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.

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
  • Gloves do not replace hand hygiene: clean hands before putting gloves on and after removal
• 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
• Sharps: do not bend, recap, or remove contaminated needles unless no alternative is feasible; use closable, puncture-resistant, leakproof containers

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.

For C. difficile (spore-forming), wash hands with soap and water - alcohol-based rub does not kill spores. COVID-19 calls for airborne plus contact precautions: N95 respirator, eye protection, gown, and gloves.

General isolation considerations:

• 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

Donning, doffing, and sterile technique

• Donning order: gown → mask/respirator → goggles or face shield → gloves
• Doffing order: gloves → goggles or face shield → gown → mask/respirator, then perform hand hygiene
• Sterile field basics:
  • Only sterile items may touch the sterile field
  • The edges of the field and anything below waist level are considered non-sterile
  • Never turn your back on an open sterile field
  • Discard or replace any item that may have been contaminated

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
  • Hold the cane in the hand opposite the affected or weaker LE (the unaffected side in hemiplegia); advance the cane together with the affected leg.
• Contraindication: Not appropriate as the sole device for NWB/PWB restrictions, which require crutches or a walker instead.
• Weight-bearing status (ordered by the provider): weight bearing as tolerated lets the patient load as much weight as pain allows, PWB assigns a target weight below body weight, toe-touch (TTWB) allows a small amount through the toes for balance, and NWB allows no weight on the limb
• 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
• Precaution: Avoid leaning body weight on the axillary pads - sustained pressure can compress the radial nerve in the axilla and cause crutch palsy (wrist drop); weight should be borne through the hands, not the axillary pads.
• 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
• Precautions:
  • Rolling walker: precaution for patients with festinating gait (e.g., Parkinson disease) - the walker can roll away from the patient.
  • Standard walker: poor fit/precaution for patients who cannot safely lift and advance it, such as those with significant UE 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

Wheelchair fitting and measurement

• 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 for a low back (allows scapular movement for propulsion); seat to axilla - 4 inches for a standard higher backrest
  • 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)
• Precautions: Reclining and tilt-in-space chairs are a precaution for patients prone to postural hypotension if tilted or reclined upright too quickly; lightweight/ultra-lightweight chairs are a poor fit without adequate UE strength for self-propulsion.

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.
• Mobilizing with lines and monitors (ICU/acute care): screen for hemodynamic instability; when there is none, progress from range of motion to sitting, standing and walking.
• 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

• If a patient becomes unsteady during gait training, guide them to the floor using proper body mechanics (never attempt to catch or lift them alone), assess for injury, and notify 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
• Watch for medication-related fall risk: taking 4 or more medications (polypharmacy), or any drug that causes dizziness, sedation, confusion, or orthostatic hypotension (e.g., benzodiazepines and other sedatives, antidepressants, antipsychotics, opioids, blood pressure medications). The AGS Beers Criteria list medications that are potentially inappropriate for older adults, including many that raise fall risk. Report new dizziness or drowsiness to the supervising PT.

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 cool running 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

Medical emergencies

• Hypoglycemia: Stop activity; if the patient is alert, give fast-acting sugar (e.g., juice or glucose tablets); if unresponsive, give nothing by mouth and activate EMS.
• Seizure: Protect the patient from injury, do not restrain the patient or put anything in their mouth, time the seizure, and position the patient on their side afterward; call EMS for a first-time seizure or one lasting more than 5 minutes.
• Restraint: only to ensure immediate physical safety, and only on the order of a physician or other licensed practitioner responsible for the patient’s care, so a PTA cannot start one independently.
• Autonomic dysreflexia (SCI at T6 or above): Sit the patient upright, check for and remove the triggering stimulus (e.g., full bladder, tight clothing), monitor blood pressure, and seek emergency care if symptoms don’t resolve quickly.

Disaster and emergency response

• Know the facility’s emergency codes (e.g., code red for fire) and evacuation routes
• Code blue: cardiac or respiratory arrest needing resuscitation
• 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

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

The recovery position is for a person who is unresponsive but breathing normally; if not breathing normally, do not use it and start CPR straight away. Abdominal thrusts are for a conscious choking victim; chest compressions for an unconscious one.

Safe patient handling

• Use a wide base of support, keep the load close to the body, avoid twisting the trunk, and lift with the legs rather than the back
• Lock wheelchair and bed brakes before every transfer
• Use a mechanical lift for patients who cannot bear weight (a dependent, full-body sling lift) or who exceed safe manual-lift limits
• A sit-to-stand lift can be used only by patients who can bear some body weight
• Check the sling size and condition before use, and follow facility policy for two-person assist

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