c.ymcdn.com · o Garritan S, Jones P, Kornberg T, Parkin C. Laboratory values in the intensive care unit. Acute Care Perspectives . 1995;3(4):7-11

Academy of Acute Care Physical Therapy The Critical Edge www.acutept.org

Updated 2013

Academy of Acute Care Physical TherapyTask Force on Lab Values

2012 Members Roya Ghazinouri, Chair Samidha Deshmukh Sharon Gorman Angela Hauber Mary Krooh Elizabeth Moritz Babette Sanders Darrin Trees

2008 Members Holly McKenzie Dawn Piech Jim Smith

Approved by the Academy of Acute Care

Physical Therapy Board of Directors:

8/2008, 12/2011

LABVALUESINTERPRETATIONRESOURCES

LABVALUESRESOURCES 2013

2 | P a g e

It is the professional responsibility of the physical therapist to interpret available

laboratory values as a component of the examination and evaluation of a patient/client, to

suggest laboratory testing when indicated, and to use lab values to guide the

determination of safe and effective interventions for the patient/client. We, as physical

therapists, act as consultants in the rendering of our professional opinion and bear the

responsibility to advise the referring practitioner about the indications for physical

therapy intervention.

The Academy of Acute Care Physical Therapy created this referenced resource for members to

provide updated information and guide your inquiry into lab value interpretation. In this document

you will find the following:

Acute versus Chronic & Risk versus Benefit Considerations

Sex and Gender Considerations

Race and Culture Considerations

Tips for Collegial Discussions with Healthcare Providers

Peer Reviewed Resources

Websites

Search Engines

Updated Lab Values and Relevant Resources

Pulmonary Function Tests

Anticoagulation for Venous Thromboembolism

Recommended Reading List

Selected full-text articles

o Polich S. Competency based assessment in acute care: theory

behind the practice. Acute Care Perspectives. 2006;15(1):1-6.

o Garritan S, Jones P, Kornberg T, Parkin C. Laboratory values in

the intensive care unit. Acute Care Perspectives. 1995;3(4):7-11.

o Costello E, Elrod C, Tepper S. Clinical decision making in the

acute care environment: a survey of practicing clinicians. J Acute

Care Phys Ther. 2011;2(2):46-54.

DISCLAIMER: The Academy of Acute Care Physical Therapy has provided this information as a

resource to the membership. The Academy will not interpret lab values as this is the

professional responsibility of every clinician.


3 | P a g e

ACUTE VERSUS CHRONIC CONSIDERATIONS

In addition to reviewing the patient’s lab value and the given reference range, the

therapist should also consider the chronicity of the change in the lab value. Acute

changes, such as those associated with blood loss due to trauma or surgery, may require

the therapist to select a more conservative plan of care. Acute changes in lab values may

have more severe adverse events in patients due to the limited amount of time for the

patient’s system to compensate for this acute change. More chronic changes in lab

values, commonly associated with chronic conditions (e.g., CHF, COPD) or longer term

medical interventions (e.g., chemotherapy, radiation therapy) allow the patient a period of

time for their body to adapt or attempt to adapt to the changes in lab values, which may

allow them to have more resources to deal with potential adverse events caused by

increasing cardiorespiratory demand, mobility, and exercise.

RISK VERSUS BENEFIT CONSIDERATIONS

The fundamental consideration when evaluating lab values to determine appropriate

physical therapy plan of care revolves around the risk to the patient posed by proceeding

with intervention versus the benefits gained by the intervention. The therapist should

carefully consider all the potential adverse events that may present during intervention

based on the lab values out of the reference range, and consider the elevated risk should a

value fall in the critical range. Understanding of the lab test in question and the potential

adverse events is critical to this aspect of patient care. Likewise, the therapist should

consider the potential benefits of increased mobility and exercise that proceeding with the

intervention may provide to the patient. Not only should the immediate risks and benefits

of the therapy session in question be considered, but also the longer term risks and

benefits over the episode of care that may be present. Often it may be that the therapist

will need to consult with other members of the medical team to fully explore the risk

versus benefits of physical therapy intervention, and assist with the development of

facility policies, procedures, and/or protocols to assist in clinical decision making

regarding the use of lab values in determining aggressiveness of physical therapy

intervention.


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SEX AND GENDER CONSIDERATIONS

Many lab results will have reference ranges reported as age-specific or sex-specific

values. With regards to interpretation of these reference ranges regarding sex-specific

norms, the therapist needs to consider the patient’s biological sex, gender, and gender

identity to avoid referencing the incorrect ‘normal’ value. A review of the differences of

these terms is provided in Table 1.

Table 1. Definitions pertaining to sex and gender roles.1

Term Definition

Sex Categorical differentiation between men and

women, assigned at birth based on brief visual

examination of external genitalia

Gender Binary social construct involving characteristics

distinguishing men from women

Gender

Identity

Person’s sense of being male or female

Transsexual Outdated term for person who feels they were

assigned the incorrect sex

Transgender Overarching term for persons with various

identities and expressions that are associated with

assignment of incorrect sex

Transition Legal, medical, and surgical processes that a

transsexual person may go through to correct the

incongruence of incorrect sexual assignment

Transwoman A person who identifies as female but was assigned

the male sex

Transman A person who identifies as male but was assigned

the female sex

Individual patients may be in the process of transitioning to their preferred gender

through medical (i.e., hormone replacement therapy), surgical (i.e., gender reassignment

surgery), and/or legal (i.e., amending legal documents to reflect gender identity) means to

correct incongruence of sex. Therapists should determine if patients in transition are

currently under treatment for medical transition, which may occur prior to or in

conjunction with surgical transition, and will be continued after surgical transition. If the

patient is on hormone replacement therapy, you should use the transitioned gender to

determine the reference value. If the patient is not receiving hormone therapy, you

should use their biological sex to determine the reference value. For example, a

transwomen on estrogen replacement therapy should have their lab values compared to

normal values of females due to the effects of estrogen on their physiology, whereas a

transman on testosterone should have their lab values compared to those of males due to

the effects of testosterone on their physiology. The key factor is not whether the medical

record assigns the patient a particular sex nor if the patient has undergone sexual

reassignment surgery, but whether they are taking hormone therapy that will affect their


5 | P a g e

physiology and lab chemistry. Knowing the medical transition status of a transsexual

person can result in avoidance of misinterpretation of lab values and ensure correct

application of normal reference values consistently.

Reference

1. Polly R, Nicole J. Understanding the transsexual patient: culturally sensitive care

in emergency nursing practice. Adv Emergency Nurs J. 2011;33(1):55-64.


6 | P a g e

RACE AND CULTURE CONSIDERATIONS

Census 2010 indicated increased minority demographic shifts in the United States.

1

McClatchey noted that “genetic heterogeneity within a population leads to person-to-

person phenotypic differences that can contribute to the variability in laboratory test

results.”2(p101)

In addition, due to culture and food preferences, it is not possible to

determine whether racial differences in laboratory values are genetic or related to lifestyle

alone (e.g., cholesterol).3 Therefore, physical therapists should be mindful of racial

differences in laboratory values and recognize that racial differences are not easily

conclusive because it is often difficult to separate effects of race per se from those of

other factors.

Genetic heterogeneity at the molecular level can lead to differences in the reactivity of a

patient’s DNA, proteins, or cells toward the nucleic acid probes and antibodies that are

used as reagents in many diagnostic tests.2 This type of genetic heterogeneity can result

in false-negative findings. Genetic variability will become an increasing consideration

for development of tests and analyzing test results as the field of clinical laboratory

medicine progresses.

In the United States, African Americans tend to have increased muscle mass and skeletal

structures than their Caucasian counterparts. Therefore, racial differences in serum levels

of creatine kinase and lactate dehydrogenase in adults and in serum alkaline phosphatase

in children are noted. African Americans also tend to have higher serum total protein

levels and higher serum levels of alpha, beta, and gamma globulins, IgG, and IgA than

Caucasians.2

There is a difference in hemoglobin (Hgb) values with African Americans having lower

hemoglobin compared to Caucasians.3 In addition, HgbA1c (A1C) lab values can be

altered in patients with sickle hemoglobin, which is present in 8% of the African

American population.4 Other studies have noted white-black differences in mean

hematocrit (Hct) readings that decreased over time due to quality of care rendered during

the onset of end stage renal disease regardless of socioeconomic status.5

Cultural competence is a non-negotiable skill, subject to rigorous testing similar to any

other core component of the physical therapy profession.6 Leavitt posits “future research

stands to provide a wealth of knowledge on the link between genetics and disparities in

health, but the differences remain to be seen.”7(p109)

Therefore, physical therapists must

consider racial variations in laboratory values in order for culturally competence care.

References

1. US Census Bureau. 2010 census shows America’s diversity. Available at:

http://www.census.gov/newsroom/releases/archives/2010_census/cb11-

cn125.html. Updated August 26, 2011. Accessed October 30, 2011.

2. McClatchey KD. Clinical Laboratory Medicine. 2nd ed. Philadelphia, PA:

Lippincott Williams & Wilkins;2002.


7 | P a g e

3. Overfield T. Biological Variation in Health and Illness: Race, Age, and Sex

Differences. 2nd ed. Boca Raton, FL:CRC Press;1995.

4. Hart CB. Race differences in long term management of diabetes in an HMO.

Response to Adams et al. Diabetes Care. 2006;29(6):1461.

5. Ward MM. Laboratory abnormalities at the onset of treatment of end-stage renal

disease. Are there racial or socioeconomic disparities in care? Arch Intern Med.

2007;167(10):1083-1091.

6. Purtilo RB. Thirty-First Mary McMillan Lecture: a time to harvest, a time to sow:

ethics for a shifting landscape. Phys Ther. 2000;80(11):1112–1119.

7. Leavitt RL. Cultural Competence: A Lifelong Journey to Cultural Proficiency.

Thorofare, NJ: Slack; 2010.


8 | P a g e

TIPS FOR COLLEGIAL DISCUSSIONS WITH HEALTHCARE

PROVIDERS

General guidelines

Do your research prior to approaching the healthcare provider.

Give them a copy of the research/evidence and ask to discuss the article

later in the day in a diplomatic way.

Follow up with them and be open minded.

Listen! Then follow up with your point, concern, or idea and cite your

resources.

KISS Principle:1

Keep

It

Short and

Simple

SBAR Communication Technique2

Situation: introduce yourself; succinctly and briefly explain the situation

Background: pertinent patient history; what preceded this point?

Assessment: summarize facts; what is going on in your judgment?

Recommendation: what do you want to happen next; what are you asking for?

References

1. KISS Principle. Wikipedia: the free encyclopedia. Available at:

http://en.wikipedia.org/wiki/KISS_principle. Updated September 27, 2011.

Accessed on September 29, 2011.

2. Institute for Healthcare Improvement: SBAR. Institute for Healthcare

Improvement. Available at:

http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationA

SituationalBriefingModel.aspx. Accessed on September 29, 2011.


9 | P a g e

PEER REVIEWED RESOURCES

NOTE: Past Acute Care Perspective and Journal of Acute Care Physical Therapy articles

may be purchased through the Academy of Acute Care Physical Therapy’s website at www.acutept.org/.

1. Hergenroeder A. Implementation of a competency-based assessment for

interpretation of laboratory values. Acute Care Perspectives. 2006;15(1):7-15.

2. Paz JC, West M. Acute Care Handbook for Physical Therapists. 3rd ed. Boston,

MA: Butterworth-Heinemann; 2008.

3. Malone D, Lindsay, K. Physical Therapy in Acute Care: A Clinician's Guide.

Thorofare, NJ: Slack; 2006.

4. Pagana, K, Pagana T. Mosby's Rapid Reference to Diagnostic & Laboratory

Tests. St. Louis, MO: Mosby; 2000.

5. Wallach J. Interpretation of Diagnostic Tests. 9th ed. Philadelphia, PA: Lippincott

Williams & Wilkins; 2011.

6. Fischbach F. Nurses' Quick Reference to Common Laboratory & Diagnostic

Tests. 5thed. Philadelphia, PA: Lippincott, Williams & Wilkins;2010.

7. Stiller K. Safety issues that should be considered when mobilizing critically ill

patients. Crit Care Clin. 2007;23(1):35-53.

8. Irion G. Lab values update. Acute Care Perspectives. 2004;13(1):1,3-5.

9. Garritan S, Jones P, Kornberg T, Parkin C. Laboratory values in the intensive care

unit. Acute Care Perspectives. 1995;3(4):7-11.

10. Deska K, Pagana T. Mosby Diagnostic and Laboratory Test Reference. 10th ed.

St. Louis, MO: Mosby; 2011.

11. Polich S. Competency based assessment in acute care: theory behind the practice.

Acute Care Perspectives. 2006;15(1):1-6.

12. Goodman CC, Boissonnault WG, Fuller KS. Pathology: Implications for the

Physical Therapist. 3rd ed. Philadelphia, PA: Saunders; 2008.

13. Hillegass E. Essentials of Cardiopulmonary Physical Therapy. 3rd ed.

Philadelphia, PA: Saunders; 2010.

14. Polly R, Nicole J. Understanding the transsexual patient: culturally sensitive care

in emergency nursing practice. Adv Emergency Nurs J. 2011;33(1):55-64.

15. Hanekom S, Gosselink R, Dean E, et al. The development of a clinical

management algorithm for early physical activity and mobilization of critically ill

patients: synthesis of evidence and expert opinion and its translation into practice.

Clin Rehabil. 2011;25(9):771-787.

16. Costello E, Elrod C, Tepper S. Clinical decision making in the acute care

environment: a survey of practicing clinicians. J Acute Care Phys Ther.

2011;2(2):46-54.

17. Gorman SL, Wruble Hakim E, Johnson W, et al. Nationwide acute care physical

therapy practice analysis identifies knowledge, skills, and behaviors that reflect

acute care practice. Phys Ther. 2010;90(10):1453–1467.

18. Masley PM, Havrilko C-L, Mahnensmith MR, et al. Physical therapist practice in

the acute care setting: a qualitative study. Phys Ther. 2011;91(6):906-919.


10 | P a g e

WEBSITES

1. Lab Tests Online: Understanding Your Tests page. American Association for

Clinical Chemistry Web site. Available at:

http://www.labtestsonline.org/understanding/index.htm. Accessed Sept 19, 2011.

Lab values, tests, and interpretation website that you can look up tests by name,

abbreviation, or by diagnosis. Peer-reviewed and non-commercial.

2. Medical Procedures and Tests, MedicineNet.com webpage. Available at:

http://www.medicinenet.com/procedures_and_tests/article.htm. Accessed Sept 19,

2011.

Part of the WebMD network, this page allows you to search for specific

information by test name. Peer and/or medical edited and content is not related to

commercial advertising on the site.

3. Interpretation of Lab Test Profiles page. Ed Uthman’s Web page. Available at:

http://web2.airmail.net/uthman/lab_test.html. Accessed Sept 19, 2011.

Site reference by the College of American Pathologists. Referenced and peer

edited.

4. Academy of Acute Care Physical Therapy website.

Available at: http://www.acutept.org. Accessed Sept 20, 2011.

Access to the peer-reviewed Journal of Acute Care Physical Therapy, practice

resources, and other information pertinent to acute care physical therapy practice.


11 | P a g e

SEARCH ENGINES

1. PubMed: A service of the U.S. National Library of Medicine and the National

Institutes of Health.

http://www.ncbi.nlm.nih.gov/pubmed/

2. Hooked on Evidence: APTA’s online database contains current research

evidence on the effectiveness of physical therapy interventions. APTA Members

only service.

http://www.hookedonevidence.org/

3. PEDro: Centre for Evidence-Based Physiotherapy’s website containing clinical

trial literature specific to physical therapy. Supported by numerous international

physical therapy associations.

http://www.pedro.fhs.usyd.edu.au/

4. Open Door: APTA’s research portal gives members free access to full-text

articles in more than 1,200 health care journals and periodicals. APTA Member

Only service.

http://www.apta.org/OpenDoor/

The following are databases on Open Door:

ProQuest Health & Medical Complete and ProQuest Nursing Journals

These databases serve the whole spectrum of users looking for

healthcare information — allied health, medical, and nursing

professionals; planners, administrators, and other researchers in

healthcare business and finance. Searchers have access to more than

1,000 publications in complete text and images. Search both

collections to maximize your results.

Cochrane Library

The Cochrane Library is a collection of databases that contain high-

quality, independent evidence to inform healthcare decision-making.

Cochrane reviews represent a high level of evidence on which to base

clinical treatment decisions. The Cochrane Database of Systematic

Reviews (CDSR) contains the full text of regularly updated systematic

reviews and protocols for reviews of the effects of healthcare. The

Database of Abstracts of Reviews of Effects (DARE) contains

structured abstracts of critical assessments of systematic reviews from

a variety of medical journals. The Cochrane Central Register of

Controlled Trials (CENTRAL) is a database of more than 350,000

abstracts of definitive randomized controlled trials and controlled

clinical trials from around the globe. Search them separately or

combined with the Cumulative Index to Nursing and Allied Health

Literature® (CINAHL®).


12 | P a g e

Cumulative Index to Nursing and Allied Health Literature®

(CINAHL®)

CINAHL® is the premier database for bibliographic information about

nursing and allied health research literature and topics. It indexes more

than 2,800 journals and other periodicals from the fields of nursing and

17 allied health disciplines. The database contains more than

1,000,000 abstract records dating back to 1982. Search CINAHL®

separately or combined with the Cochrane databases.


13 | P a g e

UPDATED LAB VALUES AND RELEVANT REFERENCES

These updated values are current as of 2011, and should be referenced as an addendum to

the following article included in this resource:

Garritan S, Jones P, Kornberg T, Parkin C. Laboratory values in the intensive care


Values documented in

article

Updated values References for updated

values Creatinine Phospho - Kinase

(CPK) 25-225microL/L

30-170 U/L Porter RS, ed. The Merck Manual

of Diagnosis and Therapy. 19th

ed. Rahway, NJ: Merck;2011.

CPK-MB begins to rise at 2-4

hours, peaks in 12-24 hours and

returns to normal within 24-48

hours

CPK-MB begins to rise at 4-6

hours, peaks in 12-24 hours and

returns to normal within 48-72

hours

Fischbach F. A Manual of

Laboratory and Diagnostic Tests.

7th ed. Philadelphia, PA:

Lippincott Williams &

Wilkins;2004.

O2 sat: 95%-98% > 94% Porter RS, ed. The Merck Manual



Partial pressure of oxygen in

arterial blood, PaO2: 80-100mm

Hg

> 80 mm Hg Porter RS, ed. The Merck Manual



Adult male Red blood cells,

(RBCs): 4.7-5.5 x 104/microL

25-35 mL/kg Porter RS, ed. The Merck Manual



Adult male hematocrit (Hct): 43-

49%

41-51% Porter RS, ed. The Merck Manual



Adult male hemoglobin(Hgb):

14.4-16.6 Gm/dL

14-17Gm/dL Porter RS, ed. The Merck Manual



Adult female white blood cells

(WBCs): 4,500-11,000 cells/mm3

3.9-10.7 x 103 Porter RS, ed. The Merck Manual



Adult female RBCs: 4.1-4.9 x 104 20-30 mL/kg Porter RS, ed. The Merck Manual



Adult female Hct: 38-44% 36-47% Porter RS, ed. The Merck Manual



Adult female Hgb: 14-17 Gm/dL 12-16Gm/dL Porter RS, ed. The Merck Manual



1. Hct < 25%-No exercise

permitted

1. Hct < 25%: essential

activities of daily living,

assistance as needed for

safety

DeVita, VT, Hellman S,

Rosenberg SA, eds. Cancer:

Principles and Practice of

Oncology. 7th ed. Philadelphia,

PA: Lippincott Williams &

Wilkins;2005.


14 | P a g e

2. Hct > 25%-Light exercise

permitted†

3. Approximately 30-32%-add

resistive exercise as

permitted†

2. Hct < 25-35%: essential

activities of daily living;


safety; light aerobics, light

weights (1-2 lbs) †

3. Hct > 35%, Ambulation and

self care as tolerated;

resistance and aerobic

exercises†






Wilkins;2005.

1. Hgb <8- No exercise

permitted

2. Hgb:8-10-light exercise

permitted†

3. Hgb >10-resistive exercise

permitted†

1. Hgb < 8gm/dL: essential

daily activities*

2. Hgb < 8-10gm/dL: Essential

activities of daily living,


safety; light aerobics, light

weights (1-2lbs)* †

3. Hgb > 8gm/dL, Ambulation

and self care as tolerated;

resistance exercises*†






Wilkins;2005.

1. Platelets (PLT) < 20,000: No

exercise

2. PLT: 20,000-50,000: Light

exercise (No PROM, but

light AROM is permitted)

3. PLT > 50,000: Resistive

AROM is permitted

1. PLT < 10,000 and /or

temperature > 100.5 degrees:

No therapeutic exercise/Hold

therapy

2. PLT: 10,000-20,000:

Therapeutic exercise/bike

without resistance

3. PLT > 20,000: Therapeutic

exercise/bike with or without

resistance

Samuelson K. Standard of care:

hematopoietic stem cell

transplant (HSCT) in-patient

phase. 2010; Brigham and

Women’s Hospital,

Rehabilitation Services.

* Recommendations for transfusion highly influence these recommendations and values,

and vary dependent on the cause of blood loss (e.g., trauma vs. perioperative) and other

comorbidities (e.g., chemotherapy, hypoxia). Interpret these values in conjunction with

the possibility of blood transfusion.

Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G.

Recommendations for the transfusion of red blood cells. Blood Transfus.

2009;7(1):49-64.

† Updated for clarification 3/2013.


15 | P a g e

PULMONARY FUNCTION TESTS

Pulmonary function tests (PFTs): This is a group of tests which help to determine the

presence, nature, and extent of pulmonary dysfunction caused by conditions which cause

obstructive, restrictive, or mixed ventilatory defects. The ventilatory defect resulting from

increase in airway resistance is called an obstructive ventilatory impairment. When

ventilation is disturbed by a limitation in chest wall excursion, the defect is referred to as

a restrictive ventilatory impairment. When ventilation is altered by both increased airway

resistance and limited chest wall excursion, the defect is termed a combined or mixed

defect.

TYPES OF VENTILATORY

IMPAIRMENTS

COMMON EXAMPLES

Obstructive ventilatory impairment Chronic obstructive pulmonary disease (COPD)

Restrictive ventilatory impairment Fibrosis

Mixed ventilatory defect Pulmonary congestion

*Predicted values are based on the individual’s age, gender, ethnicity, height, and body size.

TYPES OF PFTS

TERMS (UNITS) OF

MEASUREMENTS

NORMAL

VALUES

FOR

MALE

(Liters)*

NORMAL

VALUES

FOR

FEMALE

(Liters)*

Airway flow rates:

Measure instantaneous or average

airflow rates during a maximal

forced exhalation to assess airway

patency and resistance

Inspiratory reserve volume (IRV)

Tidal volume (Vt)

Expiratory reserve volume (ERV)

Residual volume (RV)

IRV = 3.3

Vt = 0.5

ERV = 1.0

RV = 1.2

IRV = 1.9

Vt = 0.5

ERV = 0.7

RV = 1.1

Lung volumes and capacities:

Measure the various air-containing

compartments of the lung to assess

hyperinflation or reduction in

volume

Vital capacity (VC)

Inspiratory capacity (IC) = IRV + TV

Functional residual capacity (FRC) =

ERV + RV

Total lung capacity (TLC) = IRV +

ERV + RV

VC = 4.8

IC = 3.8

FRC = 2.2

TLC = 6.0

VC = 3.1

IC = 2.4

FRC = 1.8

TLC = 4.2

Gas exchange:

Measures the rate of gas transfer

across the alveolar capillary

membranes to assess the diffusion

process

Forced vital capacity (FVC)

Forced expiratory volume at the end

of a given time (t) in seconds (FEVt)

FEV1= FEVt at the end of 1

second


seconds


seconds

FVC >80% or > 0.80 of Predicted

value*

FEV1, 80%–85% of FVC



FEV1/FVC ratio is expressed as a

percentage


16 | P a g e

Spirograms and Flow Volume Curves: This is a graphical representation of spirometry

data.

FIGURE 1. Spirograms and flow volume curves. (A) Restrictive ventilatory defect. (B)

Normal spirogram. (C) Obstructive ventilatory defect.6

This figure is used with permission and was published in Textbook of Respiratory Medicine, 3rd

edition, Murray JF, Nadel JA, page 805. Copyright Elsevier 2000.

Steps for Spirometry data interpretation:

1. Assess and comment on the quality of test. The American Thoracic Society (ATS)

have published standard guidelines for clinically acceptable spirometry tests for the

purpose of minimizing the variability in the tests and for increasing data accuracy.

These guidelines are used for assessing the quality of a spirometry test.

2. Once the quality of the tests is confirmed, assess FVC, FEV1 and absolute

FEV1/FVC ratio and interpret using the following table:

FVC

FEV1

Absolute ratio

(FEV1/FVC) %

RESULT

Decreased Decreased or normal = or > 70% Restrictive ventilatory impairment

Decreased or normal Decreased < 70% Obstructive ventilatory

impairment

Normal Normal > 70% Normal spirometry


17 | P a g e

3. Once the type of pulmonary disease is identified severity of disease can be determined

by using the following guidelines:

SEVERITY OF DISEASE ABSOLUTE RATIO (FEV1/FVC)

Normal PFT Outcomes > 100 % of predicted values

Mild Disease 70-100% of predicted values

Moderate Disease 60-70 % of predicted values

Moderately severe Disease 50-60% of predicted values

Severe Disease < 50 % of predicted values

Consideration for Physical Therapy:

PFTs are an important diagnostic tool for identifying and assessing the severity of

pulmonary dysfunctions

Results will facilitate and help guide physical therapy interventions

References

1. Barreiro T. An approach to interpreting spirometry. Am Fam Physician.

2004;69(5):1107-1115.

2. Barrett KE, Barman SM, Boitano S, Brooks HL. Ganong’s Review of Medical

Physiology. 23rd ed. New York, NY:McGraw-Hill Medical;2009.

3. Crapo JD, Glassroth J, Karlinsky JB, King TE. Baum’s Textbook of Pulmonary

Diseases. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2004

4. Fischbach F. A Manual of Laboratory and Diagnostic Tests. 7th ed. Philadelphia,

PA: Lippincott Williams & Wilkins;2004

5. Murray JF, Nadel JA. Textbook of Respiratory Medicine. 3rd ed. Philadelphia,

PA: Saunders;2000:805.

6. Standardization of spirometry-1987 update. Statement of the American Thoracic

Society. Am Rev Respir Dis. 1987;136(5):1285-1298.

7. McCarthy K. Pulmonary Function Testing. Medscape Reference. Available at:

http://emedicine.medscape.com/article/303239-overview. Updated June 7, 2011.

Accessed September 29, 2011.


18 | P a g e

Anticoagulation Therapy for Venous Thromboembolism Medications Alternate

Names

Mode of

Administration

Lab Value

(reference

range)

Therapeutic

Range

When is a

patient safe

to mobilize?

Considerations Precautions

Warfarin Coumadin

Jantoven

Marfarin

Orally (PO)1 INR

(.9-1.1)

2.0-3.0

(achieved in 2-5

days)2

When in

therapeutic range

If not in therapeutic

range, check to see

if the patient is

therapeutic on other

anticoagulants (e.g.

unfractionated

heparin)

Increased risk of bleeding if

supratherapeutic

Unfractionated

Heparin

Subcutaneous

injection

IV infusion

(continuous)2

PTT

(23.8-36.6

seconds)

PTT of 2 to 3 times

the upper limit of

normal;

approximately 60 to

80 seconds or a

weight based

protocol3

When in

therapeutic range

Contact medical

team if specific

PTT goal range is

not documented

Increased risk of bleeding if PTT is

greater than specified therapeutic range

Potential complication: heparin-induced

thrombocytopenia6

Low molecular

weight Heparin

(LMWH)

Enoxaparin

Dalteparin

Tinzeparin

Lovenox

Fragmin

Innohep

Subcutaneous

injection2

Anti-factor Xa can

be measured to

determine

therapeutic range,

but it is not

routinely measured3

Patient considered

therapeutic 3-5

hours after 1st

injection4

3-5 hours after 1st

injection

administered

Potential complication: heparin-induced

thrombocytopenia6

Fondaparinux

Arixtra

Subcutaneous

injection3

Does not require

monitoring3

Peak

anticoagulation:

1.7 hours after 1st

injection5

Once patient has

reached peak

anticoagulation

Commonly used in

patients with

heparin induced

thrombocytopenia7

Contraindicated in patients with severe

renal impairment; cleared renally3


19 | P a g e

References

1. Warfarin. National Center for Biotechnology Information. U.S. National Library

of Medicine. Available at: www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000634.

Updated September 1, 2008. Accessed September 21, 2011.

2. A Patient’s Guide to Antithrombotic and Thrombolytic Therapy: Comprehensive

Guide .American College of Chest Physicians. Available at:

http://accpstorage.org/newOrganization/patients/AT8/AT8ComprehensiveGuideP

atient.pdf. Accessed September 21, 2011.

3. Partners Handbook: Venous Thromboembolism Guidebook 5th

Edition. Brigham

and Women’s Hospital. Available at:

http://handbook.partners.org/template.aspx?uniqueID=38&pageName=Venous+T

hromboembolism+Guidebook+5th+Edition&level1ID=92. Accessed September

21, 2011.

4. Costello E, Elrod C, Tepper S. Clinical decision making in the acute care


2011;2(2):46-54.

5. Bauer K. Therapeutic Use of Fondaparinux. UpToDate. Available at:

http://www.uptodate.com/contents/therapeutic-use-of-fondaparinux. Published

January 31, 2011. Updated May 2011. Accessed September 21, 2011.

6. Coutre S. Heparin-induced Thrombocytopenia. UpToDate. Available at:

http://www.uptodate.com/contents/heparin-

inducedthrombocytopenia?source=search_result&search=heparin&selectedTitle=

6%7E150. Updated June 9, 2011. Accessed September 21, 2011.

7. Kim ESH, Bartholomew JR. Venous thromboembolism. Cleveland Clinic

Foundation. Available at:

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiolo

gy/venous-thromboembolism/#bib42#bib42. Accessed October 11, 2011.


20 | P a g e

RECOMMENDED READING

Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for

Clinicians II (HOAC II): a guide for patient management. Phys Ther.

2003;83(5):455-470.

Atkinson HL, Nixon-Cave K. A tool for clinical reasoning and reflection using

the International Classification of Functioning, Disability and Health (ICF)

framework and patient management model. Phys Ther. 2011;91(3):416-430.

Included in this resource are copies of the following:

Polich S. Competency based assessment in acute care: theory behind the practice.

Acute Care Perspectives. 2006;15(1):1-6.

Garritan S, Jones P, Kornberg T, Parkin C. Laboratory values in the intensive care


NOTE: Updated values as of 2011 to supplement this article are located in

this resource under “Updated Lab Values and Relevant Resources.”

Costello E, Elrod C, Tepper S. Clinical decision making in the acute care


2011;2(2):46-54.

Acute Care Perspectives Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.org

Acute Care Perspectives Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy

www.acutept.com

www.acutept.org

Acute Care Perspectives www.acutept.com

Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy

Acute Care Perspectives www.acutept.com

Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy

Acute Care Perspectives Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

Academy

Academythe Academy

Academy

Academy membership.

Acute Care Perspectives 95/4/7-11 Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

Acute Care Perspectives 95/4/7 11 Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

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Acute Care Perspectives 95/4/711 Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

Acute Care Perspectives 95/4/7-11 Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

Acute Care Perspectives 95/4/7 -11 Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

Acute Care Perspectives 95/4/7 -11 Reprint permission granted courtesy of the Academy of Acute Care Physical Therapy www.acutept.com

Academy of Acute Care PhysicalTherapy


Academy

Summer 2011 ● Volume 2 ● Number 2JACPT

46

Clinical Decision Making in

the Acute Care Environment:

A Survey of Practicing

Clinicians

Ellen Costello, PT, PhD is Assistant

Professor, Program in Physical Therapy

at the George Washington University

900 23rd St, 6155, NW, Washington,

DC 20037 (Correspondence Address)

Dr. Elrod, PT, PhD is an Associate

Professor, Program in Physical

Therapy, Marymount University, 2807

North Glebe Rd, Arlington, VA 22207

Dr. Tepper, PT, PhD is President of

Rehab Essentials, Monkton, MD 21111

Ellen Costello, Cathy Elrod, Steven Tepper

ABSTRACT

Purpose: To investigate current practice trends in the acute care setting

using a case-based clinical decision-making survey to clarify when exercise

or ADL training would be contraindicated.

Methods: Acute care and cardiovascular and pulmonary section members

participated in an 8-question clinical decision-making survey. Choices

included decisions “to treat” or “not to treat” based on information

provided. Additional comments were analyzed. Demographic information

was also collected.

Results: 356 PTs responded to the survey (18% response rate). Number of

correct responses was calculated per case. Responses were also analyzed

by educational training and years of experience. Respondents chose the

optimal treatment choice more than 80% of the time in five of eight cases.

Mean scores ranged from 4.85 for bachelors-trained therapists with less

experience, to 6.76 for doctorally-trained therapists with greater experience.

A two-way ANOVA indicated a significant main effect for educational

training and years of experience and also a significant interaction (p=.017).

Incorrect responses in one of the eight cases appeared to be related to

therapists using outdated information or institutional guidelines.

Conclusions: Section members appear to be utilizing current evidence

to support their clinical decision making process. Respondents with more

experience, and those who continued their professional education were

more likely to choose the optimal treatment strategy.

Key Words: acute care, clinical decision making, exercise, clinical

experience

RESEARCH

REPORT© 2011 All rights reserved. Reproduction in whole or in part by permission only.Academy of Acute Care Physical Therapy

Summer 2011 ● Volume 2 ● Number 2 JACPT47

Clinical Decision Making in the Acute Care Environment: A Survey of Practicing Clinicians

A primary purpose of physical

therapist practice is to enhance human

performance as it relates to movement

and health. Physical therapists analyze

impairments, identify deficits in activities

and participation and provide safe,

effective, and efficient interventions in

order to restore patient/client function.1

As a complex interaction of systems

permits a patient/client to perform

activities of daily living (ADL), physical

therapists draw upon multiple domains

of knowledge when examining the

client’s ability to pursue and perform

goal-directed and personally desired

tasks.

A challenge for physical therapists is to

accurately synthesize and interpret the

diverse data surrounding the client’s

presentation to determine whether

participation in therapeutic exercise

or functional tasks would potentially

result in harm. During the evaluative

process, various factors influence the

therapist’s clinical reasoning. These

factors include the clinical setting and

available resources, the patient’s age,

medical diagnosis, signs and symptoms,

and health beliefs, and the therapist’s

knowledge, expertise, values, and use

of evidence and established guidelines.2,

3 A variety of formal guidelines are

available to assist physical therapists

in determining when formal exercise

testing would be contraindicated or

when a graded exercise test should

be terminated.4, 5 However, guidelines

to address absolute or relative

contraindications for participating in

activities of daily living or therapeutic

exercise as part of a physical therapy

plan of care are often inferred or

nonexistent.

PURPOSE

The purpose of this study was to

determine factors related to the ability

of clinicians to choose the optimal

course of action when presented with

scenarios that might require withholding

or terminating therapeutic intervention.

Clinicians were asked whether they

would treat or not treat a patient, or

whether they would terminate the

physical therapy session based on a

given patient case scenario. Additional

comments were solicited to clarify

the basis for the clinical decision.

Results may provide insight into current

clinical practice and highlight the use

of published guidelines or institutional

practices as part of the clinical decision

making process.

METHODS

Participants

Part ic ipants were a sample of

convenience of all individuals who

were physical therapists and current

members of the Cardiovascular and

Pulmonary (n = 947)6 or Acute Care

Sections (n = 1980)7 of the American

Physical Therapy Association (APTA) in

the Spring of 2010. These two groups

were chosen as they were considered to

have a range of clinical experience in the

evaluation and treatment of individuals

with medical conditions that a physical

therapist might encounter in the acute

care environment. An invitation to

complete the online survey was sent

via email to the listserv subscribers of

the aforementioned section members

asking for their participation in an online

survey. Not all section members are

listserv subscribers; hence the total

number of online surveys distributed

was approximately 2,000. A follow-up

reminder was emailed one week later

to optimize the return rate.

Development of the survey

A physical therapist with greater than 30

years of clinical and academic experience

in cardiovascular and pulmonary physical

therapy developed the survey to address

the following: 1) the dearth of clinical

practice guidelines regarding exercise

and functional training in the acute care

environment, and 2) to identify the

role if any, institutional practices and

guidelines contribute to the decision

making process when physical therapists

choose a particular course of action.

This researcher used current literature

to develop eight clinically-based

patient case scenarios that required

the respondent to make a decision

regarding the course of patient care.

Cases ranged from the treatment

of an individual following a total hip

replacement who was diagnosed with

a deep venous thrombosis, to a patient

following a Q wave MI who presented

with pedal edema, jugular venous

distention (JVD) and crackles. The

survey asked the respondents whether

they would either “treat” or “not treat”

the patient, or “terminate treatment”

or “continue treatment” based on

information provided. Respondents

were asked to keep in mind that they

would be providing usual care for this

scenario rather than making clinical

decisions based on outliers. Specifically,

the survey stated, “Keep in mind that

this is related to 80% of your patients

with this scenario and try not to think

of specific outliers. You are asked to

perform usual care for this patient

type.”

Additionally, demographic information

was collected to determine the

respondent’s educational training and

years practicing physical therapy. All

survey responses were anonymous

with no identifiable information. The

protocol for this study was reviewed

by the Institutional Review Board. A

full description of the survey questions

is found in Table 1 along with the

rationale and supporting literature for

the authors’ management choice.

DATA COLLECTION

A mixed methods design was used to

analyze this eight-question survey. In five

of the eight clinical scenarios presented,

the survey asked respondents whether

they would “treat this patient” or

“not treat this patient.” In three of

the eight clinical scenarios, the survey

asked the respondents whether they

would “continue the treatment in this

patient” or “terminate the treatment

in this patient.” Each survey question

also contained a comment section for

qualitative remarks.

DATA ANALYSIS

The data were analyzed using SPSS

Version 17.0 (SPSS Inc., Chicago,

IL). Descriptive statistics were used

to summarize the demographic

variables of the respondents, as well

as the percentage of participants who

chose the correct course of patient

Academy

Summer 2011 ● Volume 2 ● Number 2JACPT 48

management. Responses were coded

as either a “correct” or “incorrect” for

each case scenario and a total score per

respondent was calculated. A correct

decision for 3 of the cases was to “treat”

or “continue to treat” the patient. A

correct decision for 5 of the cases was

to “not treat” or “terminate treatment”

for this patient. The range of scores was

zero to eight; zero indicated that the

respondent did not choose a correct

response for any of the cases and eight

reflected that the respondent chose

the correct response for all eight of

the cases.

Survey responses were analyzed by

educational training and years of clinical

experience. Years of clinical experience

were collapsed into 3 groups (1-10, 11-

20, and > 21 years of practice) in order

to increase the cell size and facilitate

data analysis. A two-way ANOVA (3

x 3 design) was used to evaluate the

effects of type of educational training

analyzed as bachelor, masters, or

doctoral (including post-professional)

trained physical therapist and years of

clinical experience divided as described

above.8 Type of training and years

of clinical experience were classified

as independent variables and the

respondent’s total number of correct

responses was the dependent variable.

The Levene’s test was used to assess

the homogeneity of variance across all

groups prior to conducting the two-

way ANOVA.9 Additional comments

provided by the respondents were also

analyzed. Statements were reviewed

for patterns of meaning. Comments

were coded by two researchers using

the open coding method described

by Patton.10 Each coding schema was

operationally defined. Axial coding

then allowed for easier identification

of key words and phrases associated

with emerging themes. Themes were

developed and agreed upon by all three

investigators.

RESULTS

Three hundred and sixty-five individuals

responded to the survey. Based on the

inclusion and exclusion criteria, nine

respondents were excluded from data

analysis as they were physical therapists

assistants. A return rate of 17.8% was

calculated based on the total number

of respondents meeting the inclusion

criteria (n = 356) and the total number

of potential email listserv subscribers

(n = 2,000). Thirty-three percent of

the respondents were trained at the

bachelor’s level, 34% at the master’s

level and 33% described themselves

as trained at the doctoral level, which

included both professional and post-

professional DPT degrees. Thirty-eight

percent of survey respondents had been

practicing between one and 10 years;

30% between 11 and 20 years; and

32% over 21 years. Table 2 summarizes

the respondents’ type of educational

training and years of clinical experience

in addition to the average correct score

per group.

Frequency responses for each case

scenario were calculated and coded

as either correct (1) or incorrect (0).

Percent correct responses ranged

from 57.3% for Case 5 to 94.4% for

Case 8. Correct frequency responses

for all respondents per case are found

in Table 1. Respondents chose the

correct management decision greater

than 80% of the time in five out of

the eight cases. Correct frequency

responses by educational training and

grouped years of clinical practice are

found in crosstab format in Table 3.

The mean score ranged from 4.85 for

bachelors-trained physical therapists

with 1-10 years of clinical experience

to 6.76 for doctorally-trained physical

therapists with greater than 21 years

of clinical experience.

The Levene’s test for homogeneity of

variance found no significant difference

among the 9 groups (F=1.572, df=8,

p=.134).9 The results of the two-way

ANOVA indicated a significant main

effect for both educational training and

grouped years of clinical experience,

in addition to a significant interaction

between educational training and years

of clinical experience (p=.017) (see

Table 4). When both main effects

and interaction effects are significant

and the interaction is disordinal in

nature, Portney & Watkins8 suggest

that only the interaction effect should

be interpreted, therefore pairwise

comparisons of the main effects were

not conducted.

DISCUSSION

Educational Training and Years of

Clinical Experience

Our results indicated that respondents

with more years of clinical experience

coupled with an advanced degree were

more accurate in choosing the optimal

treatment strategy compared with less

experienced clinicians with baccalaureate

training. Although evidence to support

experience alone as a reliable criterion

for identifying expertise is lacking,

clinical experience is one component

that separates a novice from a master

clinician.11-14 Clinical decision-making

skills evolve over time as the physical

therapist gains more experience and has

more opportunities for observation of

expert clinicians, reflection on practice

decisions, and acquisition of knowledge

through continuing education.15-17

Although the bachelors-trained physical

therapists with less clinical experience

had the lowest mean score, one

must interpret these results with

caution as this group reflects only 7

respondents, less than 2% of the total

respondents. However, our results

support the importance of continuing

one’s professional education and the

importance of clinical experience, as

the groups with master’s or doctoral

level of training and those with greater

than 10 years of experience had higher

overall mean scores (Table 2).

The Cases

More than 80% of respondents chose

the correct management decision in five

of the eight clinical cases, suggesting that

the clinicians were aware of and utilizing

current evidence in their decision making

process. In three of the case scenarios

fewer than 80% of respondents chose

the correct response (cases 1, 4, and

5). Further analysis of the cases and

the respondents’ additional comments

helped to elucidate the therapists’

decision-making processes (see Table

5). In Case 1, the patient is being treated

for a recently diagnosed DVT with

Lovenox™, a low molecular weight



heparin (LMWH) 2 days post-total hip

arthroplasty (THA). Although current

evidence supports early mobilization and

the use of compression stockings,18-21

almost 40% of the respondents

chose not to treat the patient. The

respondents were generally concerned

about the timeframe of administration

of the anticoagulant agent. Sixteen

respondents who chose not to treat

and additional respondents who chose

to treat commented that they would

only initiate treatment if Lovenox™

had been administered at least 24 hours

earlier. However, peak anticoagulation

has been noted 3-5 hours from

Lovenox™ administration.22, 23 Twelve

respondents stated they would check

the Prothrombin Time (PT) or Activated

Partial Thromboplastin time (aPTT) or

International Normalized Ratio (INR)

first before initiating treatment. These

guidelines pertain to Coumadin or

unfractionated heparin use rather


Table 1. Patient Case Scenarios

Case Description Recommendation References

1 Patient is a relatively active (walked 1 mile day

before surgery) 72 year old Caucasian female, day

two post total hip arthroplasty. This morning she

complains of tenderness in her calf region. Utilizing

the Well’s Clinical Decision Rule (CDR) she

scores +2 (moderate probability of DVT) and is

referred for vascular testing. Doppler ultrasound

reveals proximal DVT. She is given Lovenox™

(1.5 mg/kg SC once a day – standard dose for

acute DVT for in-patients) and has on thigh

length compression stockings. That afternoon

for physical therapy she is to be out of bed and

ambulating with a walker.

Our recommendation is to treat. Current evidence

supports that since this patient is being medically

managed with LovenoxTM and compression stockings, she

should participate in mobilization activities.

Aissaoui et al.8 Aldrich and Hunt9 Anderson et al.10

Junger et al.11

2 Patient is a 62 year old African American obese

male (BMI 31 kg/m2), day 1 post myocardial

infarction. Patient has a history of hypertension

and hypercholesterolemia (patient somewhat

compliant with medications). Current medications

in the hospital include Inderol, Ticlid, and Lipitor.

At rest heart rate is normal sinus rhythm 86 bpm

(2-3 PVC’s per minute), blood pressure 146/92

mmHg, respiration rate 16 bpm, O2 saturation

90% on room air. Patient complains of mild chest

discomfort radiating into left arm and ST level is

depressed by 1 mm. You are to begin Phase 1

cardiac rehabilitation.

Our recommendation is not to treat. The patient

presents with signs and symptoms of myocardial

ischemia or “unstable angina” as he complains of mild

chest discomfort radiating into left arm and the ST level

is depressed by 1 mm. An absolute contraindication for

initiating an exercise test which can be translated into

initiating aerobic activities according to AACVPR and

ACSM is unstable angina.

American Association of Cardiovascular and Pulmonary Rehabilitation.24

American College of Sports Medicine.3

3 Patient is a 66 year old male, post Q wave MI.

Patient delayed entry into the hospital following 24

hours of chest discomfort. Swan-Ganz catheter

reveals pulmonary capillary wedge pressure of 18

– 24 mmHg. Patient complains of dyspnea while

reclined, 3 + pedal edema, bilateral swollen jugular

veins, oxygen saturation of 88% on 2 l/min nasal

cannula oxygen and crackles over the lower 50%

of lungs bilaterally. Lab values reveal significant

rise in CK-MB and troponin.


presents with lab values that reveal a rise in CK-

MB and troponin, markers that indicate an active

myocardial infarction. He also has signs and symptoms

of “uncontrolled heart failure” as he has 3+ pedal

edema, dyspnea when reclined, swollen jugular veins

and crackles. The pulmonary capillary wedge pressure

should be in the range of 3-15 mmHg. The elevated

pressure in this patient indicates pulmonary edema.

Along with the complaints of dyspnea and crackles,

these symptoms suggest acute left ventricular failure, a

contraindication for mobilization.

Boissonnault25

Butman et al.26

Frownfelter and Dean.27

4 Patient is a 46 year old obese male (BMI 38 kg/

m2), waist measurement 43”, with type 2 diabetes.

He is being seen in the acute care hospital 2

day post right leg amputation. He has just given

himself an insulin injection and his blood glucose is

currently 82 mg/dL. His resting heart rate is 114

bpm, he appears somewhat confused and anxious.


has classic symptoms of hypoglycemia: high resting

heart rate, anxiety, and confusion. Guidelines from the

American Diabetes Association recommend that physical

activity should not be performed if blood glucose levels

are less than 100 mg/dL. His glucose level is 82 mg/dl.

Also, the National Diabetes Information Clearinghouse

supports that if his blood sugar is below 100 mg/dL, he

should eat a snack before engaging in physical activity.

Singal et al.14

National Institute of Diabetes and Digestive and Kidney Diseases.15


than Lovenox™. Routine coagulation

tests such as (PT/INR) or (aPTT) are

insensitive measures of Lovenox™

activity and thus would not be utilized

to measure its anticoagulant effect.

The only reliable way to monitor

LMWH is an expensive test that is not

utilized clinically unless the patient has a

history of significant renal impairment.22

Lovenox™ is considered therapeutic

once administered at the appropriate

dose. Furthermore, all of the randomized

controlled clinical trials examining

mobilization following diagnosis of

DVT and administration of Lovenox™

did not require a post-injection delay

before initiating activity.18-21 Thus,

some respondents are likely making

clinical decisions based on institutional

guidelines or they are not taking into

account the specific anticoagulant used

in the decision making process.

Case 4 involves a 46-year-old obese

patient with Type 2 DM, who is 2 days

post-right leg amputation. Following

insulin injection his blood glucose is

82mg/dL. He is confused with a HR

of 114. The literature suggests that

persons with diabetes should not

perform activity if exhibiting signs of

hypoglycemia or if the blood glucose

level is less than 100 mg/dL;24, 25 however

almost 40% of respondents chose

the incorrect response. Analysis of

additional comments suggests that

the therapists were aware that the

glucose levels were low and that this

warranted their close attention. Hence,

the intervention most frequently cited

was low-level bedside activity with

close monitoring of vital signs (n=24).

Other additional comments noted the

need to provide a snack and recheck

the blood sugar before proceeding

with treatment. One person noted

his institutional guidelines for exercise

and blood glucose was 70-110 mg/dL

and thus would have proceeded with

treatment. Respondents clearly were

addressing the low glucose levels in their

decision making process, but used these

values as only one piece of information

as they made their clinical decisions to

treat or not treat the patient.

Case 5 involved a 58-year-old woman

with leukemia awaiting a bone

marrow transplant. The patient was


Case Description Recommendation References

5 Patient is a 58 year old female who is receiving a

bone marrow transplant following the diagnosis of

leukemia. Prior to the transplant the physicians

are inducing immunosuppression and trying to

kill off neoplastic cells in her bloodstream and

bone marrow. Her lab values reveal white blood

cell count of 2,200/mm3, Hemoglobin of 7.4 g/

dl, HCT 21%, platelets 3,200/mm3. Physiological

measurements reveal resting heart rate of 114

bpm, blood pressure 114/64 mmHg, oxygen

saturation 92% (on room air), respiratory rate of

16 bpm.

Our recommendation is to treat. While many of the

laboratory values (platelets, hemoglobin, HCT, WBC’s)

are below what is often thought as contraindications for

activity, this patient is relatively young, not a falls risk,

receiving treatment causing these iatrogenic changes,

while physiological parameters are within normal

limits. Treatment would be limited in physiological cost

(possibly to bed activities) and the patient would be

monitored closely.

Boissonnault25

APTA 28 University of Pittsburgh Medical Center29

Winningham30

6 Patient is a 54 year old male 2 days post TKA.

Patient has a long history of HBP and CAD.

Patient is comfortable at rest. With usual activity

patient complains of “chest tightness”, on the EKG

the ST segment is depressed by 2 mm. Patient

also appears pale.


has a history of cardiovascular disease. With activity

he demonstrates signs and symptoms of myocardial

ischemia: pallor, chest tightness, and ST segment

depression. The risk of precipitating a cardiac event

such as life-threatening dysrhythmias or myocardial

infarction with physical activity outweighs the benefits of

mobilization following joint arthroplasty.

American College of Sports Medicine4

7 Patient is a 72 year old female one day post-THA

with a known history of dysrhythmias. While

performing her activity she goes into ventricular

tachycardia (evidenced by EKG telemetry).

Our recommendation is to terminate treatment/

activity and notify medical personnel. Guidelines for

stopping an exercise test which can be translated into

stopping any aerobic activity according to AACVPR and

ACSM include ventricular tachycardia.

American Association of Cardio-vascular and Pulmonary Rehabilitation24

American College of Sports Medicine4

8 Patient is day two post-CABG. Physiological

measurements reveal resting heart rate of 94 bpm,

blood pressure 114/64 mmHg, oxygen saturation

92% (on room air), respiratory rate of 16 bpm.

With usual activity, the patient goes into sinus

tachycardia rate of 110 bpm, blood pressure of

132/70 mm Hg, oxygen saturation 94% (on room

air), respiratory rate of 20 bpm.

Our recommendation is to treat. All physiological

variables changed as expected with the onset of physical

activity. Heart rate increased but by less than 30 bpm

as recommended by AACVPR and ACSM for the

management of patients following CABG surgery.

American Association of Cardio-vascular and Pulmonary Rehabilitation26 American College of Sports Medicine.4

Table 1. Patient Case Scenarios (continued)

AACPT


immunosuppressed prior to surgery

with depressed low white blood cells,

hemoglobin and platelets counts. Vital

signs were as follows: resting HR of

114, RR of 16, BP of 114/64 and O2

saturation of 92% on room air. Although

our recommendation was to treat

based on existing guidelines and patient

history (relatively young patient, not a

falls risk, receiving treatment causing the

iatrogenic changes) approximately 42%

of respondents chose not to treat this

patient. Additional comments highlight

the concern of the respondents over the

depressed lab values, especially platelets


Table 2. Type of Educational Training, Years of Experience and Mean Correct Score of Survey Respondents

Type of Educational Training N Percent Mean Score (s.e.)

Bachelor level trained PT 116 32.6 5.87 (.15)

Master level trained PT 121 34.0 6.26 (.11)

Doctoral or transitional Doctoral trained PT 119 33.4 6.51 (.12)

Years of Experience N Percent Mean Score (s.e.)

1 to 10 years 137 38.5 5.79 (.15)

11-20 years 107 30.0 6.47 (.11)

> 21 years 112 31.5 6.39 (.12)

Table 3. Correct frequency responses per case for 356 respondents

Case # Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8

% Correct 61.8 82.9 89.9 61.2 57.3 94.1 90.2 94.4

Table 4. Mean score by type of education and grouped years of clinical experience

Type of Education Grouped Years of

Experience

Number & (Percent) of

respondents

Mean (s.e.)

DPT or tDPT 1-10 years 76 (21.34) 6.27 (.12)

11-20 years 18 (5.05) 6.50 (.25)

> 21 years 25 (7.02) 6.76 (.21)

MSPT 1-10 years 54 (15.16) 6.24 (.14)

11-20 51 (14.33) 6.37 (.14)

>21 years 16 (4.49) 6.18 (.26)

BSPT 1-10 years 7 (1.96) 4.85 (.40)

11-20 years 38 (10.67) 6.55 (.17)

>21 years 71 (19.94) 6.22 (.12)

Table 5. Summary Table: Two –Way ANOVA: Effect of Educational Training and Grouped Years of Clinical

Experience on Score

Sum of Squares df Mean

Square

F Sig.

Educational Training 12.384 2 6.192 5.465 .005

Years of Practice 16.633 2 8.317 7.341 .001

Education Training *

Years Practice

13.395 4 3.474 3.066 .017

Error 393.133 347 1.133

Total 14625.00 356


in light of any proposed activities other

than low-level bed exercises. The

clinicians’ decision not to treat may

be based on limited exposure to this

particular patient population, which led

them to use lab value guidelines as an

absolute contraindication to treatment

without consideration of other factors.

Clinicians who frequently treat persons

with cancer may be more likely to

stretch the reference value boundaries

when weighing the benefits of mobilizing

the patient versus the deleterious

effects of continued bedrest.

Limitations

Generalizing the findings must be done

with caution for a number of reasons.

Although correct responses to the

clinical case scenarios were based on

current literature and confirmed among

all three authors, the survey itself was

constructed by only one author and

was not peer reviewed prior to its

administration. In addition, the cases

themselves were hypothetical in nature

and provided only a snapshot of the

information available to a clinician,

which may have contributed to the

respondent’s difficulty in choosing the

correct management decision.

The response rate was low (17.8%),

which may have resulted in response

bias. Individuals who found the

survey questions too challenging may

have elected not to complete the

survey, resulting in a respondent

pool more equipped to accurately

choose the correct management

decision. Additionally, the survey was

purposefully distributed to section

members, who would be familiar with

management of clients with medical

conditions one might encounter in the

acute care environment. Therefore

the respondents may be a select

group of individuals who have made a

commitment through their association

and section membership to continued

competency. Hence the findings cannot

be generalized to therapists who may

not be APTA or section members.

The demographic portion of the survey

did not address the respondent’s

current or past practice setting and

years of clinical experience in those

settings. This information coupled

with type of educational training and

total years of clinical experience would

have added another dimension to the

analysis offering further insight into

therapists’ decision-making process.

CONCLUSIONS

Overall more than 80% of the survey’s

participants answered five out of eight

cases correctly, suggesting that clinicians

who are members of the acute care and

cardiovascular and pulmonary sections

are utilizing current evidence to support

their clinical decision-making process.

Incorrect responses in two cases may

be related to the therapists’ current or

prior clinical experiences and subsequent

comfort level in treating a particular

patient population. Respondents with

less clinical experience may have been

less confident in their decision making

process, with the result that lab values

falling outside the normal range were

used as an absolute contraindication

for treatment without consideration of

other factors.

Incorrect responses in one case appear

to be related to lack of knowledge

regarding patient management following

LovenoxTM administration or the

result of institutionally-driven practice

guidelines. This highlights the need for

physical therapists to stay up to date

regarding patient medical management

and stresses the importance of educating

other health care professionals on our

role as exercise and activity specialists

in this environment. As exercise

specialists, we should act as the catalyst

for change for institutional practices

based on weak or nonexistent evidence

by bringing evidence-based practice to

the forefront of the clinical decision-

making paradigm.

Overall, physical therapists who have

more years of clinical experience and

who continued their professional

education were more likely to choose

the correct management decision

in these particular scenarios. This

emphasizes the importance of clinical

experience coupled with knowledge

in the clinical decision making process.

These individuals were more likely

to use guidelines judiciously, while

integrating other patient related factors

into their clinical decision making

process

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Table 6. Incorrect Response Comments by Case

Case 1 Case 2 Case 3

“THA with diagnosed DVT currently treated with Lovenox TM”

Wait 24 hours (n=16)yyWait 3 days (n=1)yyWait 12 hours if cleared yyby MD (n=1)Check PT/PTT or INR yyfirst (n=12)Clear with MD (n=7)yyNeed new order if it is yya new DVT (n=1)Do not treat b/c it is a yyproximal DVT (n=1)

“S/P one day AMI w/ r a d i a t i n g CP”

Treat while monitoring vitals yy&/or EKG (n=5)Check with MD (n=2)yyCheck with RN (n=2)yyModi fy intervent ion as yyindicated by S & S (n=1)1 mm only relative risk; do yybedside activities & monitorIf stable angina do deep yybreathing & relaxationSit EOB, watch ST segment & yysymptoms; education (n=1)Check troponin levels (n=1)yyStop treatment if symptoms yyworse or in CO (n=1)

“S/P Q wave MIDyspnea at rest, JVD, crackles”

Breathing activities to yyimprove O2 sat (n=3)I f g o o d h i s t o r i a n , yybasic ther. ex with VS monitoring (n=1)EOB activities; yy O2 prn & monitor VS (n=1)Dangle feetyy chair i f tolerated (n=1)Treat within parameters yyand modify to tolerance (n=1)Gentle ROM, no amb, no yyexercise (n=1)How long post MI?; ther yyex (n=1)Low level activity if cardiac yymarkers falling (n=1)Pending cardiology consult yy(n=1)

Case 4 Case 5 Case 6

“DM s/p amputation;Low Glucose & confused

Low leve l beds ide yyactivity closely monitor VS (n=24)Treat later that day yywhen glucose (n=5)P r o v i d e p r o t e i n , yycarbohydrates and modify and monitor (n=3)Give snack or ask RN yyto give him snack and recheck BS (n=6)Modify treatment as yyneed (n=2)Discuss why he is yyself injecting with RN (overmedicate?) (n=1)Check w/ RN to r/o yyAfib then start (n=1)OOByy chair (n=1)Gen t l e A / P ROM yy(n=1)Recheck BS & treat yybased on results (n=1)Norms @ our hospital yy70-110 so treat with monitoring (n=1)

“ B o n e M a r r o w T r a n s p l a n t with abnormal lab values”

Platelets too low (n=8)yyHgb too low (n=8)yyTalk to RN; if this is baseline yydo AROM/ADL as tolerated (n=3)Just take the history (n=1)yyCheck chart for last 3 days yybefore proceeding (n=1)Are WBC going up or down? yyHgb may be most compelling reason to not Rx (n=1)WBC, platelets, Hct too yylowMostly due to HR. Look at yyMD parameters for lab values (n=1)Hgb too low and HR too yyhigh (n=1)A b n o r m a l l a b v a l u e ; yyencourage ambulation if gait steady (n=1)Not clear presentation; is she yyimmunosuppressed but has not been transplanted?Depends on stand for Bone yyMarrow Transplant Unit. Needs special precautions b/c of WBC (n=1)Check with MD (n=1)yy

“S/P THA; h/o HBP & CAD; chest tightness and EKG changes”

Awa i t MD eva l and yycon t i nue i f f u r t he r intervention not indicated (n=1)Modi fy treatment as yyneeded (n=1)Hold mobility, check VS, yyconsult RN; ther ex/ROM (n=1)Back off activity & monitor. yyWhat is Hct? (n=1)Check with RN. Monitor yyactivity (n=1)Adjust POC according to yysymptoms (n=1)Check lab values (n=1)yyTher ex in sitting, find limits yyof activity w/ constant monitoring (n=1)

Case 7 Case 8

“One day post THA; h/o dysrhythmias w/ ventricular tachycardia (by telemetry)”

Monitor VS and adjust accordingly (n=5)yyDepends on symptoms, length of vtach, how extensive yyh/o dysrhythmias (n=1)If it was brief period and asymptomatic, would continue yyand monitor; if it persists, would stop (n=2)Give patient a rest period and resume if she regains yyNSR (n=1)Ask RN if normal vs. acute EKG change (n=3)yyCheck with RN & observe before deciding what to do yy(n=1)

“2 day post CABG; sinus tach 110; BP 132/70; O2 sat 94%”

Would return later to yyprovide short treatment of AROM & monitor VS (n=1)


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