When not to treat

Jason Harris over at Evidence-Based Rehab has a new blog entry about the importance of giving up sometimes on treatment, which may become more and more relevant as the reform of healthcare comes closer and the market in some sectors of healthcare becomes tighter.  Both my current and previous CI are great about treating what they can or what is necessary (definitely not a view of “Someone always needs PT” and then finding additional things to treat) and knowing when to refer back or defer treatment.  My current CI and I were just discussing today about the importance of treating what you are supposed to and doing your best so that they aren’t on service for longer than necessary, because it is not right for them (their bill) or the healthcare system (and of course there is the RAC).  With a push for productivity and a concern over hours we have right now, there is an incentive to over-utilize.  Why d/c a patient from PT service if you could treat them just a bit more (it helps them!) and you keep your productivity up?   I’ve seen a couple instances where I would be comfortable d/c’ing the pt, but they are listed as 6x/wk, but that may be due to the person getting better over the past 24 hours.  I’m currently in acute care, but I’m wondering if similar suggestions could be made for appropriate utilization (however, I think in a hospital there is likely a lot more politics and levels of management).  Here are my modifications and thoughts for acute care (remember, I am a student and I might be a bit idealistic!):

  1. Goals – set and share: This in and of itself likely wouldn’t work – over the past 3 weeks the patients I have seen have had ups and downs that are pretty significant.  When things go wrong medically, they really mess with your PT plan for both goals and treatment.  I think one thing that would work is maybe not share them with the client (it may cause too much hope or despair), but to write them down each time before going in to work towards it.  I’ve found it easy to read what the last treatment was and to see if I can advance it, but not keep the end in mind.  I think to also share them with the nurse might be helpful as they can encourage them as well, but they already have a lot on their plate.
  2. Outcome surveys – I think acute care has one basic goal – get you discharged as soon as you can safely.  The basic stuff of bed mobility, functional mobility (transfers) and gait are the staple of outcomes.  I have not heard of any acute care outcome surveys here (I’m in trauma and neuro ICU’s, and probably 9/10 people go to another floor as their status is upgraded), but I will likely be looking for something similar for my inservice (info forthcoming).  If I find one that seems to work well I’ll post it.
  3. Tracking outcomes – is this possible in acute care?  I’m sure that management does it somehow, but other than productivity I’ve never heard them mention tracking.
  4. “Question your colleagues and be open to constructive criticism from your colleagues regarding visits.”  I think this would be a great idea in either a small clinic or a setting where people are patient-driven and everyone buys in to the idea; I’m not sure how it would go over in a larger setting like acute care or inpatient rehab.  I think in the interest of furthering myself and my patients it is important, and I hope that I can both question and be open when I’m out practicing, knowing that I can always learn a better way and that I don’t know everything now or in the future.

This is a good thing to think about, regardless of the setting.


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