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.
Relevance to Clinical Practice
Deep Venous Thrombosis
- Deep Venous Thrombosis (DVT) can be a potentially serious complication in the inpatient rehabilitation setting as embolization of the thrombus to the lung or pulmonary embolus (PE) can be deadly. Other complications include post-phlebitis syndrome, chronic pain, swelling.
- Factors that predispose patients to venous thrombosis can be referred as Virchow’s triad, which include venous stasis, vascular endothelial damage, and hypercoagulability.
- Risk factors for DVT can be hereditary or acquired and are summarized below.
- There are no routine screening guidelines for DVT for at-risk individuals in the inpatient rehabilitation setting. However, Wells’ Criteria can help guide decisions regarding further workup for both DVT and PE.
- Wells’ criteria is summarized below1:
- In high-risk patients, DVT prophylaxis is recommended to prevent development of DVT or PE.
- DVT prophylaxis should incorporate early ambulation, and can be mechanical (external pneumatic compression devices or graduated compression stocking), chemical (anticoagulants), or surgical (IVC filter in patients with contraindications to chemical prophylaxis with high risk of PE)
- Health care providers should evaluate patients’ risk for bleeding before placing them on routine prophylactic anticoagulation. Prophylactic anticoagulation can include low molecular weight heparin (LMWH), low dose unfractionated heparin (LDUH), and fondaparinux.
- LMWH is generally preferred and recommended for Fractures, orthopedic surgeries, cancer, stroke, critically ill, older patients, COVID-19.2
- Fondaparinux is recommended for patients who have Heparin-Induced Thrombocytopenia.
- LDUH is recommended for renal failure and burn patients.2-3
- Other options include aspirin, Vitamin K antagonists, direct factor X inhibitors, and direct thrombin inhibitors.
- Currently, guidelines exist for prophylaxis in major orthopedic surgeries4
- According to the American College of Clinical Pharmacy (2012): LMWH, LDUH, vitamin K antagonists, Fondaparinux, direct inhibitor of factor X, direct thrombin inhibitor, aspirin for at least 10 to 14 days, up to 35 days.
- According to the Scottish Intercollegiate Guidelines Network (2015): LMWH, Fondaparinux, direct inhibitor of factor X, direct thrombin inhibitor in combination with mechanical prophylaxis. Optimal duration is unclear.
- Falls are considered multifactorial with synergism among individual risk factors.
- Risk factors can include increased age, gait and balance instability, polypharmacy, vision impairment, cognitive impairment, sedative use, environmental factors such as low lighting, rugs, furniture, etc. One study in an inpatient rehabilitation facility demonstrated the highest fall risk in individuals were with low admission functional independent measure scores, diagnosis of stroke, brain injury, amputation, neurologic disorders (Parkinson’s disease, multiple sclerosis, Guillain-Barre, myopathy, peripheral neuropathy), and spinal cord injury.5
- There is insufficient evidence for stand-alone screening tools to identify risk of falls among rehabilitation patients.
- St. Thomas Risk Assessment Tool in Falling Elderly (STRATIFY) is a screening tool that can identify at-risk patients in surgical and medical patients 65 years of age or younger6
- 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 includes additional screening assessments for at-risk patients, including measuring orthostatic hypotension, 4-stage balance test, 30-second chair stand test to assess patient strength and endurance, timed up-and-go test to assess patient mobility, evaluating for polypharmacy, asking about home hazards, checking visual acuity, assessing feet and footwear, assessing Vitamin D levels, and identifying comorbidities (such as osteoporosis, depression)7-8.
Fall prevention strategies are summarized in the table below:
- Physiatrists are referred to managing patients with complex medical problems and patients are often on multiple medications. Furthermore, as the overall patient population is aging, they are likely to be on several medications.
- 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.
- The higher number of medications prescribed can increase the likelihood of adverse drug effects as well as lead to increased risk of an inappropriate use of medications, which can correlate with increased falls, delirium, and loss of function.
- 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.
- 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.
- Patient and caregiver participation in medication decision-making facilitates adherence and decreases the risks of adverse drug reactions.
- Various criteria have been developed to assist clinicians in evaluating the appropriateness of medications.
- Explicit criteria are medication use criteria that can help assess the quality of prescribing practices.
- The most well-known explicit measure is Beers criteria, which includes a list of medications deemed inappropriate or potentially inappropriate for use in the general elderly population as well as other medications to avoid combining or use with caution in selected populations.9
- Implicit criteria require clinician interpretation and focus on patient and clinician preferences and are operator-dependent.
- The Medication Appropriateness Index is an implicit measure that assesses 10 criteria including duplication, indication of medication, cost, and effectiveness as a questionnaire in efforts to tailor the prescription regimen to avoid polypharmacy.10
- Explicit criteria are medication use criteria that can help assess the quality of prescribing practices.
- A pressure injury is a localized injury or breakdown of 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 33 mm Hg continuously for 2 or more hours.11
- 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.
- The Braden scale can help to assess risk for pressure injury development and is shown below.12
- Intrinsic risk factors can be screened utilizing standard clinical procedures.
- Nutritional status can be measured by food intake, body weight, body mass index, serum total protein, and serum total albumin and prealbumin.
- Serum albumin less than 3.4 mg/dL and hemoglobin level less than 11.4 g/dL have been associated with pressure injury development.13
- Common locations of pressure ulcers are at bony prominences and depend on the positioning. These include14
- When laying supine: occiput, shoulder, elbow, sacrum, heel
- When laying on side: ear, shoulder, trochanter, knee, ankle
- When sitting upright: scapula, sacrum, ischium, heel, ball of foot
- When pressure injuries develop, it is important to stage them appropriately and monitor for changes so the correct measures can be taken to heal them and stop them from advancing further. The most commonly used classification system is the National Pressure Ulcer Advisory Panel (NPUAP) system15
- Deep tissue pressure injury: intact or non-intact skin with localized area of persistent non-blanchable discoloration or epidermal separation with dark wound bed or blood-filled blister.
- Stage I: Skin is intact with non-blanchable erythema.
- Stage II: Partial-thickness skin loss involving epidermis and dermis.
- Stage III: Full-thickness loss of skin that extends to the subcutaneous tissue but does not cross the fascia beneath it.
- Stage IV: Full-thickness skin loss extending through the fascia with considerable tissue loss and possible involvement of the muscle, bone, tendon, or joint.
- Unstageable: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
- Early action is the key to preventing pressure injuries and stop further advancement. Many guidelines recommend turning and positioning every two hours for more than 2 minutes at a time. When patients are sitting, it is recommended to provide pressure relief every 15 to 30 minutes16.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. It is also important to have proper mattress and cushioning. Caregivers and patients should be educated on the importance of turning.
Emerging Issues and Gaps in Knowledge
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.
Further evidence-based research is needed to develop consensus guidelines for screening in the inpatient rehabilitation setting. In the meantime, clinicians are encouraged to take into account multiple medical and social factors to make the best clinical decisions for their patients in order to minimize the preventable complications that may occur.
- Modi S, Deisler R, Gozel K, Reicks P, Irwin E, Brunsvold M, Banton K, Beilman GJ. Wells criteria for DVT is a reliable clinical tool to assess the risk of deep venous thrombosis in trauma patients. World J Emerg Surg. 2016 Jun 8;11:24. doi: 10.1186/s13017-016-0078-1. PMID: 27279896; PMCID: PMC4898382.
- Grand’Maison A, Charest AF, Geerts WH. Anticoagulant use in patients with chronic renal impairment. Am J Cardiovasc Drugs. 2005;5(5):291-305. doi: 10.2165/00129784-200505050-00002. PMID: 16156685.
- Kelly BM, Yoder BM, Tang CT, Wakefield TW. Venous thromboembolic events in rehabilitation setting.PM&R. 2010;(2):647-663.
- Flevas DA, Megaloikonomos PD, Dimopoulos L, Mitsiokapa E, Koulouvaris P, Mavrogenis AF. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev. 2018 Apr 27;3(4):136-148. doi: 10.1302/2058-5241.3.170018. PMID: 29780621; PMCID: PMC5941651.
- Forrest G, Huss S, Patel V, Jeffries J, Myers D, Barber C, Kosier M. Falls on an inpatient rehabilitation unit: risk assessment and prevention. Rehabil Nurs. 2012 Mar-Apr;37(2):56-61. doi: 10.1002/RNJ.00010. PMID: 22434614.
- Tool 3G: STRATIFY Scale for Identifying Fall Risk Factors. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/stratify-scale.html
- Tool Resource Algorithm for Fall Risk Screening, Assessment, and Intervention. Content last reviewed 2019. Centers for Disease Control and Prevention, Atlanta, GA.
- 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.
- American Geriatrics Society 2019 Updated AGS Beers Criteria®for Potentially Inappropriate Medication Use in Older Adults. By the 2019 American Geriatrics Society Beers Criteria®Update Expert Panel J Am Geriatr Soc. 2019;67(4):674. Epub 2019 Jan 29.
- Hanlon J, T, Schmader K, E: The Medication Appropriateness Index: A Clinimetric Measure. Psychother Psychosom 2022;91:78-83. doi: 10.1159/000521699
- Agrawal K, Chauhan N. Pressure ulcers: Back to the basics. Indian J Plast Surg. 2012 May;45(2):244-54. doi: 10.4103/0970-0358.101287. PMID: 23162223; PMCID: PMC3495374.
- BRADEN SCALE – For Predicting Pressure Sore Risk. Form 3166P. Source: Barbara Braden and Nancy Bergstrom. Copyright, 1988. Des Moines, IA.
- EFTELİ E. (2022). Effects of Hemoglobin and Albumin Levels on the Development of Pressure Injury in Inpatients in Intensive Care Clinics. MAKU J. Health Sci. Inst., 10(1), 71-78.
- InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Pressure ulcers: Overview. [Updated 2018 Nov 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK326428/
- Zaidi SRH, Sharma S. Pressure Ulcer. [Updated 2022 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553107/
- National Pressure Ulcer Advisory Panel. Pressure ulcer prevention points. National Pressure Ulcer Advisory Panel, Washington DC, USA, 2007, http://www.npuap.org/wp-content/uploads/2012/03/PU_Prev_Points.pdf.
Original Version of the Topic
Matthew Dounel, MD MPH, David Z. Prince, MD. Incorporation of Prevention and Risk Factor Modification in Rehabilitation. 9/20/2014
Melissa Mafiah, MD
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Shaima Khandaker, MD
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