The Integration of Physical Therapists and Occupational Therapists into Burn Wound Care Increases Therapist Productivity, Job Satisfaction, and Multidisciplinary Collaboration.

When attempting to deliver specialized rehabilitation therapy interventions, physical therapists (PTs) and occupational therapists (OTs) must account for dynamic and logistical patient factors such as: daily wound care, pain, difficultly progressing range of motion with dressings donned, and ongoing surgical interventions. Additionally, they must attain institution-specific productivity standards. Given burn patients often require considerable multidisciplinary interventions, efficiently planning and delivering rehabilitation therapy interventions within productivity expectations may prove difficult. The purpose of this study was to assess the feasibility of integrating rehabilitation therapists, PTs and OTs, into daily burn wound care by investigating therapist productivity and multidisciplinary perceptions of this practice change. The quality improvement project involved six rehabilitation therapists (three PTs and three OTs) practicing exclusively in the burn unit within an American Burn Association (ABA) verified burn center at an urban, tertiary care academic medical center. One rehabilitation therapist was responsible for providing interventions within the burn wound care team five days a week. General duties included wound assessment, functional wound dressings, and skilled therapeutic interventions such as manual therapy, therapeutic exercise, and compression interventions. The primary outcome was changes in group productivity and individual therapist productivity, as measured by total billed CPT codes per hour worked, which were tracked 22 weeks pre- and 28 weeks post-implementation. Program feasibility and general perceptions were assessed by a qualitative questionnaire. For both the entire group of therapists and each individual rehabilitation therapist, billed CPT codes per hour increased post implementation, 1.81 versus 1.54 (p=0.005) and a matched increase of 0.27/hr (p=0.003). Of the 23 survey respondents, 96% had a favorable impression of the program and reported it eased staffing demands. All respondents reported improved unit workflow and multidisciplinary communication. The majority of multidisciplinary burn team members actively supported the pilot program and commented on improvements in patient care. Full-time rehabilitation therapy participation in wound care increases therapist productivity and job satisfaction. Future efforts, however, should focus on measuring specific patient outcomes and cost as a result of therapist integration into daily wound care practice.

Perspectives on Sedation Among Interdisciplinary Team Members in ICU: A Survey Study.

OBJECTIVE: To explore the interdisciplinary team members' beliefs and attitudes about sedation when caring for mechanically ventilated patients in the ICU. DESIGN: Cross-sectional survey. SETTING: A 17-bed cardiothoracic ICU at a tertiary care academic hospital in Colorado. SUBJECTS: All nurses, physicians, advanced practice providers (APPs), respiratory therapists, physical therapists (PTs), and occupational therapists (OTs) who work in the cardiothoracic ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We modified a validated survey instrument to evaluate perspectives on sedation across members of the interdisciplinary ICU team. Survey responses were collected anonymously from 111 members (81% response rate). Respondents were predominantly female (70 [63%]). Most respondents across disciplines (94%) believed that their sedation practice made a difference in patients' outcomes. More nurses (48%), APPs (62%), and respiratory therapists (50%) believed that sedation could help alleviate the psychologic stress that patients experience on the ventilator than physicians (19%) and PTs/OTs (0%) (p = 0.008). The proportion of respondents who preferred to be sedated if they were mechanically ventilated themselves varied widely by discipline: respiratory therapists (88%), nurses (83%), APPs (54%), PTs/OTs (38%), and physicians (19%) (p < 0.001). In our exploratory analysis, listeners of an educational podcast had beliefs and attitudes more aligned with best evidence-based practices than nonlisteners. CONCLUSIONS: We discovered significant interdisciplinary differences in the beliefs and attitudes regarding sedation use in the ICU. Since all ICU team members are involved in managing mechanically ventilated patients in the ICU, aligning the mental models of sedation may be essential to enhance interprofessional collaboration and promote sedation best practices.

Comparison of postoperative mobilization measurements by activPAL versus Johns Hopkins Highest Level of Mobility scale after major abdominal surgery.

BACKGROUND: The Johns Hopkins Highest Level of Mobility scale is a validated tool for assessing patient mobility in the hospital. It has excellent inter-rater and test-retest reliabilities, but it is unknown how accurately Johns Hopkins Highest Level of Mobility documentation reflects the patients' mobility performance in the immediate postoperative period compared to objective measures such as accelerometers. METHODS: In this single-center observational study, consented adults undergoing open abdominal surgery wore a research-grade accelerometer, activPAL, starting immediately postoperatively until hospital discharge or up to 7 days. We collected the Johns Hopkins Highest Level of Mobility scores documented by hospital staff via retrospective chart review and evaluated their accuracy in describing the type, frequency, and volume of postoperative out-of-bed mobilization using the activPAL as the criterion. RESULTS: We analyzed data from 56 participants. The activPAL showed that participants spent 97.7% of their time lying in bed or sitting in a chair. Meanwhile, the Johns Hopkins Highest Level of Mobility documentation of preambulatory activities (scores 1-5) was rare. The activPAL detected 4 times more out-of-bed mobilization than routine Johns Hopkins Highest Level of Mobility documentation. Whereas the frequency of activPAL-measured out-of-bed mobilization increased steadily to a median of 9 sessions by postoperative day 6, the number of Johns Hopkins Highest Level of Mobility documentation remained around twice daily. ActivPAL measurements demonstrated that Johns Hopkins Highest Level of Mobility documentation of ambulatory sessions (scores 6-8) was accurate. CONCLUSIONS: We found that routine Johns Hopkins Highest Level of Mobility documentation did not accurately detect preambulatory activities or the overall frequency of out-of-bed mobility sessions, poorly reflecting the highly sedentary behaviors of the acute postoperative inpatients and highlighting the need to improve clinical documentation or use alternative methods to track postoperative mobilization.

Accelerometer-Measured Inpatient Physical Activity and Associated Outcomes After Major Abdominal Surgery: Systematic Review.

BACKGROUND: It remains unclear how inpatient physical activity after major abdominal surgery affects outcomes. Accelerometer research may provide further evidence for postoperative mobilization. OBJECTIVE: We aimed to summarize the current literature evaluating the impact of accelerometer-measured postoperative physical activity on outcomes after major abdominal surgery. METHODS: We searched PubMed and Google Scholar in October 2021 to conduct a systematic review. Studies were included if they used accelerometers to measure inpatient physical behaviors immediately after major abdominal surgery, defined as any nonobstetric procedures performed under general anesthesia requiring hospital admission. Studies were eligible only if they evaluated the effects of physical activity on postoperative outcomes such as postoperative complications, return of gastrointestinal function, hospital length of stay, discharge destination, and readmissions. We excluded studies involving participants aged <18 years. Risk of bias was assessed using the risk-of-bias assessment tool for nonrandomized studies (RoBANS) for observational studies and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) for randomized controlled trials (RCTs). Findings were summarized by qualitative synthesis. RESULTS: We identified 15 studies. Risk of bias was high in 14 (93%) of the 15 studies. Most of the studies (11/15, 73%) had sample sizes of <100. Of the 15 studies, 13 (87%) included the general surgery population, 1 (7%) was a study of patients who had undergone gynecologic surgery, and 1 (7%) included a mixed (abdominal, thoracic, gynecologic, and orthopedic) surgical population. Of the 15 studies, 12 (80%) used consumer-grade accelerometers to measure physical behaviors. Step count was the most commonly reported physical activity outcome (12/15, 80%). In the observational studies (9/15, 60%), increased physical activity during the immediate postoperative period was associated with earlier return of gastrointestinal function, fewer surgical and pulmonary complications, shorter hospital length of stay, and fewer readmissions. In the RCTs (6/15, 40%), only 1 (17%) of the 6 studies demonstrated improved outcomes (shorter time to flatus and hospital length of stay) when a mobility-enhancing intervention was compared with usual care. Notably, mobility-enhancing interventions used in 4 (67%) of the 6 RCTs did not result in increased postoperative physical activity. CONCLUSIONS: Although observational studies show strong associations between postoperative physical activity and outcomes after major abdominal surgery, RCTs have not proved the benefit of mobility-enhancing interventions compared with usual care. The overall risk of bias was high, and we could not synthesize specific recommendations for postoperative mobilization. Future research would benefit from improving study design, increasing methodologic rigor, and measuring physical behaviors beyond step counts to understand the impact of postoperative mobilization on outcomes after major abdominal surgery.

Rehabilitation Therapy Allocation and Changes in Physical Function Among Patients Hospitalized Due to COVID-19: A Retrospective Cohort Analysis.

OBJECTIVE: Limited staffing and initial transmission concerns have limited rehabilitation services during the COVID-19 pandemic. The purpose of this analysis was to determine the associations between Activity Measure for Post-Acute Care (AM-PAC) mobility categories and allocation of rehabilitation, and in-hospital AM-PAC score change and receipt of rehabilitation services for patients with COVID-19. METHODS: This was a retrospective cohort study of electronic health record data from 1 urban hospital, including adults with a COVID-19 diagnosis, admitted August 2020 to April 2021. Patients were stratified by level of medical care (intensive care unit [ICU] and floor). Therapy allocation (referral for rehabilitation, receipt of rehabilitation, and visit frequency) was the primary outcome; change in AM-PAC score was secondary. AM-PAC Basic Mobility categories (None [21-24], Minimum [18-21], Moderate [10-17], and Maximum [6-9]) were the main predictor variable. Primary analysis included logistic and linear regression, adjusted for covariates. RESULTS: A total of 1397 patients (ICU: n = 360; floor: n = 1037) were included. AM-PAC mobility category was associated with therapy allocation outcomes for floor but not patients in the ICU: the Moderate category had greater adjusted odds of referral (adjusted odds ratio [aOR] = 10.88; 95% CI = 5.71-21.91), receipt of at least 1 visit (aOR = 3.45; 95% CI = 1.51-8.55), and visit frequency (percentage mean difference) (aOR = 42.14; 95% CI = 12.45-79.67). The secondary outcome of AM-PAC score improvement was highest for patients in the ICU who were given at least 1 rehabilitation therapy visit (aOR = 5.31; 95% CI = 1.90-15.52). CONCLUSION: AM-PAC mobility categories were associated with rehabilitation allocation outcomes for floor patients. AM-PAC score improvement was highest among patients requiring ICU-level care with at least 1 rehabilitation therapy visit. IMPACT: Use of AM-PAC Basic Mobility categories may help improve decisions for rehabilitation therapy allocation among patients who do not require critical care, particularly during times of limited resources.

Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID-19.

BACKGROUND: Survivors of the novel coronavirus (COVID-19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in-hospital rehabilitation therapy may reduce long-term impairments. OBJECTIVE: To determine the frequency of therapy referral and treatment amongst hospitalized COVID-19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation. DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing. MEASUREMENTS: Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery. RESULTS: Amongst 6239 COVID-19-related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67-0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46-1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37-1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12-1.15, p < .01) were positively associated with referral. CONCLUSIONS AND RELEVANCE: In a cohort of patients hospitalized for COVID-19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non-Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.

Safety, Feasibility, and Outcomes of Frequent, Long-Duration Rehabilitation in an Inpatient Rehabilitation Facility After Prolonged Hospitalization for Severe COVID-19: An Observational Study.

OBJECTIVE: he objective of this study was to evaluate safety, feasibility, and outcomes of 30 patients within an inpatient rehabilitation facility following hospitalization for severe Coronavirus Disease 19 (COVID-19) infection. METHODS: This was an observational study of 30 patients (ages 26-80 years) within a large, metropolitan, academic hospital following hospitalization for complications from severe COVID-19. Ninety percent of the participants required critical care, and 83% required mechanical ventilation during their hospitalization. Within an inpatient rehabilitation facility and model of care, frequent, long-duration rehabilitation was provided by occupational therapists, physical therapists, and speech language pathologists. RESULTS: The average inpatient rehabilitation facility length of stay was 11 days (ranging from 4-22 days). Patients averaged 165 min/d (ranging from 140-205 minutes) total of physical therapy, occupational therapy, and speech therapy. Twenty-eight of the 30 patients (93%) were discharged to the community. One patient required readmission from an inpatient rehabilitation facility to an acute hospital. All 30 patients improved their functional status with inpatient rehabilitation. CONCLUSION: In this cohort of 30 patients, inpatient rehabilitation after severe COVID-19 was safe and feasible. Patients were able to participate in frequent, long-duration rehabilitation with nearly all patients discharging to the community. Clinically, inpatient rehabilitation should be considered for patients with functional limitations following severe COVID-19. Given 90% of our cohort required critical care, future studies should investigate the efficacy and effectiveness of inpatient rehabilitation following hospitalization for critical illness. Frequent, long-duration rehabilitation shows promising potential to address functional impairments following hospitalization for severe COVID-19. IMPACT: Inpatient rehabilitation facilities should be considered as a discharge location for hospitalized survivors of COVID-19, especially severe COVID-19, with functional limitations precluding community discharge. Clinicians and administrators should consider inpatient rehabilitation and inpatient rehabilitation facilities to address the rehabilitation needs of COVID-19 and critical illness survivors.

Involvement of Acute Care Physical Therapists in Care Transitions for Older Adults Following Acute Hospitalization: A Cross-sectional National Survey.

BACKGROUND AND PURPOSE: Recent evidence has suggested physical therapist involvement in care transitions after hospitalization is associated with reduced rates of hospital readmissions. However, little is known about how physical therapists participate in care transitions for older adults, the content of care communications, and the facilitators and barriers of implementing evidence-based care transition strategies into practice. Thus, the purpose of this article is to evaluate participation in care transition activities known to influence readmission risk among older adults, and understand perceptions of and barriers to participation in these activities. METHODS: We developed a survey questionnaire to quantify hospital-based physical therapist participation in care transitions and validated it using cognitive interviewing. It was introduced to a cross-sectional national sample of physical therapists who participate in the Academy of Acute Care Physical Therapy electronic discussion board using a SurveyMonkey tool. RESULTS AND DISCUSSION: More than 90% of respondents agreed they routinely recommended a discharge location and provided recommendations for durable medical equipment for patients at the time of hospital discharge. Respondents did not routinely initiate communication with therapists in other care settings, or follow up with patients to determine whether recommendations were followed. A majority of respondents agreed their facilities would not consider many key care transition activities to count as productive time.This survey provides a novel insight into how hospital-based physical therapists participate in care transitions. Communications between rehabilitation providers across care settings are infrequent, even though those communications are recommended to help reduce readmissions. However, administrative barriers were elucidated in this study that may help explain lack of therapist involvement. CONCLUSIONS: Physical therapists' communications across health care setting about older adults discharging from acute care hospitalization are infrequent, but may represent a meaningful intervention target for future studies. Future research is needed to evaluate best practices for hospital-based physical therapists during care transitions.

Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community.

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. However, models of care that have been developed to reduce hospital readmission rates do not adequately address functional deficits. Physical therapists, as experts in optimizing physical function, have a strong opportunity to contribute meaningfully to care transition models and demonstrate the value of physical therapy interventions in reducing readmissions. Thus, the purposes of this perspective article are: (1) to describe the need for physical therapist input during care transitions for older adults and (2) to outline strategies for expanding physical therapy participation in care transitions for older adults, with an overall goal of reducing avoidable 30-day hospital readmissions.

Physical Therapist Practice in the Intensive Care Unit: Results of a National Survey.

BACKGROUND: Early rehabilitation improves outcomes, and increased use of physical therapist services in the intensive care unit (ICU) has been recommended. Little is known about the implementation of early rehabilitation programs or physical therapists' preparation and perceptions of care in the United States. OBJECTIVE: A national survey was conducted to determine the current status of physical therapist practice in the ICU. DESIGN: This study used a cross-sectional, observational design. METHODS: Self-report surveys were mailed to members of the Acute Care Section of the American Physical Therapy Association. Questions addressed staffing, training, barriers, and protocols, and case scenarios were used to determine perceptions about providing rehabilitation. RESULTS: The response rate was 29% (667/2,320). Staffing, defined as the number of physical therapists per 100 ICU beds, was highest in community hospitals (academic: median=5.4 [range=3.6-9.2]; community: median=6.7 [range=4.4-10.0]) and in the western United States (median=7.5 [range=4.2-12.9]). Twelve percent of physical therapists reported no training. Barriers to providing ICU rehabilitation included insufficient staffing and training, departmental prioritization policies, and inadequate consultation criteria. Responses to case scenarios demonstrated differences in the likelihood of consultation and physical therapists' prescribed frequency and intensity of care based on medical interventions rather than characteristics of patients. Physical therapists in academic hospitals were more likely to be involved in the care of patients in each scenario and were more likely to perform higher-intensity mobilization. LIMITATIONS: Members of the Acute Care Section of the American Physical Therapy Association may not represent most practicing physical therapists, and the 29% return rate may have contributed to response bias. CONCLUSIONS: Although staffing was higher in community hospitals, therapists in academic and community hospitals cited insufficient staffing as the most common barrier to providing rehabilitation in the ICU. Implementing strategies to overcome barriers identified in this study may improve the delivery of ICU rehabilitation services.

Physical therapy management and patient outcomes following ICU-acquired weakness: a case series.

BACKGROUND AND PURPOSE: Individuals with critical illness experience dysfunction of many body systems including the neuromuscular system. Neuromuscular impairments result in a syndrome referred to as intensive care unit (ICU)-acquired weakness, which may lead to difficulty with activities and participation. The purposes of this case series were to (1) describe safety and feasibility of physical intervention in individuals with ICU-acquired weakness mechanically ventilated for at least 7 days and (2) characterize physical therapist management and patient outcomes. CASE DESCRIPTION: Nineteen patients with ICU-acquired weakness who required mechanical ventilation for at least 7 days were enrolled over a 1-year period. INTERVENTION: Physical therapy (PT) was provided 5 d/wk for 30 minutes per session. OUTCOMES: Outcome measures included manual muscle tests and item scores from the Functional Independence Measure. Participants completed 170 PT sessions. Only 20 sessions (12%) were stopped before 30 minutes. Seventeen participants survived to discharge; no PT-related adverse events occurred. At discharge, participants who went home showed a trend toward greater independence and strength than those who were discharged to another level of care. Median total hospital days was 28 for those discharged to home and 22 for those discharged to other level of care. DISCUSSION: This case series demonstrates safety and feasibility of PT intervention for patients with ICU-acquired weakness requiring mechanical ventilation for at least 7 days. The examination and intervention procedures are described and could be implemented with other similar individuals in the hospital setting. Future studies should investigate frequency and duration of physical intervention, both during hospitalization and postdischarge, and how these factors influence outcomes.