Inpatient PT Consults
Lenny Noronha MD, Heidi Gober PT, Julie Rogers PT
11/11/15
UNM Hospitalist Best Practices
Background
• Inpatient PT consults are frequently ordered by IM ward teams
• Discussion from HVC student modules generated interest in optimal
use of inpatient PT services
• I think hospitalists should know something about everything in the
hospital…(personal opinion)
Objectives
By the end of this presentation, attendees will be able to:
• Prepare ward teams and patients before PT consultation
• Appreciate work load and communicate more effectively with PT
• Chart
• Phone
• Consider things we can all do, even if chronically short-staffed
Outline
• Preview cases (2 min)
• Review selected literature (6 min)
• Overview of UNM Rehab Services (10 min)
• Return to cases (10 min)
• Questions/Discussion (15 min)
Cases
• 57ym on CIWA protocol getting to br c mod assist; homeless, no
funding. No functional limitations at baseline
• 82yf transferred from MICU to your team after 6d on vent for septic
shock/CAP. Pt is on 8L nc. She has B severe knee OA, lives c son and
d-i-l in Estancia. Son has forgotten to bring in her cane 3 times. It is
Friday at 3:45pm. The PT note yesterday: “CGA/SBA, STS FWW”
• Audience case
Literature review
“Time for critically ill patients to regainmobility after early mobilization in the intensive care unit and transition to a general inpatient floor”, Journal of Critical Care 30
(2015) 1238–1242, SarahM. Pandullo, ARNP, CCNS-BC a, Sarah K. Spilman,MA b,⁎, Janell A. Smith, RN, CCRN a, Lisa K. Kingery, RRT c, Sara M. Pille, PT, DPT d, Robert D. Rondinelli, MD, PhD
e, Sheryl M. Sahr, MD, MS b
• Retrospective review of 182pts transf from ICU to SAC
• >48h in ICU (ave 4d)
• Patients who walked in ICU more likely to walk on ward
Interesting post-hoc analysis…
Hopkins RO, Miller RR III, Rodriguez L, et al.
Physical therapy on the wards after early physical activity and mobility in the intensive care unit.
Phys Ther. 2012;92:1518–1523.
• Prospective study of 72pts transferring from RICU to floor
• 61 ambulated >100’ on last day in ICU
Omission of Physical Therapy Recommendations for High-Risk Patients Transitioning From the Hospital to Subacute
Care Facilities, Archives of Physical Medicine and Rehabilitation, Brock Polnaszek, BS, Jacquelyn Mirr, BS,Rachel Roiland, RN, PhD, Andrea Gilmore-Bykovskyi, RN,
PhD,Melissa Hovanes, RN, Amy Kind, MD, PhDFrom the aDepartment of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health,
Madison, WI;
• Retrospective review of 613 PT DC reccs
• 3 Categories
UH Rehab services overview
• PT
• Inpt/outpt
• Wound
• OT
• ST
Some Inpatient PT stats
• Average 190 PT referrals/day for entire hospital
unit
# PT pts/day
average
% of unit
4W
17-24/d
20.3
51
3N
4-6
5
52
5W
11-18
14.6
55
PT teams
PT, PTA
PT
• Eval
• Plan of care
• Goals
• DC recc
Physical therapy assistant
• Ongoing tx
• Communicate c PT
Average 8 referrals/d
•
goal 5-6 visits
Average 10-12 pts assigned/d
• i.e. change DC recc
• Goal 8 visits/d
Inpatient PT consult request flow
Order
Printer
Tech adds to Cache
Cache list printed at 7am
“Team lead” distributes pts
Pre-Consult
Chart
• Activity order
• PT consult order
• VS (bp, O2)
• Labs (H/H, plts)
• Notes
• Latest PN, HP, consults (ortho)
• Text rendition: prev PT, CM, SW
Hall
• Bring new FWW & belt (single use)
• Check in with nurse
• Gown
Consult rationale at UNM
• Improve inpatient mobility
• Change in level of care
• Home services/facility placement
• SNF
• Acute rehab
Communication
• One-to-one PT training with new hire care management employees.
• Participation in patient rounds/team conferences regarding discharge
plans.
• Contact (phone number) information exchanges between rehab and care
management.
• Utilization and updating patient white boards.
• Hand-off information from ICU therapists to floor therapists regarding
patients transferring to the floors.
• Participation in weekly care management rounds for patients with
extended LOS and short stays.
Sample note language
Assessment
PT Assessment Summary : 6/22/15
5E
Pt seen to improve functional mobility, transfers and ambulation. Pt presents w/multiple lines, decreased overall strength and activity tolerance, is HOH
and using 6L O2. Pt's O2 sat ~85% w/functional mobility, requiring >2 min. to return WNL. Pt is ModA for bed mobility to EOB, CGA/SBA sitting EOB,
ModA STS w/FWW. Pt is able to follow directions with VC/TC's and is participatory in therapy, but with decreased motor planning/execution. Pt is
progressing toward PT goals and will continue to benefit from skilled interventions in order to maximize independence.
DC Rec: Inpatient Rehab
"6-clicks" score: OOB mobility not assessed
Chalisa Glenn, PTA
Referring PT, Julie Rogers, DPT
Team cell: 385-3730
Pager: 951-0370
Treatment time: 30 min.
Consult time: 30 min.
Units: 2TA 3C
DC Recommendations Recommend Discharge To: : Inpatient Rehab Glenn PTA, Chalisa - 06/22/2015 08:39
Plan Patient to Be Seen : 5-7 times per week
May treatment be provided by PTA? : Yes Glenn PTA, Chalisa - 06/22/2015 08:39
Our DC to facility instructions
SNF
• Require 1 rehab service recc
• Reccs should be updated within 72 hrs of transfer
Acute rehab
• Need 2 out of 3 rehab service reccs (PT/OT/ST)
• Reccs updated within 48h
Consult algorithm pocket card
Return to cases
• 57ym on CIWA protocol getting to br c mod assist; homeless, no
funding. No functional limitations at baseline
• 82yf transferred from MICU p 6d on vent for septic shock/CAP. She
has B severe knee OA, lives c son and d-i-l in Estancia. Son has
forgotten to bring in her cane 3 times.
• 64yo bachelor c DM adm for spine OM req IV abx x 6wks. Dr. Imber
will see in OPAT next week.
Practices to consider
• MICU accept patients
• Observe & record sitting/standing
• Assess home function, goals, motivation
• Describe initial PT consult
• DC to facility patients
• Communication with PT team
• Additional prompts for instructions (i.e. activity, assist, devices)