Order the right therapist at the right time

Many hospitalists' requests for consults fail to maximize the potential of therapy to provide high-quality, efficient care.


Do you know what the various therapists in your hospital actually do?

Many hospitalists' requests for consults fail to maximize the potential of therapy to provide high-quality, efficient care to inpatients, according to Michael Friedman, PT, MBA, director of rehabilitation services at Johns Hopkins Hospital in Baltimore.

During a session at Hospital Medicine 2014, held in Las Vegas in March, he highlighted some common pitfalls in collaborations between hospitalists and physical, occupational, and speech therapists.

Recent data about the negative effects of immobility (even among conference attendees, joked Mr. Friedman) have led to widespread agreement about the importance of getting patients off bed rest. “We now walk into meetings at Johns Hopkins and say, ‘Bed rest is bad, any questions?’ Everyone really agrees,” he said.

Hospital systems should be redesigned to encourage movement, Mr. Friedman suggested. “Three times a day for meals, do we have them sit up in their chair and have meals, or do we play toward a sickness model, bringing everything to their bed?” he said.

In the meantime, hospitalists can also help with mobility efforts. “If I could pick one thing that physicians could really do the most, it would be set the expectation that ‘We know you're not feeling well, but an important part of you getting better is you getting up and moving. People are going to ask you to get up and move even when you feel the worst. Please help us out by getting up,’” said Mr. Friedman.

But the way to get patients moving is not necessarily to order therapy. “The first question I always ask when people in our hospital say ‘I need physical therapy’ is ‘Do you need therapy or does the patient need mobility?’” said Mr. Friedman. “The skill of the physical therapist is really used for gait training, or ambulation, [or] transfers, but not as a human Hoyer lift.”

Cardiac patients, for example, may benefit from frequent ambulation during the day, but their walks may not require the expertise of a therapist. “Could the patient do that independently? Could it be done with a nurse? Could it be done with a tech? Those are often questions we need to ask,” said Mr. Friedman.

Allocating these tasks appropriately improves the cost- effectiveness of care and opens up therapists' time for patients who would most benefit from it. “Someone else should move these patients so we can help be better targeted,” said Mr. Friedman.

On the opposite end of the spectrum from patients who can ambulate themselves are those who don't ambulate at all. That alone is not reason to call a physical therapist, Mr. Friedman noted. “Does the patient have a likelihood of improving or restoring? Often we have patients who came from a skilled nursing facility with no change in function,” he said. “We order physical therapy because they are not ambulatory status.”

Therapy is unlikely to restore these patients to greater function, although it may be appropriate to request a one-time consult to develop a plan to prevent pressure ulcers and the like, he noted.

For those in-between, who ambulate imperfectly, therapists sometimes perform assessments of assistive device needs. But not all such patients require a consult. “Fear of liability—one of the biggest reasons I hear about referral for physical therapy is fear that a patient will fall [after discharge] or they weren't cleared by physical therapy,” he said.

To evaluate this concern, he did a study, searching for malpractice lawsuits based on a failure to order physical therapy before discharge. “There were no claims at all based on a patient having a fall outside the hospital,” Mr. Friedman said.

Concerns about postdischarge needs often drive therapy consults, some of which could be more efficiently left until later. “Creating a maintenance program for low back pain in the acute care hospital probably is not reasonable. It's probably best handled in a lower-cost environment like an outpatient or rehabilitory setting,” said Mr. Friedman.

Another way to make more efficient use of therapy is to think twice about checking off the box both for PT and OT. “Often we question ‘Could just physical therapy have gone, or just occupational therapy have gone?’” he said.

A greater understanding of the differences among the therapy specialties can help with this decision making. “There was a misnomer that occupational therapists took care of everything above the waist and physical therapists took care of everything that ran on two feet. That's really not the case,” said Mr. Friedman.

The division of labor varies by region and individual hospital. “In New England and the mid-Atlantic, a lot of physical therapists do airway clearance….In other parts of the country that's really done by respiratory therapy, so there's some overlap in services,” Mr. Friedman said.

Occupational and speech therapists often overlap in their treatment of cognitive problems. “I would encourage you all to speak with your own rehabilitation therapy teams to really identify where they draw those lines,” he said.

A line of work that has been keeping occupational therapists busy lately is activities of daily living (ADLs). “When you think occupational therapy, you should really be thinking about activities of daily living. This has really come to the forefront in the new conditions of participations for Medicare, which state that the assessment of every patient prior to discharge needs to include an assessment of ADLs,” said Mr. Friedman.

Inpatient speech and language pathology in the hospital setting continues to focus in large part on swallowing issues, he noted.

Some patients may need to see multiple types of therapists, along with many other types of clinicians, and in such cases, often the inpatient care coordination is lacking. “We have 5 or 6 providers all come at the same time—lab comes, imaging comes, and therapy all comes at the same time,” said Mr. Friedman. “We need to better coordinate amongst ourselves: right patient, right provider, right time.”