Conceptual variation is more damaging, and a bigger issue, than perceivable, apparent practice variation. Because of the multi-faceted nature of the mechanisms of effect in physical therapy treatments, especially for pain, striving for observable decreases in “practice variation” may not actually solve many of the issues within the profession. The real problem is conceptual differences. The stark contrast between explanatory models, and stories told, results in significant variance in explanation and education received by patients. Patients are still routinely told they have “bad” posture, an SI joint that is “out” and weakness causing their painful problems. Such unhelpful and debunked ideas are the unnecessary imaging of our profession.
Now, to be fair, striving for a decrease in practice variation within physical therapy is a worthwhile endeavor. However, I am not convinced current conceptualizations are the appropriate approach. Assessing variation in medical treatments and practice is likely easier than in physical therapy practice. Why? It’s more concrete. Medical treatment relies heavily on the appropriate diagnosis of essential, or substantial diagnoses. Treatment follows, and is mostly dependent on proper diagnosis. Thus, analysis of timely proper diagnosis, matching of treatment and diagnosis, and actual treatment content is more concrete to study. For physical therapy, a different construct is required. The complexities of the clinical encounter and individual nature of the therapeutic process in conjunction with the many potential and identified mechanisms of treatment effect complicate the study of variance. Striving for utilization of the exact same interventions is likely to be a surface level success. It appears like progress. Therapists are dealing with many nominal diagnoses and messy concepts such as unexplained symptoms, function, and behavior change. (note: medical diagnosis is still very complex and full of challenges)
Specificity should be sought after, but not assumed. As more is understood about the effects of interventions it is becoming apparent that techniques, exercises, and interventions themselves are not as specific as originally assumed. If observably clinicians appear to have no practice variation, but utilize different conceptual frameworks and tell the patient in front of them different stories, gross variation is actually still present. Utilization of similar constructs may result in similar “outcomes,” but with significantly different “interventions.” So, what are the common factors?
Regardless of setting, physical therapists should strive for the most accurate deep models of practice, validated and efficient processes in conjunction with an individualized, assessment based, response dependent approach. The best clinical research evidence should be incorporated. This will lead to less practice variation, you just might not be able to see it. Observational variation in interventions may not actually represent difference in concepts. Conversely, two clinicians may perform exactly the same “interventions” with marked disagreements in conceptual framework, reasoning, patient interaction, and patient education. Maybe the method is not the trick? Maybe the process is as important as the product? It’s high time for the accountable practitioner. That means metacognition, critical thinking, and science based practice. Simple…now only if it were easy.
Perhaps it is unfortunate that the physiotherapy profession has responded to the perception that physiotherapists must justify what they do by routinely measuring clinical outcomes. The implication is that measures of outcome can provide justification for intervention. Arguably that is not the case. Outcome measures measure outcomes. They do not measure the effects of intervention. Outcomes of interventions and effects of interventions are very different things. Clinical outcomes are influenced by many factors other than intervention, including the natural course of the condition, statistical regression, placebo effects, and so on. (Tuttle (2005) makes this point clearly in his article, in this issue, on the predictive value of clinical outcome measures.)
The implication is that a good outcome does not necessarily indicate that intervention was effective; the good outcome may have occurred even without intervention. And a poor outcome does not necessarily indicate that intervention was ineffective; the outcome may have been worse still without intervention. This is why proponents of evidence-based physiotherapy, including ourselves (Herbert et al 2005), argue it is necessary to look to randomised trials to determine, with any degree of certainty, the effects of intervention. It is illogical, on the one hand, to look to randomized controlled trials for evidence of effects of interventions while, on the other hand, seeking justification for the effectiveness of clinical practice with uncontrolled measurement of clinical outcomes.
Principles of Outcomes Measurement
1. Objective and Measurable
2. Decrease Bias and Improve Accuracy
3. Reliable and Reproducible
4. Valid: Are we measuring what we think?
5. Sensitive to Change: Does the measure detect changes in construct?
6. Patient Report vs. Patient Performance
In addition, measurement of outcomes requires understanding the various constructs and categories that are measurable. This includes, but is not limited to:
Differences and disconnect between progression of physical function via patient performance and patient report has been characterized in total hip arthroplasty. “The influence of pain on self-reported physical functioning serves as an explanation for the poor relationship between self-reported and performance-based physical functioning. When using a self-report measure such as the WOMAC, one should realize that it does not seem to assess the separate constructs—physical functioning and pain—that are claimed to be measured.” Both patient report and performance are important. Each can guide further intervention or provide insight into current deficits.
For example, a patient with improvement in performance, but no change in report, may be struggling with recognizing or understanding improvements in certain domains (symptoms, performance, function). Or, perhaps education has not addressed a patient’s main concern or perception. Mistaking outcome measures and measuring clinical outcomes for actual effect of treatment may result in improper (or even pseudo-random) intervention selection and/or patient care approaches. I postulate that this mistake is the prime reason physical therapy as a profession is quick to integrate new, “innovative” treatment “tools” with lack of true prior plausibility. Or, the continued utilization of of interventions in the face of evidence suggesting lack of treatment effect. Mistaking observed and measured clinical outcomes for treatment effectiveness likely results from the post hoc ergo propter hoclogical fallacy.
When we mistake outcomes for effectiveness, we risk assuming causation and subsequently treatment mechanism. Care must be to taken to avoid leaps in logic regarding effectiveness and mechanism of action. A review of the evolution of understanding of manual therapy mechanisms illustrates how continued observation of positive clinical outcomes likely reinforced inaccurate interpretations based upon hypothetical anatomy and biomechanics devoid of true physiology and actual tissue mechanics. We now know much more.
Although, to be fair, construction of care processes, intervention approaches, and treatment paradigms absent of (potential) theoretical mechanistic action is quite challenging. Further, human brains seek explanation for observed clinical events, even within research. So, when treatment X is routinely associated with observed patient report or outcome Y brains will automatically initiate assigning reason Z as the “why.”
Measure everything!
No. Quite the contrary. Clinicians should aim to properly select measures that are relevant to the patient: main complaint, goals, condition, and/or diagnosis (if one exists). In addition, the measures chosen should be sufficiently responsive to change, encompass multiple constructs, and cross domains. While important, relying solely on patient report is an incomplete, flawed approach to measuring outcomes and assessing treatment in the clinical setting.
Two differing scenarios may occur when utilizing outcomes observed or measured in clinic as the primary reasoning for decision making regarding interventions/treatment:
A. Effective interventions may be abandoned when outcome(s) are not improving on the assumption of lack of effect.
B. Ineffective interventions or approaches may be continued when outcomes are improving on the assumption of effect.
In scenario A, the patient may in fact worsen without the treatment. Perhaps progress is predicted to be slower without effective treatment, or natural history suggests a worse trajectory. An effective intervention or process may be ceased prematurely. In scenario B, perhaps improvement is measured. Placebo, non-specific effects, incentives, and/or bias in measuring and patient reporting contribute to the observation of a positive outcome in the clinical environment. “It works!” Or, appears to. But, a multitude of other factors affect the presence of a measured outcome (positive or negative).
The multi-factorial nature of treatment mechanisms, complicate the ability to clinically observe effectiveness. The myriad of reasons why individuals may report and/or exhibit improvements in symptoms, function, and other constructs make “outcomes” a dynamic and complicated subject. Perhaps the condition has a favorable natural history or regression to the mean is present. And, perhaps the patient would have progressed more quickly with a more effective treatment approach. It’s complicated. Don’t take all the credit, and don’t take all the blame. So, what should we do?
Measure nothing, clinical outcomes are meaningless!
No. Quite the contrary. In addition, to selecting appropriate outcomes measurements, clinicians must integrate and understand appropriate current clinical, mechanistic, and basic science research. As science based practitioners, physical therapists are charged to select effective, plausible, safe, and efficient approaches to care that are focused on the individual patient. This is not an argument for the utilization of only specific outcome measurements and interventions with strong randomized control trial level evidence. Plausibility matters. The individual person matters. It’s complicated. And, it’s easy to fool ourselves. Richard Feynman suggests:
The first principle is that you must not fool yourself — and you are the easiest person to fool.
So, measure clinical outcomes. They are important. But, ensure measurements cross constructs and domains. Don’t solely rely on patient reports. And, don’t claim effectiveness based on observation. We must acknowledge the complexity. No one is saying clinical outcomes measurement is not important, or is not illustrative of important concepts. Clinical data and outcomes are vital to self-reflection, integration of evidence, health services, and overall care processes. But, the plural of anecdote is not data, and outcome measures can not illustrate effectiveness. That’s not an argument to not measure outcomes. It’s an argument to improve measurement, and more importantly, understanding.
An incentive is something that motivates an individual to perform an action.
And, that something could be anything. Meet the omnipresent influencer of behavior. Frequently, incentive is understood to be associated with some form of monetary compensation for specific behavior. But, incentives are not merely monetary. And, they exhibit influence. Yes. Always. 100% of the time. In any environment, any scenario, any interaction, and every decision including clinical encounters. Incentives can be viewed as any tangible or intangible reinforcement, and thus influencer, of behavior. Theses “rewards” range from monetary to personal, concrete to cognitive-emotional. And interestingly, incentives still affect behavior even when individuals consciously identify and recognize their presence. They are social, contextual, or even cultural. And, they impact decisions and performance.
Incentives are present in a variety of forms and contexts. Most generally, incentives can be assessed via a variety of binary comparisons including: Explicit verses Implicit, Reward verses Punishment, Short verses Long Term, and Immediate verses Delayed. Yet, the content of incentives range from monetary to verbal, and in contexts of private and public. The environment, including people, specific location, and context of the situation, in conjunction with broader constructs such as expectation and culture also matter.
Physician’s prescribing habits are affected by pharmaceutical marketing. Prescribing is affected by the gifts, no matter how menial, of pharmaceutical companies. This effect is observed even if physicians believe the gifts have no bearing on their prescription decisions. The data and incentives lead the Office of the Inspector General to research gifts and payments that promote prescription drugs. In this instance, physicians are Prescribing Under the Influence:
This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians. Maybe the drug representative does that while the resident is slathering cream cheese on a bagel; maybe it’s while the intern is saying, “Oh, what’s this cute little stuffed bear?” Either way, the doctor stops and spends a moment.
In private practice, the little gifts are often even more important. If you’re a drug representative, physicians are usually not interested in talking to you unless you have something to catch their attention. Then you can get your three sentences in: “We’ve got such and such on the hospital’s formulary now.” Or “The new form of this drug can be given once a day instead of four times a day. The patients will love it.” It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.
Self-referral, or referral for profit, is associated with increased utilization of lab tests, imaging, and physical therapy. A meta-analysis revealed a 2.48 combined relative increased frequency of referral in refer for profit scenarios. In most cases, I truly believe physicians are not sitting in front of patients actively scheming on how to justify an imaging procedure, lab test, or referral to physical therapy in order to maximize profit. On the whole, I don’t assume the physicians in these scenarios are unethical and overtly over prescribing. But, the incentive is present, and thus behavior is altered. The evidence shows that self-referral invariably leads to higher utilization and higher costs.
What are specific incentives within the profession of physical therapy? What should be modified? Everyday outcome measures are handed to patients, clinical measurements made, and assessments written. What are patients and incentivized to say and do? Or, believe? Administrators, managers, and clinic directors in hospitals and private clinics present data to their staff. Specific metrics are identified and goals are constructed.
Recognizing the development of interaction between personal and environmental (including social, societal, cultural) influences on behavior illustrates the complexity of how, when, and why we behave in certain ways. In healthcare, the layers of systems and hierarchy of influence is complicated. Our decisions and behavior are not nearly as rationale, nor conscious, as they feel to us personally. The interplay of personal, inter-personal, and environmental influences coupled with tangible or perceived rewards influences how people act. In conjunction with individual motivation, incentives, both seen and unseen, are determinants of who will thrive in certain educational and clinical contexts. One such example is the difference between extrinsic and intrinsic motivation. What people do is just as complex as why people think they do it. And, there is a disconnect, a blind spot, between our perception of bias in ourselves verses others.
Unfortunately, incentives have unintended consequences. The cobra effect is an illustration that “incentives don’t always work out the way we expect them to.” Beyond identifying a target metric and outcome, it’s imperative to identify the actual behaviors that are desired. Sometimes a change in a specific measurement (productivity, patient report outcomes, etc) do not necessarily reflect the desired behavior changes. In particular, research investigating payment incentives and subsequent clinician behavior within healthcare illustrate tangible manifestations of “unintended consequences.”
How is the outpatient therapist incentivized if measured and assessed primarily via patient report questionnaires? How are we changing behavior in the acute care therapist by assessing them based on the number of “units” they “bill?” What about the outpatient therapist who receives a bonus based upon units billed? What if changes in the metrics we are utilizing don’t truly illustrate significant change, don’t result in the best care, and don’t reinforce ideal behavior? A health services research article on medicare payment comments:
While some payment methods may lead to excessive utilization, other payment methods may put too much pressure on cost containment and potentially lead to underprovision of resident care (Coburn et al. 1993; Cohen and Spector 1996; Murtaugh et al. 1988)
In addition to tracking specific measures, ideal behaviors need to be identified. To account for unintended consequences broadly identify various behaviors likely to lead to the measured goals. Sometimes behaviors that are actually not desired can cause significant desirable change in target measures. Undesirable action for desired outcome. So, what behaviors can cause a change in the metric? And, what contributes to encouraging such behaviors? But, also, what incentivizes behaviors that change the metric, but may also cause unintended consequences?
If a clinic, hospital, profession, or health care system seeks to fundamentally alter care delivery robust assessment of the current incentives within healthcare, including conflicts of interest is mandatory. Then change the incentives to affect and encourage ideal clinician behavior. A successful approach likely involves a combination of incentivizing important outcomes as well as specific behaviors. Changing the single data point does not necessarily reflect the desired overall change in other measurements or behavior. The depth of affect of incentives in conjunction with unintended consequences illustrate the difficulty in controlling change. A seemingly brilliant idea such as “pay for performance” or outcomes based payment is fatally flawed without a conscientious focus on the many potential behaviors that may result in the specific outcome. Might it even be chaos?
What are the incentives? Identify the answers and then target behaviors requiring alteration. Shift behaviors towards ideal processes. Ideal behaviors will likely have positive unintended consequences. A myopic focus on only the desired numeric change will produce a myriad of potentially paths to “success.” Some of these paths were never the intended action of success. And in fact, may be the opposite of the incentive’s initial philosophical goal.
A few days ago Move Forward, the APTA’s consumer targeted website, posted a podcast. The premise was inaccurate, and the conclusions appeared potentially damaging for patients and the general public. I posted a link to the original Facebook post with a brief statement of my disagreement. Via Twitter and Facebook other physical therapists expressed their disappointment with podcast.
I commend the decisive action by Jason and the APTA. I agree with decision. And further, I’m encouraged by their ability to respond to informal feedback via the conversations occurring on social media. Personally, I participated in a panel at #CSM2014 The Value of Using Twitter for Branding Yourself and the Profession, and was highly impressed with Jason’s commitment to engagement. Jason stressed that he and others at the APTA are “listening” to the conversations, discussions, and informal feedback ocurring in the realm of social medical (even if just lurking). But, he also encouraged members to actively contact the APTA with suggestions, feedback, and insight. They want to hear from concerned members. And, apparently, they are willing to act on those intentions.
The APTA listens, so speak up. Becoming a member is a start. Using your voice is next. What do you have to say?
Now that the holiday season is in full swing, we may notice our patients experiencing holiday-related stress and busier schedules that compromise their ability to stay committed to healthy lifestyles. How do you address this in your clinic to keep patients moving towards their goals? What fun promotions or #bizPT specials do you offer patients during the holidays? How do you address holiday employee scheduling? We’ll discuss these topics and more during our next #DPTstudent chat on Wednesday, December 3rd at 8pm EST! See you there.
What I couldn’t say – but wanted to – was the truth: I don’t care.
Seriously. I don’t. I can’t.
Keith P states “I don’t care.” And, I think he’s right. A certain type of detachment from the potential suffering and emotional struggles of patients is vital for a clinician. The ability to assess, analyze, and make proper decisions may be clouded if those treating are overly emotionally involved in the circumstances of those they treat. Further, shouldering the burden of the many unfortunate clinical, emotional, and social situations encountered within healthcare can easily leave one with a sense of hopelessness. It’s quite easy to succumb to pessimism and apathy when the grand scale of suffering, inequality, and just plain bad luck occupy the beds and treatment tables daily. But, is this ideal for patient interaction? What do patients prefer? Establishing and enhancing alliance, rapport, and an environment of care is necessary. An explicit connection with the patient is a precursor to, or maybe even the foundation of, the therapeutic process. Too far to one extreme and the risk is burnout. Too far to the other and the risk is a cold, distant clinician (and still burnout). As in anything, explicitly defining terms and concepts is helpful.
Definitions and Terms
Sympathy, empathy, compassion, and caring are connected concepts, but have differing definitions. And, specifically within healthcare these concepts require more specific exploration. While various, and vague, characterizations of sympathy exist within and outside of healthcare, for the sake of clarity sympathy generally centers around an emotional state of feeling. It can manifest as pity or sorrow for another, a common feeling, or a relationship in which that which affects one mutually affects the other. The simplest definition is entering into or sharing the feelings of another. Empathy, by contrast, is characterized by identification and understanding. But, empathy has been sub-characterized into two, or even three, separate conceptualizations: emotional (or affective), cognitive, and compassionate empathy. To complicate matters, compassion itself is an awareness of suffering of another and a desire to act in order to relieve it. Therefore, compassion is best understood as an action, or potential action. This desire and subsequent action may stem from both rationale and emotional sources.
Healthcare & Empathy: Emotional vs. Cognitive vs. Compassionate
Daneil Goleman briefly outlines and discusses the three (potentially) separate kinds of empathy. Empathy is founded upon understanding and identification which may include projecting ourselves (hypothetically) into another’s situations. And, it can happen emotionally and/or cognitively. Emotional empathy is the ability of a person to feel a similar emotion as another (which confusingly can be accomplished cognitively). Although this appears to mirror sympathy, sympathy is a sharing of emotion, or emotional state, feeling along with another. In contrast, cognitive empathy relates to recognizing, understanding, or even appreciating a person’s feelings. To be fair, the definitions of sympathy and empathy as well as cognitive verses emotional empathy appear to overlap. It seems they are, at times, used interchangeably. Specifically to healthcare, empathyis “a cognitive attribute that involves the ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding,” Many in healthcare education recognize IQ and didactic skill are only a portion of the ideal clinician equation. The ability to understand and perform within the above constructs relates to emotional intelligence. And, “…empathy, as defined here, must be included in the curriculum. It is a powerful communication tool that enables a clinician to clearly express his or her understanding of another’s suffering while protecting his or her own psychological integrity.”
Do you have to care to be caring in your practice?
A major issue in health care professions generally, but therapy specifically, is mistaking the necessity of cognitive empathy for a requirement to sympathize and feel with patients. Front line clinician burn out is in part due to an understandable inability to sympathize with every patient, and the resulting cold, concrete distance that can result in situations when sympathy is not feasible. Whether clinician fatigue, a need for emotional distance, or carryover from the patient before feeling the emotions, sympathizing, and providing pity to every patient is likely not possible. And, probably not effective. The issue is likely further clouded by a lack of understanding regarding the differences of sympathy and empathy. I don’t ever remember learning about this stuff. But, it’s vital. The concept of objective empathy grossly changed how I approach patient interactions. Patients and practitioners report “compassionate care” is important to successful medical treatment. So, what’s to be done?
The role of the clinical instructor is paramount in helping students to become aware of behaviors that can block empathy. We can no longer simply hope that our students will become mature professionals with compassion and empathy for patients. We must create experiences to develop these attributes, and we must take responsibility for modeling these behaviors and reflecting on them with students, to raise their consciousness about the nature of a mature healing presence.” The art of healing is, in part, made up of a therapeutic use of oneself or a therapeutic presence for patients. This presence is more than knowledge and skill alone; it is also composed of a compassionate understanding of the patient and a communication that the therapist is worthy of the trust that the patient has bestowed. Empathy enhances the therapist’s therapeutic presence and deepens the patient practitioner interactions without fear of losing one’s self in the process. This shared meaning seems to enhance the patient’s process of healing. Carol Davis, Can Empathy be taugh? PTJ, 1990
To the observer I’m sure it appears I do care, and care deeply. But, in the end Keith, you’re right. I don’t care. And, I don’t need to. Does that mean I never engage with patients on an emotional level? That patient’s circumstances never affect me? That I never feel a connection, or shared emotional states with a patient? Or, a powerful emotional response during the course of treatment? Of course not. It happens. And, that’s OK. But, we don’t need to strive for it. Someone inquired to Keith “I wonder if being detached from our patient makes for a better clinician… Any thoughts?” He responded:
A therapist needs an appropriate amount of attachment for success, but that attachment, I reason, needs to be to a high professional standard of care, not the patient’s outcomes themselves.
You don’t need to sympathize to provide appropriate empathy. You don’t need to care to be caring. You don’t need to feel the emotions of your patients to address the emotions they feel.
When I freed myself from the responsibility for the “outcome” of the clinical encounter, something interesting happened. I freed my patients from blame, also. –Jason Silvernail
It’s important to care, but maybe not in the assumed emotional involved ways. And, I think we should not apologize for claiming not to care. I’m still, I think, a caring clinician. I just don’t make a point of feeling pity for the suffering I encounter. I am passionate, empathetic, and hopefully a thoughtful interactor.
…an older relative of mine who has cancer is going back and forth to hospitals and rehabilitation centers. I’ve watched him interact with doctors and learned what he thinks of them. He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect. –Paul Bloom, Against Empathy
We need to be able to treat our patients, all of them, and still function in our own lives. If not, we risk riding the roller coaster of sympathy and pity in clinic at the potential expense of engaging emotionally in our personal lives. It’s a bad outcome all around. Our patients need us to understand, interact, and guide them along the best possible course of recovery. So, whatever we call it, put your pity aside. I’m not sure our patients want it anyway. Be resilient. You don’t need to care to provide compassionate care. Our patients need us to listen, but also to initiate difficult, honest conversations.
If immobility is pathology, then movement is medicine. But, now that the rationale is present, how is action initiated? Understanding the current literature in regards to mobility and physical therapists in the intensive care unit illustrates the need and the potential for physical therapists. This potential leads to the vision. Yet, rationale and vision do not guarantee action, nor results.
Every patient requires an individualized assessment and interaction to determine the best plan of care, outcomes tracking, and goals. So, does each individual ICU. Evaluation of current practice and culture, barriers to mobility and physical therapy, and a plan to achieve specific goals. Data and outcomes tracking can provide insight into progress.
Research surveying various professions elucidates commonly reported barriers to mobility and physical therapist involvement in the ICU. Yet, many of the identified barriers appear more perception than the reality. Fears based upon “what if?” scenarios. What if the patient falls? What if a line becomes dislodged? What if they decompensate? What’s the worst possible event? Illness severity, safety, and line dislodgment are commonly report. These fears are contrary to the literature on safety and feasibility. Does this indicate these concerns are likely unwarranted?
Barriers: Perception and Reality
Perception is reality. The multi-disciplinary environment of critical care, including the a culture of a specific unit, requires analysis to ensure specific perceptions are identified. Barriers should be overcome with education, discussion, training, and graded exposure. Individual practitioner’s perceptions, fears, and concerns contribute to professional interactions, unit culture, and ultimately patient care. Fear based barriers include illness severity, illness acuity, safety, feasibility, and perceived lack of benefit. Other reported challenges include lack of consults, staffing, knowledge, time, expertise, experience, cost, equipment, and unit culture. All unit specific and individually identified barriers must not only be acknowledge, but adequately addressed. Reported concerns are not to be discounted.
1. Do you think physical therapy should evaluate/screen all intensive care unit/cardiovascular intensive care unit patients?
2. Do you feel comfortable getting patients into neuro chairs without physical therapy?
3. Do you feel comfortable using the mechanical lifts without physical therapy?
4. Do you get patients out of bed/ambulate without physical therapy if they are able?
5. Do you think patients should be getting up on ventilators?
6. What are the barriers to mobilizing patients on ventilators?
7. What are the harmful effects of physical therapy working with patients in the intensive care unit?
8. What can physical therapy do to improve communication with the RNs, MDs, respiratory therapists, patients, families, etc.? Please be specific.
9. What can physical therapy do to improve patient care? Please be specific.
The survey questions revealed many of the barriers listed above. Interestingly, all respondents agreed that every patient in the ICU should be evaluated by a physical therapist.
As much, as soon, as often as we can?
The concept of mobility and rehabilitation during intensive care appears quite important and profound. Therefore, it’s quite obvious that every patient should be out of bed and ambulating at least three times per day. Well, not exactly. Although being in the ICU in the presence of lines, tubes, and life support equipment should not automatically preclude individuals from movement and therapy participation, each patient will present and perform quite differently.
So, what are the specific interventions? How does a physical therapist decide what to do? And, when? What about dosage, intensity, frequency, and duration? Similar to other patient populations (such as individuals with back pain), critical illness is far from homogenous. Even a very specific ICU type contains a range of diagnoses and individuals. Treatment content, duration, intensity, and frequency should likely vary. Further, given the acuity of illness and the medical complexity of patients, close monitoring of many variables is necessary. The specifics of these particular concepts remain complicated and dependent on many variables. At times it appears there are more questions than answers.
Generally, the goal is to decrease sedation, bed rest, and confusion while increasing wakefulness, movement, and engagement. There are nearly infinite options available to accomplish such goals. An approach of “as much, as soon, and as often as possible” simplifies the conceptualization of treatment. But, such an approach is always performed within the specific confines and constraints of the system, staffing, experience, and culture of the current clinical situation.
Response Dependent Progression
An individualized, response dependent approach facilitates proper monitoring from moment to moment and session to session. Decision making requires integration of information from multiple sources to reach an overall assessment that determines progression, pause, or regression. Such a system hopefully decreases the likelihood of grossly “over treating” or “under treating” a specific patient at each specific encounter. The variable nature of medical stability, presentation, and physiologic status of critical ill patients may result in robust, swift changes in vital signs, physiology, and even patient performance. A patient’s specific clinical scenario including diagnoses, physiologic state (labs, medications, vital signs), and current medical goals warrants the a priori construction of individualized safety parameters regarding upper and lower limit values for vital signs.
Response Dependent Progression. Individualized prescription & progression based upon moment to moment assessment.
An assessment of current and historic practice can include average unit census, average number of physical therapy consults, percent of the unit with consults, and number of patients actually seen per day. Average time from admit to first physical therapy encounter in conjunction with average duration and frequency of treatment provide general insights into current physical therapy practice.
Next, by assessing unit specific data in relation to current practice, predictions for future staffing, equipment, and training can be constructed. Such a model can be further specified based upon targets for the number of patients (or percentage of the unit) to be treated each day, and at what frequency. In addition, the current number (or percentage of) patients who are likely to benefit from, or be appropriate to participate in, physical therapy can illustrate a disconnect between current practice and ideal practice. Identifying a lack of consult standards may shed light on variability in consult numbers, timing, and frequency. Standardized criteria for consults, mobility, or physical therapist involvement provide assistance in decision making. But, each individual patient requires analysis within the framework of guidelines, not decisions mandated by them.
The current demand (consults), physical therapy practice, and provider perceptions are utilized to model need, illustrate the lack of physical therapist involvement, and potentially quantify a current lack of resources to provide appropriate timing, frequency, and duration of therapy. If feasible, informal or formal investigations into factors associated with physical therapy consultation provide further understanding into current practice regarding physical therapy consultation and practice. A disconnect between the research literature and current unit culture, including various professions practice patterns, highlights the need for transdisciplinary practice change and potential quality improvement.
Financial Modeling
Johns Hopkins constructed a financial model allowing prediction of staffing, costs, and potential financial outcomes. By utilizing the number of yearly admits, current ICU & hospital length of stay (for a specific targeted ICU), and direct variable costs of care a very accurate model of staffing, start up costs, and potential cost savings scenarios can be assessed. Varying possible length of stay reduction outcomes allows for a sensitive, yet conservative prediction of cost savings in multiple potential situations. Modeling various outcomes allows for the presentation of worst case, likely, and best case end points. Utilizing actual data from their own quality improvement project and data from the literature they conclude
A financial model, based on actual experience and published data, projects that investment in an ICU early rehabilitation program can generate net financial savings for U.S. hospitals. Even under the most conservative assumptions, the projected net cost of implementing such a program is modest relative to the substantial improvements in patient outcomes demonstrated by ICU early rehabilitation programs.
Measurement and Outcomes Tracking
The potential data and outcomes depend on data availability, program goals, ICU type, patient population as well as any specific research questions. Outcomes can be analyzed at the patient, unit, and hospital level.
Potential construct areas of measurement for ICU mobility, rehabilitation, and physical therapy programs
At the patient level there are a variety of impairment, patient report, and patient performance measures, many of which have been specifically investigated for utilization in the intensive care unit.
Quality Improvement Project Design
Designing and implementing a quality improvement project with a focus on research methodology improves the accuracy of measured results. Such an approach eases discussions with hospital administrators regarding need, costs, and program appraisal. Appropriate planing, background research, and project construction prior to implementation allows for more specific analysis.
Background, Construction, & Education
Assess current PT practice, unit culture, clinician perspectives
Compare current practice to ideal practice, current program models, and feasible quality projects
Construct project goals
Model staffing, training, equipment, and program requirements
Identify, acknowledge, and address current barriers
Identify champions from each discipline: PT, RN, MD, RT
Identify educational needs of PT and rehab department
Identify educational needs of other disciplines
Perform education and follow up meetings
Data
Identify target data and outcomes tracking
Obtain facility specific data for financial modeling
Build data tracking sheets & data bases (if needed)
Leverage electronic medical record (if able)
Train clinicians on documentation and “data entry”
“Go live” with documentation and data collection
Establish a post documentation training pre-project implementation baseline
Implementation
“Go Live”
Sustain & Maintain Program via Updates and Meetings
Evolve care based on observation, feedback, and data analysis
Assess & Analyze Program and Data Collected
The elegance of a quality improvement approach is the potential for an ever evolving feedback loop of assessment, planning, implementation, and analysis. At specified intervals, repeat the process based on current results, identified issues, and current research.
Facility Specific Questions and Issues
1. What if current practice illustrates a lack of consults, infrequent consults, or poor timing of consults (i.e. too late in hospital course)?
Create specific consult criteria. Educate nursing staff and physicians. Provide checklist.
2. What if there is no dedicated physical therapist in ICU?
Quality improvement project focused on unit based physical therapist and increased overall patient mobility.
3. What if patients are too sedated?
Assess RN sedation guidelines and practices. Pair therapy with sedation vacations & awakening trials. Meet with MD’s, RN’s, and RT’s. Work with RN educator to facilitate RN lead project regarding sedation.
4. What if there is a lack of patient mobility outside of therapy sessions?
5. How to prioritize if unable to address every consult and patient on caseload in the ICU(s)?
Focus on duration of bed rest, individuals requiring mechanical ventilation, especially those requiring greater than 3 days of mechanical ventilation. Assess last time mobilized and last therapy session.
Quality and Assessment
Obviously, analyzing and interpreting clinically generated data is difficult. Given the complexity of the daily clinical environment and lack of rigor available in a controlled research trial, data can often be inaccurate or even misleading if not understood properly. Utilizing a quality improvement model within the context of critical care is an evolving method for program design and interpretation, but
The results of many quality improvement (QI) projects are gaining wide-spread attention. Policy-makers, hospital leaders and clinicians make important decisions based on the assumption that QI project results are accurate. However, compared with clinical research, QI projects are typically conducted with substantially fewer resources, potentially impacting data quality…Data quality control is essential to ensure the integrity of results from QI projects.
Resources exist for appropriate design, training, data collection, implementation, sustainability, assessment, analysis, interpretation, and translation of quality improvement designs and data.
For 3 weeks I was held in a room, I was tied to the bed if I tried to get away. I couldn’t talk; I couldn’t eat; I was not allowed to sleep;
Groups of people would enter the room and look at me and talk about me and I was sometimes undressed in front a small audience.
I was shot full of drugs.
I was too weak to move.
I could not see my body, but it had been cut nearly in half.
Insects crawled on the walls and ceilings…
Sound like prison or torture? Well, it’s not. The quote is from Nancy Andrews, a survivor of critical illness who developed delirium . And, an articulate spokeswomen regarding ICU sequelae, specifically delirium, from a survivors perspective.
Now, to be fair, I am already bias. I treat primarily in ICU’s (medical, cardiac, and step down units). I also treated in the treatment arm of a randomized control trial of early, intensive physical therapy for individuals requiring mechanical ventilation for greater than 4 days. The treatment group received physical therapy 7 days a week for at least 30-60 minutes. And, I participate in research surrounding ICU physical therapy. Oh, I am also a physical therapist. So, don’t take my word for it…
But, the curse of bed rest needs to end. In 1966 “The Dallas Bed Rest Study” put five 20 year old males to bed for three weeks. Investigators conducted pre and post testing followed by exercise training and long term follow ups (30 and 40 years). The acute effects of the bed rest and long term outcomes are staggering. Net proportional decline in VO(2 max) over 40 years was comparable to that experienced after 3 weeks of strict bed rest (27% vs. 26%). Additionally, 40% of age related decline in maximal oxygen uptake could be attributed to physical inactivity specifically. Three weeks of bed rest at 20 years of age resulted in a more profound impact on physical work capacity than 30 years of aging.
Unfortunately, each day of bed rest in the ICU may predict a 3 to 11% strength decline up to 2 years later. During a 2 year investigation, the length of bed rest was consistently associated with measures of weakness at all time points. The presence of weakness correlated to decreased physical function and quality of life.
The Legacy of Critical Illness
So, why are we talking about this? It has been well established that individuals who survive critical illness requiring mechanical ventilation specifically acute respiratory distress syndrome exhibit muscle weakness, persistent physical disability, and impaired reports regarding quality of life (via the SF-36) after hospital discharge. After 5 years, with an impressive 86% follow up rate, only 75% returned to work and subjects utilized 4 times the healthcare costs (86% follow up rate).
This is a huge public health catastrophe when we’re saving people’s lives but they’re ending up with severe disability. It’s a very important message for patients, families and primary care physicians because I think patients assume they should be well, so they feel bad that they aren’t.
Sadly, the sequelae of critical illness extend beyond physiologic abnormalities of nerves and muscles, weakness, and physical function. Survivors display significant neuro-cognitive problems. At one year follow up of 821 medical and surgical ICU patients more than 50% displayed memory and attention deficits. The presence of post-traumatic stress and post-traumatic stress syndrome are now well recognized. At 1, 2, and 5 years post ICU discharge reports of depression and anxiety persist in nearly 50% of some studied cohorts. Survivors suffer not merely from physiologic and physical impairments, but significant and quite limiting neuro-cognitive deficits in conjunction with psychological difficulties.
What happened to me in the hospital? Yes, my life was saved, and I am grateful for that, but life AFTER the ICU was extraordinarily difficult, not only physically but also mentally. -Nancy Andrews
Factors associated with long term physical impairments include duration of bed rest, age, ICU length of stay, and potentially the dosage corticosteroids. Amount and duration of sedation, development of delirium, and delusional memories are associated with long term neurocognitive impairments.
And, unfortunately it doesn’t end with the patient. Family members and caregivers of ICU patients exhibit mental health difficulties including anxiety, depression, PTSD, and complicated grief following the intensive care experience. Recently, Post Intensive Care Syndrome (PICS) was constructed to assist in recognition and classification of survivors’ as well as family members’ post ICU impairments. The goal, of course, is to improve outcomes following critical illness.
Physical Therapy IN the ICU?
The focus surrounding early mobilization of critically ill, mechanically ventilated patients as well as physical therapists involvement in the ICU continues to grow. Although by no means complete, the research suggests that early mobilization and physical therapy is safe, feasible, and appears beneficial. Findings illustrate potential effects and associations at a physiologic, patient performance, functional, medical outcomes, and health care services level.
The bottom line is having a patient, who for at least a part of the day, can be awake from drug affect, and interact with the environment in a purposeful way is the key foundation to the idea. – John P. Kress, MD
Associations and effects of early mobility programs and/or physical therapist treatment include:
Does clinical practice reflect this strong premise suggesting safety, feasibility, and rationale for physical therapists in the ICU? A survey of physical therapists belonging to the acute care section of the American Physical Therapy Association from 2007 suggests physical therapists are more likely to be routinely involved in the ICU with neurologic and trauma related diagnoses as oppose to medical diagnoses. Follow up survey data from 2012 suggests a lower likelihood of mobility as perceived complexity (either medically or logistically) increases.
Now, given the limitations of survey data, firm conclusions on WHY are not possible. But, it appears that as medical complexity increases, the less likely physical therapists are to be involved. The more “medical” the diagnoses, the less likely physical therapists are to be involved. Is this secondary to perceived risk? Lack of perceived benefit? Lack of knowledge in long term outcomes, safety, and feasibility? The ICU equipment? Staffing?
What is the basis of physical therapist decision making regarding patients in the intensive care unit? Are therapists making treatment decisions based on the presence of machines, the logistics, and the fears of worst case outcomes? In proper risk analysis, it is imperative to also assess the risk of not intervening. The long term sequelae of critical illness illustrate the potential risks of a critical illness and ICU course left to “natural history.”
Road Blocks & Speed Bumps
Regardless of the evidence, rationale, safety, and feasibility barriers do exist. These barriers likely exist within and between individual clinicians, specific professions, various departments, different units, and the entirety of each specific hospital. But, barriers also involve the interactions of these individuals and professions at all levels of the hospital. The staffing, patient prioritization, training, knowledge, and historic practice patterns are all important variables requiring considerations. Many factors and individuals result in the overall, but dynamic culture of a unit and/or hospital. In order to facilitate change, an eventual transformation of ICU culture is required.
What do PATIENTS think?
I was never told by anyone what to expect – ICU Survivor
A current randomized control trial entitled Do it Now (Diagnosis and Treatment of Neuromuscular Weakness) is investigating early, intensive physical therapy (7 days a week, 30-60 minutes) and standard physical therapy (3 days a week, 15-20 minutes) in patients requiring mechanical ventilation for greater than 4 days. Part of the study is a survey investigating patient and proxy perceptions of physical therapy. To date no robust investigations of patient, family, and proxy perceptions of early, intensive physical therapy exist. The literature on long term outcomes in conjunction with individual patient stories illustrate the shattering trauma of the ICU:
It’s been two years and I’m still trying to sort out what was real and what wasn’t. I still think about it several times a week and continue to ask questions of my family. I have a compelling need to know what happened to me… – ICU Survivor
Interestingly, regardless of which arm of the above study, patient’s and proxy’s reported physical therapy as highly necessary and beneficial. Although difficult and requiring significant exertion, both patient groups were satisfied with the experience. Neither group would have requested less therapy sessions. And, in fact, both groups requested slightly more. Maybe engagement in a therapeutic process can decrease some of the trauma of the ICU experience? In a brief video, Dale Needham, MD of Johns Hopkins routinely observes that patients agree:
Patient’s overwhelming tell us is that they like the early physical medicine and rehabilitation, they like being awake. They certainly like getting out of bed and moving. It shows them that there is hope, it shows them there is a life beyond the intensive care unit. And, a life for them to get back to. It gives them goals for improvement, It shows them that they can get better.
Nancy Andrews comments from a patient’s perspective:
I can share advice based on my experience. Reach out to people. Talk about what you remember. Draw, play games, listen to music, dance, DO PHYSICAL THERAPY, Reconstruct what happened and sort it out. Talk to your doctor. Ask for help.
Summary
1. Immobility is PATHOLOGY
2. Critical Illness is a neuromuscular, cognitive, psychological INSULT
3. Long Term Functional Outcomes are POOR
4. Mechanisms of physical therapy and mobility are likely multi-factorial
5. Physical Therapist practice in the ICU is evolving, but varied
6. Patients & Family’s understand benefit of physical therapy
7. Patient’s & Family’s desire physical therapy
We must stop making excuses about why a patient can’t do rehabilitation today—he has a CT scan or she’s getting dialysis. We need to highly prioritize rehabilitation, which we now see as just as—if not more—important than many other tests and treatments we offer our patients in intensive care.
Change is possible. The rationale is present, it is time for action.
On this week’s #DPTstudent chat, we will be talking LIVE with Dr. Heather Hettrick. Dr. Hettrick is a professor at Nova Southeastern University, Past President of the American Board of Wound Management and currently on the Executive Committee of the Association for the Advancement of Wound Care. She has numerous certifications in wound care and lymphedema management. and is Program Director at Hospital St. Croix in Leogane Haiti where she is assisting in re-establishing a lymphatic filariasis clinic. Dr. Hettrick is on the Executive Board of Bring Hope to Haiti, a not-for-profit organization that runs a clinic in Haiti with the following mission:
–to train global volunteers as specialists in wound care, edema and lymphedema management
–to support locally operated clinics in under-served areas
–to alleviate global suffering caused by wounds, edema and lymphedema in resource poor nations; particularly those facing Neglected Tropical Diseases
Their focus is on Haiti where many citizens suffer needlessly from a condition called Lymphatic Filariasis (LF). This occurs when filarial parasites are transmitted to humans through mosquitoes. Globally, an estimated 40 million people are afflicted with LF and the resulting lymphedema. In the Western hemisphere, LF is endemic in 7 locations- the hardest hit being Haiti. Associated pain and profound disfigurement lead to permanent disability, and mental, social and financial losses contribute to stigma and poverty. Here is a solution that tells the reader to know where to find termites easily in any property and how it can be eradicated for our own good in the future. For the best pest control services, anyone can opt for the BBEC | Mice Rat & Rodent Removal since they are both affordable and effective too.
Bring Hope to Haiti is a wonderful example of what we, as #DPTstudent(s) and physical therapists, can do to help shape a better world. Join us LIVE on Wednesday, October 22nd at 9:00 PM EST to speak with Dr. Hettrick about her work in Haiti and her astounding career.
Follow the #DPTstudent hashtag on Wednesday to get the link to watch live and use the #DPTstudent hashtag to ask questions & contribute to the discussion.
For many DPT students, the National Student Conclave (NSC) may be their first physical therapy conference. With travel arrangements, school being in session and getting ready for the event, the process of choosing what to actually do when you get there can be an afterthought, or just completely overwhelming. But, what presentations a #DPTstudent chooses to attend can have a big impact on the experience. So how do you choose?
Some suggest researching the presenters, looking up other papers and presentations on the topic to gauge your interest and asking other students who may have seen presentations on the topic. Others just pick what sounds nice or go to what other classmates or upper classmen choose. What side of the coin are you on? Is there anything else a #DPTstudent should consider?
Join us on Wednesday, September 10th at 9PM EST to discuss! If you are attending #NSC2014 and know where you’ll be, chime in and let us know!
More about NSC 2014:
NSC Website: http://www.apta.org/nsc/
NSC2013 Highlights: http://www.apta.org/NSC/News/2013/
Also check on the NSC app from @APTAtweets on the App Store.
See you there!
@Jocelyn_SPT
#DPTstudent Chat Moderator
