Acute Care Considerations Flashcards
Competencies for Practice in Acute Care
for Physical Therapists
Clinical decision making
Patient Management
Communication
Safety
Discharge planning
Elements to collect and synthesize
Determine patients level of support- physical, social,
emotional
Previous PT
Baseline and Prior Level of Function- endurance, assistance,
fall history, activity level, airway
Risk analysis of possible abuse
Equipment
Discharge plans
Systems Screen
Monitor vitals
Exam based on medical record
Multisystem exam for more complex patient
MSK
Integ
Cardiopulm
Neuro
Cardiopulmonary:
edema
respiratory rate
heart rate
heart rhythm
blood pressure
oxygen saturation
jugular venous distension
ECG
observations/telemetry
dyspnea
posture/chest shape
cough
sputum/hemoptysis
nail appearance
auscultation
supplemental O2/ respiratory
equipment
Musculoskeletal:
strength/myotomes, ROM, posture
Neurologic:
balance
gait quality
cranial nerves
vision
tone
coordination
reflexes
sensation
tremor
vestibular testing
Integumentary:
edema
skin integrity
burns/wounds
sensation
capillary refil
Acute Care Interventions
Therapeutic Exercise
Functional mobility training
Locomotor training, as indicated
Neuromuscular re-education
Therapeutic Exercise =
Strength
Aerobic/ endurance/cardiac/
pulmonary
Flexibility
ROM
Functional mobility training =
Rolling
Scooting
Supine to/from sit
Sit to/from stand
Transfers between surfaces
bed to chair, wheelchair to commode
Pressure relief
Locomotor training, as indicated =
Gait training, with or without assistive devices
Stair training
Wheelchair mobility & management
Neuromuscular re-education =
Balance
Coordination
Vestibular interventions & exercises
Other Interventions =
Manual Therapy
Posture Training
Orthotic/prosthetic fitting/training
Functional activity training
Airway clearance, pelvic floor, respiratory muscle training
Biophysical Agent
Select and perform appropriate education intervention for patient, family or other caregiver:
Role of therapy
Impairments/ limitations
Barrier modification
Health/injury risk factor modifications
Adaptive equipment
Energy conservation
Pain management
Relaxation techniques
Safety
Precautions
Fall prevention =
Functional mobility training
Caregiver training
Home exercise program
Positioning/pressure relief
Discharge recommendations
Plan of care
Acute Care Examination
Pain
Functional mobility
Cognition
Speech and language ability
Appearance
Pain:
at rest; with activity; with recovery; quality of pain; interventions to address pain
Functional mobility:
rolling; supine to/from sit; sit to/from stand; transfers;
ambulation; stairs; curb; wheelchair mobility
Cognition:
arousal; orientation; attention; memory; calculation; language;
construction; abstraction; speed of processing; problem-solving; motor
planning; command following; delirium; and Confusion Assessment Method (CAM) positive
Speech and language ability:
aphasia, word finding, apraxia, dysarthria
Appearance:
skin color; muscle wasting/temporal atrophy; positioning upon
entering room
Safety Planning:
Consider and anticipate
compromised medical stability
Use appropriate PPE
Screen for safety with mobility
* Gait belt, slipper socks, scan room
environment, lines and tubes
Integrate and interpret information
from multiple sources
* Chart, vitals, patient response, labs, , meds
Safety Equipment:
Ask for assistance and use safe handling equipment when needed
Respond to emergent needs
Basic understanding of equipment
*Vent, IV, bed alarms, WC, call bells
Select communication style based on:
age, learning style, cognition, communication needs
Collaborate with team:
Situation Background Assessment Recommendation:
SBAR
Documentation and Electronic Medical Record
Official record of the patient’s past and current status along with a documentation of all procedures the patient has experienced
One of the primary sources of patient information for the PT to gain information about the patient as well as to share pertinent details of the
patient’s therapy session
Maintain confidentiality of protected health information based on ethical and
regulatory guidelines, including HIPAA and the APTA Guide from Professional
Conduct and Code of Ethics
Medical Record Review
Confirm PT orders
Admission note: H&P from other providers
Patient demographic: Age, Gender, Height/weight
Admission date and reason for admit
Past medical history
Reason for PT consult
Information pertaining to discharge (ex: prior level of function, home setting)
Social history, including home set up
Consult/specialist notes
Lab values
Vital signs
Retrieve =
Gather and analyze medical information to determine an image
of the patient to determine prognostic and management
strategies
Gather data on timing to see patient, if mobilization is
indicated
Document =
Clear documentation that reflects decision making
All relevant aspects of patient encounter to be understood by
team
Immediately following care
Use judgement if oral and written communication is necessary
Levels of Care
IIntensive Care Unit (ICU)
Acute Care Unit (ACU) = Hospital, Medical Center
Acute Rehabilitation Facility (ARF)
Inpatient Rehabilitation Facility (IRF)
Sub-Acute Rehabilitation Facility (Sub-acute)
Skilled Nursing Facility (SNF)
Long-Term Acute Care (LTACH)
Home with Home Health
Home with Outpatient
Home
Acute Care =
Short LOS
PT value added service
Hospitalist and Interventionist
Wide variety of patient conditions, team
Complex patient population
Set goals to prepare for DC and educate
Bedside Care
Levels of Care- Critical Access, Trauma Center, Academic Medical Center
Patient Treatment Sessions:
Acute Care: Patients receive minutes per day of treatment, often focused on stabilizing immediate medical concerns.
Subacute Care/Inpatient Rehab: In contrast, hours per day of therapy are provided, especially in inpatient rehabilitation, where patients engage in more intensive therapy sessions.
Length of Stay:
Acute Care: Patients typically have a short stay of a few days due to the high acuity of their conditions, and the focus is on stabilizing them before discharge or transfer.
Inpatient Rehab: Patients stay for a few weeks, as the goal is more focused on recovery and rehabilitation, often post-acute care or surgery.
Patient Acuity:
Acute Care: Patients in this setting are typically very ill or post-surgical with immediate, critical medical needs.
Subacute Care/Inpatient Rehab: Patient acuity decreases as they improve, requiring less intensive medical care but more rehabilitation support.
Number of Patients:
Acute Care: The environment is high-volume, fast-paced, and unpredictable, as many patients are seen for urgent or emergent conditions.
Inpatient Rehab: The patient volume is lower, and treatment is more scheduled and coordinated to meet the rehabilitation needs of each patient, often with structured sessions.
Intensive Care Unit =
Life-threatening injuries and illnesses
Team of specially-trained health care providers -> 24 hour care
Function and Mobility in the ICU
Acute Rehabilitation & Inpatient Rehabilitation =
patient requires and is able to tolerate and participate in a comprehensive
level of rehabilitation services
(3 hours minimum of rehab)
requires close rehabilitation medical supervision and available 24- hour daily
medical attention
Necessary services cannot be provided in an alternative, less costly, setting
Cannot access necessary care outside a comprehensive rehabilitation setting.
ARF & IRF
Interdisciplinary specialized care
Physiatrist or equivalent > 3days/week, available 24/7 for emergencies
24 hour rehabilitation nursing care
Need for > 2 disciplines PT/OT/SLP
Must also have SW, psychology, rec tx, access to voc rehab,
prosthetics/orthotics
ARF Therapy Requirements
Tolerate > 3 hours PT/OT/SLP 5 days/week or 15 hours/week
Need at least 2 disciplines
Benefit from > 3hours of therapy (active participation)
Measurable improvement
ARF D/C
Intended as a relatively brief start to rehab
LOS typically 5-30 days
Expected discharge: SNF or Home
IRF D/C
Intended as a longer stay then ARF
LOS typically 2 weeks - 2 months
Expected DC: SNF or Home
ARF & IRF - Advantages
Inter-disciplinary team
Specialized care
Focus on community re-entry
Availability of hospital services
Capitated reimbursement
encourages short LOS
ARF & IRF - Disadvantages
Cost $$$$$
Too fast-paced for many patients
Hospital-based (not home)
Long Term Acute Care Hospital
(LTACH)
Chronic Hospital
Patients need acute care services long-term
> 28 days average length of stay
Often used for ventilator care, wound care, TBI (esp. coma stim)
Subacute rehab
Can be in a hospital transitional care unit (TCU) or in a skilled nursing facility
(SNF)
Need skilled nursing or therapy
Covered for 100 days maximum Medicare
Paid per diem—incentive to keep patients longer
Typically 1-2 hours PT/OT/SLP daily
Often 1-2 RN/shift + CNAs
Limited nursing care, infrequent physician visits
Subacute rehab - Advantages
Cost ¢¢
Can stay longer if needed
Option for residence post-discharge
Subacute rehab
Long LOS
Less therapy
Limited RN
Limited physician visits
Away from hospital services (unless
TCU)
NH environment
High rehospitalization rates
Skilled Nursing Facility
(SNF)
Not skilled care
Considered resident’s “home”
Rules accordingly
Typically after SAR stay (after 100 days exhausted in SNF)
NO PT/OT/SLP paid for
Residential
Disabled or elderly patients with limited family support
Home care
Must be unable to leave home for rehab services -> strict criteria
Medicare pays capitated rate
Typically 2-3 x/week visits
Limited home health aide coverage(typically 5-10 hours/week)
Home care - Advantages
Cost ¢
Convenience
Adaptation to home setting
Slow paced
“No place like home”
Home care - Disadvantages
More expensive than OP tx
Limited equipment
Less aggressive
Limited goals
Need for family support
Nursing care primarily for teaching
family to do care
Outpatient care
Mobile patients
Varied settings—hospitals, free-standing
Can be sub-specialized — e.g., sports, neuro, cancer, male/female health issues
Can be up to 5 days/week
Outpatient care - Advantages
Cost ¢¢
Community level goals
Equipment
Outpatient care - Disadvantages
Time limits set by insurance(#
visits capped)
Transportation needed
Limited physician supervision
Not typically inter-disciplinary
Comprehensive Outpatient Rehabilitation Facility
(CORF)
Can be specifically licensed and CORF accredited
Inter-disciplinary
“Day hospital programs”—may have RN
Typically 4 hrs 3-5 days/week
Often sub-specialized—e.g., TBI or Cancer rehab
Assisted Living Facilities
Private pay and little regulation
Support provided by CAN and LPN
On site nursing supervisor
Meals
Medications
Rooms, cottages may be attached to other services
