acute care environment

[Julie S]

hey guys!
I am currently doing an acute care clinical in a community hospital and have been surprised by a few things, perhaps as an idealist (naive?) student . Here are some positive observations:
-The health care team really respects the PTs observations about discharge planning. I think that's pretty neat.
-Many patients are very happy to get up and moving for the first time and appreciate the PTs facilitating that.

Here are some other things that I have noticed and am questioning:
-I currently work primarily in a gym, not bedside. The PT is expected to see 3 patients every half hour. Here is the formula: vitals, AROM LE exercises, walk/stairs if they have them (hopefully twice so the PT can "bill" for it). As I was told, we don't really "treat" patients, thats for rehab.
-Patients are seen ASAP if they need to be discharged but otherwise once every 3 days or so, except if they are on the neuro floor in which they are seen 5x/week.
-Ortho patients on the other hand get post op day 0 bedside, then 2 hours therapy a day after that.

Is this the status quo in acute care PT? With what we know about dosage/intensity of our interventions, patients getting seen for 10 minutes 3x/week is obviously, not going to be very effective. I don't think acute care is for me but is something I'm considering doing on weekends.

Thanks for your input!

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[IrisSong]

I tend to have a negative view of the acute care setting. In general, I don't feel "the formula" you mention is typical but I will say acute care seems more about volume (at times) and can seem at times very "cookie cutter" since the functional level of the average patient is low. *Just my opinion*

 

[NewTestament]

Three patients every 30 minutes? How many patients are seeing each day? On my acute rotation I saw 10 at most in nine hours. I had a lot of discretion, but in general each evaluation was similar. I would check LE strength/ROM, bed mobility, transfers, gait, alertness level, and history. Then I would move the patient to the chair. But in the acute care setting I did evaluations as well as treatments. It wasn't as rote and efficient as the hospital you are in.

 

[Julie S]

To be a little more clear: Three patients every half hour is in a gym. So the aid can do vitals and their AROM exercises. We do evaluations (in fact its almost all evaluations), so its the above plus three questions (pain, living situation, assistive device) plus maybe asking where they want to go, alert and oriented if they might have neuro involvement. ROM is not done except in the context of very basic MMT (hip flexion, knee extension, dorsiflexion/plantar flexion). Not sure why we would measure PROM because we don't have time to treat it... Also you are supposed to fill cancellation spots but that doesn't always happen so we don't always have three every half hour.

Patients that need to be seen bed side sometimes have a 3 day waiting period because of lack of staffing

Since they arrive to the gym sitting we don't do transfers. You are also expected to document as you go mostly, obviously documenting 15 evals is not doable in the half hour we have set aside at the end of the morning or afternoon (plus your last pt is typically late). In theory that is 30 patients per day, usually more like 25 are seen.

I'm glad to hear that this might not be the norm.

 

[Bones26]

That sounds like an LTAC/SNF more than an acute care setting to me.

During my acute rotations and job we saw ortho patients 2x/day. Everyone else 1-2x/day. Patients were seen every day until they were discharged from PT and/or the hospital. Each PT treatment would be between 20-45 minutes long, one on one. We didn't have techs. Everyone was seen in their rooms instead of a gym. Modified independent transfers and ambulation were the two main goals so that was the focus of our treatments.

 

[truthseeker]

So, if the aide is doing the vitals and the AROM and you are seeing the patient for 10 minutes you bill one unit of ther ex? it doesn't sound like there is much skilled therapy going on. skilled therapy, IMO, is often not in what you do, but what you think and how you problem solve and teach the patient. if someone is simply doing long arc quads, SLR, and quad sets it is certainly NOT skilled and again IMO, fraud if they are asking you to bill for it. I would run away from that setting as fast as possible because as soon as there is an audit, they might be shut down.
In our acute setting we set aside a 30 min. block for every IP. we may not use the entire time for patient care but we have it. They may not even be able to participate that long.

Watching someone do shoulder pulleys for the 5th time, is not skilled, its fraud. I really don't think that most acute care settings are like you described.

 

[Schland]

This is how it was at my acute care rotation. I was at a very small community hospital so no traumas, no heart surgeries, etc. We had a lot of elective orthopedic surgeries and many evals for admits like syncope or something. I did a lot of evals. Many of them were for a discharge disposition and many times I never saw the patient again as they were discharged (but we always had to make a care plan in case they were to be there.. and these people were typically 1x/day 5-6x/week). Others were evals to make sure the patient was safe to get up and move and we would sign off after. Then the routine orthopedic surgeries where we knew the protocols and we saw those patients 2x/ day. We had no time limitation on patients and the vast majority of my treats were in the room/ hallway. But you had to know what your schedule was and plan appropriately for time sake. My CI was the only full time PT for inpatient and there were no techs/aides/etc.

I also did some acute care at my outpatient (it was hospital based). While things were different there we were never expected to see 3 patients at a time. And yes acute care does "treat." So I agree with others, that place does not sound like the norm.

 

[markelmarcel]

I was told, we don't really "treat" patients, thats for rehab.

Am I the only one who finds this part completely mortifying? Do you do intense treatments with the majority of patients, no, but there is plenty of skill going on. The PT should be taking vitals and INTERPRETING these vitals to determine if they are normal/abnormal and also what the hemodynamics response is of each patient throughout the treatment session. Although you may not get to do a lot of highly skilled exercise treatment with these patients, it is imperative to evaluate them appropriately so that the discharge location can be determined. Finding out prior level of functioning, educating patients on their condition/surgery with precautions/warning signs/symptoms/expected recovery path is skilled intervention and is in the patient's best interest. For every 1 day in the hospital, they say you lose 3 days worth of regular daily activity/movement... So yes, sometimes it is just getting someone up and moving, but it's more about interpreting what happens to the patient as you get them up and moving which is the most important. /end my two cents.

 

[Julie S]

The sad thing about said AROM exercises is its the same for every single person and seated (marches, LAQ, heel/toe raises). No SLR or quad sets as that would involve transferring them to a mat. Bed mobility is not even assessed.

I'm ready to chalk this up to a dysfunctional hospital or at least a dysfunctional PT department. I've started to move up to four patients an hour and my CI wants to me to get as close to "entry level" as I can which to him means 6 patients an hour. I think that's entry level for someone who takes a really terrible job. This has been pretty stressful but I only need to stick this one out for another 2 weeks. Just wish I could have learned something in this hospital besides how to streamline an evaluation to 10 minutes and rush through your documentation as quick as possible. On the bright side I did a vestibular internship so they give me all the dizziness cases which actually involves a little bit of skill.

 

[jblil]

6 patients/hr! Is this a for-profit hospital? Out of curiosity, do you know what is the turnover in PT personnel at that "hospital"?

 

[Julie S]

No, not for-profit. They recently had to make staffing cuts of support personnel but not PTs.

Turn over I imagine is pretty high. Hard to say for sure.

 

[jbizzle]

6/hr? Which place is this so I know not to apply even when I'm desperate.

 

[DesertPT]

So at the rate you describe seeing the typical 25 pts/day would take a PT a little less than 4.5 hours. Assuming they work full time, that would leave them charting 3.5 hours+ a day. Really? I am by no means experienced but that doesn't seem reasonable.

 

[Julie S]

Well there is an hour in the morning to set up the PT schedule, triage it and do chart reviews (needed because of communication with nursing, transport, triage, etc), then patients for 2.5 hours (15 spots), then a half hour after the morning block for documenting (but that's usually actually overflow from the schedule), an hour lunch/finish documenting, then repeat for the afternoon. So 30 spots available, 8.5 hour day including lunch. In reality 2-3 hours for scheduling/documentation/chart review, about 5-6 for seeing patients. Keep in mind that if you have 25-30 (in theory) notes to write that does require a substantial amount of time documenting, especially since most are evals.

 

[DesertPT]

Sounds like major burnout of PTs must be inevitable there...

And I realize how much time it must take to document for that many cases each day, I was just saying that that really sucks to be a PT who spends like 40% of their work week documenting. That's a shame IMHO.

 

[truthseeker]

so with all of those evaluations, are you evaluating them and handing them off to a PTA? if you are just evaluating them and not picking them up then I wonder if a better screening process would be appropriate.

 

[Julie S]

Evaluating them, seeing them within 3-4 days if they are not at baseline. unless they are on the neuro or orthosurgical floor (then seen 5x week). We don't have any PTAs.

 

[Fiveoboy11]

I work per diem in a the acute setting, see everything from mom/baby unit to ER to ortho/neuro/medical, etc. At the hospital I work at they also have a policy where post op ortho patient's "get PT" BID. I strongly disagree and have made it known many times, currently am in process of formulating a complaint to the state board as this policy yields unwarranted skewing of services. Anyone with advice along thse lines let me know. Personally, to me, it makes no sense for a PT POC to be predetermined and I feel it goes to the power of administration and physicians to dictate something they have no training in. But, it is up to the PT to fight back. As far as "gym PT", or when a tech brings the patient to the gym and the PT does some exercises on a mat table. Predetermined frequence in addition to PT POC is twice as bad. Each person does not need the same services, so it should be based on the assessment, and customized per the patient. No supine, sitting and standing exercises for everybody. No TKA or THA exercise protocol. No CPM set up. As noted above, to some extent in this setting triaging needs to occur, the amount and frequency someone can be seen is dependent on it to some extent. PT is not IV fluids where everyone can get some whenever some random person randomly decides.

 

[ptisfun2]

I work per diem in a the acute setting, see everything from mom/baby unit to ER to ortho/neuro/medical, etc. At the hospital I work at they also have a policy where post op ortho patient's "get PT" BID. I strongly disagree and have made it known many times, currently am in process of formulating a complaint to the state board as this policy yields unwarranted skewing of services. Anyone with advice along thse lines let me know. Personally, to me, it makes no sense for a PT POC to be predetermined and I feel it goes to the power of administration and physicians to dictate something they have no training in. But, it is up to the PT to fight back. As far as "gym PT", or when a tech brings the patient to the gym and the PT does some exercises on a mat table. Predetermined frequence in addition to PT POC is twice as bad. Each person does not need the same services, so it should be based on the assessment, and customized per the patient. No supine, sitting and standing exercises for everybody. No TKA or THA exercise protocol. No CPM set up. As noted above, to some extent in this setting triaging needs to occur, the amount and frequency someone can be seen is dependent on it to some extent. PT is not IV fluids where everyone can get some whenever some random person randomly decides.

I think this is an interesting point, and curious what your state board would say about this.
Healthcare right now is in this big push toward 'unwarranted variation in care' and I think people could interpret that as 'do the same for everyone' so no variation in care. But I do not think that is what anyone meant when the folks started talking about unwarranted variation.
There may be a good reason for patients post THA to have the same ther ex protocol (for example). But does it require the skills of a PT to have them do this ther ex protocol 2-3 times/day or can that task be delegated to others (family, nursing, unskilled workers [tech, CNA], patient). The PT is still ultimately responsible for the delegated task, but allows the PT to spend time with patients who need skilled care (e.g., in the acute care setting, someone in the ICU with respiratory failure to facilitate ventilator weaning).
But the move toward unwarranted variation in care is here to stay I think. I do not think there is any fighting against it due to requirements from Medicare and other insurance companies. PT, MD, RN are all probably somewhat dissatisfied, but my opinion is ultimately it will allow the right people to make the right clinical decisions for the right patients at the right time to improve patient-focused outcomes.

 

[Fiveoboy11]

I think this is an interesting point, and curious what your state board would say about this.
Healthcare right now is in this big push toward 'unwarranted variation in care' and I think people could interpret that as 'do the same for everyone' so no variation in care. But I do not think that is what anyone meant when the folks started talking about unwarranted variation.
There may be a good reason for patients post THA to have the same ther ex protocol (for example). But does it require the skills of a PT to have them do this ther ex protocol 2-3 times/day or can that task be delegated to others (family, nursing, unskilled workers [tech, CNA], patient). The PT is still ultimately responsible for the delegated task, but allows the PT to spend time with patients who need skilled care (e.g., in the acute care setting, someone in the ICU with respiratory failure to facilitate ventilator weaning).
But the move toward unwarranted variation in care is here to stay I think. I do not think there is any fighting against it due to requirements from Medicare and other insurance companies. PT, MD, RN are all probably somewhat dissatisfied, but my opinion is ultimately it will allow the right people to make the right clinical decisions for the right patients at the right time to improve patient-focused outcomes.

I think the idea behind reducing variation in care is to have similar practice patterns for the hypothetical same patient. Not the same treatment for every patient. In other words, a hypothetical patient X seen by different PT's would get similar POC and treatment (based on the assessment, evidence, patient values, etc). I'm all for guidelines, but completely against protocols. Guidelines are evidence based and patient centered, protocols are antiscientific and antiquated. I would never feel comfortable being responsible for anyone other than a PTA, or PT tech instructing a patient on elementary post op exercises; to me the point is post op exercises are not necessarily skilled, do not need "physical therapy" to instruct them and every patient does not need the same ones at the same frequency. Kind of as idiotic as a physician getting ordered "per protocol" to do a certain opioid BID. It's ridiculous and nonsensical.

 

[ptisfun2]

I think the idea behind reducing variation in care is to have similar practice patterns for the hypothetical same patient. Not the same treatment for every patient. In other words, a hypothetical patient X seen by different PT's would get similar POC and treatment (based on the assessment, evidence, patient values, etc). I'm all for guidelines, but completely against protocols. Guidelines are evidence based and patient centered, protocols are antiscientific and antiquated. I would never feel comfortable being responsible for anyone other than a PTA, or PT tech instructing a patient on elementary post op exercises; to me the point is post op exercises are not necessarily skilled, do not need "physical therapy" to instruct them and every patient does not need the same ones at the same frequency. Kind of as idiotic as a physician getting ordered "per protocol" to do a certain opioid BID. It's ridiculous and nonsensical.

Although there may be a hypothetical difference in your comment, the literature for health care reform and informatics do not make that distinction practically. As for guidelines being evidence based, if you look closely at the ones in orthopedics (on APTA Ortho section website), you will see the science and evidence is pretty weak (their grades) and rely on clinical experience (i.e., expert opinion). Protocols are not much different; just a different name. protocols are guideline for patient treatment. In 25 years of clinical practice, I have never heard of a PT who follows protocols as dogma; rather guidance. Although I was just at a state district meeting and one of the PT asked what is the ortho surgeon's (speaker and not known as a 'friend to PT') protocol post ACL, and he replied, 'You tell me. You are the expert.' So based on your clinical experience with protocols being different that my experience, perhaps 'the times they are a changing' (and yes I am dating myself probably).

 

[Fiveoboy11]

Although there may be a hypothetical difference in your comment, the literature for health care reform and informatics do not make that distinction practically. As for guidelines being evidence based, if you look closely at the ones in orthopedics (on APTA Ortho section website), you will see the science and evidence is pretty weak (their grades) and rely on clinical experience (i.e., expert opinion). Protocols are not much different; just a different name. protocols are guideline for patient treatment. In 25 years of clinical practice, I have never heard of a PT who follows protocols as dogma; rather guidance. Although I was just at a state district meeting and one of the PT asked what is the ortho surgeon's (speaker and not known as a 'friend to PT') protocol post ACL, and he replied, 'You tell me. You are the expert.' So based on your clinical experience with protocols being different that my experience, perhaps 'the times they are a changing' (and yes I am dating myself probably).

The APTA guidelines are strongly evidence based, the individual grades are irrelevant whether expert opinion or level A (for or against) or in between. And there are many grades at A and B level. The idea is to say here's the evidence for this intervention or examination for this condition. And they serve as direction for further research. Let's not get confused to think that guidelines are a springboard for non evidence based practice patterns, that's what protocols are. Protocol = "expert" opinion. "Expert" in these cases often being non PT's, thus not even qualifying as an expert. Guidelines (grades based on evidence) are peer reviewed and published, not typed up in a half hour with little to no basis.

Your surgeon anecdote does not sway me from the realities as above. But many of my own anecdotes have taught me that protocols are outdated, not scientific, and followed to the expense of the patient, critical thought and the providers professional development. Guidelines serve to guide based on critical appraisal and summary of the evidence, protocols do nothing of the sort.

And as far as diminishing practice pattern variance, my understanding is that it is aimed to actually encourage variance between patients as indicated but discourage for the same hypothetical patient.