Emory University | Woodruff Health Sciences Center
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PT in the ICU

Inside the nation's first preprofessional course on advanced acute care

By By Dana Goldman | Photography by Kay Hinton

Story Photo

Jenny Sharp (l), Courtney Beshel 17DPT (back center), Eugene O’Hanlon 17DPT, and Kathy Lee Bishop mobilize an acute care patient as part of a simulation.

There’s a simple reason why Alex Johnson 17DPT tried to avoid intensive care units (ICUs) during her first clinical rotations: “I was petrified,” she says. Ventilators, lines, monitors, and questions about patients’ medical stability made her hesitate. “When I walked into an ICU, I was automatically intimidated,” she says. “Patients were so ill. They seemed so fragile.”

Johnson knew she had a decision to make. She could continue to avoid critically ill patients with complex conditions—or she could learn everything she could to overcome her fear. Because she wanted to be able to work in a hospital, she decided on the latter. Because she was a student in Emory’s Division of Physical Therapy, there was a clear way to get the information and experience she was looking for: Emory’s Advanced Acute Care elective. It’s the first and only preprofessional course in the United States dedicated to understanding and treating the acute care patient.

Course genesis

For course co-instructor Jenny Sharp 11DPT, the idea began with a chance meeting in an ICU at Emory University Hospital Midtown. Alex Truong, MD, MPH, had been conducting research on the benefits of early mobilization, a set of coordinated protocols to help even the sickest patients begin to sit, stand, and walk again as quickly and safely as possible. He wanted Sharp’s support in creating a protocol for treating patients in intensive care who could benefit from physical therapy.

Truong knew that physical therapists would be crucial for creating and implementing a protocol that worked. “Nurses and doctors underestimate what our patients can do physically,” says Truong, an assistant professor of medicine at Emory. “Physical therapists are best at challenging patients to optimize their functioning.”

For other health care professionals, encouraging critically ill patients to be physically active can seem counterintuitive. “All everybody sees at first is risk,” says Sharp.

Yet research shows that the adverse reaction rate for early mobility efforts is between 1% and 3%. The most common reactions are drops in oxygen saturation and blood pressure.

In addition, research by Truong and others has shown that bed rest for patients may hurt more than help. “In the old model of acute care treatment, patients just languished in bed and became very weak,” says Sharp. Recent studies show that a stint of hospital bed rest may lead to weakened states for subsequent years—including decreases in nerve conduction, debilitating muscle weakness, and resulting challenges in going back to work or family life. Research has also shown that early mobilization efforts can result in decreased complications, shorter lengths of hospital stays, and lower hospital readmission rates.

Soon, Sharp found herself serving as an early mobility coordinator at Emory University Hospital Midtown, training other staff members on the benefits of getting critically ill patients moving. At the same time, she was doing what she could to gain confidence and competency with her own acute care patients. “I was educating myself on the different equipment and medical diagnoses that you typically see in critical care,” she said.

Occasionally, Sharp would think back to her coursework at Emory. “The electives I had taken were fabulous, but none of them prepared me for what I was doing in acute care,” says Sharp. In 2012, she started drafting an email to Professor Marie Johanson, PhD, PT, OCS, who chairs the division’s curriculum committee. Might Emory be open to creating an advanced acute care elective? she asked.

groupStudents debrief a simulation and discuss fundamentals of early mobilization.

Convergence

Shortly after receiving Sharp’s email, Johanson received another on the same topic from Assistant Professor Kathy Lee Bishop, PT, DPT, CCS, a longtime advocate for physical therapy in acute care settings. Bishop had taught Sharp at Emory, but they had not been in contact since Sharp’s graduation.

For Bishop, who co-teaches the course, the idea was in response to research on early mobilization as well as the reality of chronic shortages of physical therapists in acute care facilities. Recent articles in Physical Therapy and Annals of the American Thoracic Society have named physical therapy staffing shortages in ICUs as a significant barrier to rehabilitation for acute care patients.

One hurdle to physical therapist recruitment in such settings is that many therapists have not had enough experience to be comfortable. “Even if a student did a rotation in an ICU, that wasn’t enough to create a deep passion,” says Bishop. “I wanted students to realize that they could have a career in acute care, and I wanted to create that spark of passion for them.”

When Division Director and Professor Zoher Kapasi, PhD, DPT, MBA, heard about Sharp and Bishop’s idea, he connected them and gave them the division’s backing and blessing. He was aware of the research about early mobilization and the statistics on staffing shortages. He also knew that Emory had a resource that would be crucial for the type of course Sharp and Bishop envisioned: the Emory School of Medicine simulation lab. “Given the research, the simulation lab, and the caliber of Sharp and Bishop, the decision was easy,” says Kapasi. “I hoped this course would spur some of our students to go into acute care, helping to fill a great need. This was a win-win proposition.”

Course design

Soon Sharp and Bishop began meeting to discuss course design. Given the challenges of working with acute care patients, they wanted to create strong simulation, debriefing, and didactic components, with class size capped at eight students. Both were aware that this would be the first such course in the nation.

Bishop and Sharp crafted the course to center on weekly ICU simulations, each more challenging than the previous scenario. During the first, students figure out how to treat “pneumonia” in a high-fidelity mannequin that is hooked up to a ventilator. Soon they’re dealing with simulations involving acute lung injury, stroke, and pediatric illnesses. The simulations culminate with a standardized patient experiencing multi-system organ failure.

Sharp says that no matter the simulation, students have the same tasks. “They have to learn to organize the equipment lines and figure out how to help the patient get out of bed.”

Students also learn the basics of professional communication through role-playing nurses, doctors, family members, and students from other disciplines. Says Bishop, “Interprofessional communication in this setting is crucial for patient-centered care as well as for patient and staff safety.”

In addition, each week includes a simulation debriefing and hour-long lecture. Bishop explains cardiovascular and pulmonary reviews, heart rhythms, lab values, and pharmacology, while Sharp lectures about early mobility and outcome measures. Guest speakers from fields including pediatrics, neurology, and orthopedics discuss particular challenges and needed skill sets for working with patients. The course finishes with students completing 16 hours of rotations at ICUs throughout Atlanta. “We go from bench to bedside,” says Bishop.

groupKristin Muldowney 17DPT and Spencer Ashmun 17DPT practice ‘suctioning’ through an endotracheal tube.

The student experience

The course premiered in 2014. Among its first students was Jenny (Brickman) Terry 14DPT, who now works with surgery and neurology patients at Memorial Hospital Central in Colorado Springs, Colorado. “The Advanced Acute Care elective made me more confident and comfortable in the acute care setting, particularly with patients with medically complex conditions,” says Terry. “It gave me a good foundation to understand, and then explain to patients, family members, and sometimes to physicians and nurses, that in most situations patients should not be in bed 24 hours a day.”

For alums of the class who now work in acute care, their experience in the field backs up the data. Christina Sperle 14DPT also took the course in its first year. She remembers a recent patient who transferred to her unit at Johns Hopkins Hospital in Maryland after a month spent entirely in a bed at another hospital. “During his evaluation, I helped the patient sit up for the first time in more than a month,” says Sperle. “He immediately became more alert and smiled for the first time anyone had seen since he’d entered that first hospital.” Sperle says the patient’s wife immediately began crying with relief and then spoke. “That’s the man I married.” For Sperle, the episode reinforced the power of early mobilization.

New graduate Alex Johnson, who had been so petrified of ICUs, says the course provided much-needed information and experience. Johnson recently began work at Grady Hospital in Atlanta and says she now looks forward to ICU rotations. “I have a better ability to explain to patients why we’re doing what we’re doing. I have a better understanding of what the physical therapist does in the ICU and how integral my role is.”

Outcomes

As the only such course dedicated to the acute care patient, the Advanced Acute Care elective has drawn national attention. In 2016, Bishop and Sharp reported their experience at the American Physical Therapy Association Combined Sections meeting. Earlier this year, they described the course and their early findings in the Journal of Acute Care Physical Therapy. Along with co-author Patricia Ohtake of the University of Buffalo, they report that students have increased in clinical understanding, skill, and confidence as a result of the elective.

Now in the course’s fourth year, co-instructors Bishop and Sharp are continuing to fine-tune the curriculum in hopes of enhancing outcomes even more. For the first time, current students are shadowing critical care nurses and respiratory therapists as part of the course. Says Bishop, “We want them to understand different roles in the ICU, and we want to enhance interprofessional communication, understanding of lifesaving medications and delivery formats, and understanding of oxygen delivery systems and mechanical ventilation.”

So far, more than half of students who have taken the course have chosen to find work in acute care settings. Those include Spencer Ashmun 17DPT, who began a job in acute care at the Mayo Clinic in Minnesota earlier this fall. “This class really opened my eyes on how to be safe and objective in what can seem like a chaotic and fragile environment,” he says. “I know this class has pushed me in the right direction, and I can’t stress enough how grateful I am for this course.”

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