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Toni Talks about PT Today

PROM Is Not a Skilled Service

Published July 29, 2009 1:03 PM by Toni Patt
Rehab services and the Neurology physicians are having a disagreement.  The Neuro docs are upset because they don't think PT responds quickly enough to their orders.  They claim it can take a day or more before an ICU patient is seen.  That's probably true at times.  The PTs don't consider ICU patients a priority because the majority are orally intubated and either sedated or non-responsive.  Some have open EVDs which is a contraindication to movement.  If the patient isn't cleared to get out of bed the only thing the PTs can do is an evaluation and ROM exercises. 

That's the problem.  The Neuro docs want the patients mobilized every day even if it is only ROM exercises.  Because of caseload demands and staffing patients who only perform bedside exercises usually aren't seen daily.  Those that receive PROM are seen even less.   No one in the Rehab department has a problem with this.  Bedside exercise, especially PROM isn't a skilled service.  A tech or nursing assistant can be trained to do them.  Exercise only becomes skilled when additional skills such as facilitation or motor learning training is performed.  Moving a body part passively through its ROM doesn't require skill, just a little training and education.

The doctors have a valid point.  Their patients should be moved around daily and out of bed if at all possible.  The problem is who should be doing it.  As a PT, I am expected to provide skilled services.  If I perform an evaluation on a patient who isn't responsive, I may still do PROM exercises.   I usually do this as part of my ROM and strength assessments since I'm moving the limbs anyway.  I'm also assessing how the patient tolerates the movement and looking for pain responses and changes in arousal.  Those actions make that a skilled treatment.  If I come back the next day and the next and perform PROM I haven't really performed a skilled service unless there is a status change.  If I return once or twice weekly, I can include an assessment as part of my exercises which is skilled.  If the patient is waking up or cleared for out of bed I can change the POC.

Performing PROM one to three times weekly is generally accepted as adequate.  An argument can be made that the rules are a little different in a hospital, particularly an ICU.  That could be true sometimes.  But, if we as therapists, say PROM is an unskilled service in one circumstance, it should be in all circumstances.   We need to be consistent.  The exception might be a new stroke patient the therapist wants to follow a few days to monitor arousal.  PROM would be appropriate for that period of time. 

There is another part to this conflict.  If PT doesn't do the PROM, who does?  The obvious answer is nursing, or more specifically, the nursing assistants.  Bath time is an excellent time to move someone around.  So is turning for repositioning.  Nursing, however, doesn't feel that way.  I've yet to meet one nurse or nursing assistant who had the first idea about PROM.  To them it is a huge mystery.  It becomes the same argument as whose responsibility it is to get patients out of bed.  Just like the out-of-bed tug of war, if PT doesn't do it, it doesn't get done. 

The result is our conflict with the Neuro docs.  If PT doesn't do the PROM, it won't be done.  It isn't feasible for a limited staff of therapists to perform PROM on 20+ patients on a daily basis.  They barely make it through their caseloads when they divide the PROM treatments up throughout the week.  It's not realistic to expect administration to create a position just to perform PROM on ICU patients.  Nursing isn't about to add something else to their to-do lists.  The conflict will go on. 


I'm a P.T. in an ICU....

We've come up with a great solution by establishing a "Rehab Maintenance" program. When we evaluate a patient and determine that PROM will be the most appropriate (& only possible) service, for a temporary period of time, with the expectation that the patient will hopefully progress to a level benefiting from skilled intervention, we place the patient on "Rehab Maintenance". A formal eval and specific maintenance form is filled out by the evaluating therapist & POC is discussed with our aides. Then, our own rehab aides perform the POC as we've discussed. (There is obviously no charge, but the aide does fill out a short basic form everyday documenting what they did) Since we talk with them everyday, they're able to keep us directly informed of any changes warranting re-eval by the therapist (not to mention I pass by the rooms and pop my head in every day as well....) The patients are also scheduled for weekly re-evals to assess change in status, potential, progress, etc....

We also use this program for patients who've max'ed out their rehab potential for the acute care setting (i.e. reached baseline, etc) to ensure the patient is up walking every day to help prevent loss of function while in the hospital (thus leading to a need for more skilled P.T.....)

It hasn't solved all the issues with having nursing more involved as they should be... But, we've found having the best relationship possible with the nursing staff, and being POINT BLANK DIRECT about what they need to be doing, works the best: for each patient, every time..... Things still don't get done all the time as they should, but we make sure we've communicated effectively and consistently what we expect the nursing responsibility to be for each patient (i.e. P.T. will NOT be returning today to get the patient back to bed, they are min assist of 1 with a walker and they need to be up at least 2 hours, etc.....)

Anna July 29, 2009 11:01 PM

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