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Toni Talks about PT Today

Therapists Should Determine Frequency

Published September 25, 2008 7:59 AM by Toni Patt
Last week I had a situation at work that caused some controversy. A patient's wife was insisting her husband be seen twice daily. There were no orders for this. Nothing supporting this was present in the chart. However she was adamant her husband be seen twice daily. Even this week I have no idea where the idea came from. The situation was complicated by nursing. Rather than tell her our rehab policy was once daily, they obtained BID order for therapy. I'm not sure which part of this makes me more upset. 

I understand nursing was caught in the middle. They were receiving the majority of her complaints. However, I think they should have reinforced hospital policy and let rehab deal with the problem. The order was obtained without consideration of the appropriateness of the patient. This particular patient ambulates with SBA. He is nearly beyond needing skilled intervention. Obtaining an order for a treatment because a family member wants it is not my idea of good nursing. It's also determining a piece of the PT POC. Since no nurse would appreciate a PT telling him or her how to perform nursing, we should be given the same respect. 

This isn't the first time I've run into this sort of thing. Attitudes of patients and families in hospitals have changed. They are demanding more; more care, more time and more therapy. At the same time hospitals-rehab departments in particular-are able to provide less. Somewhere along the line it has become okay for a non-medical person to tell health care professionals how to provide care. I've seen doctors "fired" from caring for a patient because they didn't comply with family or patient demands. I believe nurses go along with this to reduce the number of complaints they receive.

I have a problem with this sort of thing. When I have a heavy caseload, I'm usually racing to make sure everyone gets seen. If I see one patient twice it may result in someone else not being seen at all. I can't justify that in my therapist heart. I'm old school. Everyone needs to have a chance to be seen once before anyone is seen twice.  I can't make exceptions. This isn't a problem if I have a lighter case load, but that isn't always an option. Sure, exceptions can be made. The problem with that is it starts us on a slippery slope to somewhere we don't want to go.

Back in the day things were different. Patients were seen twice daily. Nowadays total joint patients are the only exceptions, and then only because their length of stay is so short. Therapy has to be optimized. I certainly understand how this woman feels. She wants her husband to get better. It's logical that being seen twice is better than being seen once. I don't blame her. I wish the nurse would have handled this differently. This is a nice example of the need for teamwork rather than turf battles.  I solved the problem this time.  It'll happen again. This isn't an easy fix. There are too many contributing factors for a global cure all.  I think this is a symptom of what is wrong with health care.




This is one of the very reasons I left IP care.  PT was being treated more like a techical position and not one that values our skilled assessment.

Truth is, very little evidence exists to support how much PT one should or should not get.  Things were all hunkey-dorey in the world of fee-for-service where many patients DID get BID, even TID therapy. No one argued because it was simply more revenue.  Then Medicare reform happened (which as much as I hate Medicare telling me how to do my job), they were right...too much overspending.  Research is now trying to catch up to understanding how much PT is actually needed to reduce stays and limit disability.  

Nurses and doctors have the luxury of not knowing (or caring) that for every "unecessary" treatment it is another chunk of money that comes out of the that could be used to hire more PCTs, build new wings, etc.  So it's no skin off their back to order more PT...of course more PT should lead to a shorter stay, right? We've got the magic wand. Or do we?  Do we really just not know, so it's best to oil the squeaky wheel?

Which brings me to my next point. Patient satisfaction is such a goal  for hospitals. But has it made everyone a little short sighted?  Are we so eager to please and get a good survey out of that patient that we neglect evidence? Physicians are in the same position. Patients come into their office demanding MRIs for non-specfic low back pain.  Do they comply with the patient's wishes or send them to physical therapy? You and I have the luxury of knowing that MRIs are often uncessary...but it's a hard sell to a patient.

Finally, and this probably brings me to my best point is "are we being misused?"  Does it really require someone with a master's or doctorate degree to "walk" a patient or perform SLRs with them?  We've dealt with many of the same pitfalls you describe. Heck, we were down to 1x/day for our orthos and seeing most other patients only 3-5x a week.  Meanwhile, orders for BID and TID PT were largely ignored except by the "squeaky wheels."  Our solution. Deligate those who are at contact guard assist or supervison to an "activity aide". PCTs are required to learn how to ambulate patients safely for their certificate? Why do they stop doing this skill once they get on the floor?  We now have a program in place where a specialy trained PCTs sees patients for "activity" throughout the hospital. It's not being billed as physical therapy, so no harm...but even if it was, would it make a difference since we don't get paid for administering therapy anyway?

Do the physicians and patients care that they are not getting "physical therapy" just care that the person is up and active.  Meanwhile, we can administer therapy to those who really need it and at any time, we can step in and reassess those patients we've deligated to the mobility team.

Best of all, we've been able to reinstate BID therapy for orthos and daily therapy for those who need it...and finally, the mobility aid comes out of the nursing budget. No one is complaining.  

Christie, Physical Therapist October 5, 2008 10:47 PM
Streamwood IL

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