Safety

Infection control

Standard precautions

Key components

• Hand hygiene:
  • Wash hands with soap and water or use alcohol-based hand sanitizer before and after patient contact, before performing aseptic tasks, after exposure to bodily fluids, and after contact with patient surroundings
• Use of personal protective equipment (PPE):
  • Gloves: Worn when anticipating contact with blood, body fluids, mucous membranes, or non-intact skin
  • Gowns: Worn to protect clothing and skin during procedures likely to generate splashes or sprays
  • Mask and eye protection: Worn if there is a risk of splash or spray to the face
• Respiratory hygiene/cough etiquette:
  • Instruct symptomatic individuals to cover their mouth/nose when coughing or sneezing, and perform hand hygiene.
• Equipment disinfection:
  • Clean and disinfect patient care equipment and surfaces between each use

Transmission-based precautions

Contact precautions

• Examples: MRSA, C. difficile, VRE, Scabies
• Transmission: Direct contact with infected patients or contaminated surfaces
• PPE:
  • Gloves and gown upon room entry.
  • Dedicated patient equipment or thorough disinfection between uses.
• Hand hygiene: Perform before and after patient contact.
• Room Consideration: Private room preferred, or cohorting with patients with the same infection

Droplet precautions

• Examples: Influenza, Mumps, Rubella, Pertussis
• Transmission: Large respiratory droplets (>5 microns) from coughing, sneezing, or talking
• PPE:
  • Surgical mask within 3–6 feet of the patient.
  • Eye protection if risk of splash or prolonged exposure.
• Room Consideration: Private room; door may remain open

Airborne precautions

• Examples: Tuberculosis, Measles, Varicella (Chickenpox)

• Transmission: Small airborne particles (<5 microns) suspended in the air

• PPE:

  • N95 respirator or higher-level protection.

• Room Consideration:

  • Patients should be placed in a negative-pressure airborne infection isolation room
  • The room door must remain closed

• Schedule immunocompromised or high-risk patients at times when traffic is minimal

• Isolate or cohort patients known or suspected to be infected to prevent cross-contamination

• COVID-19 is airborne, and droplet precautions are combined.

Assistive and adaptive devices

Types of assistive devices

Canes

• Types:
  • Standard (Straight) Cane: For mild balance issues
  • Quad Cane: Offers a wider base of support; used for moderate balance deficits
    • Small-base quad cane (SBQC)
    • Large-base quad cane (LBQC)
• Indications:
  • Minor balance impairments
  • Hemiplegia (can be used on the unaffected side)
• Fitting:
  • Handle at wrist crease when standing upright
  • Elbow flexed ~20–30°

Crutches

• Types:
  • Axillary crutches: Temporary use; moderate to high support
  • Forearm (Lofstrand) crutches: Long-term use; for patients with good trunk control
• Indications:
  • NWB, PWB conditions
  • Neurological or orthopedic impairments
• Fitting:
  • Axillary: 2 inches below axilla, handgrip at wrist crease, 20–30° elbow flexion
  • Forearm: Cuff 1–2 inches below olecranon

Walkers

• Types:
  • Standard walker (SW): Maximum support, must lift to advance
  • Rolling walker (RW): Easier to use for patients with endurance/balance deficits
  • Platform walker: For patients unable to bear weight through the wrist/hand
• Indications:
  • Severe balance/coordination issues
  • Generalized weakness
• Fitting:
  • Handles at wrist crease with 20–30° elbow flexion

Stair training and gait patterns with devices

Stair training principles

• Up with the good, down with the bad.
• Ascend: Unaffected leg → assistive device + affected leg
• Descend: Assistive device → affected leg → unaffected leg
• Guarding:
  • Ascending stairs: Therapist stands behind the patient
  • Descending stairs: Therapist stands in front

Gait patterns

• 2-point gait: One device and opposite leg move together – for FWB, balance issues
• 3-point gait: Device(s) advance → non-weight-bearing leg swings → weight-bearing leg follows
• 4-point gait: One device → opposite leg → other device → other leg – for maximum stability
• Swing-to/swing-through gait: Crutches move forward → both legs swing forward to or past them – for paraplegia or bilateral LE weakness

Fitting and measurement wheelchairs

Accurate fitting is critical to ensure safety, comfort, and effectiveness:

• Wheelchairs:
  • Seat width: Widest point of hips + 2 inches
  • Seat depth: Posterior buttocks to popliteal fold – 2 inches
  • Seat height: Heel to popliteal fold + 2 inches (for footrests)
  • Back height: Seat to inferior angle of scapula
  • Armrest Height: Seat to bent elbow + 1 inch

Wheelchair types, modifications, and prescription

Types of wheelchairs

• Standard wheelchair: Temporary use, self-propelled or assisted
• Lightweight / ultra-lightweight: For active users or those with limited strength
• Reclining wheelchair: For patients with postural hypotension or poor trunk control
• Tilt-in-space wheelchair: Maintains hip/knee angle; ideal for spasticity or skin pressure management
• Power wheelchair: Used when minimal upper limb strength is available (ALS, high SCI)

Common modifications

• Anti-tippers: Prevent backward tipping
• Lap belts: Enhance safety
• Elevating leg rests: For lower extremity edema or post-op recovery
• Pressure relief cushions: Prevent ulcers
  • Foam: Light and low-cost
  • Gel: Distributes pressure well
  • Air (Roho): Best for high-risk patients

Special populations

• Hemiplegia: Lower seat height for propulsion using one leg
• SCI (C6–C8): Lightweight manual wheelchair or power-assist
• SCI (C5 or higher): Power chair with head/chin or sip-and-puff controls
• Amputees: Rear axle moved posteriorly to improve stability
• Bariatric Patients: Wider, reinforced frames

Safety, emergency response, and professional responsibilities

Emergency response procedures

Falls

• Immediate action:
  • Stay with the patient; do not attempt to lift them alone. *
  • Assess the patient for consciousness, pain, bleeding, or signs of injury
    • If no serious injury is evident, assist them into a seated position
    • Notify appropriate medical personnel and document the incident
• Prevention:
  • Use gait belts during ambulation
  • Remove environmental hazards (e.g., loose rugs, clutter).
  • Ensure proper footwear and assistive device use

Burns

• Types: Thermal, chemical, electrical
• Initial response:
  • Remove the source of the burn (e.g., hot packs, modality equipment)
  • For thermal burns, cool the area with lukewarm water—not ice
  • Cover with a sterile, non-adhesive dressing
  • Refer for further medical evaluation for moderate or severe burns
  • Document the cause and response

Equipment safety and maintenance

• Regularly inspect all equipment (e.g., electrical stimulation units, treadmills, lifts).
• Safety checks include:
  • Frayed cords or damaged plugs
  • Calibration and function of mechanical devices
  • Battery power for mobile units
• Maintenance logs:
  • Keep updated records of routine inspections and servicing
• Patient use safety:
  • Provide instruction and supervision during initial use of equipment
  • Ensure proper cleaning between patients to reduce infection risk

Cardiopulmonary resuscitation (CPR)

• Basic life support (BLS) steps - adults:
  1. Check responsiveness andactivate emergency medical services (EMS)
  2. If there are 2 people, send one get an AED
  3. Check breathing and pulse simultaneously.
  4. If no pulse, start chest compressions:
     • Depth: At least 2 inches
     • Rate: 100–120 compressions/min
     • Ratio: 30 compressions: 2 breaths
  5. Use an AED as soon as available