I don't think you can work in healthcare for any length of time without attending the mandatory customer service inservice. It usually includes a segment on making upset customers happy. In our case, that would be patients and families. One strategy is to listen, verbalize back and then address each complaint.
I'm skeptical when I hear that. It might prevent that customer from having a bad experience, but what about the ones waiting in line while the service is being provided? When I was in South Dakota waiting to check in, a man was complaining loudly. The registration person spent 5 minutes resolving the issues. I know this because I, and eventually four others, stood in line that long. That man was happy but five other people had a bad experience.
Last weekend I had to go in on a Saturday to do an evaluation. I was told there were a lot of problems when the patient was admitted, so everyone was trying to make the family happy. Normally the facility doesn't staff for rehab on the weekend but because the family wanted therapy to start immediately and the physician ordered it, someone had to provide the service. I work in an LTAC. Evaluating the man on Saturday instead of Monday wasn't going to make any difference in the outcome.
Everywhere I've worked, facilities have practically bent over backward to make a complaint go away. They'll do anything to prevent a bad experience. Those same facilities never think about the patients who aren't being cared for, call bells that aren't being answered and therapy not provided because everyone is trying to make one person happy.
After I return from teaching, I complete an evaluation of each facility. The one in South Dakota got a bad one because of my experience. Because I worked on a Saturday for something ridiculous, I'm much less likely to do it again. It accomplished nothing. The family was just as unhappy when I left as when I arrived. The ordering physician probably forgot about it as soon as he wrote the order, so isn't any happier either.
Maybe we need to change how we think of customer service. Facilities create much more ill will when they inconvenience one person to make another happy. The inconvenienced one might not complain but won't return either.
One of the benefits I get from traveling is talking to therapists in different parts of the country. Things are not the same all over the country but there are a few recurring themes. We all agree that our patients are getting bigger. I started including trunk exercises for the obese patient because I was asked that question in every seminar.
Whenever the topic of large patients comes up, it's always followed by the words "and we aren't equipped to treat them." Sometimes the problem is inadequate staffing. It takes more people to mobilize an obese patient. This is a problem when staffing is cut to the bare minimum. An even bigger problem is lack of adequate equipment. Bariatric wheelchairs, beds and walkers are a must for this population.
This morning, I had an order to find a wheelchair large enough to fit a patient so she could get out of bed for 30 minutes. She wasn't comfortable in our 30-inch chair. Plus we don't have elevating leg rests for that chair. Nor do we have a large enough cushion to accommodate her and her wound.
Equipment is another area feeling the brunt of cost-cutting. Anything bariatric is almost twice as expensive as its normal-sized counterpart. Facilities might buy some bariatric equipment. Problems develop when there are more plus-size patients than plus-size equipment. I have four decent cushions. To accommodate my large lady, I will need to take some away from other patients.
Meanwhile both the patient and her doctor will be complaining. The doctor will write orders for a bariatric cushion, wheelchair etc. Despite the obvious need, the facility will not allow me to purchase anything. Rather than spending some money to solve the problem, we'll be told to make do. We might save a little money but the stress will escalate.
I've heard similar stories many times. The research is showing early mobilization of stroke patients improves outcomes. Facilities say they want good outcomes but stop short of spending the money. I don't have any answers. There is no substitute for getting someone out of bed.
Recently we had an elderly man on caseload with a diagnosis of advanced dementia. It was obvious he was in the later stages of the process. He couldn't follow commands. His swallow was diminished. He was disoriented times three and demonstrated poor motor planning with any voluntary movement. However, he could still move and verbalize spontaneously.
Unless disturbed, he laid quietly in bed. The problem arose when we tried to get him out of bed. He didn't want to be disturbed. As soon as we started to move him, he told us no and began cursing. This was followed by swinging.
Anyone who works with the elderly knows there are two kinds of swings. Some are ineffectual. These may be taps. There may be a little force. Patients with brain injury frequently flail in bed during the restless state. The intent isn't to strike someone so much as to move. These people might be described as agitated. Restlessness while in bed is certainly agitated.
Then there is the man I described above. He wasn't agitated. He was aiming for us. He didn't want to be moved and was resisting it. On a few occasions, his wife was present when we attempted to get him out of bed. She told us to ignore him. He didn't mean it. Mean it or not, he was trying very hard to hit someone.
Patients have the right to refuse therapy. That statement is made with the assumption the patient understands what he is refusing. In cases of dementia and confusion, we often have to rely on family members to give consent for treatment. This man was clearly refusing despite his wife's statement to the contrary. He knew he didn't want to get out of bed.
After a couple of days of struggling, I discharged him from therapy. Someone was going to get injured if things continued. One of our PRN PTAs knew him from previous interactions. She said this was normal behavior for him and they got him up anyway. He was just agitated. Obviously I don't agree with that. Despite the benefits of being out of bed, there is the real risk of injury to either himself or a caregiver. This went beyond any level of agitation. He was aggressively trying to strike someone.
He has since discharged to a SNF. I don't know if it's the one he came from or a different one. For his sake, I hope a different one that recognizes the difference between agitation and aggression.
There were two common themes at CSM this year: dosage and intensity. Every clinical presentation I attended mentioned one or the other. Intensity was defined as how hard the patient is working. Dosage referred to the number or reps or duration in the case of a static activity. In both cases, more is considered better.
Last weekend I worked at a SNF. One of my patient's treatment notes indicated he was doing 100 reps of his exercises. Given the concept that more is better in a population that often needs encouragement to do anything, this sounds wonderful. The problem is the patient was doing 100 reps of the wrong exercises.
Yes, his legs were getting stronger but weakness wasn't the problem. It's a motor recruitment issue with compensatory movements. Unless someone corrects his gait pattern, he isn't going to improve. He doesn't need strengthening. He needs motor training. I didn't know whether to laugh or cry. More of the wrong thing isn't better. It might even be worse.
The reason the therapist was doing the wrong thing is the topic of another blog. Suffice to say that unless it's more of the correct activity, nothing will be accomplished. Obviously the treating therapist was listening to the message. He just didn't hear all of it.
LAS VEGAS -- The 2014 Combined Sections Meeting is getting started. I've been in Las Vegas since Saturday evening for my preconference course. It was two days of sitting for eight hours listening to people read information off slides. The next three days will be three presentations of two hours each spread over the course of the day. In between, the expo center will be open.
I have to say I was disappointed with the preconference course. The information was good but very basic. They stressed evidence but very little was practical application. There were several presenters. I don't think they were accustomed to presenting to groups. Reading the lecture directly off the slides is boring and invites loss of attention.
I've already changed my mind several times about which courses I'll be attending. That happened to me at other CSMs so I was prepared. I printed the handouts for every presentation I thought I would want to attend. I have them all in a binder in sequential order, divided by days. Plus I carry a pad of paper for notes. I'm prepared. Once the expo hall opens, I'll also have plenty of pens, post-it notes and notepads.
People have been arriving throughout the day. The line for registration started before 8:00 this morning and was still there when I left my class this afternoon. I'm seeing more and more people carrying the CSM program as I walk through the hospital. This year they gave us a small tote bag when we registered. It will come in handy. I brought one from home (that one of my horses won) so now I have one for my program and binder and one for the expo center.
I'm staying in the Venetian. Vegas is a completely different world compared to everywhere else. The hotel is easily the size of a city block. During breaks we joked about getting lost walking from the hotel room to the convention center. This morning it took me almost 20 minutes to complete the walk without getting lost. You have to walk through the casino to get anywhere. People really are in the casinos at all hours.
There's a shopping mall built into the hotel. I've gotten lost every time I've tried to walk through it. The shops are mostly upper-end merchandise. I did find a few bargains though. During lunch today we decided the casino, while seemingly endless, is a good marker. If you can make it to the casino, you can find your way out.
It's almost that time of year again when thousands of us gather for the APTA Combined Sections Meeting. This year we're in Las Vegas. According to what I've read, they're expecting more than 10,000 PTs and PTAs to attend. I'm going. To use a Texas-like phrase, this isn't my first rodeo.
This will be my third CSM, so I know what to expect. The exhibit hall will be the size of a football field and filled with gadgets, technology, DME, facilities looking for staff, tDPT programs looking for students, publishers and the APTA. It will take me all of two days' worth of breaks to see the entire hall.
This year I'm attending a preconference course on, of course, stroke. I've already printed the handouts. I'm familiar with everything I saw. I'm already teaching about a third of it. I know I will learn something. But this is a two-day course sponsored by the Neurology Section. I'm expecting to learn more than a few things. I hope to expand my knowledge of the things I'm already familiar with.
I pre-selected my courses when I registered. Once again, I'm pretty much sticking in the neuro section. A couple of the courses are co-sponsored by the Geriatrics Section. I naturally gravitate toward stroke and brain injury. My goal is to attend either a degenerative diseases or vestibular lecture to increase my overall knowledge.
Most of lectures I've attended have been worthwhile. But I've learned you have to read between the lines of the descriptions. Pre-reading the handouts helps with figuring out what the true topics will be. Last year one of the most interesting lectures I attended concerned gene mapping. They didn't cover anything clinical but it was fascinating. Sometimes fascinating is better. I try to pick things that I have an interest in or relate to what I'm teaching. Naturally most of the ones I want to attend are offered at the same times. Decisions, decisions, decisions.
I'm staying at the Venetian, which is the main hotel. I've checked the website. It's huge. I won't have to leave the building for anything: food, shopping, entertainment, spa services and of course casinos. There is actually a mall on site. In fact, the only time I'll go outside is to make a quick trip to the "Pawn Stars" pawn shop. It's a 10-minute taxi ride away. The last time I was in Vegas, I played the slots. I lost two dollars. Been there, done that. Now I'm going to the pawn store for entertainment.
This week I received confirmation that I would be getting a merit pay raise. It was explained to me that merit raises are based on years of employment and not linked to job performance. Thus everyone who's been there one year gets the same percentage increase. The raise went into effect as of January 1.
Imagine my surprise when I opened the letter telling me how much the raise was and learned I will get a $0.23/hour raise. That isn't even a 1% increase. My insurance premium increase alone is 3% of my salary. That's less than $10/week before taxes. I appreciate the thought.
Am I supposed to be excited about this? Yes, I'm happy I have a job. Yes, I'm happy I got a raise. There are many out there who can't say the same thing. At the same time, I'm insulted. I'll miss the 3% decrease for insurance more than I'll ever notice the increase. If you're going to give someone a raise, give them a raise.
I'm guessing the motivation is to encourage longer-term employment, as in stay with us and you'll eventually get more money. This raise isn't going to affect my employment one way or another. It makes me wonder if this is another trend to cut costs in healthcare. These raises were across the board to all disciplines.
I have friends who get significantly greater increases based on job performance, competency and experience. Healthcare is the only field where those things are a detriment rather than a plus. I can't decide if this is sad or funny.
Deciding whether or not to call in sick to work is one of those decisions everyone dreads. Some don't want to let their coworkers down. Others don't want to waste the PTO. I've never heard a universal guideline published. Although the unspoken one seems to be don't come in if you're contagious.
I've been facing that dilemma the past few days. I have whatever is making the rounds. I think I'm the third in the department to fall victim. It's very insidious. You don't feel bad in the morning but come noon and it's another story. I generally decide about work based on how I feel in the morning, not how I think I might feel, so it's hard to know.
I worked three days progressively feeling worse. I didn't have a fever, wasn't sneezing and although I was coughing, I wore a mask. When I caught myself wrapping up in an extra patient blanket right before lunch, I decided it was time to leave. I went right to one of those stop-in clinics that can be found next to almost any pharmacy.
I was in luck. I had a sore throat and therefore was given antibiotics and prescription cough medicine. Maybe lucky isn't the right word. That was a Friday. I slept two days and went back on Monday. Yes, I felt better. No, I wasn't contagious. I probably should have stayed home anyway. Before the end of the day, everyone in the department asked me why I hadn't gone to the doctor yet. I'm guessing I didn't look so good.
Or, rather, I didn't sound good. Even though the disease process itself was relaxing its grip, the cough was much worse. I was coughing so hard I had to sit when I coughed to keep my back from hurting. One of the physicians seated a few feet away glared at me so hard I thought I was about to get another prescription gratis.
Thus sickness is more the appearance of being sick, rather than actual illness. No one tried to send me home when I really was sick. As soon as I started coughing, everyone thought I should leave. It would have been smoother if I could have taken the cough medicine, but it contains something I wouldn't want to pop up on a drug screen so it's reserved for home use. I might have to risk it tomorrow.
One of my OT coworkers and I have fallen into bicker back and forth in fun. We have an unspoken agreement to agree to disagree. Usually we find some middle ground until the topic of diathermy came up. We disagree about whether this is a skilled therapy or not.
I say it's not. To me this is like a neuro chair transfer. Just about anyone could perform one. The skill isn't in performing the transfer, it's in the clinical judgment as to appropriateness and patient tolerance. Nor is the transfer therapeutic. That comes from being out of bed. Except for the first treatment, I don't believe diathermy is skilled. I can easily train someone to use the machine. Some of the newer ones even come with recommended settings printed on them.
The OT says skilled. He holds that it requires skill before and after each treatment to determine whether the treatment is needed. Further skill is needed to choose the appropriate settings and position the head. He agrees I could train someone to set it up but only a therapist can make those decisions. Hot packs are not a skilled service but diathermy is.
The discussion is further complicated because diathermy is a skilled charge. I maintain being able to charge for it doesn't make it skilled. That just means someone successfully lobbied for it to be possible. My OT counterpart maintains that because it can be charged, it is skilled.
We're not debating whether diathermy is an effective treatment modality. Research exists that supports both positions. From what I can tell it works for some, not for others. I'm told that is due to user, I mean therapist, error. Set up properly with the correct settings, diathermy is an effective treatment.
We aren't going to find common ground on this one.
Over the past weeks, I've been blogging my concerns about staffing levels and quality of care. More and more it looks like staffing will continue to be diminished in cost-cutting efforts. In one blog, I posed the question of how to prioritize patients when caseload isn't manageable with the goal of seeing as many patients as possible and still providing adequate therapy.
Last week I got my answer. On Monday we were short-staffed, with each of us having 17 patients on caseload including evaluations. I decided to limit therapy to the most important thing for each patient. Therapy sessions would be shortened but something could still be accomplished. In some cases, that meant getting out of bed without performing bed exercises. I saw all but two people on my list and thought I had done pretty well considering.
Thus we come to my patient in the ICU. My plan was to sit him edge of bed for balance, then attempt a functional transfer to a high-back wheelchair. Initially he refused to allow me to transfer him. He made no effort to balance when edge of bed. Once he was in the chair he requested the tech lift him back to bed.
On Tuesday the lead therapist, an ST, summoned me to his room because he had a complaint about his therapy. He complained that he hadn't done anything but get out of bed, via the tech, leaving out that he refused to allow me to do it. I suspect there was more to it but he toned it down when she pulled me into the room. I tried to explain to him that instead of exercises I attempted to do something more functional. That the lead therapist wasn't backing me up didn't help.
In fact, after the conversation she commented she was tired of having her behind used as a chew toy. Yes, pulling me in was politically savvy but it didn't help. I went from being proud of myself for thinking I had accomplished something to having handled the situation completely wrong. No one wants to hear the therapist is too busy, but the man was offered an opportunity for more and he declined. I wasn't going back.
I'm not sure what else I could have done. I could have spent more time with him and skipped several other patients. I've since learned his normal therapist skimps on patients who don't do much. She believes this gentleman benefits more from her time so she does little with them and spends extra time with him. Had it been her with 17 on caseload, I suspect she would have skipped the lower-level people and given him his full treatment. That doesn't work for me.
The holidays are upon us and everyone wants time off. Mangers scramble to cover for vacations, illnesses and unexpected accidents. It's a given there won't be normal staffing levels from mid-December through the first of the year. Every year I ask the same question. Why is it okay to miss treatments and skip patients, all the while struggling to meet productivity standards?
I'm tired of this. Normally I don't mind working the holidays. I used to say I'd work so coworkers with families could be off. Not anymore. My caseloads will double. I'll have even less help. Everyone will be asking me why someone hasn't been seen by therapy. I go home tired only to struggle through it all over again the next day. Meanwhile management expects all the paperwork to be kept up to date.
When I worked at the "evil empire," we were lucky to see half the patients on our caseload during the holidays. Sure, we could get overtime, but overtime only goes so far. Therapists have an ingrained need to see all of our patients every day. Not only do we see them, we must provide the best treatment possible. I'm not about to say management cares about the quality of care. They've more than proven they don't. Those of us at work stress because we're not doing enough.
It's time to rethink how we do things. This includes letting fewer people off and having more people working the weekends before and after the holidays. Nothing is as frustrating as struggling through the week doing the best you can, only to hear those who were off complain because their patients weren't seen.
This is healthcare. We know we need to work holidays. I can remember when departments closed for the holidays, but not anymore. All the current system does is cause burnout of those who work. How about two-thirds staffing instead of one-half staffing? Can't decide who works and who doesn't? Draw straws or use a lottery.
Once again, I'll be working. Once again, I'll do the best I can. This year, for the first time, I won't be happy about it.
Let me clarify that statement before I go any further. I refer to performing PROM as the only treatment on patients who are sedated, minimally responsive, have significant neurological involvement and the like. I'm not referring to outpatient settings, PROM as part of an overall treatment, stretching and the like.
I thought that argument was settled a long time ago. I have research that supports the position. Apparently the doctors where I work never read those journals. Currently I have two patients on my caseload with orders to hold all therapy except PROM. Both have poor prognoses. One has contractures. The other has a stage IV sacral wound and squirms into the fetal position.
I don't have a problem with checking once a week to see how the patient is doing. Then I can assess if any changes have occurred. Such an assessment is skilled and requires clinical judgment. I teach that. It's almost embarrassing to have to do something I preach against. I'm not saying PROM isn't appropriate. I'm saying neither I nor the OTs should be the ones providing the service.
I tried signing off and stating nursing would perform the PROM. That lasted less than a day. Then I put them on our maintenance program. Nope, our maintenance tech is too busy getting people out of bed. So it falls on me to do it, an expensive waste of resources. I have more patients on my caseload than I can see but I have to find time for PROM. Really? Most of the literature I've read refers to PROM being performed while the patient is being bathed since the limbs needs to be moved to complete the bath.
I don't know what irks me most about this; that the doctor, who I thought knew better, would write the order or that no one else has a problem with having a licensed therapist perform a task more suited to a CNA. When I worked in the neuro ICU, I performed PROM only when I couldn't do anything else with the patients or while I was waiting for the medical condition to stabilize so I could progress therapy.
This is an example of lack of respect for what I do. I've tried complaining. That was held against me on my performance review under not getting along with my coworkers and not being a team player. This week I will try talking to the physician. So help me, I will scream if I'm told it's because the family wants it. But that is the subject of another blog.
The first thing I heard when I got to work Monday morning were tales of the well-meaning relatives. We all know the type. They try to help but only make things worse. Or, with the patient's best interest in mind, they interfere with just about everything we try to do. In this case, it was a daughter who hadn't visited all week.
Like many people, she has a full-time job and can't miss work. The rest of the family has kept her informed and sent videos of the patient's progress including her first steps. The daughter spent the weekend with her mother. By Monday, nursing was ready to permanently bar her from the building.
For example, the patient wanted to use the BSC. Previously she had done so once with therapy. Both the OT and I explained several times that sitting on the BSC isn't therapy. Until she was safe with the transfer, she was going to have to use the bedpan. Everyone was happy when I left Friday. The daughter, who learned how to be manipulative from her mother, demanded that mom be placed on the BSC. And she continued to demand it, even when the transfer required three nurses and someone to stand with her mother while using it to prevent a fall.
The patient complained about her diet. She is just transitioning to solid food from a PEG. The daughter demanded a different diet for her mom. She demanded different foods that her mother preferred. She called the kitchen. She called dietary. Fortunately it was the weekend, so no one answered.
The patient complained her wheelchair was uncomfortable. The daughter demanded a different one. Apparently nursing searched the entire building looking for a different chair. They didn't find one. I'm almost surprised they didn't take one out of someone else's room to pacify the daughter. The patient is in a high-back wheelchair because she doesn't tolerate erect sitting for long periods of time. That could have been a disaster.
I truly believe the daughter thought she was trying to help her mom. She was trying to address the complaints. She didn't realize that everything being complained about had already been addressed several times and arose from specific therapeutic needs. The daughter had already left when I arrived. I would have liked to hear what she had to say.
In order to compensate for escalating case loads and inadequate staffing, prioritizing who to see each day has become a way of life. Sometimes my day is easier because patients are unavailable. Generally I start every day deciding who needs therapy the most. With the exception of which doctor will complain the most, I think that's the way everyone does it. I used to think everyone defined that need the same way.
I define need as those who have the worst impairments. These are patients who aren't able to do much on their own. They're going to need more therapy when they leave the facility. They can be time consuming. The going is slow. But there are copious amounts of research suggesting the more we do with those patients and the earlier we do it, the better the outcomes. Other research suggests the patients who are doing okay already will recover no matter what we do.
I work with an OT who thinks completely opposite. She prioritizes the patients who are mobile. They aren't severely impaired so they often make big functional gains. Her rationale is she can help these patients go home. For the more severely impaired, she makes splints, does ROM and UE strengthening exercises. Would it be inappropriate to say she drives me insane? I spend numerous sessions improving trunk control while she sees them in bed.
Nonetheless, neither of us is wrong. Both groups of patients benefit. Usually we're able to see all of our patients, just not for as long as we would like. Right now this compromise works. What happens when staffing is further cut to save money? Or, more likely, no additional staff is available despite higher caseloads? Patients will be missed on a regular basis.
Who do we treat? The ones who make quick gains with minimal staff action or the ones who need time and effort? I work in an LTAC. Most of my patients go to another facility for more therapy. What if it was a SNF? Often those patients become permanent residents if they don't make progress.
There's an even bigger question. Who makes the decision? Right now it's the individual therapist. Eventually the facility could take it out of our hands by decreasing staffing and/or increasing productivity demands. I have one tech. If that position is eliminated, I can't do as much with my impaired patients. In SNFs, the decision is made by who needs the minutes. Patients with minimal potential and great potential get the same duration of therapy if the minutes say so.
I think we've all reached the conclusion that cutting staff to save money means therapy will be asked to do even more with less. The unspoken expectation, at least in the places I've worked, is that therapy will fix everything. We're the ones who help them in the morning because night shift couldn't be bothered. We're the ones who take the patients to the bathroom.
Unfortunately this often translates into therapy being viewed as little more than a lifting service. Until last Friday, I chalked it up to nursing being busy and frequently lazy. Apparently with the ongoing changes in healthcare, therapy has been further demoted. How else can I explain what happened?
I was sitting at the nursing station. One of the nurses, known to be lazy, asked me for the number to our tech's phone. A patient who wasn't receiving any therapy or maintenance interventions wanted to get out of bed. A nice way to describe him would be belligerent. The patient is obese and a paraplegic but can easily be transferred with a Hoyer lift. Instead of giving the nurse the phone number, I told her the tech was unavailable because he was leaving early for the day and currently putting therapy patients back to bed.
I hadn't realized it at the time but the chief nursing officer was standing behind the nurse. Her response to that statement was to ask me if one of the therapists could get the patient out of bed for nursing. In that moment, I realized how little therapy is respected. I have an undergraduate degree, an advanced degree and two certificates of specialization from the APTA but am considered no more skilled than a CNA. The woman was shocked that I wouldn't help.
I am very proud of myself when I say I took the politically correct avenue and explained that everyone had a full caseload and didn't have time. There's so much more I could have said. I find it odd that as our census has increased, so have staffing levels in every department but therapy and yet nursing is too busy to help out.
When I left for the day, I noticed our manager was meeting with the facility administrator. No doubt word of my revolt moved quickly up the chain. I have no doubt the woman was apologizing that we couldn't help and trying to formulate a plan to resolve the situation. My guess is she's going to schedule a time for our only tech to be available to get the patient up and put him back to bed based on when the patient wants this done. We'll be told to make do in the meantime. Ironically that very morning she was expressing frustration that nursing was continuing to call him to get people out of bed.
In the end, it doesn't matter. We'll pull it together and get it done just like every other department does. There's one benefit to this. When I alerted the tech to the situation, we had a bonding moment.