PromotingFunction in the Hospital - hgsitebuilder.com
Transcript of PromotingFunction in the Hospital - hgsitebuilder.com
Promoting Function in the Hospital
Steve Fairbanks, PT, DPT, GCS Board Certified Specialist in Geriatric Physical Therapy
Acute and HBPC Physical Therapist at DVAHCS
Maggie Deforge, OTD, OTR/LGeriatric Mental Health
Occupational Therapy FellowDurham VAMC
Objectives■ Identify common complications of
hospitalization and how to avoid them.
■ Distinguish common and unique elements of OT and PT scope of practice.
■ Understand OT and PT’s role in improving function for older adults in the hospital.
■ Identify common evidence-based interprofessional care strategies to restore, maintain and promote functional health in older adults
Hazards of Hospitalization■ Immobility
– 10-15% loss of strength per week– 35% decline in self-care
■ Increased isolation from supports
■ Changes (environment, meds, sleep)– Delirium risk– Falls risk
Complications of Immobility
Dittmer et al. Can Fam Physician 1993;39:1428-1437Creditor, Ann Int Med 1993
Cascade of DependenceCreditor, Ann Int Med 1993
Risk Factors for Falls in the Hospital
EXTRINSIC
Non-use of Assistive Device
Unfamiliar Environment
Not Using Call Light
INTRINSIC
Dizziness or Vertigo
Orthostatic Hypotension
Visual Impairment
Medications: Benzo's, narcotics, antidepressants,
etc.
Fear of Falling
Depression
Impaired Cognition
Impaired balance and gait
Advanced Age
The Falls Cycle
Fall
Fear of Falling
Limit Activity
Decreased Strength
and Balance
Increased Risk of Falls
Why Does Function Matter in the Hospital?■ Hospital Related Hazards
– Delirium– Falls– Infection– Poor sleep hygiene– Lack of proper nutrition– Pressure ulcers– Deep Vein Thrombosis (DVT)
■ Having any of these or a combination can lead to poor outcomes
– Increased length of stay– Hospital readmission– Placement
■ Function can help prevent these poor outcomes
(Creditor, 1993)
POLL: WHICH OF THESE
ARE ACTIVITIES OF DAILY LIVING
(ADL)?
ADLsBathingToiletingDressingEating/SwallowingFeeding (food to mouth)Functional MobilityDevice CareGroomingSexual Activity
Role of the OT and PT in Acute Care
Occupational Therapy■ Identify occupations/activities the patient
needs or wants to do
■ Analyze pre-hospitalization roles
■ Restore skills and/or modify the environment or task to improve function and independence
■ Special focus on mental health, cognitive factors, physical symptoms/function
■ Facilitate progress toward performance-based goals
■ Discharge planning
Physical Therapy■ Enhance health, well-being, and quality of
life
■ Maximize function and prevent complications
■ Consulted when there is a change in ability to complete activities of daily living, ambulate, or balance or strength
■ Advocate for patients
■ Anticipate needs after discharge
(AOTA, 2014; APTA, 2019)
Reducing Hospital Readmissions■ Hospital readmissions
– Quality indicator■ Nearly 1 in 5 Medicare beneficiaries are readmitted to the
hospital within 30 days after an acute hospitalization.■ Discharge Planning
– Determination of discharge location– Needed services– Integration of patient, family, and caregiver input into
discharge plans
Falvey et al. Phys Ther. 2016 Aug;96(8):1125-34
Admission and Referral to OT/PT
Gather History
General Process Framework
Clinical Observation & Assessment
Intervention
Hospital Rehab ReferralAppropriate
■ Delirium/confusion■ Impaired ADL (eating,
dressing, bathing, toileting, grooming)
■ Recent fall■ Prolonged hospitalization■ Difficulty getting OOB or to
bathroom ■ Noticeable weakness■ New diagnoses affecting
mobility/strength
Not Always Appropriate
■ Hemodynamically unstable■ Near baseline function/pain*■ Uncontrolled pain■ Poor oxygen saturation■ Minimally able to participate
International Classification of Function (ICF) Model
(WHO, 2002)
ICF Model Health Condition
Fall with L hip fx. s/p ORIF
Body Structures & Impairments
Decreased Strength
Decreased Balance
Decreased Endurance
Increased Pain
Activity Limitations
Assistance required for bed mobility, transfers, gait
Participation
Unable to ambulate outside of home
Not able to attend church service
Not able to play with grandchildren
Contextual Factors
Lives with elderly wife, unable to assist with mobility
2nd story home
Gathering History
(AOTA, 2014; Guide to Physical Therapist Practice 3.0, 2014)
■ Chart Review– Medical condition– Previous PT/OT notes
■ Patient/Caregiver Interview– Home set up– Use of AD for ambulation– History of falls– DME/assistive equipment– Roles, habits, routines– ADLs/IADLs ability– Social support – Interests and goals
Geriatric examination
■ Vitals■ Pain■ Cognition■ Sensation■ Range of Motion (ROM)■ Strength■ Balance■ Endurance
■ Functional Mobility and Activities– Bed mobility– Transfers– Sitting/standing balance– Gait– Stairs– ADLs/IADLs
(AOTA, 2014; Guide to Physical Therapist Practice 3.0, 2014)
PT Geriatric Outcome Measures
• Standardized Tests– Gait Speed– TUG– Berg– Tinetti– SLS– 30 Sec Sit to Stand– 6-minute Walk– 2 min Step test– 4 stage balance test
(Naqvi and Sherman, 2019)
WE ARE DOING A SHORT EXERCISE TEST; PLEASE USE YOUR OWN DISCRETION WHEN DECIDING
WHETHER OR NOT TO PARTICIPATE.
10 meter walk test (gait speed)
WALKING SPEEDmeters per second (m/s)
(Middleton et al, 2015)
OT Clinical Assessments■ Cognitive Assessments
– MoCA– Weekly Calendar Planning Activity (WCPA)
■ Participation– Activity Card Sort (ACS)
■ IADL Assessments– Texas Functional Living Scales (TFLS)– Executive Function Performance Test (EFPT)
(Munro Cullum, Weiner, & Saine, 2009; Baum et al, 2008)
Barriers to OT/PT Evaluation/Assessment■ Mood
■ Cognition
■ Reliance on self-report
■ Energy level / Fatigue
■ Time
■ Clinical setting
(Lequerica et al, 2009; Tam et al, 2015; Yang et al, 2013; Salthouse, 2012)
FIM Score: What does it
mean?
Complete independence - Fully independent
Modified independence - Requiring the use of a device and/or extended amount of time, but no physical help needed
Supervision - Requiring only standby assistance or verbal prompting or help with setup
Minimal assistance - Requiring incidental hands-on help only (Veteran performs > 75% of the task)
Moderate assistance - Veteran performs 50-75% of the task and needs assistance for 25-50% of the task
Maximal assistance - Veteran provides less than half of the effort (25-49%)
Total assistance - Veteran contributes < 25% of the effort or is unable to do the task
Interventions
■ Education– Compensatory strategies– Improvements to mobility techniques– Safety
■ Provide caregiver education
■ Splinting
■ Therapeutic Exercise, therapeutic activities, balance, and ambulation
■ Recommendations for assistive equipment and home modifications
(Dovern et al, 2012)
Discharge recommendations
■ Home– No therapy follow up– Family support– HHPT/OT– Outpatient PT/OT– Cardiac Rehab
■ SNF Rehab
■ Acute Inpatient Rehab
■ Long-Term Placement: SNF, ALF, MFH, LTC
STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans)
■ Targeted gait and balance assessment by a PT, followed by 1-2x daily walks supervised by a recreational therapy assistant for the duration of the hospital stay.
■ Physical Therapy vs STRIDE– Gait Training vs Ambulation– Mobility Promotion
Hastings, et al. J Am Geriatr Soc 2014
A CULTURE OF MOBILITY
“”The results suggest that nursing interventions that support functional independence and physical activity may mitigate risk for hospital-acquired functional decline”
“Although the bulk of acute care nursing focuses on medication administration and indirect care… the nurse continues to play a key role in providing and/or supervising direct care activities including those related to activities of daily living and physical activity”.
“This will require a paradigm shift in a care delivery system that traditionally focuses on only correcting the acute problem that led to admission to one that also supports older adults resuming their roles and activities”
“Patients achieved greater functional independence and higher mobility level which reduced the level of nursing care”
“Providing an opportunity for patients to consistently engage in mobility and higher levels of activity created patient expectations for mobility during hospitalisation”
“The net outcome was a reduction of unnecessary OT and PT orders, increased nurse and physician engagement in mobility, and hospital wide implementation of the program”
Early Mobility
Fraser et al. Am J Nurs. 2015 Dec;115(12):49-58.
Falls
Ventilator Events
Pressure Ulcers
Hospital costs
Use of sedatives
Length of stay
Delirium Days
CAUTIs
DVT/PE
Independence
Function
Out of bed
Needham et al.Arch Phys Med Rehabil. 2010;91(4):536-542
Interprofessional Care Strategy:Improve Ease of Mobility
■ OT/PT Tips– Dress the weaker extremity first– Transfer towards the stronger side– Transfer from high to low surface– Lock the chair/bed before transferring in/out– Promote independence; help only as needed
Interprofessional Care Strategy:Promote Healthy Cognition
■ Orientation
■ Environment
■ Structure/Routine
(Dzierzewski et al, 2014; Mudge, McRae, & Cruickshank, 2013)
Interprofessional Care Strategies:Prevent Iatrogenic Disability
■ Early Mobility– Create the expectation– Ability based encouragement– Sitting up in bedside chair for all meals– Help patients who are not incontinent to bathroom– Use of recommended mobility devices and them make available– Provide only the required assistance, allow patients to remain as
independent as possible in care
(Brown et al, 2009)
Interdisciplinary Treatment
■ Communicate■ Pre: Medication timing, recent events,
vitals, upcoming procedures■ Post: Response to exercise, activity
recommendations/fall risk, adverse events, changes in ability
Multi-DisciplinaryApproach
Nursing
MD/PA
Psychiatry
Pharmacy
Family
SW/ Case Manager
RehabPT/OT/ST/REC
Nutrition
Chaplaincy
Respiratory
Team InterventionsDelirium• Early mobility• Photos/familiar objects from home• Glasses/hearing aids• Sleep/wake cycle• Pain management strategies• Frequent reorientation (clocks, calendars)• Calm, patient-centered environment
■ Soft voices ■ Appropriate lighting (soft, non-glare)■ Unhurried approach■ Music
• Frequent patient assessment (CAM, check in with families)
National Clinical Guideline Centre, 2010
Team InterventionsImpaired ADLs
• Involve Veterans in ADLs (early and often)
– Narrating the activity– Placing object in the Veteran’s hand or visual field– Hand-over-hand– Begin task/end task
• Toilet OOB
– BSC or toilet• Eating/nutrition/hydration (dentures, diet, positioning, equipment)
National Clinical Guideline Centre, 2010
Interdisciplinary Fall Prevention Program
Toileting schedule Room placement Low beds Personal items
within reach
Easy access to equipment and
assistive devicesAdequate room
lighting Non-skid socks Sitter vs Bed alarms
Summary: Mitigating Risk and Improving Outcomes
■ Comprehensive assessment■ Interdisciplinary collaboration and communication■ Integration of patient, family/caregiver, and
professional input■ Early and thorough discharge planning
Falvey, 2016
Questions?
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