PROM Is Not a Skilled Service
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.