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.
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.