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MODULE 22: THE HOSPITAL ECOSYSTEM
Section 2.4: The Acute Rehabilitation Unit (ARU): The Road to Recovery
Discover your pivotal role in the final, critical stage of inpatient care, where your skills in medication simplification, bowel management, and patient education directly empower patients to succeed after discharge.
SECTION 2.4
The Acute Rehabilitation Unit (ARU): The Road to Recovery
Restoring function after a life-altering event.
2.4.1 The “Why”: Restoring Function After a Life-Altering Event
The Acute Rehabilitation Unit (ARU), often called an “acute rehab facility” or simply “rehab,” represents a unique and profoundly optimistic corner of the hospital ecosystem. This is not a place where patients lie in bed waiting to get better; it is a place where they actively work to reclaim their lives. The “Why” of the ARU is centered on one goal: intensive functional restoration. After a patient has been medically stabilized from a catastrophic event—such as a major stroke, a traumatic brain injury, a spinal cord injury, or a multi-trauma accident—the ARU provides the coordinated, high-intensity therapy they need to regain as much independence as possible before returning to the community.
This environment is governed by a strict set of rules that differentiate it from any other unit. The most important is the “3-Hour Rule,” a Medicare requirement stating that patients in an ARU must be able to tolerate and benefit from at least three hours of intensive therapy per day, five days a week. This therapy is a combination of physical, occupational, and speech therapy. This single rule fundamentally changes the culture of the unit and the pharmacist’s role within it. The medical focus shifts from acute stabilization to creating the optimal physiological conditions for a patient to succeed in therapy. Your job is to be the master of a medication regimen that supports, rather than hinders, this intensive recovery process. Every medication order is viewed through a new lens: “Will this drug help or hurt this patient’s ability to participate in three hours of grueling therapy today?”
ARU vs. SNF: A Critical Distinction You Must Understand
In the community, you often see prescriptions for patients being discharged to a “rehab” or “nursing home.” In the hospital, you must understand the vast difference between an ARU and a Skilled Nursing Facility (SNF).
| Feature | Acute Rehabilitation Unit (ARU) | Skilled Nursing Facility (SNF) |
|---|---|---|
| Intensity of Therapy | High Intensity: Minimum 3 hours/day, 5 days/week. | Lower Intensity: Typically 1-2 hours/day, not always daily. |
| Physician Oversight | Daily, in-person visits by a rehabilitation physician (physiatrist). | Less frequent visits, often not daily. |
| Nursing Care | 24/7 registered nursing care with a focus on rehabilitation. | 24/7 skilled nursing care, but may be less specialized. |
| Patient Goal | Return to home/community living. | Can be short-term rehab or long-term custodial care. |
| Pharmacist’s Focus | Aggressive medication simplification and optimization for function. | Long-term medication management, regulatory compliance (e.g., psychotropic monitoring). |
2.4.2 The Pharmacist’s Role: Medication Simplification and Bowel Regimen Expert
In the ARU, your clinical focus undergoes a profound shift. The frantic pace of managing acute crises on the Med-Surg or Telemetry floors is replaced by a more deliberate, thoughtful, and forward-looking approach. You are no longer just treating the immediate problem; you are architecting a medication regimen that is safe, simple, and sustainable for the patient long after they leave the hospital. This makes the ARU pharmacist one of the most direct bridges back to community practice. Your two most vital roles are leading the charge on medication simplification (deprescribing) and becoming the undisputed expert on bowel management.
Mastery 1: The Art of Medication Simplification (Deprescribing)
Patients arrive in the ARU after a long and chaotic journey through the acute care hospital. Their medication list is often a battlefield diary, filled with short-term treatments for hospital-acquired conditions, temporary fixes, and PRN orders that are no longer relevant. This phenomenon is known as “prescribing cascade” or “medication baggage.” Your primary directive is to clean it up. The goal is to critically evaluate every single medication and ask: “Is this absolutely essential for this patient to take home?” Every drug that can be safely discontinued is a victory against polypharmacy, reducing the risk of side effects, drug interactions, non-adherence, and cost.
Retail Pharmacist Analogy: The Ultimate Adherence Packaging Service
This is the role you were born to play. Think of the meticulous care you take when a complex patient comes to your pharmacy for the first time and asks for help. You don’t just fill their 15 prescriptions. You perform the ultimate medication reconciliation. You call their doctors to clarify duplicate therapies, you identify non-essential supplements, and you consolidate dosing times. You then take this chaotic list and transform it into a simple, elegant, color-coded blister pack, with one bubble for morning, one for noon, one for evening. You have created order out of chaos.
This is exactly what the ARU pharmacist does. The patient is your new customer. Their medication list from the acute hospital is the bag of assorted pill bottles. Your job is to perform that same expert reconciliation, eliminate the unnecessary, and redesign the regimen into the simplest, safest, most logical “blister pack” possible before they are discharged. You are the architect of their post-discharge success.
Your Deprescribing Hit List: Common Targets in the ARU
| Medication/Class | Reason It Was Started in Acute Care | The Pharmacist’s Deprescribing Rationale in ARU | Your Recommended Action |
|---|---|---|---|
| Proton Pump Inhibitors (PPIs) / H2RAs | Stress Ulcer Prophylaxis (SUP) while critically ill in the ICU or on high-dose steroids. | The patient is no longer critically ill. The risk of long-term PPI use (C. diff, pneumonia, fractures) now outweighs the benefit. | “Patient was started on pantoprazole for SUP in the ICU. He is now stable and eating. Recommend discontinuing pantoprazole as it is no longer indicated.” |
| Sliding Scale Insulin (SSI) Alone | To manage transient stress hyperglycemia during acute illness or surgery. | Reactive SSI is ineffective for long-term glycemic control and increases the risk of hypoglycemia. Patient’s diet and activity are now stable. | “Patient has been on SSI only, requiring frequent correction. To provide better glycemic control and prepare for discharge, recommend converting to a scheduled basal insulin (e.g., glargine) with a target blood glucose of 140-180 mg/dL.” |
| “As Needed” (PRN) IV Medications | IV ondansetron for nausea, IV hydromorphone for pain, IV lorazepam for agitation. | The patient is stable and preparing for discharge. They will not have access to IV medications at home. An oral-only regimen must be established. | “Patient has not required IV ondansetron in 48 hours. Recommend discontinuing the IV order and ensuring an appropriate oral antiemetic (e.g., prochlorperazine PRN) is available.” |
| Sleep Aids (Hypnotics) | To manage insomnia and delirium in the disruptive, noisy acute care environment. (e.g., zolpidem, trazodone). | These agents increase the risk of falls, confusion, and daytime somnolence, which will directly impair the patient’s ability to participate in therapy. | “Patient is on scheduled trazodone for sleep. This agent can cause daytime sedation and increases fall risk. Recommend trial of non-pharmacologic sleep hygiene first, then consider discontinuing trazodone.” |
Mastery 2: The Bowel Regimen Expert
Nowhere in the hospital is the management of constipation more important than in the ARU. It may seem like a trivial issue, but for a rehabilitation patient, it is anything but. Constipation can cause pain, bloating, and urinary retention, all of which prevent a patient from participating in therapy. For a patient with a spinal cord injury, it can lead to a medical emergency called autonomic dysreflexia. For a patient on chronic opioids, it is a guaranteed consequence that must be proactively managed. You, the pharmacist, will become the go-to expert for designing effective, multi-pronged bowel regimens.
“Mush without Push is a Useless Squish” – The Cardinal Rule of Opioids
You must burn this phrase into your memory. Opioids cause constipation primarily by reducing gut motility (“push”). Giving a stool softener like docusate (“mush”) without a stimulant to promote motility is a classic, ineffective approach. A patient on scheduled opioids MUST be on a scheduled stimulant laxative (like senna). Docusate alone is never enough.
The Pharmacist’s Bowel Regimen Toolkit
| Agent Class | Examples | Mechanism | Place in Therapy & Your Clinical Pearls |
|---|---|---|---|
| Stool Softeners (Surfactants) | Docusate sodium | Allows water and fats to penetrate the stool, softening it (“Mush”). | Largely ineffective as monotherapy. Its only role is in combination with a stimulant for opioid-induced constipation (OIC). If a patient is not on opioids, docusate has very little value. |
| Stimulants | Senna, Bisacodyl | Directly stimulates nerves in the colon to increase peristalsis (“Push”). | The absolute cornerstone of OIC treatment. Should be scheduled BID. This is your go-to agent. Bisacodyl is more potent and often used as a second-line agent or for acute clean-outs. |
| Osmotics | Polyethylene Glycol (PEG) 3350, Lactulose | Draws water into the colon, hydrating and softening the stool. | Excellent for chronic constipation and as an add-on to a stimulant for refractory OIC. PEG 3350 is generally better tolerated than lactulose (less gas/bloating). |
| Suppositories & Enemas | Bisacodyl suppository, Fleets enema | Work locally to stimulate rectal evacuation. | These are rescue agents for acute impaction or for patients with neurogenic bowel (e.g., spinal cord injury) who require a scheduled “bowel program” to digitally stimulate a bowel movement. |
Case Study: Building a Bowel Regimen for a Stroke Patient
Scenario: A 72-year-old female is admitted to the ARU 5 days after an ischemic stroke. She has significant right-sided weakness and immobility. She is also on oxycodone/acetaminophen 5/325mg every 6 hours scheduled for post-stroke shoulder pain. For the last 2 days, she has had no bowel movement.
Your Systematic Approach and Recommendation:
“I’ve reviewed this patient’s profile. She has multiple risk factors for constipation: immobility from her stroke, age, and scheduled opioid therapy. Her current PRN-only bowel regimen is inadequate. To prevent constipation and ensure she can participate in therapy, I recommend initiating a scheduled bowel program as follows:
- 1. Start Senna-Docusate 8.6-50 mg, one tablet PO BID. This provides the necessary “push” and “mush” to counteract the opioid.
- 2. Add PEG 3350, 17 grams in 8 oz of water daily. This will help keep the stool soft.
- 3. Add a PRN option for rescue: Milk of Magnesia 30 mL PO every 6 hours as needed if no bowel movement in 48 hours.
- 4. Let’s monitor bowel movements daily and titrate this regimen aggressively to achieve one soft bowel movement at least every other day.”
