Title : Non-pharmacologic management of orthostatic hypotension in inpatient rehabilitation: A quality improvement initiative
Abstract:
Orthostatic hypotension (OH) is frequently encountered during inpatient rehabilitation following ischemic stroke and is associated with dizziness, instability, and therapy disruption during this critical stage of neurorecovery. On our neurorehabilitation unit, OH was identified as a common cause of missed therapy sessions. Although non-pharmacologic strategies such as compression garments, hydration, and physical counter-maneuvers are commonly recommended, implementation is often inconsistent. This project aimed to standardize OH management using low-risk, evidence supported interventions that could be initiated by nursing and therapy staff without requiring immediate physician involvement.
Conducted on a 20-bed inpatient neurorehabilitation unit in a large urban teaching hospital, this quality improvement initiative followed a literature-guided protocol developed by the team. Eligible participants were adults recovering from ischemic stroke who demonstrated OH, defined as >20 mmHg systolic or >10mmHG diastolic drop without positional change accompanied by symptoms. Exclusion criteria included NPO status, modified diets that limited oral intake, lower extremity amputation, dialysis, or existing pharmacologic OH management.
A multidisciplinary team (nurses, physical therapists, occupational therapists, and rehabilitation physicians) developed a standardized OH protocol involving knee-high compression stockings,
abdominal binders, oral bolus (480 mL water over 5 minutes), and a structured set of seated countermeasures including heel raises, toe raises, marching, long-arc quads, and gluteal sets. Staff were trained on eligibility screening, intervention steps, and given an online form with built-in safeguards. Data were collected from March 2024 – March 2025.
31 OH episodes were documented and 22 met full protocol eligibility and received non-pharmacological intervention. Of these, 15 episodes (68%) were successfully managed using the protocol, allowing patients to resume either full therapy (n=6) or seated therapy (n=9) without missed treatment time. Compression stockings were used most frequently (19/22), followed by abdominal binder (11/22), seated countermeasures (11/22), and finally oral bolus (6/22). 11 of the 31 total episodes required pharmacologic management. Staff reported this initiative established a unified, effective approach that empowered all team members to initiate treatment without requiring immediate physician involvement, reducing missed therapy sessions and supporting optimal participation in rehabilitation.
These findings suggest a standardized, multidisciplinary, non-pharmacologic protocol for OH is feasible, safe, and effective for supporting therapy participation among ischemic stroke patients in inpatient rehabilitation. Empowering nurses and therapists to initiate treatment improved timeliness for care and reduced therapy disruption. Future application of this protocol across additional settings and diverse patient populations may help address current gaps in evidence and promote wider use of low-risk interventions for OH. Reducing the incidence of OH has the potential to decrease fall risk and enhance safe mobility during stroke recovery.
