Eli's Rehab Report

Published on Tue Jan 29, 2013 PDF

Discover hidden ways rehab can make a difference in the nursing realm.

Starting last October, the Centers for Medicare & Medicaid Services required all inpatient rehabilitation facilities to begin reporting quality measure data on pressure ulcers and catheter-associated urinary tract infections (CAUTI). CMS instructed IRFs to include this data in the patient’s IRF-PAI assessment. The quality measure data does not affect your Medicare payments, but why not keep your scores high in case one day it does?

Managing pressure ulcers and CAUTI falls mostly under the purview of nursing. But that doesn’t mean rehab is out of the picture. Discover the small things rehab can do within its scope of practice to improve quality measures on the IRF-PAI.

1. Conduct Preadmission Screening With a Hawk Eye

Get started on the right foot: Look for pressure ulcers and CAUTI before the patient is admitted to inpatient rehab, and document your findings. Hunt thoroughly for any risk factors or red flags, and document these as well. Having a sharp eye at the beginning takes the heat off your facility in case a pressure ulcer or CAUTI has already started. You also have documentation to prove the patient was already on the brink of developing the condition. The preadmission screening is the perfect time to set the record straight on who should be held accountable for the pressure ulcer or CAUTI. And if risk factors are already present, you can build your care plan around mitigating the severity of a pressure ulcer or CAUTI, should one develop.

Early intervention: "If the patient already has something upon admission, you can immediately address mobility, ensure there are orders for proper turning, a proper mattress, etc.," says Fran Fowler, FAAHC, with Fowler Healthcare Affiliates in Marietta, GA.

2. Adopt Excellent Clinical Practices with Catheters

"Although quality reporting is in its infancy, in most cases, therapy doesn’t see itself in a significant role for preventing CAUTI — yet they should," Fowler says.

Working with patients who have catheters, however, is a delicate process, and if the therapist is properly trained in handling catheters, many infections can be avoided.

Example: "Sometimes the therapists don’t know they are lifting the bag too high and cause reflux to go back into the bladder," Fowler points out. Also, "when therapists disconnect the catheter, they’ll often put it in a sponge and wrap it with a rubber band when the patient is in therapy so they don’t have to worry about dragging the bag. But these are ways infections get in."

The upside: If your therapists are properly trained to handle catheters, their involvement in toileting can actually reduce infection.

"[Our] therapists are really good about offering toileting to patients during their treatment time," says Margaret Fogg, RN, BSN, CRRN, care coordinator at Whitaker Rehabilitation Center in Winston-Salem, NC. "This helps to reduce the risk of infection and provides great opportunity to work on toileting skills with the patient/caregivers, as inability to toilet independently is often what keeps a patient from being able to return home." 

3. Push for Bladder Training

If, in your preadmission screening, you’ve discovered a patient had a catheter while in acute care, include bladder training in the care plan — even if he is admitted to rehab without a catheter.

"A lot of times the patient will have urine retention after the catheter has been removed, especially in cases of stroke and neurological conditions," Fowler says. "Part of your care plan should include forcing fluids and getting the patient up to urinate whether they have to or not."

Double-whammy: If you fall short on this kind of bladder training, not only could the patient develop a CAUTI, but when the bed gets wet from an accident, that can then create risk for a pressure ulcer, Fowler points out.

4. Mitigate Pressure Ulcer Risk Factors

If a patient was admitted with a pressure ulcer or even showed risk factors of one developing, rehab can take several preventive measures.

For one, "therapists can remind patients to turn in bed and to call a nurse immediately when they have an accident," Fowler says. Many times, a patient is too embarrassed to ask for a bed change or doesn’t want to bother the nurse, she explains.

As a result, the patient lies in a wet bed, which can heighten the chances of developing a pressure ulcer. But a gentle reminder from their therapist could help nudge shy patients to ask for help when needed.

Watch for: "The biggest challenge is with strokes because often a certain side of the body cannot move and rubs against the bed," Fowler points out.

"We have asked our therapists to report any suspicion of a pressure related ulcer," Fogg says. "We then consult Wound/Ostomy services and have them evaluate and stage if skin breakdown is deemed to be pressure related."  In addition, therapists at Fogg’s facility help arrange for appropriate mattresses and wheelchair cushions both during their stay and for discharge.

Don’t miss: Although therapists aren’t involved in nutrition per se, they can still emphasize to their patients the importance of eating three meals a day. "Proper nutrition ensures healing and prevents skin breakdown," Fowler points out.

On the same note, therapists should watch the tolerance levels of their patients and level of fatigue during therapy. "Sometimes therapy exhausts patients so much they are too tired to eat," Fowler says.

5. Optimize Team Effort

Everyone on the care team has a critical role to ensure the patient’s health. Communicating regularly about each patient across specialties is key to lowering the incidence of pressure ulcers and CAUTI.

Example: "We have a Continuous Improvement Council that involves all units (we have 4), and all disciplines," Fogg says. This team meets regularly, and all members are expected to take an active role to prevent pressure ulcers and CAUTI and report any suspicions. 

"We have someone from Infectious Control come to those monthly meetings and report the CAUTI’s," Fogg says. "We also talk about patients who are at high risk during our weekly team conferences and daily team huddles." 

Important: Promote and reward a sense of community and interdisciplinary teamwork. "We empower all team members to talk to each other freely about patient concerns," Fogg says. 

While you’re at it, take advantage of the team conference Medicare requires for IRF stays. "Address the pressure ulcer and CAUTI quality indicators during this time," Fowler recommends. "Use this opportunity to discuss who’s assessed the problem, what’s in place for intervention and prevention, and how the patient is progressing."

Bottom line: "Patients who require inpatient rehabilitation are generally high risk for these complications, and it is everyone’s responsibility to avoid, report, and prepare patients and caregivers to manage these issues after discharge," Fogg adds.