Ensure a smooth transition to rehab

Patients must be stable, ready for therapy

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 therapy every day.

There are a number of factors that may result in patients 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.

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 University of Alabama at Birmingham Health System.

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.

For instance, if the patient gets agitated and confused at night and the discharge summary doesn't mention any problems, the rehab staff are likely to send the patient back to the emergency department to rule out any additional medical issues, such as a stroke.

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.

Here are some other tips for making sure patients will have a successful transition to rehabilitation:

  • If patients have had an amputation, make sure 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 patient's Foley catheter is removed before the patient is transferred, 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.
  • Transition patients from IV pain medication to oral medication before transferring them to rehab to make sure they can tolerate pain when they start moving around. Heavy doses of pain medication can make patients drowsy and increase the risk of falls or they may become constipated, experience bowel blockage or become nauseated and not able to participate in rehab.
  • See to it that patients have gotten out of bed and built activity tolerance before the move to rehab. Otherwise, they may be completely fatigued by the transfer itself and the rehab facility may send them back.
  • Keep patients in the acute care hospital until their bed sores or fractures of weight bearing limbs have time to heal. They won't be able to participate in rehab if they can't bear weight or sit up comfortably.

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.

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.

Editor's note: Lori S. Aylor, BSN, MSN, CRRN and Karion G. Waites, DNP, RN, CRRN, BS-FNP are members of the Association of Rehabilitation Nurses. For more information, see www.rehabnurse.org. To read their article on improving the transition between acute care and rehab, visit http://www.rehabnurse.org/uploads/files/pdf/pr_readmissions_article.pdf.