Ch. 26 Hospital and Pediatric Rehabilitation Services PDF

Preview

Summary

Case-Smith's Occupational Therapy for Children (8th ed), Chapter 26 on Hospital and Pediatric Rehab...

Description

Ch. 26 Hospital and Pediatric Rehabilitation Services Sunday, November 22, 2020

Most often provided to children with medical, neurological, musculoskeletal disorders, and mental health Usually reluctant to hospitalize kids given potential for psychological reactions accompanying separation from home and family. Child life specialists who attend to child's emotional and developmental needs Currently hospital programs focus on acute-onset problems and provision of specialized services for children and adolescents with disabilities that are of low occurrence and high complexity - programs extend into community

Characteristics of Children's Hospitals General hospitals - serve the needs of community Trauma centers - organized and certified to treat life threatening injuries or disorders  Multiple specialists and organized to handle the evaluations and treatments that focus on lifesaving and sustaining procedures and prevent unnecessary complications Children's hospitals offer a full range of inpt and outpt services organized for infants, children, and adolescents with wide range of dx and rarely seen conditions

Regions Served Tend to serve broader geographic region than general hospitals Distance may affect the family's ability to visit the child and remain in contact with the health personnel Team must be sensitive to cultural beliefs and practices Hospital-based and community-based therapists coordinate the child's transition to home by access community resources and oupt and school programs

Missions of Children's Hospitals Advocacy for child health, research to improve clinical outcomes, and implementing a model for familycentered care Policies and programs to promote public health and health care reforms that enable pediatric health care coverage and research Table 26.1 - rehabilitation strategies contains examples of limitations and what to do

Research regarding systems and care outcomes Research types - assessing and reducing risks of care iatrogenic causes of ill-health and developing best practices and evidence for effective outcomes with specific clinical se rvices and safety measures OT participate in evaluation of clinical services and client outcomes and describe medical and functional effects, validity of assessment tools related to clinical decision-making and effectiveness of specific treatment approaches or techniques, most outcomes research relates to common diagnostic groups seen in such settings Difficult effectiveness is particularly difficult to conduct because of heterogeneity of participant and ethical conflicts encountered by suspending or withholding services

Family- and Child-Centered Care Families are designated as a member of the healthcare team and encouraged to take an active part in decision-making about treatments Use clear descriptions to communicate evaluation results to the family, seek input from the family, come to a mutually agreed-upon intervention plan, achieve a sense of control

Understand developmental issues of concern, suggest strategies to caregivers

Accrediting and Regulatory Agencies Such guidelines may include integrated planning with community-based services and continuous quality improvement procedures Employee education regarding safety practices, report any suspicion and contact community support services or CPS

Reimbursement for services Medicaid or special programs within a state and under some circumstances by Medicare Medicare guidelines are generally universal across different states however each state's medicaid rules and regulations and local insurance companies have differing provisions Families informed about service options Changes within and across treatment settings can be problematic often creating confusion within families about entitlements and expectations for services Clearly stated goals and time frames for outcomes in each care setting is desirable OT should be aware of payment limitations when providing care and clearly communicate with families when establishing tx plans and scope of services

OT services for children and youth within a hospital Acute care - ordered directly from a medical service or unity for immediate needs Pediatric rehabilitation services - located within a specific location of the hospital Outpatient services - both regularly scheduled specialty clinics

Focus of OT in Hospital Settings Focus is on ADLs and other instrumental tasks associated with independent living, education, community participation Use occupation-centered practice and info about function, tx priorities, and guide development of goals with family Focus on prevention of problems associated with illness, trauma, disability, then resumption of the able self and restoration of lost skills and functions using variety FOR

Evaluation OT services in hospital-based care are initiated through physician's orders and must respond to referral and negotiate as necessary to add elements to assessment Review of medical records and discussions Hypotheses about impairments and initiates intervention plans, use of clinical exam and standardized tests against normed scores for dx. But then judges scores against previous performance for reassessment Wee-FIM II - children ages 6 mo to 7 years - 18 tasks including communications, social cognition PEDI - 7 mo to 21 years - ADL, mobility, social function

Determining Intervention Goals Created by collaborating with families and with consideration for setting and therapeutic techniques being used Short-term goals as interim steps toward reaching long-term goals Functional goals include specification of skills and expected level of independence

ADL goals may describe how she or he will train and manage personal care assistants to achieve a selfmanaged dependence Interdependence among family members, use the term interreliance rather then dependence

Interventions Establish realistic priorities appropriate for the child's projected length of stay in the hospital - evaluation process is streamlined, goals prioritized, and discharge plans proposed at start of admission and initial evaluation Preventing secondary disability and restoring performance Primary prevention - term used to denote efforts that decrease the likelihood of accidents, violence, or disease for everyone Secondary or tertiary prevention refers to specific interventions, arrangement of care systems, and environmental modifications to prevent the onset of problems of at-risk populations Prevention measures: safety in positioning and movement, prevention of aspiration, provision of orientation Avoid involving child in activities that would be harmful and address neuromuscular and musculoskeletal complications by using programs based on biomechanical FOR  Designed to help the client maintain or regain normal ROM for daily activities  Slow stretch and joint mobilization, correct existing limitations by using a combo of these techniques and specialized positioning and splinting, orthoses  Progressive exercise and activity routines may be appropriate  Brain injury that causes upper motor neuron dysfunction muscle tone and voluntary motor control are focused on using sensorimotor techniques to promote postural stability , balance, visual motor skills, and FM performance  Prevent pressure sores, monitor skin  Compensate for disorientation and memory loss, orientation programs and memory books to ease burden of confusion  Inform the child of unit rules and post them

Resuming and Restoring occupational performance Resuming the use of available skills and independence in easily accomplished tasks Prevent learned helplessness - condition in which child stops engaging in activities that aversive and becomes dependent on other rather than trying to engage fully Negotiates foals Guided learning the occupational therapist uses instructional aids - visual supports, visual modeling, touch cues, or verbal instruction Promote restoration of lost skills and function using biomechanical, sensorimotor, perceptual cognitive, and rehabilitative approaches in various combinations to restore function Activities that selectively challenge an individual's skills

Adaptations for ADL skills Rehabilitative approach - compensatory techniques that use existing skills to restore occupational performance  Adapted routines, joint protection, work simplification  Reducing complexity, ensuring safety, minimize complications if errors occur  AT devices to increase safety or immediate function - choose ones that child is falilar with or with features compatible with needs

  

Memorize routine Gradually reduce extent of cues and aides and assistance Visit home to survey and collaborate with family

Documentation of Occupational Therapy Services Comply with insurance companies, made available to referring physicians Include evals, progress notes, tx plan, discharge summary

Scope of OT services Evaluates level of functioning, tx plan, and involves family in goals and objectives When children hospitalized for dx testing or adjustment of medications and experience compared to long stay - focus eval and tx planning that is then likely to transfer to community providers

Organization of Hospital-Based Services Acute care - short-term medical care provided during initial phase of illness or injury  Must consider long-term implications of the illness or injury while addressing the acute needs of the pt Intensive care, NICU, PICU Medical or surgical unit = tend to be designated for specific types of pts Special care unit requirements - acute burns, infectious diseases, bone marrow transplantation

Interprofessional Teams in Hospitals Dynamic, team might change, must redefine role of OT and develop an understanding of other team members' roles

Interprofessional team interaction Interdisciplinary/Interpro care is common and mandated by most regulatory mechanisms Ensure communication and clarification Weekly rounds to review progress of each child and discuss changes in tx plan Collaborative, team efforts, joint decisions OT and PT make decisions about positioning, seating, mobility OT and Nursing make decisions about ADLs Work with psychologist to provide suggestions for school placement Social workers address issues of adjustment and coping with the child and family

Families Challenged to adapt, must understand priorities and learning preferences, routines are altered Variations in styles influence effective coping - may need increased support, maintain collaborative relationship

Intensive Care Unit Services Often evaluated and treated at beside due to critical nature Precautions, implications, monitor vitals Impact of extended immobility includes contractures, generalized weakness with decreased endurance  Provide services to prevent secondary problems by using graded activities and soliciting the child's participation to maintain strength and enhance functional capabilities

  

Involve family members Positioning recommendations, orthotics to preserve ROM and prevent deformity Counteract effects of disorientation and sensory deprivation using routine and purposeful activities

General Acute care unit Tend to be designated by medical specialty and children usually more medically stable

Oncology and Bone Marrow Transplant Units Highly specialized, undergoing chemo or newly dx Develop relationship and see the child for both inpatient and outpatient therapy or coordinate care across services and with other medical interventions Bone marrow transplants are used as medical treatment protocol for illnesses

Oncology treatment Often hospitalized for induction chemo (initial course) to watch for complications Monitor nutrition and hydration Monitored between chemo and outpt visits Often at high risk for infections and susceptible to contagious diseases especially if neutropenic OT focus on prevention of secondary complications by implementing strengthening, ROM, endurance, and resuming ADLs or play

Palliative Care Respect cultural beliefs of family and grief processes Energy conservation techniques to enable the child to continue to play and interact Positioning as child develops increased weakness, difficulty with breath support, or pain Respect wishes of withdrawal or continuation of services Look at own support system and feelings around end of life issues

Transplant procedures, complications, and interventions Bone marrow transplant involves chemo or radiation before transplant and is followed by intravenous infusion of the bone marrow taken from a compatible donor or from the pt before the pretransplant regimen of chemo and radiation Hospital environment designed to reduce risk of infection Pretransplant assessment of child's development and functional abilities and limitations by dx goals to promote age appropriate play, daily living, social participation, coping and interaction skills, plan for follow up in community

Rehabilitation services Subacute rehab - organized within SNFs or long-term care settings  Designed for children or adolescents too fragile to be cared for at home but not yet able to engage in acute rehab  Therapy to prevent secondary complications and goals of greater independent function Acute rehabilitation - inpatient hospital units and services  Broad range of services  Meet three needs:

o



organize and implement a planned approach for the management of recovery and rehab of children post trauma or with rapid-onset disorders o Redirect care after onset of complications in children with chronic disorders o Provide an environment for specialized medical or surgical procedures that involves specific care regimens and protocols Most common admission - sudden illness or injury (TBI, SCI, CVA) o Cancer, guillian-barre, congenital or chronic disordrs o Those hospitalized for treatment with special medical, surgical, or technologic procedures ex. Dorsal rhizotomy - CP

Transition from Rehabilitation to the Community Team and family develop plan of transition as soon as discharge is considered Interagency meeting - school and rehab team represented Information with school-based therapists related to concerns and priorities  Accommodations and modifications Monitors progress after discharge

Outpatient services Many of these children are never hospitalized Focus on health status and development emphasizing functional progress and participation in community and home Programs may be scheduled weekly, monthly, quarterly, or annually as needed Provided for - dx assessment, needed intervention and AT after hospital discharge, provide OT for individuals not requiring hospitalization Specialty medical clinic usually have specific focus ex. Feeding or behavior AT clinics - how child may benefit from seating, mobility, AAC, computer use through trials leading to prescription of devices Residential or intensive day treatment programs  Focus on direct assistance with community reentry and participation  Simulated or actual environment - used for skills that enable community participation and effective performance towards goals...