Edema management. It is not something that you can expect at every hospital… inpatient rehab… or even outpatient facility. Yet, I doubt there are many clinicians who wouldn’t agree- this is a big issue for our patients!
Edema is one of the most chronically underdressed issues, particularly in rehab. The reasons for this are many! It can be masked by other issues, such as medical fragility; it can hide in plain sight, for those who have had slowly worsening chronic swelling; or it can simply be written off as ‘not my area’, by therapists, nurses, and physicians. And a dedicated edema management program? Usually nowhere to be found!
This combination adds to the problem of edema. Under-recognized as an issue, it often is left to slowly progress over time, adding in a host of complicating factors along the way. Untreated edema will contribute to a lack of mobility; a higher risk for skin infections and breakdown; decreased independence and ability to engage in the community, and more. In fact, addressing edema can be incredibly helpful! Here, we can prevent our clients from entering this ‘vicious cycle’ of progressive disability and impairment.
And yet- it isn’t! But maybe, that should change.
Many in-patient rehabilitation facilities have dedicated programs for the wellness of their clients; such as brain injury/stroke/disease-specific care/palliative. These specialized services empower the clinicians and provide resources to the clients to have a more successful outcome. A specialized edema management program, however, are less commonplace – even though edema is a debilitating issue for many patients.
Edema can occur from an orthopedic injury, be neurological in nature, or even congenital. Patients who present to inpatient rehab post-surgery, CVA, or trauma, are likely to have issues with swelling. A process wherein that edema is identified, addressed as part of the plan of care, and continued follow up support given, results in far better outcomes for the patient and carer.
Setting up any type of program is intimidating- and an edema management program is no different. Let’s have a look at the reasons we should be advocating for this service, and how you can be instrumental in setting up this service in-house!
So why should we include edema management in the plan of care?
Firstly, the clinical reasons:
Mobility. The person is clearly more likely to be able to move around, walk for longer, and transfer in and out of bed if they are not struggling with heavy and edematous limbs. Stiffness and discomfort experienced with edematous limbs, also makes it more difficult for our patients to move around. They may be discouraged from ambulation by how strenuous they may find walking on heavy and stiff limbs.
This, naturally, does not help with their goals in rehab. It also impairs their chronic edema issues, and will compound upon the lack of circulation and muscle strength. In a nutshell: Swelling -> less walking -> more swelling!!
Related to this point- treating the person’s swelling is going to improve their skin integrity, aid with wound healing, and decrease the number of infections that they contract. Chronic edema is known to be a cause of cellulitis and erysipelas, both of which can continue to recur if the swelling is untreated. Wounds do not heal as quickly and as well as they might when the circulation around the wound is impaired. Additionally, stagnating lymphatic fluid leads to a cascade of unusual skin conditions, predisposing your client to skin breakdown and infections.
Footwear considerations are also key. A person with chronic and worsening edema is likely to have difficulties finding and maintaining proper footwear. This has a functional impact on their community involvement, and leave them at risk for skin breakdown and injury. Our patients should be able to don their shoes to be an active part of their community and to protect their feet- but many people with undertreated edema resort to wearing cast shoes or some other suboptimal option for community engagement. A common goal in inpatient rehab (for both OT and PT) is applying footwear/walking in shoes.
Now: the non-clinical reasons!
Aside from the clinical reasons to treat edema (of which we have so many!), there are also a host of administrative reasons to begin to address this issue. We all are working in a system, which we should strive to make as efficient and fair as possible, with best outcomes. Providing sub-standard care is unethical, AND inefficient!
From an administrative point of view- first in line is the reduction of re-admissions. We are sure to have fewer re-admissions and a higher quality of health if the patient is at a lesser risk of infections with improved skin integrity. It is also important to note that chronic edema has a progressive nature and will not just “go away by itself” if ignored. Thus, it is important to address it early on in their rehab stay, and make sure our patients are aware of the warning signs.
Additionally- it will set you and your facility apart from other places. The lack of knowledge of edema and the means to treat it in the healthcare is astounding! As clinicians, we are in a fantastic position to advocate for and educate our patients (and ourselves!), to prevent the continual worsening of edema. As we know it can lead to permanent disability, we should be educating healthcare workers all around us to recognize that this is not a transient symptom.
Patient satisfaction is, of course, hand-in-glove in addressing the areas mentioned here! Your patients are going to be so appreciative of the attention given to an issue that may have previously been completely unaddressed, and the more positive outcomes that will arrive with the treatment. Anecdotally, I have found that my patients are so grateful to be heard and treated for this condition, saying things like “I didn’t know I could do anything for this” “No one was ever listening to me about this” and “I can’t believe how much better I feel”.
Lastly, and importantly when it comes to getting the resources and support of your administration, is the marketability of a program like this. Referring doctors, referring facilities, and liaisons will be able to advertise and refer appropriate patients when there are the systems to address the areas they need.
Right! I’m convinced. But where do I start?
First- you should begin by up-skilling in the area of edema management.
Getting some practical skills that you will need in the area of edema management will be crucial in setting up a successful program- this is, after all, a clinical intervention- and you should have the clinical knowhow to support the program. There are several options to upskill- once of which is to become a certified lymphedema therapist (CLT). Becoming a CLT will provide you with a lot of clinical skills and background, intensive practice in manual drainage techniques and compression bandaging. If your facility is investing in its staff, in terms of continuous professional development and program set-up, they may pay for, or reimburse, your registration fees.
Of course, getting the certification is not mandatory for treating these issues. Edema treatment is well within the scope of Physical and Occupational Therapists and nurses! Check out Edema Management in In-Patient Rehabilitation for a comprehensive seminar that focuses specifically on how to incorporate these skills into your practice.
Second- do your assessment of need.
Do an audit, a chart review, or even a straw poll of the patients that you and your colleagues are currently seeing. Would any of them benefit from an program such as this one being in house? Do they have swelling, pain, skin issues, wounds that could be treated if an edema management program was set up? I have found, when working in in-patient rehab, that 70-80% of my patients would benefit to some degree. Swelling, skin issues, and high risk conditions such as diabetes will all be appropriate for preventative care, if not treatment.
Gaining this information will strengthen the need for your program, and get extra support from your colleagues and administrators. It will also provide a baseline that you can point to, of people who need services that are not provided.
Thirdly- Educate your staff and colleagues.
Educating your team as to what you wish to add is crucial. Change can be challenging, as especially with a condition as poorly understood as edema. By including your therapy, nursing, and admin team from the start- it can be tackled together! Educate your team about: the misconceptions of edema; the people who will be appropriate for this program; and what interventions your program will include. Explain the different bandage materials that you will be using, so that floor staff will have a heads up! You will want to clearly delineate what is expected and what will be changing, and how you can be contacted for further insights or if there are any issues.
If possible, try to assemble a sub team that can help set up your program, handle issues, and help you educate. Include wound care, nursing, RNT, PT, OT and anyone else you think would be a great advocate!
Fourthly- set up your program and examine what you need.
In order to begin your program, you will require supplies, resources, assessment tools, and informational packets. I always recommend that people run a smaller, easy-to-manage pilot group to begin with- 10 patients, who all have LE needs, for example. Prepare the order for supplies, the HEPs and plans, and any other tools you need for this group. Note your documentation and admin requirements. Make sure you are using subjective and objective outcome measures to track their progress, and take photographs as much as is possible!
It may be worth exporting their results onto a chart, or writing up a comprehensive report. This way, you can track their results and figure out what worked best. Pointing to their outcomes will also provide support for your program! If you need further supplies or more expensive equipment in the future; having this data will be invaluable.
Setting up an Edema Management Program will not be easy- but I guarantee, it will change your practice forever! This under-recognized and mismanaged condition only complicates the lives of our patients. Having a dedicated service will maximize your outcomes! No matter where you work- you’ll see the need.
If you found this program development article helpful, you’ll love our popular and engaging seminar on the topic of Edema Management. Check it out and read more right here: Edema Management in In-patient Rehabilitation!
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