When I initially received my summer full-time clinical assignment at Excela Health – Latrobe Area Hospital (LAH) in the acute care department, I have to admit, I was a little disappointed. If you couldn’t tell by the title of my blog, my interests generally lay with manual therapy, orthopedics, and sports medicine. So, I was a little less than enthused by my placement (not to mention the 3.5 hours of driving plus toll fees each day), but once the experience began, my feelings quickly changed.
Acute care is much different than any physical therapy setting that I have been exposed to at this point in my career. It involves much more emphasis on functional status, assistive device usage, and discharge recommendation. I would equate the main responsibility of the acute care physical therapist to rehabilitation triage. This requires an entire different skill set than was required in my 2 previous outpatient orthopedic clinical rotations. Determining a patient’s proper discharge is a decision that is imperative to their life-long wellbeing. Discharge planning is a complex process that involves the collaboration of many healthcare professionals. It is a joint decision that is ultimately decided with the input of the treating physical therapist, occupational therapist, social worker, case manager, and physician. According to a retrospective study by Smith et al, discharge recommendations made by 40 physical therapists in an acute care department were ultimately implemented 83% of the time. Additionally, when the therapist’s recommendation was not accepted, the patient was 2.9x more likely to be readmitted to the hospital within 30 days of initial discharge. As you can see, the acute care therapist’s decision making has a direct impact on the future well-being of the patient. Initially, knowing this information made it a fairly daunting task. However, through the help of my clinical instructor (CI) and her ‘teammate’ occupational therapist (OT), I was able to make more accurate and confident decisions as my rotation progressed.
At LAH, the acute care PT/OT department operates in a unique system. Each PT is teamed up with an OT and they provide bed-side evaluation/treatment to each patient, as is appropriate. We generally made trips to all the units of the hospital on any given day (ICU, Neuro, Oncology, ect.). Occasionally, there would be a PT-only or OT-only treatment, but the majority of the day was spent with your ‘team’. Due to the diverse patient load, I was able to see patients and diagnoses that I would have never ran across in my entire career. One such patient was an elderly lady with Parkinson’s Disease who had a Deep Brain Stimulator surgically implanted. This device is put in place to prevent or reduce the tremors that typically accompany progressive Parkinson’s Disease and, other than her festinating gait, you would have never known she was living with this diagnosis. Another fascinating aspect of LAH’s acute care rehab department is the use of Workstation On Wheels (WOW) so that they can complete real-time documentation.
I found this system to be incredibly efficient, not only in terms of documentation, but also in our ability to collaborate with occupational therapy during evaluation. This aided us in making correct and consistent discharge recommendations, which I believe ultimately will lead to better patient outcomes.
Part of our caseload involved treatment and evaluation of patients in Joint Works, which is a complete floor devoted to post-operative THA/TKA rehabilitation. Our responsibilities included initial evaluation (preferably on the day of surgery or the day after), 2 treatments per day, and 1 group session per day. Each patient also had the opportunity to attend ‘Joint Class’. This is a informational seminar put on by therapy, nursing, and nutrition and goes into all aspects of the patient’s upcoming surgery and the following rehabilitation process. This was a great experience and allowed me to gain a better perspective as to how patients present immediately after surgery and how they progress up until their discharge. To further develop my understanding of the total joint replacement process, I also had the opportunity to observe a Total Knee Arthroplasty (TKA) surgery, which was an absolutely amazing experience. Seeing the surgery first-hand allows me to better understand and empathize with what the patient is feeling in terms of pain, functional limitations, and the initial uncertainty in their new knee’s stability. If you ever have the opportunity to observe a surgery of this complexity, I highly recommend it.
Additionally, I was able to observe several other disciplines outside of acute care PT/OT. My CI set up times for me to shadow several other healthcare professionals, including Vestibular Rehabilitation, which was my first exposure to this incredibly unique and interesting sub-discipline of physical therapy. While there, I was able to get a better understanding of the evaluative process and mechanisms behind certain balance/vestibular pathologies. I was then able to spend the afternoon with a PT in inpatient rehabilitation, where I was able to get more hands-on treatment time than I did in the often ‘evaluation heavy’ acute care setting. Our first patient had recently undergone a right below knee amputation (BKA) and I was asked to wrap his stump prior to treatment… not the easiest task, but I managed. This was my first opportunity to work with an amputee in a rehab setting and is not one I will quickly forget. I went through a thorough stretching, strengthening, and functional mobility program, which really started to put some of the material I learned in class into perspective clinically. I also had the opportunity to observe 2 barium cookie swallow tests with the Speech Language Pathologist (CCC-SLP), which broadened my understanding of concurrent functional limitations associated with victims of cerebrovascular attacks (CVA) and the role of the SLP in their rehabilitation. I then had the opportunity to spend a day in the Cardiovascular Services department, which consisted of cardiac rehabilitation and outpatient/inpatient stress testing. With my exercise science background, I found the stress testing to be very interesting. I witnessed a treadmill stress test (Bruce Protocol), stress echocardiogram, and a pharmacological stress test. The last specialty I had the opportunity to observe was wound care. During this experience, I definitely tested my gastrointestinal fortitude, but seeing these wounds firsthand further reinforced the importance of pressure ulcer prevention and proper evidence-based treatment.
In a clinical rotation that seemed less than ideal, I was able to gain experiences that will aide in making me a more well-rounded and well-informed physical therapist. I now have a better understanding of how a hospital operates and how the rehabilitation team fits into the equation. I also have a better understanding of other healthcare professionals and their roles, which will aide me in understanding their viewpoints and will allow me to communicate more efficiently with them. Occupational therapy is one profession that I especially have a new found respect and understanding of. Seeing their evaluation and knowing what goals they expect their patients to meet prior to becoming functionally independent is definitely important information for any PT to have. Their profession often does not get the respect that it deserves and I think this stems from a misunderstanding of their role and the confusion that many healthcare professions have in regards to the difference between PT and OT. My time at LAH gave me a great understanding of how an occupational therapist should practice in the acute care setting and I am grateful that I was able to have this exposure to such an important and misunderstood profession.
During my time in this clinical rotation, I was able to broaden my understanding of what is required to be a successful therapist and I improved upon many of these attributes. Through the help of my CI, I was able to increase my confidence in determining proper discharge and assistive device recommendations which, as a future physical therapist, is a prerequisite to being successful in clinical practice. One aspect of acute care that I found frustrating intitially was attempting to conduct a subjective interview with patients suffering from cognitive deficits, decreased levels of alertness, or hearing deficits. However, as the clinical went on, I began to improve the conciseness and efficiency of my interview skills, which I know will carryover to any setting that I may practice in.
Now, I can’t say I ever see myself being a full-time acute care therapist, but this experience opened my eyes to the responsibilities, intelligence, and empathy needed to be an acute care therapist and this is information that I will carry with me for the rest of my career.
Thanks again to all of the PTs, OTs, PTAs, COTAs, nurses, SLPs, and technical staff in the acute care rehabilitation department… You provided a great learning environment for me and I appreciate all of your help and advice along the way.
Special thanks goes to my CI and her OT ‘teammate’, Debbie and Lisa, for putting up with all my shenanigans and allowing me to have an unforgettable acute care clinical experience.