Wednesday, December 14, 2011

Stat rehab consult!

As I'm sure many of you know, often deconditioned patients require a PT/OT eval prior to being discharged home. In one hospital where I rotated during residency, only PM&R could order PT/OT consults. Basically, we acted as a buffer to make sure nobody had inappropriate consults ordered on them. That's how much our time was worth.

The result of this was that we'd frequently get frantic pages from medicine residents who wanted to discharge their patients but couldn't until they got PT/OT consults. Some of them got a little mean when I explained that I couldn't just abandon my clinic to go to the hospital to see their patient STAT.

Anyway, this was an actual urgent consult I got during residency:

DIAGNOSIS: Morbid Obesity s/p gastric bypass. Now 415# down from 690 pre-op.

TYPE OF REHAB NEEDED: Patient requesting "dressing stick"

WEIGHT BEARING STATUS: Remarkably mobile given morbid obesity.


Morbidly obese guy needs a dressing stick?? Well, this is a TOP PRIORITY. And it was odd that nobody seemed to understand what weightbearing status even meant. An appropriate WB status is not "I can't believe he can walk!"


  1. We can get any doc to order a PT/OT consult, but good luck getting ANYONE to see them on the weekend, even if 1. they've been seen by PT during the week, 2. you have a "see over weekend" order by the MD, and 3. the final PT eval is the ONLY thing keeping the patient in the hospital (for ECF/SNF vs Home discharge).

  2. I can't imagine having to consult PM&R for anyone who needs PT/OT. We consult PT and/or OT on about 80% of our internal medicine patients, which would be 8-10 patients per day from our service alone. The one lone PM&R resident would lose her mind!

    Special Sauce - I agree entirely with your frustrations. I hate that patients end up staying in the hospital days longer than necessary just because we can't get a weekend PT assessment, and that patients who need regular PT lie in bed all weekend because there's no PT available. I understand (fully) that people need time off every week, but it seems to me that there should be a way of hiring people to work over the weekend to maintain PT services at a higher level.

    Of course, the lack of PT services on weekends is nothing compared to what's coming up over the Christmas holidays. I feel sorry for all my patients who will be stuck on the wards with no allied healthcare professionals to see them.

  3. As a soon-to-be PT, it's EXTREMELY frustrating to get orders like that from MDs. We'd see every patient every day if we could, but unfortunately there's not enough PTs and more and more silly orders like that from MDs. Not to mention nursing staff who views us as a transport service ("Can you come get this patient back to bed? Can you get this patient up? Can you walk this patient?").

    For weekends, I know for the hospital I'm at there's a priority list - TKR, THR, fractures, CABGs, and certain ICU patients. But again, this all goes to interprofessional responsibility for the patient. You can't just expect PT to be the only one who mobilize the patients. CNAs and nursing can do ROM, yes? We teach family how to help with exercises and I know there are "On the Move" type programs to encourage nursing to mobilize the patients. There are also plenty of patients who refuse PT day in and day out so they get dropped from our list only for the MD to put in another order for us to get them up.

    Basically, it's not fair to blame the PTs entirely, Special Sauce and Solitary Diner :)

  4. We got a STAT: OT order once for a reacher to the OR.
    I always liked the ones that said "Weight Bearing Status: Yes"

    And as a therapist, who did hospital life for several years- just about anyone can get just about any patient out of bed. No one should lie in bed all weekend, even if it takes a lift to transfer them. We got a sad number of re-referrals- people we cleared when initially admitted who lost their skills while being told they couldn't get OOB by other staff. There were a lot of times that I wished I could have transferred some excellent ICU nurses who were willing to get ANYONE up, no matter the equipment needed, over to the medicine or ortho floors for a day. It's up to everybody to keep people moving.

  5. There's a huge difference between OOB status in pedes vs. adult medicine too. I have spastic CP (dxed as "triplegic" at initial dx, but that doesn't exist anymore, so I'm either a really disabled diplegic or a *really* able quad now)

    I couldn't get the nurses to understand that I could *not* use only one foot to transfer after my arthrodesis, and they were not willing to use mechanical lifting. Guess who stayed in bed a lot and was threatened with a nursing home. (I'm 25 :P)

  6. Cut off half my comment :P

    This was in the adult system. As a pedes patient nurses were willing to use everything from a draw sheet to a hoyer to help me mobilize and recover.

  7. Allison - I wasn't intending to blame the PTs, but rather the system that doesn't recognize the importance of having adequate staff to assess and mobilize patients, even on weekends. You make a good point about nurses also being able to mobilize patients, but at my facility they're often understaffed on weekends as well and don't have time to do it. My point (written early in the day before I'd had my caffeine) was simply that an important aspect of patient care is often neglected over the weekends due to lack of staffing.

    As for stupid orders from MDs...absolutely guilty as charged. In fairness though, I've received absolutely no training on what PTs do, how to effectively consult a PT, or how to assess a patient for weight-bearing status. And often I have to see 10 patients in an hour before rounding in the morning, which leaves me with only enough time to address the bare bones of their medical issues. I would like to do a better job of consulting PT, but the system doesn't always make it easy for me to do so.

  8. There were some units that were allowed to order their own PT/OT, but it was a little bit ridiculous. We did stop a few useless consults, but that was usually because PT/OT had been ordered on a patient that was discharged like ten minutes after the order was placed, so we didn't do anything a trained monkey couldn't do.

    As a med student or intern, getting PT/OT to see your patient was always really difficult... not the fault of the therapists, but rather understaffing. Hospitals need to hire more therapists!

  9. I remember ordering a PM&R consult to see one of my stroke patients. I ordered it on Monday, and it took them FOUR DAYS (despite follow up) to come see the patient. It was especially annoying because she needed to be seen to get placement in a rehab facility rather than a SNF, and her discharge was delayed because of it.

    Getting PT/OT to see my patients hasn't been hard for me thus far, but that may be unique to the hospitals I've worked at.