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Raising the Bar in Rehab

The Risks of Physical Therapy

Published January 27, 2011 4:53 PM by Lisa West

One of my previous PT classmates called me a few weeks ago to tell me about an incident she had at work. Over the past few weeks, the situation has developed and the skills of my friend have been put into question. I'd like to hear your input when you are finished reading!

The patient is being seen for physical therapy in an acute-care setting following a total hip replacement. The initial goals and plan of care were outlined and the patient was progressing well. On one particular day, the patient had advanced towards a "Supervision/Contact Guard" level for ambulation and had planned to attempt stairs.

While on the stairs with bilateral railings, the patient's knees buckled and the therapist used the gait belt strongly around the patient's waist to prevent a complete fall. The patient was lowered to a chair and no contact was made with the floor. After the therapy session the patient complained of increased pain in her hip and the nurse was informed of the results to the therapy session. There was never an incident report submitted after the session... because the patient had never actually made contact with the floor.

Two days later the patient had X-rays taken of her hip and it was determined that she would need a surgical revision of her new hip replacement. The patient was very upset and requested the name of the therapist working with her during that session. The MD stated that "the patient never should have been attempting stairs so soon after a hip replacement."

While it cannot be completely proven that the therapy session alone caused the hip injury, most of the caregivers involved believe the patient's hardware loosened during the loss-of-balance episode. It is possible that simply ambulating alone, or rolling/repositioning in the bed may have predisposed the hip to further injury, or maybe the weight-bearing-as-tolerating was too much load for the hip to bear. The end result was that following the stair negotiation, the patient's pain level had increased to an intolerable level and led to further x-rays.

My friend, the therapist, felt confused and targeted. She was simply progressing the plan of care. Every step had been taken to ensure the patient's safety, including a gait belt and a chair kept nearby. The patient had agreed to the therapy session - and attempting stairs - and understood the risks of her surgery. Is the therapist to blame? Should she have been more conservative in her interventions? If the MD didn't want the patient on stairs, shouldn't he have specifically ordered that restriction?

What would you do if you were the therapist in this situation? First, how can you prevent the incident from occurring again with future patients? And how do you resolve the situation with the patient herself? What legal issues do you think this therapist is facing? What rights does the patient have when therapy poses certain risks?

3 comments

thz for this article... we have a problem in our practice ... therapist leaving patients alone during treatment... do you have ant evidance that discusses this particular issue.

thz

fayz shary, TRUMA - PT, PRIVATE June 10, 2011 11:17 AM
RIYADH

2 things caught my attention in this story. First that the patient was WBAT but there was no mention of an assistive device. I find it rare that someone WBAT shortly after surgery not use a device such as a crutch or cane. Ascending stairs without device doesn't sound like it would translate into similar function at home.

Second, why did the knees buckle? Was there a sudden increase in pain? Were vitals taken prior to beginning treatment to identify low BP? What was the patient's general appearance prior to starting the stairs?

Although the patient did not fall to the floor, any twisting of the trunk or inward rotation of the affected leg could have caused dislocation. Most definitely an incident report should have been filed. Damage can be done without hitting the floor.

Some things don't add up, Did the hardware loosen or did the hip dislocate? If the hardware loosened, the incident probably would've happened anyway somewhere down the line. Most WBAT hips I've worked with have been cemented not porous coated. Sounds like there would've been an issue with that. If the hip dislocated, well then the incident is probably the culprit.

I think all of us have dropped or come very close to dropping a patient in our careers. It happens, sometimes we're at fault, sometimes not. Most often it was something beyond our control. Mine was a nearly 400lb woman who managed to move a locked bed  supported by an assistant when she leaned against it and slid to the floor. There was no way anyone was stopping that without hurting themselves! The head nurse on that ortho ward was brilliant. She told me, "yep, you dropped someone today and feel miserable. Now get over it 'cause I've got 20 others who need you to make them able to go home". Best advice I got that day!

Another blogger, I think Jason, also posted about gait belts recently. I think this is another instance where the argument about them could come into play.

Let us know how this plays out. There will be lessons galore from this experience.

Good luck to your friend!

Dean Metz January 29, 2011 2:12 PM

Could the MD have made a mistake during surgery as well.  The difficulty is that it happened to a new therapist.  Even though we try to progress a patient,  was using the stairs a reasonable recovery activity based on the acuity of the situation?  If the patient was d/cing to home yes, if to a SNF probably not - let the SNF PT's do it.

I would question why it took several days to get an X-ray at an acute care hospital. Did the therapist request one after the incident?  Legal will review everyones response to the situation and pour over the documentation and if the MD is extremely nice to the patient and the PT is not involved with the patients recovery there is a chance no lawsuit will be brought forth.

I have had patients fall (one broke her hip while we were standing at bedside) and I too was a recent grad.  Did I do something wrong or not follow the POC? No, sometimes patients fall, hardware loosens, and transfers don't go as smoothly as we like.  Preventative measures for situations like this: limit stair use on acute care patients.  As we develop professionally we gain an increase in knowledge through mistakes, accidents and good fortune with positive results for patient outcomes in the future.

Jason Marketti January 28, 2011 12:57 AM

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