cancer, trauma and spinal cord injury patients.
    2. Fondaparinux is recommended for patients undergoing orthopedic surgery.
    3. LDUH is recommended is recommended for burn patients.1-4

5. Accordingly, the national guidelines clearinghouse recommendation for prophylaxis of venous thromboembolism (VTE) in the inpatient setting includes the following in the table below, which are cited from the Scottish Intercollegiate Guidelines Network (SIGN))5:

  1. Selected Recommendations on Venous Thromboembolism (VTE) Prevention From the National Guidelines Clearinghouse (SIGN)
  2. Hospitals should adopt approaches which are likely to increase compliance with thromboprophylaxis guidelines and improve patient outcomes.
  3. Patients undergoing orthopedic procedures such as total hip replacement (THR) or total knee replacement (TKR) surgery should receive pharmacological prophylaxis combined with mechanical prophylaxis unless contraindicated.
  4. Pneumatic foot pumps can be considered for prophylaxis as an alternative to intermittent pneumatic compression (IPC) in orthopaedic surgery patients.
  5. Patients with cancer are generally at high risk of VTE and should be considered for prophylaxis with LMWH, UFH or fondaparinux while hospitalized.
  6. Neither warfarin nor heparin should be used to prevent catheter-related deep vein thrombosis in cancer patients.

Falls

1. Falls are considered multifactorial with synergism among individual risk factors.

2. Risk factors can include increased age, gait and balance problems, medication issues, vision impairment, and cognitive impairment. One recent study in an inpatient rehabilitation facility demonstrated the highest fall risk in individuals were with low admission functional independent measure scores, central or peripheral nervous system disorders, and amputations.

3. There is insufficient evidence for stand-alone screening tools to identify fallers among rehabilitation inpatients older than 65 years of age.

a. St. Thomas Risk Assessment Tool in Falling Elderly (STRATIFY) is a screening tool that can identify at-risk patients in surgical and medical inpatients 65 years of age or younger.

b. Center for Disease Control and Prevention has initiated Stopping Elderly Accidents, Death, and Injuries (STEADI) toolkit for health care providers for integration of fall prevention into health providers’practice. The STEADI tool kit include additional screening assessments for at-risk patients, including measuring for orthostatic hypotension, 4-stage balance test, 30-second chair stand test to assess patient leg strength and endurance, and timed up-and-go test to assess patient mobility.

Fall prevention strategies are summarized in the table below6-10:

Risk Factors Interventions
Increased Age Adopt a multifactorial approach including education, physical activities, and exercise.

Assess other risk factors for fall including cardiovascular, musculoskeletal, neurological, gait and vision issues.

Gait and balance problems Refer high-risk individuals for physical therapy for fall risk assessment and intervention.

Address footwear or foot problems.

Monitor adherence to training regimen.

Medication Issues Identify and reduce the number of medications or specific medications with fall-related effect such as orthostasis or cognitive impairment.

Conduct a review of medications and targeted assessment of fall-related symptoms. Assess adherence to medications.

Check orthostatic blood pressure.

Vision Impairment Assess vision and encourage routine vision care with corrective lens and/or cataract surgery as indicated.
Cognitive Impairment Assess and address medications that may cause cognitive impairment.

Assess and address underlying medical conditions that can manifest as cognitive impairment, including electrolyte abnormalities, hypoglycemia, hyperglycemia, and infection.

Polypharmacy

1. Physiatrists are referred to managing patients with more complex medical problems, requiring patients to take multiple medications. Furthermore, as the inpatient patient population is aging, they are likely to prescribe more medications.

2. Polypharmacy has been variably defined as the use of a large number of medications, the use of potentially inappropriate medications, the underuse of medications contrary to instructions, and medication duplication.

3. The higher number of medications prescribed can increase the likelihood of adverse drug effects (ADE) as well as lead to increased risk of an inappropriate use of medications, which can correlate with increased falls, delirium, and loss of function.

4. The most critical step in improving prescribing practices is the physician’s commitment to the issue. Collaborative efforts that involve physicians, pharmacists, nurses, and other healthcare providers can improve prescribing practices.

  1. A medication history and accurate medication list are essential to proper prescribing. A review of the current medications should include all prescriptions, over-the-counter medications, vitamins, and supplements as well as incorporating all ADEs and effectiveness of medications.
  2. Patient and caregiver participation in medication decision-making facilitates adherence and decreases the risks of adverse drug reactions.
  3. Technology and computer-assisted decision tools have yielded mixed results. They may prove useful to health care providers, given the complexity of medication prescribing in the inpatient rehabilitation setting.

5. Various criteria have been developed to assist clinicians in evaluating the appropriateness of medications.

  1. Process measures are direct performance measures that help to prevent inappropriate or suboptimal prescribing. These criteria are based on consensus opinion that lacks evidence-based data.
  2. Explicit criteria are medication use criteria that can help assess the quality of prescribing practices.
    1. The best known explicit measure is Beers criteria, a list of medications deemed inappropriate or potentially inappropriate for use in the general elderly population.
  3. Implicit criteria require clinician interpretation and focus on patient and clinician preferences and are operator-dependent.
    1. The Medication Appropriateness Index is an implicit measure that assesses duplication, indication of medication, and effectiveness in efforts to tailor the prescription regimen to best fit the patient.11-13

Pressure Ulcer

A pressure ulcer is a localized injury to the skin that usually occurs over a bony prominence as a result of pressure or in combination with shear and/or friction. Tissue ischemia results when prolonged pressure over bony prominences exceed arterial perfusion pressure of 32 mm Hg.

1. Risk factors for the development of pressure ulcers can be broadly defined as extrinsic, intrinsic, or psychosocial and can be represented in the table below:

Extrinsic (external to patient’s body) Intrinsic (internal to patient’s body) Psychosocial
Applied pressure Muscle atrophy Smoking
Surface shear Impaired nutritional status Altered Mental Status
Friction Anemia
Skin temperature Impaired vascular status
Moisture Impaired mobility
Acidity Impaired sensation

2. Impaired nutritional status and anemia can be screened utilizing standard clinical procedures.

  1. Nutritional status can be measured by food intake, body weight, body mass index, serum total protein, and serum total albumin and prealbumin.
    1. Serum total protein of less than 6.4 g/dL and serum albumin less than 3.5 mg/dL have been associated with pressure ulcer development.
    2. Hemoglobin level of less than 12.0 to 14.0 g/dL has been associated with the development of pressure ulcers.

3. Risk assessment scales have been designed as a useable tool to identify patients needing preventive interventions. The three most widely used scales are the Braden, Norton, and Waterlow scales. The Braden scale has been considered the most widely utilized of the three scales.

4. The Braden Index utilizes six criteria to assess patient’s risk. These criteria include sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Each category is rated 1-4 except friction and shear, which are rated 1-3, combining for a total of 23 points. A high score predicts a lower risk of developing a pressure ulcer. Braden score assessment scale is the following:

Risk Total Score
Very high risk 9 or less
High risk 10-12
Moderate risk 13-14
Mild risk 15-18
No risk 19-23

5. Many guidelines recommend turning and positioning every two hours. It is important to pay particular attention to pressure-bearing areas such as the sacrum, ischial tuberosity, trochanter, and the heels. Turning will relieve pressure over the sacrum and ischial tuberosity but the patient should not be turned all the way on their side or the trochanteric areas will be subject to high pressure. Heels can be suspended by placing pillows in lower extremities or by utilizing orthoses that takes pressure off the heels. Caregivers and patients should be educated on the importance of turning.

6. If individuals are in the seated position it is important to utilize appropriate seating systems. Current guidelines recommend pressure relief every 15 minutes, in which health care providers or at-risk patients can be instructed to perform these pressure relief maneuvers. In addition, at-risk individuals that are immobilized in bed should utilize appropriate mattresses for pressure relief.14-17

EMERGING ISSUES

There is no optimal consensus for methods on screening and detection for DVT, falls in adults older than 65 years of age, and polypharmacy in the acute rehabilitation setting. Modified ELISA and semiquantitative agglutination assays are under investigation and may be reliable screening measures for DVT in select populations.18

Furthermore, the development of more effective screening assessments for falls in the in-patient rehabilitation population over the age of 65 are needed. Additional investigations to detect pressure ulcers are utilizing various instruments to detect interface pressures and blood flow measurements for at-risk subjects.19Technology and computer-assisted decision tools have yielded mixed results and need to be further examined to investigate a good screening systems-based approach to prevent polypharmacy.

GAPS IN KNOWLEDGE

There is no optimal consensus for screening of DVT, falls in adults older than 65 years of age, and polypharmacy. Further evidence-based research is needed to develop consensus guidelines for screening in the inpatient rehabilitation setting.

REFERENCES

1. Alikhan R, Cohen AT, et al. Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study.Arch Intern Med.2004;164:963-968.

2. Anderson FA, Spencer FA. Risk factors for venous thromboembolism.Circulation. 2003; 107(23)(supp 1):S9-S16.

3. Kelly BM, Yoder BM, Tang CT, Wakefield TW. Venous thromboembolic events in rehabilitaation setting.PM&R. 2010;(2):647-663.

4. Spinal Cord Injury Thromboprophylaxis Investigators. Prevention of venous thromboembolism in the rehabilitation phase after spinal cord injury: Prophylaxis with low dose heparin or enoxaperin.J Trauma.2003;(54):1111-1115.

5. National Guideline Clearinghouse. Prevention and management of venous thromboembolism. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2010;Dec:101. (SIGN publication; no. 122); http://www.guideline.gov/content.aspx?id=25639. Accessed March 20, 2014.

6. Lee J, Geller AI, Strasser DC. Analytical review: Focus on fall screening assessments.PM&R. 2013;(5):609-621.

7. Milisen K, Staelens N, Schwendimann R, et al. Fall prediction in inpatients by bedside nurses using the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) instrument: a multicenter study.J Am Geriatr Soc. 2007;(55):725-733.

8. Coker E, Oliver D. Evaluation of the STRATIFY falls prediction tool on the geriatric unit.Outcomes Manag. 2003;(7):8-14.

9. Lee JE, Stokic DS. Risk factors for falls during inpatient rehabilitation.Am J Phys Med Rehabil.2008;(87):341-350.

10. Centers for Disease Control and Prevention. Home and recreation safety; Falls–older adults. http://www.cdc.gov/HomeandRecreationalSafety/Falls/index.html. Accessed March 20, 2013.

11. Geller AI. Nopkhun W, Dows-Martinez MN, Strasser DC. Polypharmacy and the role of physical medicine and rehabilitation.PM&R.2012;(4):198-219.

12. Steinman MA, Hanlon JT, Managing medications in clinically complex elders: ” There is got to be a happy medium.”JAMA. 2010;304:1592-1601.

13. Gurwitz JH, Field TS, Rochon P, et al. Effect of computerized provider entry with clinical decision support on adverse drug events in the long term care setting.J Am Geriatr Soc.2008; 56:2225-2233.

14. Blaylock B. A study of risk factors in patients placed on specialty beds.J Wound Ostomy Continence Nurs.1995;22(6):263-266.

15. Tourtual DM, Riesenberg LA, Korutz CJ, et al. Predictors of hospital acquired heel pressure ulcers.Ostomy Wound Manage.1997;43(9):24-28.

16. Quintavaille PR, Lyder CH, Mertz PJ, et al. Use of high resolution, high-frequency daignostic ultrasound to invesitgate the pathogenesis of pressure-ulcer development.Adv Skin Wound Care.2006;19(9):498-505.

17. Vanderwee K, Grypdonck MH, De Bacquer D. et al. Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions.J Adv Nurs.2007;57(1):59-68.

18. Prisco D, Grifoni E. The role of D-Dimer testing in patients with suspected venous thromboembolism.Semin Thomb Hemost. 2009;(35):50-59.

19. Bosboom EM, Bouten CV, Oomens CW, et al. Quantifying pressure sore-related muscle damage using high resolution MRI.J Appli Physiol. 2003;95(6):2235-2240. Epub 2003.

Author Disclosure

Matthew Dounel, MD MPH
Nothing to Disclose

David Z. Prince, MD
Nothing to Disclose

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