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

Presenter

Presentation Notes

Steve

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

Presenter

Presentation Notes

Steve First, Thank you Our objectives today are to... Identify problems common to acute care hospitalizations Discuss PT and OT in acute care. Hopefully you will know the difference by the time we are done And We will cover evidence-based interprofessional strategies to address the disease of immobility which is common in acute care hospitals

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

Presenter

Presentation Notes

Steve There is often a culture of immobility when someone is admitted to the hospital. In an effort to prevent falls, a veteran who is fully independent at home may be instructed in the hospital to not get up without assistance. This can lead to ...

Complications of Immobility

Dittmer et al. Can Fam Physician 1993;39:1428-1437Creditor, Ann Int Med 1993

Presenter

Presentation Notes

Steve The human body is designed to be mobile Listed here are a number of complications of immobility. I will highlight a few of them. Orthostatic Hypotension can occur for multiple reasons, but with immobility it is believed that the cardiovascular system does not adapt normally to an upright posture. This patients at increased falls risk. Immobility also places patients at increased risk for developing deep vein thrombosis and pulmonary embolism. Regarding muscle atrophy and wasting, A muscle at complete rest loses 10-15% of it’s strength each week. Nearly half of normal strength is lost within 3 to 5 weeks of immobilization. The first muscles to become weak and atrophy are the postural muscles that resist gravity in the lower extremities and trunk. Difuse muscle weakness is reversed at a rate musch slower of only 6% per week using submaximal exercises (65-75% of a maximum rep) Because joints do not have good circulation, the only way to provide nourishment and lubrication to the joint is through movement. Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structures, which contribute to limitations in ROM.The negative consequences of contractures is the impaired ROM required for normal functional movement, participation in ADLs, or skin hygiene. Contractures are a consequence of chronic immobility. Being mindful of positioning in bed such as knees flexed or shoulders propped can put patients at risk for contractures. bone morphology is dependent on the forces applied to it. Without appropriately applied stress to bones in weight bearing, there is increased absorption and can lead to disuse osteoporosis. Bone resorption during acute illness with bed rest can exceed normal resorption rates by 50 times the normal rate, leading to increased risk for fracture (frail, white, females are at particular risk). The loss incurred in 10 days of bed rest required 4 months to restore. Decreased ventilation can lead to infection, atelectasis, and PE Pressure ulcers prevalence is 20-25%. Skin necrosis results from direct pressure that is greater than capillary filling pressure for more than 2 hours. Increased risk of skin breakdown can also occur secondary to shearing forces and exposure to moisture. Sensory deprivation or overstimulus – imagine waking up in an unfamiliar room with little light, not wearing your glasses or hearing aides, hearing abnormal sounds such as beeping from multiple machines or hearing your roommate talk. No wonder delirium develops. Creditor, Ann Int Med 1993 Dittmer DK, Teasell R. Complications of Immobilization and Bed Rest. Can Fam Physician 1993;39:1428-1437

Cascade of DependenceCreditor, Ann Int Med 1993

Presenter

Presentation Notes

Steve At the top of the page you will see that there are normal physiologic changes that occur with aging. They include... Unfortunately, bedrest and hospitalization accelerate these changes and lead to secondary complications Lack of movement directly impacts muscle strength, aerobic capacity, bone mineralization, and skin integrity. I have highlighted a few complications that PT can address. Take a moment and examine which complications you can address in your position at the hospital.

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

Presenter

Presentation Notes

Steve We can’t really discuss function in the hospital and not address falls. The impact of falls is multifacited. It impacts the medical system financially with increased length of stays and cost of injury. It can result in fracture or head injury. And it can negatively impact the individual cause unnecessary suffering and loss of independence. •DVAMC- FY17 •2nd most common adverse event following medication errors •More falls around meal-times and early morning (5-6am). Why do you think that is? Next, we have intrinsic and extrinsic factors that increase a patients risk for falls. Some of these risk factors are modifiable. For example, if a patient has a visual impairment that is corrected with glasses, ensure that their glasses are within reach. Or if the patient requires a walker to safely ambulate, ensure that a loaner walk is provided to the veteran. Take a moment and identify other modifiable risk factors that you can address in you duties at the hospital.

The Falls Cycle

Fall

Fear of Falling

Limit Activity

Decreased Strength

and Balance

Increased Risk of Falls

Presenter

Presentation Notes

Steve Unfortunately, once a fall occurs it can crate a cyclical pattern that leads to more falls. Imaging you have a newly admitted 80 year old Male Veteran with a recent fall. He is fearful of falling and has started spending more time sitting watching Tv and limiting his activity. As he is now sitting for hours during the day his standing balance and lower extremity strength has decreased. HE still ambulates, but now secondary to reduced balance and strength does so unsteadily. The veteran is now at an increased risk for falls. And the cycle continues It is important to break the falls cycle by promoting activity. We need to change the narrative from “Don’t get up! You’ll fall” to “How can I assist you.” Provide options for safe patient empowerment with mobility.

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)

Presenter

Presentation Notes

Maggie

POLL: WHICH OF THESE

ARE ACTIVITIES OF DAILY LIVING

(ADL)?

Presenter

Presentation Notes

Maggie

ADLsBathingToiletingDressingEating/SwallowingFeeding (food to mouth)Functional MobilityDevice CareGroomingSexual Activity

Presenter

Presentation Notes

Maggie Devices = hearing aids, glasses, walker, cane, etc)

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)

Presenter

Presentation Notes

Maggie and Steve

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

Presenter

Presentation Notes

Steve Falvey JR, Burke RE, Malone D, Ridgeway KJ, McManus BM, Stevens-Lapsley JE. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions from Hospital to Community. Phys Ther. 2016 Aug;96(8):1125-34 Hospital readmissions in older adult populations are an emerging quality indicator for acute care hospitals. Recent evidence has linked functional decline during and after hospitalization with an elevated risk of hospital readmission. Nearly 1 in 5 Medicare beneficiaries are readmitted to the hospital within 30 days after an acute hospitalization.1 Reduction of 30-day hospital readmissions is a major quality improvement goal for many acute care hospitals, partly in response to new Medicare rules that penalize hospitals that demonstrate higher-than-average readmission rates for populations of beneficiaries with certain target conditions This study by Falvey and collegues found that, Physical Therapists provide appropriate discharge recommendations for patients. We assess for discharge location and the type PT services need. We collaborate with patient, family and caregivers regarding discharge plans

Admission and Referral to OT/PT

Gather History

General Process Framework

Clinical Observation & Assessment

Intervention

Presenter

Presentation Notes

Maggie

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

Presenter

Presentation Notes

Maggie

International Classification of Function (ICF) Model

(WHO, 2002)

Presenter

Presentation Notes

Maggie

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

Presenter

Presentation Notes

Maggie An older adult can be admitted following a fall resulting in a hip fracture, s/p ORIF. A thorough assessment reveales that multiple body structures are impaired including decreased strength L LE, along with decreased balance and endurance, and increase in pain. These impairments affect the patients ability to participate in functional mobility. Patient is no longer able to participate in the things he enjoys including church services, playing with his grandchildren and getting out in the community. Through an interdisciplinary approach of early mobility with additional appropriately dosed PT we can assist with discharge back to previous environment and improve patient’s participation.

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

Presenter

Presentation Notes

Maggie Emphasize that we are gathering a history about their abilities with all of these things, prior to the decrease in function that caused their admission.

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)

Presenter

Presentation Notes

Steve

Presenter

Presentation Notes

Steve From a PT perspective, gait assessment is vital. We can learn a lot just from observing someone ambulate. Here are a few videos to demonstrate.

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)

Presenter

Presentation Notes

Steve Listed here are some of the outcome measures that a PT might use during an examination to gleen more information. They assess factors such as falls risk, lower extremity weakness, endurance, and general mobility. For example, an individual who completes the Timed Up and Go test in more than 12 seconds is at increased risk for falls. Let's have everyone try one of our tests.

WE ARE DOING A SHORT EXERCISE TEST; PLEASE USE YOUR OWN DISCRETION WHEN DECIDING

WHETHER OR NOT TO PARTICIPATE.

Presenter

Presentation Notes

Steve We are going to do the 30 second sit to stand test (also known as the 30 second chair rise test). Use your own discretion when deciding to participate. 1. Sit in the middle of the chair. 2. Place your hands on the opposite shoulder crossed, at the wrists. 3. Keep your feet flat on the floor. 4. Keep your back straight, and keep your arms against your chest. 5. On “Go,” rise to a full standing position, then sit back down again. 6. Repeat this as many times as you safely can for 30 seconds and keep track of the number. Ready, go... stop. If any of you are 60 years old or older, you can compare how you fared with your age related peers. If you stood less times than indicated here, you are at increased risk for falls.

10 meter walk test (gait speed)

Presenter

Presentation Notes

Steve I mentioned earlier the how much we can learn by examining the quality of gait. The 10 meter walk test allows us to quantify gait into gait speed. A patient is timed, walking at their usual pace for 10 meters, allowing for acceleration and deceleration time

WALKING SPEEDmeters per second (m/s)

(Middleton et al, 2015)

Presenter

Presentation Notes

Steve When we quantify it in this manner, we discover the importance of gait speed. The cut-off for an individual to be at low risk for falls and be more likely to be independent is 1 meter/second. The slower the gait speed, the more troubling the limitations. For example, an individual who walks less than .8 m/s is more likely to struggle when ambulating in the community. They may not be able to cross a crosswalk in the alotted time, or may struggle to complete their grocery shopping. Additionally, If your gait speed falls less than .6 m/s you are more likely to be dependent with ADL and IADL.

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)

Presenter

Presentation Notes

Maggie

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)

Presenter

Presentation Notes

Maggie

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

Presenter

Presentation Notes

Maggie

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)

Presenter

Presentation Notes

Maggie and Steve

Presenter

Presentation Notes

Steve As part of a PT and OT intervention, the therapist talks with the patient about their goals. These goals are often centered around what would be required in order to discharge home safely. When setting goals, we follow the SMART outline. S stands for Specific...

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

Presenter

Presentation Notes

Steve One of our major roles in the hospital is to provide discharge recommendations. As mentioned earlier, studies have found that PTs provide accurate d/c recommendations which lead to fewer hospital readmissions. Our discharge recommendations typically fall into one of these 4 categories. Discharge recommendations are highly individualized and are dependent upon an patients function, mobility, available equipment, and level of social support. For example, A bedbound patient who is dependent with all ADL and IADL may require long-term placement. However, if that patient has 24/7 support at home from a dependable family member who has been trained, the patient could discharge home without additional therapy needs. More often than not patients fall into one of two categories: home with HHPT/OT or SNF with PT/OT. One of the reasons why additional therapy is needed after a hospitalization is because of physical and functional changes that have occurred while hospitalized and the culprit can often be immobility while in the hospital. One program that has been implemented to combat this problem is STRIDE

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

Presenter

Presentation Notes

Steve Hastings SN, Sloan R, Morey M, Pavon J, Hoenig H. Assisted Early Mobility for Hospitalized Older Veterans: Preliminary Data from the STRIDE Program. J Am Geriatr Soc 2014 62:2180-2184 *Read slide* A study of the STRIDE program by Dr Susan Hastings and collegues from here at the Durham VA compared STRIDE participants with individuals who were referred but not enrolled in the program. The Median length of stay was 4.7 days for STRIDE participants and 5.7 days for individuals receiving usual care. They also found that 92% of STRIDE participants were discharged to home compared to 74% receiving usual care At first glance it may appear that PT and STRIDE are the same. The difference is that PT provides interventions taylored to the individual, targetting the impairements and functional limitations that were identified during the evaluation and treatment is centered around the patient's goals and modified as the patient progresses. Whereas STRIDE does not provide this level of skilled intervention. They are providing a very beneficial walking program while the patient is in the hospital and they are helping to combat the disease of immobility. If a patient is independent and safe with mobility (either with or without an AD), and just needs a companion to help motivate them to stay active, then STRIDE is the right program. If a patient needs training or issuing a new assitive device, needs assistance with mobility, an individualized exercise program, and recommendations for d/c, then PT would be the right referral.

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”

Presenter

Presentation Notes

Steve There has been quite a bit of research done on the importance of creating a culture of mobility in the hospital. Here are a few studies that I will highlight today. The first is Functional decline in Hospitalized Older Adults: Can Nursing Make a Difference? Marie Boltz, et al. Geriatric Nursing 2012. Prospective Observational study of hospitalized older adults who received Function-Focused Care. Function Focused Care is an approach in which nurses help patients engage in ADL and physical activity. They report that FFC in the acute care setting is feasible and they found that adults who received FFC were more likely to d/c home instead of an institution. Here are some of the noteable results. The second article is Mobility Bridges a gap in care: findings from an early mobilization quality improvement project in acute care. By Johnson and Howell, a PT and OT respectively. This was a qualitative study focusing on the response of patients, nurses, and physicians who were involved in an early mobilization project. This project included a mobility aide which was similar to that of our STRIDE program. These were some of the results… This relates to the previous articles suggestion of a paradigm shift… The third article entitled Creating a Culture of Mobility: An Interdiciplinary Approach for Hosptialized patients is from research that was done at Vident Hospital in Greenville from 2014. The researchers had observed a culture of immobility that had developed in the hospital and that the responsibility for mobilizing had shifted from a team approach to solely that of the PT and OT staff. They developed a team and implemented a program that involved assessing the patients mobility with a tool similar to the BMAT, improving access to mobility equipment, triaging therapy consults, and providing education. Essentially they created a paradigm shift so that PT, OT, nursing, and physicians all had a hand in promoting mobility. This was the result…

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

Presenter

Presentation Notes

Steve The 66 patients who received the mobility intervention from the ICU mobility team had significantly fewer falls, ventilator-associated events, pressure ulcers, and catheter associated urinary tract infections than the 66 patients in the routine care group. The mobility group also had lower hospital costs, fewer delirium days, and improved functional independence compared with the routine care group. Patients in the mobility group got out of bed on 2.5 more days than patients in the routine care group. There were also no adverse events in the mobility group. Fraser D, Spiva L, Forman W, Hallen C. Original Research: Implementation of an Early Mobility Program in an ICU. Am J Nurs. 2015 Dec;115(12):49-58.

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

Presenter

Presentation Notes

Maggie

Interprofessional Care Strategy:Promote Healthy Cognition

■ Orientation

■ Environment

■ Structure/Routine

(Dzierzewski et al, 2014; Mudge, McRae, & Cruickshank, 2013)

Presenter

Presentation Notes

Maggie

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)

Presenter

Presentation Notes

Steve

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

Presenter

Presentation Notes

Steve We are all a part of the team, each discipline brings their unique perspective and skills to provide optimal care for the older adult when hospitalized. We need to communicate relevant information clearly with each member of the team and with the patient The Irish playwight, George Bernard Shaw once sait “ The single biggest problem in communication is the illusion that it has taken place”. Unfortunately, lack of communication leads to errors which can have serious effects for the patient. I am often guilty of assuming that I have adequate information about a patient because I have reviewed the chart and so I may not always check with the nurse prior to treating a patient, but this is my own illusion that communication has taken place. There can be serious issues that have occurred in the patient’s care since the last documentation and there may be important information that needs to be communicated prior to seeing a veteran. This doesn’t just apply to PT and OT but all other disciplines involved in the patient’s care. Pre - Medication timing, recent events, vitals, and upcoming procedures are all helpful information that nursing can provide prior to seeing a patient Post – Response to exercise, activity recommendations, falls risk, adverse events Encourage Early Mobility: Encourage active patient participation in their own care or functional activities

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

Presenter

Presentation Notes

Maggie

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

Presenter

Presentation Notes

Maggie

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

Presenter

Presentation Notes

Steve Toileting schedule Room placement (such as closer to the nurse) Low beds Personal items within reach – bedside table, call light Easy Access to equipment and assistive devices Adequate room lighting Non skid socks Sitter vs Bed alarms Bed alarms Use of bed or chair alarms is not efficacious. There is no difference in change in fall rates per 1000 patient-days Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients. Ann Internal Med. 2012 Nov 20; 157(10):692-699 The routine use of sensors isn’t recommended in good practice guidance. For those with dementia or delirium, having an alarm sound could worsen their distress and disorientation. Alarms are disturbing, contributing to noise pollution and can worsen the cycle of immobility and deconditioning. David Oliver: Do bed and chair sensors really stop falls in hospital? BMJ 2018;360:k433 doi: 10.1136/bmj.k433 Bed alarms could be considered to determine circumstances or time of day associated with fall. Siderails, restraints increase fall related injuries Schorr et al. Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients: A Cluster Randomized Trial. Ann Intern Med. 2012;157(10):692-699 A recent article published in August 2018 examined the use of PTs in the ER for ground related falls in the elderly. An assessment performed by a PT in the ER resulted in reduced 30 day and 60 day hospital revisit for a fall related event. Association Between Physical Therapy in the Emergency Department and Emergency Department Revisits for Older Adult Fallers: A Nationally Representative Analysis. Lesser A, Israni J, Kent T, Ko KJ. J Am Geriatr Soc. 2018 Aug 21

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

Presenter

Presentation Notes

Maggie

Questions?

Presenter

Presentation Notes

Maggie

References■ American Occupational Therapy Association (AOTA). Occupational therapy practice framework: Domain and process, 3rd ed. The

American Journal of Occupational Therapy. 2014; Vol. 68(Suppl. 1): S1-S48.

■ Academy of Acute Care Physical Therapy. (2019). Information for Other Health Care Providers. [online] Available at: https://www.acutept.org/page/20 [Accessed 19 Nov. 2019].

■ American Physical Therapy Association. (2019). The Physical Therapist Scope of Practice. [online] Available at: https://www.apta.org/ScopeOfPractice/ [Accessed 19 Nov. 2019].

■ Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–223. doi:10.7326/0003-4819-118-3-199302010-00011

■ Goins RT, Jones J, Schure M, et al. Older Adults' Perceptions of Mobility: A Metasynthesis of Qualitative Studies. Gerontologist. 2015;55(6):929–942. doi:10.1093/geront/gnu014

■ Glover, JS & Wright, J. Special needs of the older adult. In: Pedretti, LW, Pendleton, HMH, & Schultz-Krohn, W, 7th ed. Pedretti's occupational therapy: Practice skills for physical dysfunction. St. Louis, MO: Elsevier; 2013: 1229-1241.

■ Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS), 2015

■ Reeves GR, Whellan DJ, Patel MJ, et al. Comparison of Frequency of Frailty and Severely Impaired Physical Function in Patients ≥60 Years Hospitalized With Acute Decompensated Heart Failure Versus Chronic Stable Heart Failure With Reduced and Preserved LeftVentricular Ejection

■ Yazdanyar A, Newman AB. The burden of cardiovascular disease in the elderly: morbidity, mortality, and costs. Clin Geriatr Med. 2009;25(4):563–vii. doi:10.1016/j.cger.2009.07.007

■ Iwashyna, TJ, Cooke, CR, Wunsch, H, & Kahn, JM. Population burden of long-term survivorship after severe sepsis in older americans. Journal of the American Geriatrics Society. 2012; Vol. 60(Issue 6): 1070-1077.

Presenter

Presentation Notes

Maggie

https://www.acutept.org/page/20

https://www.apta.org/ScopeOfPractice/

References■ Yoshikawa, TT, Reyes, BJ, & Ouslander, JG. Sepsis in older adults in long-term care facilities: Challenges in diagnosis and

management. Journal of the American Geriatrics Society. 2019; Vol. 67(Issue 11): 2234-2239.

■ Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: http://guidetoptpractice.apta.org/. [Accessed November 19, 2019].

■ Gordon DB, Dahl JL, Miaskowski C, et al. American pain society recommendations for improving the quality of acute and cancer pain management: American Pain Society Quality of Care Task Force. Arch Intern Med. 2005;165(14):1574–1580. doi:10.1001/archinte.165.14.1574

■ Fink R. Pain assessment: the cornerstone to optimal pain management. Proc (Bayl Univ Med Cent). 2000;13(3):236–239. doi:10.1080/08998280.2000.11927681

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Maggie

http://guidetoptpractice.apta.org/

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Maggie

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Maggie

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Maggie

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Maggie

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