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The Good and Bad of Acute Inpatient Rehab

Written by Shannen Marie Coley OTR/L, Published on February 6, 2018

So you’re thinking about becoming an acute inpatient rehab OT?

Newly graduated, in the midst of studying for the NBCOT, and on the pursuit of applying for a plethora of OT jobs: sound familiar? There are so many settings from which to choose: outpatient ortho, home health, acute inpatient rehab . . . the list goes on.

At this point you’re feeling nervous. Fieldwork experience helps tremendously in identifying and solidifying your interests in prospective patient populations and types of working environments, but you still aren’t sure about your ideal setting to kickstart your career as a new grad OT.

First and foremost, every OT setting will have its challenges alongside many highlights. Sometimes it can be reassuring to have a subjective perspective in that setting in order to determine if it is a place you can see yourself being, growing, learning, and thriving.

What is acute inpatient rehab?

Often referred to as an Acute Rehab Unit (ARU) or an Inpatient Rehab Facility (IRF), this post acute care setting is hallmarked by a patient receiving intensive therapy services at least 3 hours per day, 5 days per week. These services involve specialized and skilled intervention from at least 2 -3 rehab therapies (Physical, Occupational, Speech Therapy). The length of stay typically varies from about 7 days to 28 days depending on how debilitated the individual, as well as any medical complications and comorbidities.

While in a skilled nursing facility a patient would typically receive less intensive therapy in a shorter duration (such as 1-2 hours), in order to qualify for admission to an acute inpatient rehab unit, a patient must be able to tolerate 3 hours of therapy daily.

Who are the Key Players?

The interdisciplinary team at an ARU typically includes:

  • Physiatrist
  • Physical Therapist, Physical Therapist Assistant
  • Occupational Therapist, Certified Occupational Therapy Assistant
  • Speech Language Pathologist
  • Rehab Nurse
  • Social Work
  • Clinical Liaison
  • Nursing assistants, Care techs
  • With a Physician referral, other team members from fields such as Respiratory Therapy, Radiology, Wound Care, and Nutritional Care/Dietetics may be included

THE MORE YOU KNOW: A physiatrist is a type of allopathic or osteopathic physician with the credentials of M.D. or D.O. who is qualified to treat a multitude of medical conditions affecting the spinal cord, brain, bones, joints, ligaments, and muscles and is specially trained in rehabilitation. They are also known as physical medicine and rehabilitation physicians.

Who Qualifies?

Patients in this setting are typically moderately-severely impaired functionally and medically as well as not yet at the stage to transition back to their home (which is always the goal) or to the least restrictive environment such as an assisted living facility. The fact of the matter is after a major medical complication, many individuals need more than a brief acute care stay before they can safely return home.

Now let’s dive deeper into the challenges and highlights of working in this setting.

CHALLENGE: Documentation Nation

In this setting you complete A LOT of detailed documenting. There are daily treatment notes, Functional Independence Measure (FIM) score notations, chart reviews, evaluations, discharges, individual plan of care notations . . . etc. At an ARU, insurance expects detail that shows the skill that we provide as well as the step by step progress that demonstrates a patient’s likelihood to return home.

In addition, registered therapists attend weekly Team Conferences, which bring more documentation emphasizing a patient’s progress or limitations to progress week to week.

CHALLENGE: Events Out of your Control

Let’s be real, things happen in every setting that delay or impair therapy from beginning on time or being completed to the full duration. Flexibility is key in this setting, because the vast majority of the patient population served are fragile.

Physicians may order a STAT CT or even a Therapy Hold due to a patient’s medical decline. A phlebotomist may have orders to draw blood for different tests. Radiology might interrupt a therapy session due to necessity to perform a Modified Barium Swallow as a result of suspected aspiration. You may walk into your patient’s room while he or she is having an elective respiratory treatment. Nursing might be administering medications during the patient’s scheduled therapy time due to patient complaints of nausea or increased pain.

Although not ideal, all of these factors are a part of inpatient life!

Yet another event out of your control is reality in all settings: A few members of the healthcare team might be content with performing their job duties at the bare minimum. This is a limiting factor in patient outcomes.

CHALLENGE: Patients Who Perceive Therapy as “Taking Exercise”

Let’s all take a moment of silence for the OTs convincing little Ms. Smith that therapy is more than “walking more” and “taking exercise.”

Perhaps a patient states that he or she “can do everything” for himself/herself. This is where we gently allow our patients to attempt to perform their self care routine during our ADL assessment, which usually leads to increased insight in regards to what tasks of their daily routine that they cannot complete independently.

Nonetheless, although we know physical therapy includes much much more than walking and building strength, we OTs admit we are jealous when patients at initial evaluation tell us “they just want to walk more” . . .

Curious to find out what PTs actually do from an OT’s perspective? Check out NewGradPhysicalTherapy.com or APTA.org.

CHALLENGE: Compassion Fatigue

Compassion fatigue is stress that occurs from helping or wanting to help others who are experiencing trauma or suffering.

A common maxim is to “leave work at work.” This, frankly, is much easier said than done. There are and will be many times you will leave the hospital thinking, wishing, yearning to do more, be more, and give more of yourself to your patients. These unending feelings of hopelessness at times may cause therapist burnout which can then lead to compassion fatigue.

In order to provide skilled therapy to empower health and wellness while working toward enabling functional independence you must put your own self care first.

“Self care is never a selfish act -
It is simply good stewardship
Of the only gift I have,
The gift I was put on earth
To offer to others.”

-Parker Palmer

CHALLENGE: Lack of Intrinsic Motivation + Enabling Family Members = Poor Rehab Potential

Some patients just do not want to get better. This is by far the most distressing and profoundly difficult challenge to understand and accept in my opinion.

As a new grad (or even as a senior therapist) it is natural to think that you can find a way (using motivational interviewing, positive reinforcement, client-centered care, empathetic listening, etc) but there will be patients who are content in their function. Likewise, you will come across family members who unfortunately enable the patient to rely on them.

This is hard to report, but necessary to mention.

HIGHLIGHT: Congruency in the Lingo

FIM all day everyday!!! At an ARU, expect to FIM every patient. Therapists of every discipline, nursing, and even social work contributes to “FIMming” every patient.

What does this mean exactly? The Functional Independence Measure (FIM) is an assessment tool used to track changes in the functional ability of a patient during hospital care in a rehabilitation setting.

You can expect an Admission assessment within the first 72 hours of the start of rehab care; whereas Discharge assessment will be collected within the last 72 hours of care. Comprised of 18 items, there is a Motor subscale and a Cognition subscale which are scored on a 7 point ordinal scale ranging from 1 - Total Assistance with helper all the way to 7 - Completely Independent.

Occupational therapists are extremely valuable to this setting as we play an instrumental role in all 18 items especially Eating, Grooming, Bathing, Upper Body Dressing, Lower Body Dressing, Toileting, Transfers, among others! Therefore, because all disciplines utilize this tool there is more congruence and understanding in regards to the level of assistance the patient requires.

HIGHLIGHT: Occupation is the Expectation

One of the best aspects of working in an inpatient rehab unit is the emphasis on “occupation”. This setting as mentioned above operates with the intent of discharge to the community home environment. The treatment focus is on functional independence in self care, mobility, cognitive, bowel and bladder management, and community reintegration while simultaneously working toward stabilizing medical needs.

In acute inpatient rehab, a therapist can only “FIM” (see above) if the patient performs the actual task in all of its parts. In other words, simulations of occupations does not suffice the demands of this setting. AKA to assess a patient’s ADL skill level, they actually will complete the entire routine including taking actual showers.

Performing the occupation to its full capacity allows the therapist to develop an intervention plan that addresses the specific factors such as decreased ROM and activity tolerance, poor safety, or impaired sequencing that are limiting independence.

HIGHLIGHT: Flexibility in Your Workday

Have a doctor’s appointment at 8am or have to pick up your little cousin at 5pm? In an inpatient setting (and in most cases especially if you communicate with your program director and fellow therapists in advance) you have some sort of flexibility in your workday and will be more apt to having a few short days to compensate later with longer hour days.

Unlike in an outpatient setting where your day is typically scheduled to the “T”, acute inpatient rehab will keep you on your toes. There will be days where you may go home early after 5-6 hours of scheduled treatment and an hour allotted time for documentation and huddle with the nursing staff. Likewise, there may be days where you are the registered therapist that is scheduled to perform treatments, write discharges, and evaluate all of the late admissions! #reality

HIGHLIGHT: Variability in your Caseload

Huge bonus. Highly recommend this setting for this reason!!

Unlike in acute care where the length of stay is only about 1 - 3 days, in acute inpatient rehab you work with patients for a few weeks which ultimately leads to seeing more progression due to the longer length of stay.

Some of the typical diagnoses served in this setting are for…

  • Neurological Disorders -Strokes, Seizures, Traumatic Brain Injury, Spinal Cord Injury
  • Orthopedic Conditions -Hip replacement, Major Multiple Trauma, Amputation, Fractures
  • Cardiopulmonary Complications -Chronic Heart Failure, Chronic Obstructive Pulmonary Disease, Dypsnea, Pulmonary Hypertension
  • Miscellaneous -Cancer, Debility, Lymphedema, Cognitive Impairments, Macular Degeneration… and so much more!!!

All of the above mentioned may be further complicated by a significant number of comorbidities such as Morbid Obesity, Renal Failure, Diabetes Mellitus, having a Wound Vac etc. . . .

If you are hoping to broaden your perspective and increase your clinical competence in evaluating and treating a wide range of diagnoses, this is a good setting.

HIGHLIGHT: Good Pay

In this setting it is more typical to be paid hourly than salary which provides a great opportunity to achieve overtime pay to pay back those hefty student loans. There are typically opportunities for cross training (such as performing administration work, or working as a FIM coordinator) which may also increase the number of hours you work equating to increased pay.

Every specific ARU is different, but you can expect to be paid at least the average salary for that state. The median national annual wage for OTs working in this setting according to bls.gov is $81,910.

HIGHLIGHT: Opportunities to Learn from Various Healthcare Professionals

In other settings you might only see the doctor 1x/week, but in this setting you will be in contact with a multitude of physicians in addition to the medical director who is typically a physiatrist. Nurse practitioners, physician assistants, wound care nurses . . . etc.

Personally, I have learned from a Care Assistant how to put telemetry wiring through a hospital gown! The opportunity to learn from others of all disciplines is endless!

To Sum Up . . .

Acute inpatient rehab units offer a dynamic and valuable experience for new grad occupational therapists. The multitude of people from your patients to family members to other therapists to the medical staff that you interact and collaborate with daily provide you with a chance to flourish while developing your clinical skills. All settings have their ups and downs, and it’s important to note that this Challenges and Highlights list is not all-inclusive!

Interested in sharing your perspective or experience in acute inpatient rehab? Leave us a comment!

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Topics:acute careacute inpatient rehabapplying to OT jobsARUCareersFirst JobIRFpatientsRehabself-caresettings

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