When I am teaching a course, it is common for students to ask me what a clinical schedule might look like in the “real world.” I am going to share my experience with you from both an acute care setting and an inpatient rehabilitation setting. My first clinical position after graduation was a position that was split across two hospitals—50% of my position assigned to acute care at a heart hospital and 50% assigned to inpatient rehabilitation facility (IRF) as a float physical therapist. Having navigated a position split between an acute care heart hospital and an IRF, I've encountered the nuances of patient care scheduling, documentation, and discharge planning. From triaging patients in acute care where interruptions are the norm, to a more structured IRF environment with scheduled therapy sessions, each setting presents its own set of considerations. Based on my experience in both acute care and IRF settings, I strive to provide insights into the intricacies of a clinical schedule, highlighting the diverse demands and unique challenges of each environment.

Navigating Patient Care Schedules: Contrasts Between Acute Care and Inpatient Rehabilitation Facilities

Acute care is a different setting than IRF, and sometimes students are surprised by this during a clinical rotation. When I worked in acute care, which also had an Intensive Care Unit, I would receive a list of patients in the morning with orders for physical therapy (PT). For those patients with orders, it was up to me to triage the patient list to determine who was prioritized for PT, and which patients could wait until the next day. Therapy was not formally scheduled with patients, although I would try and give a “heads up” to nursing and/or patients when possible. After getting that list in the morning, I would review medical charts for information related to surgery date, surgical report, labs, electrocardiograms (ECG/EKGs), medications, and estimated discharge date. I would also review physician orders for information pertinent to PT such as sternal precautions, pacemaker precautions, activity restrictions, blood pressure or heart rate limits, range of motion restrictions, and/or weight bearing restrictions.

Patients in acute care are busy, often getting multiple medical tests and receiving consultations from various doctors and other healthcare professionals throughout the day. Many of my PT sessions with patients were interrupted, stopped, or modified. I worked to strengthen relationships with nursing staff and respiratory therapists, so that we could work together to optimize schedules for patients to manage medications, fatigue, pain, and sleep. An acute care hospital may or may not have a therapy gym. If they don’t have a therapy gym, sessions are often completed in the patient’s room or in a hallway.

Alternatively, when I worked in an IRF, therapy was scheduled, which provided more structure for therapy than the acute care environment. Patients had to be medically stable to transfer to the IRF, and all patients arrived from another facility. Patients had standing orders for PT evaluations, and some patients had initiated PT at the prior facility. Patients were expected to tolerate 3 or more hours of therapy per day, and that therapy could be a combination of PT, occupational therapy, and/or speech therapy. The multidisciplinary team at the IRF focused on maximizing the patient’s participation in therapy among other needs such as nursing care, neuropsychology, recreational therapy, pet therapy, spiritual care, and schoolwork for some children. Since there were potential therapy specialty equipment needs and multiple therapy appointments, therapy schedules were distributed in the morning to patients, nursing staff, and therapists. Some examples of specialty therapy equipment include Lokomat robot-assisted walking therapy and Functional Electrical Stimulation (FES) lower extremity bike. These schedules avoided conflicts such as multiple therapists taking patients to utilize the same piece of specialty equipment at the same time. Like acute care, changes still occurred at the last minute due to staff being out unexpectedly, equipment issues or medical needs. Most IRFs will have some sort of therapy gym space with mats.

Discharge Planning

While working in acute care, I quickly learned that many post-acute care facilities required a PT evaluation for admission, including skilled nursing facilities, IRFs, and some home health care agencies. Patients were discharged from acute care once they were medically stable, and if they were going to another facility, they were a priority as the PT evaluation had to be completed before the patient could discharge. Sometimes I would find out on the day of discharge that someone was transferring to another facility, which required me to rearrange my schedule so that I could complete their required evaluation in time. I was asked daily in acute care for my input on if I thought the patient could go directly home with outpatient cardiac rehab, home with home health care, home with outpatient PT, or if they needed placement in a skilled nursing facility or IRF. I would consider how the patient might function if they were to improve one or two functional levels, such as if they improved from moderate assist to hands on assist in acute care. I also considered factors such as home environment and caregiver support. Could the patient safely ambulate the distance required to walk into an outpatient cardiac rehabilitation center? Some post-acute care discharge facilities even required therapist-to-therapist phone calls to assure that the patient was appropriate for continued therapy services.

Discharge planning in IRF also began as soon as possible for the patient, which involved a team discussion at a team meeting where multiple disciplines could provide their input regarding discharge date and destination. Like acute care, plans could change daily, but discharge planning still seemed to have more lead time than acute care which provided more time to coordinate family training, recommend equipment at home, and advocate for patients and their families.

Documentation

For both acute care and IRF, point of service (POS) documentation was recommended, which means trying to complete documentation during the session. However, POS documentation is not always appropriate or feasible based on how much physical assistance and/or supervision the patient required during the session. POS documentation might occur via utilization of a hospital-issued laptop or a desktop computer at a nursing station or therapy office.

While some hospitals provide dedicated documentation time, other hospitals may just expect you to integrate documentation into your day. The most common documentation includes visit/daily notes, evaluations, care plans and charges. Beyond that, there is much more documentation for the patient that occurs throughout the entire day. Managing a case load includes chart reviews for patients who are new to you or new evaluations, re-evaluations including updating care plans, calling back family members, time for clinical reasoning and/or brainstorming with team members, replying to emails, requesting specialty equipment, providing coverage notes for expected time off, preparing and documenting for team and family meetings, updating internal documents, recommending and completing durable medical equipment scripts, and assuring timely communication with team members. To perform these tasks successfully and simultaneously while prioritizing patient care requires multi-tasking and constant flexibility to change course as needed.

Stay tuned for Part II, as I explore what it looks like to evaluate and treat patients with cardiovascular and pulmonary conditions.

About the author: Sonya L. Irons, PT, DPT, CCS is a Board Certified Cardiovascular and Pulmonary Clinical Specialist and a course instructor for Scorebuilders.