Fieldwork Module 1 ICU & Acute Care OT Practice: Safety, Early Mobilisation, Documentation and Course Logistics

Safety‐First Mindset

• “Expect the best, plan for the worst.”
  • Visualise the worst-case scenario every time you mobilise a patient.
  • Mentally rehearse: “Where am I going if the patient buckles with $5$ lines, $O_2$ tubing, catheter, etc.?”
• Always aim for a landing surface other than the floor (bed, chair, wheelchair, commode).
• Ask for help early—use the call-bell, recruit nursing, RT, rehab techs.
  • Not a sign of weakness; even clinicians with $20$+ years’ experience still call.
• Confront “snarky” resistance professionally; patient safety > staff ego.

Personal Anecdotes & Professional Culture

• Early career reality: historical lack of onboarding (“Are you breathing? Have a licence? You’re hired.”).
• First day alone in burn unit created lasting respect for defaulting to safety & questioning.
• Least-favoured diagnosis to treat (emotional & physical load): acute spinal cord injury “with ventilator chaser.”

Course Structure & Progression

• Sync sessions mirror continuum of care: ICU/critical → acute → SNF/IPR → home health/outpatient → community.
• Goal: produce entry-level competence across all settings; discovering your personal “niche” is acceptable.

Session Objectives (ICU/Medically Complex)

• Identify safe-care methods in ICU.
• Explain value & evolution of early mobility.
• List ≥$3$ pieces of adaptive equipment useful in ICU (e.g., ceiling/track lift, multipodus boots, overhead trapeze).

Common ICU Environment – Lines, Wires, Equipment

• Expect multiple infusions (IV, arterial line, central/PICC) → observe rail “Christmas tree” of $4$–$5$ drips.
• Ceiling-mounted track/Heuer lift enables first mobilisations with minimal manual lifting.
• Ventilator alarms, high-pressure beeps: partner with RT; keep suction, ambu-bag nearby.
• Large abdominal incisions = higher gait-belt placement & log-roll strategies.

Early Mobilisation Paradigm Shift

• $\text{Pre-2000s}$ mindset: “Patient on vent ⇒ hold therapy until extubated.”
• Research now links immobility to:
  • Pressure injuries, contractures, delirium, cognitive decline.
  • ↑ ICU LOS, ↑ hospital LOS, ↑ readmissions.
• Early mobility correlates with:
  • ↓ Vent days, ↓ ICU stay, ↓ global de-conditioning.
  • Improved pulmonary, cardiac, musculoskeletal outcomes.

MD Anderson Early Mobilisation Algorithm (Key Points)

• Step $1$: Confirm order received.
• Screen for absolute contraindications (e.g., uncontrolled intracranial pressure, uncorrected DVT).
• If only relative precautions (e.g., abnormal labs, mild agitation) → discuss with team; may still proceed.
• Facility protocols may supersede algorithm; physician order is final authority.

Absolute vs. Relative Precautions

• Absolute = “No mobility today.”
• Relative = adjust plan, e.g., edge-of-bed (EOB) vs. standing/walking; document team consensus.

Sample Chart Review Checklist

• Verify OT order & weight-bearing status.
• Medical/surgical diagnosis, procedure notes (e.g., Whipple, CABG).
• Past Medical History (PMH) & risk factors.
• Vent settings, FiO$_2$, sedation scale (RASS), lines present.
• Recent lab values (H/H, platelets, Na/K, glucose).
• Prior Level of Function (PLOF), supports, home layout, community resources.

Bedside Scenario – Goal-Setting Example

Patient: $45$-year-old roof fall, bilateral leg fractures, pneumothorax; healthy pre-morbid.

• Eval: Max-assist sit→stand, stood $8$ s w/ RW; dizzy → sitting; A&Ox$3$; lives in single-story home ($2$ steps).
• STGs (within $1$ week):
  • Increase standing tolerance to $30$–$45$ s with Mod-A.
  • Perform toilet transfer with RW & Mod-A.
• Reassess frequently; goals are dynamic—surpassing goals early = rewrite higher-level functional aims (e.g., shower independence).

Clinical Reasoning Nuggets

• Co-treat OT/PT when tolerance is limited; one session may be all patient can handle.
• Engage RT for vented patients; suction, parameter changes in real time.
• Use edge-of-bed work for cognition, sitting balance, core activation when full standing unsafe.
• Emotional reality: initial doorway “deep breath” remains normal even after $5$, $10$, $20$ years.

Documentation & EMR Efficiency (Dr. Alteheath)

• Good notes = inter-professional communication, legal protection, reimbursement.
• Multiple EMRs (Epic, Cerner, WebPT, CRIS) combine: free text, check-boxes, drop-downs—learn them all.
• Custom Baylor PDF mimics mixed interface:
  • Demographics, Dx, PMH, meds, referring provider.
  • Precautions.
  • Subjective “client report.”
• Acute care goals ≠ SNF goals ≠ outpatient goals; adapt assessment tools accordingly.
• Efficiency tip: streamline template so you can remain present with patient, minimise screen-time.

Fieldwork / On-Site Simulation

• Upcoming on-site labs supply standardised patients & full lines/wires mock-ups—safe space to practice.
• Performance evaluated via FW Competency Eval (same rubric used in Level I A).
• Documentation competence is a graded element—begin practising with the PDF in advance.

Emotional, Ethical & Practical Implications

• Acute trauma = shared learning curve for patient & clinician; maintain supportive, non-fearful stance.
• Ethical priority: safety over ego, efficiency, or staff convenience.
• Recognise physical toll on therapist (back, knees); self-care & ergonomic aids (ceiling lifts) are vital.

Quick-Reference Equipment List (≥$3$ items)

• Ceiling/track lift.
• Rolling walker or hemi-walker sized for lines.
• Multipodus/post-op boots for pressure relief.
• Bed trapeze/over-bed bar.
• Reclining shower/commode chair.

Key Numbers & Fun Facts Captured

• $90$-day onboarding now common vs. $0$ days “back in the day.”
• Presenter’s $23$-year tenure in single acute job.
• First burn-unit exposure “$12$ minutes” post-graduation.
• Instructor still loves “solid medical model” after $20$ years.
• Course includes $6$ synchronous sessions.

Take-Home Mantras

• “Default to SAFE.”
• “What’s the plan, Phil?”—have a surface & exit strategy.
• Early mobilise: the data, the patient, and your own future self will thank you.