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PTA Blog Talk

Patient Effort

Published September 7, 2011 8:40 PM by Jason Marketti

Some facilities I have been to have residents who see us in the halls joking and laughing with other residents and they felt left out so they practically begged to be seen by the therapy department. Once in therapy, they realized all the work that goes into it, began to refuse and were finally discharged until a few months later when the process repeated itself. These are the misdirected patients who see something they do not have, but then realize that to achieve the fun in therapy takes work they are unwilling to do.

The unsolicited patients are the ones who show up to therapy without orders and ask if they can do something to get stronger. When it is explained to them they will have to speak with the MD, they seem put out and think it is a waste of time to talk to the doctor if all they want to do is get a little stronger. When and if they do get orders, they do not follow along with the therapy activity for very long, are often discharged to a restorative program and eventually stop coming.

This seems like a waste of time and resources. Is it? All patients should have the right to therapy services but they should also understand the work involved and commitment it takes to get stronger, have fewer falls and move easier. Initially, patients are gung ho to get to therapy but once they see what it takes to develop skills, some are not willing to invest the time and effort.

Perhaps we should develop a program where the PTA can initiate the activity with the patients and pass the information to the PT, who can make further assessments regarding the patient's abilities and commitment to follow through before an evaluation is done. This might cut care costs and free the PT from doing evaluations and developing a plan of care that only lasts a week or so before the patient decides he does not want to do it anymore.

8 comments

Janey- I totally agree with your post.  Completely.  

The reason CNAs and LPNs are "initiating activity", and PTAs are not, is because they are not billing for that time, and they are not calling it skilled.  

There are thousands of examples and reasons why we have a clear set of responsibilites for a PT and for a PTA.  Jason, I applaud your enthusiasm for wanting to do more at your facility but a patient needs to be seen by a PT first, and the relationship between the PT and PTA needs to remain open to discuss the patient case.  

Lisa West September 9, 2011 5:30 PM

Karen,

I think you are asking the same question that was addressed in the other blog Jason referenced, "Narrow Scope of Practice".  I believe what you refer to would fall under the Good Samaritan Act.  I would not consider that initiating activity.  I would consider that intervening in an effort to "first do no harm".   If I'm mistaken and a different question is on the table, please clarify; and I'll take another stab at it!

Jason,

This brings me to my thoughts on your comment.  In my opinion, preventing a fall or an elopement is intervening, NOT initiating activity.  If you did intervene in one of those instances, in every facility I have ever worked in you would be required to report it, in nauseating detail.  Your report would be an objective record of the events as they transpired.  If during that event you observed behavior that appeared to be appropriate for rehab by any of the disciplines, I would expect you to report it immediately for followup by the appropriate therapist.  You are correct, you could not legally make an assessment of the patient, any more than the CNA could make an assessment of the patient.  You would be making an observation; and based on that observation and your clinical experience, you would be making a recommendation.  At this point, that is all the law allows you to do.  

I think you are confusing two sets of terms:  "observe" with "assess", and "intervene" with "initiate activity".  You appear to believe you are comparing apples to apples, but as I see it you are comparing apples to oranges.  We can agree to disagree.

Here is the problem.  If I am right, your presentation is driving a wedge between PTs and PTAs when what you desperately need is solidarity.  You appear to be asking professionals to put their stamp of approval on PTAs performing tasks that are currently illegal.  Those you get to agree with you are not individuals with whom you should want to share a boat.

Currently your choices are to secure a PT license or fight to change legislation.  If you believe a PTAs education merits a change in legislation, clearly state that and win professional supporters who can help make your voice heart.  

What we THINK we should be able to do really doesn't matter.  When we choose to ACT on what we think, then we can make a tremendous impact.

I hope you'll do a blog on activities directors and the specific PT exercises they use, how they use them, etc.  That is a whole separate issue that deserves time of its own.

Thanks for the opportunity to discuss!

Janey Goude September 9, 2011 12:34 AM

I'd like to see Janey's response.  Should PTA's allow a patient to fall if they have not been evaluated by a PT first.  

Initiating activity can be anywhere from w.c. mobility to bicep curls, LAQ's, and ankle pumps.  Maybe limiting what PTA's can initiate could begin with bed mobility and exercise.  The PT should definitely be the one to assess and evaluate out of bed activity.

Karen September 8, 2011 10:23 PM

This actually ties in with my May 18th blog "Narrow Scope of Practice".  If by definition I am not allowed to "initiate activity" with a person prior to a PT eval then I have to let a person fall or elope the facility rather than intervene.  And I, by definition, cannot report on it because I am not legally able to assess the events that occured because a PT did not eval first.  However, I could tell the OT, NSG, and ST people.  Is relegislation likely? Probably not.  Should PTA's be able to do more, yes, but the law does not allow it.  The law however allows the CNA's and LPN's to move a patient and assess their movements prior to a PT eval.  And sometimes their assessments are not fully accurate to their true abilities.  A PTA's assessment would be more accurate to pass along to the PT.  Activities departments do exercises with pateints.  Some of the same exercises we do in therapy.  They are not looking at the same things we are but they know when a patient is having a hard time moving during their class.  Could a PTA's assessment help, yes, and we could also correct a lot of mistakes during the process in regards to posture, form, and correct application so patients do not get injuried.

Jason Marketti September 8, 2011 9:56 AM

I'm going a bit out of the box with this post.  Perhaps the topics you are choosing to address in some of your blogs are symptoms and not the real issue.  Consistently this theme you revisit comes down to PTAs being able to do something that is currently illegal.  Period.  

Is the heart of the matter that you believe the current laws need to be reconsidered?  Do you feel the current education of a PTA is such that they are capable of more than the law allows them to do?  If that is what you are saying, then the issue is relegislation.  

"Should the laws be different?" is an altogether different question than "Should PTAs be permitted to practice illegally?"

Or, perhaps I have misread your intent entirely.  It happens!  If that is the case, please accept my apology and take this opportunity to educate me!!

Janey Goude September 8, 2011 2:05 AM

On one hand I can see where your recommendation is coming from.  A nursing aid who works closely with a patient can be the one who recognizes the need for therapy.  One could say that aid "assessed/evaluated" a need.  This is also true for the activities director.  She may be working with a patient in an activity and see that the patient could benefit from rehab services.  A natural question arises:  If these caregivers - who have no training in therapy - can evaluate a therapeutic need, why not the PTA?  

First, to ascribe the term "evaluate/assess" to either the nursing aide's or activities director's performance would be to use a very liberal definition of the term, a definition that is altogether different from a therapist who "evaluates" the patient's appropriateness for therapy.  In actuality, the nursing aide and activities director in these scenarios did not technically "evaluate/assess" anything.  

More accurately, during the course of their treatment - providing patient care that falls within the scope of their occupation - they observed a potential deficit or need.  This is similar to a PT or PTA working with a patient and noticing a swallowing difficulty and referring to speech therapy.  We are not treating the patient for speech, but we have enough medical background to pick up on a potential problem while we are performing tasks within our scope of practice.

If I am reading this post correctly, you are suggesting the PTA use his/her clinical skills to assess the patient's readiness/appropriateness for a PT evaluation.  The main difference is that in this case the PTA would not actively be engaging the patient within the scope of the PTAs practice act.  

A PTA "observing" an OT or speech deficit while rendering physical therapy treatment is equivalent to an activities director or nursing aide "observing" a PT deficit while rendering their patient care.  

I have never known an activities director to independently initiate exercises that would fall in the realm of PT (which is what it sounds like you are inferring in your response to Lisa).  For me, that would be the equivalent of a PTA "initiating activity" without a PT evaluation.  Both would be out of line.

Janey Goude September 8, 2011 2:01 AM

Good question, however, is the therapy department concerned when an activities person initiates exercises with the patients without a doctors order or an initial PT evaluation?

I suggest the PTA be allowed to do the same (and more) to observe potential rehab clients.

Jason Marketti September 7, 2011 10:44 PM

Isn't initiating activity considered an evaluation?  

Some patients are just amotivational, but that doesn't mean their care should be any different that those who are highly motivated.  

Lisa West September 7, 2011 7:32 PM

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    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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