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What does it mean for Physical Therapists, especially those in Acute Care Practice to be practicing to the Top of their Licenses?
Approach to the Patient in Case 3 – Heart Failure – PT 783
Sections Links
Complexity Variations
Heart failure is the number one cause of hospital readmissions among every chronic medical disease in the world.1
The most obvious reason for patient to be in the hospital is decompensation of heart failure and is manifested by the specific-type of heart-failure syndrome that is predominating in the patient.
Forward directed, or Systolic Heart Failure will have symptoms of Left-Heart Failure
Backward directed, or Diastolic Heart Failure will have symptoms of Right Heart Failure
End-Stage Heart Failure Patients
These patients will have severely exercise intolerance – this is NOT the same as PICS. These are patients whose heart is unable to tolerate exercise. The signs & symptoms of exercise intolerance is an inappropriate cardiac response to exercise. These patients require definitive management, either bridge-therapies, or destination therapies before they are candidate for rehabilitation.
During your examination use the classification schemes of NYHA Class of Functional Heart Failure, the (original) Borg Scale. or the RPE Scale to stratify the extent of aerobic deconditioning and this will serve the basis for outcomes assessment.
Pre-condition to Plan of Care
It appears extremely attractive to jump to the plan of care of a patient. However, the plan should be LAST thing to do, unless it is an emergency. There is a checklist of thoughts that need to be organized before we get to the intervention on a patient
It is not just customary, but to organize your thoughts on the condition of the patient. This organization is represented by your writing the examination & assessment of the patient. You should have a good understanding of how medical documentation (including physical therapy in acutely ill patients should flow, because this has to universally appreciated across your stakeholders, including your physician colleagues, as well as insurance providers, and other medical & non-medical personnel. I am listing a few resources to allow you to review organized documentation structures in medical documentation.
- University of California, San Diego – Writing Guidelines
- UNC School of Medicine – Examples of History & Physicals
The Summary Statement
The Summary Statement in an interpretative & executive summary – Defined as providing a concise summary statement that uses semantic vocabulary to highlight the most important elements from the history, exam, and testing and to interpret and represent the patient’s main problem.
- minimal to none
- some to many elements
- most or all elements
Following examples will highlight Summary Statements & Problem Lists that could be written by physical therapists for variations of patients presenting with Acute Myocardial Decompensated Failure. Where possible, I have included actual case reports that show more details than is included in the summary statement
Examples of Summary Statement – How You Write
Example 1 – Same as the Case 3
This is a 69 year-old male, who presented with symptoms of (type of heart failure), and was diagnosed as decompensated (left or right sided) heart failure (or, stated as systolic, or diastolic heart failure) with preserved ejection fraction (HFpEF). Ejection Fraction is 40%. Admitted for tailored inotropic therapy.
The overarching problems are:
- Impaired overall functional mobility due to generalized exercise intolerance due to reduced cardiovascular endurance
- Further impediments to mobility include significant water retention with distal symmetrical edema with significant short-term weight gain of 40 lbs.
- Unknown baseline exercise tolerance in terms of standardized outcome measures.
Discussion on example 1: Note the succinct but complete nature of the summary statement that rapidly summarizes with enough details to give a quick lead into the diagnostics of the case, and its problem list (relevant to your role in the case) without repeating any of the examination minutiae that exists only to inform your critical thinking & decision-making. Also note the semantic vocabulary. Vocabulary is important to show your maturity of thinking and expression.
Reference for this case:
Paul E H R, Camarda R, Foley LL, Givertz MM, Cahalin LP. Case report: exercise in a patient with acute decompensated heart failure receiving positive inotropic therapy. Cardiopulm Phys Ther J. 2011;22(2):13-8.
Example 2 Write-up
This is a 62 year old male who presents with:
a. Severe decompensated heart failure with pulmonary edema
b. Pulmonary edema secondary to global heart failure.
c. Left-sided pleural effusion – requires chest tube to water seal.
d. Severe shortness of breath with respiratory failure secondary to #a: Was put on BIPAP with poor response. Pt. was put on AVAPS and able to hold SaO2 in the high 80s and low 90s. (note to students: The links here in on BIPAP & AVAPS is for your curiosity but not relevant to this case. You may study it now, or just do a cursory glance, or avoid altogether. The advanced practitioner, the Cardiovascular & Pulmonary Rehab Resident, and the science of sleep apnea require an understanding of CPAP, BIPAP, and AVAPS).
e. Medical impression of poor prognosis, but may be candidate for circulatory assist device as a bridge or destination therapy.
Additional issues are per history & physical in the medical chart. From our standpoint, patient is has severe exercise intolerance due to impairment of cardiopulmonary endurance related to his cardiac issues; & respiratory failure due to above issues. His problem list from our standpoint:
- Impaired motor function – likely multifactorial, but cognition impairment while on vent, sedation, paralytic agents, all have major contributions.
- Inadequate lung expansion due to pleural effusion – Chest Tube to H20 Seal has been placed by CTS.
- Impaired oxygen exchange due to fluid retention and pulmonary edema.
- Impaired global functional activities (note to student: The word “global” would cover all functional activities. However, if you, or your clinical instructor want you to be specific, just break it down into bed mobility, transfers, gait, endurance).
PT Interventions in Case III – Patient with Heart Failure
PT Interventions will be relative to stage at which you find your patient.
Interventions for Example 1 above
In example 1 – the patient presented to you has an exacerbation of heart failure but is not end-stage. He can be medically re-compensated and can be expected to return home to near-baseline level of function, once treated.
While PT can be of help during this period, the focus is not so much physical rehabilitation, as much as it is supportive care and ultimate goal of sufficient ability to return home, and reduce the subsequent readmissions.
Tailor your exercise interventions according to the level of patient tolerance. Analyze what is the baseline level of function vs. what type of activity increase caused the decompensation. That is the main guide.
Problems:
- ROM Impairments & Compromised Skin Integrity
- Impaired peripheral circulation
- Risk of venous thromboembolism
- Impaired ability to maintain blood gases & respiratory acid-base balance
- Impaired global functional mobility
Goals: This is where you use relevant outcome measures – titrate to baseline performance
- Pressure Ulcer Prophylaxis
- Venous Thromboembolic Prophylaxis
- Independent in Bed Mobility by LOS (length of stay)
- Independent with Transfers by LOS
- Independent Gait for household distances by LOS
- Establish a 2-minute, or 6-minute walk-test baseline by discharge (if appropriate & feasible)
Monitor:
- Hemodynamics*
- Blood Pressure
- MAP > 65 mm Hg
- Medications
- Inotropic support
- Negative inotropes
- Other drugs
*References for Monitoring:
a. *Hemodynamics in critically ill – monitoring for cardiac output
b. Fundamentals of Critical Care – Hemodynamics, Monitoring, Shock
Perform:
- Positioning & ROM: Patient is not usually in ICU – can perform most of this by themselves – education should suffice with periodic follow ups.
- Skin Care – If skin is weeping or if there is need to provide support to certain body parts, e.g. swollen testicles at risk of breaking down, consider ways to off-load them from bed friction.
- General optimal breathing exercises using incentive spirometer
- Careful analysis of benefit vs. risk needs to be exercised for Circulatory Venous Thromboembolic Prophylactic Exercises. Risks: Significant circulatory exercises may increase venous return to heart and cause worsening of heart failure. The benefits are well understood.
- Bed mobility: Safe progression to sitting, and dangling the legs. Turning in bed may be difficult in scenarios where there is severe weight-gain due to water retention (bilateral swelling in legs; ascites)
- Transfers: Sit to stands & pivot to bedside chair. Try different height surfaces to get up/down from.
- Gait training: Initiate similar to transfers guidelines above. March-in-Place before progressing to full gait. Stay close to walls or furniture. Use DME as needed. Use daily outcome measures to evaluate progress made.
- Take note of, and educate on daily weight measurements, water restrictions, salt-restrictions per medical advice.
- Strengthening exercises – Helpful for overall fitness. Good support in literature. However, time of introduction of resistive training has to be carefully considered. Best for home & community based vs. Acute Care but can be done if you have all the logistics considered.
Interventions in Example 2 – End-stage Heart Failure
Consider that the patient who is on maximum cardiac inotropic support, but is still swollen, short-of-breath, and unable to ambulate 5 steps, even with oxygen support
Problems
- ROM Impairments & Compromised Skin Integrity
- Impaired peripheral circulation
- Risk of venous thromboembolism
- Impaired ability to maintain blood gases & respiratory acid-base balance
- Impaired global functional mobility
Goals
- Pressure Ulcer Prophylaxis
- Venous Thromboembolic Prophylaxis
- Independent in Bed Mobility by LOS (length of stay)
- Independent in Transfers by LOS (use same outcome measure as at evaluation)
- Independent in Gait over 80 meters or house-hold-distances using least restrictive device (use same outcome measure as at evaluation)
- Improve oxygenation as imposed by O2 Saturations > 92% (may be less if patient has COPD).
Monitoring:
- Arterial Blood Gas Report for Acid-Base Balance
- Amount of oxygen support needed – >50% FIO2 is usually worse.
- Fluid balance – is the total fluid output greater than the total fluid input (will be in the chart) – this indicates a negative fluid balance and is desirable)
- VADs – if patient transitions to VADs – you will need more experienced mentorship.
Perform:
- Positioning & ROM: If patient is ICU bound and unable to perform himself
- Pulmonary expansion exercises using incentive spirometer. Device may be provided by Respiratory Therapist but may not in which case, you can ask for one be given, or, if your center supports it, you can provide yourself. Generally secretions are not an issue with CHF Exacerbation – hence clearance techniques not needed.
- Circulatory Venous Thromboembolic Prophylactic Exercises must be instituted.
- Reversing Pulmonary Atelectasis exercises
- Bed mobility: As tolerated.
- Transfers: Sit to stands – Done when patients are hemodynamically stable and can stand with support.
- Gait training: Initiate similar to transfers guidelines above. Use daily outcome measures to evaluate progress made.
- Prior to discharge: Depending on the exact state of the patient, a 2-minute, or a 6-minute walk test may, or may not be feasible.
Additional Care Based on Medical Interventions
Pacemaker; Automatic Internal Cardiac Defibrillators; Life-Vest(R)
Educate Precautions
- no lifting of arms above shoulders for 3 weeks post-implantation
- no heavy exercise on side of the implantation
- Expectations of “kick-in-the-chest” if device fires
- Life-Vest(R) – specifically in this case, should the gel-pack release the gel, it will be visible due to spread of blue dye on clothing – caregivers should stand clear for delivery of shock
http://box5122.temp.domains/~sujoybos/home/courses/pt-783-cardiopulmonary-rehabilitation/rehabilitation-approach-to-the-patients-in-cases-presented-in-pt-783-class/monitoring-parameters-during-exercise/
Disposition
Options: Home vs. Inpatient Rehabilitation – Which one is appropriate?
Most Common Disposition is Home with family care and Outpatient Cardiac Rehabilitation.
If unable to achieve goals of independent functional mobility, option is usually inpatient rehabilitation.
The inpatient rehabilitation criteria are:
- If medically able to tolerate 3 hours of therapies between PT/OT
- Expectation of short-term stay with discharge home – usually 2 weeks; Rarely longer.
The Skilled Nursing Facility (Sub-acute Rehabilitation) option:
- Reserved for patients who would not tolerate 3 hours of combined therapies
- Patients who are more frail, and would likely need longer than 2-3 weeks of rehabilitative therapies
- Ultimate goal would still remain as discharge to home.
Durable Medical Equipment
The choice of DME is large and the decision may appear confusing. Among other things, do make sure to consider patient’s ability to pay for DME. These are not cheap, except for small items like canes ($10-15 at Walmart, or Drug Stores). Unlike healthcare that cannot be denied, DME certainly can be denied if no payment source. Do not promise DME without verifying payment source available.
- Walkers
- Wheelchairs
- Bedside Commodes
- Shower chairs & benches
- Oxygen – arranged by Respiratory Therapists on written prescriptions of Physicians
Decision-making with DME
Walkers Decision: Always best to have rolling walkers. A rolling walker decreases the workload by not having to pick-up and advance the device. Rollators make for the best option in patients with heart failure – it has 4 wheels, and a seat, often with a basket, that is helpful for various purposes.
Wheelchairs: Some patients will no longer be able to tolerate gait. One must think of wheelchair-level mobility for these patients.
These are covered by insurance. Exercise some analytical thought. A standard vs. a large wheelchair? (Often patients with advanced heart failure are also overweight or obese). Can the patient push the wheelchair themselves? If they cannot, do they have someone to always help? Can the patient be more functional AND be productive if they are independent in pushing the wheelchair by themselves? In such scenarios, a power wheelchair may be an option. However, analytical considerations in deciding a power wheelchair must ponder over life-expectancy. If patient is younger or has a chance at longer life-expectancy, then a power wheelchair expense makes sense. Be careful in promising equipment for which you cannot determine patient’s longevity, or, ability to pay for.
Bedside Commodes: There are many types. These are covered by insurance. Consider the types available (see the link – these will evolve over time as new kinds are engineered – so stay abreast of new equipment). A bedside commode (BSC) is best if they have removable buckets which then transforms into a raised toilet seat (RSC) that can be placed above a regular commode in the bathroom. There are BSCs with removable arm-rests if one would serve the cause better.
Shower Chairs: Shower chairs are NOT COVERED by insurance. Apparently, they are not considered “essential” items for life. These are not cheap either. One work-around is that a bath/transfer bench is ordered that is actually covered by insurance. With a transfer bench, a patient sits down on the bench outside of a bathtub, then swings legs over into the bathtub. Check the link for examples of Shower Chairs vs. Transfer Benches. Some patients will opt to buy shower-chairs out-of-pocket.
References
- Donzé Jacques, Lipsitz Stuart, Bates David W, Schnipper Jeffrey L. Causes and patterns of readmissions in patients with common comorbidities: retrospective cohort study BMJ2013; 347 :f7171 . Available at: https://www.bmj.com/content/347/bmj.f7171
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