Getting the 'all clear' for physical therapy

Functional, fall risk assessments alert staff to need

The "red flags" that signal the need for teaching by a physical therapist may be more pronounced than the red flags that signal the need for any other kind of health education. "There are specific deficits and precautions that warrant a consult to physical therapy," says Susan Brenneman, PT, MS, education/development coordinator for the Occupational and Physical Therapy Department at the Hospital of the University of Pennsylvania in Philadelphia.

For example, total joint replacement patients must learn specific home exercises and methods of mobility to avoid injury such as how to move, sit, and transfer weight. There are also particular ways to use assistance devices where the physical therapist would be the appropriate teacher. Physical therapists teach heart transplant patients exercise tolerance and how to monitor their response to exercise, says Brenneman.

The Joint Commission has "must teach" standards, says Michelle Barnhart, RPT, director of physical therapy at Phillipsburg, NJ-based Warren Hospital. "According to the Joint Commission, the physical therapist teaches ways to regain strength and mobility, how to adapt and function more independently, and the use of medical equipment and supplies," says Barnhart.

The reason the therapist is the best person to do the teaching is simple, says Brenneman. "Therapists are better able to individualize their teaching to the patient's diagnosis, and particularly their specific physical impairments and limitations. If adaptations need to be made in how something is done, the therapist can give more individualized teaching to the patient with respect to physical limitations," she explains.

Connecting physical therapist and patient

To determine if a patient needs to be taught by a physical therapist, a functional and fall risk assessment is part of the nursing assessment at Warren Hospital. The patient's activities of daily living are discussed, such as whether or not the patient is currently eating, dressing, and bathing him- or herself. Also discussed are assistance devices being used, such as a cane or walker.

A nurse or case manager at Warren Hospital will often suggest the physician write a referral to a physical therapist for the patient, says Barnhart.

Although a physician may write a referral on his or her own, or have a consult with a physical therapist as part of the standard post-op orders, the nurse plays a critical role in the recommendation for a referral, agrees Brenneman.

Good communication and relationships between the nurses on the units and physical therapists is critical. "Nursing staff has a big role in recommending that a therapist be consulted and brought in for different patients. It is almost as if nurses do the first triage," says Brenneman.

Critical pathways are another way that many hospitals set standards for teaching by physical therapists. "There are certain pathways, like for joint replacement, where the physical therapist comes in to teach the patient on certain days," says Brenneman.

Pathways ensure that teaching takes place in a timely manner. Another method many hospitals use to make sure the physical therapist has time to teach is to move the education to the pre-op setting. "We do much of our teaching prior to admission, especially for the hip and knee joint replacement surgeries," says Mary Wolcott, RN, MSN, patient education coordinator at Methodist Hospital in Omaha, NE.

A pre-surgery class for joint replacement patients is held at the hospital once a week, and nurses and physical therapists share the teaching. The nurse discusses safety issues and what to expect following surgery. The physical therapist discusses exercises and the use of assistance devices. Wolcott films the class and sends videos to all patients who can't attend. She also tapes the discharge teaching for patients to review in advance. Those who attend the class are welcome to take the videos home as well.

Whatever method of referral and teaching is used, communication is key, says Wolcott - not just between disciplines, but also with patients and their family members. That is why a white board hangs in every patient's room so the names of staff who will be working with the patient on any given day can be listed. Also listed are the various treatments, such as "crutch walking at 2 p.m." In that way, family members can arrange to be at the hospital if they want to participate in teaching sessions. "It is a good communication tool for everyone," she says.