Dr. Gojraty: Thank you and good afternoon everyone. Thank you to occupationaltherapy.com for having me today to discuss the rehab process in acute care setting. I hope to share some information for the OTs who are working with or are interested in learning more about patients on mechanical ventilation, and as well as the implications for OT treatment. This course is not meant to go into great depth when it comes to patients on a vent, but it is more of a introductory level for therapists working with and treating these patients.
Challenges of Acute Care
Acute care occupational therapists have very little time to administer standardized assessments, so we often rely on occupation-based activities, particularly self-care activities to perform client evaluations. An acute care OT often provides simultaneous eval intervention and discharge planning. As the occupational therapist you have to consider discharge planning in each treatment session, because hospital stays are typically short and discharge decisions can be made fairly quickly as a patient's medical status changes. Some other challenges include patient's medical instability; unstable vital signs, lab findings presenting acute health risk, complications due to coexisting medical problems, limitations in the physical setting, assessing the appropriateness of a physician order, as well as limited time for eval and intervention.
Challenges of Acute Care Evaluation
The focus of OT evals is usually on cognitive and physiological performance factors like strength, range of motion, balance, mobility, cardiopulmonary functions, and their ability to participate in basic ADLs. A therapist during an eval can learn how to use data from machines and monitors as part of the assessment of the patient's response to intervention or as a baseline measure of physiological responsiveness, but machinery and monitors can also be a limiting factor during the eval process. If you are maneuvering a patient attached to a machine or need additional healthcare providers to move the patient during the eval process, it can affect your ability to gather the data on the patient's current status.
Specific care protocols or patient restrictions may also hinder your ability to perform an eval. For example, post-surgical protocols or precautions can limit mobility. Often questioning the patient about his or her knowledge of these precautions can be a part of the assessment and provide you with information on their safety awareness so that is always good to do.
Infection control may be in place and a therapist has to follow isolation procedures before entering and exiting a patient's room. These procedures should be factored into your schedule and time management. There are times when you have to walk into a patient's room and you have to put on a gown, a mask, gloves. You realize you need something from the supply linen closet outside. You have to take all of that off, sanitize your hands, wash your hands, gather whatever materials you need, and then do the same thing all over again. You really need to plan ahead.
Many healthcare professionals will also be interacting with patients on an ongoing basis to determine medical status so it can also seem chaotic or disjointed at times with assessments being repeated by providers from different disciplines so you have to learn to be flexible.
Tackling the Challenges of Acute Care
Let's briefly discuss how to tackle some of the challenges that we just talked about. Therapists often compete for time to see patients as we said because other services or tests take precedence at times. Sometimes having people from more than one discipline, like a PT and OT evaluating a client at the same time, can become efficient. It can reduce the need to compete for time to see the patient, but more importantly it reduces patient fatigue from having to perform the same activities multiple times. Also occupational therapists often end up using deductive reasoning because a patient might not have endurance to participate in a detailed evaluation procedure.
If you look at what makes up an OT eval, it is pretty similar in any setting (Figure 1).
Figure 1. OT eval.
We have the preadmission status, their prior level of function, their current level of performance, ADLs/IADLs, the neuromuscular performance, range of motion, gross control, sensation, strength, the patient's mobility status, how they are with the transfers, and sitting and standing balance. We also look at pain, their performance skills, and their rehab potential because not every patient you eval is going to be a good candidate. If they have poor rehab potential, we do not pick them up. Finally there are the goals. There is really a lot that goes into that eval.
OTs are skilled at using activity analysis in combination with our clinical reasoning to acertian which functional skills a patient can likely perform and which the patient will likely have difficultly with or need assistance. This is why we do not sit there for an hour in the setting doing a very thorough eval. As soon as we walk into the room and observe the patient in their room, we can get a lot of information.
Acute Care Evaluation
A typical occupational therapy eval in the acute care setting usually follows the following sequence. There is the chart review, interview and occupational profile, the specific assessment measures, interpretation and findings, as well as the recommendations for intervention. This is something that I see people getting confused a lot when they first start working in this setting and even physicians get confused with these terms. Sometimes we'll get orders for an OT screening when the physician meant an eval, or we will get orders for the eval when they meant to put in a screen order. Figure 2 shows the difference.
Figure 2. Definitions.
