Beyond TEDS and Meds:

Mobility Strategies for Prevention of Post-Stroke DVT and Other Complications

Dori Tooke, MHA, PT, CSCSAurora St. Luke’s Medical CenterMilwaukee, 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 TookeAurora St. Luke’s Medical Center

414-649-5541dori.tooke@aurora.org