Beyond TEDS and Meds:

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Beyond TEDS and Meds

• Mobility Strategies for Prevention of Post-Stroke
  DVT and Other Complications
• Dori Tooke, MHA, PT, CSCS
• Aurora St. Lukes Medical Center
• Milwaukee, Wisconsin

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Objectives

• At the end of the lecture, the listener will
• Have an increased awareness of the importance of
  patient mobility post-stroke in the prevention of
  common complications
• Recognize the need to approach patient mobility
  from a medical and rehabilitative team
  perspective
• Describe at least two cost effective and time
  efficient strategies to incorporate patient
  mobility into an acute care setting

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Common Post-Stroke Complications

• As a result of impaired mobility, post-stroke
  survivors can encounter
• DVT/VTE
• Pneumonia
• Depression
• Falls
• Decubiti
• Contracture
• UTI
• Delirium

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DVT Prevention Literature Search

• 196 abstract reviews
• Medications effective
• External compression devices effective
• Mobility absent from the literature except to
  acknowledge immobility is a prognosticator of
  complications
• One study did cite early mobility after DVT as
  having no increased risk of consequences if
  proper secondary prophylaxis applied

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Early Mobility of Post Stroke Patients

• Literature does support early mobility as a means
  to improve rehabilitative outcomes (short and
  long term)
• Mobility benefits include prevention of
  complications, maximizing outcomes, and
  prediction of appropriate post-stroke service
  needs
• Quality indicator for rehabilitation plan and DVT
  prophylaxis

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Mobility Barriers

• Medically unstable patients
• Severely impaired patients
• Lack of expertise and / or comfort with patient
  mobility
• Time perception

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Mobility Solutions

• Lift equipment for severe impairments or use the
  space youve got for positioning and PROM
• Utilization of mobility experts partnership
  with therapies
• Incorporate strategies into the day

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Therapy Partnership

• Provision of recommendations for mobility or
  activity
• Training for carryover of mobility
• Recommendations for maximal safety
• PT, OT, ST, and Physiatry

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Severely Impaired Patients

• Lifting equipment
• P-AAROM to affected limbs
• AROM for unaffected limbs
• Activity schedules
• Positioning techniques (example shoulder
  approximation and wrist elevation of affected
  arm with finger extension)
• Optimize stimulation in the environment
• Therapy goals may be pre-ADL or pre-gait
  activities

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Moderately Impaired Patients

• As per severely impaired
• Considerations for cognitive issues and safety
• Pivot transfers if safe
• Up in chair for meal times
• Use commodes avoid bedpans and catheters
• Have therapy train staff for the best/easiest
  transfer technique

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Minimally Impaired Patients

• Walk each shift
• Watch for equipment needs (communication strategy
  with therapy!)
• Up in chair for all meals
• Use the bathroom or commode
• Encourage active motions
• Encourage leisure interests (example knitting,
  word puzzles - with caution)

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Mobile Patients

• Normalize function
• Independent in room clear with therapy
• Ensure post-stroke resources for rehab are
  ordered (for all patients)
• Watch for high-level cognitive deficits that are
  subtle

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Communication Strategies

• White boards (activity section)
• Posters (examples swallow precautions, swallow
  strategies, activity schedules, positioning
  cards, equipment lists, etc.)
• Education sheets
• Plan of care rounding

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Activity Specialists Programs

• Model that adds FTE(s) whose purpose is to ensure
  activity occurs-
• Nursing works on medical needs
• Therapists work on skilled therapy components
• Activity specialist carries out routine and/or
  supportive therapeutic mobility
• Ambulation teams
• Therapy extension programs

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How Does a Hospital Pay for an Activity
Specialist?

• Generally entry level or slightly higher pay
  (similar to CNAs)
• Compare with the costs of a single complication
  that can be prevented
• Cost of a fall with injury 6,437
• Fall with significant injury upwards of 60,000
• Cost of a pressure ulcer 7,310
• Data from 2005 to 2007, conservative estimates

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Activity Specialist Training

• Would be jointly nursing and therapy trained
• Could be unit specific
• Would be supervised by nursing
• Could incorporate leisure and social skills, as
  well

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Patient Activity

• Prevents complications
• Minimizes decline
• Ensures team commitment to the patient
• Maximizes outcomes
• Provides for highest quality care

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Contact me

• Dori Tooke
• Aurora St. Lukes Medical Center
• 414-649-5541
• dori.tooke_at_aurora.org