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Toni Talks about PT Today

Patients are Getting Sicker

Published April 8, 2009 8:53 AM by Toni Patt
I've noticed something over the last several months. The patients I've been treating are sicker and more involved than they were even two years ago. I'm not sure when this started or why.  But it's been happening and gradually getting worse. The patients I see today are sicker, more medically complex and have poorer prognoses.  They are more challenging to treat and frequently require two people to properly mobilize.  Therein lies the problem.  Many times I end up treating these patients by myself because no help is available.  On one hand we have patients who need more intensive care.  On the other hand we have facilities cutting costs by cutting staff.

There are many reasons why I'm seeing sicker patients.  The population is aging and living longer than previously.  Most of the patients I see are 70+ years old.  The fact that someone is that old is already a complication.  Having medical problems on top of that makes it worse.  People are also waiting longer to seek medical attention and so are sicker when they are finally admitted to the hospital.  Those people now require longer, more involved care than if they would have come in sooner.  Technology has improved so that doctors are able to save people who would have died a few years ago.  And, my personal favorite, many of these people are obese with poorly managed co-morbidities. 

I can treat these patients by myself, but I can't mobilize them by myself.  Bed level exercises can only accomplish so much. There comes a point when I have to sit someone up to progress them.  For that I need help.  If help isn't available, those patients don't sit up.  In the rehab department cost cutting means cutting out support and clerical staff.  It's not realistic to split one tech between four therapists and expect every patient to be seen and mobilized.  Even if I have help, that's no guarantee the patient will be treated.  Many times I arrive only to find the patient is unavailable or gone for a test.  I can come back later but my tech will be elsewhere.

PTs are caught in the middle.  Case loads become prioritized, often by who can be seen the easiest or which attending will scream the loudest.  Deciding who to see can come down to deciding between two higher-level patients that can be seen quickly or one lower-level patient that will take time.  The problem is exacerbated in departments where performance appraisal is based on productivity.  Patients who are heavy or otherwise difficult to move often get skipped.

This is an observation.  I don't have an answer.  It's not realistic to think departments are suddenly going to reverse direction and hire more support staff. If anything, there will be fewer support staff as facilities cut more corners to accommodate the higher salaries demanded by DPTs. Having fewer PTs and more PTAs may keep the overall salary costs down, but won't support additional support staff.  Meanwhile patients will continue to require extra man power that doesn't exist.  Certainly treatment frequencies can be decreased.  I've done that on occasion but never felt right about doing it.  It was pounded into my head during school that daily is best. I still haven't gotten past it.  Another option is co-treatment. The problem there is poor reimbursement for co-treatments. Most facilities don't want it to happen. Most therapists aren't able to compensate for the lost productivity in an 8-hour day.  I know I can't.

The problem is isolated to inpatient facilities.  I've worked in several SNFs with many multiple-man power patients. The SNFs I've been in recently had support personnel so it was a little bit easier. That's a double-edged sword. On one hand I can work with the patient. On the other, the patient doesn't have the endurance to participate in therapy. Outpatient clinics are beginning to feel this, too.  I've been in a few with labor intensive patients.  Most clinics are set up to accommodate those patients. If I have a patient with 02, a RW, min assist for gait and poor endurance, I need help to do it safely. 

Right now all we can do is wait and see what happens while we do the best we can with our patients.  Healthcare is on a crash course for disaster as it is.  This is one of the many problems we're facing. Hospitals and physicians are beginning to recognize the benefit of early mobilization on shortening stays. Maybe some bright money person will explain to them how having more rehab staff actually saves them money by shortening stays and preventing bed rest complications.  The evidence exists to support the rehab side of things. That's a start.

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