Early Rehabilitation Interventions
Rehabilitation interventions contribute positively to overall patient outcome of trauma patients. In a rehabilitation system, each member has a specific role and follow specific treatment guidelines that are important to early rehabilitation interventions.
Philosophy of Early Intervention
A good trauma center recognizes the advantages of a very early rehabilitation intervention program. Rehabilitation specialists, such as physical therapists, speech/language therapists, therapeutic recreational therapists, and occupational therapists, are often brought into the picture as early as when the patient is in the intensive care unit. All units must follow the same standard of care so that patients receive adequate rehabilitation at all levels of their care.
Early intervention optimizes functional outcomes, provides better patient and family education, and allows opportunities for collaboration between the rehab services and bedside nurses, who assist in the rehabilitation process. Specific discipline recommendations can be addressed early on and complications that could hinder the patient from receiving their fullest potential are prevented, with discharge planning developed as soon as the patient is admitted.
Acute Care Model
The structure of a good rehabilitation department allows for streamlined communication between nurses, therapists, and physicians within the rehabilitation department caring for the patient. This structure allows for therapists to be active on the acute care unit and in the ICU.
The previously mentioned rehabilitation therapists, regardless of the area of the hospital they work in, are all members of the rehabilitation department. Rehabilitation therapists are generally organized into workgroups rather than along discipline-specific lines.
A workgroup consists of an occupational therapist, a physical therapist, a speech and language therapist and a rehabilitation specialist. Each workgroup provides therapy coverage to the various medical services in the hospital. Each workgroup has a supervisor or manager that can be from any one of the disciplines in the workgroup.
On acute care services, the roles of the therapist are defined as follows to allow for the best patient care:
- Occupational Therapy (OT). They are responsible for administering assessments and treatment for basic activities of daily living and instrumental activities of daily living, sensorimotor skills, positioning and splinting, cognition through functional activity, patient/family education and providing assistive devices.
- Physical Therapy (PT). They assess the musculoskeletal, neurological, cardiopulmonary and integumentary systems. Interventions by physical therapy include improving range of motion, strength training, functional mobility training, endurance training, patient/family education, and provision of durable medical equipment or assistive devices.
- Speech and Language Pathology. These are responsible for assessing swallowing, communication, and cognitive-communication skills. They aid in swallowing problems and recommend appropriate food textures, liquid consistencies and develop ways to avoid aspiration. Many trauma patients have problems with communication. This can be due to brain trauma, tracheostomy tubes, and ventilators that prevent vocalization. Speech and language pathologists help maximize residual speech and language function, providing ways for the patient to communicate with family and caregivers. Cognitive communication deficits are treated with patient/family/caregiver education and the provision of guidelines for interaction through communication, however it can be obtained.
The Consult Team
There should be acute care rehabilitation therapists available on each unit in a trauma center. All general surgery patients are cared for by a designated unit unless a bed is unavailable. Occupational therapy, physical therapy and speech/language therapy personnel are assigned to each unit—whether it be a medical or surgical care unit. This way, there is a strong rapport among the therapists and other caregivers caring for the patient. The use of workgroups throughout the facility has led to the development of consistent standards of practice among the therapists so that trusting relationships can develop.
The Rehabilitation Consult Team
This is a team consisting of physicians, nurses, therapists, social workers, psychologists and vocational counselors. Team members make individual contributions to the care of the trauma patient with the key to a successful plan of care being the coordination of those individual efforts.
The rehabilitation consult team has the following goals:
- To identify trauma patients needing rehabilitation within 48 hours of admission.
- To identify rehabilitation needs and develop a plan of care to address those needs.
- To institute the plan once the patient’s medical condition allows.
- To evaluate the success of the plan and modify the plan as necessary.
- To discuss the plan with patient and family.
- To educate others caring for the patient about the involvement of the rehab team.
- To ensure a timely discharge to the most appropriate setting.
The team members on a rehabilitation consult team include the following:
- This includes physiatrists who consult on patients throughout the acute care areas of the hospital as well as having responsibilities in the outpatient clinic. The doctor reviews all hospital admissions and screens for diagnoses that might require rehabilitation input.
- Trauma Rehabilitation coordinator. This is a person collaborates with the appropriate disciplines in order to coordinate continuity of care for trauma patients within the facility. Usually, the trauma rehabilitation coordinator is a registered nurse who facilitates communications between the rehab team and other professionals involved in the care of the patient. They review the recommendations of the physiatrist and facilitates the implementation of the recommendations. They also coordinate transfers to acute care rehabilitation facilities.
- Social workers. There are social workers who work with the different kinds of trauma, including spinal cord trauma and burn trauma. They help the family and patient with issues that often accompany trauma. Families who live out of town may need a place to stay and family conferences may need to be undertaken. Emergency funds for food for the family may be needed. The social worker also focuses on discharge planning with an understanding of the issues around insurance coverage for various discharge options. Some families need help in arranging for public assistance.
- Occupational Therapists. They evaluate things like feeding, hygiene, grooming, bathing, and dressing the patient. They also help with higher order issues like shopping, money management and cooking. They help with things like functional transfer training, cognition, sensorimotor function, range of motion, strengthening, and coordination. They assist with issues like splinting, skin protection, edema management, and positioning. They intervene in the ICU setting with things that help reduce skin breakdown and joint contractures.
- Physical therapists. They specialize in the musculoskeletal, cardiopulmonary, neurologic, and integumentary systems. They provide interventions and education, addressing patient impairments in order to provide maximal functional independence. They provide care in the emergency room, intensive care setting, and the postoperative care setting. The goal of the physical therapist is to initiate rehabilitative techniques that foster early restoration of maximum function. They also provide mobility training for those injured persons who do not require hospitalization. They make recommendations for those who need long term placement because they cannot care for themselves at home.
- Speech language pathologist. These professionals provide diagnostic and rehabilitative services for problems with swallowing, communication, and cognitive problems as they relate to communication. The goal is to identify problems affecting a patient’s ability to communicate effectively with family and caregivers and to take in nourishment. They provide counseling and education, swallowing therapy, communication therapy and therapy for those who have cognitive communication problems. They supply the patient with alternative means of communication when they have dysarthria, ventilator dependent, or nonvocal. They make recommendations as to whether the patient can have nothing by mouth or need different dietary and liquid textures.
- Therapeutic recreation specialists. The aid in restoring patient function and independence, eliminating the effects of illness or disability. They assess the individual and provide training for community integration skills. These skills include pathfinding, problem solving, safety skills and judgment in high stimulus areas.
Rehabilitation begins with a referral to the rehab team. Specific therapy orders are written when the patient is physically ready. Nurses and physicians are provided with ongoing education on detecting new disabilities and therapists provide nurses with daily reports that explain the interventions being provided. Therapists provide education to physicians about the role of therapists, the patient’s progress and follow up therapy needs they may need after discharge.
Once a therapy order is written, therapists interact with the patients and communicate with the physicians and physiatrists, if necessary. Early physicians’ orders for appropriate therapy services provide the optimal conditions for early rehabilitation interventions.
There are primary team discharge planning rounds, in which the physicians and therapy services are involved. They provide a forum for discussing upcoming medical plans, pharmacology issues, cognitive status, functional status and post-hospital discharge needs. These rounds allow for all members of the team to contribute toward a common goal.
There are consult rounds, in which the physiatrist is involved. It includes recommendations from all the different therapy modalities and helps facilitate transfers from the acute part of the hospital to the rehabilitation unit.
It is important that all trauma patients have their rehabilitation needs met in a timely fashion by the rehabilitation consult team. All members of the rehab team seek to educate their colleagues on other units about rehab services and how to access them. The trauma rehabilitation coordinator is also in a position to identify patients that may have been overlooked. The trauma rehabilitation coordinator screens all ICU trauma admissions, attends care rounds, and communicates with the caregivers of the trauma patients. They alert the physiatrists to any additional trauma patients who may need evaluation
All therapists do a complete history and systems review before going on to their specific area of expertise. From this information, a formal plan of care is developed and interventions identified. Reexaminations are conducted at regular intervals and patient outcomes are measured. If there is a change in patient status, a full evaluation process may have to be repeated. This may identify other consultants which may be necessary in the patient’s care.
The termination of therapy services is determined by the patient’s progress in meeting their therapy goals. Discharge occurs when the patient has met all their goals. Patients with some types of trauma may require an annual review to make sure they don’t need any other services. Patients with mild communication deficits may require an outpatient evaluation and treatment by a speech language pathologist who will train them in various strategies and recommend return to work issues and community re-entry. Discontinuation of services happens when the patient declines continued intervention and is unable to make progress toward anticipated goals and expected outcomes because of medical or psychosocial issues.
Occupational Therapy Evaluation
Occupational therapists take a patient history that includes past and present medical conditions and identify any precautions that could affect functional outcome. They take note of any psychosocial, emotional, vocational, and leisure histories that may affect the patient’s goals. Preexisting problems can interfere with the new disability and will need to be addressed as part of the evaluation.
Occupational therapists use a variety of tests and measurements as part of their clinical evaluation. Things like range of motion issues, muscle strength, coordination, gross and fine motor control, sensation, circulation, skin integrity, visual perception, and cognitive function are some of the areas that may be tested.
They determine the level of improvement that can be expected through intervention and the amount of time needed to reach the goal. They incorporate the patient’s and family’s goals into the overall goal-setting process. They communicate the goals to the patients and family.
Physical Therapy Evaluation
Physical therapists take into account medical history that may impact functional outcomes. New and baseline disease processes can impact the therapy treatment plans. How pre-existing problems affect new trauma injuries needs to be assessed. Activity level prior to admission needs to be determined as this can affect outcomes. If the patient was sedentary prior to the injury, they cannot be expected to rise above that level without a great deal of intervention.
After organizing the available history, a system review is performed. Vital signs are taken and lab values reviewed. Skin integrity assessment and gross range of motion needs to be assessed along with strength measurements, balance, and coordination testing.
Physical therapists use a variety of tests and measurements during their evaluation. They may measure things like joint range of motion, muscle performance, motor control, and reflex/sensory integrity. On the basis of the evaluation, the physical therapist will make a diagnosis. They may make a determination as to the expected level of improvement the patient will make.
Speech Language Pathology Evaluation
These specialists review the medical records to identify areas of brain injury or other cognitive deficit that might impact communication. Information from the chart regarding the patient’s complaints, family perceptions, and treatments of other disciplines can help.
Speech language pathologists also focus on swallowing difficulties along with communication difficulties and cognitive deficits. The patient may have a swallow study to evaluate conditions that might limit their ability to take in nutrition. Oral trials begin with ice chips and/or water and then a variety of food and liquid textures are evaluated. The purpose of this evaluation is to identify any aspiration risks and swallowing problems that might inhibit the taking of pills or eating.
The communication evaluation looks at things like language, motor speech, reading, writing and functional use of language. Communication problems can come from a variety of sources and these must be assessed. Hearing acuity is also important and must be evaluated. An audiology evaluation may be in order.
Communication problems secondary to cognitive issues fall into the category of cognitive communication disorders. Evaluation of the cognitive communication issue is similar to a communication evaluation but the focus is different.
Based on the medical record review and evaluation, the speech language pathologist identifies the areas of problems and formulates a plan of intervention. The plan of care is established is based on the needs of the patient, the prognosis for recovery, and the environment most conducive to recovery. Therapy can be instituted at any point along the patient’s recovery.