Prevention of complications

1. Prevention of complications Debbie Petersen, RN, MSN Sandra Bond, RN, BSN

2. Objectives • Understanding why prevention is key to the success and management of a rehabilitation patient. • Understanding key interventions to assist the rehabilitation patient who has complications. • Understanding why complications directly impact progress and discharge to home.

3. Catheter Associated Urinary Tract Infections (CAUTI) Why Prevent • Never Event • Pain/lethargy • Sepsis • Permanent damage • Increased LOS • Use of antibiotics • Quality Measure- considered a Hospital Acquired Condition (HAC)

4. Catheter Associated Urinary Tract Infections (CAUTI) Interventions to prevent • Hand washing • Insert foley catheter using aseptic technique and sterile equipment • Closed System • No leg bag • Sample thru sampling port only after cleansing with disinfectant and using sterile syringe • Smallest catheter possible to minimize urethral trauma

5. Catheter Associated Urinary Tract Infections (CAUTI) Interventions to prevent • Limited use of Foley catheters • External catheters • Intermittent catheterization • Timed voiding schedule • Remove as soon as possible • Maintain unobstructed urinary flow • Properly secured to prevent urethral traction • CDC Guideline for Prevention of Catheter Associated Urinary Tract Infections • Monitor CAUTIs Identify problems and areas for improvement

6. Catheter Associated Urinary Tract Infections (CAUTI) Barriers to progress and discharge home • Lethargy- unable to participate and benefit from therapy • Long term antibiotics • Long term damage to urinary tract • Incontinence • Pain with voiding • Obstruction

7. Deep Vein Thrombosis/Pulmonary EmbolusWhy Prevent • Pain • Therapy limited for a period of time • Risk for further complications • Pulmonary Embolus-In 90% of the cases of PE the thrombosis originates in the deep veins of the legs www.dvt.org • Death- 80% of the PEs occur without signs and 2/3 of the deaths occur within 30 minutewww.dvt.org s • Anticoagulant medications- • Long term up to 3 months • IVC filter- procedure risk • Vessel Wall damage

8. Deep Vein Thrombosis/Pulmonary EmbolusInterventions to prevent • Initial assessment to identify risk • Mobility • Type of surgery/injury/disease process • Age • BMI • Prolonged bed rest • History of DVT/PE

9. Deep Vein Thrombosis/Pulmonary EmbolusInterventions to prevent • Appropriate intervention • Pharmacological prophylaxis • Already on- stay on same/change • Need to start • Heparin • Coumadin • LMW heparin: Lovenox • Other pharmacological intervention: Dextran; Aspirin • Contraindicated • GI bleed/hemorrhage • Recent surgery • Bleeding disorder • History of HIT

10. Deep Vein Thrombosis/Pulmonary EmbolusInterventions to prevent • Other methods of prophylaxis • SCDs • Foot pumps • TEDs- knee hi is preferred • Mobility • Exercises while in bed/sitting • EARLY detection

11. Deep Vein Thrombosis/Pulmonary EmbolusInterventions to prevent • Daily assessment for: • Calf tenderness • Positive Homans’ sign- resistance in the calf/popliteal area with dorsiflexion • Swelling • Increased LE pain • Dyspnea • Pleurtitic chest pain • Cough • Hemoptysis

12. Deep Vein Thrombosis/Pulmonary EmbolusInterventions to prevent • Early diagnosis with any Signs and symptoms • Ultrasound • D-Dimer • V/Q scan; Spiral CT • Start intervention timely if DVT identified • IV Heparin gtt • Transfer to acute care if PE identified

13. Deep Vein Thrombosis/Pulmonary EmbolusBarriers to Discharge Home • Delay in progress due to Medical Hold or acute care admission • Long Term medications that require ongoing management • Potential for surgical intervention

14. ContracturesWhy Prevent • Limits function • Pain • Permanent shortening of a muscle • Deformity • Joints immobile • Swelling • Poor circulation • Pressure ulcers • Difficult transfers

15. ContracturesInterventions to Prevent • Results from unmoved joints • Prevention begins on the day of the injury • Prevention is critical- muscle not used loses 10-15% of its strength each week (Contractures; The Research and Training Center on Independent Living) • At least daily Range of Motion movements of each muscle

16. ContracturesInterventions to Prevent • Prolonged stretch to reverse or “treat” a developing contracture • Serial casting • Splinting • Heat helps • Proper posture • Good back support • Proper joint positioning

17. ContracturesInterventions to Prevent • If spasticity is a problem include weight bearing exercise to strengthen the muscles • Avoid skin breakdown • Surgery to lengthen tendons but will not lengthen the thickest part of the muscle

18. ContracturesBarriers to discharge home • Increased difficulty with transfers • Increased difficulty with all care • Decreased independence

19. Infections • Infections that most impact the rehabilitation patient • MRSA • C-Diff • Pneumonia • Wound • UTI and CAUTI • CLABSI • Sepsis • CRE

20. InfectionsWhy prevent • Pain • Lethargy • Limits participation in therapy • Antibiotic treatment • Increased LOS

21. InfectionsInterventions to prevent • Hand washing • PPE • Isolation • MRSA surveillance • Early identification • Patient/Family education

22. VISITORS • CHECK with the NURSE before entering the room • NO Children in the room • Wash hands before leaving the room Patient Wash hands before leaving room Gown/Mask when leaving room if necessary Meals and therapy in room if draining wound/incontinent; check with nurse STAFF Wash hands before/after pt. contact Gown/Gloves when in contact with body fluids Mask when in room- if necessary-check with nurse

23. InfectionsInterventions to prevent • Aseptic technique • Wound care • Foley catheters • Central Line care • Good perineal care • Quickly identify signs and symptoms of sepsis • Confusion • Fever • Tachycardia • Low blood pressure

24. InfectionsBarriers to Discharge home • Increased LOS • Long Term IV Antibiotics • Decreased strength • Decrease Independence

25. Wound Care ComplicationsWhy Prevent • Decreased Mobility • Pain • Increase LOS • Increased Fatigue • Increase Morbidity and Mortality

26. Wound Care ComplicationsInterventions to prevent • Early recognition- assess skin frequently • Immobility • Neuropathic Disease • Arterial Inflow Disease • End stage Renal Disease • Systemic Infection

27. Wound Care ComplicationsInterventions to prevent • Early Intervention • Positioning every 2 hours • Prevent friction injury • Get patient out of bed as soon as possible • Float heels • Perform range of motion exercises • Keep skin dry, decrease moisture • Devices such as heel boots, air mattress

28. Wound Care ComplicationsInterventions to prevent • Infection Control • Medical Management • Nutritional Management • High Protein foods will promote healing • Adequate Hydration

29. Wound Care ComplicationsBarriers to progress and discharge home • Wound complications can result in delay of patient getting home. • Wound vacuum can result in Skilled Facility Placement • Pain • Increase LOS • Long Term IV Antibiotic Use

30. Hypotension • Hypotension is defined as abnormally low blood pressure • Causes • Dehydration • Beta Blockers • Decreased Cardiac Output • Diuretics • Hemorrhage

31. HypotensionWhy Prevent • Complications • Decrease Immobility • Dizziness • Seizures • Fainting

32. HypotensionInterventions to prevent • Increase fluid intake • IV fluids • Tilt Table • Medical Management

33. HypotensionBarriers to progress and discharge home • Increased LOS • Inability to participate in therapy treatments • Increase fatigue • Decreased strength

34. Central Line Catheters ComplicationsWhy Prevent (What to Prevent) • Migration of Catheter Tip into the heart • Pinch-off Syndrome • The anatomic, mechanical compression of a catheter as it passes between the clavicle and first rib at the costoclavicular space • Occlusions • Infections • Increased LOS • Increase incidence in severe medical complications

35. Center Line Catheters ComplicationsPinch-Off Syndrome Image from Oncology Nursing Society, Access Device Guidelines, 2011

36. Central Line Catheters ComplicationsInterventions to prevent • Migration • Non-invasive: Patient reposition • Invasive: Remove catheter, Surgical reposition port, fluoroscopic catheter guidance. • Pinch-off Syndrome • Surgical Intervention – Removal of Catheter

37. Central Line Catheters ComplicationsInterventions to prevent • Occlusions • Adequate flushes with normal saline and locking with low dose heparin solution routinely and after catheter use. • Oral low-dose warfarin has been shown to decrease the rate of catheter related thrombosis but may increase the patient’s risk of bleeding (Currently this is not recommended. • Routine locking with thrombolytics such as high-dose heparin and tissue plasminogen activator (tPA) requires more research.

38. Fibrin Tail Fibrin tail with “initial” attachment on the outside of catheter, allowing for “trap door” effect and demonstration of partial withdraw occlusion; ability to flush easily but no blood return when attempting to aspirate

39. Central Line Catheters ComplicationsInterventions to prevent • Occlusions • Flush the catheter with normal saline gently using the push-pull method. • Reposition the patient. • Ask the patient to cough and deep breath • Perform tPA treatment • Perform fibrin sheath removal in interventional radiology.

40. Central Line Catheters ComplicationsInterventions to prevent • Infections • Frequent hand washing before and after all Catheter care. • Routine surveillance for infection • Patient and caregiver education • Administration of pre-placement antibiotic is not effective in preventing catheter-related infections (CDC, 2007) • Co-morbid diseases such as diabetes or chronic obstructive pulmonary disease or those on corticosteroid therapy can be predispose a patient to infection. • Treatment includes IV antibotics and catheter removal.

41. Central Line CathetersBarriers to Discharge • Invasive Medical Treatment • IV antibiotics • Pain • Increase LOS

42. Constipation • Constipation is defined at going longer than three days without a bowel movement. • Constipation is a preventable side effect of medication and immobility.

43. Constipation Why Prevent • Causes • Medicines (Narcotics, Antidepressants, or iron pills) • Spinal Cord Injury • Immobility • Dehydration • Neurological Conditions (Parkinson’s Disease) • Complications • Pain • Increased Immobility • Loss of Appetite

44. Constipation Interventions to Prevent • Diet and Lifestyle Changes • High-Fiber Diet • Regular exercise • Adequate fluid intake • Laxatives • Fiber Supplements, Stimulants, Lubricants, Stool softeners, Osmotics, Saline laxatives • Procedures • Manual Procedures • Surgical Procedures

45. Constipation Barriers to Discharge • Increase LOS • Pain

46. Summary • Complications can result in multiple Length of Stay delays for rehabilitation patients. • Early Recognition and Early Intervention can reduced overall impact of a complication.

48. Thank You

49. Questions