Effectively transferring patients to rehab
Effectively transferring patients to rehab
Make sure patients are ready for PT
To prevent readmissions when patients are transitioning from the acute care hospital to an inpatient rehabilitation center, case managers should make sure the patients are appropriate for acute rehab, that their medical conditions are stable, and that they can tolerate three hours of physical therapy every day.
"It's challenging to successfully transition patients from acute care to inpatient rehab, and there are a number of factors that could result in the patient returning to the acute care hospital or being transferred to the emergency department for evaluation and treatment," says Lori S. Aylor, BSN, MSN, CRRN, chief nursing officer, at UVa-HealthSouth Rehabilitation Hospital, a 50-bed inpatient rehabilitation hospital in the University of Virginia Health System in Charlottesville, VA.
Communication is a key component of successful transitions, and making sure that the receiving facility has a detailed and complete discharge summary can help avoid an emergency room visit or readmission, adds Karion G. Waites, DNP, RN, CRRN, BS-FNP, nurse practitioner at Spain Rehabilitation Center, a 47-bed inpatient rehabilitation hospital that is part of the UAB Health System in Birmingham, AL. "Complex issues shouldn't necessarily delay transition. Even very complex patients will do very well if they are stable enough to get started in rehab, but there needs to be much better communication between the sending hospital and the receiving rehabilitation facility," she says.
When patients are being transferred, make sure your documentation is complete, legible, and, in addition to details on medical issues, includes information about the patient's behavior at different times of the day during the last few days in the hospital, Aylor and Waites suggest.
"Knowing if someone's mental status has waxed and waned or that they become agitated and confused at night helps us prepare for them and avoid sending them back," Aylor says. If the patient is agitated or confused and the discharge summary doesn't mention any problems, the rehab facility staff have to try to figure out what is causing it, and most of the time they send the patient to the emergency department to rule out any additional medical issues, she says.
Patients with urinary tract infections also get confused when they come to a new facility. "If we don't have a diagnosis that indicates the reason for the confusion, we have to rule out other complications such as stroke, and this means a trip back to the hospital," she says.
When you gather the hospital records to send to rehabilitation, include any information you have on family dynamics, particularly if the family members are anxious, if the patient doesn't have a good support system, or if a caregiver might do something harmful, such as wanting to do everything for the patient during rehab.
"The way people cope is so different. Rehab patients and family members are learning a new reality and new skills. If we have an idea of the patient's situation at home and how the family has been behaving, it gives us a good starting point for working with them," Aylor says.
The nurses say that it is helpful if case managers in the inpatient setting start educating patients and family members about the rehab process and how it differs from the acute care hospital and other post-acute facilities. "A lot of case managers compare rehab facilities to skilled nursing facilities and they're not the same thing. What patients need to know about rehab is that they will be seeing a physician every day and participating in three hours of therapy each day. Rehab is a very different level of care," Waites says. It's also helpful if patients are aware that the doctors they will see in rehab are not those who treated them in the acute care setting, she adds.
Inform the patients and family members that in rehab, patients are expected to learn to do as much as they can for themselves, rather than having the staff or family members to do it for them. Prepare the family to understand that if patients don't demonstrate functional improvement in rehab, they probably will need to go to another level of care.
If patients have had an amputation, Waites recommends that they have an ultrasound to check for clots and remain in the hospital until they no longer need bed rest. "We can work with an anticoagulation regimen, but we don't want to keep patients in bed for several days. If bed rest is indicated, we send them back to the acute setting," she says.
If the hospital removes a patient's Foley catheter before transferring the patient, make sure he or she has voided and that it is documented in the medical record.
Make sure patients are up on their pain medications so they don't arrive in a lot of pain. If patients take medication that requires food, the hospital should either back off the medication before transfer or give them something to eat. "It takes time for the rehab hospital to get orders in place after the patient arrives," Aylor says.
Conditions could result in readmit from rehab Make sure patients are medically stable Rehab facilities often send patients back to the acute care hospital when they are not medically stable enough to participate in rehab, says Karion G. Waites, DNP, RN, CRRN, BS-FNP, nurse practitioner at Spain Rehabilitation Center in Birmingham. "Medical issues out-trump the rehab situation. We can handle patients with complex medical issues, but if their medical condition will interfere with three hours of rehab a day, they're not suitable for rehab," she says. Here are some examples of issues that indicate patients may not be appropriate for acute rehab: • High oxygen demands. Patients on two liters of oxygen may be able to tolerate rehab, but it is cumbersome to drag an oxygen tank to therapy. "If patients still need three to four liters of oxygen at rest, they won't be able to maintain proper saturation when they exercise," Waites says. •Bed sores or fractures of weight-bearing limbs. These patients need to time to heal before they can participate in rehab. "There's not a lot of we can do during the healing process, but once the patient can bear weight or sit up comfortably, we can work on mobility and transfers," Waites says. •Intravenous pain medication. Heavy doses of pain medication can make patients drowsy and increase the risk of falls. Patients need to transition from IV pain medication to oral medication before transferring to rehab. Waites recommends that patients be placed on oral medication for a few days before going to rehab to make sure the patients can tolerate pain when they sit up and start moving. Patients on high doses of pain medication may become constipated, experience bowel blockage or become nauseated and not able to participate in rehab. • Lack of activity in the hospital. If patients have not gotten out of the bed and built activity tolerance during the hospital stay, just the process of transferring them by ambulance to the rehab center may exhaust them. "It's amazing how much stress and pressure the transition puts on patients. Many people become completely fatigued by the transfer itself. It's not unusual for us to send patients back to the hospital within hours if they have not sat up on the bed in the hospital and are exhausted by the transfer," says Lori S. Aylor, BSN, MSN, CRRN, chief nursing officer, at UVa-HealthSouth Rehabilitation Hospital, in Charlottesville, VA. Encourage patients to increase their activity every day while they are in the hospital to build tolerance. You don't want to test the patient's ability to tolerate activity when they are put on the stretcher to transfer to rehab. •Malnourished patients. If patients have problems eating and drinking enough to sustain themselves, they are unlikely to get enough added nutrition for the exercise they need during rehab. Patients with nasogastric tubes don't do well in rehab. Percutaneous endoscopic gastrostomy (PEG) tubes are more appropriate for rehab, but patients need to make the transition to nocturnal feedings which don't interfere with therapy, Aylor says. Patients who have problems tolerating tube feeding may need to be readmitted if they experience unresolved fullness, diarrhea, or abdominal pain. • Medical instability. Patients who are experiencing atrial fibrillation, unstable vital signs, or elevated blood pressure may not tolerate a transfer well. Patients with infections or poorly healing wounds may have an underlying medical condition that will inhibit their ability to tolerate rehab. Patients who need long-term IV antibiotics or frequent blood draws are not suitable for rehab. |
To prevent readmissions when patients are transitioning from the acute care hospital to an inpatient rehabilitation center, case managers should make sure the patients are appropriate for acute rehab, that their medical conditions are stable, and that they can tolerate three hours of physical therapy every day.
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