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.
Last week while I was in New Jersey to teach seminars, I was involved in a motor-vehicle accident. I hit my head on the steering wheel, was taken to the emergency room and diagnosed with a concussion. During the time immediately following the accident, I was able to experience a brain injury from the other side of the hospital bed.
I have no memory of the accident. I was told there was a brief loss of consciousness. I still have a memory gap of about 90 minutes beginning just before the accident until some point in the emergency room. My first clear memory is being told I was being taken for a CT scan and thinking, "Well of course, you have to look for blood." I hope I didn't say that out loud. I know I didn't ask to see the scan but I wanted to.
I have no memory of the being taken to the hospital via ambulance. Nor do I remember discussing the accident and resulting ticket with the state trooper. I don't remember providing anyone with identification or insurance information. Yet, all of that happened. I was awake, alert and following commands.
Now I know how TBI patients feel. No one realized I wasn't processing any of the information. Apparently neither did I, as I didn't write anything down. The state trooper said he was with me from the accident until well after I arrived at the hospital. I couldn't describe him if my life depended upon it. I was alert enough at the time of the accident to request that my GPS device be removed from the car. I found it in my computer bag, which I also requested remain with me. I wish I would have asked for my heavy coat.
Naturally I researched concussion as soon as I could get Wi-Fi. All of my symptoms are typical. I also learned I shouldn't have been surfing the web. Instead I should have let my brain rest. I was exhausted the next day but functional. The fatigue is finally resolving. This is making me rethink some of what I say about patients being out of bed and active. Once I got back, I immediately went to the barn. As much as I wanted to stay there and ride both horses, I had to go home and sleep.
Now I am dealing with insurance companies. The problem isn't the car insurance. It's the health insurance. Seems no one wants to be responsible. No one will agree to pay unless the others deny the claim. I'm not surprised.
At the SNF where I work part-time, the parking lot behind the building is built on an incline with a bend about three-fourths of the way down. There is a curb along the entire length of the descent. Last weekend, a resident told me it's possible to descend the length of the parking lot in a wheelchair without using the brakes or crashing.
He was very proud that his was the fastest of all the descents. All he did was use his hands to control the wheelchair wheels to prevent hitting the curb. His performance improved after he tried wearing his gloves to decrease the friction on his hands.
This man was one of the original aero-engineers at NASA. He oversaw the design of the Apollo moon program. He wasn't doing this for fun so much as to figure out the most efficient and economical way of completing the descent. Being the fastest was a bonus.
There's an ongoing struggle between PTs and nursing over who is responsible for getting patients out of bed. Both agree patients need to get out of bed. Easily transferred patients get out of bed regularly. The disagreement arises over max and total-assist transfers. There's nothing therapeutic about a mechanical lift transfer. Being out of bed is the therapy, not getting there. Every facility I've worked at has provided annual training to nursing on how to perform those transfers. And every time one needs to be performed, they seem to forget how.
As a PT, I put the blame on nursing. They've been trained. The responsibility should be shared. The unspoken assumption is that pressure is being put on nursing to help us out. That assumption isn't always true. I work in a relatively small facility. Nursing never gets anyone out of bed. Instead they've been told to call our technician to do so. This didn't come from nursing administration. Nor did it come from facility administration. It came from our rehab manager.
It seems our manager is more concerned with getting along, and I assume, remaining in the position. Rather than attempting to stop the practice, it is encouraged. If I refuse to get someone up, she calls the tech and instructs him to do so without notifying me. If nursing wants someone up, the tech is instructed to do so for them. When an order is written for someone to be out of bed who isn't on caseload, the same tech is called.
Naturally there are some consequences to this practice. The tech is so busy getting patients up for nursing, he's unable to assist the therapists with treatments. It then falls on the rehab staff to do the work of two people. Sometimes all I need is someone to follow with a chair while someone ambulates, but if the tech is busy that may not happen.
I've never experienced anything like this. Even the worst managers seemed to have a grasp on this. It's especially frustrating to hear her at our regular meetings talking about how this isn't acceptable. There is a simple solution. Instruct the tech to stop getting up people not on caseload and being at nursing's beck and call. Then enforce it. That's all. It would take the word "no" and meaning it. While there have been several discussions, not once has she actually stopped the practice.
Thus nursing will never get anyone out of bed. Our tech will. The ridiculousness of the situation becomes apparent whenever the tech is off. No one gets out of bed. It isn't nursing's fault if no one is holding them accountable and telling them no. But it does cut down on the strife within the facility.
I just finished my first conference call as a member of the Advocacy Committee of the Neurological Section. It was very refreshing. The other members of the committee were voicing the same frustrations and experiences I do. We may not have accomplished everything we wanted to, but did unanimously agree there's more to physical therapy than outpatient orthopedics.
We recognized there seems to be an imbalance in focus within the APTA and thus with the course of action it pursues. Just look at the people in power. Most of them have an orthopedic or sports medicine background. Naturally that's where they will focus. An argument could be made that lack of difference of opinion has created tunnel vision. One of our objectives is to increase awareness of neurological PT within the organization.
I'm drawn to the education aspect. There's a general lack of insight into what physical therapists do. First we have to educate the public, and maybe a few others, on what we do. Then we have to demonstrate what's unique about neurological therapy.
Of thing that aggravates me is the referral of neurological patients to outpatient orthopedic clinics. I can see how it happens. The doctor has a relationship with the clinic. Or maybe the clinic is the most conveniently located for the patient. Maybe the clinic is the only one on the insurance plan. Whatever the reason, the patient ends up being treated by someone who isn't familiar with what needs to be done.
When I was getting my DPT, one of my classmates (an orthopedic therapist) talked about treating a patient with continuous chloric movements. He didn't have a clue but continued to see the patient for the full 12 visits. That patient would have been better served being treated by someone with a neuro background.
Another goal of the committee is to work within the community to recognize the significance of the NCS. The APTA continues to push for specialization but does little to support those who become credentialed. In my experience, neither employers nor consumers put much value in the credential. Sure a higher salary would be nice. But so would simple recognition of the achievement.
Educating the public on what PTs do will help everyone across the board. In the process, we must create an awareness of the different varieties of practice. Physicians have been specializing for years. Consumers seem to recognize the differences. It would be nice if the same were true of physical therapy.
While I was driving home this evening, a news report came on the radio. Some professional football players have been placed on the injured list because they developed MRSA. I had to chuckle at the reporter as he conveyed the gravity of the situation. His report implied these players were at risk of dying at any time.
MRSA, or methicillin-resistant staphylococcus aureus, is a well-known infection to healthcare professionals. It has been a problem for years and has become more prevalent as antibiotic use has increased. Infected patients are placed on isolation, require additional antibiotics and don't feel very well. In my experience, no one has died specifically from being infected with MRSA. This is the first time I've heard it discussed in the media.
According to the news, the players became infected through cuts on their hands. I find this curious as hand-washing is the first defense against most infective agents, MRSA included. This would have been a perfect opportunity to encourage the practice for prevention of infection. I heard nothing of the sort. Nor did I hear anything about its risk to the general public outside of a hospital. Nope, the big news was that some football players were infected.
I'm not surprised. This was an educational opportunity but inadequate information was provided. Right now, half the people on my caseload are on isolation due to MRSA. Who knows how much information their families received? It would have been nice if the information was put into perspective and context. Instead the report has probably generated misconceptions about MRSA, how it's contracted and what that means to those infected.
When I teach, I describe using mental imagery in motor learning and as anti-neglect strategy. One of the main tenets of motor learning is repetition or as I say, practice, practice and practice some more. The concept of using mental imagery isn't new. Sports therapists and trainers have been preaching it for decades. What's new is how the concept is gradually working its way into the neurological world.
There are great divides between the different sections of physical therapy. Reading orthopedic literature is almost like reading another language to me. The terminology is foreign and the techniques aren't easily visualized. I do better with pediatrics since there's a neurological foundation to what they do. I'm sure the ortho people think the same of neurological literature.
I always poll the OTs when I teach. They consistently tell me it isn't the same in their literature, which is more global in its topics. I don't know if OTs have less specialization and therefore less need of special terminology, or if everything they do generalizes.
Over the years, I've noticed the divide widening. It's good to have therapists who need special terms to describe clinical skills in whatever section they identify with. The problem is the growing inability of sections to communicate and therefore borrow from another. Not that long ago, I attended an ortho-oriented CEU session where the topic was neuroplasticity. They were just discovering it.
The information is out there. All it takes is someone to make the leap to new applications of how we already do something. That will only happen if we step out of our comfortable worlds and see what others are doing. I'm guilty. When I go to CSM, I stick to neurological and some geriatric courses. Worse, I choose anything stroke-related first. I'm not going to get much outside exposure doing that. CSM might not be the best time to widen my horizons but there's plenty of home-study material available.
We need to start sharing more. Maybe it's time for someone to develop a physical therapy dictionary as an adjunct to the medical one most of us already own.
Last weekend I evaluated a woman who had been readmitted to the facility after yet another hospitalization. Before I could start taking a history, she told me she was never returning to that hospital. She was particularly upset with the therapy department. This isn't the first time I've heard something negative about that facility but it's the first time I've heard the therapy department specifically mentioned.
As she continued to talk, I realized two things. First, nothing was going to make her happy. Second, based on her complaints it could have been any therapy department I've worked in that was guilty. She complained they wanted her to get up after dialysis. They told her the bed wasn't her friend. She had to sit up in a chair for an hour at a time. No one believed her when she said she was nauseated.
Not having been there, I don't know what really happened. I doubt any of her therapists meant to upset her. Nor did they deliberately ignore what she said. The problem wasn't so much what they did as her perception of what they did or perhaps didn't do. She perceived that those therapists weren't listening to her.
I can see how she would have been tired after dialysis and not want to get up. Maybe at home she was used to sleeping whenever she wanted. She seemed like someone who was used to telling other what to do, not vice versa. Maybe there was also a personality conflict with one of the therapists. Doesn't matter. Her perception is the therapy department didn't help her. Instead they made her worse.
It's good to remember a well-meaning comment can be taken the wrong way. Just as encouragement to one person may sound like an order to someone else. I wish her family had been present for the evaluation. I would have liked to hear another version of the events.
In previous posts, I've discussed staffing issues where I work. Those problems continue. So does the return of the frequent flyer. Now we have something even more troubling. Our census continues to drop. The facility is at one-tenth of its capacity. There doesn't seem to be an end in sight. As of the time I left work this afternoon, no admissions were expected.
I've worked in many facilities. They've handled census drops in various ways. At the "evil empire," we were so busy that a census drop meant a day when we didn't feel overwhelmed before starting. Other places cut support staff hours. No matter where I was, eliminating prn hours was the first response. Full-time staff was encouraged to keep busy and go home if there was nothing to do.
Today I was told our hours will be cut if the census doesn't improve. Increasing treatment durations is not an acceptable option. We can do that, but will still need to leave early. At the same time, a lot of things need to be done that aren't specifically patient care. When we're busy, we don't have the time. Now we'll have the time but not the opportunity.
Remember, like many facilities, staff has been cut to the bare minimum. There are always complaints about how long it takes for a bed pan, pain medicine or just about anything else. Obviously we aren't the only department feeling the pinch. But wouldn't it be nice if, instead of sending everyone home and cutting hours, the facility allowed enough staff to answer call bells or whatever else patients need instead of making them wait even longer?
"Frequent flyer" is a term given to any patient with serial admissions to a facility. They discharge. They admit. They discharge. They admit. Eventually everyone on the staff will have worked with the patient. Some are remembered fondly. Some never see the same therapist twice. Sometimes the multiple admissions are due to progressive disease processes and medical management. Sometimes medical non-compliance is the cause.
I've noticed some things about our frequent fliers lately. They're coming back more often. The duration between admissions is getting short. With one or two exceptions, they're sicker when they come back than when they left. I'm not sure why this is happening.
Any time a patient discharges from a hospital and then bounces back within 30 days is a ding for the hospital. Any time a SNF sends a patient back within the same 30 days, it's a ding on them. If this happens enough times, there has to be some kind of blow back on the facilities. Frequent readmissions also deplete Medicare days and insurance funds.
At the same time, I'm seeing new trends. Patients are being discharged quicker than ever. They're also sicker than ever before. Remember that illness severity doesn't correspond to being medically stable. Medically stable patients can be discharged no matter how sick they are. Those same patients are telling me with increasing regularity that they aren't receiving any therapy while in acute-care hospitals. Maybe a third of them haven't been out of bed since admission when I'm doing my assessment.
I think it's safe to say without presenting supporting research that getting patients out of bed helps them improve. And the sooner they get up, the better. We also know that acute therapy staffs are stretched very thin. I would love to see a longitudinal study looking at the correlation between therapy staffing, early mobilization, outcomes and readmissions.
Left unsaid here is the influence of continued cuts in reimbursement. I'm sure someone is looking at these numbers. Nonetheless, healthcare is profit-driven. If getting patients discharged as fast as possible saves money, the practice will continue until frequent readmissions cost them more.
Until recently, I had never worked closely with PM & R (physical medicine & rehabilitation) physicians. When I worked at the "evil empire," I dealt exclusively with neurologists. Some were good. Some weren't so good. Either way, their purpose for being involved in the patient's care was clear. There was a PM & R service. From what I could tell, they ran interference on the rehab unit with other services.
Now I have three that cover my facility. I've yet to figure out what they do or why they are needed. This is long-term acute care. These patients are sick. Rehab isn't their biggest concern. They don't need a multitude of physicians writing orders for their care. It's not a question of what kind of therapy they need so much as whether they can tolerate it in the first place.
One of the physicians doesn't read the chart. He has written orders to continue care on patients we've signed off on three or four times. Another simply copies our notes into his, then writes that therapy should be continued. At any given time, either one of them is apt to write an order for something beyond the patient's capabilities or that has already been accomplished. I don't understand why they think PTs need to be told what to do with patients in the first place.
Last week, an order was written for an Achilles tendon brace to prevent foot drop. A PRAFO would have worked just as well. So would an off-the-shelf leaf AFO since the real problem manifested itself during gait. No one asked my opinion. I don't see myself discussing brain injuries and presentations with these guys. I'm not sure they would know what I'm talking about.
Maybe the specialty is better served on a rehab unit. I can see having someone to oversee the care and management of meds. Discharge, prosthetics, spasticity management and community reintroduction are also areas where I can see their value. Of course, I'm assuming my crew is the exception rather than the norm.
To me it comes down to the one question. Why do I need a physician to tell me what kind of therapy I should be doing? That's what I went to school for. That's why I have specialty certifications. I'm assuming the majority of practicing PTs and PTAs are more than competent at what they do. Why do any of us need someone else to tell us how to use our skills?
In recent posts, fellow ADVANCE bloggers Dean and Michael have been discussing how companies cut staff as a measure to lower costs. Neither of them supports the idea. Both make valid arguments against the practice that I'm sure would fall on deaf ears. Anyone who works in patient care sees the foolishness of the practice. The facility I'm working in now has cut staff to the bare minimum. Now they are seeing unexpected results.
The obvious result of fewer workers is the rest must pick up the slack. Everyone is given more patients and expected to accomplish everything in the same amount of time. Most of us buckle down and get it done. This doesn't appear to be true of CNAs. They keep quitting. Or they simply stop coming to work. There must be many more CNA jobs than there are CNAs because they keep quitting and we can't replace them.
This means the remaining CNAs must do even more work. So naturally even more of them quit. The staffing matrix places two CNAs on each hall. Now we have two halls per CNA. Needless to say, the response time to call bells is slow. Patient satisfaction continues to fall. Surveys sent out after discharges come back with lower and lower scores. Many patients refuse to come back, even frequent flyer patients, because they're unhappy.
Fewer patients translates into lower census and lower census means decreased revenue on top of already decreased reimbursement. In order to further decrease costs, more staff is eliminated. For some reason, no one makes the connection between inadequate staffing, patient dissatisfaction and lack of return admissions.
One of the PTAs I work with didn't meet her CEU requirement for license renewal. She found out Friday. A one-hour course she listed wasn't approved for credit in the state of Texas. She now has to pay a fine and do community service. Her initial response was denial. Then she blamed the company who provided the CEU. Now she has accepted it.
There's plenty of blame to go around here. She admits she should have checked the certificate to make sure it was approved. There is an approval number on it. Where it should say "the state of Texas," it says Rehabilitation Council of America. Her mistake is easy to understand. To superficial inspection it looks correct.
The course was provided by a DME vendor. Apparently once a year they make the rounds of various facilities presenting an "in-service" on their products and services. I attended my first one last week. The first thing the presenter said was the course was approved for CEUs. Given what happened to the PTA, I think it's safe to say that statement is misleading. I'm sure the point of the CEUs is to encourage staff attendance.
I'm familiar with that company. I've had bad experiences with it in the past. The so-called in-service was simply a presentation of various AFOs and braces available. It was so pathetic I didn't bother to engage the presenter in a debate about the proper AFO for extensor tone with equus deformity. He wouldn't have known. To me, the question is whether the company realizes the CEU statement is incorrect, doesn't know the difference or doesn't care.
It's unfortunate this happened to the PTA. She submitted the course in good faith. I believe she got the same penalty as someone who didn't even make the effort. She was wrong but the punishment doesn't fit the crime. To simplify things, there's probably one punishment for each offense. That said, I think the company should at least get a slap on the wrist for misrepresenting the CEU approval. I wouldn't be surprised if she isn't the only victim. For simplicity's sake, how about they don't mention CEU approval?