Update

2013

LAB VALUES INTERPRETATION RESOURCES

Acute Care Section-APTA

The Critical Edge

www.acutept.org

AcuteCareSectionAPTA TaskForceonLabValues 2012Members RoyaGhazinouri,Chair SamidhaDeshmukh SharonGorman AngelaHauber MaryKroohs ElizabethMoritz BabetteSanders DarrinTrees 2008Members HollyMcKenzie DawnPiech JimSmith ApprovedAcuteCareSectionAPTA BoardofDirectors: 8/2008,12/2011

LAB VALUES RESOURCES 2013

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 Acute Care Section-APTA 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 Acute Care Section-APTA has provided this information as a resource to the membership. The Section will not interpret lab values as this is the professional responsibility of every clinician.

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ACUTE VERSUS CHRONIC CONSIDERATIONS
In addition to reviewing the patients 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 patients 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 patients 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 Persons sense of being male or female Identity 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 4|Page

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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.

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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-toperson 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 patients 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 Americas diversity. Available at: http://www.census.gov/newsroom/releases/archives/2010_census/cb11cn125.html. Updated August 26, 2011. Accessed October 30, 2011. 2. McClatchey KD. Clinical Laboratory Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins;2002. 6|Page

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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):11121119. 7. Leavitt RL. Cultural Competence: A Lifelong Journey to Cultural Proficiency. Thorofare, NJ: Slack; 2010.

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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.

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PEER REVIEWED RESOURCES
NOTE: Past Acute Care Perspective and Journal of Acute Care Physical Therapy articles may be purchased through the Acute Care Sections 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):14531467. 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.

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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 Uthmans 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. Acute Care Section-APTA 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.

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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: APTAs 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 Physiotherapys 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: APTAs 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 highquality, 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).

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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.

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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 unit. Acute Care Perspectives. 1995;3(4):7-11. Values documented in article
Creatinine Phospho - Kinase (CPK) 25-225microL/L CPK-MB begins to rise at 2-4 hours, peaks in 12-24 hours and returns to normal within 24-48 hours

Updated values
30-170 U/L

References for updated values

Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Fischbach F. A Manual of Laboratory and Diagnostic Tests. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2004. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. Porter RS, ed. The Merck Manual of Diagnosis and Therapy. 19th ed. Rahway, NJ: Merck;2011. DeVita, VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2005.

CPK-MB begins to rise at 4-6 hours, peaks in 12-24 hours and returns to normal within 48-72 hours

O2 sat: 95%-98%

> 94%

Partial pressure of oxygen in arterial blood, PaO2: 80-100mm Hg Adult male Red blood cells, (RBCs): 4.7-5.5 x 104/microL Adult male hematocrit (Hct): 4349% Adult male hemoglobin(Hgb): 14.4-16.6 Gm/dL Adult female white blood cells (WBCs): 4,500-11,000 cells/mm3 Adult female RBCs: 4.1-4.9 x 104

> 80 mm Hg

25-35 mL/kg

41-51%

14-17Gm/dL 3.9-10.7 x 103

20-30 mL/kg

Adult female Hct: 38-44%

36-47%

Adult female Hgb: 14-17 Gm/dL

12-16Gm/dL

1.

Hct < 25%-No exercise permitted

1.

Hct < 25%: essential activities of daily living, assistance as needed for safety

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2. Hct > 25%-Light exercise permitted 2. Hct < 25-35%: essential activities of daily living; assistance as needed for safety; light aerobics, light weights (1-2 lbs) Hct > 35%, Ambulation and self care as tolerated; resistance and aerobic exercises Hgb < 8gm/dL: essential daily activities* Hgb < 8-10gm/dL: Essential activities of daily living, assistance as needed for safety; light aerobics, light weights (1-2lbs)* Hgb > 8gm/dL, Ambulation and self care as tolerated; resistance exercises* PLT < 10,000 and /or temperature > 100.5 degrees: No therapeutic exercise/Hold therapy PLT: 10,000-20,000: Therapeutic exercise/bike without resistance PLT > 20,000: Therapeutic exercise/bike with or without resistance DeVita, VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2005.

3.

Approximately 30-32%-add resistive exercise as permitted Hgb <8- No exercise permitted

3.

1.

1.

2. 2. Hgb:8-10-light exercise permitted

DeVita, VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2005.

3.

Hgb >10-resistive exercise permitted Platelets (PLT) < 20,000: No exercise

3.

1.

1.

2.

PLT: 20,000-50,000: Light exercise (No PROM, but light AROM is permitted) PLT > 50,000: Resistive AROM is permitted

2.

Samuelson K. Standard of care: hematopoietic stem cell transplant (HSCT) in-patient phase. 2010; Brigham and Womens Hospital, Rehabilitation Services.

3.

3.

* 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.

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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 Obstructive ventilatory impairment Restrictive ventilatory impairment Mixed ventilatory defect COMMON EXAMPLES Chronic obstructive pulmonary disease (COPD) Fibrosis Pulmonary congestion NORMAL VALUES FOR MALE (Liters)* IRV = 3.3 Vt = 0.5 ERV = 1.0 RV = 1.2 NORMAL VALUES FOR FEMALE (Liters)* IRV = 1.9 Vt = 0.5 ERV = 0.7 RV = 1.1

TYPES OF PFTS

TERMS (UNITS) OF MEASUREMENTS

Airway flow rates: Measure instantaneous or average airflow rates during a maximal forced exhalation to assess airway patency and resistance 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 Inspiratory reserve volume (IRV) Tidal volume (Vt) Expiratory reserve volume (ERV) Residual volume (RV)

Gas exchange: Measures the rate of gas transfer across the alveolar capillary membranes to assess the diffusion process Forced vital capacity (FVC) FVC >80% or > 0.80 of Predicted Forced expiratory volume at the end value* of a given time (t) in seconds (FEVt) FEV1, 80%85% of FVC FEV2, 90%94% of FVC FEV1= FEVt at the end of 1 FEV3, 95%97% of FVC second FEV1/FVC ratio is expressed as a FEV2= FEVt at the end of 2 percentage seconds FEV3= FEVt at the end of 3 seconds *Predicted values are based on the individuals age, gender, ethnicity, height, and body size.

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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:
Absolute ratio (FEV1/FVC) % = or > 70% < 70% > 70%

FVC Decreased Decreased or normal Normal

FEV1 Decreased or normal Decreased Normal

RESULT Restrictive ventilatory impairment Obstructive ventilatory impairment Normal spirometry

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3. Once the type of pulmonary disease is identified severity of disease can be determined by using the following guidelines:
SEVERITY OF DISEASE Normal PFT Outcomes Mild Disease Moderate Disease Moderately severe Disease Severe Disease ABSOLUTE RATIO (FEV1/FVC) > 100 % of predicted values 70-100% of predicted values 60-70 % of predicted values 50-60% of predicted values < 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. Ganongs Review of Medical Physiology. 23rd ed. New York, NY:McGraw-Hill Medical;2009. 3. Crapo JD, Glassroth J, Karlinsky JB, King TE. Baums 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.

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Anticoagulation Therapy for Venous Thromboembolism

Medications Alternate Names
Coumadin Jantoven Marfarin

Mode of Administration
Orally (PO)1

Lab Value (reference range)

INR (.9-1.1)

Therapeutic Range
2.0-3.0 (achieved in 2-5 days)2

When is a patient safe to mobilize?

When in therapeutic range

Considerations

Precautions

Warfarin

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 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 Does not require monitoring3 Peak anticoagulation: 1.7 hours after 1st injection5

When in therapeutic range

If not in therapeutic range, check to see if the patient is therapeutic on other anticoagulants (e.g. unfractionated heparin) Contact medical team if specific PTT goal range is not documented

Increased risk of bleeding if supratherapeutic

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

3-5 hours after 1st injection administered

Potential complication: heparin-induced thrombocytopenia6

Fondaparinux

Arixtra

Subcutaneous injection3

Once patient has reached peak anticoagulation

Commonly used in patients with heparin induced thrombocytopenia7

Contraindicated in patients with severe renal impairment; cleared renally3

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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 Patients 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 Womens 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 environment: a survey of practicing clinicians. J Acute Care Phys Ther. 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/heparininducedthrombocytopenia?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.

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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 unit. Acute Care Perspectives. 1995;3(4):7-11. 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 environment: a survey of practicing clinicians. J Acute Care Phys Ther. 2011;2(2):46-54.

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Acute Care Perspectives ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives 95/4/7-11 ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives 95/4/7-11 ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives 95/4/7-11 ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives 95/4/7-11 ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

Acute Care Perspectives 95/4/7-11 ! Reprint permission granted courtesy of the Acute Care Section-APTA, Inc. ! www.acutept.com

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Clinical Decision Making in the Acute Care Environment: A Survey of Practicing Clinicians
Ellen Costello, Cathy Elrod, Steven Tepper

RESEARCH  REPORT
2011 Acute Care Section-APTA, Inc. All rights reserved. Reproduction in whole or in part by permission only.

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: experience acute care, clinical decision making, exercise, clinical

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

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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 clients 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 clients presentation to determine whether participation in therapeutic exercise or functional tasks would potentially result in harm. During the evaluative process, various factors influence the therapists clinical reasoning. These factors include the clinical setting and available resources, the patients age, medical diagnosis, signs and symptoms, and health beliefs, and the therapists 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 Participants 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 respondents 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

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Clinical Decision Making in the Acute Care Environment: A Survey of Practicing Clinicians 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 bachelors level, 34% at the masters level and 33% described themselves as trained at the doctoral level, which included both professional and postprofessional 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 Levenes 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 ones professional education and the importance of clinical experience, as the groups with masters 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

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, 1120, 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 respondents total number of correct responses was the dependent variable. The Levenes test was used to assess the homogeneity of variance across all groups prior to conducting the twoway 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

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

Table 1. Patient Case Scenarios

Case 1 Description 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 Wells 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. 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 PVCs 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. 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. Recommendation 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. References
Aissaoui et al.8 Aldrich and Hunt9 Anderson et al.10 Junger et al.11

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

Our recommendation is not to treat. The patient presents with lab values that reveal a rise in CKMB 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. Our recommendation is not to treat. The patient 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.

Boissonnault25 Butman et al.26 Frownfelter and Dean.27

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.

Singal et al.14 National Institute of Diabetes and Digestive and Kidney Diseases.15

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

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Clinical Decision Making in the Acute Care Environment: A Survey of Practicing Clinicians Table 1. Patient Case Scenarios (continued)
Case 5 Description 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. 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. Recommendation Our recommendation is to treat. While many of the laboratory values (platelets, hemoglobin, HCT, WBCs) 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. References
Boissonnault25 APTA Acute Care Section28 University of Pittsburgh Medical Center29 Winningham30

Our recommendation is not to treat. The patient 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. 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 College of Sports Medicine4

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).

American Association of Cardio-vascular and Pulmonary Rehabilitation24 American College of Sports Medicine4 American Association of Cardio-vascular and Pulmonary Rehabilitation26 American College of Sports Medicine.4

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.

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

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

Table 2. Type of Educational Training, Years of Experience and Mean Correct Score of Survey Respondents Type of Educational Training Bachelor level trained PT Master level trained PT Doctoral or transitional Doctoral trained PT Years of Experience 1 to 10 years 11-20 years > 21 years N 116 121 119 N 137 107 112 Percent 32.6 34.0 33.4 Percent 38.5 30.0 31.5 Mean Score (s.e.) 5.87 (.15) 6.26 (.11) 6.51 (.12) Mean Score (s.e.) 5.79 (.15) 6.47 (.11) 6.39 (.12)

Table 3. Correct frequency responses per case for 356 respondents Case # Case 1 Case 2 Case 3 Case 4 Case 5 % Correct 61.8 82.9 89.9 61.2 57.3

Case 6 94.1

Case 7 90.2

Case 8 94.4

Table 4. Mean score by type of education and grouped years of clinical experience Type of Education Grouped Years of Number & (Percent) of Experience respondents DPT or tDPT 1-10 years 76 (21.34) 11-20 years 18 (5.05) > 21 years 25 (7.02) MSPT 1-10 years 54 (15.16) 11-20 51 (14.33) >21 years 16 (4.49) BSPT 1-10 years 7 (1.96) 11-20 years 38 (10.67) >21 years 71 (19.94)

Mean (s.e.) 6.27 (.12) 6.50 (.25) 6.76 (.21) 6.24 (.14) 6.37 (.14) 6.18 (.26) 4.85 (.40) 6.55 (.17) 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 F Sig. Square Educational Training 12.384 2 6.192 5.465 .005 Years of Practice 16.633 2 8.317 7.341 .001 Education Training * 13.395 4 3.474 3.066 .017 Years Practice Error Total 393.133 14625.00 347 356
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

1.133

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

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Clinical Decision Making in the Acute Care Environment: A Survey of Practicing Clinicians 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 surveys 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 Lovenox TM 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 decisionmaking 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 REFERENCES 1. American Physical Therapy Association. Guide to Physical Therapist Practice: Second Edition. Alexandria, Va: American Physical Therapy Association; 2003. 2. O'Sullivan S. Clinical decision making. In: O'Sullivan S, Schmitz T, eds. Physical Rehabilitation. 7th ed. Phila: F.A. Davis; 2007:3-25. 3. McGinnis PQ, Hack LM, NixonCave K, Michlovitz SL. Factors that influence the clinical decision making of physical therapists in choosing a balance assessment approach. Phys Ther. 2009;89:233247. 4. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2010. 5. Hillegass E, Sadowsky HS. Essentials of Cardiopulmonary Physical Therapy. 2nd ed. Philadelphia: Saunders; 2001. 6. American Physical Therapy Cardiovascular and Pulmonary Section. American Physical Therapy Cardiovascular and Pulmonary Section Membership and Leadership. Available at: www.apta.org/AM/Template. cfm?Section=Chapters&template=/ aptaapps/componentsonline/ componentsonline.cfm&processF orm=1&componentType=Section s&specChoice=L&convertList2For m=yes. Accessed June 10, 2010. 7. American Physical Therapy Acute Care Section. American Physical Therapy Acute Care Section Membership and Leadership. Available at: www. apta.org/AM/Template. cfm?Section=Chapters&template=/ aptaapps/componentsonline/ componentsonline.cfm&processF orm=1&componentType=Sections &specChoice=I&convertList2Form =yes. Accessed June 10, 2010.

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 respondents 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 respondents current or past practice setting and years of clinical experience in those

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Clinical Decision Making in the Acute Care Environment: A Survey of Practicing Clinicians Table 6. Incorrect Response Comments by Case
Case 1 THA with diagnosed DVT currently treated with Lovenox TM yy yy yy yy yy yy yy Wait 24 hours (n=16) Wait 3 days (n=1) Wait 12 hours if cleared by MD (n=1) Check PT/PTT or INR first (n=12) Clear with MD (n=7) Need new order if it is a new DVT (n=1) Do not treat b/c it is a proximal DVT (n=1) Case 2 S/P one day AMI w/ radiating CP yy yy yy yy yy yy yy yy yy Treat while monitoring vitals &/or EKG (n=5) Check with MD (n=2) Check with RN (n=2) Modify intervention as indicated by S & S (n=1) 1 mm only relative risk; do bedside activities & monitor If stable angina do deep breathing & relaxation Sit EOB, watch ST segment & symptoms; education (n=1) Check troponin levels (n=1) Stop treatment if symptoms worse or in CO (n=1) Case 3 S/P Q wave MI Dyspnea at rest, JVD, crackles yy yy yy yy yy yy yy yy yy Breathing activities to improve O2 sat (n=3) If good historian, basic ther. ex with VS monitoring (n=1) EOB activities; O2 prn & monitor VS (n=1) Dangle feet chair if tolerated (n=1) Treat within parameters and modify to tolerance (n=1) Gentle ROM, no amb, no exercise (n=1) How long post MI?; ther ex (n=1) Low level activity if cardiac markers falling (n=1) Pending cardiology consult (n=1)

Case 4 DM s/p amputation; Low Glucose & confused yy yy yy Low level bedside activity closely monitor VS (n=24) Treat later that day when glucose (n=5) Provide protein, c a r b oh y d r at e s a n d modify and monitor (n=3) Give snack or ask RN to give him snack and recheck BS (n=6) Modify treatment as need (n=2) Discuss why he is self injecting with RN (overmedicate?) (n=1) Check w/ RN to r/o Afib then start (n=1) OOBchair (n=1) Gentle A/P ROM (n=1) Recheck BS & treat based on results (n=1) Norms @ our hospital 70-110 so treat with monitoring (n=1)

Case 5 Bone M a r r o w Transplant with abnormal lab values yy yy yy yy yy yy yy yy yy yy yy yy Platelets too low (n=8) Hgb too low (n=8) Talk to RN; if this is baseline do AROM/ADL as tolerated (n=3) Just take the history (n=1) Check chart for last 3 days before proceeding (n=1) Are WBC going up or down? Hgb may be most compelling reason to not Rx (n=1) WBC, platelets, Hct too low Mostly due to HR. Look at MD parameters for lab values (n=1) Hgb too low and HR too high (n=1) Abnormal lab value; encourage ambulation if gait steady (n=1) Not clear presentation; is she immunosuppressed but has not been transplanted? Depends on stand for Bone Marrow Transplant Unit. Needs special precautions b/c of WBC (n=1) Check with MD (n=1)

Case 6 S/P THA; h/o HBP & CAD; chest tightness and EKG changes yy Await MD eval and continue if further intervention not indicated (n=1) Modify treatment as needed (n=1) Hold mobility, check VS, consult RN; ther ex/ROM (n=1) Back off activity & monitor. What is Hct? (n=1) Check with RN. Monitor activity (n=1) Adjust POC according to symptoms (n=1) Check lab values (n=1) Ther ex in sitting, find limits of activity w/ constant monitoring (n=1)

yy yy yy yy yy yy yy

yy yy yy yy yy yy yy yy

yy

Case 7 One day post THA; h/o dysrhythmias w/ ventricular tachycardia (by telemetry) yy yy yy yy yy yy Monitor VS and adjust accordingly (n=5) Depends on symptoms, length of vtach, how extensive h/o dysrhythmias (n=1) If it was brief period and asymptomatic, would continue and monitor; if it persists, would stop (n=2) Give patient a rest period and resume if she regains NSR (n=1) Ask RN if normal vs. acute EKG change (n=3) Check with RN & observe before deciding what to do (n=1)

Case 8 2 day post CABG; sinus tach 110; BP 132/70; O2 sat 94% yy Would return later to provide short treatment of AROM & monitor VS (n=1)

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8. Portney L, Watkins M, eds. Foundations of Clinical Research: Applications to Practice. 3rd ed. Saddle River, NJ: Pearson Education Inc; 2009. 9. Lewis-Beck MS, Bryman A, Liao TF. The Sage Encyclopedia of Social Science Research Methods. Vol 1. Thousand Oaks, Ca: Sage Publications; 2004. 10. Patton MQ, ed. Qualitative Evaluation and Research Methods. 3rd ed. Newbury Park, CA: Sage Publications, Inc.; 2001. 11. Rassafiani M. Is length of experience an appropriate criterion to identify level of expertise? Scand J Occup Ther. 2009;16:247-256. 12. Jensen G, Shepard K, Gwyer JH, L. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedics settings. Phys Ther. 1992;10:711-722. 13. Jensen GS, K., Hack L. The novice versus the experienced clinician: Insights into the work of the physical therapist. Phys Ther. 1990;70:314323. 14. Embry D, Guthrie M, White O, Dietz J. Clinical decision making by experience and inexperienced pediatric physical therpists for children with diplegic cerebral palsy. Phys Ther. 1996;76:20-33. 15. Jensen G, Gwyer JH, L., Shepard K. Expertise in Physical Therapy Practice. 2nd ed. St. Louis: Saunders; 2007. 16. Spake E. Clinical reasoning and decision making of experienced clinicians and entry-level physical therapist students. [PhD]. Kansas: University of Kansas; 2003. 17. Wainwright SF, Shepard KH, L., Stephens J. Novice and experienced physical therapist clinicians: A comparison of how reflection is used to inform the clinical decision-making process. Phys Ther. 2010;90:75-88. 18. Aissaoui N, Martins E, Mouly S, Weber S, Meune C. A meta-analysis of bedrest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both. Int J Cardiol. 2009;137:37-41. 19. Aldrich D, Hunt D. When can the patient with deep venous

20.

21.

22.

23.

24.

25.

26.

27.

28.

thrombosis begin to ambulate? Phys Ther. 2004;84:268-273. Anderson CM, Overend TJ, Godwin J, Sealy C, Sunderji A. Ambulation after deep vein thrombosis: A systematic review. Physiother Can. 2009;61:133-140. Junger M, Diehm C, Storiko H, et al. Mobilization versus immobilization in the treatment of acute proximal deep venous thrombosis: A prospective, randomized, open, multicentre trial. Curr Med Res Opin. 2006;22(3):593-602. U.S. Department of Health and Human Services. Drugs at FDA: Lovenox. Available at: www. accessdata.fda.gov/drugsatfda_ docs/label/2009/020164s085lbl.pdf. Accessed November 5, 2010. Frydman AM, Bara L, Le Roux Y, Woler M, Chauliac F, Samama MM. The antithrombotic activity and pharmocokinetics of enoxaprarin, a low molecular weight heparin, in humans give single subcutaneous doses of 20 to 80 mg. J Clin Pharmacol. 1988;28:609-618. Singal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: A consensus statement from the American Diabetes Association. DiabetesCare. 2006;29(6):1433-1438. National Institute of Diabetes and Digestive and Kidney Diseases. Hypoglycemia. Available at: diabetes.niddk.nih.gov/dm/ pubs/hypoglycemia/. Accessed November 7, 2010. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign, IL: Human Kinetics; 2004. Boissonnault WG. Primary Care for the Physical Therapist: Examination and Triage. 2nd ed. St. Louis: Saunders; 2011. Butman SM, Ewy GA, Standen JR, Kern Kb, Hahn E. Bedside cardiovascular examination in patients with severe chronic heart

failure: Importance of rest or inducible jugular venous distention. J Am Coll Cardiol. 1993;22:968-974. 29. F r o w n f e l t e r D , D e a n E . Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. St. Louis: Mosby; 2006. 30. American Physical Therapy Association Acute Care Section. Laboratory values interpretation resource. Available at: www. acutept.org/displaycommon. cfm?an=1&subarticlenbr=27#lab_ values. Accessed November 7, 2010. 31. University of Pittsburgh Medical Center. Stem cell transplant rehab: what to expect. Available at: www.upmc.com/healthatoz/ patienteducation/documents/ stemcell.pdf. Accessed November 7, 2010.

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