Safety

Infection control

Standard precautions

Standard precautions are the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status. These practices are essential to reduce the risk of transmission of microorganisms in healthcare settings.

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

These precautions are used in addition to standard precautions for patients who may be infected with pathogens spread by contact, droplet, or airborne routes.

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

Assistive and adaptive devices are essential tools that enhance a patient’s functional mobility, safety, and independence. They are used temporarily or long-term, depending on the patient’s diagnosis, recovery stage, or permanent impairments. This chapter covers the most common devices, including their types, fitting, indications, contraindications, usage in stair negotiation, and wheelchair prescription.

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 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 (C4 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

Lines, tubes, and monitoring devices

Patients often arrive at therapy with medical devices attached, and the PTA needs to know how each affects positioning and mobility.

• IV lines: Keep the bag above the insertion site during transfers, and avoid tension or kinking the line.
• Urinary catheters: Keep the drainage bag below the level of the bladder at all times, and secure the tubing before moving the patient.
• Chest tubes: Keep the collection unit upright and below chest level; report sudden changes in drainage or bubbling.
• Feeding tubes: Avoid pulling or dislodging the tube during transfers.
• Monitoring devices (pulse oximeter, telemetry, blood pressure cuff): Note baseline readings, and watch for changes during activity.
• Oxygen delivery devices (nasal cannula, mask, ventilator): Confirm the prescribed flow rate, keep tubing free during mobility, and never adjust ventilator settings - report any change in respiratory status to the supervising PT.

Safety, emergency response, and professional responsibilities

PTA insight: During an emergency or adverse response, ensure the patient’s safety, collect relevant data, and report to the supervising PT rather than re-evaluating or altering the plan of care. Stop any intervention immediately for an abnormal blood pressure or heart rate response, new chest pain or shortness of breath, or marked dizziness, pallor, or diaphoresis.

Recognizing abuse and neglect

• Physical abuse: Bruising or injuries in patterns inconsistent with the reported cause, or in various stages of healing
• Sexual abuse: Unexplained genital or anal injury, pain, or sudden behavioral changes
• Psychological abuse: Fearfulness, withdrawal, or reluctance to speak in front of a caregiver
• Neglect: Poor hygiene, malnutrition, or untreated pressure injuries

Report suspected abuse or neglect as state law and facility policy require. State law often makes health care workers, including physical therapist assistants, mandated reporters in their own right, and that duty is not met by telling someone else; inform the supervising PT as well.

Emergency response procedures

Falls

Scenario: patient collapse during gait training

While ambulating a patient with a rolling walker, the patient suddenly becomes unsteady and begins to fall.

• Guide the patient to the floor using proper body mechanics - do not attempt to catch or lift them alone.
• Assess the patient for consciousness, pain, bleeding, or signs of injury.
• If no serious injury is evident, assist the patient into a seated position before standing them up.
• Notify the supervising PT and document the incident according to facility policy.

Answer: Ensure the patient’s safety, assess for injury, and report the event to the supervising PT - the PTA does not independently decide to resume treatment or alter the plan of care.

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

Disaster and emergency response

• Know the facility’s emergency codes (e.g., code red for fire) and evacuation routes
• RACE for fire response: Rescue anyone in immediate danger, sound the Alarm, Confine the fire by closing doors, then Extinguish or Evacuate
• Follow the facility’s disaster plan, prioritizing patients who cannot self-evacuate

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 and activate emergency medical services (EMS)
  2. If a second rescuer is present, send them to get an AED
  3. Check breathing and pulse simultaneously.
  4. If no pulse, start chest compressions:
     • Depth: At least 2 inches (5 cm), not exceeding 2.4 inches (6 cm)
     • Rate: 100-120 compressions/min
     • Ratio: 30 compressions: 2 breaths
  5. Use an AED as soon as available