Inpatient Physical Therapy

What it is:

PTs are movement dysfunction specialists. Inpatient PTs perform gait analysis and training, safe mobility assessments, functional exercise prescription and dosing, and safe discharge recommendations.

**Research shows that patients are 2.9 times more likely to be readmitted when PT discharge recommendations are not followed[1]

 

How to consult:

  • Use Rehab Med- Acute Inpatient Therapy Consult

  • Document change from patient’s baseline level of mobility prior to admit (examples: independent, uses walker, wheelchair dependent)

  • Answer EACH question in the consult (ie weight bearing status, precautions) -- without this information we cannot safely evaluate the patient and initiation of inpatient PT will be delayed

  • Please place Team# on the consult

 

When to consult:

  • Change in functional mobility compared to pre-admission abilities

  • Acute onset weakness or difficulty with gait

  • Post-op condition

  • Evaluate for prosthetic device

  • Need placement recommendations

  • For ALL Armed Forces Retirement (Soldiers) Home residents

  • Occupational Therapy (OT) should be consulted for assessment of Activities of Daily Living (ADL’s)

 

When NOT to consult:

  • Skilled therapy does not include OOB to chair, basic ambulation, or PROM

  • Patient unable to follow commands, decreased arousal/sedation, etoh withdrawal

  • Patient is unwilling to participate

  • Patient is at their baseline functional mobility

  • Replacement assistive devices – PLACE ORDER for AD and report to GC210

  • From the ER/ MAR team – please do not place consult unless patient is with a team

  • RASS (Richmond Agitation Sedation Scale

    • Score +3 Very Agitated – pulls or removes tubes or catheters, aggressive

    • Score +4 Combative – overtly combative, violent, immediate danger to staff

    • Score -4 Deep sedation – no response to voice, but movement or eye opening to physical stimulation

 

 

REHAB DEFERRAL GUIDELINES

Alertness &/or Agitation Measures:

Clinical Institute Withdrawal Assessment (CIWA)

hold physical therapy if score is > 8

Richmond Agitation-Sedation Scale (RAAS)

hold physical therapy if score is > 2 or < -2

 

Vital Signs              **Hold and engage team (HET)

Blood Pressure

  • Systolic Blood Pressure (SBP) – HET > 200mmHg or < 90mmHg

  • Diastolic Blood Pressure (DBP) – HET > 110mmHg or < 40mmHg

  • Orthostatic Hypotension (OTH) – HET for a decrease in SBP > 20mmHg &/or DBP > 10mmHg with positional change

Heat Rate

HET if resting > 120bpm or < 50bpm

**Monitor and Reassess if HR increases by 50bpm or decreases by > 15bpm proceed to discuss with medical team

Mean Arterial Pressure

HET therapy if MAP is <65mmHG or > 110mmHG

Oxygen Saturation

HET if resting O2sat < 85% or a decrease of > 4% occurs with activity-discuss with medical team

Respiratory Rate

HET therapy if RR is > 30bpm or < 5bpm

Temperature

HET therapy if temperature is > 101.5

 

Laboratory Values

Blood Glucose

 

HET therapy if hyperglycemic ≥ 300mg/dL or hypoglycemic ≤ 70mg/dL

Hematocrit (Hct)

Hemoglobin (hgb)

  • Hgb < 8g/dL & Hct < 25% functional mobility restricted to bedside assessment

  • Hgb < 7g/dL & Hct < 20% hold therapy after consulting with medical team

***if patient has baseline anemia therapy will need written clearance by medical team for functional mobility < 7g/dL and Hct <20%

[written clearance obtained via consult or addendum on therapy note]

International Normalized Ratio (INR)

Ratio of 0.8 - 1.2

therapeutic range for CVA prophylaxis

Ratio of 2.0 – 2.5

therapeutic range for VTE, PE &/or Afib

Ratio of 2.5 – 3.5

therapeutic range for patients at higher risk

Ratio > 3.5

Written clearance for mobility by medical team

Ratio > 5.0

Hold physical therapy

 

Platelet Count (PLT)

HET for PLT < 10,000 K/cmm

Potassium (K)

HET for Potassium <3.0 or >5.5mmol/L

Prothrombin Time (PTT)

HET if PTT is > 25seconds due to high risk of bleeding into tissues

Troponin

> 0.04ng/mL is a sign of a new onset heart dysfunction ---if troponin is elevated without a reasonable differential diagnosis, contact medical team and monitor troponin ONLY initiate therapy 24 hours after the peak troponin level or two consecutive down-trending values

WBCs

HET if new WBC> 9.5 obtain written clearance by medical team for functional mobility

 

Medical or Diagnostic Procedures

Arterial Blood Gases (ABG)

if ordered statim (STAT) then hold therapy 

Blood Transfusion

Hold until a new complete blood count (CBC) is completed with Hgb & Hct (>7/20 see above)

Bone Scan &/or X-ray imaging

for a suspected fracture - if positive for a new diagnosis, then physical therapy will discharge from caseload requiring a new consultation with updated precaution (i.e. weight bearing status)

Peripherally Inserted Central Catheter (PICC) Line

hold therapy for 24 hours

Rapid Response Team (RRT)/Code Blue

therapy will discharge from caseload requiring a new consultation

DVT, Ventilation Perfusion (VQ) scan or Venous Doppler

Suspected new DVT, PE, or VTE – hold therapy until appropriately anticoagulated 24 hours