Acute Care and Occupational Therapy

Acute Care

• Acute care necessitates immediate and vigorous medical treatments encompassing surgery, diagnostics, and stabilization
• A tertiary hospital offers specialized services and equipment; example: Royal alex
• Community, regional, and general hospitals provide essential care, including critical care
• Patient populations influence organizational structures
• Mental health and pediatric programs might need distinct management frameworks
• An acute care facility can exist independently or in conjunction with continuing care, outpatient care, or rehabilitation services
• Once a patient’s condition stabilizes, transitioning them to a different level of care is recommended
• Post-acute care involves rehabilitation and restorative therapies
• Continuing care encompasses in-home assistance and extended care options

OT in Acute Care

• Occupational therapy is essential because it addresses the most costly aspect of healthcare by influencing healthcare expenditure
• Length of stay is a key metric in acute care, and OT plays a role in reducing it
• There is an increasing focus on measuring 30-day readmission rates
• Functional impairments or safety concerns contribute to readmissions, highlighting OT's importance

OT Focus

• OTs collaborate to address occupational and functional issues impacting discharge planning
• A key goal is identifying a patient's functional level and required support to reduce risks post-discharge
• In acute care, OTs commonly assess patients utilizing occupational based activities
• OTs frequently engage in simultaneous intervention, assessment, and discharge planning
• Due to brief stays and evolving medical conditions, rapid decision-making and discharge readiness are essential

Challenges for OT

• Medical instability, fluctuating cognitive abilities, and complexity
• Time limitations, high caseloads, and discharge pressures can affect assessment and intervention suitability
• Challenges include communicating the importance of OT's role in ADL, and clear collaboration
• Standardized assessments are limited by environment and validity

Productivity and Discharge

• Administrative guidelines dictate client quotas and influence financial models, necessitating tracking of client interactions
• Effective communication with the team is important to understand expectations and potential influencing factors
• Adequate community support impacts discharge options
• Transdisciplinary care employs a primary therapist model where evaluation and prioritization of OT roles are needed upon referral
• Essential areas to prioritize are screening and assessment considering clinical history, chart review, and inter professional input
  • The main areas are BADL, functional mobility, cognition, IADL, pain, skin and wound, eating, feeding and swallowing
• Evaluate the requirements to participate (physical, cognitive, sensory, psycho-social etc.)
• Keep in mind medical stability and time available

Chart Review

• Analyze lab results (hemoglobin, white blood cells, sodium, potassium, glucose) to understand their effects on patient occupations
• Be aware of medications
• Be aware of investigations (x-ray, CT Scan/MRI, endoscopy)
• Pay attention to Vital signs (Oxygen saturation, pulse, respiratory rate, temperature)
• Consider team notes from the nursing staff, consultants, and IP team
• Consider orders written by a physician (contraindications, precautions including infection control)
• Check if there is any previous AH notes
• The use of Screening Tools includes (Falls, Behavioural Risk Assessment, CIWA)
• Normal results, trends and critical levels, and how they affect FUNCTION

Medication Awareness

• Know the general category (analgesic, antidepressant, cardiac, hypoglycemic)
• Use Naming tips (root word)
• What is the mode of delivery?
• If it fits clinical history
• How OT assessment or interventions are impacted
• Caution, contraindications (analgesic, psychotropic)
• General falls risk awareness, continence, heart rate, shortness of breath
• Schedule effectiveness and potential impact on discharge (blood glucose or lab monitoring)
  • po = by mouth
  • inhaled = inhaler
  • qid = 4x daily
  • bid = 2x daily
  • qam = every morning
  • qhs = every night
  • ou = left eye
  • prn = as needed

Activity Orders

• Consider AAT (activity as tolerated)
• Consider BR (bed rest)
• Consider BR with BRP (bed rest with bathroom privileges)
• Consider up to chair
• To administer activity staff use assessment skills and clinical judgement
• Seek advice from the physician or delegate
• Therapists assess whether a patient can participate
• Consider premorbid status, test results, electrolytes, lab results, blood glucose levels, vital signs, musculoskeletal stability, and neurological status

Weight Bearing Orders

• Weight bearing orders are distinct from activity orders
• Orders apply to the upper and lower extremities
• Movement limitations and protocols are based on injury/surgical procedure
  • Spinal and total hip precautions
  • Flexor tendon repair protocol
  • Sternal precautions

Lines and Tubes

• Look out for respiratory tubes
• Look out for arterial and venous tubes
• Be aware of drains and tubes (foley catheter, feeding)
• And wound vac, ostomy and monitoring lines
• Make sure you have enough space to safely perform ADLs

Preparation

• Coordinate with the team regarding the schedule, medication and assistance
• Source and understand the equipment and patient education
  • Transfer belt
  • Mobility aid
  • Footwear, housecoat, pants, incontinence brief and PPE
• Consider environment
  • Chair, pathway
  • Enough lines or tubes (portable oxygen?)
• Take braces, splints and devices into consideration

Initiating Assessment

• Beginning with introduction (NOD, name, occupation, duty)
• Get consent as first priority
• Analyze the patient's readiness
• Assessments take place in small increments with symptoms monitored

Progression and Monitoring

• Stop when you can
• Set goals, progress and assess further
• Refer if need be
• Important factors that need to be monitored include dizziness, vertigo, fatigue, nausea, and pain
• Objective is heart rate, O2 saturation, respiratory rate, blood pressure, balance, cognition
• Consider use of scales

Cognitive Assessment

• The key indicator of delirium is fluctuating cognition, team communication is essential
  • Delirium occurs for 8-17% older adults, 40% for LTC emergency residents, 50% for hospitalized older adults, 80% of older ICU patients and 80% end of life
  • 30-40% of cases are preventable
• Evaluate delirium, use CAM and collaborate with family
  • Use collateral history and baseline
  • Collaborate with IP teams and physicians
  • Take into account fluctuating status, lab results and tests
• Conduct a general interview, check with nursing, light ADLs

Cognitive Screening

• Occupational therapists play a role in the following
• Aid in discharge planning and detecting impairment
• Diagnose and set the baseline for acute care

General Ax

• Include orientation (How long have you been in the hospital? What day is it today?)
• Consider the insight/judgement of (Can you tell me how you were managing [BADL/IADL] at home? What are your plans when you leave the hospital? What kind of help do you think you might need? What does your family think?)
• Understand initiation, problem solving and sequencing
• Test short term memory (Show me which room is yours. What did you have for lunch today?)
• Rely on remote memory and prospective memory

Risk

• Support patients living with risk
• Positive risk can improve self efficacy
• Establish the risk tolerance values of the family, client and care team
• Use systematic approach
• Access client strengths

Risk Considerations

• Recognize if the risk is new or pre-existing
• Determine patient wishes and the consequences
• Has risk been reduced and was that successful
• Apply only the most limiting options
• Be aware of ethical codes and standards
• Include critical and intensive care plans

OT Interventions

• OTs consider Positioning, Splinting, seating, education, cognition, referrals and delirium management
• Early mobilization and ICU issues are all important to consider
  • 23-38% experience delirium during ICU stays, and post ICU 18-46% experience anxiety and depression
• Delirium prevention bundles include pain management, awakening trials, medication and mobility, and family engagement

Mobility Events

• OT mobility events include passive and active range of motion
• OTs can provide resisted exercise, and pivot transfer
• OTs can provide sitting edge of bed, standing and progressive ambulation, as well as grooming hygiene participation

Acute Care Skills

• OTs should be decisive, and challenge themselves
• OTs should know equipment and use positive communication
• OTs must be able to schedule, communicate and prioritize safety