Acute Care with Maureen

Today on the blog, we have an interview with Maureen on her experience in acute care at a level 1 trauma center as a level 2 student. Maureen shares the highs and lows of this setting and her best advice!

What setting are you sharing about today and can you give a brief description of it? What qualifies a person to receive therapy in this setting?

My final rotation was in an acute hospital, specifically my rotation took place in the CSICU, CICU, and their respective stepdown units. The hospital that I was at is a level 1 trauma center so there were many people who were transferred from outside community hospitals across the state to this facility. Any individual who was not completely independent based on nursing mobility assessments were referred to PT and/or OT. Often, the individual would be evaluated by PT and if PT felt that they may be appropriate for rehab then they would request an OT consult. 

What is OT’s role in this setting?

The primary role of OT in this setting is early mobilization. Some of the patients have been in bed for a week or two and have become very weak in that time and it is our responsibility to assist them out of bed. For some people that could be a dependent transfer from the ceiling lift to the chair, but for others it could be a stand pivot, or in best case scenarios we would be able to assist people to the sink or bathroom to perform BADLs (Basic Activities of Daily Living) at the sink.

For insurance to approve each individual’s stay, we had to make sure we were having them perform an ADL. Hypothetically, this would include brushing their teeth (to assess sequencing and fine motor tasks) and taking their socks off (functional reach, core strength, grasp), but often times depending on the level of the patient, just having them try to bring a warm washcloth to their face with hand-over-hand assist was what was most appropriate. 

Did you feel prepared going into this setting based off of your classes? And how did you prepare before starting?

I don’t think there is enough preparation for participation and practice in the acute setting. There are so many lines and tubes that a clinician comes across that were not addressed in my program. I think it is also difficult to prepare for transfers when lines and tubes are part of the equation, so it is a difficult setting to prepare for in that respect.

I also was not prepared for the Moderate and Maximal assist transfers. We practiced transfers in school, but your friends always help more than they should (or they are just completely dead weight) so actually transferring a large individual who hasn’t been out of bed in two weeks is a learning curve to say the least!

What resources were the most helpful during your time there?

I think there are not enough resources for this setting. I used resources from OT Unfiltered as well as Seniors Flourish, but I had a really hard time finding resources for treatment ideas in this setting to make them more client-centered and enjoyable. 

How did you stay organized and manage your time?

I had a checklist that my CI helped me come up with to help to stay organized when going into a room including setup of the room, setting up the chair, managing lines, organizing the path to/from the bed. I also made an evaluation worksheet that I used in order to remember all of the questions to ask in determining PLOF (prior level of functioning). 

What was your schedule like?

My CI worked 4 10 hour days. This was not common in our hospital, but it was helpful to have a PT and OT available later in the day in case a case manager needed an updated note for a patient who was ready for discharge. Most therapists who worked a traditional 8 hour day were supposed to see 5 patients a day, but since we had longer hours it was expected that we would see 7-8 patients a day. During my rotation the most I got to was 7, but I consistently met the required patient hours.

What assessments did you use most?

We didn’t use any standardized assessments while I was in the hospital. During our evaluation we did UE ROM and MMT if the individual did not have sternal precautions. Every note that we wrote included the Boston AM-PAC ADL which identified how much assistance an individual needed when performing ADLs. 

What conditions/diagnoses did you see most often?

Most often we saw individuals with congestive heart failure, myocardial infarction, angina, and dyspnea. I also saw a lot of individuals who just had surgeries such as TAVR, CABG, heart transplant, and VAD placement.

What did a typical session look like?

At the start of every session we take starting vitals which includes HR (heart rate), BP (blood pressure) and MAP (mean arterial pressure), and oxygen percentage. Then it is important to get the room setup which includes untangling lines, setting up the chair, and clearing paths in the room if ambulation was going to happen. If we are doing the initial evaluation, we usually would try to get all of the information for the occupational profile prior to getting out of bed, at this time we will address MMT and ROM as well as any precautions if they have them. Then if they are in bed we would assess bed mobility and sitting balance and hopefully progress to OOB (out of bed). From there we would assess how we would proceed, whether we would perform ADLs EOB, seated in a chair, standing in front of the chair or if they were safe to ambulate to the bathroom. 

How did you stay client-centered and occupation-based?

I think this setting is very hard to stay client-centered because the main goal is mobilizing the individual and often this is not what the client wants to do. We are also limited in what resources we have available for the session which can make it difficult. Often we would rely on brushing teeth as the ADL that we would focus on with individuals, but one session I had a gentleman mention that he had not been able to wash his hair in a week so after we had transferred him to his chair, I got a shampoo cap so he could wash his hair. 

Did you have to do a project or in-service? Could you share what topic you chose?

My project was a new handout for the office to hand out on energy conservation techniques specific to cardiopulmonary patients. Prior to this, there were 3 different handouts that were available, but they weren’t evidenced-based so I performed a lit review and completed the handout based on my findings. The department is currently handing it out to individuals who are discharging home, but soon it will go into the sternal precautions packet that goes home with individuals recovering from sternotomies as well. 

What was your favorite part of this fieldwork experience?

Being able to see someone in the ICU stand for the first time and follow them through their journey and progressing to a point where they no longer need to discharge to a rehab facility and they are now safe to go home. Not much beats that satisfaction of seeing how far they have come. 

What was your least favorite part of this fieldwork experience?

This fieldwork setting can be very hard and cause a lot of anxiety. I had a difficult time communicating with my CI at the beginning of my rotation and I was so nervous that I was going to fail that it caused me to be very anxious in my treatments and not do as well as I could have. For that reason it is super important to advocate for your needs as a student and what would help you be successful. 

What is something you learned that you will take with you for the rest of your career?

Advocate for yourself! Confrontation is hard, but not speaking up for yourself and suffering in silence is harder. 

What advice do you have for a student about to start in this setting?

Practice transfers!! Also review various precautions based on the population that you are going to be working with, for instance we had a lot of patients with sternal precautions and spinal precautions. Be flexible, as much as I hated hearing “it depends” from professors in school, it really is good advice because in this setting things change so quickly and you have to adapt and move on. You could have a great game plan for the day and you go in to see your first patient and they are going for a CT scan so you move onto the next, and they are not medically stable. You have to be able to roll with the punches and stay calm.

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Thank you so much for sharing, Maureen! I loved my acute care rotation as it was the perfect amount of challenge and reward. I hope all you readers enjoyed Maureen’s words on this awesome setting!