Key Clinical Questions
What are the roles of physical and occupational therapy in the inpatient setting?
Which patients should be seen by a physical or occupational therapist?
What is a physiatrist? What role does he or she play in the care of hospitalized patients, and how does it differ from the role of the hospitalist?
How can rehabilitation services assist in discharge planning?
Physical therapists (PTs) and occupational therapists (OTs) address the functional needs of patients through mobilization, conditioning, and training in self-care, and other specific tasks. PTs and OTs practice in many settings, including the hospital, clinic, skilled nursing facility (SNF), long-term care facility, freestanding inpatient intensive rehabilitation center, and home. A smaller number also practice in emergency departments in the assessment and treatment of musculoskeletal injury. Less heralded is the role that PTs and OTs play in minimizing specific in-hospital complications, and optimizing successful transitions to outpatient care. Given the growing economic pressures on hospitals, including nonpayment for some nosocomial complications or for rapid readmission to the hospital after discharge (bounce-backs), PTs and OTs are not only crucial in helping patients regain functional capacity, but are also vital to the financial well-being of inpatient hospitals. Unfortunately, the scope of practice of PTs and OTs often lies beyond the focus of physicians. Medical education often underemphasizes the role of allied health providers and their contributions to restoring health and function. This chapter attempts to correct this underexposure by delineating the roles and responsibilities of these therapists, and indicating their impact on specific diagnoses commonly encountered by the hospitalist.
CASE 69-1 AN ICU TRANSFER TO THE MEDICAL SERVICE AFTER A DEBILITATING MEDICAL ILLNESS
A 53-year-old previously healthy male, with a past medical history of hypertension, developed a febrile illness over several days, and collapsed at his small business. The emergency medical technicians successfully resuscitate him and he is admitted to the intensive care unit. Over a period of 4 weeks he has a complicated course including prolonged intubation necessitating tracheostomy placement due to respiratory failure from community-acquired methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, encephalopathy attributed to acute illness delirium, acute kidney injury requiring dialysis, and demand ischemia characterized by an elevated troponin without ECG changes. Ultimately, the patient stabilizes and is transferred to the general medical service after tracheostomy and placement of a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. Communication is difficult due to the tracheostomy. Overnight he becomes agitated and receives haloperidol. He requires suctioning every 1 to 2 hours, and is not yet ready for discharge to a hospital-level rehabilitation facility. On rounds he appears agitated when he requires suctioning. Assessing mental status is difficult due to tracheostomy, and he does not appear to respond to commands optimally.
Although this patient clearly requires acute medical treatment, how can you improve this individual’s level of functioning within the framework of his illness? What steps can you take to fast track him to a rehabilitation facility ...