Chapter 53: Emergencies in the Rehabilitation Unit

INTRODUCTION

One of the major duties of a physiatrist attending on an inpatient rehabilitation unit is the prevention and management of medical complications. Physiatrists may find this a daunting task because severely disabled patients requiring hospitalization for acute rehabilitation frequently suffer from many comorbidities. Most of these arise from the multiple-organ-system complications of prolonged immobility. Additionally, physiatrists are increasingly under pressure to decrease readmission rates to the acute care hospital.

Prevention of morbidity and mortality in the rehabilitation unit requires the implementation of basic patient safety principles. First and foremost among these principles is teamwork and communication, a skill for which rehabilitation professionals hold much pride. However, the communication skills around medical urgencies may be unfamiliar to some in the rehabilitation setting. It behooves the medical director to ensure that all staff has been trained in communication tools such as SBAR (situation, background, assessment, response).¹

Infection control is critical, and this includes close monitoring and enforcement of proper hand hygiene. Rehabilitation units should implement protocols to standardize admission orders to ensure that proper preventative measures are taken (e.g., prophylaxis for venous thromboembolism). Medication reconciliation on discharge can prevent rehospitalizations.² Lastly, rehabilitation programs should monitor quality improvement through a dashboard.³

This chapter outlines major complications and provides recommendations for prevention, diagnosis, and treatment, as well as a list of relevant therapy precautions.

VENOUS THROMBOEMBOLISM

Background

The prevalence of venous thromboembolism (VTE) is approximately 0.2% within the general population; however, the incidence of detected and undetected VTE varies widely.⁴ The prevalence of VTE increases markedly in patients recovering from stroke, major orthopedic or general surgery, spinal cord injury (SCI), or other major trauma and incapacitating medical illnesses. Pulmonary embolism (PE) occurs in 26% to 67% of patients with untreated proximal deep vein thromboses (DVTs), with a mortality rate of 11% to 23%.⁵ The economic burden/direct cost of VTE in the United States is estimated to be $3 billion to $4 billion annually, which does not reflect additional indirect costs of lost workdays and productivity.⁵ Use of guideline-driven VTE prophylaxis can reduce the incidence of VTE in rehabilitation patients sixfold.⁶

Prevention

Preventing DVT/VTE in the rehabilitation unit depends on the primary diagnosis (Table 53–1). The recommendations in Table 53–1 are based on American College of Chest Physician Guidelines.⁷