pte unit 5

The Acute Care Setting

§ Immediate, short-term medical
treatment
§ Acute illness, injury, or surgery recovery
§ Often involve a multidisciplinary team
§ Protocols and standards of practice and
safety

admission and Stay Criteria

§ Admission through ER or direct from physician
§ Based on:
§ Doctor’s judgment
§ Patient’s need for medically necessary hospital care
§ Room for the patient
§ Patient (or the responsible party) must agree
§ 23-hour observation
§ Expected LOS: 3+ days

Health Conditions Encountered

§ Deconditioning – Hospital acquired disorders
§ Neuromuscular disorders
§ Neurological
§ Neurosurgical
§ Cardiopulmonary disorders
§ Cardiac dysfunction
§ Pulmonary dysfunction
§ Immune system and Infection disease
§ Musculoskeletal/Orthopedic disorders
§ Trauma
§ Elective surgery
§ Vascular and Hematology
§ Transplantation
§ Integumentary and Wound Care
§ Burns
§ Oncological
§ Gastrointestinal
§ Endocrine
§ Genitourinary

Lines and Tubes

Role of the PT

§ Assess patient and determine likely
discharge location
§ Make recommendations
§ Equipment
§ Discharge transportation
§ Optimize functional abilities
§ Safety and fall prevention

Patient safety is top priority

§ Keep patient safe at all times
§ Comply with hospital initiatives to maximize patient safety
§ Understand patient safety goals established by the
Department of Health Services.
§ Guidelines:
§ Reduce rate of infections
§ Confirm correct patient
§ Use equipment in good working order
§ Follow protocols for use of AD and equipment

Regulatory Agencies

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
§ Ensure patient safety
§ Monitors state and federal legislative and regulatory initiatives
§ Occupational Safety and Health Administration (OSHA)
§ Health and safety of employees
§ Assess safety needs in hospital setting and enhances patient safe handling
§ Centers for Disease Control (CDC)
§ Aimed at protecting public health
§ Provides guidelines for contact and isolation precautions and personal protective
equipment (PPE)

Team Members Encountere

§ Physicians
§ Physician Assistant
§ Nurse practitioner
§ Nursing (RN, LPN, CRNA)
§ Psychologist/Neuropsych
§ Patient care managers (SW or RN)
§ Pharmacist
§ Therapists (OT, PT, SLP, RT)
§ Dietitian
§ Orthotist
§ Interpreter

Physician Hierarchy in Medical Centers

Attending
Fellow
Chief Resident
Resident
Intern
Medical Student

Interdisciplinary
Communication

§ Know the roles of the team members
§ Gather information
§ Be confident in your PT knowledge
§ Be clear, concise, confident, and objective
§ Show and expect respect

SBAR for Effective Communication

Situation
Background
Assessment
Recommendation

§ Standardized means for communicating in
patient care situations
§ Common and predictable structure
§ Can be used in any clinical domain

Introduction to SBAR

§ Situation: What is going on with the patient?
§ Background: What is the clinical background or
context?
§ Assessment: What do I think the problem is?
§ Recommendation: What do I think needs to be done
for the patient?

Current Challenges
in Acute Care

§ Sicker patients
§ Increased push for productivity

Chart Review

 Alertness
 Pain
 Motivation

 Preadmission screening (PAS) documentation
 Physician notes from previous facility
 Physical, Occupational, and Speech Therapy notes
 must have had evaluations from at least two disciplines for admission
 Functional Assessments
 Recent labs
 Recent imaging
 Discharge plan from previous location

Preadmission Screening (PAS)

 Patient's prior level of function (PLOF) before the event leading to rehabilitation need
 Expected level of improvement
 Evaluation of risk for clinical complications
 Conditions requiring rehabilitation
 Anticipated therapy needs (physical, occupational, speech)
 Expected discharge destination

Physician Discharge Summary

 Comprehensive summary of stay in previous setting
 Medical history relevant to rehabilitation needs
 Summary of labs, imaging, and course of care

Functional Assessments

 Documentation of patient's functional abilities across domains like mobility, self-care,
communication, and cognitive function
 Standardized assessment tools
 i.e. Perme-ICU or AMPAC 6-clicks from acute care hospital
 Cognitive assessments
 ADL based assessments

Interdisciplinary
Team Notes

 Communication between different
disciplines regarding patient progress and
care coordination
 Documentation of team meetings and
collaborative decision-making
 Documentation from case management
or social work for discharge planning

Discharge Planning

 Discharge destination and anticipated post-
discharge needs
 Patient and caregiver education regarding
discharge plan

Patient Interview

§ Communication with RN about patient status
§ HAND HYGIENE and infection control/PPE
§ Introduction to patient
§ Confirm patient identity
§ Explanation of your role
§ Description of session’s plan
§ Receipt of consent (if able)
§ Inquiry of patient experience and goals

Medical Record

§ General Demographics
§ Current Condition/Chief
Complaint
§ Medical/Surgical History
§ Family History
§ Medications
§ Other Clinical Tests

Patient / Caregiver Interview

§ Social History
§ Social/Health Habits
§ Employment/Work
§ Growth and Development
§ Living Environment
§ General Health Status
§ Functional Status and Activity
Level

Social History and Habits

§ Level of support:
§ Physical
§ Emotional
§ Financial
§ Identify roles and
responsibilities
§ Employment/work roles
§ School roles
§ Social roles
§ What IADLs do they
perform?
§ Cultural beliefs and
behaviors

Living Environment

Type of residence
§ Potential barriers associated with physical environment
§ Access and ownership of durable medical equipment
§ Who will be available to help?
§ Will the patient be returning to their primary residence?
§ Who will live with the patient upon discharge? What is their ability to assist
if needed?
§ If living alone, who will be available to assist if needed?

Functional Status and Activity Level

§ Abilities and need for assistance
§ Bed mobility
§ Transfers
§ ADLs
§ Ambulation
§ Endurance and activity tolerance
§ Ambulation distance
§ Prior exercise/activity regime
§ Fall history
§ Airway considerations
§ Use of AD
§ Use of other DME

Systems Review

§ Screening exams (brief systems review)
§ Discovering areas of deficit along with another
accurate knowledge of the condition

§ Cognition:
§ How did the patient respond when you
entered the room?
§ Alert? Aware? Oriented?
§ Cardiopulmonary:
§ Is there a monitor displaying values?
§ What equipment do you need to assess
vitals?
§ Are there parameters from the chart
indicating precautions/contraindications?
§ Integumentary:
§ What factors will influence your screening
of skin?
§ Health condition – sensation, motor
ability, cognition
§ LOS
§ Prior level of function and admission
with integrity issues
§ Observed positioning
Systems Review

Systems Review
§ Musculoskeletal:
§ What factors influence this screening?
§ Health Condition – motor function,
cognition, sensation
§ PLOF
§ Concurrent MSK conditions?
§ Risk of Contracture?
§ LOS- muscle atrophy
§ Neuromuscular:
§ What factors influence this screening?
§ Health condition – did it involve the CNS or
PNS causing primary impairments?
§ Age related changes
§ Impact of LOS- immobility
§ Multi-system exam for more complex
patients

Decision Making Time

§ Is this patient appropriate for a full PT
examination?

§ If NO…Now what?
§ Who do you communicate this with?
§ How do you document?
§ When will the patient be appropriate?

§ If YES….Then
§ Select appropriate test and measures
§ Select outcome measures as
appropriate
§ Begin formulating anticipation of
response to activity
§ Begin hypothesizing potential
discharge destination

Decision Making Time
Patient IS appropriate for PT exam:

§ Select appropriate test and measures
§ Select outcome measures as appropriate
§ Begin formulating anticipation of response to activity
§ Begin hypothesizing potential discharge destination

Examination

Examination : Selection of
Tests and Measures

Cognition

§ Orientation:
§ Name
§ Current location
§ Month/day/year
§ Reason for admission
§ STM: Ask patient to repeat your name and discipline
§ Glasgow Coma Scale
§ Mini-Mental State Examination

Integumentary

§ Color and temperature
§ Positioning for relief
§ Wound assessment
§ location
§ size
§ classification

Neuromuscular

§ Cranial Nerves
§ Muscle Tone
§ Coordination
§ Reflexes
§ Sensation
§ Vestibular
§ Motor Function

Cardiopulmonary

§ Respiration
§ Heart rate
§ Blood pressure
§ Edema
§ O2 saturation
§ ECG observation
§ Posture/Chest expansion
§ Cough
§ Auscultation

Musculoskeletal

§ Range of motion
§ Muscle performance
§ Anthropometrics

Pain Assessment

§ Intensity
§ Quality
§ Location
§ Pain Scales
§ Numerical Rating Scale
§ Wong-Baker FACES
§ FLACC Pain Scale

FLACC Pain Scale

Functional Mobility Examination

Patient's Response

Constantly monitor the patient's response to
activity
§ Vital sign response
§ Emotional/behavioral response
§ Communication response
Guides progression of plan of care
Informs decisions about interventions

Documentation for patient NOT
appropriate for full exam

Patient evaluation attempted, however after reviewing medical chart,
communicating with nurse, and reviewing the patient’s systems, pt was displaying
uncontrolled heart rate and rhythm, effortful breathing, and complaint of dizziness
and headache. Pt did not appear medically stable therefore eval deferred at this
time. Plan to reattempt

Communication for patient NOT
appropriate for full exam

Verbally communicate with the RN
§ Uncontrolled heart rate and rhythm
§ Effortful breathing
§ Headache
§ Dizziness
Request pt status be assessed by RN and/or physician

Barriers to Implementation

 Too time consuming for patients to complete
 Too time consuming for therapists to analyze
 Too difficult for patients to complete independently

Outcome Measures in
Acute Care

 May only be performed at intake
 Often concise
 Used to assist with discharge planning

Acute Care Specific Outcome
Measures

 Activity Measures for Post Acute Care (AM-PAC)
 AM-PAC “6 clicks”
 Acute Care Index of Function (ACIF)

Activity Measure for Post Acute
Care (AM-PAC)

 Assesses activity limitations based on ICF framework
 Measures three domains
 Cognitive
 Activities of Daily Living
 Basic Mobility
 Patient or clinician report

AM-PAC “6 clicks”

 Shortened form of AM-PAC
 Assesses 6 mobility domains
 Bed mobility
 Sit to stand
 Supine to sit
 Seated transfers
 Ambulation
 Ascending stairs
 Helps predict discharge destinations

Acute Care Index of Function (ACIF)

 Assesses basic mobility, metal status
impairments, and activity limitations
 20-items
 Score: 0 to 1
 Assists in discharge planning

Outcome Measures: Balance and Fall Risk

Outcome Measures: Cognition

Glasgow Coma Scale
 Assesses
consciousness
 3 items (eye response,
verbal response,
motor response)
 Score 3 – 15
 <9 indicates severe
brain injury and coma
states
Mini-Mental State
Examination
 Assesses 5 cognition
functions (orientation,
registration,
attention, calculation,
recall, and language)
 11 items; Score 0 - 30
 <24 indicates
cognitive impairment

Evaluation

 Organization and analysis of
data collected from the
initial examination
 Leads to the
development of a
problem list
 An accurate evaluation
supports the therapist’s
ability to determine a
diagnosis and prognosis and
develop a plan of care

Example Problem List for Acute Care

Goals of Acute Care Physical Therapy

 Facilitation of transition to next level of care
 Promotion of recovery
 Minimize functional limitations and disability
 Safety and fall prevention
 Reduction of length of stay

Example Goals in Acute Care

STG:
 In 3 days, patient will be able to perform sit to stand from EOB with min A or less while
maintaining sternal precautions to reduce risk of re-injury.
 In 3 days, patient will be able to maintain static standing balance at EOB with no UE
support for 2 minutes with SBA to reduce risk of falls.
 In 3 days, patient will be able to ambulate 50 ft across level ground with min A to improve
independence

discharge plan

successful d/c plnning

PT important role

entry level d/c planning

possible recommendations

home health

homebound criteria

snf

homebound criteria from snf

irf

ltac

op

other recs

Reviewing Medical Chart

§ Activity Orders
§ Precautions
§ Weight Bearing: LE/UE
§ Sternal
§ Spinal
§ Fall Risk

braces

Cervical Orthoses: Minimal to Moderate Control

§ Soft Collar – whiplash, cervical weakness
§ Rigid SOMI collars (ex. Philadelphia, Aspen, Miami-J)
§ Stable cervical fractures; limits flex, ext, lateral flexion and rotation

Cervical Orthoses: Maximum Control

Halo
§ Fixed to skull with 4 screws
§ Donned following facet subluxations and dislocations
that have been reduced with traction

Minerva
§ Non invasive
§ Donned following cervical fractures

Thoracic Orthosis

Cash extension brace
§ Donned following a compression fracture

Jewett
§ Restricts flexion and encourages hyperextension
§ Limits rotation and SB to some degree
§ Improper adjustment could lead to pressure on throat or genitals in sitting

Knight-Taylor
§ Rigid frame worn posteriorly

Molded Thoraco-Lumbo-Sacral Orthoses (TLSO)

§ Maximal stability to trunk
§ Limits all planes of motion
§ Thigh extension (spica) for immobilization at and below L5
§ At or above C8- shoulder outriggers or cervical extension

Hip Abduction Orthosis

§ Used for total hip revisions or to ensure hip precautions (i.e. patient with dementia)

Characteristics of an Acute IRF

 Intensive, round-the-clock care
 Typically provided in a hospital-based rehabilitation facility
 Licensed as a hospital
 Nurse to patient ratio typically is 1:5 or 1:6
 Physiatrist (DO/DM) sees patients daily
 Therapy in two or more disciplines at minimum 15 hours per
week
 Reasonable expectation of significant functional
improvement

Goals of IRF

 Promote Independence
 Prevent Complications

Patient Diagnoses: IRF

 Severe injury
 Post surgery
 Post illness
 Rehabilitation units include:
 Stroke/CVA
 Spinal cord injury (SCI)
 Traumatic brain injury (TBI)
 Amputation/Medical complex

History After a Chart Review

Reconciliation of charts
Confirmation with patient and/or family
Focuses the review of systems with patients

Communication
Screening

 Communication ability
 Affect
 Language
 Cognitive ability
 Learning preferences

Review of Systems –
Major Body Systems

 Cardiopulmonary system
 Endocrine system
 Gastrointestinal system
 Hematologic/lymphatic
system
 Immune system
 Nervous system
 Musculoskeletal system
 Integumentary system
 Genitourinary

Patient Interview

Initial interview > shared decision making
 Identify the nature and history of the current problems
 Engage the patient in treatment planning
 Identify desired outcomes in terms of functional activities
 Identify environmental conditions where activities occur
 Identify available social supports
 Identify patient’s knowledge of current condition and
potential disablement risk factors

Systems Review

Cardiovascular: shortness of breath, chest pain or pressure, irregular heartbeat, leg cramps,
measures of heart rate, blood pressure, temperature, pedal pulses
Pulmonary: shortness of breath, difficulty breathing, cough, wheezing, breathing pattern,
respiratory rate, oxygen saturation
Integumentary: skin pallor/color, temperature, integrity, pliability, scar formation
Endocrine: fatigue, recent weight loss or gain, blood sugar anomalies
Neuromuscular: numbness, pins and needles, weakness, dizziness, problem with
balance/falls, headaches, loss of consciousness, visual changes, gross sensory or gross reflex
changes

CARE Tool

Inpatient Rehabilitation
Facility Admission

 Administrative
 Prior level of function
 Pertinent discharge information
 Hearing and speech
 Cognition, mood, pain
 Functional abilities and goals
 Diagnosis
 Bowel and Bladder function
 Health conditions
 Nutritional status
 Skin conditions
 Medications

CARE Tool Functional
Domains

There are two sections for
health professionals to
complete

Prior level of function

Admission/goals/discharge

CARE Tool Scoring – Prior level
of function

Mobility CARE Scoring
Admission/Goals/Discharge

CARE Tool Scoring

Examination Progression

 PT Objective Examination
 sensation, strength, range of motion
 transfers
 gait or wheelchair
 All of Section GG: scored within three (3) days
of admission
 Constantly evaluate patient safety, insight,
and judgment

Sensation, ROM, and Strength Testing

 Review techniques from previous coursework
 Overall muscle grade for major motions
 i.e. hip flexion 4/5 or knee extension 3/5
 Overall sensation grossly intact/impaired
 Include level that sensation is impaired, i.e. stocking
glove pattern to popliteal space
 Overall range of motion intact/impaired with estimation
 i.e. knee flexion contracture ~10-15 degrees

Insight and Judgement

QRP and Section GG of the IRF PAI

 Inpatient Rehabilitation Facility Quality Report Program Measure
(IRF QRP)
 IRF Patient Assessment Instrument (IRF PAI)
 Multi-page document for all disciplines to contribute to
 Reported to Medicare
 Influences payment/reimbursement and scores
 Also Known As: The CARE tool or Quality Indicators (Qis, QI codes)
 Section GG for Physical, Occupational, Speech Therapists as well
as nursing staff

Example of Section GG: Functional Abilities

Functional Independence Measure (FIM)

 Measures level of disability
 Administered by observation or interview
 Determine functional status based on level of assistance required
 18 items
 13 motor tasks
 5 cognitive tasks
 Scoring
 Minimum: 18
 Maximum: 126

FIM Scoring Language

 7 Complete Independence (no helper, timely and safely)
 6 Modified Independence (uses a device with no helper, or needs a bit of extra time/safety)
 5 Supervision (patient completes 100% physical burden of care, does require eyes on and verbal
cues, whether intermittent or constant)
 4 Minimal Assistance (patient completes at least 75% of burden of care)
 3 Moderate Assistance (patient completes at least 50% of the burden of care)
 2 Maximal Assistance (patient completes at least 25% of the burden of care)
 1 Total Assistance (patient completes less than 25% of the burden of care)
 Also called not testable, or requires a second person

Section GG Scores

Section GG Items

Section GG Items Continued

Decision Tree
Section GG