PT in the ICU

Physical Therapists in Acute Care Settings
Physical therapists in acute care settings must possess an extensive skill set. The rapidly evolving health care environment is adding new challenges, while offering new rewards, to those PTs.
By Michele Wojciechowski
When you think of "acute care" in physical therapy, what do you envision? Physical therapists (PTs) simply following directions of the physician in the intensive care unit (ICU)? If so, Mary Sinnott, PT, DPT, MEd, suggests that you think again.
Sinnott, a clinical associate professor at Temple University's Department of Physical Therapy in Philadelphia, as well as the president of APTA's Section on Health Policy & Administration, has spent her career working in acute care. (In fact, APTA even presents the "Mary Sinnott Award for Clinical Excellence in Acute Care.")
And if there's one thing she knows, it's that acute care physical therapists are challenged constantly-they must be smart, flexible, innovative, and have great communication skills. In the course of a single day, a PT working in acute care may act not only as a care provider, but also as a consultant, a researcher, an educator, and an advocate.
Acute, Critical, and Urgent Care
The term "acute care" doesn't always refer to patients in a hospital's intensive care unit (ICU). In fact, it's quite the contrary. "In acute care, typically you're dealing with people who are not in ICUs. They are at a sufficient level of medical stability that they don't need intensive monitoring," explains Sinnott.
If you're talking specifically about "critical care," though, patients typically are in the ICU, are medically unstable, may be on medications that can have cardiovascular, neurological, or pulmonary consequences, and usually are not mobile. "With critical care, some of your practice is prevention and some is intervention. The objective is to help get the person to the next level of care-ie, out of intensive care-as fast as possible," says Sinnott.
Urgent care refers to patients in the emergency department of a hospital. While PTs may be assigned specifically to the emergency department, many times a PT on the hospital staff or on call will address patient injuries on a case-by-case basis.
Anita Bemis-Dougherty, PT, DPT, MAS, is the manager of physical therapy at Johns Hopkins Hospital in Baltimore, Maryland, and has worked in acute care since she graduated in 1975. And at Hopkins, she's seen it all. "It's pediatrics through geriatrics and every service you can imagine," she says. "If you work in acute care, you see a multitude of diagnoses."
Because acute care PTs can encounter everything from severe fractures to traumatic brain injuries, from gastroenteritis to congestive heart failure, and from gall bladder problems to multiple trauma, they must be able to blend a number of skills in order to properly diagnose and treat their patients, Bemis-Dougherty notes.
As a result, they need to act both quickly and accurately to do their best for those they see.
Mary Pat Corrigan Jobes, PT, MA, president of APTA's Acute Care Section, has spent 26 years in acute care-first in pediatrics, and since 1994 in an adult acute care hospital (which also has outpatient pediatrics). She currently is the administrative director, rehabilitation services, at Methodist North Hospital in Memphis, Tennessee.
"The goal of acute care is to help the patient progress and gain the strength they need to move to the next level of care," says Corrigan Jobes. For that reason, she says, "The acute care therapist has to be a generalist. In any given day, in any acute-care hospital, someone has got to cover for somebody. So you have to be able to adapt to different types of diagnoses and different kinds of patients-even if you are a specialist in one area-because the patient comes first."
Meanwhile, Sinnott points out that today, with the average length of stay being anywhere from three days in a community hospital to five or six days in a university tertiary-care hospital, "The role of physical therapy very often is that of triage." PTs in acute care must evaluate the functional consequences of acute pathology and make recommendations for the next level of care that the person may need.
"This is a real challenge because you have to take into consideration the status of their pathology, the impairment, the functional limitations, and the consequences of those factors," says Sinnott. "as well as past medical histories and the psycho-social issues to make the best possible decision for the individual first, and to help the institution move patients through the system as safely and quickly as possible.
"You know that you're not making the final decision; you're making the next decision. So physical therapy often plays the role of consultant in acute care."
There's also another consequence to shortened hospital stays. Because patients today are discharged from the hospital much sooner than in the past, Bemis-Dougherty says, "Acute care really isn't a place. It's the acuity of the patient. So you may have patients who leave the hospital in three days and go to home care, but they really still are acute. Or they could go to outpatient, but they still are acute. They may have compromised cardiac status or compromised endurance; they, too, are acute care patients.
"Acute care is not just working in a hospital. Acute care is everywhere. So the skills you acquire by working in a hospital can be transferred to any practice setting."
The Necessary Skills
Because they face a vast array of injuries and patients on a daily basis, acute care PTs must possess an extensive skill set. Sinnott says that, in addition to their physical therapy knowledge, PTs must understand physiology, pathophysiology, pharmacology, the roles of other health care personnel, and much more.
"The patient's safety depends on the PT being aware of his or her role in an interdependent care model," Sinnott says.
"They need to know the different systems-like the pulmonary system-because that might affect what the PT is doing. [They must know] wound care. They need to know all about lines, tubes, drains, monitors, and precautions," says Bemis-Dougherty. "It is very fast-paced. PTs need to be flexible and multitask. They constantly are going from one thing to another. PTs in acute care have to be alert to infection control procedures...then [have] the ability to take and interpret vital signs continuously with each patient. That's just a smattering of what [acute care PTs] need."
She adds that while a PT may have orthopedic or wound care specialties, a patient may have cardiac or pulmonary problems, "So you have to assess all of those systems to develop a plan for that patient.
"What I tell people is that once you work in an acute-care setting, you probably can go to any other setting and know the medicine part of it. You will be so much more prepared for whatever you are going to see away from that acute care hospital."
Why Acute Care?
Dawn Piech, PT, MPT, CWS, has been a PT for eight years. She is the acute care physical therapy coordinator at Advocate Christ Medical Center in Oak Lawn, Illinois. She also is the vice president of APTA's Acute Care Section and certified as a wound care specialist by the American Academy of Wound Management.
Piech had thought that she would make orthopedics her career. But her first job after graduation changed all that. In it, she learned how much knowledge was necessary for acute care and how many different challenges there were on a daily basis. "I never looked back," she says today.
Corrigan Jobes suggests that all new grads seriously consider acute care. "From my perspective, acute care is the best place for a new [physical therapy] grad to start because they get exposed to all kinds of patients and all kinds of situations so that they can integrate information they have learned in school," she says.
Piech adds, "I think the great thing about acute care is that you need to have a wide wealth of knowledge to work with patients because you have a little bit of everything in each patient you work with. It forces you to continue to work on your clinical practice so that you can stay on top of all the things you need to for each patient."
Collaboration With Other Staff
A key skill in acute care is the ability to collaborate with other hospital staff. "The role of acute care physical therapy mandates interdependent collaborative practice because you have to be in contact with the attending physician, consultants who are brought in, nursing and case management, social service, [as well as] the family and the patient," says Sinnott. "It mandates that you get all that information together as best you can and as fast as you can so that you can make the right decision for that person."
Corrigan Jobes agrees. She says that when working with health care professionals who may not have a good understanding of what physical therapy actually is, PTs may have to educate them-and explain that they are providing skilled services. Piech adds, "Unfortunately, sometimes the doctors think all we do is 'walk' patients in acute care. They are amazed to see us working with these [patients with] traumatic brain injuries and what we do."
Excellent communication skills are crucial to foster collaborative relationships. And these communication skills must work in both directions. As Bemis-Dougherty says, "You need to work very closely with physicians, nurses-the other members of the team. You can't be afraid to ask questions.
"You have to gather a patient's history; you have to ask about the precautions. Doctors may not put it down, and you may be the one who discovers something because you work more closely with the patient than the doctor does."
Corrigan Jobes says that, perhaps surprisingly, there can be autonomy of practice in an acute care setting. She explains that acute care PTs work collaboratively with physicians to develop evidence-based protocols. Because the physicians then recognize the PT's area of expertise, Corrigan Jobes says, "Physicians can rely on you to know what needs to be done for that total joint patient or that wound care patient. You have to prove it, but you can have autonomous practices in acute care settings without having to be an independent practitioner."
The role of the physical therapist assistant (PTA) also is important in acute care. "The PT may establish a plan of care, and the PTA works with the therapist to carry out the plan," says Corrigan Jobes. "They are very effective in this setting."
Educating the Patients And Family
Another facet of acute care involves PTs educating not only their collaborative partners, but also--and sometimes most important--their patients and the patients' families.
"Patient education is a big part of [acute care] physical therapy. You always are talking to the patients, telling them what you are doing, and why you are there. If family members are present, you are educating the family on what you are doing and what they can do to help the patient," says Corrigan Jobes.
"When patients move out of critical care into a med-surg or in a medical bed, the PT is working with the patient on what he or she should do for safety. Fall initiatives are very big in hospitals now and rehabilitation services are very much involved in working with patients and identifying those patients who need to be on 'falls risk.'
"You are educating the patient and the family about what that patient needs to do so they can be safe as well as what they need to do to continue their progress to become stronger or more functional," Corrigan Jobes says.
Patient Advocacy
In addition to collaborating with everyone from doctors and nurses to techs and nutritionists, acute care PTs often serve as advocates for their patients. One area where this is particularly important, Sinnott notes, is in the development of a discharge plan. For example, she says that often others may assume that because a patient has had a stroke or a fall-related compression fracture of the spine, that patient will need to be in a nursing home for the rest of his or her life. "Then the PT comes in and the patient is walking down the hall. The patient doesn't need that higher level of care. What they do need is rehabilitation. Or they need to be in an environment where they are safe while they are healing so they can return to their lives," says Sinnott.
"You also have to take into consideration a patient's financial resources. That often will dictate what type of discharge plan you can make. Sometimes that can be fortuitous, and sometimes it can be unfortunate. You have to work within the patient's means and the family's means," Sinnott adds.
Evidence-Based Practice
Because acute care PTs work with a variety of patients with a range of injuries or illnesses as well as collaborate with many health care professionals, it follows that evidence-based practice plays an important role.
Katherine Biggs-Harris, PT, MS, has worked at Yale New Haven Hospital for 24 years. Although now a full-time professor, she still works one day a week at the hospital. She says that a wealth of evidence exists to help PTs progress a patient from point A to point B, but not all of it will be found within physical therapy literature. In fact, answers may be found in physiology, nutrition, or even nursing literature.
For example, she explains, she may have patients in critical care on IV solutions or tube feedings. The PT must work with a nutritionist to determine if the patients are receiving the appropriate number of calories to meet the metabolic demand not only of their illnesses, but also for those activities that the PT wishes them to perform. "Plenty of literature supports that collaborative approach," says Biggs-Harris. "But it is not just PT literature. "We all have to be better about researching and publishing and doing case reports to enhance the literature so that we can continue to move forward."
Corrigan Jobes says that it's necessary for acute care PTs to regularly review evidence on the injuries or illnesses they are working on to determine, for example, the best practice or the most current information on a condition. She says, "We have to do our research."
Attracting New Grads to Acute Care
While all the PTs working in acute care interviewed for this article would like to see new graduates enter their chosen profession, they agree that it's not always easy. "It's hard to get new grads into acute care," says Corrigan Jobes. "You've got to get to them in their rotations, and not every school even requires an acute care rotation anymore. We need to take students because that is the future of the profession. They need to see what acute care is and that they can really learn and have an exciting and viable and challenging practice."
Biggs-Harris says that while, from an educational perspective, many academic institutions are addressing acute care issues in their curriculum, more mentorship programs are needed to help graduates apply what they've learned in school to the ICU or to treat acute care patients. "A number of large facilities do have mentorship programs in critical care," says Biggs-Harris. "They are making sure the therapist is prepared to go into a unit and treat patients."
She gives an example of how mentorship helps new graduates: "Remember when you were in school, [and] you used to get bits and pieces of information, and sometimes the light bulb would click and you would know exactly what you were supposed to do-how to integrate all the information? Often when you are working in critical care, you have so many things going on, the light bulb clicks with somebody there helping you."
But with all they would have to learn, why should new grads or other PTs entertain the thoughts of heading into acute care? Piech likes the challenge of the profession. "It forces you to be on your toes."
"It's an exciting environment, and you learn so much," says Bemis-Dougherty. "It doesn't matter whether you are here a year or 15 years. There is always something new to learn...You don't see the typical patients, and you are critically thinking all the time. It is always a challenge. There is communication with physicians and nursing. That piece is stimulating for me."