PT7130- Acute Care Physical Therapy

Schedule; 10-12

No ________________________, PT must determine who is seen first. On average, PT is assigned _______________________ patients/day. Usually, 1-2 patients refuse or are unavailable for treatment/eval.

Hospital to discharge

What is setting of acute care?

Discharge planning (what level of care you need next, what equipment you need, and what level of activity is restricted)

What is role of PT in acute care?

Response

Point of Care Clinical Decision Making:

___________________________-dependent care.

Be prepared to do as much as possible!

Function, strengthening, mobility

What is focus of treatment in acute care?

Function

What is main goal of acute care?

Unstable

If your patient is highly _______________________, you must decide whether or not to pass treatment onto PTA. → Usually not

Static; dynamic

Physician assessment is ________________________. PT eval is _________________________ despite medical instability.

Physiologic response; functional mobility

Role of PT is to determine the patient's __________________________ to exercise in the presence of medical instability and link to the patient's ability to complete ______________________________.

- Discharge planning

- Education and prevention

- Increasing ROM, endurance, and strength

- Improving gait, balance, transfers

- Shortening length of stay

- Advocate and consult

Response-dependent care

- Real time decisions based off the patient's current presention.

- Assumed degree of physiologic instability.

More

Studies have shown patients are 2.9x _______________________ likely to be re-admitted when the therapists discharge recommendations not implemented.

30 days

1 in 5 Medicare patients discharged are re-admitted within __________________________ (26 billion/year).

Hospital Readmissions Reduction Program

Incentive to cut down preventable re-admissions.

PNA, COPD, AMI, HF, CABG, elective THA, TKA

What are the included diagnoses in the Hospital Readmissions Reduction Program?

Low socioeconomic status

People with _________________________ were exploited by this act. However, it has been effective over time.

Dizziness and low back pain

ER consults are typically for ___________________________, but most consults are completed after the patient has been admitted.

Medicare Part A

What insurance is used for hospital (inpatient) coverage?

Medically necessary

Medicare covers services (lab tests, surgeries, and doctor visits) and supplies (wheelchairs and walkers) when considered __________________________ to treat a disease or condition.

Observation

We will keep a patient at the hospital under "____________________________" status if we are unsure of the diagnosis. Sometimes patients will be switched from admission to observation and vice versa.

3 night stay and admission status

What are requirements to be discharged to a SNF from hospital?

Pre-certification

Some insurance requires _________________________ before acceptance into a SNF from hospital. → The insurance company wants to read your eval for discharge to determine whether or not the patient needs SNF care.

1-20

Days ______________________ of SNF care has 100% coverage.

80%

Days 21-100 of SNF care has ________________________ coverage.

Medicare Part B

What insurance is used for outpatient coverage?

Deductible

With Medicare insurance, you pay a ___________________________ for the first day you are a hospital inpatient. This covers the next 59 days in the hospital for the same benefit period.

Copayment

With Medicare insurance, days 61-150 are covered by a ______________________________ provided by the payer.

Diagnostic-related groups (DRGs)

System used to classify hospital cases into a group based on the International Classification of Diseases (ICD); started 1982.

Medical history

Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG. → Does not take into account the patient's _________________________ which could complicate the length of stay.

Resources

DRGs assume that patients within each category are clinically similar and are expected to use the same level of hospital ___________________________.

Worse

The longer that a patient is in the hospital unneccesarily, the ________________________ their outcomes!

Observation status

Evaluation of patient's condition to determine if admission is reasonable and medically necessary. Documentation will (should) support this status.

Need; avoid

Purpose of Observation:

- To determine _________________________ for inpatient services or evaluate a patient's condition.

- To _______________________ unnecessary hospital admissions.

Medicare Part B

How is a patient billed under "observation" status?

Level I

- Provides the highest level of surgical care to trauma patients

- Full range of specialists and equipment available 24 hours a day

- Required education program, and preventative outreach programs

Level II

- Works in collaboration with a Level I center

- Provides 24-hour availability of all essential specialities

- Not required to have an ongoing program of research

Level III

- Does not have the full availability of specialists (high specialization), but does have resources for emergency resuscitation, surgery, and intensive care of most trauma patients

- Has transfer agreements with Level I or Level II trauma centers that provide back-up resources

- Example: Rural or community hospitals

Level IV

- Exists in some states where the resources do not exist for a Level III trauma center

- Provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care

Level V

- Provides initial evaluation, stabilization, diagnostic capabilities, and transfer to a higher level of care

- May not be open 24 hours/day (urgent care level potentially); will have an after-hours trauma response protocol.

Consult specialists when necessary

What is role of hospitalists in acute care?

Case manager

Coordinates with agencies, organizations, and facilities to find the best help for the patient; ensures effective and efficient management of resources; no degree required; no counseling.

Social worker

Resolves the social, financial, and psychological problems related to their health condition. Degree in social work required.

CNP (Certified Nurse Practitioner)

RN with advanced training; can examine, diagnose, order, and interpret tests, prescribe meds, and initiate treatment.

RN (Registered Nurse)

Medicine administration, interpretation of physician orders, assessment.

LPN (Licensed Practical Nurse)

Basic medical care, patient status reporting.

ICU

RNs and LPNs are particularly important in _______________________.

STNA (State Tested Nursing Assistant)

Change linens, take vitals, walk patients, assist with ADLs, communicate with RN regarding patient's status.

Skilled Physical Therapy

Rehabilitative therapy occurs when the skills of a therapist are needed to provide services of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can only be safely and effectively performed by a qualified clinician. → Patients must require the unique skills of a therapist to realized improved function.

ICU, PICU. SCU, general medical, pediatric, ortho, neuro, ED

Where does acute therapy occur?

1:1 to 1:2

ICU RN:patient ratio.

1:3 to 1:4

Post-intensive care unit (PICU) RN:patient ratio.

1:5 to 1:6

Special or stepdown care unit (SCU) RN:patient ratio.

1:10 to 1:12

General medical unit RN:patient ratio.

Contact precautions

Spread through close or direct contact; animate and inanimate objects.

Gown, gloves, hand sanitizer or hand washing, dedicated equipment

What PPE is required for contact precautions?

Scabies, lice, MRSA, VRE, bedbugs

What are some examples of diseases that require contact precautions?

Contact plus precautions

Spread through close or direct contact; animate and inanimate objects. Requires gown, gloves, hand washing (cannot just used hand sanitizer) and dedicated equipment.

C. diff (Clostridium difficile)

What is an example of a disease that requires plus contact precautions?

Droplet precautions

Spread through air short distances via large particles.

Surgical mask, protective eye wear, gloves, hand sanitizer or hand washing, gown (if required by facility), dedicated equipment, private room

What PPE is required for droplet precautions?

Pertussis (whooping cough), rubella, influenza

What are some examples of diseases that require droplet precautions?

Airborne precautions

Spread through air via small particles.

N95 FIT tested mask (if fail, then use PAPR), protective eye wear, gloves, hand sanitizer or washing, gown (if required by facility), dedicated equipment

What PPE is required for airborne precautions?

Negative pressure room and closed doors

What room requirements are necessary to maintain airborne precautions?

Tuberculosis, rubella/measles, COVID-19

What are some examples of diseases that require airborne precautions?

Urticaria (hives), contact dermatitis, naso-rhinitis, upper respiratory tract irritation, conjunctivitis, local angioedema, ashtma, hypotension, anaphylaxis

What are signs and symptoms of latex allergy?

Delayed

Latex allergy can have immediate or ________________________ reaction.

Gloves, stethoscopes, BP cuffs, ambu bags, adhesive tape, electrode pads, hand grips on assistive devices

What are some examples of products/equipment containing latex that you need to pay attention to (for a potential latex allergy)?

Unconscious, AMS, risk for pulling out lines/tubes, unsafely mobile, physically aggressive, too active/agitated that medical needs cannot be otherwise met

What are indications for restraints?

24 hours

Restraints can be chemical or physical, and require physician order to be updated every __________________________.

Chemical restraints

"Any medication that is used for the specific purpose of restricting the patients movement which is not a standard treatment for the patient's medical or psychiatric condition" - CMS

Often side effects do not allow Pt participation in skilled

PT services.

Physical restraints

"Any manual method or physical or mechanical devices, material or equipment attached to or adjacent to a patient's body that he or she cannot easily move, that restricts freedom of movement or normal access to one's body" -CMS

Wrist, ankle, mitt, vest restraints, and 4 bedrails

What are some examples of physical restraints?

Slipknot; 2 fingers

For physical restraints, always use a _______________________ tied to an immovable, unreachable area. Be able to place ________________________ between skin and restraint.

Not; yellow

A physical restraint is __________________________ a contraindication to PT; it is a _______________________ flag!

Full code

All measures taken to preserve life.

DNR-CCA

- Do not resuscitate - comfort care arrest

- A dying person receives treatment until cardiac or pulmonary arrest, at which CC measures taken

DNR-CC or CMO

- Associated with hospice

- Do not resuscitate - comfort care or comfort measures only

- A dying person recieves comfort measures, but no resuscitation measures to save or sustain life

- Typically no PT services

DNI

Do not intubate.

Medical power of attorney

An individual that a patient has chosen to make any necessary health care decisions in the event that the patient is unable to make own decisions.

Living will

A document that outlines specific health care preferences in the event that the person becomes incapacitated, typically end-of-life.

Disposition

Place the patient is discharged to.

Acute PT

- Hospitalized patients

- PT delivered on medical floors (in room or hallways)

- 15-60 minutes

- QD vs. BID (1-2x/d)

Long-term acute care (LTAC)

Specialty-care hospital → We are done /c diagnostics, but your condition requires extensive care.

20-30 days

For LTAC after discharge, medical problems require specialty treatment for an extended period of time (___________________). → Must have a medical reason to be there, not just a therapy reason.

Ex: Burns, respiratory failure with continued ventilator needs, wound care

Medical care

LTAC means that patient requires ongoing ________________________, but longer require intensive or diagnostic procedures.

Inpatient rehabilitation

Rehab facility that may be housed within the hospital but not actually a hospital itself.

CVA, TBI, SCI, bilateral joint replacement, amputation, femur fracture with comorbidities, severe OA, congenital deformities, neurologic disorder, multiple major trauma, active polyarticular RA, systemic vasculidities with joint inflammation (ex: lupus), burns

What are the qualifying diagnoses for inpatient rehab?

60% rule

What percentage of IPR census must meet qualifying diagnosis?

Compliance threshold

Inpatient rehab: Medicare "__________________________" for payment and reimbursement, used to distinguish IPRs from

acute hospitals. If not met, the IPR risks losing all reimbursement from Medicare for that fiscal year.

3 hours; 5; 2; learn; 7-21 days

IPR:

- Tolerate ______________________ of therapy/day, ______________________ days/wk

- Require at __________________ disciplines (PT, OT, ST) → One must be PT or OT

- Safe DC disposition → After IPR, pt must have goal of going home, family's home, or assisted living facility.

- Demonstrates ability to __________________________

- Requires close monitoring by a physician

- Ability to make significant functional gains

- Therapy: 5-6 days/week

- Staff: Medical director, skilled nursing, social services, interdisciplinary team including recreation therapy

- Length of Stay (LOS): __________________________

Skilled nursing facility (SNF)

- Has a skill, usually skilled rehab or nursing

- Less intensive therapy → Not inpatient rehab candidate, not diagnosis specific

- 1-3 hours/day

- PT, OT, ST

Long-term care/extended care facility (LTC/ECF)

- Residents of a nursing home

- May have therapy → outpatient or home health

- 24/7 care

- Some facilities have certain # of beds dedicated to SNF. If patient does SNF for ~30 days and fails, transition to ECF.

- No automatic level of therapy

Outpatient rehabilitation

- Patients live at home → Residential, assisted living facility, independent living facilty

- Seek services at an outpatient facility

Home health services

- Home nursing involved

- PT delivered in home

- Must be homebound to be eligible for HHPT → Leaving the home poses extreme difficulty or safety concerns, physical impairments prevent ability to leave/enter home safely and easily, can leave the home with assist for medical treatments, religious events

Assisted living facility (ALF)

- Apartment style living with assistance as needed

- Handicap accessible

- No automatic level of therapy → Home health or outpatient

Independent living facility (ILF)

- Apartment style living

- No assistance needed

- Handicap accessible

- No automatic level of therapy → Home health or outpatient