This document discusses the coordinated rehabilitation efforts for patients in acute care. It notes that rehabilitation involves a team that assesses patients' mobility, daily living skills, cognition, and swallowing to establish their current level of function. The goals are to identify needs, educate patients and caregivers, and plan for discharge. Therapists provide standardized cognitive tests and modify the environment to accommodate any deficits. Education is key to engaging patients and facilitating discharge plans that consider a patient's abilities, goals, and support system.

1. G-60: A Rehab Perspective
Tracy Seeley, MA, CCC-SLP, MHA
Jamie Idriss, PT, DPT, GCS, CEEAA

2. It takes a coordinated effort!
• The Rehab Team - Physician, Nursing,
Therapy Services, Nutrition Services,
Respiratory Services, Case
Management/Social Services, other
consultants
• Therapy Services:
– Physical Therapy
– Occupational Therapy
– Speech Language Pathology

3. Goals of Therapy
Services in Acute Care
• Establish current level of function
• Identify the patient’s goals to assist
with recommendations for further
therapy
• Educate patient, family and caregivers
• Identify needed modifications to
maximize function in hospital setting
• Discharge planning

4. Slippery Slope of Aging
Schwartz, 1997

5. Myths about Aging
• “Let them rest”
• The geriatric population is fragile
• Cognitive decline = no rehab potential
• Falls are a natural part of the aging
process
• “You can’t teach an old dog new tricks”
• Resistive exercises will cause injury
• Accommodate rather than challenge

6. Establish current level of function
• Early intervention is critical
• Therapists assess areas of mobility,
activities of daily living, cognition
and swallowing
• Need to understand “the gap”
• Standardized tests

7. What we know!
• Early intervention in the ICU
• Decreased ICU length of stay
• Decreased days of mechanical ventilation
• Decreased risk & days of delirium
• Decreased hospital length of stay
• Patients with cognitive deficits can still
benefit from therapy intervention

8. The hip bone is connected
to the swallow bone!
• High incidence of dysphagia
• “Red flags” to evaluate swallowing
– Hip fractures s/p fall and post
anesthesia
– UTI
• Transient in nature-usually requiring
texture modification and Speech
Pathology on-going swallowing
management

9. “So they can walk 600’ but do they
know where they’re going?”
• Any suspicion of head injury receive two
standardized assessments from speech
pathology, regardless of imaging results
• SLUMS (Saint Louis University Mental Status)
and ACE (Acute Concussion Evaluation)
• Purpose to ID patients with concussion to provide
education and resources
• Many patients can pass the SLUMS with a high
score, but were presenting to the clinic weeks
later with deficits once engaged in more complex
life skills.

10. Standardized Cognitive Testing
• SLUMS
– 11 quick questions testing orientation, short term
memory, and concentration
– Standardized to ID neurocognitive disorder and early
onset dementia
• ACE
– Symptomology checklist with 22 possible symptoms
across 4 domains: physical, cognitive, emotional and
sleep
– Allows for identification of concussion through
symptoms
• Positive results yield educational handout and follow
up by the Brain Injury Alliance of AZ

11. Modifications
• Environment
• Lighting, contrast, noise, clutter free,
size of objects
• Safety
• Communication & cognitive strategies
• Adaptive equipment
• Least restrictive

12. G-60 Room Remodel
• PT and OT representatives
• Room Considerations:
• Lighting
• Color contrast
• Size of white board, clock, TV
• Bathroom layout
• Space utilization

13. Bathroom

14. Education
• Patient
• Engaging patient in goal setting is key
to participation
• Family & Caregivers
• Help facilitate plan of care
• Play important role in discharge
planning
• A new reality

15. Discharge Planning
• Upon evaluation, all therapists are
thinking, “What does this patient need
to reach his/her maximum potential?”
• Multidisciplinary rounding
• Frequency of therapy matters
• In one study, patients were 2.9 times
more likely to be readmitted within 30
days when the PT’s discharge
recommendation was not implemented

16. Complex Discharge Plan
Patient
Current
Function
Goals
Family
Support
Therapy
Tolerance
Payer
Source
Prior Level
of Function
Community
Resources

17. Rehab Challenges
• Pain control
• On-Q pump
• Discussion with physicians
• Silo thinking
• Co-morbidities (osteoporosis, dementia,
inadequate nutrition, abnormal sleep patterns)
• Discharge recommendations
• Meeting the requirements of the payer source
• Balancing the patient’s wishes vs. patient’s needs
• Family & Caregiver support

18. “Life is not a journey to the grave with the
intention of arriving safely in a pretty and
well preserved body, but rather to skid in
broadside, thoroughly used up, totally worn
out, and proclaiming, ‘Wow, what a ride!!!’”

19. References
• Balas MC et al. Effectiveness and safety of the awakening and breathing coordination,
delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med. 2014
May;42(5):1024-36.
• Clark DE et al. Effectiveness of an early mobilization protocol in a trauma and burns
intensive care unit: a retrospective cohort study. Phys Ther. 2013 Feb;93(2):186-96.
• Guccione AA, Fagerson TL, Anderson J. J. Regaining functional independence in the acute
care setting following hip fracture. Phys Ther. 1996;76:818-826.
• Hengel HJ et al. ICU early mobilization: from recommendation to implementation at three
medical centers. Crit Care Med. 2013 Sep;41(9 Suppl 1):S69-80.
• McWilliams D et al. Enhancing rehabilitation of mechanically ventilated patients in the
intensive care unit: a quality improvement project. J Crit Care. 2015 Feb;30(1):13-8.
• Needham DM et al. Early physical medicine and rehabilitation for patients with acute
respiratory failure: a quality improvement project. Arch Phys Med Rehabil. 2010
Apr;91(4):536-42.
• Schwartz RS. Sarcopenia and physical performance in old age: introduction. Musc Nerve.
1997;Suppl 5:S10-S12.
• Schweickert WD et al. Early physical and occupational therapy in mechanically ventilated,
critically ill patients: a randomised controlled trial. Lancet. 2009 May 30;373(9678):1874-
82.
• Smith B, Fields C, Fernandez N Physical Therapists make accurate and appropriate
discharge recommendations for patients who are acutely ill. Phys Ther. 2010;90:693-703.

20. Questions?