Acute Care: Considerations Before Evaluation

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Hospital Culture

I could provide you an outline of the acute care day and I would say that it is probably pretty familiar most places that you go. Determine your patients for the day, chart review, check with floor nurse, evaluate patient, handoff, write evaluation, and get ready for your next one.

Determine your patients

In today’s world of technology, you might be surprised to know that up until 2-3 months ago, at our hospital our rehab aide printed up the orders and wrote “tags” and we would select patients accordingly. Oddly Covid-19 has pushed us departments to innovate so that multiple people aren’t standing around and use our technology tools to prevent socializing too closely together. Lately, we have been using UI tools to populate the orders and we pick our patients right out off of Epic. We have our system for making sure people are seen, signing off appropriately however I won’t get into those nuances.

Hospital Floors

We are a smaller hospital, not rural however not a big, downtown location either. Recently our hospital made the decision to place OTs, PTs on one floor – we are on telemetry, ICU, CVICU, advanced care unit, inpatient rehabilitation, and/or medical-surgical. Those seem to be the typical floors in most hospitals. We rotate between floors with the exception of inpatient rehabilitation as those have dedicated therapists.

(We might be a unique situation in our hospital. It seems over the past 5 years, Inpatient rehabilitation units are moving towards a free-standing inpatient rehabilitation unit. It’s no longer within the hospital, instead it’s housed in a free-standing hospital where it might be a 40-60 bed hospital with a larger staff dedicated to IPR. I’ve noticed these usually occur as a partnership between a local, nonprofit health system and national, for-profit rehabilitation hospital.)

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Chart Review

This deserves it’s own post however I won’t get too into the nuances on this. The chart review is such a critical piece prior to evaluation. Imagine the day, and in some settings this still occurs, when you had to open a physical paper-based chart and someone else had it?? Then you moved on. Luckily I would think most hospitals and most settings at this time, although I realize this is not everyone yet – an electronic medical record (EMR) system usually helps you access a chart anywhere within the hospitals network. In my hospital system we use Epic however there’s Kerner and other systems out there.

At this point I’m starting to review orders, lab values, Notes by the physician, nursing notes, therapy noted, interdisciplinary care management/social work.

Check for the Order

Always the first thing to check. Was the order written for now? It could have appeared and the ordering physician wants you to see them later. Sometimes we get orders for patients who literally walked through the door. Use your critical thinking skills (and check with the floor nurse) regarding if it’s the appropriate time to see this patient. They may be awaiting a test or a consult from another physician that may provide an opinion, such as the need for surgery.

Lab Values

It’s interesting because in school we learned the pre-determined guidelines for lab values. Once they reach this lab value “you can’t see them,” and what you learn on the job that you didn’t read in the textbook is that other factors come in to play. Every patient is different and while some numbers may read below a range or above a range, it may not necessarily mean this patient cannot be treated. There may be a reason a physician wants a particular patient seen despite a particular lab value out of range. We have to think is it critically out of range, or an abnormally high/low value. Caution may be necessary when approaching a treatment/evaluation of the patient. We have to consider safety with patients – by mobilizing a patient to either sit at the edge of the bed or mobilize within the room, are we placing the patient at greater risk? This is where collaboarting with nursing and obtaining a well-rounded picture of the patient is necessary.

Weight Bearing Status

It’s very critical to get an idea of a patient’s weight bearing if you are seeing a surgical patient or any patient who have fractured an area of their body. We must wait for the consulting physician to place orders. Generally, patients who fracture their humerus/shoulder region generally may get a sling and they will be non-weight bearing. Someone who broke their wrist may be unable to bear weight in their wrist but they can weight bear through their elbow to use a walker. There are many nuanced weight bearing statuses so it’s crucial to understand each one and how that could impact your intervention.

Many times the type of fracture, location of the fracture may give you an idea of what to expect before the ortho consult. Regardless, it is highly recommended to wait before seeing any patient even if the hospitalist has already placed their orders.

Checking with the floor nurse

Occupational therapists may feel a need to “know everything,” however there may be critical pieces of information left out of the patient’s chart. The floor nurse likely knows the answer as they received verbalized reports from the physician, the previous floor nurse, and so on. Many physicians are consulted to see patients and may not have had a chance to place orders or publish their note concerning their assessment of the patient. It is possible neurology wants an MRI to determine if the patient had a CVA because the CT scan was inconclusive. As stated in the previous example, maybe orthopedics consulted the patient and the nurse hasn’t released the new orders for weight bearing as tolerated (WBAT) or non-weight bearing (NWB). I’ve seen it happen a few times where the orders might be pending from the surgery and the surgical physician didn’t confirm anything in their note.

Final Thoughts on Clinical Decision Making

We are all people trying to help our patients. Everyone has that common goal. It is so crucial to be a team player with the nursing, physicians, imaging, respiratory therapy, dietary and housekeeping. Everyone is busy and on a schedule especially with productivity standards applying in the hospital however you can never diminish the importance of safety and great communication. We will all make mistakes along the way, but making sure you have the most information necessary to guide your clinical decision making is critical.

Happy chart reviewing! Drop me a line on what you do for the chart review process, I’m open to reading new ideas.

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