Beyond TEDS and Meds: Mobility Strategies for Prevention of Post-Stroke DVT and Other Complications Dori Tooke, MHA, PT, CSCS Aurora St. Luke’s Medical Center Milwaukee, Wisconsin

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

Common Post-Stroke Complications As a result of impaired mobility, post-stroke survivors can encounter: -DVT/VTE -Pneumonia -Depression -Falls -Decubiti -Contracture -UTI -Delirium

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

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

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

Mobility Solutions Lift equipment for severe impairments; or use the space you’ve got for positioning and PROM Utilization of mobility experts; partnership with therapies Incorporate strategies into the day

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

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

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

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)

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

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

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

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

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

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

Contact me: Dori Tooke Aurora St. Luke’s Medical Center