Use of an expert panel to identify domains and indicators of delirium severity.

PURPOSE: Our purpose was to create a content domain framework for delirium severity to inform item development for a new instrument to measure delirium severity. METHODS: We used an established, multi-stage instrument development process during which expert panelists discussed best approaches to measure delirium severity and identified related content domains. We conducted this work as part of the Better ASsessment of ILlness (BASIL) study, a prospective, observational study aimed at developing and testing measures of delirium severity. Our interdisciplinary expert panel consisted of twelve national delirium experts and four expert members of the core research group. Over a one-month period, experts participated in two rounds of review. RESULTS: Experts recommended that the construct of delirium severity should reflect both the phenomena and the impact of delirium to create an accurate, patient-centered instrument useful to interdisciplinary clinicians and family caregivers. Final content domains were Cognitive, Level of consciousness, Inattention, Psychiatric-Behavioral, Emotional dysregulation, Psychomotor features, and Functional. Themes debated by experts included reconciling clinical geriatrics and psychiatric content, mapping symptoms to one specific domain, and accurate capture of unclear clinical presentations. CONCLUSIONS: We believe this work represents the first application of instrument development science to delirium. The identified content domains are inclusive of various, wide-ranging domains of delirium severity and are reflective of a consistent framework that relates delirium severity to potential clinical outcomes. Our content domain framework provides a foundation for development of delirium severity instruments that can help improve care and quality of life for patients with delirium.

A Retrospective Analysis of Ischemic Stroke Patients Supports That Very Early Mobilization Within 24 Hours After Intravenous Alteplase Is Safe and Possibly Beneficial.

ABSTRACT: BACKGROUND: Stroke care guidelines recommend early mobilization of acute ischemic stroke patients, but there are sparse data regarding early mobilization of stroke patients receiving thrombolytic therapy. We developed the Providence Early Mobility for Stroke (PEMS) protocol to mobilize patients to their highest individual tolerance within 24 hours of stroke admission in 2010, and it has been in continuous use at our primary and comprehensive stroke centers for over a decade. In this study, we evaluated the PEMS protocol in all patients treated with intravenous alteplase without endovascular treatment. METHODS : This retrospective study includes 318 acute ischemic stroke patients treated with alteplase who were admitted to 2 urban stroke centers between January 2013 and December of 2017 and were mobilized with the PEMS protocol within 24 hours of receiving alteplase. Safety of PEMS was assessed by change in National Institutes of Health Stroke Scale at 24 hours by time first mobilized. Using multivariate and logistic regression models, we analyzed time first mobilized and 90-day modified Rankin scale (mRS). RESULTS : Median time first mobilized was 9 hours from administration of alteplase. For every hour delay in mobilization, the odds of being slightly or moderately disabled (mRS, 2-3) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .004), and the odds of being severely disabled or dead (mRS, 4-6) at 90 days increased by 7% (adjusted odds ratio, 1.07; P = .02). In addition, for every hour delay in mobilization, 24-hour National Institutes of Health Stroke Scale increased by 1.8%. DISCUSSION: Our results support that the PEMS protocol is safe, and possibly beneficial, for acute ischemic stroke patients treated with intravenous alteplase. Our protocol differs from other very early mobility protocols because it does not prescribe a "dose" of activity. Instead, each patient was mobilized to his/her individual highest degree as soon as it was safe to do so.

Teaching to Lead: One Program's Experience With Integrating Personal Leadership Into a Doctor of Physical Therapy Curriculum.

BACKGROUND AND PURPOSE: Doctor of Physical Therapy (DPT) programs accept responsibility for the development of clinical skills and professional behaviors in students. Academic and clinical faculty endeavor to teach and mentor at the highest levels. Doctor of Physical Therapy programs that develop leadership intentionally, specifically personal, or self-leadership may be successful in leading positive change within their graduates' relationships, environments, and patient outcomes. Personal leadership means leading from within as an individual and does not require the individual to have a leadership title or role. It includes characteristics such as authenticity, passion, emotional intelligence, trustworthiness, and credibility. CASE DESCRIPTION: This case report will unveil how 1 established residential DPT program integrated personal leadership explicitly as a curricular thread. The 3 pillars are leading self, leading others, and leading systems: organizations and communities. The program used evidence-based processes used to build materials, learning activities, and assessments. The program achieved purposeful integration, including academic/clinical faculty development and progressive student learning experiences. OUTCOMES: Program assessment through focus groups and curricular surveys shows that students value the curricular content in personal leadership and are meeting the curricular thread behavioral objectives. DISCUSSION AND CONCLUSION: The personal leadership curricular thread shows promise to promote leadership behaviors in students and graduates.

The Relationship Between Professionalism and Leadership: Parent-Child or Sibling?

Professionalism has been the foundation of physical therapy's contract with society, with the American Physical Therapy Association's (APTA) Core Values and Code of Ethics serving as its building blocks. Professional formation has focused on professionalism and has been taught in a manner that is more implicit than explicit in doctor of physical therapy (DPT) curricula. As a domain of competence, professionalism alone has not been broad enough to meet societal needs. In reaching our centennial year, many have reflected on what competencies are needed to move forward. The need for leadership competencies is not new and has been espoused by our leaders over the past 100 years. Some advocate for the adoption of leadership as a unique domain of competence, separate from the domain of professionalism, whereas others propose that either professionalism or leadership is one domain of competence that subsumes the other. The purpose of this Perspective is twofold: to compare and contrast the concepts of professionalism and leadership, and to make recommendations regarding what constitutes domains of competence within the professional formation of physical therapists. This Perspective offers recommendations addressing professional formation and the adoption of leadership and professionalism as 2 distinct domains of competence and discusses educational and clinical implications of the recommendations. This Perspective asserts that these recommendations must be adopted to move the profession forward into the next century so that physical therapists are recognized as adding value to the health care system and the evolving needs of society.

Exploring the Concept of Leadership from the Perspective of Physical Therapists in the United States.

Purpose: The purpose of this study was to examine the perceptions of physical therapists practising in the United States of the importance of leadership characteristics and of demographic traits and other factors that might be associated with perceptions of leadership in three contexts: workplace, health care system, and society. Method: An online questionnaire was distributed through snowball sampling to physical therapists practising in the United States over an 8-week period between October and November 2019. A total of 15 leadership characteristics were rated on a 5-point scale of importance. Results: A total of 278 physical therapists responded to the questionnaire. They rated communication and professionalism as the top two leadership characteristics across all settings. Self-awareness and business acumen were not perceived as important for leadership. No relationship was found between gender and self-declaration as a leader or between a participant's practice setting and their rating of the importance of leadership characteristics. Conclusions: Our results further the discussion of leadership in the physical therapy profession. They highlight a comprehensive acceptance of leadership characteristics as important regardless of context. Further work will be necessary to transition this declaration of the importance of leadership skills to identifying the essential leadership skills for physical therapist education and clinical practice.

Objectif : examiner les perceptions des physiothérapeutes des États-Unis à l'égard de l'importance des caractéristiques de leadership, des caractéristiques démographiques et d'autres facteurs susceptibles d'être associés aux perceptions de leadership dans trois contextes : le milieu de travail, le système de santé et la société. Méthodologie : distribution en ligne d'un questionnaire par échantillonnage en boule de neige aux physiothérapeutes qui exercent aux États-Unis, sur une période de huit semaines entre octobre et novembre 2019. Au total, les chercheurs ont évalué 15 caractéristiques de leadership sur une échelle de cinq points. Résultats : au total, 278 physiothérapeutes ont répondu au questionnaire. Ils ont classé la communication et le professionnalisme au sommet des caractéristiques du leadership dans tous les contextes. Ils n'ont pas perçu la conscience de soi ni le sens des affaires comme des éléments importants du leadership. Ils n'ont constaté aucun lien entre le genre et l'autodéclaration de leader ou entre le milieu de pratique d'un participant et son classement de l'importance des caractéristiques de leadership. Conclusion : les résultats font évoluer les échanges sur le leadership dans la profession de la physiothérapie. Ils font ressortir l'acceptation complète de l'importance des caractéristiques du leadership, quel que soit le contexte. D'autres travaux s'imposent pour faire transiter cette déclaration sur l'importance des capacités de leadership vers la détermination des compétences de leadership essentielles pour l'enseignement de la physiothérapie et la pratique clinique.

Self-Leadership Is Critical for All Physical Therapists.

Evidence that supports the explicit need to develop leadership skills at all levels of clinical practice is prevalent,1-8 yet intentional development of "self-leadership" within health care, and particularly within physical therapy, remains slow, fragmented, and inconsistent. Delineation and standardization of the definition of leadership, and the approach to developing leadership skills in individuals practicing within health care continues to be debated, producing several key dilemmas. Moreover, there is a lingering misperception that developing leadership capacity is reserved for physical therapists who assume positional or formal roles as "leaders" within communities, health care organizations, practices, or teams. This misperception focuses leadership development on "leading others" rather than "leading self." Similarly, challenges exist between balancing the leadership development needs of the leader as a positional role and the act of "leading" as physical therapists practice and engage within all levels of care and within different communities-as individuals and within teams. This tension further complicates when and how best to prepare physical therapists to meet this essential skill set in clinical practice. The purpose of this perspective is to describe nonpositional self-leadership and its importance to physical therapy practice, to propose common or contemporary leadership-related terminology, and to suggest a framework for leadership development. Through accomplishing these purposes, readers may be encouraged to change and adopt recommendations.

Health Competency Standards in Physical Therapist Practice.

Although the physical therapist profession is the leading established, largely nonpharmacological health profession in the world and is committed to health promotion and noncommunicable disease (NCD) prevention, these have yet to be designated as core physical therapist competencies. Based on findings of 3 Physical Therapy Summits on Global Health, addressing NCDs (heart disease, cancer, hypertension, stroke, diabetes, obesity, and chronic lung disease) has been declared an urgent professional priority. The Third Summit established the status of health competencies in physical therapist practice across the 5 World Confederation for Physical Therapy (WCPT) regions with a view to establish health competency standards, this article's focus. Three general principles related to health-focused practice emerged, along with 3 recommendations for its inclusion. Participants acknowledged that specific competencies are needed to ensure that health promotion and NCD prevention are practiced consistently by physical therapists within and across WCPT regions (ie, effective counseling for smoking cessation, basic nutrition, weight control, and reduced sitting and increased activity/exercise in patients and clients, irrespective of their presenting complaints/diagnoses). Minimum accreditable health competency standards within the profession, including use of the WCPT-supported Health Improvement Card, were recommended for inclusion into practice, entry-to-practice education, and research. Such standards are highly consistent with the mission of the WCPT and the World Health Organization. The physical therapist profession needs to assume a leadership role vis-à-vis eliminating the gap between what we know unequivocally about the causes of and contributors to NCDs and the long-term benefits of effective, sustained, nonpharmacological lifestyle behavior change, which no drug nor many surgical procedures have been reported to match.

Trajectories of Community Mobility Recovery After Hospitalization in Older Adults.

OBJECTIVES: To identify trajectories of recovery of community mobility in acutely ill older adults using the University of Alabama at Birmingham Life-Space Assessment (LSA). DESIGN: Prospective observation cohort study. SETTING: Central Alabama, Birmingham Veterans Affairs Medical Center. PARTICIPANTS: Community-dwelling adults aged 65 and older hospitalized for nonsurgical medical reasons (N=173). MEASUREMENTS: We determined LSA scores for the month before and monthly for 6 months after hospitalization (composite scores ranging from 0-120, with 120 reflecting completely unrestricted mobility). RESULTS: In the month after hospitalization, 92 (53%) participants had a clinically significant decrease in life-space mobility, while 42 (24%) were unchanged, and 39 (23%) had an increase from the month preceding hospitalization. Of participants with a life-space decrease, the majority recovered their prehospitalization mobility status during 6 months of follow-up, whereas 34% did not recover. Participants whose life-space decreased were hospitalized significantly longer (P=.01) and, on average, had higher prehospital life-space scores (P=.01) than those who maintained or increased their life-space. CONCLUSION: A clinically significant loss of community mobility was common after hospitalization, but most participants recovered to prehospitalization mobility within 6 months of discharge. Research examining in-hospital and posthospitalization interventions to achieve faster recovery of community mobility is needed.

Comparing hand washing to hand sanitizers in reducing elementary school students' absenteeism.

PURPOSE: To compare the efficacy of an alcohol-based hand sanitizer to standard hand washing in reducing illness and subsequent absenteeism in school-age children. METHOD: A randomized cross-over design was used with 18 classrooms of 2nd and 3rd grade students (n = 383) from 4 elementary schools. Half of the classes from each school used an anti-microbial gel hand sanitizer while the other half used soap and water for regular hand hygiene for 2 months, then, the students switched cleaning methods for the following 2 months. RESULTS: No significant differences in absenteeism rates were demonstrated. A follow-up focus group comprised of teachers and school nurses indicated that hand sanitizers were preferred over soap and water. CONCLUSION: Hand sanitizers are an appropriate alternative to hand washing for hand cleansing and may offer additional benefits in the school setting.

A Model to Integrate Health Promotion and Wellness in Physical Therapist Practice: Development and Validation.

BACKGROUND: Globally, physical therapy professional organizations have called for physical therapists to perform lifestyle behavior management during customary care, or health-focused care, due to increasing morbidity and mortality related to noncommunicable diseases. Given the potential for health-focused care to improve health outcomes, physical therapists should integrate health promotion into their daily clinical practice. A clinical model that illustrates necessary steps to deliver health-focused care would be helpful to educate present and future physical therapists. OBJECTIVE: The purpose of the study was to develop and validate the Health-Focused Physical Therapy Model (HFPTM) for physical inactivity and smoking. METHODS: The authors used a mixed method approach. The preliminary model was informed by previous research and the investigators' shared experience in health promotion and physical therapy. An interdisciplinary group of health professionals provided input into the preliminary model by way of a World Café format. Eight physical therapists with health promotion and education expertise then engaged in a Delphi process to establish content validity. RESULTS: World Café participants indicated that: (1) physical therapists are well positioned to engage in health promotion and wellness, and (2) the model facilitates interdisciplinary collaboration and consultation. Delphi process participants reached majority consensus in 1 round. The average model content validity index (CVI) was .915 for physical inactivity and .899 for smoking. Agreement concerning the model schematic was 88% for either behavior. Investigators made few editorial changes after the Delphi process. LIMITATIONS: Limitations of this study include using only 2 unhealthy lifestyle behaviors for testing, and performing the testing in a nonclinical setting. CONCLUSIONS: An interdisciplinary group of health professionals believes that physical therapists should practice health-focused care and that the HFPTM is a valid model. This model could help physical therapist educators when educating physical therapist students and clinicians to practice health-focused care.

Effectiveness of an early mobilization protocol in a trauma and burns intensive care unit: a retrospective cohort study.

BACKGROUND: Bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU) have detrimental effects. Studies in medical ICUs show that early mobilization is safe, does not increase costs, and can be associated with decreased ICU and hospital lengths of stay (LOS). OBJECTIVE: The purpose of this study was to assess the effects of an early mobilization protocol on complication rates, ventilator days, and ICU and hospital LOS for patients admitted to a trauma and burn ICU (TBICU). DESIGN: This was a retrospective cohort study of an interdisciplinary quality-improvement program. METHODS: Pre- and post-early mobility program patient data from the trauma registry for 2,176 patients admitted to the TBICU between May 2008 and April 2010 were compared. RESULTS: No adverse events were reported related to the early mobility program. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post-early mobility program. Ventilator days and TBICU and hospital lengths of stay were not significantly decreased. LIMITATIONS: Using a historical control group, there was no way to account for other changes in patient care that may have occurred between the 2 periods that could have affected patient outcomes. The dose of physical activity both before and after the early mobility program were not specifically assessed. CONCLUSIONS: Early mobilization of patients in a TBICU was safe and effective. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the ICU.

Medicolegal considerations with intravenous tissue plasminogen activator in stroke: a systematic review.

Background. Intravenous tPA (tissue plasminogen activator) therapy remains underutilized in patients with Acute Ischemic Stroke (AIS). Anecdotal data indicates that physicians are increasingly liable for administering and for failure to administer tPA. Methods. An extensive search of Medline, Embase, Westlaw, LexisNexis Legal, and Google Scholar databases was performed. Case studies that involved malpractice litigation in ischemic stroke and thrombolytic therapy were analyzed systematically. Results. We identified 789 ischemic stroke litigation cases, of which 46 cases were related to intravenous tPA and stroke litigation. Case descriptions of 40 cases were available. Data for verdicts were available for 38 patients. The most frequent plaintiff claim was related to failure to administer intravenous tPA (38, 95%). Only 2 (5.0%) claim involved complications of treatment with tPA. Hospitals were defendants in majority of the 36 cases. Physicians were involved in 33 cases. While ED physicians were involved in 25 (60.52%) cases, neurologists were involved in 8 (20.0%) cases. There were 26 (65%) defendant-favored and 12 (30%) plaintiff-favored verdicts. Conclusion. Physicians and hospitals are at an increased risk of litigation in patients with AIS when in IV-tPA is being considered for treatment. While majority of the cases litigated were cases where tPA was not administered, only about 1 in 20 cases was litigated when complications occurred.

Physical therapy management of a patient on portable extracorporeal membrane oxygenation as a bridge to lung transplantation: a case report.

INTRODUCTION: Although the life expectancy for patients with cystic fibrosis (CF) has increased dramatically in the preceding decades, often the final therapeutic option for patients with end-stage CF is lung transplantation. Prior to transplantation, patients with severe disease may require mechanical ventilation. Those refractory to mechanical ventilation may require extracorporeal membrane oxygenation (ECMO). The purpose of this case report is to describe the physical therapy management of a patient who received ECMO as a bridge to lung transplantation. CASE PRESENTATION: A 16-year-old girl with severe acute respiratory failure due to a CF exacerbation eventually required ECMO to maintain adequate gas exchange. While on ECMO, she received physical therapy interventions ranging from therapeutic exercise, manual therapy, and integumentary protection techniques in addition to airway clearance techniques. Prior to her transplant, she was standing multiple times per day with moderate assistance, was sitting on the edge-of-bed, as well as taking steps to transfer to/from a chair. She successfully received a bilateral lung transplant after 8 days on ECMO. CONCLUSION: Physical therapy interventions, including out-of-bed mobility, can be safely provided to patients on portable ECMO as a bridge to lung transplantation. These interventions were focused on preventing the negative sequelae of bed rest, increasing her strength and endurance, as well as improving her level of consciousness and psychological well being in preparation for lung transplantation.

Devastating cerebral air embolism after central line removal.

BACKGROUND: Air embolism is a well-published complication arising from central venous catheter use. Literature and case studies provide information regarding clinical sequelae. Preventable mistakes still occur despite following what is considered appropriate protocol. This case report describes the neurological complications likely caused by a cerebral air embolism related to central venous catheter removal. CASE: An 84-year-old man was admitted to the neuroscience critical care unit with acute stroke symptoms and seizures after removal of a central venous catheter. CONCLUSION: There is an abundance of literature describing best practice, complications, and treatment of venous air embolism associated with central line catheter use. Utilization of central venous catheters is increasing. With increased utilization comes the responsibility to improve commonplace knowledge and ensure that practice guidelines and protocols are dependable and consistent.

Strategies for optimizing nutrition and weight reduction in physical therapy practice: the evidence.

Poor nutrition and obesity can directly lead to pathological conditions managed by physical therapists or negatively influence recovery from movement dysfunction. The physical therapist/client relationship provides an opportunity for screening for poor nutrition as well as recommending and supporting better nutrition practices by the clients under their care. As such, it is important for the physical therapy professional to understand optimal nutrition for healthy living and serve as a consultant for better nutrition for their clients. To achieve this end, this article addresses strategies for identifying nutritional trends for the specific groups of clients, screening for nutritional problems, assessing clients' readiness to change eating habits, providing useful information and resources concerning optimal nutrition, and recognizing the need for referral to nutrition professionals.

ERBB4/HER4 potentiates STAT5A transcriptional activity by regulating novel STAT5A serine phosphorylation events.

The epidermal growth factor receptor family member ERBB4 is required for mammary gland development and lactation. ERBB4 activities in the breast are mediated through the signal transducer and activator of transcription (STAT) family member STAT5A, and ERBB4 directly activates STAT5A, in part, through phosphorylation of STAT5A at the regulatory Tyr-694. Here we show that STAT5A regulation by ERBB4 is also mediated through STAT5A serine phosphorylation. Using a reverse-phase high performance liquid chromatography tandem mass spectrometry analysis of proteolytically digested STAT5A coexpressed with ERBB4, we identified STAT5A serine phosphorylations at the previously described Ser-779 and at the novel Ser-127/Ser-128. Immunohistochemistry of wild-type and ERBB4-null mammary glands at late pregnancy showed that ERBB4 expression was required for STAT5A phosphorylation at Ser-779. Independent serine-to-alanine residue substitutions in full-length STAT5A revealed that although STAT5A Ser-779 phosphorylation was dispensable for phosphorylation of STAT5A at Tyr-694 and subsequent DNA binding, Ser-779 was required to stabilize an interaction with ERBB4 and mediate ERBB4-induced STAT5A stimulation of gene expression. STAT5A Ser-127/Ser-128, on the other hand, was required for ERBB4-induced phosphorylation of Tyr-694, whereas Ser-779 and as yet unidentified tyrosine residues were phosphorylated in the absence of Ser-127/Ser-128. In addition, STAT5A S127A/S128A remained associated with ERBB4 but failed to bind DNA or activate transcription in response to ERBB4 coexpression. Our studies demonstrate that phosphorylation of STAT5A at Ser-127/Ser-128 and Ser-779 are obligatory events regulating ERBB4-mediated activation of STAT5A.

The reality of a self-occluding pump head: Case report.

A malfunction of an oxygenator pumphead during aortocoronary bypass surgery is described. Corrections were made and the operation proceeded without further incident. Although this malfunction is extremely rare, it is reviewed in detail to alert perfusionists to the possibility of such an occurrence.

Evaluation of a new modified pediatric bubble oxygenator.

A comparison was made of the S-070 Pediatric Bubble Oxygenator, which was unreliable above flow rates of approximately 1.5 L/min, with a modified S-070A, which proved to be extremely efficient to flow rates of 2.5 L/min.

Use of cardiopulmonary bypass, hypothermic perfusion, and circulatory arrest in the surgical management of basilar artery aneurysm.

Two cases of intracranial aneurysm are discussed in relation to surgical management. The superiority of vena cavae/ascending aorta to femoral vein/femoral artery cannulation is indicated, thus minimizing ventricular fibrillation and myocardial damage.