Level IIB Fieldwork: Acute Care

12 weeks in acute care – DONE! It feels amazing to actually finish a whole fieldwork (no thanks to COVID). Acute care is definitely an intimidating practice area – I consider myself lucky because I shadowed in acute care for 6 months (I was still pretty intimidated lol). Acute care is full of medically complex and medically fragile patients and half the time I was afraid that I would do more harm than good. Knowledge on vital signs, lab values and common conditions is very important in determining whether a patient is a good fit for therapy and being mindful of how they are feeling at every step in the process so as not to push them too far.

I learned so much during my time in the hospital – how to be creative with minimal resources, how to adapt to any situation, how to encourage patients when they feel their worst… Acute care is truly a special place and there is a surprise at every corner!

Though every hospital is different, providing you with an overview of my experience and some tips I picked up along the way may help you prepare for your fieldwork in acute care (if you have one), or even just a peek into what acute care occupational therapy can look like!

My Schedule

M, T, W, F: 7:30am-4pm; Th: 7:30am-11:30am

Every morning, as soon as I entered the acute rehab office, I would go to the new consult table to pick up patient evaluations. Depending on the number of evaluations and the number of therapists working that day, I would pick up 2-6 evaluations. If I didn’t have a lot of evals, I would pick up treatments- aiming for patients that I evaluated previously.

I spent the first 30 minutes to an hour in the morning chart reviewing, preparing for my sessions and coordinating with the PTs and PTAs on co-treats. Then I was off to the floors. Between about 8 and 11:30am I completed evals and treatment sessions, and if I didn’t have to meet up with a PT I would try to complete documentation between sessions.

Lunch was 11:30am-12:30pm and during lunch I would document morning sessions and briefly chart review my remaining patients to see if anything happened in the morning that I should be aware of. From 12:30 to about 3pm I would finish up with the rest of my patients and then return to the office to complete documentation. My CI would review my documentation at that point and then the day was over by 4pm!

Assessments/Screenings

***This is what my CI taught me at the hospital I was at –
always make sure to ask your CI/mentor about that hospital’s protocol!***

Orientation/Cognition
– Tell me your full name and date of birth; place, time, situation

Pain
– Chronic or acute?
– Pain scale (1-10)
– Can you alleviate the pain right now? When did they last receive pain meds? Do you need to ask the nurse about pain medications?

6 Clicks
Upper and lower body dressing
Upper and lower body bathing
Grooming
Feeding
Toileting
Toilet transfers

MMT
– Grip, wrist, elbow, shoulder
– This will most likely not be very formal!
– Make sure to test the patient’s strong side first (if applicable) so that you have something to compare to

ROM
– Digits, wrist, elbow, shoulder
– Touch your shoulders, back of your head, lower back – I like asking the patient to do these because they are functional movements!

Vision
– Ask if they have vision problems, or new onset vision problems
– Do they wear glasses? All the time, or just for reading/distance?
– Tracking
– Field of vision
– Ask them to read your name tag or something on the wall

Sensation
– Ask if they have numbness or tingling anywhere
– Occlude their vision and ask them to name the part of the body you are touching
– A step further, you can alternate tapping and rubbing and ask them to differentiate

Coordination
– Finger-to-thumb
– Finger-to-nose
– Pronation-supination
– Observe their coordination during ADLs

Diagnoses Seen

Traumatic Brain Injury
SCI – high and low level injuries
Congestive Heart Failure
Hip/Knee Replacements
Subdural Hematoma
Cerebrovascular Accident
Chronic Obstructive Pulmonary Disease (COPD)
Amputation
Myocardial infarction (heart attack)
Respiratory failure
Drug overdose
Acute metabolic encephalopathy
Multiple Sclerosis
Parkinson’s Disease
Intracranial Hemorrhage
Atrial fibrillation
Trauma/Broken bones
Scaphoid fracture
Acute kidney injury/failure
General weakness
Falls
Spinal surgery (spinal fusions)
Dementia*
GI bleed
Schizophrenia*
Central Cord Syndrome
Dupuytren’s contractures*
Arthritis*
Anxiety/Depression*
Fibromyalgia*

*Secondary condition, not the primary rehab diagnosis or reason for admission to hospital

Tips

Evaluations

• To avoid making the patient feel silly or like you suspect something is wrong, say “I know this sounds silly but I have to ask everyone,” before asking them to recall the day, their name or really anything! This always puts them at ease and they understand that in the hospital sometimes you just have to do what you’re asked to do, and it eases their anxiety because now they don’t think something is actually wrong.
• If they are already wearing socks, just ask them to take them off and put them back on again – “because I need to be able to see what you can and can’t do so I can tell your doctor…”
• If you have trouble remembering all of the questions you have to ask, write them on a slip of paper and let the patient know you have a list of questions.
• Oftentimes if a patient has a chronic condition or illness that is not the primary diagnosis, such as dementia, Parkinson’s, MS, etc., I will ask if they currently receive OT or have in the past. If they have not, I use this opportunity to educate the patient on adaptive strategies, fall prevention, or adaptive equipment that may be useful for them – this is why it is good to stay up to date on disease processes and OTs role in enhancing participation in functional activities!

Lines and Leads

• This can often be one of the most intimidating aspects of acute care, no one wants to accidentally pull an IV out of someone’s arm, or a catheter out of you-know-where
• Take it slow! You set the pace for the session, and by taking a minute or so to assess all lines and leads, untangle anything, and determine the lengths of the lines can make all the difference and reduce a whole lot of stress for both parties.
• Familiarize yourself with common lines and leads before starting, some lines have precautions associated with them and it is important to follow them.
  • Lines with precautions may include central lines, PICC lines, chest tubes, ventriculostomy drains, and others.
• Check with the nurse to see if it is possible to unhook any lines during treatment! This was very helpful when I wanted to get a patient out of bed but their IV line was too short.
• Don’t forget to replace anything that was removed or moved during treatment (such as the O2 monitor or blood pressure cuff), and if in doubt, let the nurse know!

Documentation

• Try to write down as much as possible right after the session so that by the time you get to type or by the end of the day you haven’t forgotten everything. If I don’t have a lot of time to jot down notes, I will write down the most important things – assist levels and all the activities we completed.
• You will be slow at first but you will get the hang of it!

Treatment Sessions

• Start simple and then slowly build your repertoire by adding one or two new ideas every week.
• Use items you have available to you in the room or supply closet.
• Make it functional! (Obviously) Sometimes I would have patients that would tire easily when doing grooming activities, like hair brushing, so I would have them brush for intervals of time – it’s like working out but functional.
• If they are independent with ADLs in sitting but need to work on standing balance, do ADLs while standing at the sink! If that doesn’t take much time, have them clean the sink area or their room!
• Ask the patient what they want to do! If they say they don’t want to do anything, then sympathize with them but encourage them to get up and moving because this will help them get home faster.

Communication

• Don’e be afraid to ask for guidance from your CI! They are there to help you learn!
• After a session take the time to reflect with your CI on what you could have done better, or what you did well on.
• Don’t forget to communicate with your patient on what you think their plan of care should be, keep it client-centered!
• Always ask the nurse about your patients! The nurse will know if the patient is medically stable enough to handle therapy and may make recommendations (i.e. they need to stay in bed but you can do therapy)

What To Study in Preparation for an Acute Care Rotation:

• Ortho precautions – hip, spine, weight bearing, etc.
• Lab vitals – heart rate, blood pressure, oxygen saturation, hematocrit & hemoglobin, INR, Protime
• If you are able, ask your CI before you start to provide a list of common conditions and assessments they use at that facility
• Myotomes and dermatomes – I was surprised at how often I had to test sensation, and it was helpful to know muscle/skin innervations in order to understand what might be happening
• Types of lines and leads and their precautions (if any)

Resources I Used:

AOTA Fact Sheets! – these are usually my go-to resource when I want a quick overview of OT’s role with various conditions or in various settings.

Seniors Flourish Blog – Mandy’s blog is full of helpful tips for the aging population (which is the population that mainly comprises acute care!). Reading through her blogs was extremely helpful!

AcuteCarae4OT Facebook Group – This Facebook group was started by Alexis Joelle (@8alexisjoelle on Instagram), this is a great forum to ask questions and learn from OTs who have practiced or currently practice in acute care!

OTReference Pocket Guide – From OTReference on Instagram, and she recently released her digital version! This pocket guide was very helpful when it came to quickly looking up a common conditions, manual muscle testing guidelines and range of motion norms! I had this baby out every day, especially during documentation!

1 Day Experience in Inpatient Rehabilitation

At one point during my rotation, my roommate and I decided we each wanted to see what the other was experiencing in their setting, so we switched for a day (I went to inpatient rehab and she went to acute care), btw we coordinated this with our CI’s!

This was such an amazing opportunity and I’m so thankful I was able to observe, even if it was just for a day. Acute care and inpatient rehab are vastly different, more than I originally thought, but this is definitely a setting I could see myself working in.

Main Differences:
– Patients that go to inpatient rehabilitation are required to be medically stable enough to tolerate 3 hours of interdisciplinary therapy for 5 days during the week. In acute care, patient’s are often unable to tolerate intensive therapy.
– Patients must require hospital-level care in inpatient rehabilitation.
– Patients must have a condition that qualifies for inpatient rehab under Medicare:
Stroke
TBI
SCI
Congenital deformity
Amputation
Major multiple trauma
Hip fracture
Neurological disorders (MS, motor neuron disease, polyneuropathy, muscular dystrophy, Parkinson’s)
Burns
And more.
– The patient has the potential to progress in less than 4 weeks to a functional level.
– The patient must have a firm plan for return to home if they require care or further therapy at a less intense level.

The length of stay for patients in acute care is usually not long (the average is 4.5 days), and the goal of acute care is to stabilize the patient and refer them to another rehab facility (depending on their needs), or home.

Occupational therapy is also slightly different in these settings. While the OT is still looking at increasing participation in ADLs in both settings, inpatient rehabilitation has more tools and more time to help their patients reach these goals. The OT in inpatient rehab is also assigned a certain number of patients who they follow during their entire length of stay. In acute care, the OT sees new patients every day and that is often the only time they will see the patient (this can be due to a short length of stay, needing to complete new evaluations every day, or because COTAs provide treatments).

In short: acute care is the first step, this is where the patient goes right after initial injury or decline in function. Inpatient rehab is where the patient goes (if they qualify) to receive intense, interdisciplinary therapy to achieve functional goals.

Inpatient Rehab Facility Fact Sheet (American Hospital Association)

Inservice: Reassessment vs Supervisory Visit

If you’re like me, you’ve never heard of a supervisory visit, and this is at no fault to you or your education! Every state has different guidelines when it comes to these things. Now I happened to have my internship in Mississippi, where the guidelines are way more specific than in Florida.

A supervisory visit is a visit that the supervising OT conducts with the OTA for a patient on their 7th treatment, or on their 21st day of their stay in acute rehab. During this documented visit, the OT reviews the patient’s plan of care and makes adjustments as needed to their functional goals.

A supervisory visit is different from a reassessment because the patient has not had a decline in function. If the patient has a significant decline in function, has a new onset diagnosis that impacts their function (such as a stroke or a major surgery), then the OT will need to complete a reassessment and change the patient’s plan of care.

OTA Supervision Requirements – Here are the state-by-state guidelines