TRAINING MODULE FOR TRAINING MODULE FOR OCCUPATIONAL AND OCCUPATIONAL AND PHYSICAL THERAPISTS IN PHYSICAL THERAPISTS IN THE NICUTHE NICU

Presented by Presented by Lisa Bader, OTR/L, CEIMLisa Bader, OTR/L, CEIM

August, 2008August, 2008

PURPOSEPURPOSE

To provide a systematic structure of learning To provide a systematic structure of learning for OT’s and PT’s who want to work in the for OT’s and PT’s who want to work in the NICUNICU

Ensure that the quality of care given by Ensure that the quality of care given by therapists in our NICU is world-class and therapists in our NICU is world-class and recognized as such by other members of the recognized as such by other members of the NICU teamNICU team

Follow national AOTA and APTA guidelines for Follow national AOTA and APTA guidelines for therapists working in the NICUtherapists working in the NICU

WHAT ARE THE WHAT ARE THE GUIDELINES?GUIDELINES?

AOTA and APTA have similar articles and AOTA and APTA have similar articles and guidelines written regarding OT and PT guidelines written regarding OT and PT services in the NICUservices in the NICU

Both emphasize the specialized knowledge Both emphasize the specialized knowledge required to practice in the NICU because of the required to practice in the NICU because of the medical fragility and developmental variability medical fragility and developmental variability of NICU infantsof NICU infants

““Interactions and therapeutic interventions that Interactions and therapeutic interventions that may appear innocuous can trigger physiologic may appear innocuous can trigger physiologic instability in an infant and can be life instability in an infant and can be life threatening.” (AOTA, 2006).threatening.” (AOTA, 2006).

OUR SPECIFIC TRAINING OUR SPECIFIC TRAINING MODULEMODULE

Each specific area of 5 page outline from Each specific area of 5 page outline from AOTA’s guidelines was addressed AOTA’s guidelines was addressed

For example, outline reads as follows:For example, outline reads as follows: D. Formulate an individualized therapeutic intervention planD. Formulate an individualized therapeutic intervention plan 1. Determine appropriate timing of infant interventions on 1. Determine appropriate timing of infant interventions on

basis of medical and physiological status, postconceptual basis of medical and physiological status, postconceptual age, and NICU routinesage, and NICU routines

2. Modify sensory aspects of physical environment according 2. Modify sensory aspects of physical environment according to infant thresholdto infant threshold

3. Participate with infant and caregivers in interventions that 3. Participate with infant and caregivers in interventions that reinforce the role of the family and support the infant’s reinforce the role of the family and support the infant’s medical and physiological statusmedical and physiological status

D. Formulate an D. Formulate an individualized therapeutic individualized therapeutic intervention planintervention plan 1. Determine appropriate timing of infant interventions on 1. Determine appropriate timing of infant interventions on

basis of medical . . . . basis of medical . . . . In general, infant evaluations and treatments are done prior to a In general, infant evaluations and treatments are done prior to a

“care time” to allow the infant to have as much sleep and “care time” to allow the infant to have as much sleep and undisturbed time as possible. Often, a therapist finds out what the undisturbed time as possible. Often, a therapist finds out what the care times are for a particular baby and then requests to see the care times are for a particular baby and then requests to see the baby 15-30 minutes prior depending on how long a session is baby 15-30 minutes prior depending on how long a session is planned. Older infants may tolerate close to 25-30 minutes where planned. Older infants may tolerate close to 25-30 minutes where a younger premie may not even tolerate 15 minutes. a younger premie may not even tolerate 15 minutes. Nevertheless, this is the general guidelines followed at this time. Nevertheless, this is the general guidelines followed at this time. However, it is important to determine the timing of assessments However, it is important to determine the timing of assessments and interventions according to that individual infant. “Safety for and interventions according to that individual infant. “Safety for the infant takes priority over convenience for the therapist in all the infant takes priority over convenience for the therapist in all aspects of care.” (Case-Smith, 2001, p. 652). An evaluation may aspects of care.” (Case-Smith, 2001, p. 652). An evaluation may have to be done in parts and no part of an evaluation should be have to be done in parts and no part of an evaluation should be done if it is not necessary. The evaluation can be almost entirely done if it is not necessary. The evaluation can be almost entirely completed through clinical observation of the infant. (Als, 1986). completed through clinical observation of the infant. (Als, 1986).

D. Formulate an D. Formulate an individualized therapeutic individualized therapeutic intervention plan intervention plan

2. Modify sensory aspects of physical environment 2. Modify sensory aspects of physical environment according to infant thresholdaccording to infant threshold Sensory stimulation is constant in the life of a baby in the Sensory stimulation is constant in the life of a baby in the

NICU. Noise from machines, phones, voices; tactile input from NICU. Noise from machines, phones, voices; tactile input from I.V. lines, NG tubes, oxygen, CPAP; lights, position changes, I.V. lines, NG tubes, oxygen, CPAP; lights, position changes, nursing procedures and cares-the list can go on and on. With nursing procedures and cares-the list can go on and on. With all of the sensory stimulation the infant must endure just to all of the sensory stimulation the infant must endure just to maintain his/her medical status, therapists must be aware of maintain his/her medical status, therapists must be aware of the infant’s physical environment and modify it as needed. the infant’s physical environment and modify it as needed. Physical environment modification may include the use of Physical environment modification may include the use of positioning devices to decrease the effects of gravity or make positioning devices to decrease the effects of gravity or make an invasive tube more tolerable to the infant. Using the frog for an invasive tube more tolerable to the infant. Using the frog for example over a baby’s back or torso, allows constant firm example over a baby’s back or torso, allows constant firm pressure for small premies or those that are easily agitated. pressure for small premies or those that are easily agitated. During position changes. . .During position changes. . .

D. Formulate an D. Formulate an individualized therapeutic individualized therapeutic intervention planintervention plan

3. Participate with infant and caregivers in 3. Participate with infant and caregivers in interventions that reinforce the role of the family interventions that reinforce the role of the family and support the infant’s medical and and support the infant’s medical and physiological statusphysiological status The infant’s medical and physiologic status guides all The infant’s medical and physiologic status guides all

interventions. The therapist may be planning a interventions. The therapist may be planning a specific intervention but the baby may be telling her specific intervention but the baby may be telling her “not today.” As stated previously, the infant’s status “not today.” As stated previously, the infant’s status dictates all interventions. With that said, there are dictates all interventions. With that said, there are many ways the NICU therapist can reinforce the role many ways the NICU therapist can reinforce the role of family in the NICU. . . . . of family in the NICU. . . . .

What do other hospitals What do other hospitals have around the country?have around the country?

Literature review comes up with nothingLiterature review comes up with nothing Most practitioners agree and feel strongly about Most practitioners agree and feel strongly about

who should or should not work in the NICU who should or should not work in the NICU Lots of definitions about OT and PT roles in the Lots of definitions about OT and PT roles in the

NICU but OT/PT are almost always part of the NICU but OT/PT are almost always part of the team (examples)-YEAH!!!!team (examples)-YEAH!!!!

1996 AJOT article which surveyed 174 NICU 1996 AJOT article which surveyed 174 NICU therapists showed inadequate training of NICU therapists showed inadequate training of NICU therapists and therapists expressed a desire for therapists and therapists expressed a desire for specialized training to work in this practice area specialized training to work in this practice area

RequirementsRequirements

Our goal is to have 2 OT’s and 2 PT’s trained Our goal is to have 2 OT’s and 2 PT’s trained to work in the NICU—this will help deal with to work in the NICU—this will help deal with staffing issues and have near 7 day coveragestaffing issues and have near 7 day coverage

The initial requirements may be changed The initial requirements may be changed according to an individual therapist’s past work according to an individual therapist’s past work experienceexperience

A therapist must have a minimal of 2 years A therapist must have a minimal of 2 years experience as a licensed therapist before experience as a licensed therapist before entering the NICU independentlyentering the NICU independently

Requirements (Cont.)Requirements (Cont.)

40 pediatric patients—must see for evaluation and at 40 pediatric patients—must see for evaluation and at least 1 additional visitleast 1 additional visit

8 infants—either outpatient or from pediatric floor and 8 infants—either outpatient or from pediatric floor and complete in-depth care plans on each with specific complete in-depth care plans on each with specific treatment techniquestreatment techniques

Write a 3 page paper on any of the following subjects Write a 3 page paper on any of the following subjects with literature review and references includedwith literature review and references included Family stress in the NICUFamily stress in the NICU Bonding/Attachment as it relates to the NICUBonding/Attachment as it relates to the NICU Risks of developmental problems in premature infants and ways Risks of developmental problems in premature infants and ways

to identify those infantsto identify those infants Movement and posture in premature infantsMovement and posture in premature infants Any other topic you find interesting Any other topic you find interesting

Requirements (Cont.)Requirements (Cont.)

Complete tests on infant and NICU Complete tests on infant and NICU environmentenvironment

Interview one family about their NICU Interview one family about their NICU experience and write a paper about your experience and write a paper about your findingsfindings

Attend infant massage inserviceAttend infant massage inservice Attend developmental care inserviceAttend developmental care inservice Watch specific CD’s/videos listedWatch specific CD’s/videos listed 6 month mentorship period in NICU6 month mentorship period in NICU

Example Test QuestionsExample Test Questions

Name 3 different types of brachial plexus Name 3 different types of brachial plexus injuries, therapy interventions for each, and injuries, therapy interventions for each, and prognosis.prognosis.

An infant was born 8 weeks premature and is An infant was born 8 weeks premature and is now 6 months old. What is the infant’s now 6 months old. What is the infant’s corrected age?corrected age?

When looking at an infant’s physiologic status, When looking at an infant’s physiologic status, name 5 things that can be observed.name 5 things that can be observed.

Name 3 types of sensory input in the NICU that Name 3 types of sensory input in the NICU that is disruptive to the infant’s neurobehavioral is disruptive to the infant’s neurobehavioral organization.organization.

Test questions during Test questions during mentoring periodmentoring period

A baby must have splints on his feet but has A baby must have splints on his feet but has poor skin integrity resulting in pressure areas poor skin integrity resulting in pressure areas from the splints. What would you do? What from the splints. What would you do? What could your wearing schedule be? How could could your wearing schedule be? How could you prevent pressure areas?you prevent pressure areas?

You are planning to see a baby for a treatment. You are planning to see a baby for a treatment. Care times are at 8-11-2 and 5. The RN says, Care times are at 8-11-2 and 5. The RN says, “You can see the baby anytime.” When is it “You can see the baby anytime.” When is it appropriate to see the baby “anytime”?appropriate to see the baby “anytime”?

When would it be appropriate to discharge a When would it be appropriate to discharge a baby from OT/PT services before they are baby from OT/PT services before they are discharged home from the NICU? discharged home from the NICU?

ReferencesReferences

American Occupational Therapy Association. (2006). American Occupational Therapy Association. (2006). Specialized Specialized knowledge and skills for occupational therapy knowledge and skills for occupational therapy practice in the practice in the neonatal intensive care unit. American Journal of neonatal intensive care unit. American Journal of Occupational Occupational Therapy, 60, 110 – 123.Therapy, 60, 110 – 123.

Als, H. (1982). Toward a synactive theory of Als, H. (1982). Toward a synactive theory of development: development: promise promise for the assessment of infant for the assessment of infant individuality. individuality. Infant Mental Infant Mental Health Journal, 3, 229-243. Health Journal, 3, 229-243.

Case-Smith, J. (2001). Occupational therapy for children. St. Case-Smith, J. (2001). Occupational therapy for children. St. Louis: Louis: Mosby.Mosby.

Sweeney, J. K., Heriza, C. B., Reilly, M. A., Smith, C., Sweeney, J. K., Heriza, C. B., Reilly, M. A., Smith, C., VanSant, VanSant, A. F.(1999). Practice guidelines for the A. F.(1999). Practice guidelines for the physical therapist in the physical therapist in the neonatal intensive care unit. neonatal intensive care unit. Pediatric Physical Therapy, 11, 3, Pediatric Physical Therapy, 11, 3, 119-132.119-132.