Occupational Therapy in Acute Care – Is Acute Care Right for You?

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An occupational therapy career in acute care can be as exciting and rewarding as it is demanding and overwhelming. The acute care setting is fast-paced and complex with a lot of moving elements and shifting priorities. Since clients typically have very short stays of two to three days, you must be able to think quickly on your feet and help facilitate important decisions and recommendations to promote optimal client outcome and progress after discharge. In addition to strong clinical reasoning and problem solving skills, a successful therapist will possess the flexibility and adaptability to manage high-stress situations and work under pressure. Effective communication and ability to work as a collaborative member of the team will be important to ensure continuity of care that is well coordinated, effective and client-centered.

If you enjoy working in a fast-paced environment and are seeking to quickly expand your clinical knowledge base and experience, acute care might be the right setting for you. Read on to learn more about the role of occupational therapy in acute care and how you can best prepare yourself to thrive in this practice setting. Be sure to also check out our guest interview blog article A Day in the Life of an Acute Care OT with Ashley Hayward.

The American Occupational Therapy Association (AOTA) defines acute care as an “inpatient hospital setting for individuals with a critical medical condition.” Patients admitted into the acute care hospital often present with complex medical issues that require immediate medical attention. This can include new injuries and medical conditions such as a traumatic brain injury (TBI), or it may be a sudden change or exacerbation of a chronic condition, such as multiple sclerosis. The Length of Stay (LOS) in the Acute Care Setting can vary and can last months, but generally, the hospital stays are short lasting a few days to a couple of weeks. 

Length of Stay: 2 to 3 days — 1 to 2 weeks  |  Frequency of Services: Daily

Did you know that Occupational Therapy is only spending category that has been shown to reduce hospital readmissions? According to Medical Care Research and Review, occupational therapy was identified as “one spending category that affects both the clinical and social determinants of health” and stated that “investing in OT has the potential to improve care quality without significantly increasing overall hospital spending.”

In the following sections, we will go over OT Evaluation and Intervention to describe the important role OT practitioners play in the acute care setting.

Every client with an order for occupational therapy (OT) is evaluated to determine whether or not OT service is appropriate. Always be sure to confirm the physician’s order to verify the request for occupational therapy services before initiating evaluation. If OT service is deemed appropriate and the client is medically stable, the therapist will initiate treatment. Due to the short nature of the client’s hospital stay, time is often a limiting factor in the acute care setting. Occupational therapists must complete the assessments within the same day or within 24 hours of receiving the referral.

A typical evaluation will include a chart review, H&P Report (History and Physical Examination), client interview, Occupational Profile, clinical observation, assessments, interpretation of findings and recommendations for intervention. Due to the short hospital stay and time constraint, the therapist may not be able to complete many standardized assessments, relying instead on interviews and clinical observation of functional task performance.

For example, the therapist may perform bedside evaluation to assess safety in eating and swallowing as well as evaluate the need for assistive devices. To assess balance, the therapist may perform functional reach tasks by placing objects to the left, right, back and in the midline of the patient and asking the patient to reach for these objects. When assessing motor control, the therapist may begin with clinical observation to assess the tone, coordination, postural control and reflexes. To assess the range of motion (ROM), the therapist may have the patient perform various movements for a quick assessment, such as raising the hand toward the ceiling, touching the back of the head, making a fist, tapping the toes, bending the knee, etc. Goniometers are rarely used in the acute care setting due to the time limitations that places priority on functional goals and outcomes. Occupational therapists also play an important role in evaluating the need for splints and ensuring optimal positioning, as well as provide wheelchair assessment.

  Before performing evaluation, always be sure to check the post-surgical protocols and precautions following orthopedic or neuro-surgeries that may restrict patient movement and mobility. Equally important, be sure to check the vital signs – blood pressure, respiration rate, temperature and pulse rate and watch out for any significant change in vital signs after movement or activity.

For your reference, here is a copy of a sample evaluation template that Catherine Verga created to help her through her first year as an acute care occupational therapist at the Baylor Institute for Rehabilitation at Baylor All Saints Medical Center.

A Typical OT Session

Due to the acute nature of injuries and conditions, OT sessions may be short, often taking place by the client’s bedside with emphasis on self care, patient education and discharge setting. During the first visit, the occupational therapist will explain the important role of occupational therapy, establish an occupational profile and identify intervention priorities. The intervention plan must include a well coordinated Plan of Care (POC) and recommendations for the next best level of care. Additionally, the OT will identify any potential needs for modifications, environmental supports and/or durable medical equipment to facilitate progress towards what the client needs and wants to do.

Here are some examples of what may occur during a typical OT session:

  • Teach energy conservation techniques to manage fatigue, stress and pain.
  • Splinting and positioning to prevent skin breakdown and maintain joint integrity.
  • Control and manage edema. The prevention and treatment of edema are of critical importance in acute care.
  • Improve client’s balance, range of motion and activity tolerance through various task performance and functional activities.
  • Train clients in the use of adaptive equipments or compensatory techniques to maximize independence.
  • Delirium management
  • Teach coping skills and strategies to manage stress and anxiety.
  • Educate and train clients in self-care activities such as dressing and bathing.
  • Educate and train family and caregivers to assist with transfers, mobility, skin inspection and ROM exercises as needed.

In the acute care setting, it is not unusual for the client to receive OT service on the day of discharge. In this case, the therapist must be able to quickly establish an occupational therapy profile and make a clinical judgment to identify priorities and anticipate potential issues that may arise post discharge. In addition, it will be important to identify any necessary durable medical equipment and/or other environmental supports to ensure optimal outcome and progress.


Discharge planning

Discharge planning begins on the day of the initial evaluation and this is one of the primary responsibilities of an acute care occupational therapists. Families members and members of the healthcare team will look to the occupational therapist to determine where the client should go next as well as to determine and implement appropriate supports post discharge.

Utilizing strong clinical judgment and decision-making skills, occupational therapists help to identify the most appropriate, efficient and safe post-acute setting, whether that’s inpatient rehabilitation, long-term acute care, sub-acute rehab, a skilled nursing facility, or the client’s home.


Client Education

Clients in the acute care setting often experience stress due to a sudden change in their environment and roles. During this time, client education is essential for not only improving safety and adherence to interventions, but to reduce anxiety and increase a sense of self-efficacy. Educational handouts and resources can further aid in client understanding of medical complexities while providing the knowledge needed to enhance client outcomes in the continuum of care at home.


Client Advocacy

In order to ensure a well-coordinated plan of care and determine the next best level of care for the client, it is important to collaborate closely with the interdisciplinary team of doctors, nurses, physical therapists, speech-language pathologists and case managers. By working together with the client and the healthcare team, the therapist can identify barriers in the discharge environment and facilitate the implementation of the recommendations to ensure the client has adequate environmental supports, adaptive equipment or modifications after discharge. In that sense, occupational therapy practitioners serve as an important client advocate to ensure appropriate environmental supports are available to the client after discharge.

There is a wide range of diagnoses from planned (elective) admissions such as orthopedic surgeries and procedures to unplanned (emergency) admissions related to spinal cord injury (SCI), Cerebrovascular accidents (CVAs) and Traumatic Brain Injury (TBI). Cardiac and pulmonary conditions, such as congenital heart failure (CHF), pneumonia and acute respiratory failure are also common. You may also see patients being admitted for sepsis, a life-threatening condition that can lead to death.

Many patients present with underlying co-morbidities and conditions that make it difficult to identify one particular case mix for the acute care setting.

Due to the short stays in acute care settings, you may not always have time to do standardized assessments. However, it is important to know your assessments and have multiple strategies to gather all the information you need to facilitate optimal client progress and outcome.

  • Barthel Index – Measure of functional independence, generally in stroke patients and other neuromuscular or musculoskeletal disorders.
  • FIM – Many hospitals base their evaluation on the FIM so this is important to know.
  • Interest Checklist
  • Nine Hole Peg Test – Measure of finger dexterity and upper extremity function.
  • Mini-Mental State Examination – Quick screening to assess for mild cognitive impairment. Assesses attention, calculation, orientation, language, praxis and registration (~10 minutes). Note: Must have facility license to use MMSE
  • Occupational Profile– AOTA’s Occupational Profile Template
  • SLUMS Examination – Alternative screening to Mini-Mental. Quickly assess for mild cognitive impairment (~10 minutes). Related to functional ability.
  • The Berg Balance Scale – To assess client’s static and dynamic balance during a series of predetermined tasks.
  • The Kansas University Sitting and Standing Balance Scale (KUSSBS)– Quick, easy and objective way to assess and document balance during any functional task without any equipment or designated space.
  • The Kettle Test – Function-based cognitive assessment to observe clients making a cup of tea with an electric kettle. This assessment requires time to set up and may not always be possible, but it’s a great functional cognitive assessment to determine a client’s higher level cognitive function.
  • The Montreal Cognitive Assessment (MOCA) – Rapid screening instrument for mild cognitive dysfunction (~5-10 minutes).

Here are other assessments mentioned in the Day in the Life of an Occupational Therapist article by Ashley Hayward.

1. Know Your Post-Acute Rehab Sites 

Discharge planning is one of the primary roles and responsibilities of the acute care occupational therapist. Therefore, having a solid understanding of post-acute rehab sites as well as the rationale for each option is critical to facilitate a safe, educated and informed decision making process. Here are some examples:

  • Nursing Home
  • Inpatient Rehab (Must qualify under one of the 13 diagnostic categories and the client must be able to tolerate 3 total hours of combined therapy per day)
  • Long-Term Acute Care (Client requires significant, high degree care – e.g. wound care, long term antibiotics)
  • Subacute Rehab or SNF (Client cannot tolerate 3 hours of combined therapy per day)
  • Hospice or Palliative Care (Client is terminally ill with <6 months to live)
  • Home Health (Client must be homebound)
  • Outpatient Occupational Therapy
  • Day Treatment
  • Home

2. Know Basic Medical Terminology 

Basic medical terminology can include abbreviations for medical terms such as EKG, FBC, etc, as well as health insurance terminology, medical equipment and medications. The sooner you familiarize yourself with these terms, the easier it will be for you to communicate with the medical staff and navigate the acute care setting. Below are just a few of the free medical terminology apps available for download:

  1. Dorland’s Illustrated Medical Dictionary
  2. Medscape
  3. Medical Terminology Dictionary 
  4. Oxford Medical Dictionary
  5. Psych Terms
  6. Skyscape Medical Library
  7. Taber’s Medical Dictionary

3. Know Critical Lab Values and Associated Symptoms

Depending on the patient’s condition, occupational therapy may be contraindicated or need to be modified in acute care. For that reason, it is imperative to check the lab values as well as consult the client’s nurse before initiating evaluation or treatment. Even if you have not yet learned all the lab values and its clinical implication for therapy, you can easily identify abnormal lab values, which will often be marked with the letters L (low), H (high), or C (critical). When in doubt, always consult with the medical team first.

To review the lab values, check out the Laboratory Values Interpretation Resource by Academy of Acute Care Physical Therapy.


4. Be Familiar with ICU Equipment and Environment

Here are some resources you can check out to familiarize yourself with the ICU environment:


5. Understand Safety and Infection Control Protocol

Every hospital will have some type of infection control protocol in place to prevent the spread of disease and infection. Be sure to take some time to understand your facility’s infection control protocol, as well as have a good working knowledge of both the standard and transmission-based precautions.


6. Review Important Precautions and Contraindications 

It is critical to review any precautions written in the physician’s order or other medical documentation. These precautions may follow orthopedic and surgeries such as joint replacements or a cardiac surgery, limiting patient’s ROM, endurance or weight-bearing status. For patients with cardiac or pulmonary limitations, be sure to check for all precautions and measure activity tolerance during each session utilizing the MET chart or the Borg Rating of Perceived Exertion Scale. Measuring the activity tolerance will be important for documentation as well. Here are some common precautions you should review:

  • Sternal/Cardiac precaution
  • Hip precautions
  • Spinal precautions
  • Weight bearing precautions
  • Deep vein thrombosis (DVT) precautions
  • Lymphedema precautions
  • Wound care precautions

For more information on these precautions, check out Common Precautions for HealthCare Professionals.


7. Know Your Durable Medical Equipment

A good knowledge of Durable Medical Equipment (DME) is essential since you will be recommending them to your clients. It might be helpful to also have handouts readily available so that your clients can make an informed decision that factors in the cost, feasibility of ordering (local store vs. online) and whether or not it is covered by insurance. There may be local donation-based centers or charitable organizations that offer DME for those with limited resources so explore and research all these options so that you can make the best recommendation for your clients. 

Online courses

If you would like to access these courses on MedBridge, you can Subscribe for $200/year using my promo Code “OTmiri.” This is a $175 discount, which is the best discount available to individual subscribers. If you are a student, you can take advantage of this wonderful resource for $100/year by using the Promo Code “OTmiriStudent” and your .EDU school email. Find out more at MedBridge for Students.

**This section includes affiliate links, which support the continued creation of free content and resources for our community. Thank you for your support! 


Books

1. Occupational Therapy in Acute Care

Occupational Therapy in Acute Care is an essential textbook for anyone considering the acute care setting. From demystifying lab values and medical conditions to intervention and discharge planning, this book will give you everything you need to feel confident and competent in navigating the acute care setting.

2. Occupational Therapy Toolkit

With 283 pages of fully illustrated patient education handouts organized by 85 treatment guides, the Occupational Therapy Toolkit is one of the most popular and frequently utilized resource for OT practitioners working with physical disabilities and older adults. I recommend this book wholeheartedly and unreservedly!

3. Quick Reference to Occupational Therapy

The Quick Reference to Occupational Therapy will quickly become one of your favorite go-to resource for everything occupational therapy. Take this book with you and keep it handy for anytime you need that quick, At-A-Glance fact sheet on a disease, injury or disorder. I used this book so much that it’s already beginning to show wear and tear!


Websites

1. The American Occupational Therapy Association (AOTA)

The AOTA website has great resources and fact sheets to help you understand the role of occupational therapy in Acute Care. Be sure to take some time perusing the website so you can be fully equipped with the knowledge you need to thrive in this setting.

“If you don’t have a membership, I highly recommend getting one. You get OT practice magazine sent to your house (awesome articles in there, I’m a nerd and I clip/save them for future reference). You also have access to AJOT and evidence based articles – I use these all the time for treatment ideas for various diagnoses.” – Ashley Hayward, in Acute Care Trauma Hospital

2. Centers for Medicare and Medicaid Services (CMS)

It is our responsibility to stay abreast of current laws and regulations related to ethical billing, CPT codes and other policy/practice issues affecting our profession and scope of practice. Be sure to bookmark Centers for Medicare and Medicaid Services for regular access to important information and updates.

3. Rehabilitation Measures Database

The Rehabilitation Measures Database will allow you to quickly look up assessments based on the type of condition, population, body part and area of assessment. Very helpful tool!

4. Compendium of Physical Activities

Compendium of Physical Activities allows you to easily look up the MET levels by activity. Great resource to add to your bookmark!


Online Support Group

If you are a newly licensed OT practitioner, consider joining the “New OT Practitioner Support Group” on Facebook. It’s an incredibly supportive group of newly licensed OTs and OTAs who continue to give their time and energy to encourage, inform and inspire fellow colleagues and members of our community.

THIS SETTING MAY BE A GOOD FIT IF YOU:

  • Enjoy working in a fast-paced environment
  • Want variability in the caseload, treating clients with a wide range of diagnosis and conditions
  • Desire to expand your knowledge base through exposure to complex medical cases
  • Don’t mind being on your feet all day
  • Are not squeamish about blood and bodily fluid

Due to the short stays in acute care, you may not be able to spend too much time getting to know and rehabilitating your clients. If this is important for you and you would like to spend more time rehabilitating patients, you may want to consider inpatient rehab, subacute, SNF or outpatient sites.

To read about Ashley Hayward’s first year as a new grad occupational therapist in the acute care setting, be sure to check out A Day in the Life of an Acute Care OT.

YOUR COMPLETE GUIDE TO THE PERFECT OT JOB

Begin your job search and application process with OT Miri’s OT Job SearchSample Cover LetterSample ResumeInterview TechniquesFrequently Asked Questions and Salary Information. These pages were designed specifically with new OT grads in mind to ensure you are well equipped and best positioned to stand out and get hired.

  • Pedretti, Lorraine Williams, Pendleton, Heidi McHugh.Schultz-Krohn, Winifred., eds. Pedretti’s Occupational Therapy: Practice Skills For Physical Dysfunction. St. Louis, Mo. : Elsevier, 2013. Print.
  • Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016, September 2). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 1–19. dx.doi.org/10.1177/1077558716666981
  • Smith-Gabai, Helene., eds. Occupational Therapy In Acute Care. Rockville, MD : American Occupational Therapy Association, 2011. Print.
  • The American Occupational Therapy Association Website. https://www.aota.org/about-occupational-therapy/professionals/rdp/acutecare.aspx. Retrieved March 9, 2018.

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