TRAINING MODULE FOR OCCUPATIONAL AND PHYSICAL THERAPISTS IN THE NICU

Presented by Lisa Bader, OTR/L, CEIM August, 2008

PURPOSE  To provide a systematic structure of learning for OT’s and PT’s who want to work in the NICU  Ensure that the quality of care given by therapists in our NICU is world-class and recognized as such by other members of the NICU team  Follow national AOTA and APTA guidelines for therapists working in the NICU

WHAT ARE THE GUIDELINES?  AOTA and APTA have similar articles and guidelines written regarding OT and PT services in the NICU  Both emphasize the specialized knowledge required to practice in the NICU because of the medical fragility and developmental variability of NICU infants  “Interactions and therapeutic interventions that may appear innocuous can trigger physiologic instability in an infant and can be life threatening.” (AOTA, 2006).

OUR SPECIFIC TRAINING MODULE  Each specific area of 5 page outline from AOTA’s guidelines was addressed  For example, outline reads as follows:  D. Formulate an individualized therapeutic intervention plan  1. Determine appropriate timing of infant interventions on basis of medical and physiological status, postconceptual age, and NICU routines  2. Modify sensory aspects of physical environment according to infant threshold  3. Participate with infant and caregivers in interventions that reinforce the role of the family and support the infant’s medical and physiological status

D. Formulate an individualized therapeutic intervention plan D. Formulate an individualized therapeutic intervention plan  1. Determine appropriate timing of infant interventions on basis of medical....  In general, infant evaluations and treatments are done prior to a “care time” to allow the infant to have as much sleep and undisturbed time as possible. Often, a therapist finds out what the care times are for a particular baby and then requests to see the baby minutes prior depending on how long a session is planned. Older infants may tolerate close to minutes where a younger premie may not even tolerate 15 minutes. Nevertheless, this is the general guidelines followed at this time. However, it is important to determine the timing of assessments and interventions according to that individual infant. “Safety for the infant takes priority over convenience for the therapist in all aspects of care.” (Case-Smith, 2001, p. 652). An evaluation may have to be done in parts and no part of an evaluation should be done if it is not necessary. The evaluation can be almost entirely completed through clinical observation of the infant. (Als, 1986).

D. Formulate an individualized therapeutic intervention plan  2. Modify sensory aspects of physical environment according to infant threshold  Sensory stimulation is constant in the life of a baby in the NICU. Noise from machines, phones, voices; tactile input from I.V. lines, NG tubes, oxygen, CPAP; lights, position changes, nursing procedures and cares-the list can go on and on. With all of the sensory stimulation the infant must endure just to maintain his/her medical status, therapists must be aware of the infant’s physical environment and modify it as needed. Physical environment modification may include the use of positioning devices to decrease the effects of gravity or make an invasive tube more tolerable to the infant. Using the frog for example over a baby’s back or torso, allows constant firm pressure for small premies or those that are easily agitated. During position changes...

D. Formulate an individualized therapeutic intervention plan  3. Participate with infant and caregivers in interventions that reinforce the role of the family and support the infant’s medical and physiological status  The infant’s medical and physiologic status guides all interventions. The therapist may be planning a specific intervention but the baby may be telling her “not today.” As stated previously, the infant’s status dictates all interventions. With that said, there are many ways the NICU therapist can reinforce the role of family in the NICU.....

What do other hospitals have around the country?  Literature review comes up with nothing  Most practitioners agree and feel strongly about who should or should not work in the NICU  Lots of definitions about OT and PT roles in the NICU but OT/PT are almost always part of the team (examples)-YEAH!!!!  1996 AJOT article which surveyed 174 NICU therapists showed inadequate training of NICU therapists and therapists expressed a desire for specialized training to work in this practice area

Requirements  Our goal is to have 2 OT’s and 2 PT’s trained to work in the NICU—this will help deal with staffing issues and have near 7 day coverage  The initial requirements may be changed according to an individual therapist’s past work experience  A therapist must have a minimal of 2 years experience as a licensed therapist before entering the NICU independently

Requirements (Cont.)  40 pediatric patients—must see for evaluation and at least 1 additional visit  8 infants—either outpatient or from pediatric floor and complete in-depth care plans on each with specific treatment techniques  Write a 3 page paper on any of the following subjects with literature review and references included  Family stress in the NICU  Bonding/Attachment as it relates to the NICU  Risks of developmental problems in premature infants and ways to identify those infants  Movement and posture in premature infants  Any other topic you find interesting

Requirements (Cont.)  Complete tests on infant and NICU environment  Interview one family about their NICU experience and write a paper about your findings  Attend infant massage inservice  Attend developmental care inservice  Watch specific CD’s/videos listed  6 month mentorship period in NICU

Example Test Questions  Name 3 different types of brachial plexus injuries, therapy interventions for each, and prognosis.  An infant was born 8 weeks premature and is now 6 months old. What is the infant’s corrected age?  When looking at an infant’s physiologic status, name 5 things that can be observed.  Name 3 types of sensory input in the NICU that is disruptive to the infant’s neurobehavioral organization.

Test questions during mentoring period  A baby must have splints on his feet but has poor skin integrity resulting in pressure areas from the splints. What would you do? What could your wearing schedule be? How could you prevent pressure areas?  You are planning to see a baby for a treatment. Care times are at and 5. The RN says, “You can see the baby anytime.” When is it appropriate to see the baby “anytime”?  When would it be appropriate to discharge a baby from OT/PT services before they are discharged home from the NICU?

References  American Occupational Therapy Association. (2006). Specialized knowledge and skills for occupational therapy practice in the neonatal intensive care unit. American Journal of Occupational Therapy, 60, 110 – 123.  Als, H. (1982). Toward a synactive theory of development: promise for the assessment of infant individuality. Infant Mental Health Journal, 3,  Case-Smith, J. (2001). Occupational therapy for children. St. Louis: Mosby.  Sweeney, J. K., Heriza, C. B., Reilly, M. A., Smith, C., VanSant, A. F.(1999). Practice guidelines for the physical therapist in the neonatal intensive care unit. Pediatric Physical Therapy, 11, 3,