L1: Intro to Acute Care PT

What makes acute care physical therapy different from other settings?

• Schedule

• Setting

• Role

• Point of Care Clinical Decision Making

• Focus of Tx

• Goals

Discuss the schedule of an acute care PT.

• Acute care PTs do not have a set schedule like in outpatient

• Instead, they have to prioritize who is seen first (because you may not be able to see everyone)

Discuss the setting of an acute care PT.

• Typically located in the hospital (but think of the hospital as a "state")

• However, most hospitals do not have a gym

• We will be working in the patient's room, hallway, stairwells, etc.

Discuss the (general) role of an acute care PT.

• Acute Care PTs are ""discharge planners""

• Acute Care PTs goal is to discharge you so you have a shorter length of stay in the hospital (which is good for both the patient and hospital)

Discuss the focus of treatment in acute care PT.

• When you get to a patient, you don't know exactly what you will be doing until you get to the patient and see their status, etc.

• As a PT, you may have an idea/plan, but that can quickly change depending on their physiologic state

  • We want them to do as much as they can 

• Therefore, we need to be ready for progression and regression

Discuss the goals of acute care PT.

• Increase function, strength, mobility, ROM, etc.

• We want these increased so we can discharge 

• It is important to note that in PT, goals are function-based

As acute care PTs, we need to determine the patient's ________ to exercise in the presence of ________ and link this to the patient's ability to complete ________

Physiologic response, Medical instability, Functional Mobility

What is response dependent care?

• Real time decisions based of the patient's current presentation

  • We decide what interventions to perform or if treatment needs to be stopped, etc. based on their physiological response

• There is an assumed degree of physiologic/medical instability

What are the five core competencies in acute care PT?

• Sound Clinical Decision Making

• Safety

• Skills

• Discharge Planning

• Communication

What is the core competency of sound clinical decision making?

• Predict patient presentation and anticipate needs

• Screen medical record for PT benefit

• Choose appropriate examination and interventions (response dependent care)

• Be observant of patient history, physical examination, and environment

What is the core competency of safety?

• Determine preliminary precautions list and plan

• Anticipate when movement might compromise medical stability

  • Want to perform the "right treatment at the right time"

• Line management

• Use of PPE

• Environmental management (create more space)

What is the core competency of skills?

• Patient management (right patient, right time, right setting)

• Gather and interpret medical information to determine appropriateness

• Determine the urgency of communication

  • Do I need to verbally communicate with other HCP right now?

  • Or is it something that I can leave in the notes / chart?

What is the core competency of discharge planning?

• Destination

• Level of Support

• Need for Continued Services

• Safety / Equipment

Does every patient in the hospital need PT?

• Not necessarily!

• If deficits will resolve spontaneously as natural recovery occurs → probably do not need PT

What is the core competency of communication?

• Select the most appropriate style for patient

• Communicate clinical decisions to team

• Collaborate with IPE team

• Use effective strategies (SBAR) for communication

Studies have shown that patients are ________x more likely to be re-admitted when the ________ discharge recommendations are not implemented

2.9x, therapist’s

What is the Hospital Re-Admissions Reduction Program?

• Medicare program that acts an incentive to cut down preventable re-admissions

• They will not re-imburse the hospital as much when a patient is re-admitted for the same condition within 30 days

• This applied to select conditions (PNA, COPD, AMI, HF, CABG, Elective THA, TKA)

• It does not consider patient adherence to the plans that their medical team has made

  • e.g., if someone with HF continues to eat a salt-heavy diet despite the medical care plan advising them not to

Discuss the generic flow of hospital operation. Think of if you were a patient, where do you start? Where do you end?

• Patient starts in the ER, is met by someone in intake, nurses, and ER doctor where tests are ordered and run (and eventually read by doctor)

• At this point, it is decided whether the patient will be admitted, remain under observation, or be discharged (and told they can leave the hospital)

  • On average, it takes about 6-8 hours for this process and even longer to actually get admitted

• The order in which the medical staff sees the patient is dependent on the acuity of that patient's condition, as well as other patient's acuity who are coming into the ER

  • If your level of acuity is pretty low, and five people come in that have a much higher level of acuity (e.g., gunshot wound), they will essentially get moved to "the front of the line" 

Where does a PT work with / see patients in the hospital?

• Most often, once a patient has been admitted, there will be an order for a PT (so often see in hospital room, etc.)

• A patient may be seen in the ER in case of dizziness, mechanical back pain, etc.

What does Medicare Part A cover?

• Covers the following when considered medically necesary to treat a disease or condition

• Services:

  • Lab Tests

  • Surgeries

  • Doctor Visits

• Supplies:

  • Wheelchairs

  • Walkers

What settings does Medicare Part A typically apply to?

• Inpatient Hospital Services 

• Home Health Services

• Skilled Nursing Facility (under certain conditions)

What conditions need to be met for Medicare Part A to cover a Skilled Nursing Facility? How does the coverage work?

• 3 night stay and admission status (before benefit kicks in an allows them to go to SNF)

• Some insurances requires pre-certification before acceptance

  • They want to see PT eval to see if patient meets the threshold for skilled care

• Coverage:

  • Nights 1-20 at 100% coverage

  • Nights 21-100 at 80% coverage

• There was a waiver in 2021 d/t COVID and needing to discharge people from the hospital sooner

What is a Diagnostic-Related Group (DRG)?

• System used to classify hospital cases into a group based on International Classification of Disease (ICD)

• Each DRG has a payment weight assigned to it, which is based on the average resources used to treat Medicare patients in that DRG

• Assumes that patients within each category are clinically similar and are expected to use the same level of hospital resources

  • Does not consider pre-existing or co-morbid conditions

What is Observation Status?

• Evaluation of a patient's condition to determine if admission is reasonable and medically necessary

• Documentation should support observation status
  

If someone is under observation status, how are they being billed? [Hint - think Medicare]

• Billed as outpatient services (Medicare Part B)

• This is more expensive because in Medicare Part B everything is itemized (so paying for each individual test, etc.) rather than a deductible with Medicare Part A

What is the purpose of observation status?

• To determine the NEED for inpatient services or to evaluate a patient's condition

• Want to avoid unnecessary hospital admissions

Describe a Level 1 Trauma Center. What does it provide? What is required (to be considered a Level 1)? Etc.

• Provides the highest level of surgical care to trauma patient

  • "Specialists are here"

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

• Required education program, and preventive and outreach programs

• Typically these are larger (1,000+ beds)
  

Describe a Level 2 Trauma Center. What does it provide? What is/is not required (to be considered a Level 2)? Etc.

• Works in collaboration with a Level 1 trauma center 

  • Probably has some sort of transfer agreement with a Level 1 (if patients are too severe / specialized for them to treat)

• Provides 24-hour availability of all essential specialities 

• Not required to have an ongoing program of research

Describe a Level 3 Trauma Center. What does it provide? What is/is not required (to be considered a Level 3)? Etc.

• Does not have the full availability of specialists, but does have resources for emergency resuscitation, surgery, and intensive care for most trauma patients

• Has transfer agreements with Level 1 or Level 2 trauma centers that provide back-up resources

• Example: Rural or Community Hospitals

  • Typically smaller (250 - 300 beds)
    

Describe a Level 4 Trauma Center. Where does it exist? What does it provide?

• Exists in some states where the resources do not exist for a Level 3 trauma center

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

Describe a Level 5 Trauma Center. What does it provide?

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

• May not even be open 24 hours a day

• Will have an after-hours trauma response protocol

What is the job of a 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

What is the job of a social worker?

• Resolves the social, financial, and psychological problems related to their health condition

• Degree in social work required

• Can also be a case manager (but a case manager cannot be a social worker unless proper degree)
  

What is a Certified Nurse Practitioner?

• RN with advanced training

• Can examine, diagnose, order and interpret tests, prescribe medicine, and initiate treatment

• (think of them essentially like a doctor)
  

What is a Registered Nurse allowed to perform / do?

• Medicine administration

• Interpretation of physician orders

• Assessment

What is a Licensed Practical Nurse allowed to perform / do?

• Basic Medical Care

• Patient Status Reporting

What is a State Tested Nursing Assistant (CNA) allowed to perform / do?

• Change linens

• Take vitals

• Walk patients

• Assist with ADL's

• Communicate with RN regarding patient's status

What is the difference between walking and gait training?

• Walking = just getting them mobile 

• Gait Training is skilled care 

  • May be working on endurance and need to check vitals

  • Educate the patient on breathing exercises

  • How to pace their walking

  • How to use an assitive device during walking

  • Etc.

What is considered Skilled Physical Therapy?

Rehabilitative therapy 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 realize improved function

Where can Acute Care PT occur?

• Intensive Care Unit (ICU)

  • RN/Patient Ratio = 1:1 or 1:2

• Post-Intensive Care Unit (PICU)

  • RN/Patient Ratio = 1:3 or 1:4

• Special or Stepdown Care Unit (SCU) = 1:5 or 1:6

• General Medical

  • RN/Patient Ratio = 1:10 to 1:12

• Can also occur in pediatric, ortho, neuro, and emergency department

The level of nursing changes with ________

the floor the patient is on

Higher level of care required = more likely to have one nurse per patient
This is definitely the time to communicate with nurses about whether to initiate care before working with patient

What are Seizure Precautions?

• Seizure pads on bed at all times

• All bed-rails up

What are Contact Precautions?

• Spread through close or direct contact with either animate or inanimate object

• PPE Required:

  • Gown

  • Gloves

  • Hand Sanitizer or Wash Hands

• Specific dedicated equipment required

• Diseases: scabies, lice, MRSA, VRE, bed bugs

What are contact plus precautions?

• Used for diseases that are spread through close or direct; and either animate or inanimate objects

• PPE

  • Gown

  • Gloves

  • Hand Washing (hand sanitizer is not sufficient)

• Dedicated Equipment

• Disease Examples: Clostridium Difficile

If a patients has transmission based precautions, what is required if the patient leaves the room?

• Patient must put on required PPE

• PT must take off the PPE that was on in the room

What are droplet precautions?

• Spread through air short distances via large particles

• PPE:

  • Surgical Mask

  • Protective Eye Wear

  • Gloves

  • Hand Sanitizer or Hand Washing

  • Some facilities may require a protective gown
    

• Dedicated Equipment; Patient has private room

• Disease Examples: Pertussis (whooping cough), rubella, influenza

What are airborne precautions?

• Spread through air via small particles

• PPE:

  • N95 Tests Mask or PAPR

  • Protective Eye Wear

  • Gloves

  • Hand Sanitizer or Hand Washing

  • Some facilities require protective gown
    

• Dedicated Equipment; Negative Pressure Room w/ Closed DOors

• Disease Examples: Tuberculosis, Rubella/Measles, COVID-19

What is a negative pressure room?

• Air from the room gets "pumped" outside 

• It does not get recirculated to other rooms in the hospital

Discuss latex allergies. What are the signs and symptoms? What equipment may contain latex?

• Immediate or Delayed Reaction

• Signs and Symptoms:

  • Urticaria, Contact Dermatitis, Naso-Rhinitis, Upper Respiratory Tract Irritation, Conjuctivities, Local Angioedema, Asthma, Hypotension, and Anaphylaxis

• Products/Equimnet Containing Latex:

  • Gloves, Stethoscopes, BP Cuffs, Ambu Bags, Adhesive Tape, Electrode Pads, Hand Grips on ADs

What potential indications for the use of restraints?

• Unconscious but rousing sometimes with multiple invasive lines

  • We do not want the patient waking up and pulling out the lines

• Altered Mental Status (AMS)

• Risk for pulling out lines / tubes

• Unsafely mobile

• Physically aggressive

• Too active / agitated that medical needs cannot otherwise be met

• Can be chemical or physical

The use of restraints requires a ________

Physician order updated every 24 hours

Restraints can be ________ or ________

Chemical, Physical

What is a chemical restraint?

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

• Often side effects do not allow patient participation in skilled PT services (e.g., patient becomes lethargic, etc.)

What are physical restraints?

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

• Can Include:

  • Wrist/Ankle/Mitt/Vest Restraints

  • Four bedrails

• Always use a slip-knot tied to an immovable, unreachable area

With physical restraints, how do we know if it is too tight / loose?

We should be able to place 2 fingers between skin and restraint

Why do we always use a slip-knot for physical restraints?

• Allows for some movement (but not all movement)

• It allows to quickly fasten or un-fasten restraints for any purpose needed

What does it mean if someone's code status is a full code?

All measures taken to preserve life

What does it mean if someone's code status is DNR-CCA?

• Do Not Resuscitate -- Comfort Care Arrest

• A dying person receives treatment (see additional handout) until cardiac or pulmonary arrest, at which Comfort Care (CC) measures are taken

What does it mean if someone's code status is DNR-CC or CMO?

• Do Not Resuscitate -- Comfort Care / Comfort Measures Only

• A dying person receives comfort measures, but no resuscitation measures to save or sustain life

  • E.g., can give O2, morphine, etc. so patient is not in pain / suffering

• Typically no PT services

What does it mean if someone's code status is DNI?

Do Not Intubate

What is a medical power of attorney?

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

What is a living will?

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

Considering discharge planning, what would acute physical therapy include?

• Hospitalized Patients

• Physical Therapy delivered on medical floors

  • In rooms or hallways

• 15 - 60 minutes

• QD (1x day) or BID (2x day)

Considering discharge planning, what would long term acute care include?

• Specialty-Care Hospital

• Medical problems require specialty treatment for an extended period of time (20-30 days)

  • Example: burns, respiratory failure with continued ventilator needs, wound care

• Require ongoing medical care, but no longer require intensive or diagnostic procedures

What are the admission requirements for inpatient rehabilitation?

• 60% of patients must have a qualifying diagnosis

• Patient must have certain degree of rehabilitation potential where after inpatient rehabilitative care they will be able to go home (not to SNF, etc.)

What are the qualifying diagnoses for inpatient rehabiliation?

• CVA, TBI, SCI

• Bilateral joint replacement, amputation, femur fracture with comorbidities, severe OA

• Congenital deformities

• Neurologic disorder

• Multiple Major Trauma; Burns

• Active Polyarticular RA

• Systematic Vasculidities with Joint Inflammation (e.g., Lupus)

Considering discharge planning, what qualifications must individuals meet to receive inpatient rehabiliation?

• Patient must

  • Have a qualifying diagnosis

  • Be able to tolerate 3 hours of therapy / day, 5 days / week

  • Require at least 2 disciplines (PT, OT, ST)

    • At least one must be PT or OT 

  • Have a safe discharge deposition that is not a SNF, etc.

  • Demonstrate ability to learn (must be mentally aware, etc.)

  • Require close monitoring by a physician

  • Have ability to make significant functional gains

How often does therapy occur if you are in inpatient rehabiliation?

Therapy 5-6 days a week (typically about 3 hours / day)

What is the typical length of stay for a patient at an inpatient rehabiliation facility?

7-21 days (average)

Tyically has a shorter length of stay compared to a SNF whose average stay is 30+ days

Considering discharge planning, what would a skilled nursing facility include?

• Less Intensive Therapy

  • Not an inpatient rehabiliation candidate

  • Not diagnosis specific

• Therapy occurs 1-3 hours / day

• PT, OT, ST

T/F: If a patient does not qualify for inpatient rehabiliation, but requires skilled therapy, the best option is a SNF

False

Depends on context! If you have good family support, the patient may do better (and heal faster) at home. (This is because sometimes at a SNF you coudl only get 30 minutes of care a day)

Considering discharge planning, what would long-term care include?

• Also known as an extended care facility (ECF)  

• Includes residents of a nursing home

  • (patient lives at this location)

• May or may not have therapy

  • This patient will either go to outpatient PT or Home Health PT

Considering discharge planning, what would outpatient rehabiliation include?

• Patients live at home 

  • Residential

  • Assisted Living Facility

  • Independent Living Facility

• Patient seeks services at outpatient facility specifically

Considering discharge planning, what would home health services include?

• Must be home bound to be eligible (cannot be a transportation issue)

  • 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 or religious events 

• PT is delivered in the home
  

Considering discharge planning, what would an assisted living facility include?

• Apartment style living with assistance as needed 

• Handicap accessible

Considering discharge planning, what would independent living facility include?

• Apartment style living, no assistance needed 

• Handicap accessible