PART III

Rehabilitation and Skilled Nursing Care

68 Postacute Care Rehabilitation Options . . . . . . . . . . . . . . . . 463 72 Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491

69 Physical Therapy and Rehabilitation . . . . . . . . . . . . . . . . . . 469 73 Patient Safety and Quality Improvement
70 The Role of Speech/Language Pathologists in Postacute Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
in Dysphagia Management . . . . . . . . . . . . . . . . . . . . . . . . . . 476 74 Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
71 Incontinence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482

461
 68
CHAP TER Following acute treatment o injury or illness, many patients require
continued medical care, either at home or in a specialized acility.
Postacute care re ers to a range o such medical, nursing and reha-
bilitation services that support the individual’s continued recupera-
tion and rehabilitation rom illnesses or management o a chronic
illness or disability.
Medicare’s payment to postacute care acilities totaled $59 billion
in 2014, more than double since 2001. Also, variation in postacute
care is the leading driver or overall Medicare cost. Postacute care

Postacute Care providers include three acility based providers: (1) inpatient reha-
bilitation acilities (IRFs); (2) long-term care hospitals (LTCHs); (3) skilled

Rehabilitation
nursing acilities (SNFs); as well as home based providers, such as
home health agencies (HHAs) and hospice. More than 40% o the
ee- or-service Medicare bene ciaries received postacute care ser-
Options vices a ter being discharged rom an acute care hospital in 2013.
The Medicare Post-Acute Care Trans ormation (IMPACT) Act
o 2014 requires a standardized patient assessment data to be
reported by all postacute care providers. In addition, there is signi -
Eddy Ang, MD cant work accomplished by Medicare policymakers to create a uni-
ed postacute care prospective payment system (PAC PPS) due to:
Jatin K. Dave, MD, MPH
• our separate payment systems or SNFs, IRFs, LTCHs and HHAs;
• similar services provided in all settings with signi cant pay-
ment di erences;
• the evidence that placement is driven at times by nonclinical
actors such as provider availability;
• signi cant unexplained variations in postacute care services;
• the paucity o evidence on where the best care is provided.
One o the rst steps to site-neutral payment is being imple-
mented in LTCH setting since late 2015. Traditionally, the selection
o appropriate postacute care setting and provider was determined
by the hospital care managers/discharge planners. However in light
o the increasing complexity o patients and rapidly changing post-
acute care regulations, it is important or hospitalists to be amiliar
with the options o multiple postacute care sites as well as the
capabilities and types o patients di erent postacute settings care
or. Additionally, due to the need or continuity o care and ocus on
sa e transitions, 30% o the hospitalist groups are now practicing in
postacute care settings.
The Centers or Medicare & Medicaid has identi ed 30-day
readmission rate as a quality indicator across the nation. There is
emerging evidence indicating that the 30-day readmission rates
range rom 5.8% to 19% among postacute rehabilitation acilities
among Medicare bene ciaries. We will describe the di erent types
o rehabilitation/postacute care options (see Table 68-1 or types
o post-acute care options) ollowed by strategies or selecting the
right setting or hospitalized patients (see Figure 68-1 or a ow-
chart o post-hospital disposition).

INPATIENT REHABILITATION FACILITIES

(IRF OR “ACUTE” REHABILITATION)
Inpatient rehabilitation acilities are designed or the patients
requiring intense multidisciplinary rehabilitation. Rehabilitative care
typically takes place under the guidance o a physiatrist. Under the
guidelines o Centers or Medicare & Medicaid (CMS), there is a
requirement that 60% o patient admitted to an IRF meet 1 o ol-
lowing 13 medical diagnoses (Table 68-2).
In addition, an interdisciplinary team con erence is mandated
within 4 days o admission and weekly therea ter. In order to remain

463
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 Home

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Ca n pa tie nt re turn home from the a cute ca re s e tting? -Without s e rvice s or

H
YES -With home ca re /hos pice

A
NO -With outpa tie nt the ra py

P
T
E
P a tie nt ne e ds MD a s s e s s me nt a nd inte rve ntion a t le a s t 5–7 d/wk a nd me e ts crite ria

R
for hos pita l le ve l of re ha bilita tion, cons ide r hos pita l le ve l of re ha bilita tion firs t.

6
P a tie nt ne e ds 3 or more h of the ra py pe r da y in a t le a s t 2 a re a s : P T, OT, a nd S LP .

8
P a tie nt wa s in ICU for 3 d or will re quire ve ntila tor s upport for 96 h a t the pos ta cute
ca re fa cility.

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c
u
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Doe s pa tie nt me e t Doe s pa tie nt me e t Doe s the pa tie nt ha ve more Doe s the pa tie nt me e t

C
IRF le ve l of ca re ? LTCH le ve l of ca re ? inte ns ity tha n tra ditiona l s kille d s kille d le ve l of ca re ?

a
r
e
(ie , P a tie nt wa s in ca re ? Or

R
ICU for 3 d or will Nurs ing ne e ds a re inte ns ive

e
h
Re ha b ne e ds a re be on ve ntila tor for (ve nts , che mothe ra py, Tra ditiona l S NF

a
ma jor drive r of ca re a t le a s t 96 h a t the

b
te le me try, wound ca re ,

i
LTCH)

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(s e e re ha b he modia lys is ): 6–8 h pe r d MD/NP : 1–2 time s

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dia gnos e s ) Me dica l ne e ds a re cons ide r pre fe rre d S upe rS NF pe r wk

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* if a va ila ble in your ge ogra phy.

n
Re a s ona ble This ma y not be a va ila ble a s a Nurs ing ne e ds : 3–4 h

O
e xpe cta tion of pos ta cute ca re s ite in a ll a re a s pe r d

p
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i
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improve me nt MD/NP : 2–5 time s pe r wk The ra py: 0–1.5 h

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pe r d
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a n a ve ra ge of 3 h
of the ra py pe r d, 5 d The ra py: 0–3 h pe r d
pe r wk for a t le a s t 2
dis cipline s (P T, OT,
a nd S LP )

Figure 68 1 Algorithm for patient disposition. SuperSNF, SNF with enhanced capabilities such as daily MD/NP/
PA rounds, radiology onsite, ability to manage complex medical patients (eg, with tracheostomy or TPN).

on Medicare coverage, patients must be able to tolerate at least
3 hours a day o physical and occupational therapy and must show
signs o progress each week. The costs incurred in this particular
setting are relatively high compared to those o other options. Physi-
cian coverage is available 24 hours a day, 7 days a week.
LONG-TERM CARE HOSPITALS (LTCHs)
These Medicare-certi ed acilities provide medically intense care
and the care teams are usually led by hospitalists. The vast majority
o the patients are severely and chronically ill necessitating contin-
ued physician-level care which encompasses, but is not limited to,
ventilator/tracheostomy care and weaning, acute dialysis, etc. This
type o setting may be the most expensive across the many other
postacute care options. Physician coverage is available 24 hours a
day. The LTCHs receives discrete payments o more than 5 billion
annually rom Medicare. In 1997–2006, the average 1-year mortal-
ity remains dismal at 50%. During the same period, the number o
LTCHs in the United States increased at a rate o 8.8% per year on
average.
The average length o stay at the LTCHs approaches 1 month.
Traditionally, an LTCH acility has to demonstrate an average
length o stay o 25 days or greater in its inchoate demonstration
period in order to ensure admissions are appropriate. Neverthe-
less, the Pathway or SGR Re orm Act o 2013 proposed that
starting in October 2015, LTCHs will only receive ull Medicare
payment rate i patients can meet one o the ollowing criteria:
(1) having spent at least 3 days in an intensive care unit (ICU);
(2) remaining on a ventilator at LTCH or at least 96 hours. Patient
not meeting either o these criteria will be reimbursed at a per
diem “site-neutral” payment rate, which is a 50/50 blended rate
o the LTCH reimbursement rate and the Inpatient Prospective
Payment System (IPPS) rate or a period o 2 years. Beginning in
October 2017, admissions not satis ying the criteria will be reim-
bursed solely at the IPPS rate. Notably, the “25% Rule” remains in
place which prohibits LTCHs rom accepting more than 25% o its
Medicare inpatients rom any single hospital. Due to this payment
change, other complex patients (who did not require intensive
care unit or will be on ventilator or 96 hours at the LTCH) may be
trans erred to Skilled Nursing Facility requiring increased capabili-
ties. Examples o such complex patients who will not quality or ull
LTCH payment include:
a. Complex Medical with multiple comorbidities not requiring
ICU or ventilator at the LTCH
• Multiple comorbidities
• Complex wound care
• Delirium/sitter
• Frequent trans usions
• Tracheostomy care
• Hemodialysis
b. Complex psychosocial actors impeding discharge
c. Complex wound care requiring extensive dressings and

465
 HOME HEALTH AGENCIES (HHAs) AND OUTPATIENT
TABLE 68-2 Medicare Inpatient Rehabilitation Facility (IRF) THERAPY SERVICES
Classification Requirements
Home health agencies are certi ed by Medicare and operate under
P
Stroke the supervision o registered nurses. It requires physician re erral
A
and recerti cation every 60 days. The patient pro les in this set-
R
Spinal cord injury
T
Congenital de ormity ting are largely similar to those receiving SNF care. Comprehensive
I
services, such as complex medication schedules and wound care,
I
Amputation
I
are provided with this option. The interdisciplinary team consists o
Major multiple trauma physical, occupational, and speech therapists, and social workers.
Femur racture (hip racture) Reimbursement occurs per episode based on case mix.
Brain injury Medicare spent $18.2 billion on home health agencies in 2012
R
e
Neurological disorders (including multiple sclerosis, muscular with more than 3.5 million bene ciaries receiving care. Home health
h
a
dystrophy, Parkinson disease) care seems e ective in bringing support to the struggling patients
b
i
in the community particularly in the transitions rom institutional
l
Active polyarticular rheumatoid/psoriatic arthritis and
i
t
care to home. Nonetheless, numerous issues ensuing the initial
a
seronegative arthritides, with quali iers
t
i
implementation o home health care have begun to sur ace, includ-
o
Systemic vasculitides with joint in lammation, with quali iers
n
ing suboptimal coordination with primary medical care, geographic
a
Severe or advanced osteoarthritis involving two or more major
n
weight-bearing joints, with quali iers variation in utilization, raud, etc.
d
Since depression is highly prevalent among the Medicare home
S
Hip or knee joint replacement, or both, with quali iers
k
health care recipients, Bruce et al. investigated the ef cacy o imple-
i
l
l
menting depression care management in routine practice in 2015.
e
Source: CMS Manual System. Pub. 100-04, Medicare Claims Processing,
d
Transmittal 347. Department o Health and Human Services, Centers or
The preliminary results demonstrated promising data but the clini-
N
cal bene t was rather lackluster among patients with moderate to
u
Medicare and Medicaid Services; 2005.
r
severe depression.
s
i
n
Many outpatient settings (hospital or ree-standing clinic) are
g
dressing changes: or example, those requiring specialty beds certi ed to provide rehabilitative service at the same level o reha-
C
or antibiotics regime that is multiple and requent
a
bilitation provided in IRFs. In general, it requires physician re erral
r
e
d. New oncology patients with evolving chemotherapy and and recerti cation every 30 days. Depending upon the individual
radiation plan requiring requent appointments and outpatient insurance coverage, there may be limitations in the number o
care and lab work visits per year. Patients with more severe diseases are more likely to
• Intermittent or continuous chemotherapy be treated in an inpatient setting; whereas those with more stable
• Radiation and physical limitations conditions are inclined to be treated through outpatient rehabilita-
• Regional patients who cannot travel tive programs.
With changing payment methodology or LTCH many SNFs will Binder et al. conducted a randomized controlled trial in 2004
need to sta and develop capabilities to manage such complex comparing the ef cacy o extended outpatient rehabilitation with
patients. We are calling such advanced SNFs “SuperSNFs.” low-intensity home exercise among community-dwelling rail older
adults with hip racture and concluded that the 6 months o
extended outpatient rehabilitation not only improved physical unc-
SKILLED NURSING FACILITY (SNF OR tion and quality o li e, but also reduced disability.
“SUBACUTE” REHAB)
Most o the patients requiring subacute rehabilitative services
are discharged to nursing homes that are certi ed to provide this HOSPICE/PALLIATIVE CARE
level o posthospital care. There is a lack o consensus to the term Hospice care is intended or those who have reached terminal
“skilled nursing” and there ore the services provided at the SNFs phase o li e with expected prognosis o less than 6 months. It com-
can vary rom one institution to another. However, these acilities monly takes place at home and is a speci c bene t under Medicare.
are ideal or providing a continuum o care that is typically initi- However, some hospitals and nursing homes may have designated
ated prior to discharge rom a hospital, such as wound care and hospice units. Comparing Medicare bene ciaries who died in 2000
complex medication schedules. Care usually occurs under the and those in 2005 and 2009, a declining number o deaths occurred
leadership o hospitalists and nurse practitioners. Physician evalu- in an acute care hospital. However, patients with limited resources
ation is mandatory within 2 weeks o admission and every 30 days may be more likely to die in a nonhome setting. As shown in a
therea ter. study by Obermeyer et al. in 2014, the patients with poor-prognosis
For the traditional Medicare bene ciaries, there is a 3-night stay cancer who received hospice care had signi cantly lower rates o
rule to the trans er o care rom an acute-care hospital to a SNF. hospitalization and intensive care unit admission. They were also
This policy has ineluctably led to unnecessary health care spending less likely to be subject to invasive procedures at the end o li e. The
stemming rom patient care that can sa ely take place in a subacute total health care costs were signi cantly lower during the last year
setting rather than a hospital. Currently, there are some accountable o li e among those on hospice care.
care organizations that can waive this 3-night stay restriction and Once in the program, patients are allowed to disenroll at any
allow subacute patients to bypass a hospitalization and be directly point in time. It is not uncommon that some patients may “graduate”
admitted to a SNF. The savings generated rom this waiver could be rom hospice care and continue to live beyond 6 months. With
utilized toward the postacute care or these patients. Some research respect to the prediction o 6-month li e expectancy among nursing
that analyzed the available quality indicators o a SNF (eg, staf ng home residents with advanced dementia, the per ormance o hos-
intensity, the percentages o patients with delirium, pain level, new pice eligibility guidelines appear somewhat nebulous. A prospective
or worsening pressure ulcers) have concluded that those indicators study illustrated that the per ormance o the Advanced Dementia
were not consistently correlated with the adjusted risks o readmis- Prognostic Tool (ADEPT) was slightly superior to hospice eligibil-
sion or death. ity guidelines, though the initiation o hospice care should still be

466
based upon the patient’s goals o care as well as their estimated li e
expectancy.
Hospice Program aims at ameliorating uncom ortable physical
symptoms, such as pain, dyspnea, constipation, nausea, excessive
mucus production. It also provides emotional and spiritual support
or the patients and their amily members rom the very beginning
and continues through the bereavement period. The core sta
includes palliative care specialists, chaplains, and social workers. In
2015, Ornstein et al. showed that there was a slight reduction in
depressive symptoms among spouses o hospice users compared
with spouses o nonhospice users.
In general, hospice use was more common among whites. A
study (Givens et al., 2010) that analyzed a national cohort o Medi-
care bene ciaries with heart ailure in 2010 revealed that blacks and
Hispanics were less likely to utilize hospice care or heart ailure than
whites. Interestingly, a survey conducted by Chinn et al. in 2014
explored physicians’ pre erences or hospice i there terminally ill
disclosed that especially emale physicians and primary care physi-
cians were more in avor o hospice and thus more likely to discuss
the option o hospice care with their patients.
In the Veterans Health Administration (VHA) population, medical
patients are more likely to receive either hospice or palliative care in
their last 12 months o li e compared with surgical patients. Further
research is needed to elucidate the disparity o use o hospice care
in such cases.
DISCHARGING TO A POSTACUTE CARE SETTING
(1) Who requires Postacute care
Patients at high risk or requiring postacute care services include
those over the age o 75, with decreased physical or social unction-
ing, patients who were dependent or iADLs but independent o
ADLs at baseline, patients with delirium, hospitalization durations
greater than 1 week, and patients with previous trans er to a post-
acute care acility or similar problem.
(2) When to Make the Re erral to Postacute Care
Re errals should be made early in most patients, once the diagnostic
workup is completed and the plan or treatment is in place. Early
re errals are bene cial to patients because o the emphasis on reha-
bilitation, reduced iatrogenesis, improved continuity o care, and
increased chances o quali ying or more appropriate and aggressive
levels o care. This, in turn, is associated with reduced length o stay
and cost savings in the acute care setting.
(3) Where: Strategies or selecting appropriate high-value post-
acute care setting based on patient’s needs, postacute care
capabilities and current payment model:
The selection o an appropriate postacute care setting is contingent
upon the patient’s needs (eg, medical, nursing, rehabilitation, etc.)
and Postacute Care Setting capabilities (Table 68-3). It would also
involve the patient’s level o motivation and participation. Also, the
availability o services may vary signi cantly among di erent set-
tings in di erent geographic locations.
With movement toward value-based payment, creating list o
high-value pre erred postacute care partners based on quality and
clinical criteria is becoming increasing common. Hospitalists can
create a scoring system based on their organizational goals and
screen available postacute care setting to select pre erred postacute
care partners. The best practice is to regularly meet and communi-
cate with these pre erred providers (home care, SNF or Hospice) to
set clear expectation and accountability.
(4) How: Barriers to Discharge to Postacute Care
Although early re errals may be made, there are some nonmodi able
and potentially modi able barriers to early discharge. It is important
or the health care providers to identi y those potentially modi able
barriers to early discharge and change the plan accordingly.
C
Nonmodi able barriers include lack o bed availability at the
H
postacute care site or i the patient is ineligible by postacute care
A
P
admission standards.
T
Modi able barriers may include:
E
R
a. Uncertainty in the clinical trajectory. Health care providers
6
should not get caught up on knowing all the answers or ear-
8
ing the unknown. Once patients have completed their diag-
nostic workup and a treatment plan is in place, they can be
P
re erred to the postacute care site. I medical complexity is the
o
s
uncertainty, patients will be better managed at appropriately
t
a
c
sta ed acility, such as IRF or LTCH.
u
b. Patient or amily reluctance. Many patients and their amilies
t
e
do not recognize the term “postacute care.” I the health care
C
a
team is knowledgeable about these di erent settings and
r
e
the requirements or each setting, this can alleviate some o
R
e
the patient’s and amily’s concerns, questions, or uncertainty.
h
Also, it may be help ul to underscore the important act
a
b
that many o these postacute care settings are designed to
i
l
i
t
continue care initiated in the hospital with a larger ocus on
a
t
i
rehabilitation.
o
n
c. Loss o involvement with patient’s care. This can be improved
O
by continuous communication. The providers at postacute care
p
t
settings are more than willing to communicate with the acute
i
o
care physicians about the status o the patient, and likewise,
n
s
are always appreciative o updates at the time o admission to
the postacute care setting. Thorough discharge summaries (at
both settings) are key to updating the next health care provider
on continuing issues or items that require ollow-up.
d. Unawareness and inconsistencies o clinical capabilities o
nonacute options. Postacute care acilities do di er rom site to
site. Many o the social workers or case managers will be able to
identi y some key di erences, but it is important that upon the
initiation o screening that physicians and health care provid-
ers accurately document in the medical record what services/
therapies would be expected at the time o discharge.
e. Poor communication back rom acilities.
. Inadequate documentation o patient’s complexity and needs.
(5) Steps to Promote Timely Discharges to Postacute Care
Health care providers should:
a. identi y unctional needs early and address these with the help
o the multidisciplinary team.
b. anticipate which o these medical or unctional needs will need
to be addressed, i any, at the time o discharge.
c. communicate these needs in the medical record, to the nurs-
ing sta , and to the case managers.
d. set clear expectations with the amily and the patient about
the length o stay and the need or postacute care. The choice
o acility at this time o planning is not as important, since this
may change and will likely be addressed with the patient and
amily by the case manager.
e. begin thinking about the discharge process at admission. For
example, i discharge to a skilled nursing acility is planned,
keep in mind that Medicare patients must be in the hospital
under admission status or three midnights to access their SNF
bene t. I the plan is to discharge to LTAC or IRF, this does not
apply since these are hospital-level acilities.
. simpli y medications and discontinue any unnecessary medica-
tions (especially prn medications).
g. complete the discharge summary the day be ore discharge. By
doing so, it can be transmitted to the accepting postacute care
acility and medications can be ordered and be ready or the
467
 patient. Any questions or discrepancies can be addressed by
TABLE 68-3 Criteria Example for Selecting Preferred the admitting providers be ore the patient has le t the acute
Postacute Care Partners care setting.
P
A
Access/geography Total capacity/occupancy
SUGGESTED READINGS
R
Capacity to accept patients during
T
weekend
I
Feder J. Bundle with care—rethinking Medicare incentives or post-
I
Contracted with multiple payers
I
acute care services. N Engl J Med. 2013;369:400-401.
Integration with the same Electronic
Medical Records Kane, RL. Finding the right level o posthospital care. JAMA. 2011;
Quality/utilization Medicare Star Rating 305(3):284-293.
R
Medicare Payment Advisory Commission. Medicare’s post-acute care:
e
Department o Public Health Score
h
trends and ways to rationalize payments. March 2015 Report to the
a
Accreditation
b
Congress: Medicare payment policy. Washington, DC: MedPAC.
i
Length o Stay
l
i
t
Mitchell, SL, Miller, SC, Teno, JM, Kiely, DK, Davis, RB, Sha er, ML.
a
Readmission Rate
t
Prediction o 6-month survival o nursing home residents with
i
o
Communication Clear rules o engagement and hand o
n
advanced dementia using ADEPT vs hospice eligibility guidelines.
a
Regular review o outcomes (such as JAMA. 2010;304(17):1929-1935.
n
d
readmissions)
Neuman, MD, Wirtalla, C, Werner, RM. Association between skilled
S
Clinical capabilities Specialized clinical programs and services,
k
nursing acility quality indicators and hospital readmissions. JAMA.
i
l
such as heart ailure or COPD program
l
2014;312(15):1542-1551.
e
d
Responsiveness: See patients within 24-48 h
The Society o Hospital Medicine (SHM). 2014 State of Hospital
N
Able to handle complex patients via
u
Medicine Report.
r
individualized care plan
s
i
n
g
C
a
r
e
468
CHAP TER
69 INTRODUCTION
Physical therapists (PTs) and occupational therapists (OTs) address
the unctional needs o patients through mobilization, conditioning,
and training in sel -care, and other speci c tasks. PTs and OTs prac-
tice in many settings, including the hospital, clinic, skilled nursing
acility (SNF), long-term care acility, reestanding inpatient intensive
rehabilitation center, and home. A smaller number also practice in
emergency departments in the assessment and treatment o mus-
culoskeletal injury. Less heralded is the role that PTs and OTs play in
Physical Therapy and minimizing speci c in-hospital complications, and optimizing suc-
cess ul transitions to outpatient care. Given the growing economic

Rehabilitation pressures on hospitals, including nonpayment or some nosocomial

Thomas E. McNalley, MD
Christopher J. Standaert, MD
complications or or rapid readmission to the hospital a ter discharge
(bounce-backs), PTs and OTs are not only crucial in helping patients
regain unctional capacity, but are also vital to the nancial well-
being o inpatient hospitals. Un ortunately, the scope o practice
o PTs and OTs o ten lies beyond the ocus o physicians. Medical
education o ten underemphasizes the role o allied health providers
and their contributions to restoring health and unction. This chapter
attempts to correct this underexposure by delineating the roles and
responsibilities o these therapists, and indicating their impact on
speci c diagnoses commonly encountered by the hospitalist.

Key Clinical Questions CASE 69-1

1 What are the roles o physical and occupational therapy
in the inpatient setting?
2 Which patients should be seen by a physical or
occupational therapist?
3 What is a physiatrist? What role does he or she play in
the care o hospitalized patients, and how does it di er
rom the role o the hospitalist?
4 How can rehabilitation services assist in discharge
planning?
AN ICU TRANSFER TO THE MEDICAL SERVICE AFTER A
DEBILITATING MEDICAL ILLNESS
A 53-year-old previously healthy male, with a past medical his-
tory o hypertension, developed a ebrile illness over several
days, and collapsed at his small business. The emergency medical
technicians success ully resuscitate him and he is admitted to the
intensive care unit. Over a period o 4 weeks he has a complicated
course including prolonged intubation necessitating tracheostomy
placement due to respiratory ailure rom community-acquired
methicillin-resistant Staphylococcus aureus (MRSA) pneumonia,
encephalopathy attributed to acute illness delirium, acute kidney
injury requiring dialysis, and demand ischemia characterized by an
elevated troponin without ECG changes. Ultimately, the patient
stabilizes and is trans erred to the general medical service a ter
tracheostomy and placement o a percutaneous endoscopic gas-
trostomy (PEG) tube or nutrition. Communication is di cult due
to the tracheostomy. Overnight he becomes agitated and receives
haloperidol. He requires suctioning every 1 to 2 hours, and is not
yet ready or discharge to a hospital-level rehabilitation acility. On
rounds he appears agitated when he requires suctioning. Assess-
ing mental status is di cult due to tracheostomy, and he does not
appear to respond to commands optimally.
Although this patient clearly requires acute medical treat-
ment, how can you improve this individual’s level o unction-
ing within the ramework o his illness? What steps can you take
to ast track him to a rehabilitation acility so that he can receive
the complex multidisciplinary care he needs to ultimately
return home to his amily and maybe even return to work?
I available, early consultation with a physiatrist can be instru-
mental to:
• Reduce the complications that he has already experienced
during his hospitalization
• Improve physical and social unction

469
 • Identi y cognitive and emotional complications o traumatic A common concern in patients with neuromuscular dys unction
brain injury (even i not physically apparent by head CT) is the risk o joint contractures. Up to 39% o patients who stay in
• Concentrate coordinated therapy the intensive care unit (ICU) or longer than 2 weeks develop at least
P
• Improve the likelihood that this patient may eventually go one joint contracture. A stay o 8 weeks in the ICU increases the odds
A
home ratio o contracture to 7.1, compared with patients staying 2 to 3
R
weeks. Joint contractures may result in pain, permanent de ormity,
T
For this patient, physiatry consultation assisted the team in
gait abnormality, and loss o mobility. Contractures also predispose
I
properly diagnosing and treating his agitation, which was initially
I
the patient to skin breakdown. Prevention is again best acilitated
I
assumed to be due to a combination o delirium and inability
by early PT consultation. Stretching, strengthening, and protective
to communicate when he needed suctioning. The physiatrist,
splints all reduce the likelihood o plantar exion de ormity and
however, identi ed that he had cognitive and emotional
other lower-extremity contractures. OTs usually address concerns
R
complications analogous to patients who had suf ered
with the upper extremity, as discussed below.
e
traumatic brain injury while he was in the intensive care unit.
h
The PT may help prevent and treat skin injury by ensuring
a
The physiatrist made speci c pharmacologic recommendations,
b
adequate movement to reduce the risk o decubitus ulcers, pro-
i
l
engaged the amily who had not visited him, coordinated the
i
t
tect surgical incisions and skin gra ts, and reduce discom ort rom
a
care o physical therapy, occupational therapy, speech therapy,
t
malpositioning or immobility. The therapist may also instruct the
i
o
and communicated with a rehabilitation acility best able to
n
patient about the avoidance o aulty trans er techniques or seating
meet his complex needs. Due to the physiatrist’s intervention,
a
arrangements that may lead to shear injuries to the skin.
n
the patient was ast-tracked to a rehabilitation center, which
d
Falls, and the ear o alling, contribute to morbidity both in and
gave him the greatest chance o achieving unctional recovery.
S
out o the hospital. In the debilitated elderly, alls may lead to rac-
k
i
l
tures, especially o the hips and orearms, or intracranial pathology,
l
e
d
including subdural hematomas. Fear o alls may lead to a down-
PHYSICAL THERAPY
N
ward spiral o immobility and progressive weakness that actually
u
Physical therapists have completed 4 years o postgraduate training, increase the risk o alls. Prevention should begin in the hospital. The
r
s
i
with a ocus in musculoskeletal assessment and treating impair-
n
PT can assess all risk using the Berg Balance Scale, and intervene
g
ments in sa ety and mobility. Although they most actively provide as needed. For some patients, simple reminders and strengthening
C
care or orthopedic and neurosurgical patients, they also clinically are adequate protection; or others, an assistive device may su ce.
a
r
e
assess patients with medical problems such as breathing dys unc- Still others may require intervention in an intensive, interdisciplin-
tion, the need or cardiac rehabilitation, and chronic vertigo. For ary rehabilitation environment. Patients in the latter group usu-
example, patients with respiratory disease are o ten readmitted due ally need evaluation by a physiatrist prior to trans er to in-patient
to exacerbations o their chronic disease. PTs ocus on breathing, rehabilitation.
posture, mobility, range o motion o joints, and strengthening o
the respiratory muscles, and they use physical modalities to assist OCCUPATIONAL THERAPY
patients with musculoskeletal derangements in the thoracic or rib
The title occupational therapist may con use both patients and other
area. On a busy medical service, PTs can prevent loss o unction
health care pro essionals. An occupation is de ned as a job or pro-
during long-term hospitalization by improving the patient’s ability
ession, but in OT it is de ned as a task or activity ul lled in daily li e.
to move within a bed, and progress rom supine to sitting, sitting to
OTs ocus on restoring patients to their basic sel -care, and ideally to
standing, and nally to ambulation. PTs review the medical record
independent living. Like the PT, OTs have completed 4 years o post-
and the history provided by the patient and amily, and per orm a
graduate training, but with a special ocus on assessing, preserving,
ocused musculoskeletal examination to identi y de ormities, atro-
and restoring upper-extremity strength, unction, and ROM. Some
phy, limitations in range o motion (ROM), weakness, and unctional
undergo additional training to become certi ed hand therapists.
impairments that can be addressed with various interventions. They
OT interventions include stretching and ROM exercises. Bracing and
also provide a wide range o tests and measurements.
splinting may be recommended or patients with increased upper-
Hospitalists nd PTs help ul in many areas, but may not request
extremity tone rom neurologic disease, or scarring rom burns that
their services until the time o discharge, when the therapist is
place them at risk or joint contracture. OTs participate in identi ying
urgently requested to “assess or home sa ety.” Involving the
postdischarge needs, and in some hospitals, they per orm home-
therapist as early as possible is ideal, since early interventions may
sa ety evaluations by observing patients in typical tasks done at
decrease the length o hospital stay and increase the likelihood o
home, such as cooking a meal. As with physical therapy, the wise
the patient being discharged directly to home. As well, the patient’s
clinician will involve OT early in the hospitalization.
mood, appetite, sense o well-being, and general medical condition
may all bene t rom increased activity.
PT interventions may be educational, such as teaching a patient SPEECH THERAPY
how to sa ely roll in bed to allow nursing care. They can also be more The ability to swallow or eat af ects nutritional status and also quality
complex, including moving rom supine to sitting, evaluating and o li e. Many conditions increase the risk o swallow disorders, which
improving sitting balance, and progressing to standing while moni- are more common in the elderly (Table 69-1).
toring or hemodynamic changes. Once upright, the patient may As part o the unctional assessment o patients at admission, hos-
be able to ambulate, and the therapist can recommend assistive pitalists should evaluate or the possibility o a dysphagia disorder.
devices such as canes or walkers. New gait impairments may require Family members may be the rst to suspect a problem. Recurrent
urther training, and occasionally lower-extremity bracing with pneumonias, malnutrition, and social isolation are important clues
orthoses. I the patient is unable to reliably stand or walk, or lacks (Table 69-2).
adequate endurance, he or she may need a wheelchair. The power The role o the speech and language pathologist is to diag-
wheelchair and the much-promoted power scooter allow greater nose swallowing disorders, make treatment recommendations,
mobility, with the loss o the aerobic challenge o sel -propulsion. In and coordinate an interdisciplinary approach with the health care
the United States, Medicare will o ten cover part o the cost o pow- team, including nurses, respiratory therapists, physical therapists,
ered mobility devices in patients who meet certain criteria. and nutritionists, as well as educating the patient and amily.

470
TABLE 69-1 Risk Factors for Dysphagia
Complications of Hospitalization
• Intubation
• Deconditioning
• Medications (including anesthesia, opioids, sedatives, some
antibiotics, carbidopa-levodopa)
• Delirium
Disorders
• Cancer (especially head and neck)
• Stroke, neurodegenerative
• Burns and trauma
• Diabetes
• Cardiac dys unction
• Chronic obstructive pulmonary disorder
• Cervical hypertrophic osteoarthropathy (encroachment o
osteophytes at the C-6 cricoid cartilage)
Adapted rom Brown CJ, Peel C. Rehabilitation. In: Hazzard’s Geriatric
Medicine and Gerontology, 6th ed. New York, NY: McGraw-Hill; 2009.
The speech therapist per orms a bedside swallowing assessment
unless there are contraindications. Examples that would require
postponement o an evaluation include inability to cooperate
because o an unstable medical condition such as active gastroin-
testinal bleeding or respiratory distress, inability to maintain upright
or side-lying at 90 degrees, unexplained sudden change in tempera-
ture, active ventilator weaning, or altered mental status. I the bed-
side evaluation is inconclusive, nothing by mouth is recommended
until a complete evaluation can be per ormed under video uo-
roscopy. This study examines the oral, pharyngeal, and esophageal
stages o ingestion, and should identi y i there is aspiration, or sig-
ni cant risk o aspiration, below the level o the vocal cords. It may
also evaluate whether the compensatory swallowing techniques are
ef ective in preventing aspiration. Speech and language patholo-
gists may recommend speci c techniques to reduce the risk o
aspiration such as head posture (chin tuck, turning head to weaker
or stronger side, tilting head backward), body posture (upright at 90
degrees, lying on one side between eedings rather than supine),
and manner o oral intake (rate, consistency, sizes, liquids by spoon).
PHYSIATRY
A rehabilitation physician, or physiatrist, is a specialist in physical
medicine and rehabilitation (PM&R). Physiatry has been recognized
as a specialty by the American Medical Association since 1946.
The original impetus or growth o the eld was the demand or
TABLE 69-2 Indications for Swallowing Evaluation
Any patient with:
•  Past medical history o reported dysphagia symptoms
•  Observed dysphagia
•  Suspected aspiration
•  Decreased oral eeding, dehydration, malnutrition
•  Parenteral or enteral eeding
•  Intubation, tracheostomy, or ventilator weaning
•  Vocal cord paresis, paralysis, or laryngospasm
•  Deconditioning
TABLE 69-3 Common Indications for Physiatry Consultation
C
H
Amputation
A
Spinal cord injury
P
T
Stroke, in conjunction with speech therapists, recreational
E
therapists, physical therapists, and occupational therapists
R
Traumatic brain injury
6
Medical patients requiring complex rehabilitation
9
Musculoskeletal syndromes: low back pain, ibromyalgia
Chronic pain management, in conjunction with psychologists,
P
h
physical therapists, occupational therapists, chiropractors, and
y
s
anesthesiologists with expertise in pain management and
i
c
interventional procedures
a
l
T
h
e
r
a
p
y
sophisticated rehabilitation techniques or the large in ux o injured
a
n
soldiers returning rom World War II. Physiatrists concentrate on
d
the ability o patients to unction optimally within the limits placed
R
e
upon them by disease processes which may not be reversible. A
h
a
team approach to chronic conditions is emphasized to coordinate
b
care by building on and strengthening the resources o the person
i
l
i
t
and amily, providing or a acilitating environment, and developing
a
t
i
per ormance goals in that environment.
o
n
A PM&R residency includes training in spinal cord injury, brain
injury, stroke, neuromuscular disease, and musculoskeletal injury,
as well as the per ormance o electrodiagnostic studies and the
assessment o neuromusculoskeletal impairment. A physiatrist can
help determine why a patient is weak, distinguishing between criti-
cal illness neuromyopathy, steroid myopathy, and other causes o
debility. They can evaluate patients with speci c impairments and
recommend orthoses, bracing, or other assistive devices to improve
mobility, and provide recommendations or ormal physical or
occupational therapy, as well as weight-bearing and all precautions.
Physiatrists work closely with PTs, OTs, speech-language patholo-
gists, and allied providers in the coordinated delivery o multidisci-
plinary care. They o ten oversee the rehabilitation process, and work
with hospitalists to ensure that care is appropriate or the medical
context (Table 69-3).
REHABILITATION
The de nition o rehabilitation by the World Health Organization is
“the use o all means aimed at reducing the impact o disabling and
handicapping conditions and at enabling people with disabilities to
achieve optimal social integration.”
Acute rehabilitation re ers to treatment that occurs within the rst
month o illness once the patient has been resuscitated or received
de nitive care, and by de nition involves more acute medical or
surgical issues than postacute rehabilitation.
Rehabilitation begins with improving mobility by getting the
patient out o bed. Depending on the underlying condition o
the patient, this may begin immediately, or be delayed or weeks
with patients with spine injuries. Patients with upper extremity
injuries will need to learn how to get out o bed without using that
arm, and require orearm supports on ambulatory assistive devices.
I the lower extremity is af ected, the patient must learn how to get
out o bed while elevating the injured leg. Walking with a walker or
crutches or patients with reduced or no weight-bearing requires
30% to 50% more energy compared with normal walking. For
patients with decreased cardiopulmonary reserve, this can be espe-
cially challenging. For patients with preexisting impaired mobility,
the goal o rehabilitation is to return the patient to unctional status
prior to the injury. As the patient regains mobility, rehabilitation
471
 also addresses af ected joints with the goal o regaining range o unstable conditions. Still other patients who have complex dis-
motion. The next step o rehabilitation is to improve motor control abilities as a consequence o an acute injury, stroke, or medical
and coordination so that the patient will eventually be able to exer- conditions or an acute event in a patient with prior disabilities,
P
cise. Strengthening exercises with progressive resistive exercises can such as multiple sclerosis, bene t rom high-level rehabilitation.
A
then begin. Finally, rehabilitation helps patients and amilies adapt Complex rehabilitation requires the involvement o at least three
R
to permanent impairments. specialists such as gait retraining, continence management, and
T
Rehabilitation is provided at dif erent levels with a hierarchy o speech therapy.
I
I
interventions depending on the complexity o the patient’s prob- To quali y or a rehabilitation hospital, patients generally carry a
I
lems and needs. The lowest level o consultation in the hospital “rehab diagnosis”—stroke or traumatic brain injury or spinal cord
setting is a single therapeutic intervention by PT or OT, such as a PT injury, among many—and must demonstrate the ability to per orm
sa ety assessment or home discharge, or to identi y postdischarge over 3 hours o therapy daily or require complex treatment such
R
needs or PT and OT. Other patients with complex needs may as ventilator care, wound care, physical therapy, OT, and speech
e
h
require continued acute hospitalization or active and potentially therapy (Table 69-4).
a
b
i
l
i
t
a
t
i
o
TABLE 69-4 Rehabilitation Providers and Typical Methods Used for Evaluation and Treatment
n
a
Provider Methods o Evaluation and Treatment
n
d
Physical therapist Assessment:
S
k
Joint range o motion, muscle strength, motor skills, coordination
•   
i
l
l
e
Gait and mobility, including ability to per orm ADLs
•   
d
N
•  The need or appropriate assistive devices
u
r
Educational goals:
s
i
n
•  Relieve discom ort
g
C
•  Regain, maintain, or improve unction
a
r
Treatment:
e
Active and passive exercise training to increase range o motion, strength, endurance, balance,
•   
coordination, and gait
Physical modalities (heat, cold, ultrasound, massage, hydrotherapy, and electrical stimulation)
•   
Occupational therapist Assessment:
•  Sel -care skills and other activities o daily living
•  Home environment
•  The need or assistive technology
Education:
•  Sel -care skills training
•  Training in use o assistive technology
Treatment:
•  Fabrication o splints
•  Upper extremity de icits
Speech therapist Assessment:
•  All aspects o communication
•  Swallowing disorders
Education:
•  Alteration o diet to reduce aspiration risk
•  Maneuvers to reduce aspiration risk
Treatment:
•  Communication de icits
Nurse Assessment:
•  Sel -care skills
•  Family and home-care actors
Education:
•  Sel -care training
Patient and amily regarding ADLs, IDLs, medications, underlying medical problems, preventive
•   
measures
Treatment:
Primary ocus on cure o acute medical issues or palliation i patients are terminal
•   
•  Liaison with community
(Continued )

472
TABLE 69-4 Rehabilitation Providers and Typical Methods Used for Evaluation and Treatment (Continued)

C
H
Provider Methods o Evaluation and Treatment

A
Social worker Assessment:

P
T
•  Family and home care actors

E
•  Psychosocial actors

R
Education:

6
9
•  Patient and amily rights
Treatment:

P
•  Counseling

h
y
•  Liaison with community

s
i
c
Dietician •  Assess nutritional status

a
l
T
•  Recommend dietary alterations to maximize nutrition

h
e
•  Monitor TPN

r
a
Recreation therapist •  Assess leisure skills and interests

p
y
•  Involve patients in recreational activities to maintain social roles

a
n
Prosthetist •  Makes and its prosthetic limbs

d
R
Orthotist •  Makes a variety o orthotics including braces, ankle– oot orthoses, splints, and shoe inserts

e
h
•  Assesses it o orthotics

a
b
i
l
i
Adapted rom Brown CJ, Peel C. Rehabilitation. In: Hazzard’s Geriatric Medicine and Gerontology, 6th ed. New York, NY: McGraw-Hill; 2009.

The term rehab is o ten applied to SNFs that of er therapy services,
but do not provide hospital-level or more ormal inpatient interdis-
ciplinary rehabilitation. Many elderly patients, in particular, primarily
need physical therapy or endurance training so that they can sa ely
per orm ADLs and go home. Despite having a “rehab diagnosis,”
these patients are not candidates or intensive rehabilitation because
o low endurance, weight-bearing precautions, or other actors such
as inability to participate due to dementia. These patients may be
more appropriate or “subacute rehab,” o ten delivered in a SNF, with
a less intensive schedule o rehabilitation services. Rehabilitation
providers can generally make recommendations or the proper level
o intensity in the patient’s ongoing recovery, and assist with the
process o establishing an appropriate discharge location.
Homebound individuals may quali y or home-health physical or
occupational rehabilitative therapies, with an eye toward eventually
transitioning to outpatient therapies. In general, patients receive
2 to 3 days o therapy per week in SNFs, outpatient clinics, or at home.
COMMON INPATIENT CONDITIONS THAT BENEFIT FROM
REHABILITATION CONSULTATION
■ MUSCULOSKELETAL IMPAIRMENTS
Although rarely the primary cause o a patient’s admission, osteoar-
thritis (OA) and other joint complaints are requent in hospitalized
persons. Joint complaints impair mobility through pain, restricted
movement or contracture, and weakness rom disuse. Low back pain
is a particular source o limitation, and is highly prevalent in older
populations. Knee osteoarthritis is also common, particularly in the
obese and the elderly. Mobilization requently requires adequate pain
control. Both acetaminophen and nonsteroidal anti-in ammatory
drugs (NSAIDs) are ef ective in osteoarthritis pain, although the risks
o bleeding, renal damage, and hypertension limit the use o NSAIDs.
For acute ares o joint pain, intra-articular injections may reduce pain
and improve mobility and unction. Splinting and bracing may also
contribute to pain relie and mobility. Opiates are generally reserved
or the nal stages o OA, and should be used with great restraint.
PTs are o high value to patients with back and knee pain, as
they can help to improve gait mechanics, strengthen weak muscles
t
a
t
i
o
n
around pain ul joints, and provide assistive devices or joint pro-
tection and stability, and thereby allowing aster mobilization o a
hospitalized patient. In the order or physical therapy, the physician
should detail speci c joints known to be af ected. The PT should
also know about upper extremity limitations, especially when use
o crutches or a walker may be required. OTs are help ul or patients
with upper extremity dys unction related to OA or other causes.
■ JOINT REPLACEMENT
PTs and OTs are an integral component o care or patients under-
going joint-replacement surgery, assisting in tasks ranging rom
mobilization, education, and sel -care to home sa ety and modi ca-
tions. Surgeons involve these providers early in the care process to
individualize exercises depending on the patient’s condition. In the
immediate postoperative period, patients are educated about the
importance o early mobilization to optimize unction o the new
joint, movements to avoid to protect the prosthetic joint, exercises
to per orm to avoid thrombophlebitis, and when to call or assis-
tance. Weight-bearing progresses based on the surgical technique
and materials and the patient’s ability to participate. PTs acilitate
better outcomes, shorter hospital stays, ewer medical complica-
tions, and more success ul transitions to home or rehabilitative care.
■ OSTEOPOROSIS
Risk actors or osteoporotic ractures include age, emale gender,
tobacco use, corticosteroid treatment, caf eine intake, low body
weight, and inactivity. As inactivity is common in hospitalized
patients, early mobilization, strength, and gait training are important
strategies to mitigate the risk o worsening osteoporosis, in addition
to drug therapies such as calcium and vitamin D supplementation,
bisphosphonates, and teriparatide.
■ STROKE
There is now evidence that the best results or unctional recovery
occur or young patients and when PT and OT are involved early
a ter the stroke occurs. In the early phase o stroke, individuals o ten
have accid paralysis and are at high risk or pressure palsies and

473
 joint injury. Proper positioning and support are essential at this junc- value o CR in reversing coronary artery disease, reducing lipopro-
ture. The speech-language pathologist has an equally important tein levels, and increasing physical work capacity. In the hospital
role. Death rom aspiration and pneumonia is common a ter stroke, setting, CR ocuses on the identi cation o risk actors, previous and
P
and a speech-language pathologist can assess aspiration risk and current per ormance status, and re erral or outpatient activity. For
A
devise an appropriate diet or approach to eeding. those recovering rom surgeries, this phase o CR also includes edu-
R
Loss o bladder control is a troubling complication o stroke cation on protecting sternal incisions. Education on sa e activities
T
that may be aggravated by problems with muscle control, speech, to resume a ter discharge, risk actor modi cation, and vocational
I
I
and cognition. Improving mobility, attention, and communication counseling may complete the acute CR process. Both PTs and OTs
I
through physical, occupational, and speech therapy interventions should be part o the CR team.
can greatly improve bladder management. This may lessen the risk
o urinary tract in ections during hospitalization and lead to more ■ PULMONARY REHABILITATION
R
success ul home discharge. Depression is another signi cant and
e
Rehabilitation programs in patients with chronic obstructive pul-
h
common complication o stroke; roughly 30% o stroke patients
a
monary disease and other chronic lung diseases have been shown
b
develop clinical depression. In addition to psychological and phar-
i
to improve exercise capacity and quality o li e, and reduce dys-
l
i
t
macologic intervention, the role o rehabilitation services in enhanc-
a
pnea and hospitalization. The main ocus o pulmonary reha-
t
ing recovery may also be help ul in depression.
i
bilitation is exercise, including strength training or the upper and
o
n
Although neurologic impairments older than 4 to 6 months are lower extremities, as well as respiratory muscle-speci c training.
a
unlikely to be completely reversed by therapy, unctional per or-
n
Patients with chronic sputum production bene t rom chest physi-
d
mance may bene t rom skilled therapies. Thus, the patient with an cal therapy. Patients receive education about medications, energy
S
older stroke who is readmitted to the hospital may enjoy a better
k
conservation, work simpli cation, and breathing techniques, such
i
l
outcome i PTs, OTs, and speech therapists are consulted early in
l
as pursed-lip breathing, posture, and diaphragmatic breathing.
e
d
the hospital stay. Nutritional interventions and psychosocial and emotional support
N
are also provided. Pulmonary rehabilitation may be carried out in
u
■ CRITICAL ILLNESS NEUROMYOPATHY
r
inpatient and outpatient settings.
s
i
n
Persons who have had sepsis, hypotension, or hypoxemia may
g
develop critical illness neuromyopathy. An electrodiagnostic study
C
PRACTICE POINT
a
may clari y the diagnosis and provide prognostic in ormation.
r
e
Patients with more pro ound axonal damage generally have a worse Strategies to minimize negative consequences of bedrest
outcome. Patients with critical illness neuromyopathy may need
weeks to months to recover rom their neurologic impairment; •  Minimize duration o bedrest
some never do. Weakness predisposes the individual to loss o joint •  Avoid strict bedrest
movement and contractures. Decubitus ulcers are a threat. These •  Allow bathroom privileges
individuals requently require a high level o care upon discharge. •  Have patient stand 30 to 60 seconds when trans erring rom
Mobilization with a therapist can improve blood ow, encourage bed to chair
cardiovascular tness, and contribute to better pulmonary hygiene. •  Encourage amily to ambulate patient, engage patient with
With true muscle atrophy (loss o muscle bers), there is unlikely to meals, and walk to hospital testing
be an improvement in muscle bulk through short-term interven- •  Encourage daily exercises adapted to individual patient (such
tions by therapists. However, neuromuscular control and improved as ankle exercises to prevent venous thromboembolism)
recruitment o extant bers likely contribute to improved per or- •  Involve physical therapy, occupational therapy, and nursing to
mance. Similarly, unction can improve with adaptive techniques encourage mobilization, optimize eeding, use o protective
and equipment provided by therapists. splinting, and pain management
•  Avoid physical or pharmacologic restraints
■ DEBILITY •  Daily reassessment o the need or tethers such as Foley
catheter, supplemental oxygen, IVs, and other devices that
For deconditioning related to bed rest or inactivity, also known as
con ne the patient to bed
debility, the loss o strength in healthy young men is about 1% per
day, or roughly 10% per week. In elderly patients, this process is accel-
erated signi cantly, and the recovery time may exceed the duration ■ OTHER CONDITIONS
o the initial hospitalization. In the general medical inpatient setting, Other conditions less commonly seen in the standard inpatient set-
debility can be compounded by medical illness, poor nutrition, ortho- ting require rehabilitation services. These include closed head injury,
pedic problems, and contractures. The cardiopulmonary system also spinal cord injury or in ection, burns, amputation, polytrauma, and
declines with inactivity. Ferretti and colleagues ound that a ter 42 the Guillain-Barré syndrome (acute in ammatory demyelinating
days o bed rest, VO2 max was reduced by 16%, cardiac output by 30%, polyneuropathy). In acute trauma, patients are requently taken to
and oxygen delivery by 40%. Maintenance o muscle strength during level I trauma centers where rehabilitation services are ingrained
immobility can be accomplished by muscle contractions o 30% to into the provision o health care services. When trauma patients
50% o maximal tension or several seconds each day. Studies have are cared or in settings with less ormal in rastructure, it may be
shown an improvement in ability to per orm activities o daily living help ul to proactively involve PTs, OTs, physiatrists, and other reha-
in elderly patients who had an exercise program while in the hospital. bilitation providers in the care process. Many o the same issues o
concern described above, such as contractures, immobility, and skin
■ CARDIAC CONDITIONS breakdown, are present in these other processes. Additionally, reha-
Formal cardiac rehabilitation (CR) programs may bene t a wide bilitation providers may also be particularly aware o the potential
range o patients: those recovering rom myocardial in arction, or medical complications in speci c conditions (eg, heterotopic
those with stable heart ailure, and those who have had coronary ossi cation a ter burns, autonomic dysre exia a ter spinal cord
artery bypass gra ting, heart transplantation, valve surgery, angio- injury, pulmonary aspiration, or bladder dys unction associated with
plasty, and pacemaker placement. Studies have demonstrated the neurologic injury).

474
CONCLUSION Ferretti G, Antonutto G, Denis C, et al. The interplay o central and
peripheral actors in limiting maximal O2 consumption in man

C
Hospitalists can enlist numerous pro essionals in the acute treatment
a ter prolonged bed rest. J Physiol. 1997;501(Pt 3):677-686.

H
o impairment and in discharge planning. Involving PTs and OTs early

A
in a patient’s hospital course may reduce length o stay, minimize Hochberg MC, Altman RD, April KT, et al. American College o Rheu-

P
inpatient complications, and lead to a more success ul discharge at a matology 2012 recommendations or the use o nonpharmaco-

T
higher level o independence. Physiatrists can assist in the diagnosis logic and pharmacologic therapies in osteoarthritis o the hand,

E
R
and management o neurologic and musculoskeletal conditions, and hip, and knee. Arthritis Care Res (Hoboken). 2012;64:465-474.

6
recommend appropriate levels o therapy upon discharge. Other Kosse NM, Dutmer AL, Dasenbrock L, Bauer JM, Lamoth CJ. Ef ective-

9
providers, such as speech-language pathologists, psychologists, ness and easibility o early physical rehabilitation programs or
vocational counselors, and therapeutic recreation specialists, contrib- geriatric hospitalized patients: a systematic review. BMC Geriatr.
ute to the restoration o unction a ter illness or injury. Understanding

P
2013;13:107. http://www.biomedcentral.com/1471-2318/13/107.

h
the role o these providers and utilizing their services in an ef ective

y
Mueller E. In uence o training and o inactivity on muscle strength.

s
and timely manner are essential skills or the hospitalist.

i
c
Arch Phys Med Rehabil. 1970;51:449-461.

a
l
Siebens H, Aronow H, Edwards D, Ghasemi Z. A randomized con-

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SUGGESTED READINGS

h
trolled trial o exercise to improve outcomes o acute hospitaliza-

e
r
tion in older adults. J Am Geriatr Soc. 2000;48:1545-1552.

a
p
American Physical Therapy Association. Guide to Physical Therapist

y
Practice 3.0. Alexandria, VA: American Physical Therapy Association; Uusi-Rasi K, Patil R, Karinkanta S, et al. Exercise and vitamin D in all

a
prevention among older women: a randomized clinical trial. JAMA

n
2011.

d
Intern Med. 2015;175:703-711.
de Morton NA, Keating JL, Jef s K. Exercise or acutely hospi-

R
e
talised older medical patients. Cochrane Database Syst Rev.

h
a
2007;(1):CD005955.

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l
i
t
a
t
i
o
n
475
 CHAP TER
70 INTRODUCTION
The term dysphagia re ers to any type o di culty with moving
ood and/or liquid rom the mouth to the stomach. A wide variety
o conditions and circumstances can cause dysphagia. Speech/
Language Pathologists (SLPs) typically receive specialized training in
the diagnosis and treatment o oropharyngeal dysphagia. However,
physicians working in both acute and subacute settings must be
able to recognize the signs, symptoms, and possible causes o dys-
phagia in order to direct a plan o care that maximizes patient sa ety.
The Role of This chapter will ocus on the di erences between normal and dis-
ordered swallowing and management o swallowing disorders, with

Speech/Language an emphasis on oropharyngeal dysphagia.

Pathologists EPIDEMIOLOGY
There is a lack o clear data regarding the prevalence o dysphagia

in Dysphagia in the general population; however, Bhattacharyya (2014) analyzed

Management
Marianne E. Savastano, MS, CCC-SLP
the 2012 National Health Interview Survey and ound that in a
single 12-month period, an estimated 9.44 million adults in the
United States reported a swallowing problem, which correlates to
1 in 25 adults annually. The survey urther revealed that approxi-
mately 31% o those with dysphagia reported it to be a moderate
problem and approximately 25% o those with dysphagia elt that
it was a very large problem. The average number o days that indi-
viduals reported being a ected by dysphagia was 139 ± 7. While
stroke was ound to be the most common cause o dysphagia,
other neurologic conditions and head and neck cancer were also
common etiologies.
Dysphagia may occur at any point throughout the li espan and
it may result rom a wide variety o circumstances rom acute
medical events, to diseases, to normal aging. Neurological events,
conditions, and diseases that can be associated with dysphagia
include but are not limited to stroke, traumatic brain injury, brain
tumor, cerebral palsy, Parkinson’s disease, and amyotrophic lateral
sclerosis. Many autoimmune diseases and conditions such as
multiple sclerosis, myasthenia gravis, Guillain Barre Syndrome,
and various orms o myositis may also be associated with dyspha-
gia. Physical changes to the anatomy such as development o a
Zenker’s diverticulum, cervical osteophyte, Schatzki ring, or dam-
age to the vocal olds may result in dysphagia. Numerous surgical
and/or medical interventions such as intubation, anterior cervical
spine surgery, carotid endartarectomy, and resections or various
orms o head and neck cancer may also be associated dysphagia.
A variety o medications used to treat other conditions such as
antipsychotics, antidepressants, anticonvulsants, and medications
to treat anxiety may actually induce or worsen dysphagia. Finally,
prolonged illnesses that require hospitalization may cause muscu-
lar deconditioning which may be correlated with the development
o dysphagia.
Common, physical complications o dysphagia include, but
are not limited to choking, dehydration, malnutrition, respira-
tory distress, and pneumonia. Additional, but o ten overlooked,
complications o dysphagia are its social and psychological
impacts. Since a great deal o the social occasions that people
enjoy are centered around preparing and consuming ood,
individuals who are unable to swallow sa ely are o ten embar-
rassed by their swallowing problem and become isolated when
they eel unable to participate in social events that involve ood
and drink.

476
 NEURAL CONTROL OF THE SWALLOW ■ BRAINSTEM

C
Swallowing is a complex activity which involves 26 pairs o muscles The swallowing command center is contained bilaterally in the

H
and six cranial nerves. In 2008, Mistry and Hamdy published an upper medulla and pontine areas o the brainstem and is part o

A
article on the neural control o eeding and swallowing that con- the reticular ormation. A complex network o neurons containing

P
tained a use ul, detailed description o the roles o various parts o a erent portions, e erent portions, and interneurons are known as

T
the brain in the process o eeding and swallowing. That in ormation the central pattern generator or swallowing. The interneurons are

E
R
is summarized in the ollowing section, but the reader is directed to separated into a dorsal group and a ventral group, with the dorsal
neurons lying in the nucleus o the tractus solitarius and the ventral

7
the ull article or urther in ormation.

0
neurons lying in the nucleus ambiguus. The dorsal neurons o the
nucleus tractus solitarius integrate in ormation rom the cortex as
■ CRANIAL NERVES well as sensory in ormation rom cranial nerves V, IX, and X. The

T
h
The trigeminal nerve (V) conveys sensory in ormation, with the dorsal neurons o the nucleus tractus solitarius then activate the

e
exception o taste, rom the anterior two thirds o the tongue. It is ventral neurons o the nucleus ambiguus, which activates the motor

R
o
also responsible or motor innervation o muscles involved in masti- neuclei o cranial nerves V, VII, and X to trigger the swallow.

l
e
cation and posterior bolus propulsion. The acial nerve (VII) conveys

o
in ormation about taste rom the anterior two-thirds o the tongue. ■ CORTEX

S
p
It also plays a role in motor innervation or acial muscles such as the Research demonstrates that both cerebral hemispheres are respon-

e
lips, which help to clear utensils and keep boluses in the oral cavity.

e
sible or swallowing. Esophageal and pharyngeal muscles have

c
The glossopharyngeal nerve (IX) conveys sensory in ormation rom

h
been ound to have representation in the motor cortex. In addition,

/
the posterior one third o the tongue as well as the palatine tonsils

L
multiple studies agree to support the assertion that cortical con-

a
and aucial arches. The glossopharyngeal nerve also works with the

n
trol o swallowing is dominant in the le t hemisphere in humans

g
vagus nerve (X) to help with the superior and anterior movement o

u
(Hamdy et al., 1996).

a
the larynx, which assists with cricopharyngeal relaxation. The vagus

g
e
nerve assists with velar elevation, works with the glossopharyngeal

P
nerve to innervate the pharyngeal constrictors or bolus propulsion, THE PHASES OF THE SWALLOW

a
t
works with the spinal accessory nerve (XI) to innervate the intrinsic In order to understand dysphagia, one must rst have a clear

h
o
lingual muscles, and innervates the muscles that cause vocal old understanding o normal swallow unction. There are our com-

l
o
adduction during the swallow in addition to those that assist with

g
monly accepted phases o the swallow: The oral preparatory phase,

i
s
cricopharyngeal relaxation. Additionally, the superior and recurrent the oral transit phase, the pharyngeal phase, and the esophageal

t
s
laryngeal nerves (branches o the vagus nerve) convey sensory phase. Typically, an SLP’s scope o practice ocuses on the rst three

i
n
in ormation rom the velum and portions o the pharynx as well as phases o the swallow. While SLPs are knowledgeable about the

D
the larynx. The recurrent laryngeal nerve also controls the majority

y
esophageal phase o the swallow, they typically re er to a gastroen-

s
p
o the intrinsic laryngeal muscles, which open and close the vocal terologist or more ormal evaluation, diagnosis, and treatment o

h
olds to assist with airway protection. Finally, the hypoglossal nerve esophageal conditions (eg, ref ux). Figure 70-1 provides an illustra-

a
g
(XII) innervates all o the intrinsic lingual muscles as well as most o tion o the oral preparatory, oral transit, and pharyngeal phases o

i
a
the extrinsic lingual muscles. the swallow.

M
a
n
a
g
e
Ha rd pa la te

m
Ve llum

e
n
t
Va lle cula e
Bolus

Tongue

Hyoid
P ha rynx
Voca l folds
Epiglottis
Tra che a
Es opha gus

A Oral pre parato ry phas e B Oral trans it phas e C Pharyng e al phas e D Es po phag e al phas e

Figure 70-1 (A). Oral preparatory phase: The lips are sealed to prevent anterior bolus loss and velum makes contact with the tongue base to
prevent posterior bolus loss. The tongue moves the bolus around the oral cavity to assist with mastication and to mix the bolus with saliva
prior to orming the bolus into a cohesive ball. (B). Oral transit phase: The tongue elevates to make sequential contact with the palate in order
to squeeze the bolus toward the posterior oral cavity and into the pharynx while the velum begins to elevate. (C). Pharyngeal phase: The velum
is ully elevated to prevent bolus entry into the nasal cavity. The vocal olds adduct and the epiglottis de lects to protect the airway. The upper
esophageal sphincter relaxes to allow the bolus to pass into the esophagus. (D). Esophageal phase: The epiglottis has returned to the home
position, the vocal olds have reopened, the bolus has ully entered the esophagus, and the upper esophageal sphincter has closed.

477
 ■ ORAL PREPARATORY PHASE
Prior to any bolus manipulation, an individual must rst open
his or her mouth to accept the ood or liquid. Once the ood or
P
liquid has entered the oral cavity, bilateral labial seal is necessary
A
to prevent any portion o it rom spilling back out o the oral
R
T
cavity. With the ood or liquid ully contained, bolus preparation
I
can begin. The amount and type o manipulation necessary will
I
I
depend on the texture o the material to be swallowed (eg, liquid
vs solid). With liquids and most purees, the tongue will create a
cohesive bolus in the center o the oral cavity. I mastication is
required, the tongue will propel the bolus toward the dentition
R
e
in order or mastication to occur. In adults, the mandible and
h
a
tongue will move in a rotary ashion to mix solids with saliva, pro-
b
i
pel solids toward the teeth, and ultimately orm a cohesive bolus
l
i
t
a
o masticated ood. During this process, tension is present in the
t
i
buccal musculature, which prevents ood rom accumulating in
o
n
the lateral sulcus that exists between the teeth and cheeks. With
a
Figure 70-2 Aspiration during videofluoroscopic swallow study.
n
liquid and pureed boluses, the velum is in the descended position
d
and making contact with the posterior portion o the tongue in
S
k
order to keep the bolus in the oral cavity. With solids, particularly
i
l
l
those requiring mastication, the velum is also in the descended
e
d
position; however, it is normal or a portion o the bolus to exit SIGNS AND SYMPTOMS OF DYSPHAGIA
N
the posterior oral cavity and begin to enter the pharynx during Some people who experience di iculty swallowing will seek out
u
r
this phase. the expertise o a health care pro essional. Others may develop
s
i
n
clinical presentations that signal a possible swallowing problem
g
(eg, recurrent pneumonia). When assessing a patient to deter-
C
■ ORAL TRANSIT PHASE
a
mine i he or she has dysphagia, medical pro essionals are o ten
r
Once a bolus has been ully prepared and organized into a cohesive
e
observing the patient or signs and symptoms that suggest the
ball, the tongue will begin to propel it toward the posterior portion presence o either aspiration or penetration on ood, liquid, or
o the oral cavity. There is a sequential, anterior to posterior elevation secretions. Aspiration is commonly de ined as the entrance o
o the tongue against the hard palate that causes the bolus to be any ood or liquid into the trachea below the level o the true
squeezed toward the back o the oral cavity. vocal cords (Figure 70-2). Aspiration should trigger some type
o visible and/or audible response such as throat clearing or
■ PHARYNGEAL PHASE coughing. However, some people with dysphagia present with
When the anterior aspect o the bolus passes any point between silent aspiration in which there are no outward signs that aspi-
the anterior aucial arches and the area where the base o the ration has occurred. Penetration is commonly de ined as the
tongue crosses the lower rim o the mandible, the pharyngeal entrance o any bolus into the larynx or laryngeal vestibule up
phase o the swallow should be triggered. A number o events to but not below the level o the true vocal cords (Figure 70-3).
occur with the triggering o the pharyngeal swallow in which the Penetration may trigger a cough or throat clear; however, it may
bolus passes rom the oral cavity, through the bilateral valleculae, also be silent. It is important or clinicians to be able to identi y
along the aryepiglottic olds, and into the bilateral pyri orm sinuses the common signs and symptoms o dysphagia so that they can
at the entrance o the upper esophagus. The velum elevates com- begin to di erentially diagnose the problem as well as request
pletely to prevent any portion o the bolus rom entering the nasal appropriate consultative services as necessary (eg, Otolaryngol-
cavity. The hyoid bone and larynx elevate and move in an anterior ogy, Gastroenterology, Speech/Language Pathology). Some o
direction. The alse vocal olds and true vocal olds adduct to protect
the entrance o the larynx (respiration halts). The epiglottis def ects
to o er urther laryngeal closure and protection. The base o the
tongue f attens and moves in a posterior direction to propel the
bolus into the pharynx. The posterior pharyngeal wall moves in
an anterior direction to make contact with the tongue base, and
the pharyngeal constrictor muscles contract to squeeze the bolus
through the pharynx into the esophagus. At the same time, the
cricopharyngeus muscle (upper esophageal sphincter) relaxes to
allow the bolus to pass into the esophagus. Respiration typically
resumes with an exhale upon completion o the pharyngeal swal-
low response.

■ ESOPHAGEAL PHASE
Once the bolus has entered the esophagus through the upper
esophageal sphincter, tension returns to the cricopharyngeus
muscle to prevent the bolus rom moving backward and reentering
the pharynx. A series o peristaltic waves propel the bolus through
the esophagus to the lower esophageal sphincter, which relaxes to
allow or bolus passage into the stomach. Figure 70-3 Penetration during videofluoroscopic swallow study.

478
 availability o various resources. The most common assessments
include bedside swallow assessments, videof ouroscopic swallow

C
studies, and beroptic endoscopic evaluations o the swallow.

H
A
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■ BEDSIDE SWALLOW ASSESSMENT

T
E
Regardless o patient presentation, the majority o patients who

R
present with signs or symptoms o dysphagia will rst be seen or

7
a bedside evaluation o the swallow. Ideally, due to their training

0
in dysphagia diagnosis and treatment, an SLP would complete the
bedside swallow assessment. However, other medical pro ession-

T
h
als including physicians, physician assistants, nurse practitioners,

e
nurses, and occupational therapists can all be trained to administer a

R
o
basic bedside swallow screening in the case that an SLP is not avail-

l
e
able. While a great deal o use ul in ormation can be obtained rom

o
the completion o a bedside swallow assessment, it is important

S
to note that it is the most subjective type o swallow assessment

p
e
Fig ure 70-4 Residue in the valleculae during videofluoroscopic discussed in this chapter.

e
c
swallow study. The ollowing is a description o a basic bedside swallow screen-

h
/
ing which can be used by physicians, particularly resident MDs who

L
a
may nd that they need to assess swallowing status in a hospitalized

n
g
patient a ter hours or when an SLP is not immediately available or

u
the most common signs and symptoms o dysphagia include
consultation, as may be the case in smaller acilities and/or more

a
g
the ollowing:
rural areas.

e
• Residue, which is any portion o a bolus remaining in the oral

P
Cognitive/Linguistic Status: While it may seem obvious, it is impor-

a
cavity or throat a ter a swallow (Figures 70-4 and 70-5)

t
tant to ensure that the patient is awake and alert. I a patient has di -

h
Holding boluses in the oral cavity without triggering a swallow

o
• culty achieving or maintaining alertness, he/she may not be sa e or

l
o
• Food alling out o the oral cavity appropriate or per os (PO) intake. It is also use ul to determine i the

g
Additional time or e ort needed to chew and swallow

i
• patient is able to ollow basic commands and express basic needs.

s
t
s
• Wet or gurgly vocal quality However, keep in mind that while patients with communication

i
n
• Frequent coughing or throat clearing (particularly in the disorders such as aphasia may not be able to express themselves or

D
context o eating/drinking) ollow verbal commands, many o these patients retain the ability to

y
s
• Increased congestion including pneumonia interpret gestures and mimic behavior and can still participate in a

p
h
• Increased work o breathing or shortness o breath during bedside swallowing assessment.

a
eating/drinking

g
Speech and Vocal Status: An in ormal, qualitative assessment

i
a
• Odynophagia, which is a complaint o pain with swallowing o a patient’s speech output and vocal quality can provide use-

M
• Globus, which is the sensation that ood or liquid is stuck in ul in ormation related to strength and coordination o the oral

a
n
the throat musculature as well as respiratory drive and vocal old mobility,

a
g
which is important or airway protection during the swallow.

e
m
DYSPHAGIA ASSESSMENTS Listen to the patient’s speech quality. One who presents with

e
There are a variety o ways in which to assess or dysphagia. imprecise articulation due to muscle weakness may demonstrate

Choosing which assessment is most appropriate or your patient
will depend both on your patient’s presentation as well as on the
Figure 70-5 Residue in the pyriform sinuses during videofluoroscopic
swallow study.
n
t
di culty managing oral intake in the oral preparatory and/or oral
transit phases o the swallow. I a patient has a wet or gurgly vocal
quality, it may indicate that the patient is not managing his/her
secretions appropriately due to a swallowing problem. I a patient
has a vocal quality that is weak, breathy, hoarse, or harsh, it may
indicate a problem with respiratory drive and/or a problem with
vocal old mobility. I the vocal olds are not unctioning properly,
they may ail to adduct and protect the airway during the swal-
low, which places the patient at a signi cantly greater risk o
aspiration. It is also use ul to determine i the patient can ollow
commands to clear his/her throat and cough, as these are protec-
tive mechanisms that can clear the airway o material i penetra-
tion or aspiration occurs.
Posture: Make note o the patient’s habitual posture. Is the patient
able to sit up straight in bed or in a chair? Upright posture typically
allows or sa er oral intake.
Respiratory Status: It is important to be aware o the patient’s respi-
ratory status, as those with a compromised respiratory system may
experience an exacerbation o their respiratory symptoms when eat-
ing and drinking (eg, increased shortness o breath, increased need
or supplemental oxygen, etc).
Oral Mechanism Exam: Prior to providing any ood or drink, it is
necessary to evaluate the strength, symmetry, and unction o the
muscles needed or eating and drinking. Observe the patient’s ace

479
 or signs o weakness and/or asymmetry. A use ul set o basic com- ■ VIDEOFLUOROSCOPIC SWALLOW STUDY (VFSS)
mands to determine general strength and symmetry include: The videof uoroscopic swallow study or modi ed barium swallow
1. Open your mouth and do not let me close it (apply upward (MBS) is a f uoroscopic procedure in which the patient is provided
P
pressure to the chin) with various consistencies o barium to swallow under f uoroscopy.
A
The resulting exam allows a trained SLP to watch a video o the
R
2. Close your jaw tightly and do not let me open it (apply down-
T
ward pressure to the chin) liquids and solids passing rom the oral cavity through the pharynx
I
3. Close your lips tightly and do not let me open them (apply and into the upper esophagus. The VFSS is particularly use ul as it
I
I
up/down pressure to the lips) allows the clinician to observe instances o penetration and aspira-
4. Smile tion that occur be ore, during, and/or a ter the swallow. In addition,
5. Pucker your lips this study a ords the clinician the opportunity to observe the
6. Fill your cheeks with air and do not let it out (apply pressure to location and amount o residue in the pharynx (such as valleculae,
R
e
the cheeks) pyri orm sinuses), as well as the impact o trialing di erent viscosi-
h
a
7. Stick out your tongue ties and textures o liquids and solids. Finally, this study allows the
b
i
8. Move your tongue to the le t side and right side (use a tongue clinician to see, in real time, the e ectiveness o various sa e swal-
l
i
t
a
blade to provide resistance) low maneuvers and strategies (eg, chin tuck, head turn, etc.). Due to
t
i
9. Open your mouth and say “ah” to assess or velar elevation the act that the VFSS allows the SLP to observe the entire swallow
o
n
A patient who exhibits signs o labial weakness may experience rom the oral to the upper esophageal phase, it is o ten considered
a
n
di culty sealing on a cup/straw, di culty stripping ood rom to be the gold standard o swallowing assessments.
d
utensils, or di culty containing ood/liquid in the oral cavity. I
S
■ FIBEROPTIC ENDOSCOPIC EVALUATION OF
k
secretions are ound pooled in a patient’s oral cavity, it may indicate
i
l
SWALLOWING (FEES)
l
e
reduced oral sensation and/or di culty swallowing. A patient who
d
has inadequate dentition or who demonstrates di culty opening/ The FEES is another objective evaluation o swallowing that can be
N
completed by SLPs who have undergone speci c training. During
u
closing the jaw may have trouble with timely and/or e cient mas-
r
s
tication. A patient who demonstrates signs o lingual weakness or the FEES, a f exible endoscope is passed through the patient’s nares,
i
n
reduced coordination may have trouble orming a cohesive bolus and held in place in the pharynx just above the tongue base in order
g
to provide a view o the pharynx and larynx. Observations may be
C
or moving ood/liquid through the oral cavity. Lastly, a patient who
a
exhibits reduced velar elevation may experience premature spill- made regarding the presence and management o secretions, as
r
e
age o boluses out o the oral cavity prior to the onset o the pha- well as in ormal observations o the integrity and mobility o the true
ryngeal swallow, which places them at greater risk or aspiration. vocal olds and other pharyngeal and laryngeal structures. Typically,
Oral Trials: In the next section o the bedside swallow evaluation, patients are provided with various textures o ood and liquid to swal-
the patient should be provided with various liquids and solids to low during this assessment, which allows the clinician to observe the
consume while the clinician assesses the patient’s ability to manage passage o boluses through the pharynx to the upper esophageal
these textures in the oral and pharyngeal phases o the swallow. sphincter. While the FEES is particularly use ul or observation o
In the oral phases o the swallow, the clinician should assess the secretions and residue in the pharynx as well as observation o vocal
patient’s ability to accept and contain ood and drink in the oral cav- old mobility, there are limitations to the FEES that are not present in
ity, chew, and propel the bolus rom the oral cavity into the pharynx. the VFSS. The FEES does not allow visualization o the oral phases o
A ter each swallow, the clinician should examine the oral cavity to the swallow. In addition, during the FEES, there is complete oblitera-
determine i there is any residue le t on the lingual sur ace, in the tion (known as “white out”) o the image at the height o the swallow
anterior sulcus, or in the lateral sulci. I residue is present, the patient when the pharyngeal musculature contracts around the endoscope.
should be cued to use a lingual sweep or nger sweep to clear the Due to this period o white out, episodes o penetration and aspira-
residue rom the oral cavity. I the patient is unable to masticate ood tion that occur during the swallow ref ex are not observed, whereas
in a timely manner, or i he/she experiences consistent residue in the episodes o penetration/aspiration that occur be ore and a ter the
oral cavity, a so ter solid or a pureed solid may be more appropriate. swallow are able to be visualized. It is o ten possible to see evidence
In the pharyngeal phase o the swallow, the clinician should assess the o penetration/aspiration that occurred during the swallow i residue
patient’s laryngeal elevation as it provides in ormation about the timing, is le t in the laryngeal vestibule or upper airway.
completion, and strength o the swallow. This is best done through a
combination o visual and tactile assessment. Have the observer place DYSPHAGIA MANAGEMENT
the ring, middle, and index ngers on the anterior sur ace o the throat
Once causes and characteristics o dysphagia are diagnosed, a
while keeping the index nger in the superior position with the thyroid
variety o treatment approaches can be utilized. An SLP should be
notch between the middle and ring ngers. When the patient swallows,
consulted to assist with diagnosing dysphagia and with creation o
the thyroid notch should elevate above the middle nger at the height
o the swallow i elevation is to be considered normal. the treatment plan that will include a number o di erent strategies
Throughout the assessment, the clinician should assess the patient to maximize sa e oral intake. Compensatory treatment approaches
or signs and symptoms o aspiration or penetration. It is use ul to are o ten attempted rst as they can quickly alter the f ow o ood/
have the patient vocalize a ter every swallow in order to determine i liquid to eliminate signs/symptoms o dysphagia, although they
his or her vocal quality sounds wet or gurgly. I an altered vocal qual- do not alter the physiology o the patient’s swallow. Three types o
ity is appreciated, cue the patient to cough or clear his/her throat and compensatory treatment approaches include diet modi cations,
then per orm a dry swallow. I other signs or symptoms o aspiration postural changes, and swallow maneuvers. Other approaches to
are observed (eg, more consistent coughing, throat clearing, vocal dysphagia treatment can include exercises or surgery.
wetness), the patient may require an altered texture such as a so ter
solid or thickened liquid. I the signs/symptoms o aspiration persist, ■ DIET MODIFICATIONS
it may be necessary to recommend NPO status until an SLP can pro- Food and liquid may be presented in a variety o di erent textures.
vide a more detailed assessment. Depending on the cause and sever- Solids may be modi ed so that they have increased moisture and/
ity o a patient’s dysphagia, nonoral nutrition and hydration rom a or require less mastication. In addition, liquids may be modi ed rom
nasogastric tube or gastrostomy tube may be necessary. a thinner consistency to a thicker consistency, which allows the

480
swallowing mechanism more time to propel them sa ely through established diet level structure or recommended terminology to
the pharynx to the esophagus. describe diet levels, nor does it provide guidelines or the types o

C
ood that should be included on a particular diet level.

H
■ POSTURAL ADJUSTMENTS

A
In 2002, the American Dietetic Association established a set o

P
Some patients bene t rom postural adjustments to alter the way guidelines known as the National Dysphagia Diet. While very ew

T
ood/liquid f ows through the system, or to change the dimensions acilities speci cally use this terminology to describe the diet levels

E
available at their acility, the descriptions o each solid diet level are

R
o the pharynx to improve sa ety. Two o the most common postural
adjustments include a chin tuck (swallowing while looking down at use ul or illustrative purposes.

7
0
one’s chest) and a head turn (typically turning the head to look over
the shoulder on the weaker side). However, it is critical to understand ■ NATIONAL DYSPHAGIA DIET (NDD)
that there is no single postural adjustment that works or all patients, NDD 1 Dysphagia Pureed—all oods must be pureed and thickened

T
h
and some patients actually experience worsening symptoms o (i necessary) to a pudding-like consistency. It must be lump ree and

e
dysphagia i the wrong postural adjustment is utilized. There ore, little or no chewing is required.

R
o
consultation with an SLP trained in dysphagia management is rec- NDD 2 Dysphagia Mechanically Altered—all oods are moist,

l
e
ommended prior to prescribing any postural adjustments. so t-textured, and easily chewed. Meats are ground and served with

o
gravy or sauce. Cooked cereals, so t breads, and well-cooked pastas

S
p
■ SWALLOW MANEUVERS are allowed. Some chewing is required.

e
NDD 3 Dysphagia Advanced—includes most regular consistency

e
Some patients bene t rom per orming additional maneuvers dur-

c
oods but excludes hard, dry, sticky, or crunchy oods. Food should

h
ing the swallow, provided that their cognitive status is su cient to

/
L
allow or success ul implementation o such maneuvers. Sa ety may be moist and in bite-size pieces. Dry break ast cereals must be well

a
n
be enhanced by placing di erent aspects o the pharyngeal swal- moistened and meats must be tender.

g
NDD 4 Regular—No restrictions.

u
low under voluntary control. One example o a swallow maneuver

a
In general, medical acilities seem to have greater agreement

g
is called the supraglottic swallow. Here, the patient is instructed to

e
hold his or her breath, then swallow, and then cough immediately among one another with the terminology used to describe di erent

P
liquid viscosities. Typically, liquids may be described as thin (water

a
a ter the swallow. This maneuver is intended to assist with volitional

t
consistency), nectar thick, honey thick, and pudding/spoon thick. A

h
airway protection be ore, during, and a ter the swallow. A second

o
wide variety o products on the market o er prethickened liquids

l
swallow maneuver is the Mendelsohn maneuver. Here, the patient

o
g
is instructed to try to prolong laryngeal elevation at the height o the in various consistencies. In addition, there are numerous gels and

i
s
powders available that can be added to thin liquid in order to create

t
swallow. This maneuver is intended to prolong the amount o time

s
nectar thick, honey thick, or pudding thick liquids.

i
that the upper esophageal sphincter is relaxed, in order to allow a

n
greater portion o the bolus to pass into the esophagus. A trained

D
y
SLP is best suited or making recommendations regarding swallow CONCLUSION

s
p
maneuvers, and this is done only a ter thorough evaluation.

h
Dysphagia is a serious and sometimes li e threatening condi-

a
g
tion, which a ects millions o people each year. There are a wide

i
■ SWALLOW EXERCISES

a
range o causes or dysphagia, as well as a variety o management

M
The a orementioned compensatory techniques are not expected approaches. While SLPs working in the medical setting o ten special-

a
n
to alter swallow physiology. However, patients may be instructed ize in the diagnosis and treatment o oropharyngeal dysphagia, it is

a
to complete various swallow exercises to improve the strength or

g
critical that all members o the medical team recognize the signs

e
coordination o various muscles involved in swallowing. An SLP will and symptoms o dysphagia in order to expedite treatment with the

m
be able to make appropriate exercise recommendations based on

e
ultimate goal o maximizing patient health and sa ety.

n
each patient’s presentation. Some possible exercises include lingual

resistance exercises, tongue base retraction exercises, and laryngeal
elevation exercises.
■ SURGICAL INTERVENTIONS
Some swallowing disorders may bene t rom surgical intervention
to alter the eeding/swallowing anatomy. These include, but are not
limited to, cervical osteophytes and dys unction o the cricopharyn-
geal muscle. Bony prominences that grow on the cervical vertebrae
may cause anterior bulging o the posterior pharyngeal wall and
disrupt bolus f ow. In severe cases, it may be necessary to surgically
reduce the osteophyte in order to allow boluses to pass through the
pharynx. In patients who have severe dys unction o the cricopharyn-
geal muscle such that it does not relax properly to allow boluses to
enter the esophagus, cricopharyngeal myotomy may be per ormed
to allow or greater relaxation o this muscle during the swallow.
DIET LEVELS
While all medical acilities o er oods and liquids in a variety o di -
erent textures to accommodate the needs o those with dysphagia,
there is a wide variety o terminology used to describe each o these
diet levels. The American Speech/Language Hearing Association
(ASHA), the governing body or SLPs, does not currently have an
t
SUGGESTED READINGS
Bhattacharyya N. The prevalence o dysphagia among adults in the
United States. Otolaryn Head Neck Surg. 2014;151(5):765-769.
Bosma J. Physiology o the mouth, pharynx and esophagus. In:
Paparella M, Shumrick D, eds. Otolaryngology, Volume 1: Basic Sciences
and Related Disciplines. Philadelphia, PA: Saunders; 1973:356-370.
Hamdy S, Aziz Q, Rothwell JC, et al. The Cortical topography o
human swallowing musculature in health and disease. Nat Med.
1996;2(11):1217-1224.
Logemann JA. Evaluation and Treatment of Swallowing Disorders,
2nd ed. Austin, TX: Pro-Ed; 1998.
Mistry S, Hamdy S. Neural control o eeding and swallowing. Phys
Med Rehabil Clin N Am. 2008;19(4):709-728.
Murray J. Manual of Dysphagia Assessment in Adults. San Diego, CA:
Singular Publishing Group; 1999.
The National Dysphagia Diet Task Force. The National Dysphagia Diet:
Standardization for Optimal Care. Chicago, IL: American Dietetic
Association; 2002.
Palmer JB, Rudin NJ, Lara G, Crompton AW. Coordination o mastica-
tion and swallowing. Dysphagia 1992;7:187-200.

481
 CHAP TER
71
Incontinence
Alayne D. Markland, DO, MSc
Catherine E. DuBeau, MD
Key Clinical Questions
1 How should you evaluate urinary and ecal incontinence
in the hospital or rehabilitation setting?
2 How do you treat urinary and/or ecal incontinence?
3 What are the important elements o incontinence man-
agement in transitions o care?
4 What are the treatment options or urinary retention in
hospitalized patients?
5 What are the guidelines or urinary catheter use and
management in hospitalized patients?
482
INTRODUCTION
It has been estimated that 22% to 35% o patients on general
medical wards have UI and 10% have FI. In the hospital setting,
both UI and FI may coexist with urinary retention (UR). Incontinence
may cause skin breakdown and pressure ulcers, and UI may cause
increased use o indwelling catheters, and alls. Catheter-associated
urinary tract in ection (CAUTI) accounts or up to 70% to 80% o all
hospital health care acquired in ections (HAIs). Hospital-acquired
CAUTI, a “never event,” is both a marker o insu cient quality per-
ormance and negatively impacts reimbursement. The duration o
catheter use is strong risk actor or CAUTI in hospital settings. Poor
quality incontinence management also increases costs rom absor-
bent and containment products and increased use o already lim-
ited resources (eg, nursing and aide time), and may lead to increased
caregiver burden a ter discharge.
PRACTICE POINT
• Although continence care is o ten delegated to nursing sta ,
ailure to recognize, evaluate, and treat incontinence and UR
as signi cant “hazards o hospitalization,”especially in older
patients, may increase morbidity, length o stay, and unctional
impairment, even up to 30 days postdischarge.
NORMAL MICTURATION AND DEFECATION
Normal micturition and de ecation involve similar neural control
and muscular coordination. Continence results rom e ective
storage during lling and e cient emptying during the voiding
phase or de ecation phase. E erent nerves arising rom the sacral
micturition center at S2-S4 mediate bladder muscle (detrusor)
contraction via muscarinic receptors. Sympathetic, adrenergic
nerves arising rom T11-L2 sustain contraction o smooth muscle
in the proximal urethral and internal anal sphincters. The distal
urethral sphincter and the external anal sphincter are voluntarily
controlled via somatic cholinergic nicotinic nerves arising rom
the sacral micturition center. Urethral and anal closures are also
maintained through contraction and support rom striated muscle
and ascial elements in the pelvic f oor. A micturition center in
the pons linked to subcortical and rontal centers that inhibit
urgency and voiding controls coordination o bladder lling and
emptying. Less is known about neurological control o de ecation,
although similar mechanisms have been proposed that coordinate
relaxation o the external anal sphincter with the change o the
ano-rectal angle with valsalva. Normal de ecation also depends on
stool consistency (a ected by diet and colonic transit time), rectal
compliance and sensation (ability to retain stool in the rectum and
delay de ecation until socially appropriate), and integrity o the
internal and external anal sphincters and the puborectalis muscles.
INCONTINENCE
■ PATHOPHYSIOLOGY
Especially relevant in the hospital setting, urinary and ecal incon-
tinence may result or be exacerbated by impaired unction (eg,
decreased mobility, altered manual dexterity rom IVs) and cog-
nition (eg, delirium), and the presence o comorbid conditions
(Table 71-1) and medications (Tab le 71-2) that may directly or
TABLE 71-1 Comorbid Conditions Causing or Exacerbating Urinary and/or Fecal Incontinence

C
H
Comorbidity Effect on Continence

A
Cardiovascular disease

P
T
Acute coronary syndrome Altered mental status

E
Congestive heart ailure Nocturnal polyuria; treatment with loop diuretics

R
Metabolic disease

7
1
Diabetes mellitus Osmotic diuresis rom hyperglycemia, altered mental status rom hyper- or hypoglycemia,
urinary retention rom constipation, gastroparesis, neuropathy
Hypercalemia Diuresis, altered mental status

I
n
c
Vitamin-B12 de iciency Impaired bladder sensation, peripheral neuropathy

o
n
Thyroid disease Changes in cecal transit time rom hypo- or hyperthyroidism

t
i
n
Neurologic disease

e
n
Cerebrovascular disease, stroke Upper motor neuron disease with impaired bladder sensation, acutely impaired physical

c
e
unction and cognition
Seizures Acute loss o motor control/sphincter impairment
Delirium Impaired cognitive unction
Dementia Impaired cognitive unction
Parkinson’s disease Impaired CNS control impaired physical unction, constipation
Spinal cord injury or impairment Dependent on level: suprasacral—uninhibited contractions and dyssynergia between
bladder and sphincter contraction; sacral—impaired detrusor contractility, sphincter
incompetence
Psychiatric disease
A ective disorders, psychosis Decreased motivation; cognitive impairment
Alcoholism Functional and cognitive impairments; acute intoxication: diuresis, diarrhea, urinary retention
Gastrointestinal disease
Constipation Urinary retention, impaired urgency sensation, impaction
Diarrhea (in ectious causes) Increase in rectal volume, impaired ability to voluntarily contract external anal sphincter
Malabsorptive syndromes Loose stool, increase bowel requency
In lammatory bowel disease Stool consistency changes, altered recto-anal anatomy, reduced rectal storage capacity
Others
Musculoskeletal disease Functional impairment, detrusor overactivity rom cervical myelopathy in rheumatoid
arthritis and osteoarthritis
Peripheral venous insu iciency Nocturnal polyuria
Pulmonary disease Exacerbation o stress incontinence and ecal leakage with chronic cough

Adapted rom DuBeau CE. Incontinence. In: Durso SC, Sullivan GM, eds. Geriatric Review Syllabus, 8th ed. American Geriatric Society, 2013, pp. 244-253.

indirectly a ect neural and muscular control o micturition and ■ CLASSIFICATION

de ecation. Recognition and management o these potentially
remediable actors are essential or e ective incontinence treat-
ment and prevention. Procedures and monitoring in the acute
care setting can also impact continence status (Table 71-3).
Imposed bedrest makes toileting impossible, and predisposes to
impaired bladder emptying, UR, and constipation that can lead to
dual incontinence.
Iatrogenic changes in stool consistency are major causes o FI in
the hospital setting. Constipation and impaction may cause UI by
impairing bladder emptying by mechanical obstruction and/or a
ref ex sympathetic stimulation or when watery stool “leaks” around
impacted stool. Impaction in the rectal canal also may impair a er-
ent sensations o bladder and rectal ullness, leading to leakage
without sensory awareness. Anal ssures, hemorrhoids, stulas, and
abscesses in close approximation to the anal sphincters may all lead
to FI by impairing anal sphincter unction. Large volume, watery
diarrhea may cause FI by overwhelming the rectal capacity and
voluntary anal sphincter contraction.
UI is typically classi ed into our main symptom types: urge, stress,
mixed urge and stress, and impaired bladder emptying ( ormerly
called “overf ow”) (Table 71-4). Hospitalized patients may have
uncommon causes o UI, such as extra-urethral urine leakage rom
vesico-vaginal or vesico-rectal stulas.
The main types o ecal leakage are urge (associated with urgent
need to pass stool), passive (without sensation), mixed (urge and
passive leakage), or seepage (low-volume staining in underwear).
■ EVALUATION
As noted above, hospitalized patients are at high risk or new or
worsening UI and FI due to underlying and acute multiple medical
conditions, pre-existing and new medications, immobilization, new
unctional impairment, IV f uid support, delirium, acute interven-
tions and iatrogenic complications. The basic evaluation or UI
should include a ocused history, physical examination, labora-
tory evaluation, and, less requently, radiology tests (Table 71-5)

483
 TABLE 71-2 Medications Associated with Urinary and Fecal TABLE 71-3 Other Hospital-Acquired Causes of Urinary and
Incontinence Fecal Incontinence
P
Medication Effect on Continence Causes Impact on Continence
A
R
Alcohol Frequency, urgency, sedation, Prolonged use o transurethral Stress UI rom urethral
T
delirium, immobility, change in catheters damage; urge UI rom bladder
I
stool consistency irritation
I
I
α-Adrenergic agonists Outlet obstruction (men) Prolonged use o rectal tubes Fecal incontinence (urge
α-Adrenergic blockers Stress leakage (women) and passive types) due to
weakness in anal sphincters
Angiotensin-converting Associated cough worsens stress
Epidural or spinal anesthesia Urinary retention, UI and FI
R
enzyme inhibitors and urge leakage in persons with
e
rom interruption o e erent
h
impaired sphincter unction
a
and a erent pathways
b
Antibiotics/anti ungals Increase gastrointestinal side-
i
Decreased mobility rom Limit toilet access leading to
l
i
e ects, including diarrhea
t
a
physical or chemical UI and FI
t
Anticholinergics Impaired emptying, retention,
i
restraints, Foley catheters,
o
delirium, sedation, constipation,
n
IVlines, casts, etc
ecal impaction
a
n
d
Anticholinesterase Increased gastrointestinal side-
S
inhibitors e ects, including diarrhea
k
i
l
Antipsychotics Anticholinergic e ects, rigidity,
l
e
and immobility relevant symptoms, including acute dysuria or ever and either new
d
or worsening urgency, requency, UI, suprapubic pain, hematuria,
N
Calcium channel blockers Impaired detrusor contractility
u
and retention, constipation, or costovertebral angle tenderness. Delirium with positive culture
r
s
does not indicate UTI unless there are additional relevant symptoms
i
dihydropyridine agents increase
n
g
pedal edema and may lead to or the patient has an indwelling urinary catheter. In catheterized
C
nocturnal polyuria patients, urine samples should be collected at the time o place-
a
r
Cholinesterase inhibitors Urge incontinence ment o a new catheter, and not rom the side port or collection bag
e
Colchicine Increase in bowel requency, o a current catheter.
diarrhea The basic FI evaluation is similar to that or UI, with particular ocus
on the perineal and anorectal exam (Figure 71-2). Further work-up
GAGAnergic agents Pedal edema leading to nocturia
(gabapentin, pregablin)
Loop diuretics Polyuria, requency, urgency
Narcotic analgesics Urinary retention, ecal TABLE 71-4 Types of Urinary Incontinence
impaction, sedation, delirium
Nonsteroidal anti- Pedal edema leading to Type Symptoms Common Pathophysiology
in lammatory drugs nocturnal polyuria, constipation Urge Leakage associated Uninhibited bladder
Nonsul onurea glucose Alterations in stool consistency with urgency, the contractions due to:
lowering drugs (met ormin) relatively sudden • Increased a erent
Osmotic laxatives (lactulose, Diarrhea and compelling signaling rom the
polyethylene glycol) need to void. detrusor and urothelium
O ten coexists with
Proton pump inhibitors Diarrhea urinary requency • Impairment in CNS
Sedative hypnotics Sedation, delirium, immobility and nocturia inhibitory control
Thiazolidinediones Pedal edema leading to • Interruption/damage
nocturnal polyuria to suprasacral spinal
pathways
Adapted rom DuBeau CE. Incontinence. In: Durso SC, Sullivan GM, eds. • Idiopathic
Geriatric Review Syllabus, 8th ed. American Geriatric Society, 2013, pp. 244-253. Stress Leakage with • Impaired urethral support
increased • Impaired urethral closure
abdominal pressure
(coughing,
laughing, change in
(Figure 71-1). Postvoiding residual volume should be checked in position, straining)
all hospitalized patients with acute UI.
Mixed Combination Combination urge and
I general measures do not immediately remediate incontinence, urge and stress stress causes
then the next step is to evaluate the possible role o multimorbidity symptoms
(Tables 71-1 and 71-3) and medications (Table 71-2). Such acute or
Incomplete Elevated • Urethral obstruction
worsening UI and FI is requently re erred to as “transient,” because emptying postvoiding
the underlying precipitants may be reversible. However, some • Weak or absent detrusor
residual contractility
patients can leave the hospital with “transient” incontinence still in
Other symptoms • Combination o both
place i precipitants have not or cannot be resolved. nonspeci ic; may
Urinalysis should be interpreted with caution to avoid over- include dribbling,
treatment o asymptomatic bacteriuria which is ound in at least urgency, stress,
20% o older women (see Chapter 197 [Urinary Tract In ections]). stranguria
Diagnosis o urinary tract in ection (UTI) requires positive culture and

484

TABLE 71-5 Evaluation of Incontinence in Acute Care
Focused • Acute vs chronic
history • Onset, duration, requency, previous
evaluation/treatment
• Review o comorbid conditions, medications,
mobility, access to toilet/commode
• Review nursing assessment or bladder and
bowel unction
• Fluid status—intravenous and oral
Physical • General
examination • Volume status
• Abdomen (masses, suprapubic tenderness)
• Neurological (motor strength, sensation)
• Cognition (eg, MiniCog, Con usion
Assessment Method, see Chapter 81 on
delirium)
• Bedside pelvic (check or signi icant pelvic
organ prolapse, pain on bimanual exam)
• Rectal (in all patients, check or impaction
and masses; in patients with retention,
check sacral nerve innervation by perineal
sensation, sphincter tone, and anal wink and/
or bulbocavernosus re lex*)
• Perineal skin (dermatitis, cellulitis, pressure
ulcers)
Laboratory • Urinalysis
• I diarrhea, consider stool studies appropriate
to patient’s condition (eg, Clostridium difficile
antigen, ova and parasites, culture, ecal
leukocytes, ecal at)
• Other: i chronic UR, consider vitamin B12
level; with chronic diarrhea or constipation,
thyroid studies
Radiology • Postvoid residual volume (by bladder
ultrasound, i available)
• Abdominal KUB i constipation
• Neurological and/or pelvic imaging i
indicated by known or suspected comorbidity
(eg, pelvic mass, new neurological de icits)
• Indigo carmine or methylene blue testing i
urinary tract istula suspected
*To do anal wink, lightly scratch perineal skin lateral to anus and visually
check or anal contraction; or bulbocavernosus re lex, lightly squeeze
either the clitoris or glans and check or anal contraction (either visually or
with inger inserted in rectum).
may include anoscopy, f exible sigmoidoscopy, or colonoscopy to
exclude mucosal disease or to evaluate rectal bleeding.
■ PREVENTION
Prevention and Treatment o UI and FI in hospitalized patients begin
with addressing contributing comorbidity, iatrogenic complications,
and medications. General measures include removal o impedi-
ments that limit access to toilets or commode, regular toileting by
sta (eg, every 2 hours while awake), bedside commodes, condom
catheters, and handheld urinals.
■ TREATMENT OF URINARY INCONTINENCE
Indwelling (Foley) catheters should only be used or ve speci c
indications (Table 71-6). Indwelling catheter should never be used
or sta or patient convenience because o the high risk o catheter
associated urinary tract in ection (CAUTI). CAUTI increases the risk o
C
a publicly reported marker o poor quality care and not reimbursed
H
by Medicare. Clean intermittent catheterization has little role in the
A
P
acute care setting.
T
E
R
PRACTICE POINT
7
1
Management o Urinary Incontinence
• Cognitive impairment: management starts with
nonpharmacological approaches (prompted voiding,
I
n
c
scheduled toileting); these patients are especially vulnerable to
o
anticholinergic side e ects.
n
t
• Heart ailure: administer diuretics early in the morning and early
i
n
e
a ternoon to avoid nighttime f uid overload and nocturia.
n
c
• Actively dying: guidelines or catheter management may not
e
apply; the goals o care ocus on patient com ort and wishes.
Medications or urge UI include antimuscarinic agents oxybutynin,
dari enacin, tolterodine, soli enacin, trospium, and esoterodine, and
the β-3 adrenergic agonist mirabegron. The antimuscarinic agents
may cause dry mouth, constipation, and dyspepsia; hospitalized
patients are at higher risk o an elevated PVR/partial retention with
antimuscarinics because o their many other risk actors or UR. Anti-
muscarinics have also been associated with cognitive impairment.
Antimuscarinics (with the exception o trospium and esoterodine)
are metabolized by CY34A and 2D6, with potential interactions with
macrolide antibiotics, oral anti ungals, and SSRIs. Antimuscarinics
should not be combined with cholinesterase inhibitors used to treat
dementia Mirabegron does not have anticholinergic side e ects, but
may elevate blood pressure and has signi cant drug interactions
with metoprolol and digoxin. There are no medications to treat stress
UI. Most patients with stress UI can be re erred or appropriate gyne-
cology or urology ollow-up a ter discharge; however, in-hospital
neurology consultation should be considered i neurogenic sphinc-
ter dys unction is suspected because o other symptoms or signs or
spinal cord injury. Treatment o UI with indwelling catheters should
be reserved or only speci c indications (Table 71-6). Clean intermit-
tent catheterization has little role in the acute care setting.
■ MANAGEMENT OF FECAL INCONTINENCE
Management o FI with diarrhea may include medications (bulking
agents and antidiarrheals); containment by absorbent products or
external ecal collectors, bowel management systems, or diversion by
rectal tube. Data on the e cacy and utility o most o these options in
the acute care setting are limited. Diphenoxylate should be avoided
because o potential drug interactions and cognitive changes. Exter-
nal ecal collectors are pre erable to rectal tubes, which can damage
anal sphincters continence and rectal mucosa, and block ecal pas-
sage as diarrhea resolves. They are contraindicated in patient with
recent rectal or prostate surgery, recent myocardial in arction, rectal
mucosal disease, clotting disorders, and impaired immune status. FI
due to impaction is treated with oral laxatives and enemas; methyln-
altrexone may be e ective or opiod-induced constipation in pallia-
tive care settings. Evidence exists or the use o polyethylene glycol
versus lactulose or chronic constipation.
■ MANAGEMENT OF INCONTINENCE IN SPECIAL
POPULATIONS
Surgery: Catheters should not be used to manage incontinence
or generalized bladder management in the perioperative period.
Guidelines suggest that catheters may be used a ter speci c uro-
logic and pelvic surgery or surgery on structures contiguous to the
485
 Ne w or wors e ning UI in hos pita lize d pa tie nts UI as s o c iate d with
• P a in
HIS TORY • He ma turia not
P
S YMPTOM Mixe d urg e a s s ocia te d with UTI
A
Urg e nc y S tre s s
AS S ES S MENT and s tre s s • P e lvic ma s s
R
• P e lvic irra dia tion
T
• P e lvic/LUT s urge ry
I
CLINICAL
I
• As s e s s , tre a t, a nd re a s s e s s for contributing fa ctors (Ta ble s ) • P rola ps e be yond
I
AS S ES S MENT hyme n
• Ma ximize toile t/commode a cce s s ibility
• Che ck pos tvoid re s idua l • S us pe cte d fis tula
• Urina lys is /culture only if othe r UTI s ymptoms pre s e nt
• Multimorbidity
• Ta rge te d phys ica l e xa m: volume ove rloa d, impa ction,
R
• Me dica tions
e
ne w ne urologica l s igns (e g, ca uda e quina ), mobility
h
• De cre a s e d mobility
a
• De lirium
b
i
• UTI
l
IF UNCERTAIN
i
Urge ncy UI P os tvoid Re s idua l S tre s s UI
t
a
• Me dica tions >100 mL
t
i
• P olyuria
o
n
• S tool impa ction
a
a nd othe r fa ctors
n
• Re gula r toile ting while • Tre a t cons tipa tion Outpa tie nt
d
Avoid ove rtre a tme nt
a wa ke • Re vie w me dica tions ma na ge me nt
S
of a s ymp toma tic
k
• Cons ide r me dica tion • Cons ide r tria l of
i
b a c te riuria
l
l
tre a tme nt, if a ppropria te a lpha -blocke r (me n)
e
d
a nd no contra indica tions • Ca the te r dra ina ge if
N
INITIAL P VR 200-500 mL,
u
the n re a s s e s s
r
INTERVENTION
s
i
n
g
C
ONGOING
a
MANAGEMENT AND If ins uffic ie nt impro ve me nt, re as s e s s fo r tre atme nt o f c o ntributing c o mo rbidity,
r
e
REAS S ES S MENT me dic atio ns , func tio nal impairme nt

Inc lude e valuatio n and If c o ntinue d ins uffic ie nt impro ve me nt, o r s e ve re as s o c iate d s ympto ms are pre s e nt, c o ns ide r s pe c ialis t
tre atme nt in trans itio ns re fe rral as appro priate pe r patie nt pre fe re nc e s and
c o mmunic atio n

Figure 71 1 Algorithm for treatment of new or worsening urinary incontinence in hospitalized patient.

genito-urinary tract; anticipated long duration surgery (with cathe-
ter removal in postacute care unit); when there is a need or intraop-
erative urinary output measurement; and when large volume f uids
or diuretics are required during surgery. In the postoperative period,
catheters should be removed as soon as possible and appropriate
toileting and use o bedside devices should be considered.
Dementia: Management o UI in patients with dementia in
the hospital setting should ocus on potentially reversible actors
(see above) and nonpharmacological approaches (containment,
prompted voiding, scheduled toileting). Antimuscarinic medica-
tions or urge UI should not be started in patients with dementia in
the acute care setting because o the likelihood that new or worsen-
ing UI is due to “transient” causes, and because o the risk o wors-
ening cognition. Antimuscarinics should not be given to patients
taking cholinesterase inhibitors (eg, donepezil); mirabegron can be
used instead, i there are no contraindications to its use.
Heart failure: Patients with diastolic and systolic heart ailure may
develop UI rom new or higher doses o loop (but not thiazide) diuret-
ics, and nocturia rom remobilized lower-extremity edema. There is
no speci c evidence-based recommendation regarding timing o
diuretics to prevent UI and nocturia in hospitalized patients. Data
rom a small, short term randomized trial in nonhospitalized patients
showed that oral urosemide 40 mg given 6 hours be ore bedtime had
no impact on nocturia episodes but did increase daytime requency.
Alteration in positioning and prolonged time supine also a ect diuresis
and natriuresis, and patients with CHF likely have other multimorbidity
that contributes to incontinence and nocturia. Patients may bene t
rom general HF management strategies, such as compression stock-
ings and avoidance o medications causing edema and f uid retention,
as well as repeated “n o 1” trials o optimal diuretic timing in indi-
vidual patients. Catheter insertion to measure urine output should be
avoided, especially outside o the critical care setting unless UI poses a
signi cant barrier to accurate urine output measurement.
End of life: Urinary catheters are appropriate to use in dying
patients or com ort, especially to avoid requent changes o protec-
tive garments.
Neurologic diseases: Adults with complex neurologic diseases
(eg, multiple sclerosis, spinal cord injury, Parkinson’s disease, stroke)
requently have UI and FI because o direct e ects on areas o the
neuroaxis important or bladder and bowel unction (especially
pre rontal cortex, pontine and suprapontine areas, and thoracic and
lower-lumbar spinal cord), as well as associated cognitive and unc-
tional impairments. These patients should always have PVR checked
as part o the evaluation. Consideration o medications and other
actors that may contribute to urinary retention is important prior to
placing a urinary catheter (Table 71-7). Constipation can be com-
mon and contribute to urinary symptoms and FI.
Select patients (especially those with high PVR or UI and no
external anal sphincter tone at rest or diarrhea with nonin ectious
etiology or FI) may need urther evaluation by a specialist in urol-
ogy, gynecology, gastroenterology, colorectal surgery, or neurology
depending on the type o incontinence and potential etiologies.
Nurses specializing in Wound, Ostomy, and Continence (WOC) care
are also a valuable resource in the acute care setting.

486
 FI as s o c iate d with

C
• Blo o d in s to o l and

H
Ne w or wors e ning FI in hos pita lize d pa tie nts o the r “re d flag ”

A
s ympto ms not

P
HIS TORY/ a s s ocia te d with

T
S YMPTOM Mixe d urg e ga s troe nte ritis
Urg e nc y

E
Pas s ive
AS S ES S MENT and pas s ive • Impaire d re s ting

R
re c tal to ne

7
• P e lvic/re cta l ma s s

1
CLINICAL • As s e s s , tre a t, a nd re a s s e s s for contributing fa ctors (Ta ble s ) • P e lvic irra dia tion
AS S ES S MENT • Ma ximize toile t/commode a cce s s ibility • P e lvic/lowe r GI tra ct
s urge ry

I
• As s e s s nutritiona l inta ke

n
c
• S tool s tudie s /culture if othe r GI s ymptoms pre s e nt • Re cta l prola ps e

o
• Ima ging s tudie s de pe nde nt on s ymptoms a nd phys ica l • S us pe cte d fis tula

n
• Multimorbidity

t
• Me dica tions e xa m findings

i
n
• Ta rge te d phys ica l e xa m/digita l re cta l e xa mina tion: impa ction, ne w

e
• De cre a s e d mobility

n
• De lirium ne urologica l s igns (e g, ca uda e quina ), mobility, a na l s phincte r tone

c
e
• Nutrition a t re s t a nd with volunta ry contra ction, a nocuta ne ous re fle x (a na l wink)
• Ga s troe nte ritis
• Dia rrhe a Anal S phinc te r Lo o s e S to o l Hard S to o l
IF UNCERTAIN
• Cons tipa tion Impairme nt Co ns is te nc y Co ns is te nc y
• S tool impa ction (S que e ze )

• Re gula r toile ting while
a wa ke
• Cons ide r furthe r
e va lua tion with
INITIAL ma nome try (outpa tie nt) or
INTERVENTION ima ging s tudie s if
ne urologic ca us e is
s us pe cte d (inpa tie nt)
• Re vie w me dica tions
• Re vie w die ta ry inta ke
• Cons ide r tria l of
Iope ra mide for
noninfe ctious dia rrhe a
• Tre a t ma la bs orption
s yndrome s , if pre s e nt
• Re vie w me dica tions
• Re vie w die ta ry inta ke
• Eva lua te for impa ction
• Tre a t with ora l la xa tive
a nd e ne ma s (if indica te d)

ONGOING
MANAGEMENT AND
REAS S ES S MENT
If ins uffic ie nt impro ve me nt, re as s e s s fo r tre atme nt o f c o ntributing c o mo rbidity,
me dic atio ns , func tio nal impairme nt

Inc lude e valuatio n and If c o ntinue d ins uffic ie nt impro ve me nt, o r s e ve re as s o c iate d s ympto ms are pre s e nt, c o ns ide r s pe c ialis t
tre atme nt in trans itio ns re fe rral as appro priate pe r patie nt pre fe re nc e s and
c o mmunic atio n

Figure 71 2 Algorithm for treatment of new or worsening fecal incontinence in hospitalized patients.

PRACTICE POINT
Indications or re erral or incontinence include (see also
treatment algorithms):
• Urology: hematuria without UTI, pelvic mass, prior pelvic
radiation, prior pelvic/lower urinary tract surgery, suspected
bladder stula
• Gynecology: pelvic pain not responding nonpharmacologic
and pharmacologic treatments, pelvic mass, prior pelvic
radiation, prior pelvic/lower urinary tract surgery, suspected
stula, prolapse beyond the hymen
• Gastroenterology:“Red f ag”or alarm symptoms (chronic GI
bleeding, progressive unintentional weight loss, progressive
dysphagia, nocturnal symptoms, iron de ciency anemia, amily
history o colon cancer or inf ammatory bowel disease), acute
inf ammatory bowel disease, pancreatitis, malabsorption
syndromes, stool impaction not responding to pharmacologic
treatment and enemas
• Colorectal surgery: rectal mass, colon cancer, congenital
abnormalities, inability to reduce rectal prolapse
• Neurology: cauda equina or tumor, spinal cord injury, multiple
sclerosis, stroke, prior back surgery with other neurologic
ndings
• Nurses specializing in Wound, Ostomy, and Continence
(WOC): incontinence associated dermatitis, pressure wounds,
management in spinal cord injury, special containment
requests
URINARY RETENTION
■ PATHOPHYSIOLOGY
Urinary retention (UR) may be acute or chronic, and partial (patient
may still void or leak urine) or complete (inability to void). Acute UR
presents with a relatively sudden di culty or inability to pass urine,
usually with abdominal or suprapubic pain. Pain may be absent due
to impaired sensory a erents (eg, with cauda equina syndrome), med-
ication (eg, narcotics), or not recognized (eg, cognitive impairment).
Chronic retention may be asymptomatic except or associated UI.
The causes o UR all into three general categories: increased
bladder outf ow resistance (mechanical or dynamic); interruption o

487
 UTI, hip racture, ecal impaction, male gender, bedrest, and benign
TABLE 71-6 Indications for Indwelling Urethral Catheters prostatic enlargement.
Neither abdominal palpation nor percussion is sensitive or speci c
Indication Management
P
or bladder distension. Only by bladder scan or catheterization accu-
A
Acute urinary retention • Remove catheter as soon as possible
rately determines the presence or absence o UR accurately. I the
R
or obstruction (eg, a ter reversible causes identi ied
patient can void, bladder volume should be determined only a ter
T
and removed)
they void, and the percentage emptying considered as well as the
I
• Arrange appropriate outpatient care
I
absolute postvoiding residual (PVR) volume. There is no consensus on
I
ollowing hospitalization
cut-o values or “normal” PVR either rom the perspective o de ni-
Accurate measurement • Minimize time with catheter inserted tion or clinical relevance. Women may tolerate higher PVRs than men
o urinary output in • Remove catheter when alternative because they have less urethral resistance, and PVR up to 200 mL
R
critically ill patients means o urinary collection are may not be clinically relevant unless the patient has UTIs, requency,
e
h
available urgency, or UI. In men, PVR > 100 mL are generally considered abnor-
a
b
Perioperative use • Urologic surgery or other surgery on mally elevated. In the absence o new renal impairment men and
i
l
i
contiguous structures in the genito-
t
especially women have a low prior probability o hydronephrosis due
a
urinary tract
t
to elevated PVR and upper-tract imaging is not necessary.
i
o
• Anticipated long duration surgery
n
The gold standard or the diagnosis o outlet obstruction is uro-
(with catheter removal in PACU)
a
dynamic pressure-f ow study; cystoscopy alone is nonspeci c and
n
d
• Need or intraoperative urinary insensitive. Acute UR, prostate in ection, and urethral instrumenta-
S
output measurement tion/catheterization may elevate prostate speci c antigen (PSA).
k
i
l
• Large volume luids or diuretics
l
e
d
during surgery ■ MANAGEMENT
N
Stage 2 or greater • To improve healing and reduce Figure 71-3 presents a general management approach or patients
u
open sacral or perineal exposure to moisture
r
with suspected acute urinary retention.
s
i
wounds in incontinent
n
For acute retention, all patients should have bladder decompres-
g
patients
sion with an indwelling catheter or several days. Antibiotic and
C
Com ort care at the • When goal is to improve quality o
a
antimicrobial catheters are not recommended or short-term hos-
r
e
end o li e li e or patient and caregivers pital usage due to the relative lack o e cacy, as well as patient dis-
com ort and cost. Following catheter insertion, patients should be
Adapted rom the Centers or Disease Control and Prevention: Guidelines
treated or potentially remediable causes such as medications, and
or Prevention o Catheter-Associated Urinary Tract In ections 2009. http://
www.cdc.gov/HAI/ca_uti/uti.html. Accessed April 1, 2015. impaction. Medications may expedite catheter removal in selected
patients. Alpha-adrenergic antagonists (eg, terazosin, doxazosin,
tamsulosin, al uzosin) can be used or UR due to prostatic obstruc-
detrusor sensory a erents or motor e erents; and decreased detru- tion. 5-Alpha reductase inhibitors ( nasteride and dutasteride) are
sor contractility (neurogenic, myogenic, or iatrogenic [medications]) not use ul in the acute care setting because o the delayed onset o
(Table 71-7). UR is common a ter spinal or epidural anesthesia. treatment e ect (up to 6 months). Methylnaltrexone (0.15 mg/kg o
Although prostate enlargement is common in older men and i body weight) may be used or opioid-induced and possibly postop-
advanced can cause outlet obstruction and chronic UR, acute UR is erative urinary retention. Bethanecol chloride is ine ective.
usually precipitated by other actors. Outlet obstruction in women A voiding trial without catheter should ollow decompression.
is uncommon; when present, it is usually due with prior anti-incon- With the patient adequately hydrated, the catheter is removed
tinence surgery or marked pelvic organ prolapse. (never clamped), and a PVR checked a ter the rst void (or bladder
volume checked i there is no void a ter about 6 hours). I the PVR
is <100 to 150 mL, the catheter can stay out but the patient should
■ EVALUATION
have close ollow-up—both in the hospital and a ter discharge—to
The evaluation o urinary retention also is similar to that o UI and FI ensure that retention does not recur. I the PVR remains high, one
(Table 71-7). Risk actors or elevated PVR, in addition to medications can consider short-term intermittent catheterization or reinsertion
(Table 71-2), include previous history o UR, new stroke, untreated o the catheter while urther evaluation and treatment o the inabil-
ity to void continues. Patients who must leave the hospital with
catheter in place should have a ollow-up appointment within
TABLE 71-7 Common Causes of Urinary Retention in 1 week and another voiding trial attempted at that time.
Hospitalized Patients Select patients may need urther evaluation by a specialist in urol-
ogy, gynecology, gastroenterology, colorectal surgery, or neurology
Mechanical Neurogenic Medications depending on the type o incontinence (UI with high PVR) and
Stool impaction Acute cauda equina Anesthesia potential etiologies (cauda equina syndrome). Nurses specializing
Catheter syndrome Opiates in Wound, Ostomy, and Continence (WOC) care are also a valuable
obstruction Sacral/subsacral Anticholinergics resource in the acute care setting.
(eg, blood clot, spinal cord injury (eg, phenergan,
twisted catheter) Bedrest metoclopramide, TRANSITIONS OF CARE
Sacral herpes zoster antispasmodics)
Medication reconciliation should consider possible drug interac-
Urinary tract tions between previous or new bladder antimuscarinics and new
in ection medications at discharge. Hospital-acquired deconditioning may
Bladder greatly impact continence; discussion with the patient, amily, and
overdistention rom other care providers must anticipate and help with new home
rapid dieresis needs such raised toilet seats, bedside commodes or urinals,

488
 P a tie nt with s us pe cte d a cute urina ry re te ntion

C
H
A
HIS TORY/
Diffic ulty o r Vag inal o r Ure thral Hx o f ure thral

P
S YMPTOM
inability to pas s s e ve re pain, infe c tio n, s tric ture o r

T
AS S ES S MENT
urine o r ve s ic ular le s io ns impas s able c athe te r

E
R
CLINICAL

7
AS S ES S MENT

1
As s e s s c o ntributing Tre at and re as s e s s Re c e nt GU o r GYN Co ns ult a Uro lo g is t
fac to rs : s urg e ry o r Gyne c o lo g is t
• BP H/pros ta te CA

I
Me dic atio ns

n
c
• Anticholine rgics • Ne urologica l dz

o
• Ca nce r No improve me nt S ig ns o f ure thral

n
• Opia te s
trauma o n e xam

t
• Acute UTI

i
• β-a dre ne rgic a ge nts

n
• He ma turia

e
• α -a dre ne rgic a ge nts

n
• Ane s the tics • P ote nt diure tic (incl Exam:

c
EtOH) • Re c tal: impac tio n,

• Mus cle re la xa nts
• Mis c: hydra la zine ,
nife dipine , dopa mine ,
ca rba ma ze pine
e
• Me dica tions mas s , to ne
• Bowe l pe rfora tion, • If ne uro dz o r c anc e r:
is che mia , infe ction s ac ral re fle xe s

INITIAL Ins e rt ure thra l ca the te r a nd

Una ble to ins e rt
INTERVENTION a ddre s s contributing fa ctors

ONGOING Co ns ide r me dic atio ns (s e e te xt)

MANAGEMENT AND
REAS S ES S MENT
Trial witho ut c athe te r Fa ilure
Inc lude e valuatio n and
tre atme nt in trans itio ns
c o mmunic atio n

Figure 71 3 Algorithm for treatment of patient with suspected acute urinary retention.

protective garments, adsorbent products, and skin care. I long
term catheter use is indicated, speci c instructions or management
and ollow-up are needed or subacute care settings; nursing care
should be arranged or patients returning home.
Management o UI in post acute care ollows the same principles
and management as in the acute care setting, with two di erences.
Prompted voiding and regular toileting may be more easible. Two
systematic reviews ound prompted voiding was moderately e ec-
tive in reducing daytime UI in post acute patients with cognitive
impairment. At skilled nursing acilities institute prompted voiding
was ound to be somewhat e ective at short-term ollow-up in
reducing daytime incontinence in two systematic reviews o ran-
domized trials involving SNF patients with cognitive impairment
and urinary incontinence. One study suggested a persistent bene t
4 months among long-stay patients a ter the intervention period.
Most trials used research sta to provide the prompting interven-
tion, and it is uncertain whether implementation with usual nurs-
ing sta would be similarly e ective, given constraints o added
cost and nursing time. An exercise program (graded strength
and endurance training) may be considered as an adjunct to
prompted voiding, although its e ectiveness is uncertain, with
bene t ound in two trials and no bene t in one. Addition o
medications or urge UI may be considered, especially i “tran-
sient” contributing actors have resolved or improved.
QUALITY IMPROVEMENT
Hospitals have implemented daily order renewal and review o
indwelling catheter need to reduce the incidence o catheter-
associated urinary tract in ection. Screening and recognition o a
prior UI, FI, and UR history upon hospital admission will identi y
hospitalized patients at risk or these conditions. Discussion o con-
tinence care and options or management may help reduce adverse
e ects o leakage on skin. Development o pharmacy reminders
or medications that are associated with incontinence and UR
among hospitalized patients may also help improve outcomes.
Lastly, improvements in bowel regimens, especially or hospitalized
patients on narcotics and at risk or constipation, are needed.
SUGGESTED READINGS
Candy B, Jones L, Goodman ML, Drake R, Tookman A. Laxatives or
methylnaltrexone or the management o constipation in pallia-
tive care patients. Cochrane Database Syst Rev. 2011;(1):CD003448.
Centers or Disease Control and Prevention. Guidelines or Preven-
tion o Catheter-Associated Urinary Tract In ections; 2009. http://
www.cdc.gov/HAI/ca_uti/uti.html. Accessed April 1, 2015.
Gulur, DM, Mevcha AM, Drake MJ. Nocturia as a mani estation o
systemic disease. BJU Int. 2011;107(5):702-713.
Lam TBL, Omar MI, Fisher E, Gillies K, MacLennan S. Types o indwell-
ing urethral catheters or short-term catheterisation in hospital-
ised adults. Cochrane Database Syst Rev. 2014;(9):CD004013.
Lee-Robichaud H, Thomas K, Morgan J, Nelson RL. Lactulose versus
polyethylene glycol or chronic constipation. Cochrane Database
Syst Rev. 2010;(7):CD007570.
Lo E, Nicolle LE, Co n SE, et al. Strategies to prevent catheter-associ-
ated urinary tract in ections in acute care hospitals: 2014 update.
Infect Control Hosp Epidemiol. 2014;35(5):464-479.

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 McCormick KA, Scheve AA, Leahy E. Nursing management o Tannenbaum C, Johnell K. Managing therapeutic competition in
urinary incontinence in geriatric inpatients. Nurs Clin North Am. patients with heart ailure, lower urinary tract symptoms and
1988;23(1):231-264. incontinence. Drugs Aging. 2014;31(2):93-101.
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Ostaszkiewicz J, O’Connell B, Millar L. Incontinence: managed or
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mismanaged in hospital settings? Int J Nurs Pract. 2008;14(6):
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ONLINE RESOURCES
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Petrilli CO, Traughber B, Schnelle JF. Behavioral management Catheterout.org. This comprehensive web site includes evidence-
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in the inpatient geriatric population. Nurs Clin North Am. based toolkits and team work to reduce hospital-acquired CAUTI.
1988;23(1):265-277. Centers or Disease Control and Prevention. Guidelines or Preven-
P sterer MH, Johnson TM 2nd, Jenetzky E, Hauer K, Oster P. Geriatric tion o Catheter-Associated Urinary Tract In ections; 2009. http://
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patients’ pre erences or treatment o urinary incontinence: a www.cdc.gov/HAI/ca_uti/uti.html. Accessed April 1, 2015.
e
h
study o hospitalized, cognitively competent adults aged 80 and Lo E, Nicolle LE, Co n SE, et al. Strategies to prevent catheter-
a
b
older. J Am Geriatr Soc. 2007;55(12):2016-2022. associated urinary tract in ections in acute care hospitals: 2014
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l
i
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Sier H, Ouslander J, Orzeck S. Urinary incontinence among update. Infect Control Hosp Epidemiol. 2014;35(5):464-479. Pub-
a
t
geriatric patients in an acute-care hospital. J Am Med Assoc. lished by Cambridge University Press on behal o The Society
i
o
n
1987;257(13):1767-1771. or Healthcare Epidemiology o America Stable. http://www.jstor.
a
org/stable/10.1086/675718. Accessed June 17, 2016.
n
Society or Hospital Medicine—Adult Hospital Medicine. Choosing
d
Wisely®An Initiative o the ABIM Foundation. Five things physi- Society or Hospital Medicine – Adult Hospital Medicine. Choosing
S
k
cians and patients should question. Released February 21, 2013. Wisely®An Initiative o the ABIM Foundation. Five things physicians
i
l
l
and patients should question. Released February 21, 2013. http://
e
http:/ / www.choosingwisely.org/ doctor-patient-lists/ society-
d
o -hospital-medicine-adult-hospital-medicine/. Accessed April www.choosingwisely.org/doctor-patient-lists/society-o -hospital-
N
1, 2015. medicine-adult-hospital-medicine/. Accessed April 1, 2015.
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CHAP TER
72 INTRODUCTION
Pressure ulcers, or bedsores, are a key clinical indicator o quality
o care in hospitals. Their occurrence is widely seen as a marker or
substandard care, triggering anger and sometimes litigation on the
part o patients and amilies. However, they remain common in
hospitalized patients. In 1993, pressure ulcers were diagnosed dur-
ing 280,000 hospital stays in the United States, a number that rose
to 503,300 in 2006. Up to 15% o elderly patients develop pressure
ulcers within the rst week o hospitalization. Mortality may be as
Pressure Ulcers high as 60% or older persons with pressure ulcers in the year a ter
hospital discharge.
Pressure ulcers are also expensive, with an average charge per
stay o $43,180. In 2007, the Centers or Medicare and Medicaid
Courtney H. Lyder, ND, ScD(Hon), FAAN Services (CMS) made payouts o more than $11 billion or bene -
ciaries admitted to hospitals who developed Stage III and Stage IV
pressure ulcers. The Centers or Medicare and Medicaid Services
subsequently stopped reimbursement or hospital-acquired Stage III
and Stage IVpressure ulcers in October 2008.

Key Clinical Questions
1 What is a pressure ulcer? How are pressure ulcers
staged?
2 Which patients are at risk or pressure ulcers?
3 What measures are e ective in pressure ulcer
prevention?
4 How should pressure ulcers be cleansed, debrided, and
dressed?
5 What role do adjunctive therapies have in pressure ulcer
treatment?
PATHOPHYSIOLOGY
Pressure ulcers are ocal injuries o skin and subcutaneous tissue
resulting rom pressure, shear orces, riction, or some combination
o these. They most o ten overlie bony prominences o the pelvis
and lower extremities, such as the sacrum, greater trochanter o the
hip, and heels, but they may appear in other locations, depending
on patient positioning (Figure 72-1).
Tissue ischemia occurs when external pressures exceed per usion
pressures. Normal blood pressure within capillaries ranges rom 20
to 40 mm Hg; 32 mm Hg is considered average. An external pres-
sure 32 mm Hg usually su ces to prevent pressure ulcers. However,
capillary blood pressure may be less than 32 mm Hg in critically ill
patients due to hemodynamic instability and comorbid conditions.
Frictional orces, like those generated between the heels and
bedsheets, can lead to blisters and skin breakdown, avoring the
development o pressure ulcers. Bedbound patients are also prone
to shear orces, which occur when bone and so t tissue move rela-
tive to the skin, which is held in place by riction.
Older patients are more susceptible to shear orces, as their so t
tissues are atrophied and contain less elastin. Moisture, as in urine,
stool, and sweat, acts synergistically with pressure, riction, and shear
orces to acilitate skin breakdown.

PREVENTION
Pressure ulcer prevention requires a team e ort, involving physi-
cians, nurses (including wound, ostomy, and continence nurses),
dietitians, and physical therapists. Studies have demonstrated that
comprehensive pressure ulcer prevention programs can decrease
incidence rates, although not to zero. For optimal e ectiveness,
pressure ulcer prevention must begin as soon as patients enter the
hospital. There are ve basic components to comprehensive pres-
sure ulcer prevention: risk assessment, skin care, mechanical loading,
support sur aces, and nutritional support.

■ RISK ASSESSMENT
The identi cation o patients at greatest risk o pressure ulcers
involves the use o a risk assessment tool, skin assessment, and clini-
cal judgment. More than 20 pressure ulcer prediction tools are used
throughout the world, with the most popular being the Braden,

491
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Figure 72 1 Pressure ulcer locations. The most common sites of pressure ulceration are the sacrum and coccyx,
heels, and greater trochanters of the hip. (From Preventing Pressure Ulcers: APatient’s Guide. Washington, DC: U.S.
Department o Health and Human Services; 1992, USGPO 617-025/68298.)

Norton, and Waterlow scales. The Braden Scale or Predicting Pres-
sure Sore Risk is the most widely used in US hospitals. (The copy-
righted tool is available at http://www.bradenscale.com/images/
bradenscale.pd .) The Braden Scale is designed or use with adults,
and consists o six subscales: sensory perception, moisture, activity,
mobility, nutrition, and riction and shear. Total scores on the Braden
Scale range rom 6 (high risk) to 23 (low risk); a score o 18 is the cut-
o score or onset o pressure ulcer risk.
There is general consensus rom most pressure ulcer clinical
guidelines to do a risk assessment on admission, at discharge, and
whenever the patient’s clinical condition changes. Skin assessment
should also be correlated with risk assessment. Close attention
should be paid to greater trochanters, heels, sacrum, and coccyx, as
>60% o all pressure ulcers occur at these locations.
■ SKIN CARE
The skin o patients at risk o pressure ulceration should be
inspected regularly or erythema. This includes pressure points, as
well as areas o contact with medical devices, such as catheters,
oxygen tubing, ventilator tubing, and semirigid cervical collars, as
these may also cause ulceration. Pain over an erythematous area
may herald skin breakdown. It is not always possible to see redness
on darkly pigmented skin. Depending on the degree o pigmenta-
tion, erythema may appear blue or purple, compared to adjacent
skin. Erythema should be categorized as blanching or nonblanch-
ing. Localized heat, edema, and induration over pressure points are
additional warning signs or pressure ulcer development. Patients
may need more requent inspection in response to any deteriora-
tion in condition.

492
 Protecting skin rom excessive moisture with barrier paste or
other products is essential, as moisture and warmth impair the
mechanical integrity o the stratum corneum. Massaging areas o
reddened skin should be avoided, as these may contain damaged
blood vessels or ragile skin. Skin emollients to hydrate dry skin
should be considered.
■ MECHANICAL LOADING
Decreasing mechanical load and pressure exposure are crucial in pre-
venting pressure ulcers. High pressures over bony prominences or
short periods o time and low pressures over bony prominences or
long periods o time are equally damaging. Repositioning requency
should be determined by the patient’s skin condition and tissue tol-
erance, level o activity and mobility, general medical condition, over-
all treatment objectives, and support sur aces applied to the bed or
chair. Turning and repositioning hospitalized patients every 2 hours
while in bed, and every hour while seated, is reasonable or most
hospitalized patients. Those who are critically ill may require hourly
repositioning, while stable patients on specialty beds, such as low air
loss or air uidized, may only need repositioning every 4 hours.
The patient should be repositioned to relieve or redistribute pres-
sure. Trans er aids that reduce riction and shear orces, such as the
Hoyer li t or trapeze, should be used. Avoid positioning the patient
directly on a bony prominence or directly onto medical devices,
such as tubes or drains. The 30°-tilt position and the standard 90°
side-lying position seem to be equivalent in protection against the
development o pressure ulcers.
■ SUPPORT SURFACES
Pressure should be distributed as evenly as possible across the
patient’s body to reduce the incidence o pressure ulcers. The use o
support sur aces may assist in pressure redistribution. The Centers
or Medicare and Medicaid Services have divided support sur aces
into three categories or reimbursement purposes. Group 1 devices
are static and do not require electricity. Static devices include air,
oam, gel, and water overlays or mattresses. These devices are
ideal when a patient is at low risk or pressure ulcer development.
The devices have some drawbacks: oam may degrade and lose its
sti ness over time, and gel mattresses can increase skin heat and
moisture. Group 2 devices are dynamic and powered by electricity
or pump action. These devices include alternating and low-air-loss
mattresses. These mattresses are better or patients at moderate
to high risk or pressure ulcers, or who have ull-thickness pressure
ulcers (Stage III and Stage IV). Critically ill patients are excellent can-
didates or this group o support sur aces.
Group 3 devices, also dynamic, comprise only air- uidized beds.
These are electric, and contain silicone-coated beads that lique y
when air is pumped through the bed. These beds are used or
patients at very high risk or pressure ulcers, patients with non-
healing ull-thickness pressure ulcers, and patients with numerous
truncal ull-thickness pressure ulcers. The National Pressure Ulcer
Advisory Panel has suggested new de nitions or support sur aces
that move away rom these categories and divide support sur aces
into simply powered or nonpowered.
Approximately 20% o all pressure ulcers are ound on the heels.
Heel-protection devices should be considered or hospitalized
patients at risk or pressure ulcers. The heels should be elevated and
of oaded to distribute the weight o the leg along the cal without
putting pressure on the Achilles tendon. The knee should also be in
slight exion to avoid hyperextension o the knee, which could lead
to obstruction o the popliteal vein and deep vein thrombosis. Some
hospitals may alternatively use a pillow to oat the heels. I the use
o a pillow is pre erred, then the pillow should be placed under the
calves to elevate the heels rom the mattress.
■ NUTRITION
C
While nutritional status in patients with pressure ulcers is o ten
H
poor, the evidence or a relationship between nutrition intake and
A
pressure ulcer prevention is not always supported by randomized
P
controlled trials. There is also a lack o empirical evidence to link the
T
use o vitamin and mineral supplementation to the prevention o
E
R
pressure ulcers. There ore, while nutritional status should be opti-
mized in patients at risk or pressure ulcers, overtreatment should
7
2
also be avoided.
P
TREATMENT
r
e
s
When a pressure ulcer develops, the hospitalist must provide local
s
u
care o the ulcer, but also assess the patient’s overall physical health,
r
e
nutritional status, pain level, and psychosocial health, considering
U
l
the whole patient, not merely the ulcer. In addition to mechanical
c
e
loading and support sur aces, as discussed above, pressure ulcer
r
s
management includes the ollowing.
■ ULCER ASSESSMENT
The ulcer bed should rst be cleansed with a nontoxic solution.
Cleaning removes necrotic debris and bacteria that may delay heal-
ing. Normal saline (0.9% sodium chloride) or water solutions are
best, as neither is toxic to healthy tissue. Although the active ingre-
dients in newer wound cleansers may be nontoxic sur actants, the
inert carrier may be toxic to healthy granulation tissue.
The pressure ulcer should be assessed or location, stage, size
(length, width, and depth), sinus tracts, undermining, tunneling,
exudate (quality and quantity), necrotic tissue, and the presence or
absence o granulation tissue and epithelialization. This comprehen-
sive assessment establishes the baseline or measuring ulcer healing
or deterioration. Ulcer assessment should be done at least weekly.
■ STAGING
Upon completing the pressure ulcer assessment, the ulcer should
be staged. The most commonly used pressure ulcer staging system
was developed by the National Pressure Ulcer Advisory Panel. Their
system classi es skin changes into ve levels o skin ulceration
(Table 72-1 and Figure 72-2).
This system rates the pressure ulcer rom super cial tissue dam-
age (Stage I) to ull-thickness skin loss involving muscle or bone
(Stage IV) and deep tissue injury. I the pressure ulcer is covered with
necrotic tissue (eschar), it is noted as unstageable.
■ WOUND BED PREPARATION
A recent concept in the healing o chronic ulcers is wound bed
preparation. The goal o wound bed preparation is to provide the
ulcer with an optimal environment or healing: a wound bed that is
highly vascularized, with minimal exudate. The three main principles
are debridement, bacterial balance, and exudate control.
There is no optimal debridement method. The pre erred method
is determined by the goals o the patient, the presence or absence
o in ection, the amount o dead tissue present, and cost consider-
ations. There are ve common types o debridement: mechanical,
autolytic, enzymatic, sharp, and biosurgery. Mechanical debride-
ment uses wet-to-dry gauze to adhere to the necrotic tissue, which
is then removed. Removal o the gauze dressing also removes
necrotic tissue and wound debris. The challenge with mechani-
cal debridement is the possibility that healthy granulation tissue
may also be removed along with devitalized tissue, thus delay-
ing wound healing. Autolytic debridement involves semiocclusive,
transparent lm dressings, and occlusive dressings, such as hydro-
colloids and hydrogels, which create a avorable environment or
the body’s enzymes to break down the necrotic tissue. Enzymatic
493
 TABLE 72-1 National Pressure Ulcer Staging System

Pressure Ulcer Stage Definition Description

P
A
Deep tissue injury Purple or maroon localized area o • The area may be preceded by tissue that is pain ul, irm, mushy,
R
discolored intact skin or blood- illed blister boggy, warmer, or cooler, as compared to adjacent tissue
T
due to damage o underlying so t tissue • Deep tissue injury may be di icult to detect in individuals with
I
rom pressure and/or shear dark skin tones
I
I
• The area may rapidly evolve to expose additional layers o tissue,
even with optimal treatment
Stage I Intact skin with nonblanchable redness • The area may be pain ul, irm, so t, warmer, or cooler, as
R
o a localized area, usually over a bony compared to adjacent tissue
e
h
prominence • Stage I may be di icult to detect in individuals with dark skin
a
b
tones
i
l
i
t
Stage II Partial thickness loss o dermis presenting Presents as a shiny or dry shallow ulcer without slough or bruising.
a
t
as a shallow open ulcer with a red, pink This stage should not be used to describe skin tears, tape burns,
i
o
wound bed without slough. May also perineal dermatitis, maceration, or excoriation
n
present as an intact or open/ruptured
a
n
serum- illed blister
d
S
Stage III Full-thickness tissue loss. Subcutaneous • The depth o a Stage III pressure ulcer varies by anatomical
k
i
at may be visible, but bone, tendon, or location. The bridge o the nose, ear, occiput, and malleolus
l
l
e
muscle are not exposed. Slough may be do not have subcutaneous tissue, and Stage III ulcers can be
d
present but does not obscure the depth o shallow. In contrast, areas o signi icant adiposity can develop in
N
tissue loss. May include undermining and extremely deep Stage III pressure ulcers
u
r
s
tunneling • Bone/tendon is not visible or directly palpable
i
n
g
Stage IV Full thickness tissue loss with exposed • The depth o a Stage IVpressure ulcer varies by anatomical
C
bone, tendon, or muscle. Slough or eschar location. The bridge o the nose, ear, occiput, and malleolus do
a
r
may be present on some parts o the not have subcutaneous tissue, and these ulcers can be shallow
e
wound bed. Often includes undermining • Stage IVulcers can extend into muscle and/or supporting
and tunneling structures (eg, ascia, tendon, or joint capsule), making
osteomyelitis likely to occur
• Exposed bone/tendon is visible or directly palpable
Unstageable Full thickness tissue loss in which actual • Until enough slough and/or eschar is removed to expose the
depth o the ulcer is completely obscured base o the wound, the true depth, and there ore stage, cannot
by slough (yellow, tan, gray, green, or be determined. Stable (dry, or adherent, intact without erythema
brown) and/or eschar (tan, brown, or black) or luctuance) eschar on the heels serves as the body’s natural
in the wound bed biological cover and should not be removed

debridement employs proteolytic enzymes, such as papain-urea,
collagenase, and trypsin, to remove necrotic tissue. While enzy-
matic debridement is e ective, it is slower than other types and
o ten costly. Sharp debridement with scalpel or laser is probably
the most rapid and e ective type o debridement, and should be
strongly considered when the patient is suspected o having celluli-
tis or sepsis. Finally, biosurgery (maggot therapy) is another e ective
and relatively quick method o debridement. Maggot therapy is
very speci c or devitalized tissue, although patient and provider
unease have limited its acceptance.
Managing bacterial burden is an important consideration in
wound bed preparation. All pressure ulcers contain a variety o bac-
teria. Bacteria are more likely to impede wound healing when their
concentration exceeds 106 organisms per gram in the ulcer. Certain
bacteria may impair ulcer healing at lower concentrations. Signs o
ulcer in ection include odor, purulent exudate, excessive draining,
bleeding, and pain. I these are present, wound cultures should be
obtained, and treatment with oral or intravenous antibiotics should
be considered based on antimicrobial sensitivity testing. Other
strategies to reduce bacterial bioburden include the use o silver
impregnated dressings and topical sul a silverdiazine.
Exudate management is the last component o wound bed
preparation. Excessive exudate decreases ulcer healing, and may
damage healthy surrounding tissue. Exudates are managed by
selecting an appropriate dressing. Dressings can be classi ed as
gauze, petroleum-based nonadherent gauze, transparent lms,
hydrocolloids, oam islands, alginates, hydrogels, composites, and
combinations (Table 72-2).
Whichever dressing is selected, the pressure ulcer should be kept
moist to optimize healing. Since no studies exist that demonstrate
that one dressing heals all pressure ulcers within an ulcer classi ca-
tion, a care ul assessment o the pressure ulcer, patient needs, and
environmental actors ( requency o dressing changes to increase
adherence) must be considered.
Since wet-to-dry gauze dressings are a orm o debridement, they
should only be used in necrotic wounds. Once healthy granulation
tissue is observed, wet-to-dry dressing should be stopped, and other
dressings should be used. Negative pressure therapy, or vacuum-
assisted closure (VAC) therapy, should also be considered or exu-
dative ulcers. Negative pressure therapy removes excess exudate,
increases local blood ow, and promotes granulation tissue. Nega-
tive pressure therapy should not be used in pressure ulcers with
suspected osteomyelitis, eschar, or exposed blood vessels or viscera.
■ NUTRITION
Many patients with pressure ulcers are malnourished. High-protein
diets in poorly nourished patients with pressure wounds are reason-
able, although there is a paucity o evidence to support their use.

494
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Epide rmis

H
A
P
T
De rmis

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R
7
2
Adipos e
tis s ue

P
r
e
Mus cle

s
s
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Bone

e
A B S ta ge I

U
l
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r
s
C S ta ge Il D S ta ge Ill

E S ta ge IV F S us pe cte d de e p tis s ue injury G Uns ta ge a ble

Figure 72 2 National pressure ulcer staging system. (A) Normal skin. (B) Stage I pressure ulcer. (C) Stage II pressure ulcer. (D) Stage III pressure ulcer.
(E) Stage IVpressure ulcer. (F) Deep tissue injury. (G) Unstageable pressure ulcer. (Reproduced with permission rom the National Pressure Ulcer
Advisory Panel, 2011.)

■ PAIN MANAGEMENT
Pressure ulcers are o ten pain ul, especially Stage IVulcers. Strategies
to reduce pain include the use o dressings that may mitigate pain,
such as those containing so t-silicone, and administering analgesic
prior to dressing changes.
■ MONITORING HEALING
There is considerable debate regarding the use o reverse staging o
pressure ulcers to monitor healing. Staging o pressure ulcers is only
appropriate or de ning the maximum anatomic depth o tissue dam-
age. Since pressure ulcers heal to progressively more shallow depth,
they do not replace lost muscle, subcutaneous at, or dermis be ore they
reepithelialize. Instead, pressure ulcers are lled with granulation (scar)
tissue composed primarily o endothelial cells, broblasts, collagen, and
extra cellular matrix. Thus, a Stage IV pressure ulcer cannot become a
Stage III, Stage II, or subsequently Stage I. When a Stage IVpressure ulcer
has healed, it should be classi ed as a healed Stage IVpressure ulcer, not
a Stage 0. There ore, reverse staging does not accurately characterize
what is physiologically occurring in the pressure ulcer.

495
 TABLE 72-2 Pressure Ulcer Dressing Classification Selection

Moderate Heavy
P
Dressing Classification Partial Thickness (Stages I and II) Full Thickness (Stages III and IV) Drainage Drainage
A
R
Transparent ilms X
T
Hydrocolloids X X (As a secondary dressing) X X
I
I
Alginates X (Stage II only) X X
I
Foams X (Stage II only) X X X
Composites X (Stage II only) X X X
Hydrogels X (Stage II with dry wound bed only) X (Dry wound beds only)
R
e
Hydro ibers X X
h
a
Antirecalcitrant dressings X X X
b
i
l
i
t
a
t
i
o
n
a
n
The Pressure Ulcer Scale or Healing (PUSH) and the Bates-Jensen DISCHARGE CHECKLIST
d
Wound Assessment Tool (BWAT) are both valid and reliable or
S
□ Have the patient and outpatient caregivers been given clear
k
measuring pressure ulcer healing. The PUSH tool requires less time,
i
instructions on wound care, turning, and positioning?
l
l
having only three items, compared to the 13 items o the BWAT tool.
e
□ Do outpatient caregivers have appropriate support sur aces,
d
For both tools, a lower score indicates a greater degree o healing.
N
trans er devices, and wound dressings or the patient?
Both tools are usually used weekly.
u
□ Has the patient’s nutritional status been optimized? Are addi-
r
s
i
tional measures necessary or nutritional support in the outpa-
n
■ ADJUNCTIVE THERAPY
g
tient setting?
C
When the pressure ulcer is not showing signs o healing within 2 to □ Has outpatient ollow-up been arranged with wound clinic, in ec-
a
r
4 weeks, adjunctive therapies should be considered. The most com- tious diseases, and plastic surgery, as appropriate?
e
monly adjunctive therapies include electrical stimulation, hyperbaric
oxygen, growth actors, and autologous skin. Electrical stimulation is
the use o electrical current to stimulate cellular processes important SUGGESTED READINGS
to pressure ulcer healing. These processes include increasing bro-
blasts, neutrophils, and macrophages, collagen and DNA synthesis, Ayello EA, Braden B. How and why to do pressure ulcer risk assess-
and increasing the number o receptor sites or speci c growth ac- ment. Adv Skin Wound Care. 2002;15:125-132.
tors. Electrical stimulation is most e ective in healing Stage III and Bolton LL, van Rijswijk L, Sha er FA. Quality wound care equals
IVpressure ulcers. cost-e ective wound care: a clinical model. Adv Skin Wound Care.
Hyperbaric oxygen is believed to promote wound healing by stim- 1997;10(4):33-38.
ulating broblast, collagen synthesis, epithelialization, and control o
Lyder C, Grady J, Mathur D, et al. Preventing pressure ulcers in Con-
in ection. However, there remains a dearth o studies investigating
necticut hospitals using the plan-do-study-act model or quality
the association o hyperbaric oxygen and healing pressure ulcers.
improvement. Jt Comm J Qual Patient Saf. 2004;30:205-214.
The use o growth actors and skin equivalents in healing o pressure
ulcers is relatively new. The use o cytokine growth actors, such as Lyder CH, Preston J, Grady J, et al. Quality o care or hospitalized
recombinant platelet-derived growth actor-BB (rhPDGF-BB) and Medicare patients at risk or pressure ulcers. Arch Intern Med.
broblast growth actors (bFGF), and skin equivalents are currently 2001;161:1549-1554.
under study. Further research is needed to identi y the appropriate National Institute or Health and Clinical Excellence. The Preven-
ulcer environment or growth actors to be optimally e ective. tion and Management of Pressure Ulcers in Primary and Secondary
Care. London: National Institute or Health and Care Excellence
(UK); 2014. http://www.ncbi.nlm.nih.gov/pubmedhealth/
PRACTICE POINT PMH0068960/pd /PubMedHealth_PMH0068960.pd . Accessed
• All wounds may be pain ul, and they may become more September 12, 2016.
sensitive over time. Light touch or even air movement across National Pressure Ulcer Advisory Panel, European Pressure Ulcer
a pressure ulcer may be exquisitely pain ul or some patients. Advisory Panel and Pan Paci c Pressure Injury Alliance. In: Haesler
Control o background pain and incident pain (pain with E, ed. Prevention and Treatment of Pressure Ulcers: Quick Reference
dressing changes) may require basal pain medication, as well Guide. Perth, Australia:Cambridge Media;2014. http://www.npuap.
as premedication or dressing changes. Nonpharmacologic org/ wp-content/ uploads/ 2014/ 08/ Updated-10-16-14-Quick-
measures that may reduce patient discom ort during dressing Re erence-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pd .
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stress ul, such as noise reduction, engaging amily members Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic
and ancillary personnel in hand holding when appropriate, review. JAMA. 2006;296:974-984.
requent explanation and verbal engagement with the
patient, and limiting wound manipulation and exposure to the
minimum necessary.

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CHAP TER
73 INTRODUCTION
Review o patient sa ety issues and opportunities or quality
improvement in skilled nursing acilities (SNFs) begins with the
index hospitalization and the necessary steps to guarantee a sa e
transition rom the re erring hospital to the receiving acility. The
transition o care rom hospitalization to postacute care presents a
signi cant risk to the sa ety o the older adult patient. Two key areas
that require the clinician’s attention to ensure a sa e transition o
care are e ective discharge communication including the discharge
Patient Safety and summary and the discharge medication reconciliation process. Sa e
and e ective transitions reduce preventable readmissions and other

Quality Improvement adverse events.

in Postacute Care PREVENTABLE READMISSIONS

Mousumi Sircar, MD
Jatin K. Dave, MD
Matthew L. Russell, MD
Helen Chen, MD
Key Clinical Questions
1 Is each medication indicated or either an acute or
chronic medical indication?
2 I the drug does not have an indication or either an
acute or chronic condition, was it prescribed to treat an
adverse e ect o another medication?
3 Is the patient near the end o li e?
4 I you plan to discontinue a medication, does the drug
require tapering rather than abrupt discontinuation?
5 Are all underlying medical problems optimally treated
with drug therapy according to established guidelines?
The costs associated with the current transitions system illustrate
the danger o care transitions and the need or a coordinated e ort
to ensure patient sa ety. Readmissions rom skilled nursing acilities
to the hospital increased by 29% rom 2000 to 2006. Up to 24% o
Medicare bene ciaries were readmitted to the hospital rom a skilled
nursing acility within 30 days at a cost o $4.34 billion in 2006. One-
third o these occurred within just a week o initial discharge.
Older adults are at higher risk or readmission rom skilled nursing
acilities and more requently experience care transitions. Patients
who are rail or cognitively impaired o ten cannot actively par-
ticipate in their transition processes and critical in ormation (such
as prehospital admission medications that were held) may be lost
as a result.
Skilled nursing acilities are increasingly being held accountable
or preventable readmissions. Similar to hospital metrics, Center or
Medicare & Medicaid Services (CMS) is planning to use the 30-day
readmission metric as a quality measure or skilled nursing acilities
that provide postacute care (PAC). It is there ore important or indi-
vidual clinicians to have a clear understanding o the PAC capabili-
ties o their community SNFs. Clinicians and health care systems are
creating pre erred SNF networks based on readmission rate, length
o stay, and other quality measures. Provider groups and hospitals
are increasingly partnering with SNFs in quality improvement ini-
tiatives that help to ensure patient sa ety and reduce unnecessary
utilization and readmissions.
PRETRANSFER CONSIDERATIONS IN THE SELECTION
OF A SKILLED NURSING FACILITY
■ STAFFING
Nurse and medical sta ng ratios can be quite variable across acili-
ties. Re erring clinicians should be mind ul that while the acuity level
o PAC admissions has increased, nurse sta ng ratios continue to
remain ar lower than those o acute care hospitals. Some nursing
homes employ physicians and mid-level sta while others rely on as
needed medical coverage rom attending physicians in practice or
whom “SNF rounding” is an additional responsibility, and who may
not have special expertise in managing postacute care patients.
Many postacute care transitions occur a ter hours or on weekends.
Facilities with decreased a ter-hour sta ng and coverage may not
be ideal receiving acilities or highly medically complex patients. It is
important or re erring clinicians to understand and con rm what is
reasonably available in these acilities to ensure that sa er transitions
can be supported (Table 73-1).

497
 TABLE 73-1 Basic Considerations When Selecting a Skilled TABLE 73-2 Handoff Process
Nursing Facility
Identi y high-risk patients
P
1. How many hours per day/week are physicians and mid-level
A
Complete discharge summary using joint commission
clinicians on-site?
R
requirements
T
2. What is the a ter-hours sta ing and coverage? Ensure sa e medication reconciliation
I
3. What is the acility’s capacity to per orm diagnostic testing?
I
Use step-wise approach (Project RED, Project BOOST) to provide
I
4. Is there an on-site pharmacy or do medications need to be sa e transition or high-risk patients
delivered rom an o -site vendor?
5. What disciplines are available at the acility?
R
Standardizing the hando using evidence-based models such
e
6. What quality data can be obtained rom the acility? Do they
h
have the capacity to respond to clinical quality o care concerns? as RED (Re-Engineered Discharge) and Project BOOST (Better Out-
a
b
7. Are all readmissions to acute care hospitals regularly reviewed comes or Older adults through Sa e Transitions) is shown to reduce
i
l
i
t
using a standardized tool such as INTERACT to identi y root avoidable readmissions (Tables 73-3, 73-4, and 73-5).
a
t
causes rom preventable readmissions?
i
o
■ THE DISCHARGE SUMMARY
n
a
The Joint Commission has recommended guidelines or discharge
n
d
summaries including diagnosis (admission and discharge), key phys-
■ LOGISTICS OF PATIENT TRANSFER
S
k
ical examination ndings, key test results, discharge medications,
i
l
Logistical aspects o patient trans er must be accounted or to
l
ollow-up appointments, patient and amily education provided,
e
d
ensure a sa e transition. I the patient is trans erred very late in the and tasks to be completed. As anticoagulation is a speci c high-risk
N
day or on the weekend, the clinician primarily responsible or the intervention that can lead to adverse outcomes, it is particularly
u
patient may not be available, and there ore an on-call physician may
r
important to clearly communicate to community or PAC clinicians
s
i
n
not receive critical in ormation about the patient. This is particularly the goals or anticoagulation, current and recent INR levels (when
g
true or the high-risk patient who is cognitively impaired or deliri- appropriate), and current anticoagulants in use.
C
ous or whom a simple trans er to another site o care may cause
a
Clear language should be utilized on the summary, and any barri-
r
e
decompensation. Nurse sta ng also decreases at this time, which ers in language or cognition should be elicited such that a translator
may slow the trans er rom the receiving end. Late day trans ers may in the ormer case and a caregiver in the latter may be made avail-
occur near shi t changes that create yet another transition o care or able. In addition, baseline and discharge mental status assessment
the patient as clinicians are changed. To minimize this, the patient should be clearly communicated so that receiving clinicians will be
should be trans erred as early in the day as possible. able to e ectively assess or delirium or other changes in mental sta-
tus. Red f ags in terms o signs and symptoms should be elucidated
■ DIAGNOSTIC TESTING AND OTHER SERVICES such that the patient or clinician will know when rehospitalization
At baseline, postacute care skilled nursing acilities provide skilled may be required. Goals o care discussions should occur to ensure
nursing, rehabilitation therapies, and medical oversight. In some that the level o postacute care that has been chosen is consistent
communities, some SNFs are di erentiating themselves by o ering with the patient’s sel -de ned quality o li e. Should a Physician
advanced services such as in-house diagnostic testing, palliative Order or Li e-Sustaining Treatment orm be available in the state,
care services, or specialty cardiac, pulmonary, or other condition it should be utilized and transmitted to the PAC clinician to clari y
speci c medical care, as well as the ability to manage intravenous resuscitation measures or the patient across all settings.
medications and other in usions.
MEDICATIONS
THE DISCHARGE PROCESS ■ MEDICATION RECONCILIATION FAILURES
Inconsistencies with medications and ollow-up care result in The Joint Commission US Pharmacopeia Medmarx reporting pro-
adverse health outcomes. Barriers to sa e transitions include lack o gram or medication reconciliation ailures noted 2022 medication
standardization o the discharge process across institutions (o ten
hindered by lack o nancial incentive and ragmentation o com-
munication). In addition, electronic medical records requently TABLE 73-3 Re-engineered Discharge
cause data overload with multiple medication lists on admission
and discharge. Transitions o care contribute to this problem 1. Identi y language barriers
through di erences in medication lists that are not requently 2. Make ollow-up appointments
explained in documentation. 3. Plan or ollow-up o inpatient tests
4. Arrange outpatient services and equipment (eg, home
■ MULTIDISCIPLINARY TEAMS oxygen)
Daily interdisciplinary rounds at the hospital with care ul planning 5. Medication reconciliation with patient
o discharge with timely discharge summary and insurance autho- 6. Compare treatment plan with national guidelines
rization as well as warm hando i necessary can minimize errors
7. Teach patient using a written treatment plan
and last minute trans er issues. Interdisciplinary teamwork between
social work, physicians, and nursing may accelerate the discharge to 8. Educate patient regarding diagnosis and medications
earlier in the day. 9. Educate patient about what to do i a problem arises
10. Assess patient’s understanding o plan
■ INTENSITY OF HANDOFF 11. Send discharge summary to receiving physician
Clinicians should pursue a more thorough hando based on risks. 12. Provide telephone support or patient
(Table 73-2).

498
TABLE 73-4 Start-to-Finish Guidelines for the Discharge Process That Have Been Published

C
H
Project BOOST 1. Identi ies patients at high risk o rehospitalization

A
(Better Outcomes or 2. Targets speci ic interventions to mitigate potential adverse events

P
Older adults through Sa e

T
Transitions) 3. Improves low o in ormation between hospital and outpatient physicians and clinicians

E
4. Improves communication between clinicians and patients

R
CHAMP (Collaboration or Originally developed or home care o the geriatric patient, the CHAMP website now eatures a Care

7
Homecare Advances in Transitions toolkit with

3
Management and Practice) 1. Validated tools to identi y patients at risk or an unsa e transition
2. Intervention tools or patient sa ety

P
a
t
3. Tools or patients and caregivers

i
e
n
4. Tools to improve communication between clinician, patient, and caregivers

t
S
Community-Based Care In 2011, the Center or Medicare &Medicaid Services (CMS) began unding or acute-care hospitals

a
Transition Program (CCTP) with high readmission rates which partner with community-based organizations providing transition

e
t
services to improve patient’s transition rom the acute to long-term settings. Application requirements

y
or the Community-based Care Transition Program (CCTP) are described in detail on the CMS webpage

a
n
d
Q
u
a
l
i
t
reconciliation errors, 66% occurring during change in level o care, 4. Make clinical decisions based on the comparison and adjust

y
I
22% during admission to acility, and 12% discharge. Improper dose/ medications.

m
quantity or omission o medications represented the majority o ail- 5. Communicate the new list to the patient and caregivers.

p
r
o
ures. In response, the Joint Commission in 2004 designated medica- The current list, including immunization and allergies, should

v
tion reconciliation as national patient sa ety goal, and in 2005, began

e
be shared with patients, nursing, and pharmacy. The reconciliation

m
requiring accredited organizations to develop and test a designated is required at all inter aces o care and patient should be guided

e
n
process or medication reconciliation. Despite these e orts, a 2012 in creating a personal/portable medication list with stop dates

t
article cited that medication discrepancies occur in up to 70% o

i
i appropriate. Prior to transition, it is essential to ensure that the

n
patients at admission or discharge, and one-third o these have

P
acility, home care clinician or caregiver/patient is able to admin-

o
potential to harm the patient. Actual adverse drug events occur in ister the planned medication in the new care setting. Orders such

s
t
up to 12% to 17% o patients postdischarge.

a
as IV diuretics may be essential in preventing rehospitalization but

c
In 2006, Joint Commission advised the ollowing as a process

u
require sta /caregiver education and may not be available at all

t
e
or medication reconciliation, which was de ned as the process o sites o care.

C
comparing current medication orders to all medications the patient Improving transitions requires understanding common barriers to

a
r
has been taking. This is expected to occur during any transition in

setting, service, practitioner, or level o care. The requirement is rep-
resented by a ve-step process.
1. Develop the current list by ensuring preadmission list is correct.
2. Develop updated list.
3. Compare the two lists.
TABLE 73-5 The Transition of Care from Hospital to Skilled
Nursing Facility
Safe Transition
• Education o patient and
amily
• Coordination among
health care pro essionals
with timely exchange o
in ormation about complex
care needs with a warm
hando or high-risk
transitions
• Goals o care/clinical status
• Logistical arrangements
Unsafe Transition
Complex, chronic conditions
requiring multiple clinicians
Absence o in ormation
speci ying names o
consultants, contact
in ormation, ollow-up plans
Each clinician works alone
lacking knowledge o :
- Problems addressed
- Services provided
- In ormation obtained
- Medicines prescribed
(discrepancies may result)
e
a sa e reconciliation process and developing strategies to overcome
them. Common barriers include:
• Cumbersome or di cult process o trans erring or harmonizing
in ormation within the permanent medications record
• Lack o clinician reimbursement or completing the medication
reconciliation
• Failure to assign responsibility or signing o on the reconcilia-
tion tool to one clinician
• Failure to assign responsibility to complete list and pass docu-
ment rom one clinician on to the next clinician
• Di cult process o trans erring in ormation rom the medica-
tion reconciliation tool at the clinician’s level to the patient’s
personal medication list
The reimbursement and implementation o Transitional Care
Management Visits o ers an opportunity to improve medication
reconciliation a ter discharge.
■ PHARMACOKINETIC CHANGES WITH AGING
Pharmacokinetic changes with aging, which o ten increases hal -li e
o many drugs (Table 73-6). Five classes o medications in which
discrepancies can be particularly hazardous and common include
anticoagulants, diuretics, ACE inhibitors, lipid-lowering agents, and
proton-pump inhibitors.
■ POLYPHARMACY AND UNNECESSARY DRUGS
Few studies have measured the prevalence o unnecessary drug
use in the elderly population and only one study has evaluated the
prevalence o unnecessary drug use speci cally in the inpatient
setting. That study reported in a population o 384 rail hospitalized

499
 be discontinued. Down-titration is necessary prior to ull dis-
TABLE 73-6 Pharmacokinetic Changes Leading to Adverse continuation or β-blockers, opiates, sedatives, gabapentin,
Effects clonidine, and selective serotonin reuptake inhibitors. I a
P
Body System Changes Associated with Aging medication cannot be stopped, the dose should be lowered
A
when possible.
R
Liver ↓ First-pass metabolism
2. Medications should be eliminated when not consistent with
T
Kidney ↓ Renal clearance o drugs the patient’s goals o care. Discontinuing some medications
I
I
• Serum creatinine unreliable is appropriate i the patient is expected to pursue a palliative
I
• Cockcro t-Gault ormula required or approach, or i estimated li e expectancy is likely too limited to
reliable prediction o renal unction obtain bene t rom a medication (such as a statin in the case
Fat ↑ Distribution o lipophilic drugs due to ↑ at o quickly progressive terminal cancer).
R
3. Medications that may pose higher risk or adverse e ects in
e
Total body water ↓ Distribution o water-soluble drugs due to
h
older adults according to the “Beers” list should be reassessed,
a
(TBW) ↓ TBW
b
including sedative hypnotics, antidepressants, anticoagulants/
i
l
i
t
antiplatelet agents, hypoglycemic agents, opiates, and anti-
a
t
cholinergic medications. There are o ten sa er alternatives or
i
o
veterans aged 65 and older, 44% o patients had at least one unnec-
n
many o these drugs that should be chosen. One algorithm or
a
essary drug at time o discharge rom the hospital. The reasons or a reducing polypharmacy is illustrated below in Table 73-7A,
n
d
medication to be classi ed as unnecessary included lack o indica- through stepwise evaluation o the patient’s current medica-
S
tion (33%), lack o e cacy (19%), and therapeutic duplication (8%). tion risk and utility.
k
i
l
This study also noted that approximately 75% o those receiving an
l
Another use ul method, STRIP (Structured Tool to Reduce Inap-
e
d
unnecessary drug were prescribed that medication prior to admis- propriate Prescribing) is a more concise, ve-step process with a
N
sion while the remaining 25% had an unnecessary drug started yearly review: obtain a drug history, per orm an analysis o drugs,
u
during hospitalization.
r
develop a treatment plan, review patient pre erences, and provide
s
i
n
ollow-up and monitoring (Table 73-7B).
g
PRACTICE POINT
C
a
r
On admission, throughout hospitalization, and with any transition
e
o care: TABLE 73-7A Reducing Polypharmacy: Evaluation and
• Determine whether drug side e ects are responsible or any Management*
new symptoms or exacerbating underlying medical conditions.
Evaluation Corresponding Management
• Establish clear and practical therapeutic goals and monitoring
1. Ensure medication list is
plans.
correct
• Review periodically medications and per orm drug
2. Ascertain risk o adverse drug I 3 criterion met, reduce
reconciliation with each transition, including screen or reaction medication list to 5 or less
adverse drug reactions, therapeutic ailures, and adverse drug medications
- ≥8 Medications
withdrawal events.
• Taper or discontinue ine ective or redundant or possibly - Age >75
harm ul medications. - High-risk medications
• Minimize adverse e ects by screening or drug-drug and 3. Prognosticate li e expectancy
drug-disease interactions be ore prescribing a medication to a 4. De ines goals o care I li e expectancy <2 y,
patient. preserve unction and
• Develop expertise in prescribing a ew select drugs—the quality o li e instead o
medication’s dosing, therapeutic and adverse e ects—to using medication to
manage common problems in the elderly. prolong li e
• When in doubt, consult with a pharmacist. 5. Con irm indications or all Discontinue drugs that are
drugs ine ective or or which
• In older patients, i starting a new medication, start low and
diagnosis no longer exists
gradually titrate when possible.
6. Con irm need or Discontinue drugs that will
preventative medications not have bene it during
limited li espan
Inappropriate polypharmacy is a particular danger that needs
to be addressed both during hospitalization and during PAC. Hal 7. Determine bene it vs harm Discontinue drugs where
o the geriatric population is using more than ve medications. O using a tool (www.mdcalc. harm exceeds bene it
com)
these patients, 1 in 20 experiences an increase in morbidity and
mortality. Not only does the patient su er the adverse e ects o the 8. Rank drugs rom high to low Remove low utility drugs
utility
medication itsel , but they also experience interactions between
medications and incur additional cost. There ore, prior to discharge, 9. Obtain patient consent or
care ul review and relevant de-prescribing should be done to the discontinuing the above
drugs
bene t o patients. Step to reduce polypharmacy include:
10. Implement discontinuation
1. Identi y potentially inappropriate medications (PIM) or the or deprescribing plan
older adult using tools such as STOPP (Screening Tool o (eg, tapering)
Older Persons’ Potentially Inappropriate Medications) with
the reasons or stopping each medication. Medications or *Adapted rom Appropriate Prescribing and Important Drug Interactions in
which there is little evidence or bene cial e ect should also Older Adults.

500
 Long-Term Care Medicine ( ormerly AMDA) has de ned the ollow-
TABLE 73-7B Stepwise Approach for Safe Prescribing ing critical SNF quality measures.

C
H
1. Develop the current list (ensure preadmission list is correct) • Timely removal o Foley catheters.

A
• Identi y high-risk drugs based upon the tables above • Pressure ulcer prevention.

P
• E ective pain management.

T
A. Class o drug
• Timely response to delirium.

E
B. Pharmacokinetic changes

R
• E ective management o depression may also be relevant to
• Identi y drugs currently unnecessary/causing side e ects preventing adverse outcomes.

7
3
2. Develop updated list with the plan or deprescribing PIMs Education o nursing sta including greater requency o interdis-
3. Compare the two lists ciplinary meetings (weekly vs biweekly) may be help ul, as well as

P
4. Make clinical decisions based on the comparison timely and e ective discharge planning that includes communica-

a
t
tion with home care agencies and amily or other caregivers.

i
• Adjust medications based upon table above or

e
The INTERACT (Intervention to Reduce Acute Care Trans ers) is a

n
polypharmacy

t
use ul tool or quality improvement to prevent avoidable hospital-

S
5. Communicate the new list to the patient and caregivers

a
ization. INTERACT consists o the ollowing:

e
t
1. Designating a team with leadership support that will be

y
a
responsible or quality improvement

n
d
2. Early identi cation o changes in condition

Q
PREVENTING READMISSION 3. Managing changes in condition early to prevent hospitalization

u
4. Increased utilization o advanced care planning, hospice, and

a
A ourth o Medicare bene ciaries discharged rom hospitals to

l
i
palliative care

t
SNF are readmitted in 30 days. Reducing preventable readmissions

y
5. Improved communication between SNF, hospital, and amily

I
require risk strati cation and care ul strategies or patients who are

m
p
at higher risk or readmissions.

r
■ THE CONTINUING NEED FOR QUALITY IMPROVEMENT

o
v
■ RISK STRATIFICATION TO PREVENT READMISSION IN THE DISCHARGE PROCESS

e
m
Discharge diagnoses with high risk o readmission include heart Despite the recommendations above, every health care system

e
n
ailure, chronic obstructive pulmonary disease, renal ailure, urinary needs to reassess their own barriers to a sa e and e ective transi-

t
tion and then design interventions to account or these barriers as

i
tract in ections, and pneumonia. The immediate common cause o

n
a continual process. The work o Eric Coleman illustrates three types

P
readmission is o ten delirium, polypharmacy, pressure ulcers, decon-

o
ditioning, and iatrogenic illnesses. o barriers: patient, clinician, and system.

s
t
a
c
Patient education: discharge planning checklist/personal

u
Critical quality measures of care during hospitalization and

t
e
SNF placement which predispose to readmissions health

C
Patient level barriers are lack o health literacy and sel -e cacy. As

a
There are also practical measures that can be taken while the patient

is hospitalized to reduce the risk o readmission back to the hospital.
Some o these measures have been detailed by the American Medi-
cal Directors Association (now called the Society or Post-Acute and
Long-Term Care Medicine).
Hospitalized patients should be mobilized rom bed as soon
as possible. Bedrest increases disability and delays rehabilitation.
Lack o ambulation also increases risk or pressure ulcers, comor-
bid in ections, and depression. The lack o rehabilitation then
eeds orward to unctional decline, which can increase the risk o
rehospitalization.
Foley catheters without a speci c medical indication should be
discontinued as soon as possible to minimize the risk o catheter-
related urinary tract in ections that can occur upon receipt o the
patient at the SNF. This increases the risk o delirium.
Patients may incur additional costs rom transportation or
diagnostic studies that are not available at the SNF. This should be
taken into consideration be ore de erring inpatient studies to the
outpatient setting. It is best practice to complete the diagnostic
workup in the hospital to ensure that there is a clear, well-de ned
plan prior to a trans er to a SNF. Other actors o inpatient care
that can subsequently a ect outcome o care at the SNF and
readmission are untreated pain and depression that can likely
be identi ed prior to trans er with the assistance o the patient’s
bedside care team.
SNF Quality measures that impact readmission rates
The quality o care at the SNF may also a ect readmissions. Qual-
ity SNF care begins with excellent communication between both
nursing and medical clinicians. The Society or Post-Acute and
r
e
mentioned above, patients may not be aware, able to understand
or able to communicate their medical history or their medication
list. Patients also are aced with new diagnoses while hospitalized
requiring new medications, sel -care, and monitoring o symptoms.
Clinician communication
Clinician level barriers are primarily in communication ailures.
Discharge summaries o ten do not arrive in a timely manner or ail
to include key in ormation including ollow-up appointments and
pending results. Phone call and e-mail communication between
transitioning clinicians are in requent. Clinicians o ten do not have
a working knowledge o what can be done in the postacute care
setting. This can include things such as requency o vitals, sta ng
levels, and availability o timely diagnostics (x-rays, labs).
System level
Privacy measures limit sharing o clinician contact in ormation. Di -
ering ormularies between institutions have led to multiple drug
substitutions. Quality improvement projects can rst identi y and
then target sa ety ailures at each o these levels in order to ensure
patient sa ety (Table 73-8).
SNF level opportunities for quality improvement
Because health plans and other payers, including ACOs, are seek-
ing ways to reduce readmissions, some nursing homes, particularly
those with a substantial postacute patient population, are devel-
oping innovative strategies to better partner with their re erring
network hospitals. Some, such as the Community-based Care Transi-
tions program, are highlighted above. In addition, because o health

501
 patients with serious and li e-limiting illnesses in PAC settings
TABLE 73-8 Best Practices for Continuous Quality bene t rom palliative care. In addition to addressing symp-
Improvement to Improve Patient Safety tomatic issues, palliative care teams can provide the needed
P
• IDENTIFYcompromises in patient sa ety education and support as well as assist amilies and patients
A
in clari cation o their goals o care. This can also prevent
R
• Standardize medication reconciliation process
unnecessary or burdensome hospitalizations, particularly or
T
• Identi y barriers in medication reconciliation conditions that are likely to worsen over time such as conges-
I
I
• Standardize discharge process tive heart ailure.
I
• Identi y patients at high risk or readmission 4. Participation in waiver programs: Historically, ee or service
• Increase hando intensity Medicare bene ciaries have been required to have a quali ying
3-day hospital admission in order to receive Medicare cover-
• Identi y patient, provider, and system barriers
R
age or postacute SNF care. With the rise o observation stays,
e
h
• INITIATE continuing quality improvement projects based on
many patients and their amilies have learned that they did not
a
sa ety ailures identi ied using multiple interventions such
b
meet the criteria or a Medicare-covered SNF stay even though
i
as The Joint Commission recommendations, Project RED, or
l
i
t
they assumed that they had o cially been admitted. In 2014,
a
Project BOOST
t
CMS approved a 3-day SNF waiver program or bene ciaries
i
o
n
attributed to a Pioneer ACO. These bene ciaries could be
a
directly admitted to SNF rom observation, ER or even rom the
n
d
physician’s o ce or other sites o care. Each ACO has speci c
S
care re orm and the rapidly changing reimbursement environment, criteria or approving SNF participation in the 3-day waiver pro-
k
i
many SNF-level quality improvement initiatives are being driven by
l
gram. These criteria generally include quality o care metrics
l
e
health plans, health systems, and newer payment models. A ew
d
such as sta ng, readmission rates, and average length o stay
models are highlighted below.
N
as well as the availability o physicians and other clinicians a ter
u
1. Bundled payment models: In 2013, expanded participation hours. SNFs participating in the 3-day waiver program have
r
s
i
n
in the Bundled Payments or Care Improvement to include been required to track and report their per ormance on qual-
g
postacute care settings. As o 2015, there are 678 participants ity metrics. It is too soon to deem the 3-day waiver program
C
in BPCI Model 2 in which the postacute care clinician is held a success. However, in eastern Massachusetts, where there
a
r
e
responsible or costs incurred within 30, 60, or 90 days o are 5 Pioneer ACOs, the 3-day waiver program has resulted in
discharge or episodes o care related to speci c conditions some improvements in average length o stay as well as acute
such as congestive heart ailure or joint replacement. As a care utilization rates.
result, participating acute and PAC clinicians are developing 5. Improvement o post-SNF discharge communication: Dis-
the in rastructure to communicate e ectively beyond the charge rom SNF to home or other care settings represents
initial discharge period with skilled home care clinicians as another transition o care that can be a risk to patient sa ety.
well as patients and their amilies to ensure that the patients’ Similar to hospital discharge, SNF clinicians need to ensure
needs are being appropriately met and so that readmissions that there is complete and clear communication with the
can be prevented. It remains to be seen whether the BPCI primary care physician or practitioner who will be caring
models will result in signi cant and sustainable savings, how- or the patient in the community. The SNF clinician has
ever, on ace, they are requiring a greater level o account- the added responsibility o communicating any remaining
ability and attention to transitional care improvement on the issues that were identi ed as needing “primary care ollow-
part o PAC clinicians. (https://innovation.cms.gov/initiatives/ up” during the acute care stay. Speci c in ormation that is
BPCI-Model-2/) important to include in SNF discharge communications are
2. Direct partnerships with Accountable Care Organizations listed in the practice point box on discharge in ormation.
(ACOs): Understanding that many ACOs have a vested inter- Increasingly, SNFs are employing templates and checklists to
est in managing total medical expenditure (TME) including ensure that this in ormation is being accurately documented
costs incurred during stays in PAC acilities, some Pioneer and are also requiring that appropriate ollow-up appoint-
ACOs have elected to directly manage the care o their ment scheduling occurs prior to SNF discharge. For some
attributed members while in PAC settings by deploying ACO ACOs, particularly those who are participating in the CMS
clinicians to provide primary care in those settings. It is di - SNF 3-day waiver program, postdischarge communication,
cult to obtain published data regarding these interventions; hando s, and timely post-PAC ollow-up are being moni-
however, anecdotal data rom a Massachusetts ACO would tored as quality metrics.
support that the ACO physicians can reduce both average
length o stay and readmission rates in their PAC patients.
Additionally, patients have reported increased satis action PRACTICE POINT
with communication between the ACO PAC physician/mid-
levels and their primary care physicians because they are part Discharge information from rehabilitation
o the same health system and share the same electronic • Detailed instructions or speci c/high-risk drugs in addition to
health record. The use o ACO-medical sta in PAC settings an updated, reconciled discharge medication list:
is likely most success ul in those PAC settings without an 1. Anticoagulation
employed medical sta model. War arin: start date, recent dosage changes, target INR,
3. Provision o palliative care within PAC settings: Patients tran- duration o treatment, date o next scheduled INR, responsible
sitioned to PAC settings o ten have serious and li e-limiting clinic or physician or monitoring.
illnesses such as stroke or congestive heart ailure. They Low-molecular-weight heparin: duration o treatment, time o
may or may not be able to actively participate in rehabilita- next scheduled dose, any insurance issues, as patients may not
tion and some may ail to improve substantially. There is an be able to a ord medication a ter discharge rom rehabilitation.
increasing body o literature that as in other care settings,

502
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Duration o treatment: Indications or an extended course o American Medical Directors Association. American Medical Direc-

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antibiotics and identi cation o who should be consulted in

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tors Association Policy Resolution H 10. 2010. Accessed at https://
case problems arise, and monitor therapy i continued post

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www.nhqualitycampaign.org/ iles/ Transition_o _Care_Re er-
rehabilitation. I patient is to be discharged on extended IV

T
ence.pd .

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antibiotics, type and placement o line should be documented.

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3. Narcotic/benzodiazepine dosing American Medical Directors Association. Nursing Home Quality
Improvement Initiative. Accessed at http://www.amda.com/

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Indication, therapeutic endpoint, recent changes, and reason.

3
consumers/initiative.c m.
4. Insulin therapy
Indicate exact doses, whether additional control was required Berkowitz RE, Fang Z, Hel and BK, Jones RN, Schreiber R, Paasche-

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by a sliding scale, and include amount o additional insulin in Orlow MK. Project ReEngineered Discharge (RED) lowers hospital

a
t
readmissions o patients discharged rom a skilled nursing acility.

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prior 24 hours as well as whether there were any issues relating

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n
to hypoglycemia. J Am Med Dir Assoc. 2013;14(10):736-740.

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S
• Nutrition Butter eld S, Stegel C, Glock S, Tartaglia D. Understanding Care Tran-

a
e
1. I discharged with tube eedings, discussion o who will sitions as a Patient Sa ety Issue. Patient Sa ety &Quality Healthcare.

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y
administer and manage eedings. Special equipment and New York, Medicare Quality Improvement Organization, 2011.

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supplement supplies should be available at the patient’s home

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Flint L. Transitions and Continuity o Care. In: Williams BA, et al, eds.

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or other site o care at the time o discharge. Current Diagnosis and Treatment Geriatrics, 2nd ed. New York, NY:

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2. Speci y goals o therapy and who will ollow-up i problems

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McGraw Hill; 2014:75-78.

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arise.

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i
Florida Atlantic University. Interventions to Reduce Acute Care

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• Supplemental oxygen

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Trans ers. (2011). Accessed at https://interact2.net/.

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m
1. Document O2 saturation and requirement o O2 to maintain O2

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saturation above 88%. Gnjidic D, Kouladjian L, Hilmer S. Deprescribing trials: methods to

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o
2. Ensure that O2 delivery systems and transport O2 are available reduce polypharmacy and the impact on prescribing and clinical

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e
at the time o discharge. outcomes. Clin Geriatr Med. 2012;28:237-253.

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• Wound care

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Greenwald JL, Denham CR, Jack BW. The Hospital Discharge:

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A Review o a High Risk Care Transitions With Highlights o

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1. Documentation o speci c wound care instructions.

i
n
2. I complex dressing/supplies are used that require special a Re-engineered Discharge Process. J Patient Sa . 2007;3(2):

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orders, this should be addressed prior to discharge. 97-106.

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s
t
Monitoring: particularly important i patients are being Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary drug use

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discharged to skilled home care or acility based in rail older people at hospital discharge. J Am Geriatr Soc.

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long-term care. 2005;53:1518-1523.

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1. Document monitoring, i required, or speci c drugs or Harris-Kojetin L, Sengupta M, Park-Lee E, Valverde R. Long-term care

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interventions. services in the United States: 2013 overview. National Center or

2. Document discharge weight, especially i there will be need or
ongoing diuresis.
• Summary in ormation
1. Very brie description o reason or index rehabilitation
admission, course, complications, how the patient is at time
o discharge (cognitive, cardiopulmonary, and unctional
status).
2. Identi y consultants by name and who to contact i a problem
arises.
3. Brie summary o relevant and abnormal test results and
identi cation o person responsible or ollow-up o abnormal
or pending test ndings and unresolved issues as well as
ollow-up appointments with consultants and primary care
physician.
4. Family spokesperson with numbers, code status, health care
proxy.
Goals or continued rehabilitation (i needed) and contingency
planning i patient does not respond to treatment.
CONCLUSION
The process o discharge rom the hospital to a postacute acil-
ity is raught with danger or the patient and can predispose to
readmission. By standardizing sa ety into medication reconcilia-
tions and discharge summaries between acilities, adverse events
to the patient may be prevented, thereby optimizing quality o
patient care.
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Health Statistics. Vital Health Stat. 3. 2013;(37):1-107.
The Joint Commission. Sentinel Event Alert. 2006. Accessed at http://
www.jointcommission.org/assets/1/18/sea_35.pd .
Meulendijk MC, Spruit MR, Drenth-van Maanen AC, et al. Computer-
ized Decision Support Improves Medication Review E ectiveness:
An Experiment Evaluating the STRIP Assistant’s Usability. Drugs
Aging. 2015;32(6):495-503.
Mor V, Intrator O, Feng Z, Grabowski DC. The revolving door o
rehospitalization rom skilled nursing acilities. Health Af (Millwood).
2010;29:157-164.
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based
medication reconciliation practices: a systematic review. Arch
Intern Med. 2012;172(14):1057-1069.
National Transitions o Care Coalition. National Transitions o Care
Coalition. 2016. Accessed at http://www.ntocc.org/WhoWeServe/
HealthCarePro essionals.aspx. Accessed January 27, 2016.
Oakes SL, Gillespie SM, Ye Y, et al. Transitional care o the long-term
care patient. Clin Geriatr Med. 2011;27:259-273.
Ouslander JG, Diaz S, Hain D, Tappen R. Frequency and diagnoses
associated with 7- and 30-day readmission o skilled nursing acil-
ity patients to a nonteaching community hospital. J Am Med Dir
Assoc. 2011;12(3):195-203.
Smith CM. Practice Brie . Documentation requirements or the acute
care inpatient record. American Health In ormation Management
Association. J AHIMA. 2001;72(3):56A-56G.

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 Society o Hospital Medicine. Project BOOST Mentored Implementa- Project BOOST Toolkit http://www.hospitalmedicine.org/Web/Qual-
tion Program. 2015. Accessed at http://www.hospitalmedicine. ity_Innovation/Implementa tion_Toolkits/Project_BOOST/Web/
org/boost/. Quality___Innovation/Implementation_Toolkit/Boost/Overview.
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Wallace J, Paauw DS. Appropriate prescribing and important drug aspx. Accessed January 27, 2016.
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interactions in older adults. Med Clin N Am. 2015;99:295-310.
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Project RED website http://www.ahrq.gov/pro essionals/systems/hos-
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pital/red/index.html. Accessed January 27, 2016.
I
ONLINE RESOURCES
I
I
Champ transitions o care toolkit http://www.champ-program.org/
page/100/geriatric-care-transitions-toolkit. Accessed January 27,
R
2016.
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h
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 74
CHAP TER INTRODUCTION
Hospice is a concept o care delivered by an interdisciplinary team
that ocuses on providing best supportive care to terminally ill
patients and their amilies with the goal o maintaining the patient’s
com ort and quality o li e. Hospitalists, caring or patients with
chronic, progressive illness, many o whom are nearing the end o
li e, are uniquely positioned to improve the quality o care that these
vulnerable patients receive and to more closely align their care with
patient pre erences. Hospitalization represents an opportunity to
Hospice reassess patients’ prognoses, their understanding o their illnesses
and how available treatment options align with their care pre er-
ences. Hospice o ers high-value end-o -li e care and minimizes
unwanted interventions and care transitions.
Julia M. Gallagher, MD In the United States, “hospice” is an insurance bene t as well as
a concept o care. More than 85% o patients enrolled in hospice in
2014 were covered under Medicare Hospice Bene t (MHB). Most
commercial insurers, state Medicaid programs and other govern-
ment insurance programs have eligibility requirements similar to
those or Medicare. This chapter will review the hospice bene t and
strategies to overcome common barriers to the timely transition o
appropriate patients to hospice care.

VALUE BASED CARE

Out o 2.6 million total deaths annually in the United States, one in
ve occurs in the hospital setting. Many o those patients who died
had multiple advanced chronic illnesses, su ered rom progressive
railty and had a series o hospitalizations prior to their deaths.
Many had a likely prognosis o less than 6 months during at least
one o the hospitalizations preceding the terminal hospitalization.
As payment re orm shi ts rom an episodic, ee- or-service model
to a longitudinal, shared risk model, an acute care hospitalization
is no longer viewed as an isolated event along the patient’s trajec-
tory o illness. Hospitalists play an increasingly important role in
this longitudinal model o care as each hospitalization represents
an opportunity to reassess a patient’s prognosis, his or her under-
standing o their illness and how goals o care may have changed
in the ace o disease progression. Hospitalists should consider
re erral or palliative care or those patients who require assistance
with complex symptom management and advance care planning
(Figure 74-1). For those patients without complex symptom
management or advance care planning needs and who have a
likely prognosis o less than 6 months and com ort as the primary
goal, the hospitalist can manage the transition to best supportive
care with hospice. The transition to hospice care may, at times,
present a unique set o challenges rom provider, patient and
hospice standpoint.

STRATEGIES TO OVERCOME UNDERUSE OF HOSPICE

While the number o patients served by hospice has steadily risen
over the years and the percent o patients who die while enrolled
in the Medicare hospice bene t has increased, recent studies have
raised concerns that hospice enrollment in and o itsel is an incom-
plete marker o higher-quality end-o -li e care. Many patients
continue to experience multiple care transitions in the days to
months be ore death including ICU admissions. The percentage o
patients enrolled in hospice or 3 days or ewer has also increased
and many o these patients are hospitalized just prior to enrolling
in hospice.

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 Chronica lly, progre s s ive ly ill Te rmina lly ill a nd dying
P
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Dis e a s e ta rge te d the ra py: cura tive
T
a nd modifica tion of dis e a s e progre s s ion
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s
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Hos pita lize d Hos pita lize d Hos pita lize d
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a
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Pa llia tive ta rge te d the ra py: ma na ge me nt
i
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of symptoms, dis cus s ions re : ca re pre fe re nce s
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Months to ye a rs 6–12 mo Be re ave me nt
t
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o
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Hos pita l-ba s e d pa llia tive ca re cons ult s e rvice
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Pa llia tive ca re outpa tie nt clinic:
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Home -ba s e d pa llia tive ca re
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Figure 74 1 Access to palliative care and hospice along the trajectory o disease.
a
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e
Timely transition to hospice requires an understanding o a
patient’s goals and values and how available treatment options
based on a patient’s prognosis align with those patient pre erences. TABLE 74-1 Steps to Hospice Enrollment
The patient and amily meeting is a critical intervention during
which the hospitalist gains an understanding o a patient’s goals Eligibility Medicare Bene it To be eligible to elect
Policy Manuel hospice care under
and values and then discusses his or her recommendations or treat-
Medicare, an individual
ment, including hospice when appropriate, based on those goals must be entitled to
and values. Public policy e orts to increase awareness o the impor- Part A o Medicare and
tance o advance care planning and medical school and residency be certi ied as being
educational programs to improve communication skills have likely terminally ill with a
led to improvements in these end-o -li e care discussions over the projected li e expectancy
last decade (Table 74-1). (<6 months)
However, despite improved end-o -li e communication there are Terminal Local coverage While these guidelines
still multiple barriers and delays to appropriate and timely transitions status determinations are roughly similar,
to hospice including: discontinuities o care (replacement o primary guidelines (LCDs) as de ined by di erent MACs have
specialist and/or primary care physician with multiple rotating Medicare and the developed slightly
hospitalists), requent hospitalizations with transitions to other set- applicable MAC* di erent LCD de initions
tings be ore these conversations take place, societal myths about o terminal status
hospice (especially or certain cultures) a lack o consensus among Certi ication Hospice Medical In addition to the LCD
clinicians regarding prognosis as well as the appropriate timing o o terminal Director and the guidelines, the hospice
status Attending o Record** medical director uses his
the hospice re erral and insurance coverage that may involve nan-
at enrollment; the or her clinical judgment
cial disincentives to enrolling in the hospice insurance bene t. In Hospice Medical to consider the terminal
addition, hospice providers’ serving the same geographic area may Director at each diagnosis, related
have di erent enrollment policies, inconsistency in capability to han- certi ication period conditions, the patient’s
dle advanced symptoms and variable availability o acilities such as therea ter likely clinical course
hospice residences. Table 74-2 reviews steps to hospice enrollment.
*LCDs are decisions by Medicare and their administrative contractors
■ PROGNOSTICATION (MACs) that provide coverage in ormation and determine whether services
are reasonable and necessary. MACs are private organizations that carry
Given the increasing attention to end-o -li e care, many people,
out the administrative responsibilities o Medicare (Parts A and B); di erent
rom health care administrators to health care researchers to MACs serve di erent geographic areas.
patients and their amilies, are asking “What i a patient dies without **The Attending o Record (AOR) is the physician whom the patient choos-
the support and management o a hospice team?” rather than “What es to manage their care while on hospice; patients o ten chose the physi-
i the doctor is wrong and the patient doesn’t die within 6 months?” cian who has been most involved with their care and the management o
Re raming the question in this way allows everyone involved in the their terminal illness.

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TABLE 74-2 Levels of Care under the Medicare Hospice Benefit
Routine Home Care Continuous Home Care
Approximate $150/d $900/d
daily rate paid
to the hospice
agency
Site o care Home, skilled nursing acility, assisted Home
living, rest home, hospice residence
Services Routine nursing visits required Increased hospice team participation
provided under approximately twice a week; required during a period o crisis to
the designated participation o social worker, chaplain, support the patient and amily at
level o care home health aides, volunteers and home: 8 h o support in a 24-h period,
therapists visits determined by the 4 h o which must be skilled nursing
care plan; medical director dictated by or ongoing pain and symptom
clinical condition management
care o the patient to consider the bene ts orgone by the patient
who dies without hospice care and helps to mitigate some o the
internal biases regarding prognostication and the transition to
hospice. Most patients and their amilies report high satis action
with hospice care once they transition to their hospice insurance
bene t. Furthermore, there is no penalty i a patient is re erred to
hospice and does not die within the current eligibility requirement
o an expected prognosis o less than 6 months i the disease runs
its natural course. The hospice eligibility requirement acknowledges
the inherent uncertainty in prognostication and the role o best
clinical judgment. Once enrolled in hospice, the hospice medical
director assumes the responsibility or the ongoing assessment o
the patient’s prognosis and documenting that assessment in what
is called a certi cation narrative. Table 74-3 describes levels o care
under the Medicare hospice bene t. See Chapter 105 (Using Prog-
nosis to Guide Treatment).
■ COMMUNICATION WITH PATIENTS
When the Medicare hospice bene t was rst enacted in 1982, the
majority o patients cared or under the bene t had a cancer diag-
nosis and the transition between “treatment” and “best supportive
care” was much starker. The regulation does not, in act, use the
words “cure” or “treatment” in de ning hospice eligibility but
this binary distinction has persisted. Today, only about a third o
Medicare hospice bene ciaries have a diagnosis o cancer and the
use o advanced palliative therapies has become commonplace
blurring the distinction between cancer “treatment” and “best
supportive care.” Additionally, patients with a diagnosis o demen-
tia, heart disease or lung disease are enrolling in hospice with
increasing requency and accounted or 14.8%, 14.7%, and 9.3%,
respectively o Medicare bene ciaries enrolled in hospice in 2014.
There is no cure or any o the above noncancer diagnoses: all are
TABLE 74-3 Poor Prognostic Factors
Recurrent hospitalization especially to intensive care unit
Activities o daily li e (ADL) dependency
Weight loss
Recurrent alls, in ections
Declining per ormance status and score on the palliative
per ormance scale (PPS)
Laboratory indings: low albumin, low hemoglobin
C
H
General Inpatient Care
A
$700/d
P
T
E
R
7
Hospital, skilled nursing acility,
4
hospice residence
Ongoing skilled nursing required
to assess pain and symptom
H
o
management, adjust medications
s
p
and coordinate care with the
i
c
attending physician and/or
e
hospice medical director: daily
visits by a hospice team member
chronic, progressive, li e-limiting illnesses. All patients, regardless
o their underlying chronic progressive illness, bene t rom maxi-
mal medical management targeted toward disease modi cation
as well as the involvement o palliative care whenever there is
signi cant or complex symptom burden as is o ten encountered in
the advanced stages o many illnesses. There ore, in conversations
regarding end-o -li e care, it may be help ul to re rame the transi-
tion to hospice as the “standard o care” at that point along the
disease trajectory when urther disease modi cation is no longer
possible and symptom burden becomes more prominent. When
a patient transitions to hospice, clinicians should continue to
provide maximal medical management in addition to palliation o
symptoms in a way that is not unduly burdensome to the patient
as many patients pre er to remain home and avoid burdensome
care transitions i possible during the last weeks to months o li e.
Some patients and amily members may continue to request that
“everything be done” during this di cult transition rom chroni-
cally, progressively ill to terminally ill and dying. This request is
o ten made by the patient or amily member looking or reassur-
ance that they or their amily member will not be “abandoned,”
that active medical management will continue and that long
term care providers will remain involved supporting the patient
and the amily. When explored skill ully, the request may be less
about seeking speci c interventions and more about ensuring
the ongoing involvement o the care providers. See Chapter 215
(Communication Skills or the End o Li e Care).
■ HOSPICE ENROLLMENT POLICIES AND
PATIENT CHOICE
Hospitalists o ten encounter barriers to hospice use at the level o
the hospice provider due to restrictive and o ten variable enrollment
policies and at the level o the patient and amily due to the nancial
disincentives associated with some insurance coverage. While it is
unclear how much hospice enrollment policies and patient choice
due to nancial concerns contribute to some o these observed
hospices re erral patterns, hospitalists may e ectively navigate those
barriers on behal o their patients by working closely with case
managers and hospice providers to clari y these barriers and identi y
alternative pathways to hospice enrollment.
■ CLARIFYING COMMON SOURCES OF CONFUSION
Palliative care versus hospice
Palliative care is delivered across the entire trajectory o illness and
in parallel with curative therapy as well as with disease modi ying
507
 therapy. Hospice care is that small segment o palliative care that Hospice coverage Chapter 9 o The Medicare Bene t Policy
addresses the needs o patients and their amilies at the end o li e, Manual details the hospice insurance bene t. Coverage o Hospice
needs that are covered by the comprehensive hospice insurance Services alls under Medicare Part A; Medicare Part B provides
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bene t. coverage or services such as laboratory tests and doctor visits. To
A
be eligible to elect hospice care under the Medicare bene t, the
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patient must be entitled to Medicare Part A and be terminally ill
T
Hospice is “a place” which is de ned as having a “li e expectancy (o ) 6 months or less
I
I
Hospice re ers to a concept o care not a location. An interdisci- i the illness runs its normal course” (Table 74-1). The language is
I
plinary team provides hospice care to patients and their amilies straight orward and does not state that the patient must orego
and each member o the team visits a patient wherever the patient treatment related to the terminal illness. However, additional lan-
happens to live. The majority o patients who receive hospice care guage in the regulation states that or care related to the terminal
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live in their own homes but hospice team members may also visit illness “only care provided by (or under arrangements made by) a
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h
patients who live in nursing homes, rest homes, assisted living Medicare certi ed hospice is covered under the Medicare hospice
a
b
acilities or even the hospital. A “hospice house” generally re ers to bene t.” This subsequent language o ten shi ts the cost o provid-
i
l
i
t
a reestanding hospice residence or house built by an individual ing care related to the terminal illness to the individual hospice
a
t
hospice agency. Not all hospice agencies build or own a hospice agency: the patient and his or her amily are responsible or the
i
o
n
residence. Patients may transition to a hospice residence or any cost o care not included in the hospice plan or care or arranged
a
number o reasons, including increasing care needs that the am- by the hospice agency. Stated another way, Medicare reimburses a
n
d
ily can no longer manage or a desire not to die in their own home. hospice agency or care under a capitated payment system and the
S
All hospice residences must be licensed by the state in which hospice assumes all o the nancial risk or the cost o care related
k
i
l
they operate and are certi ed to provide either “routine level” to the terminal illness. Please note that the services unrelated to
l
e
d
o care or both “routine level” o care and “general in-patient” hospice diagnosis continue to get reimbursed under traditional
N
level o care. A hospice residence that provides “routine level” o Medicare (ie, a patient admitted to hospice or end-stage COPD
u
care provides a supportive environment similar to that ound in may be admitted to the hospital and have his or her care covered
r
s
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n
a patient’s home with the addition o on-site home health aides, under Medicare Part B or an episode o GI bleeding related to
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LPNs and o ten volunteers. Patients and their amily are required diverticular disease).
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to pay or room and board i they transition to a “routine level” In the 1980s, the nancial implication o such language was
a
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e
o care residence. A hospice residence that provides “general in- not unduly burdensome: the majority o hospice patients had
patient” level o care provides an enhanced skilled nursing envi- cancer, there were ewer disease modi ying or palliative therapies
ronment or patients who require more intensive skilled nursing and the trajectory toward death generally took place over a ew
assessment and medication administration, care that could not short months and was predictable. Today, that language has led
reasonably be provided in the home. Hospice agencies without some hospice agencies to develop restrictive enrollment policies
a hospice residence certi ed or “general in-patient” level o care based on the cost o various treatments and medical management
contract with either a local nursing home or acute care hospital options. Hospice agencies receive a xed “per diem” payment
in order provide this level o care. The “general in-patient” level o (Table 74-2). The hospice agency must cover all o their xed
care is utilized during shorter, more intense periods o symptom operating costs (salaries and bene ts, support sta , in ormation
management and the cost o room and board is included in the technology, space) as well as the costs related to terminal illness
“general in-patient” level o care. (medication and palliative interventions, medical equipment, sup-
plies) with daily reimbursement or routine hospice o about $150.00
Role of hospice The interdisciplinary hospice team helps to sup- per day per patient.
port and guide the care o the patient while the patient is enrolled The number o palliative interventions and therapies we o er
in hospice. For patients who chose to remain at home, the patient’s patients near the end-o -li e has expanded tremendously since the
amily and/or caregivers manage the patient’s physical care needs 1980s and many o those interventions are o ten costly relative to
and administer all o the medications used to manage pain and the “per diem” the hospice agency receives. While the language
symptoms. Patients and their amilies may call the hospice agency o the Medicare hospice bene t does not explicitly exclude what
at any time and speak to a triage nurse who will respond to their a patient may or may not receive or care o their terminal illness,
questions and concerns over the phone. I the triage nurse is hospice agencies at times choose not to assume the cost or certain
unable to adequately manage pain or symptoms over the phone, a treatments based on their ability to absorb those costs and remain
responding nurse is sent to the home to urther assess and manage nancially viable.
the symptoms or to address patient and amily concerns. Aside rom
Impact of hospice on survival The goal o hospice is neither to
these “as needed visits,” the nurse care manager typically visits the
hasten death nor to prolong su ering. The goal is to ocus on quality
patient once or twice a week or approximately an hour, depending
o li e or both the patient and his or her amily through the support
on the care needs o the patient and the support and educational
o a multidisciplinary team. Various studies have shown that hospice
needs o the amily. In complicated situations the nursing visit
enrollment is not signi cantly associated with shorter survival. In
requency may be increased to several times a week. The hospice
act, or a subset o patients with end-stage heart ailure, colon can-
social worker and chaplain assess patients and their amilies upon
cer and lung cancer, hospice enrollment has been associated with
admission to hospice and determine their visit requency based
longer survival times.
on identi ed needs. Likewise, the RN case manager arranges home
health aides and volunteers based on the needs o the patient and Barriers to hospice The ollowing two cases review some o
amily. The vast majority o patients cared or at home are cared or the barriers hospitalists requently encounter when transitioning
under this “routine level” o hospice care. I a patient experiences patients to best supportive care with hospice. These cases assume
di cult to manage pain or symptoms and requires more requent that the clinician has already determined that the patient has a likely
skilled nursing care, the hospice agency may provide or this more prognosis o ewer than 6 months and has guided the patient and
intense level o care under the “general in-patient” level o care their amily through the decision to transition to best supportive
discussed above. care with hospice.

508

CASE 74-1
An 82-year-old woman with moderate to advanced dementia
developed mental status changes, hypotension, and pneumonia
at home. She was initially admitted to the intensive care unit
where she received peripheral partial nutrition (PPN) through a
midline. Her past medical history included a similar presentation
6 months ago and a more recent hospitalization or a mechanical
all at home ollowed by several weeks o rehabilitation at a skilled
nursing acility. Since returning home, the patient had become
increasingly rail and wheelchair bound. She slept most o the day
and had lost 15 pounds but still enjoyed eating small amounts o
ood, particularly ice cream. A ter several days without a change in
her ability to swallow, the clinicians readdress goals o care with
the amily. Observing her decline, the amily agrees with the
recommendation to transition to best supportive care with hospice.
Hospice enrollment policies Overwhelmed by the rapidity o the
patient’s decline, the amily asks that PPN be continued or a little
while hoping that her swallowing improves. However, the hospice
agency re erred by the nursing acility does not accept patients on
PPN likely due to cost.
Clinicians may take the ollowing steps:
• They may call the hospice agency and ask to speak with the
hospice medical director or the operations manager to review
the case and request that they accept the patient in order to
help support the amily through the nal steps o discontinu-
ing PPN.
• They may call the nursing acility and ask the director to
consider issuing a one-time contract with another hospice
agency that might have less restrictive policies with regards to
costly interventions such as PPN.
Barrier two—financial issues The patient is able to return to the
nursing home on her Part A Medicare Skilled Nursing Care Facility
bene t due to her “skilled needs” or PPN as well as speech and
physical therapy. Medicare covers the ull cost o the skilled services
provided as well as the room and board at the acility or up to 100
days per a de ned bene t period. I she elects to access her Part A
Medicare Hospice Bene t, the patient orgoes her Skilled Nursing
Care Facility bene t under the Part A Medicare while she is on hos-
pice. While Medicare covers the cost o room and board under the
skilled nursing bene t it does not cover the cost o room and board
under the hospice bene t. This discrepancy is likely an unintended
consequence o how the original bene t was structured given the
expectation that most patients would be cared or at home. As a
result, the patient and her amily would have to pay the cost o room
and board which is o ten costly and can average $400 a day.
While the patient cannot access her Medicare hospice bene t
without signi cant nancial implications or the amily, the overall
goal o care or the patient does not change. The goal remains to
transition her back to her acility with best supportive care. Her
advanced directives should ref ect her goals o care and include
orders or DNR and DNI. Additionally, an order or Do Not Hospitalize
(DNH) should be discussed with the amily as repeated hospitaliza-
tions or expected clinical complications related to her progressive
dementia would be burdensome and not align with the goal o
preserving the patient’s com ort and dignity at the end o li e. Clini-
cians should call the attending physician or the nurse practitioner
caring or the patient at the acility to review and clari y the goals
o care or the patient and to reassure the provider that the am-
ily understands and appreciates the order or DNH. The patient
returns to the acility with the opportunity to improve with speech
and physical and therapy interventions but with an overarching
goal o best supportive care and avoidance o burdensome hos-
pitalizations, even while she was not able to access her Medicare
C
hospice bene t due to nancial disincentives. The skilled nursing
H
A
acility may also have access to certi ed palliative care physicians
P
or nurse practitioners that it could consult or assistance with
T
symptom control and ongoing decision support around goals o
E
care. I the patient was experiencing di culty to control symptoms
R
that required ongoing skilled nursing assessment and medication
7
titration, the patient could access their Medicare hospice “gen-
4
eral in-patient” level o care and remain in the hospital until their
symptoms stabilized: patients who are imminently dying but are
H
otherwise com ortable and do not require ongoing skilled nursing
o
s
interventions do not quali y or the “general in-patient” level o care
p
i
c
bene t.
e
Patients with Medicaid and Medicare I this patient had both
Medicaid and Medicare coverage (ie, dual eligibility), room and
board at the acility may be covered. However, some skilled nurs-
ing acilities may discourage patients and their amilies rom “dis-
enrolling” rom the Medicare skilled nursing care acility bene t
because the acility is reimbursed under that bene t at a much
higher rate than they are reimbursed by the hospice agency under
the hospice bene t or dual eligible patients. Additionally, hospice
agencies may suggest that some interventions such as speech and
physical therapy are not necessarily part o “best supportive care”
and may not actively o er those services as they add to the total
cost o providing care or the patient. Such services may be of ered
under the Medicare hospice bene t and clinicians should advocate
on the part o the patient and their amily i this misunderstanding
emerges as a barrier to transitioning a dual-eligible patient to the
Medicare hospice bene t.
PRACTICE POINT
• Clinicians should become amiliar with the enrollment policies
o local hospice agencies, cultivate relationships with these
hospices, and navigate potential gaps in insurance coverage
that result in nancial barriers to patients transitioning to end
o li e care.
CASE 74-2
A 58-year-old man receiving palliative chemotherapy or nonsmall
cell lung cancer is hospitalized with new widespread metastasis
to the bone and liver. He begins radiotherapy to his right emur.
Based on his previous discussions with his oncologist, he under-
stands that his prognosis is likely limited and he wants to go home
as soon as possible.
Hospice enrollment policies None o the area hospices accept
patients undergoing radiation therapy, likely due to the voluntary
restrictive enrollment policies o individual hospice agencies. This
patient is under 65-year old and likely has commercial insurance.
Hospice agencies may contact a commercial insurer and request
that they consider allowing what is called a “carve out” to their
hospice coverage. Under a “carve out” agreement, the insurer allows
the patient to access their hospice insurance bene t, and the insurer
agrees to pay or the cost o a speci c treatment such as radiation
therapy separately: the hospice agency does not have to assume the
cost o the palliative radiation. Peer to peer communication by the
clinician to the hospice medical director may acilitate the necessary
coverage by clari ying goals o care and asking the medical director
to advocate on the patient’s behal .
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 The need for a primary caregiver None o the local hospice agen- CONCLUSION
cies will accept the patient i he lives alone and does not have
Hospitalists encounter patients at their most vulnerable moments,
a “primary caregiver.” Hospice agencies pre er that patients have
and o ten at a time when they are transitioning rom chronically,
P
clearly identi ed amily and/or caregivers who could support the
A
progressively ill to terminally ill and dying. In addition to the chal-
patient as the patient declines and ensure that the patient is sa e at
R
lenges associated with prognostication and communication at the
home. However, a primary caregiver is not a requirement or care
T
end o li e, clinicians are aced with deciphering the complexities o
under the Medicare hospice bene t or under most other hospice
I
hospice insurance coverage. Addressing barriers to transitioning a
I
insurance programs. It is the role o the hospice nurse care manager
I
patient to best supportive care with hospice, may both enhance the
and social worker to work with the patient to establish a sa e care
end-o -li e care many patients receive and simultaneously acilitate
plan when the patient is no longer able to care or himsel at home.
the ability o clinicians and health care systems to meet quality
metrics in an emerging value-based health care.
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Patient and family issues A limited number o hospice agencies
e
have an “Open Access” policy and accept patients who are receiv-
h
a
ing a broad range o palliative and o ten costly interventions. These SUGGESTED READINGS
b
i
l
agencies hope that i they are responsive to the needs o their
i
t
a
re erral base (hospitalists, oncologists) that they will receive re errals Aldridge Carlson MD, Barry CL, Cherlin EJ, McCorkle R, Bradley
t
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o
or other patients who might not have such extensive care require- EH. Hospices’ enrollment policies may contribute to under-
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can take the time to help support the patient and their amily as they
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consider discontinuing what are o ten burdensome interventions.
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ously ill older adults. J Palliat Med. 2012:15(12):1356-1361.
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amilies bene t rom the support and guidance o a hospice team Finucane TE. How gravely ill becomes dying: a key to end-o -li e care.
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JAMA. 1999:282(17):1670-1672.
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during that di cult transition. Under new provisions enacted with
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the passage o the A ordable Care Act o 2010, Medicare will reim- Holden TR, et al. Hospice enrollment, local hospice utilization
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burse selected hospices under the Medicare Care Choices Model or patterns, and rehospitalization in Medicare patients. J Palliat Med.
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routine and respite level care or patients who choose to continue 2015:16(7):601-612.
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to receive a range o interventions: phase one o the program is
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Hooton TM, Roberts PL, Cox ME, Stapleton AE. Voided midstream
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scheduled to begin January 2016 and a list o participating hospices urine culture and acute cystitis in premenopausal women. N Engl
is available on the Medicare Innovations website. J Med. 2013;369:1883-1891.
Patie nts with a military conne ctio n Patients with a military Lin RJ, Adelman RD, Diamond RR, Evans AT. The sentinel hospitaliza-
connection may be eligible to receive hospice care in an inpatient tion and the role o palliative care. J Hosp Med. 2014;9(5):320-323.
hospice unit at select Veterans A airs acilities at little to no cost to NHPCO Facts and Figures: Hospice Care in America. Alexandria, VA:
the patient. However, the number o VA acilities with dedicated National Hospice and Palliative Care Organization; October 2014.
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Teno JM, et al. Change in end-o -li e care or Medicare bene ciaries:
to shoulder the burden o the prolonged travel necessary to visit the
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Clinicians and case managers should work together to: illness. J Gen Intern Med. 2009;24(8):923-928.
• Identi y opportunities or “carve out”options with commercial
insurance carriers.
• Determine the availability o “Open Access”hospice agencies in
their area and hospice agencies participating in the Medicare
Care Choices Model.
• Identi y patients who are eligible or VA bene ts including
trans er to an inpatient hospice unit at little to no cost to the
patient.

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