1 CLINICAL DECISION MAKinGAcute Care CLINICAL DECISION MAKinG © Rehab Resources, Inc. 2017

2 Objectives Based on chart review and evaluation of patient, the learner will be able to determine if continued skilled OT is appropriate or not. The learner will be able to analyze lab values and determine if it is safe to treat or not based on information gathered. The learner will effectively communicate with the multi-disciplinary team his/her recommendations for the safest discharge plan based on a multitude of factors. The learner will develop a comfortable level with management of lines in ICU.

3 Core Competencies in Acute CareDeveloped by a task force of 6 PTs in 2015 for any diagnosis in acute care across the lifespan Recognizes acute care is medically complex requiring high level clinical decisions in a rapid and dynamic changing environment Goal to assist in providing safe, efficient and effective care by defining required knowledge, behaviors and actions of clinicians with unique and overlapping skills Developed not only for the clinicians, supervisors and educators – developed PRIMARILY for the patients receiving care Will discuss the 5 competencies (which are interconnected) with an emphasis on clinical decision making with a focus on ICU and lab values

4 Core Competencies in Acute Care

5 Core Competency #1 – Clinical Decision MakingClinical decision making is thinking about course of action and ability to anticipate outcome based on previous experience and knowledge of best practice Focus is that all behaviors, actions and skills are guided by best evidence Ability to shift and change thinking in medically complex and challenging environments Goal to be competent and confident in decision making, as well as collaboration with the medical team Selection of best measures to determine if OT appropriate for patient and assist in discharge planning This competency is the foundation of all the other competencies From Felicia Foci, OT student, after acute care fieldwork – trust your gut and don’t ignore it!

6 Core Competency #1 – Clinical Decision Making examplesObserve details of patient history, evaluation and environment Determine based on chart review if patient would benefit from OT services at that time and if not, the ability to communicate the rationale to the medical team Assess patient throughout session and adjust intervention based on patient response Utilize best practice and evidence to predict level of improvement to determine goals, discharge plans and prognosis Identifying personal factors, co-morbidities and participation restrictions/activity limitations of patient Later in presentation will use lab values to demonstrate importance of clinical decision making

7 #1 – Clinical Decision Making Triage SystemAlgorithm developed to determine who needs skilled therapy services in acute care Reduced number of inappropriate therapy evaluations by 29% Average number of patients per day reduced from 18.9 to 12.1 in one academic hospital and from 15.1 to 12.8 in another academic hospital, which results in increased skilled care for the patients that would benefit the most Missed visits decreased from 24% to 2% in one institution and 4% to 0.8% in the other

8 From: Development of a Unique Triage System for Acute Care Physical Therapy and Occupational Therapy Services: An Administrative Case Report Last slide – tests/procedures safe to mobiitze? When a referral was deemed inappropriate, the referring provider was contacted to explain the rationale for cancellation. If additional information indicating the need for an evaluation was obtained during the discussion with the referring provider, the evaluation was scheduled. If no additional information warranting an evaluation was obtained, the referral was cancelled. If a patient's needs were not evident despite the use of the decision tree, the patient was placed on the therapist's caseload. Decision tree for acute care referrals for therapy. D/C=discharge, OT=occupational therapy, PT=physical therapy, SLP=speech and language pathology, SNF=skilled nursing facility. Date of download: 3/9/2017 © 2010 American Physical Therapy Association 8

9 Core Competency #2 - Communication examplesAbility to communicate with the medical team, especially the patient and family Alter communication style based on needs of patient Communicate clinical decision making in regards to reason for evaluation and\or continuing, withholding or discontinuing treatment Maintain professional communication especially in difficult situations From OT student after acute care fieldwork – patient involvement. Explain to the patient what you are doing and how it links to occupations (her example – ROM assessment for grocery shopping).

10 Core Competency #3 – Safety examplesCreate and maintain safe environment Awareness of precautions Communication with health care team of activity outside of therapy Determination if movement would compromise medical stability Infection control Responding to an emergent situation Management of lines – will discuss more in depth with ICU equipment, also from OT student after acute care fieldwork – communicate to patient you are organizing/securing lines and plan where lines will be at end of session to prevent tangles Medical stability – x rays as example

11 Core Competency #4 – Patient Management examplesImportance of thorough chart review Ability to document clinical decision making for continuing or discontinuing services Ability to document rationale for holding treatment Documentation to support reimbursement and in a court of law Communication to other clinicians who may be treating patient in hospital or when transferred to a different level of care Determine when need to communicate with another discipline orally prior to written communication From OT student after acute care fieldwork – add detail to documentation to communicate to next therapist who may be treating patient, more details about patient/family education and psychosocial concerns. Quicker communication – discharge planning, medical concerns DME - 4 wheeled walker requirements

12 Core Competency #5 – Discharge Planning examplesAbility to communicate discharge recommendation to medical team, including patient and family Determine destination and continuity of care in light of: safety/cognition, assistance available, PLOF, regulations/payment, environment Goal of cost containment and optimizing patient outcomes One study stated therapist used 4 areas to determine: function/disability, patient’s plan, patient’s ability to participate in care and patient’s life context From OT student after acute care fieldwork – “Recommend and advocate!” to prevent discharge to unsafe environment Readmission reduction (1 in 5 Medicare readmitted in 30 days)

13 # 5 – Discharge Planning Acute RehabRED LIGHT Inability to participate Unwillingness to participate Poor rehabilitation potential Dementia Doesn’t need 2 therapy disciplines Acute illness Procedure or work up pending

14 # 5 – Discharge Planning Acute RehabYELLOW LIGHT Possible poor rehabilitation potential Mild dementia or chronic cognitive impairment Unclear benefit for acute rehab as compared to sub-acute rehab Unclear safe discharge plan Insurance denial Severe behavioral disorder Not one of 13 impairment categories approved by CMS

15 # 5 – Discharge Planning Acute RehabGREEN LIGHT 1. Medical necessity Medical condition requiring consistent physician supervision Able to tolerate 3 hours of therapy daily Able to actively participate Significant potential for improvement within 7-14 days Discharge plan 2. Diagnosis code – CVA, SCI, congenital deformity, amputation, major multiple trauma, hip fracture, brain injury, neurological disorders, burns, arthritis, vasculitis, severe or advanced OA, TJR Bold has additional qualifications

16 ICU Line Management Count number of lines at beginning and end of treatment Pre-plan movement Detangle lines No tension on line Prevent occulsion

17 ICU Line Management IV No contraindication to activityAsk nurse if can disconnect Accidental pull out > pressure and tell nursing Catheter Drain tube before moving Clamp if put above bladder

18 ICU Line Management Chest tubeNo contraindications to movement – can roll Keep pleuravac upright DC suction only if allowed by nursing Mediastinal – CABG, Pleural – Pneumothorax (suction keeps lung inflated) Drains – Vacuum Evacuation, such as JP (Jackson-Pratt) Keep compressed

19 ICU Line Management Central lineTunneled – 24 hour decreased activity at site of placement after surgically implanted Arterial Access Pulmonary – watch PA pressure and watch transducer position to R atrium (1” below = 2 mmHg decrease in BP, 1” above = 2 mmHg increase in BP

20 ICU Line Management Telemetry Brown – chocolate (heart)Smoke (Black) above fire (Red) Clouds (White) above grass (Green) Image – content/uploads/2010/05/5-electrode-ECG.jpg

21 ICU Ventilator Normal breathing air pulled into lungs but ventilator PUSHES air into lungs Note point of attachment and how secured (should have one finger play between) Watch vitals Alarms Neutral head position When do we start – Immediately upon stabilization of hemodynamic and respiratory physiology (frequently occurs hours after ICU admission) Mechanically ventilated >4 days = target population Median 1 day after discontinuation of catecholamines/ sedatives

22 Ventilator - Neurologic CriteriaNot comatose Patient response to verbal stimulation 3/5 correct response: Open/ close your eyes Look at me Open your mouth and put out your tongue Nod your head Raise your eyebrows when I have counted up to 5

23 Ventilator -Respiratory CriteriaRequires only moderate ventilator support PEEP ≤10 cmH2O and FiO2 ≤60% No absolute limit with regards to FIO2/ PEEP (Morris et al) On assist-control ventilation for at least 30 minutes prior (treat before spontaneous breathing trials) Oxygen Saturation >88% Reasons to hold – Increase in PEEP on the ventilator Change to assist control mode once in a weaning mode on ventilator

24 Ventilator - Circulatory CriteriaAbsence of orthostatic hypotension Absence of catecholamine drips (vasopressor infusion) Had no increase in the dose of any vasopressor infusion (used for the management of hypotension/ shock) for at least 2 hours Systolic BP >90mmHg or <200mmHg; MAP >65mmHg or <110 mmHg

25 Monitor As You Go- Red FlagsVentilator Asynchrony Concern for airway device integrity RR (<5 or >40 breaths/min) or excessive RR increase(>20 breaths/ min) BP (< 90mmHg or >200 mmHg) or MAP (<65mmHg or >110 mmHg) HR (<40 bpm or >130 bpm) or excessive HR increase Patient being physically combative or patient distress

26 ICU Reasons to discontinue treatmentOxygen saturation <88% - unless order to titrate (will discuss more later) Drop in MAP HR greater than maximum heart rate (220-age/60-80%) Change in heart rhythm Increased accessory muscle use for breathing Respiration rate increase 20 breaths per minute above resting respirations Extreme fatigue or pallor Patient requesting to stop

27 ICU - General goals for treatmentOptimize patient sedation and analgesia practices to decrease delirium and permit for physical rehabilitation while maintaining patient comfort Schedule time with RN for “sedation vacation” Bolus administration vs. continuous IV drip (e.g. tPA bolus for stroke) Increase the frequency of PT/OT consultation to improve patients’ functional mobility in the ICU Establishing/ disseminating simple guidelines (what are they?) Modifying standardized admission orders for default activity level from “bed rest” to “as tolerated” Consult to physiatrist and neurologist Maintain critical lines and airway (schedule time with RN, RT)

28 ICU Outcomes to Early MobilityFewer days on ventilator Fewer ICU LOS days Fewer Hospital LOS days Faster return to more complete functional independence

29 Other areas for Clinical Decision MakingImaging Spinal instability Pharmacology

30 To guide safe therapy interventionsLab Values To guide safe therapy interventions © Rehab Resources, Inc. 2017

31 Objectives Participant will be able to describe purpose of lab values.Participant will be able to identify normal and abnormal lab values. Participant will be able to analyze lab values and determine if it is safe to treat the patient. © Rehab Resources, Inc. 2017

32 Defining Lab Values “Generally, statistically and biologically significant qualitative and/or quantitative measurements of cellular and clinical components of the body. The values derived from such measurements are based on averages of a survey of presumably healthy persons. The concept of individual normal values is based on an acceptable response (comparable with known evidence of health or disease) of an individual to a known alteration of cellular and/or chemical components or systems.” (2) © Rehab Resources, Inc. 2017

33 Defining Lab Values cont.“Laboratory values reflect the overall health of an individual. They are generally used for diagnostic purposes, or for monitoring the effects of medications or other medical treatments.” (3) © Rehab Resources, Inc. 2017

34 Defining Lab Values cont.Lab tests are also used for screening purposes, such as teenager lipid profile. (13) Lab tests are used to confirm a diagnosis based on clinical presentation. (13) © Rehab Resources, Inc. 2017

35 Defining Lab Values cont.Need to understand acute versus chronic change in value: With an acute change, the body has less time to compensate so interventions more conservative. (1) © Rehab Resources, Inc. 2017

36 How do we determine “Normal Values”?Normal values are typically determined based on 95% of healthy people in a certain group. For many tests, normal ranges vary depending on your age, gender, race and other factors (such as body size, muscle mass). (3,5) Normal values vary between labs due to the method used to test. (13) CBC is age dependent (variable birth to 16 years). Hgb/Hct different ranges for male/female in EPIC. GFR (Glomerular Filtration Rate for kidney function) is different for African Americans. Therefore, you need to use your computer systems’ reference ranges. DUE TO DIFFERENT NORMAL VALUES BETWEEN LABS, I HAVE NOT PUT NORMAL VALUES ON THE SLIDES!!!!!!!!!!!!!! © Rehab Resources, Inc. 2017

37 Abnormal Lab Values Abnormal is any value that is outside the reference range. (3) If lab value is outside the reference range, need to consider risk of intervention versus the benefit of increased mobility. Therefore, it is beneficial to consult medical team. (1) EPIC uses down arrow for low, up arrow for high and exclamation point over arrow for critically high or low value © Rehab Resources, Inc. 2017

38 Abnormal Lab Values cont.When a value is in the critical range, as opposed to high or low abnormal value, typically therapy should be deferred. (3) A lab value can be abnormal/inaccurate due to fluids (such as patient is dehydrated) or drugs (NSAIDs can affect kidney or liver tests). Therefore, it is important to watch trends and compare to patient’s baseline. (13) EPIC uses down arrow for low, up arrow for high and exclamation point over arrow for critically high or low value © Rehab Resources, Inc. 2017

39 Anticoagulation Therapy for Venous Thromboembolism (19)PTINR for Warfarin/Coumadin, PTT for Heparin. Coumadin avoid foods high in Vitamin K. D dimer (type of fibrin degradation product) to test for DVT or PE (positive = elevated). Fondapainux = Arixtra. NOAC – Xarelto. UFH – unfractioned heparin. Lovenox is low molecular weight heparin.

40 INR (International Normalized Ratio)Used to determine adequacy of blood coagulation system - normal or prolonged time to clot (13) Therapeutic range 2-3 (up to 4.5 for recurrent embolism) © Rehab Resources, Inc. 2017

41 INR (International Normalized Ratio) cont.Edge of bed, bed mobility, ROM, ankle pumps. No resistive exercise. INR > 5 Hold exercise. Evaluate if appropriate to perform bed mobility, edge of bed. INR > 6 Consider bed rest. Per Laboratory Tests Made Easy book, panic value for INR > 4.5. © Rehab Resources, Inc. 2017

42 PATIENT EXAMPLE Date INR Dr note 03/06/17 Admission 4.6(R TKR 02/27/17) 03/07/17 (Tuesday) 4.9 Ortho Dr states may begin PT at end of week depending on INR 03/08/17 4.5 Ortho Dr note “He would like to begin mobilizing.” Order – “Begin gentle mobilization around the room with walker assisted ambulation, WBAT on right leg. Gentle ROM exercises of R knee.” Activity level – “Bed to chair transfers. May ambulate around the room and use bathroom with walker.”

43 PATIENT EXAMPLE cont’dPT evaluation 03/08/17 Admitted due to Dx of cellulitis then popliteal DVT Precautions – bleeding, fall risk Nursing stated therapy could see patient Subjective – “I told the Dr I want therapy” No MMT due to high INR Limited gait to bathroom and back Only QS, SLR, heel slides for 10 reps Educated patient – limited exercises to perform once more that day due to supra-therapeutic, stated understanding Each treatment increased reps and number of exercises Discharged home with home PT on Friday STEVEN KELLY

44 Complete Blood Count (CBC)Components of all the formed elements of venous blood: WBC, RBC, Hgb and Hct. Evaluates the immune system and inflammatory responses, as well as bleeding. WBC fights infection and foreign material in body. RBC transport oxygen to cells and carbon dioxide to lungs. Hgb oxygen carrying protein in RBCs. Hct measures % by volume of RBC in whole blood sample. (1, 13) ESR/sed rate measurement of inflammation (Dx RA, PMR, THR/TJR infections) © Rehab Resources, Inc. 2017

45 Complete Blood Count (CBC) cont.Increased Hct increases blood viscosity, which may limit blood flow to essential organs, such as the brain, or increase likelihood of blood clots. © Rehab Resources, Inc. 2017

46 Complete Blood Count (CBC) cont.Intervention WBC: <5,000 with fever = no exercise but can do positioning/breathing techniques, >5,000 = light exercise progressed to resistive exercise as patient tolerates © Rehab Resources, Inc. 2017

47 Complete Blood Count (CBC) cont.Intervention Decreased RBC (anemia) - frequent rest breaks and monitor vital signs Increased RBC (polycythemia) - consider hold due to increased risk of stroke or blood clot (1,7, 13) © Rehab Resources, Inc. 2017

48 Complete Blood Count (CBC) cont.Intervention Hgb: <8 = No exercise but can do essential ADLs 8-10 = Light exercise (1-2 pounds), essential ADLs, assistance as needed for safety, light aerobics >8 = Resistive exercise, ambulation and self care as tolerated © Rehab Resources, Inc. 2017

49 Complete Blood Count (CBC) cont.Intervention Hct: <25% = No exercise but can do essential ADLs, assistance as needed for safety 25-35% = Light exercise (1-2 pounds), essential ADLs, assistance as needed for safety, light aeorbics >35% = Resistive exercise as tolerated, ambulation and self care as tolerated, aerobics (1) © Rehab Resources, Inc. 2017

50 “THE GENTLE GIANT” Height 6’6” Weight 410# Motorcyle accidentChart review – CT abdomen on 09/11/16: “There is a small amount of what appears to be blood in the posterior retroperitoneum. 2 areas of small hematomas left mesentery.”

51 “THE GENTLE GIANT” Date Hgb Hct Therapy 09/11 13.1 40 09/12 10.5 31(Admitted) 09/12 10.5 31 Evaluation – transfer to chair only due to pain level. 09/13 8.7 26 Walk to bathroom, rest then back = 10’ x 2. 09/14 8.1 24 Walk 60’ with RW and chair follow. 09/15 7.9 Therapy gym for one step and second person assist. 09/16 7.5 22 Therapy HELD. CT scan – At least Grade 2 splenic injury. 09/17 8.6 Different therapist – walk 12’, limited by RN and trauma to in room only (09/18 50’).

52 Retrospective Study – HgbPurpose – Objectify adverse events in acute care related to hemoglobin level <8 g/dl Completed by chart review of 4 months of PT Adverse event defined during activity as: systolic BP >200 mmHg, pulse ox < 90%, systolic BP drop more than 10 mmHg below resting, orthostatic response, HR increase >120 BPM Total of 3314 sessions 3236 with Hgb >8 g/dl – 13.8% adverse event 78 with Hgb <8 g/dl – 6.4% adverse event Conclusion – Due to low % adverse event, failure to support “no exercise/contraindicated” <8 g/dl. Recommendation – use caution. (15) PATIENT EXAMPLE Orthostatic response defined as systolic BP drop greater than/equal to 20, diastolic BP drop greater than/equal to 10, HR increase greater than 15 BPM

53 Blood transfusions Hgb <6 g/dl – recommended except in exceptional circumstances Hgb 6-7 g/dl – generally indicated Hgb 7-8 g/dl – consider for postop patients after clinical assessment if stable cardiovascular status Hgb 8-10 g/dl – not indicated except certain circumstances (such as anemia with symptoms, continued bleeding, ischemia in coronary disease) Hgb >10 g/dl – not indicated except in exceptional circumstances Decision to transfuse should not be based on a single criteria - hemoglobin level AND each patient history and symptoms (such as weakness, fatigue, dizziness, dyspnea, decreased exercise tolerance, mental status change, feeling faint). Also consider benefits versus risks, cause of blood loss and co-morbidities. (14) Prior to 1980’s used 10/30 rule (maintain above 10 hgb/30 hct), then concern over blood-borne pathogens, cost containment, supply versus demand

54 Platelets Major line of defense from bleeding by formation of plugs inblood vessels – indicator of ischemia and end organ inflammation Intervention <10,000 and/or temperature >100.5 degrees = No exercise, hold therapy 10,000-20,000 = Light exercise (no PROM, but light AROM permitted) >20,000 = Resistive exercise Decreased platelets associated with acute kidney injury post- operatively (1, 13,16) >600,000 increased clotting risk. PANIC VALUES <20,000 or >1,000,000 © Rehab Resources, Inc. 2017

55 Arterial Blood Gases Assess the gas exchange functioning of the cardiopulmonary system (oxygenation, ventilation). Indicates presence or degree of hypoxia at rest. Includes pH, PCO2, HCO2, PO2 (measurement of oxygenation), and O2Sat. (1, 13) pH = measure of blood acidity (7.4 normal), PCO2 = partial pressure of carbon dioxide dissolved in arterial blood/influenced by pulmonary function, HCO2=amount of bicarbonate dissolved in blood/influenced by metabolic changes, PO2=partial pressure of oxygen dissolved in arterial blood, O2Sat=% of oxygen carried by hemoglobin. (1, 13) © Rehab Resources, Inc. 2017

56 Arterial Blood Gases cont.Results in acid-base disorders as follows: respiratory acidosis (CO2 retention), respiratory alkalosis (CO2 excretion), metabolic acidosis, metabolic alkalosis. (1, 13) ABGs affect arousal. Respiratory acidosis caused by neuromuscular weakness and COPD. Respiratory alkalosis – hyperventilation (anxiety, pain). Metabolic acidosis – shock, infection, GI tract. Metabolic alkalosis – vomiting, burns. © Rehab Resources, Inc. 2017

57 Arterial Blood Gases cont.Main focus in therapy is O2 Sat. As saturation drops below 90%, partial pressure of oxygen in arterial blood rapidly decreases. Less than 84%, hemoglobin’s ability to carry oxygen greatly impaired. Study showed use of third or fourth digit (middle or ring finger) gives most accurate readings for pulse oximetry. (1, 13) O2 sat = % of O2 carried by hemoglobin. © Rehab Resources, Inc. 2017

58 Intervention Keep oxygen on during treatment. (1)O2 Saturation cont. Intervention Keep oxygen on during treatment. (1) Maintain saturation greater than 90-92% for activity if possible. Modify treatment plan by rest breaks, upright posture and education in pursed lip/diaphragmatic breathing which moves CO2 out of lungs so increased oxygen can enter. (1) © Rehab Resources, Inc. 2017

59 O2 Saturation cont. Intervention If there is an order to titrate oxygen to keep saturations above 90-92%, increase oxygen until reach that O2 sat level then reduce back to original liters. COPD patients due to destroyed alveolar septum have air trapping, decreased gas exchange and CO2 retention. (6, 13) Titrate 1 L/min at a time – some orders say up to 6 L . CO2 retainers have increased disorientation or decreased respiratory rate/depth with no increased O2 sats with oxygen increased with activity = not candidate for supplemental O2 with activity. © Rehab Resources, Inc. 2017

60 Intervention O2 Saturation cont. Flow rate FiO2 Room air 21% O21 L/Min 24% O2 2 L/Min 28% O2 3 L/Min 32% O2 4 L/Min 36% O2 5 L/Min 40% O2 6 L/Min 44% O2 Increased length of tubing = increased resistance to flow. © Rehab Resources, Inc. 2017

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62 MAP (Mean Arterial Pressure)Normal values - 70 to 105 mmHg It is a mathematical calculation of the systolic and diastolic blood pressure due to ⅔ of the cardiac cycle are in diastole. It is an indicator of tissue perfusion of coronary arteries, brain and kidneys. Adequate tissue perfusion >60. Therefore, recommendation not to treat if less than 60 MAP. (11, 12) © Rehab Resources, Inc. 2017

63 Cardiac Markers CPK-MBCreatine Phosphokinase - found in cardiac muscle Released into circulation after MI; it rises 4-6 hours after acute MI, peaks in hours and returns to normal in hours CPK can also be elevated to 1,000-5,000 after trauma indication acute compartment syndrome (17) Creatinine only increase can indicate rhabdomyolysis (troponin can be elevated also) NO NORMAL given – as stated earlier, varies widely by lab and the method that they use © Rehab Resources, Inc. 2017

64 CPK-MB cont. Intervention Cardiac Markers cont.Contraindicated until levels begin to decrease, then continue as patient tolerates with close monitoring of vitals and frequent rest breaks. If patient has dysrhythmia, angina or hypotension (as examples), consider holding treatment (1,7) B North does not use CK-MM. Does calculate CK-MB when CPK less than When LDH1>LDH2, strongly suggestive of acute MI (13). © Rehab Resources, Inc. 2017

65 Troponin Cardiac Markers cont.Preferred test for myocardial injury since they are the contractile proteins of the myofibril Rises 4-6 hours post injury and remain elevated for a week or more (good late marker) Can be false positive if kidney dysfunction (13) All cardiac lab tests must be used in conjunction with history, clinical exam and EKG for diagnosis of MI. Troponin T <0.01 ng/mL (nanogram/milliliter). Troponin I < or = 0.04 ng/mL © Rehab Resources, Inc. 2017

66 PATIENT EXAMPLE – Per Dr note, it is definitely not a cardiac eventDate Troponin (normal <0.04 ng/mL) 2011 0.01 2012 0.08 2013 0.04 2014 0.05 11/25/ 11/25/ 0.25 11/26/16 0.16 Due to demand ischemia from an infection

67 Electrolytes PotassiumAffects skeletal muscles function and nerve conduction, as well as rate and force of heart contraction. Dangerous cardiac arrhythmia or muscle spasms also with increased calcium levels (7, 13) © Rehab Resources, Inc. 2017

68 Electrolytes cont. Potassium cont.Intervention <2.8 or >5.1 = hold therapy due to possibility of arrhythmia or muscle spasms, could be life threatening Exception - Patients with CHF who can tolerate increased levels. Consult nurse due to medications quick acting and can change quickly due to hydration status (1,7, 13) Dangerous cardiac arrhythmia or muscle spasms also with increased calcium levels (7, 13) Dialysis also used to manage potassium levels. © Rehab Resources, Inc. 2017

69 PATIENT EXAMPLE 12/09/16 Critical potassium at 0732Seen in PT at 0830 – patient reports “My heart is racing” after ambulation. Informed nursing of 2 minute recovery time. At 1304 Dr ordered treatment for hyperkalemia and remote telemetry.

70 Sodium Electrolytes cont.Functions to transmit nerve impulses. Reflects changes in salt and water balance. Decreased value can be due to alcohol consumption. Numbers can also be skewed if blood glucose levels are fluctuating. (7, 9, 13) © Rehab Resources, Inc. 2017

71 Sodium Intervention Electrolytes cont.<120 (weakness, neurological symptoms) or >155 (seizures) are life threatening. Therapy contraindicated. © Rehab Resources, Inc. 2017

72 PATIENT EXAMPLE Date Sodium Notes 08/15/16 122 Admission 08/16 125Evaluation 08/17 119 Refused 08/18 Neuro consult pending – no LE weakness, abscess L2-S1 08/19 Therapy note - Lethargic at times. Reports she just suddenly falls asleep. Forgetful, slightly confused, slow responses. Her speech is slightly garbled. Decreased awareness of body in space – can’t tell pillows under limbs in supine. 08/20 124 Transferred to TCU. Therapy medical downgrade. 08/22 126 Therapy re-eval. No neurological symptoms. VITAMIN B6 GANGLIOPATHY CAN CAUSE PROFOUND SENSORY LOSS – CAN”T TELL WHERE LIMBS ARE IN SPACE

73 BUN (Blood Urea Nitrogen)Electrolytes cont. BUN (Blood Urea Nitrogen) Measures how well the liver and kidneys are functioning. Can be influenced by GI bleeding. Intervention If increased, monitor for light headedness and dizziness, as well as confusion. (7, 9, 13) © Rehab Resources, Inc. 2017

74 Liver Function Tests Use standard precautions and monitor vital signs due to increased risk of infection and bleeding (7, 9, 13) Due to glial cells ability to remove K++ is perturbed © Rehab Resources, Inc. 2017

75 Ammonia If elevated - significantly effects brain function, such as confusion, delirium, seizures or coma (7, 9, 13)

76 Blood Glucose Monitors diabetes diet and medication, as well as, altered levels of consciousness HbA1c (Glycosylated hemoglobin) - average blood sugar level over a 2-3 month period of time prior to the test. Used to evaluate treatment of diabetes. © Rehab Resources, Inc. 2017

77 Intervention Blood Glucose cont.If low (symptoms: labile, irritable, nervous, difficulty concentrating/speaking, shaky, hungry, headache, dizziness, pallor, sweating), need sugar (juice, candy, etc). <60 will have poor tolerance to exercise and may show mental status change; notify RN. If high (symptoms: lethargic, confused, thirsty, weak, nausea, vomiting, flushed), need immediate medical attention. >300 exercise may increase glucose levels even more; treatment contraindicated. (7, 13) © Rehab Resources, Inc. 2017

78 Ejection Fraction Amount of blood pumped divided by amount of blood ventricle contains Normal is 50% or higher Intervention Monitor vital signs Progressively increase activity as patient tolerates Do not treat if less than 20% (7,8) Due to diagnosis of cardiomyopathy or heart failure © Rehab Resources, Inc. 2017

79 New lab test Lab test being developed to detect concussionsWill measure proteins that indicate TBI First need to determine baseline level of proteins (18) Check TSH for ataxia/vertigo with Dx of hypothyroidism

80 Using Lab Values to Guide Safe InterventionsKnow your facility guidelines/policies if applicable, as well as the individual physician who may be more aggressive or conservative in his/her approach based on his/her research or preference. (4, 5) The goal is EITHER not over stressing unstable/fragile patients OR not under exercising stable patients who could tolerate increased physical activity (1) © Rehab Resources, Inc. 2017

81 Using Lab Values cont. Modify the intervention by one or more of the following: decrease frequency of repetitions, decrease intensity of exercise/activity, increase rest breaks. (3) Monitor the patient’s response to therapy if lab values abnormal. Consider the individual based on prior interactions. (4) © Rehab Resources, Inc. 2017

82 Using Lab Values cont. “Pawlik et al states in a 2013 article that patients with acute illness “require timely and accurate assessment and modification of activity by the intervening PT (or OT) and titration of activity in response to changes in physiological status.”” (5) Overall, use clinical judgement by thorough chart review, review of lab trends and review with clinical team then monitoring patient if you are treating! (4, 5) © Rehab Resources, Inc. 2017

83 Case Studies

84 References Greenwood K, Stewart E, Milton E, et al. Core Competencies for Entry-Level Practice in Acute Care Physical Therapy. Acute Care – The Critical Edge in Physical Therapy. First Edition 2015: Smith B, Fields C, Fernandez N. Physical Therapists Make Accurate and Appropriate Discharge Recommendations for Patients Who Are Acutely Ill. Phys Ther May; 90(5): Jones, V. Mystery Solved: Which Patients Are Good Candidates For Acute Inpatient Rehabiltation. rehabilitation/ ?wpmp_tp=1. June 2014. Hobbs JA, Boysen JF, McGarry KA et al. Development of a Unique Triage System for Acute Care Physical and Occupational Therapy Services: An Administrative Case Report. Phys Ther October; 90(10): Sadowsky HS. Lines, Tubes, Ventilators and Diagnostic Screening for Stability vs Instability. Education Resources Inc.

85 References cont’d Zanni J and Needham D. Promoting Early Mobility and Rehabilitation in the Intensive Care Unit (ICU). PT in Motion. May 2010: Kache S. Mechanical Ventilation. Foci, F. 5 Skills to Master in an Acute Care Fieldwork Setting. https://www.aota.org/Education- Careers/Students/Pulse/Archive/fieldwork/acute-care.aspx. Bailey P, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med 2007; 35: Morris PE, et al. Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008; 36: Needham DM, et al. Early Physical Medicine and Rehabilitation for Patients with Acute Respiratory Failure: A Quality Improvement Project. Arch Phys Med Rehabil 2010; 91: Schweickert WD, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009; 373: © Rehab Resources, Inc. 2017

86 Lab References Acute Care Lab Values Interpretation Resources. APTA website. Published Accessed 11/17/15. Normal Lab Value definition. The free dictionary website. Published Accessed 11/30/15. Demystifying Lab Values. Archives/Demystifying-Lab-Values.aspx. Advance Healthcare Network website. Posted January 5, Accessed 11/17/15. Lab Values Update. Acute Care Perspectives. Volume 13, Number 1, Spring 2004. The Role of Lab Values in clinical decision making and patient safety for the acutely ill patient. Physical Therapy website. October 2, Accessed 02/22/16. Hillegass E, Fick A, Pawlik A et al. Supplemental Oxygen Utilization During Physical Therapy Interventions. Cardiopulmonary Physical Therapy Journal. June 2014; 25(2): © Rehab Resources, Inc. 2017

87 Lab References cont’d CEU Cardiac considerations handout Relevance of Lab Values and Medications in Dysphagia Management. Northern Speech Services website. in-dysphagia-management/. Reviewed and registered December 31, Accessed 02/22/16. Mean Arterial Pressure. MD+Calc website. Accessed 07/26/16. Mean Arterial Pressure. Global RPh website. Last updated 07/26/16. Accessed 07/26/16. Rothenberg MA, Smith SG. Laboratory Tests Made Easy: A Plain English Approach. Eau Claire, WI: PESI Inc; Richards N, Giulilano K, Jones P. A prospective comparison of 3 new-generation pulse oximetry devices during ambulation after open heart surgery. Respir Care. 2006;51(1):29-35. © Rehab Resources, Inc. 2017

88 Lab References cont’d Sharma S, Poonam Sharma, Tyler L. Transfusion of Blood and Blood Products: Indications and Complications. Ahm Fam Physician Mar 15;83(6): Peterson M. The Impact of Low Hemoglobin on the Percentage of Adverse Events During Physical Therapy in the Acute Care Setting: A Retrospective Study. JACPT ; 6(1): Kertai, Zhou S, Karhausen JA, et al. Platelet Counts, Acute Kidney Injury and Morality after Coronary Artery Bypass Grafting Surgery. Anesthesiology Feb; 124(2): Acute Compartment Syndrome Workup. Medscape website. Accessed 11/29/16. Perez AJ. Blood tests to diagnose concussions to be discussed at summit on Monday. USA Today Sports. September 26, 2016. Hillegass E, Puthoff M, Frese E et al. The Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed with Venous Thromboembolism: Executive Summary of an Evidence-Based Clinical Practice Guideline. JACPT ; 7(4): © Rehab Resources, Inc. 2017