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  • Nurses' 'Choosing Wisely' List Should Resonate With PTS, PTAs

    A recently released list of practices nurses and patients should question will likely get nods of agreement from physical therapists (PTs) and physical therapist assistants (PTAs) for the ways the recommendations promote early mobility in hospital settings.

    The American Academy of Nursing (AAN) became the most recent nonphysician profession to add to the American Board of Internal Medicine (ABIM) Foundation's Choosing Wisely® campaign aimed at educating consumers and health care professionals on health care-related tests, procedures, and practices that may not be necessary or appropriate under certain circumstances. In September, APTA became the first nonphysician group to join the campaign when it unveiled its list of "5 Things Physical Therapists and Patients Should Question."

    Of particular interest to PTs and PTAs in the AAN list of "5 Things Nurses and Patients Should Question" (.pdf) are recommendations that nurses should not let older adults lie in bed or only get up to a chair during their hospital stay, that physical restraints should not be used with patients who are older and in the hospital, and that urinary catheters should not be placed or maintained in a patient "unless there is a specific indication to do so."

    "PTs know that an important contributor to hospital-associated disability is immobility during hospitalization, which leads to decreased function, increased fall risk, and increased length of stay—especially in older adults," said Anita Bemis-Dougherty, PT, DPT, MAS, clinical practice director at APTA. "The AAN Choosing Wisely list is an excellent addition to the support for greater mobility in hospitalized patients."

    Bemis-Dougherty noted that the AAN recommendations around restraints are consistent with The Joint Commission (TJC) restraint standards. In addition, she said, the AAN list correlates strongly with APTA's Choosing Wisely recommendations against using continuous passive motion machines after uncomplicated total knee replacement, and against bed rest following diagnosis of acute deep vein thrombosis after anti-coagulation therapy, unless significant medical concerns are present.

    "Improved strength in older adults is associated with improved health, quality of life and functional capacity, and with a reduced risk of falls," noted Bemis-Dougherty. "If the patient is restrained, the immobility could lead to poor outcomes."

    APTA Senior Director of Practice and Research Nancy White, PT, DPT, OCS, was involved in the development of the APTA Choosing Wisely list, and thinks that the AAN recommendations add to the reach of a campaign that's making a difference.

    "Choosing Wisely is recognized as a great way to improve outcomes of care and reduce the use of treatment approaches that are either not effective or that may even be harmful," White said. "AAN has identified several practices that are common in many hospital settings that result in prolonged and unnecessary bed rest—something that PTs know leads to poorer outcomes and prolonged hospital stays."

    Bemis-Dougherty believes that the AAN list can help APTA in its efforts "to change the culture of immobility in the hospital to one of mobility."

    "Creating that kind of change is a daunting task and can't be accomplished by PTs alone," Bemis-Dougherty said. "To have nursing recognize the problem caused by immobility is huge and hopefully can contribute to a more widespread culture of mobility that involves all health care professionals within hospital settings."

    APTA's Choosing Wisely list is offered in several forms, including consumer-focused versions in English and Spanish, and an expanded version containing citations on the association's Center for Integrity in Practice website. Resources on that site also include a ProfessionWatch paper from Physical Therapy that details the process of the list's development and provides professional context for APTA's decision to partner with the ABIM Foundation.


    • I'm all for a multi-disciplinary approach to early mobility, but we need to be careful as PTs to protect what we are more skilled at in mobility in general. We are currently having hypothetical talks with our CNO about why can't nursing just mobilize everyone? Of course our answer is that risk of more falls would likely occur, hence length of stay would go up, and possible increased re-admissions. Let's not just give the green light to nursing for full access to mobilizing patients. We as a PT profession should dictate what nursing can do versus what a PT can provide in early mobility to a patient.

      Posted by Joel Blanco on 11/20/2014 9:43 PM

    • When we get enough help to do our job and yours maybe we can implement this!

      Posted by Susan on 11/21/2014 9:58 AM

    • The bigger question here is "what is best for the patient?" There are acute care triaging algorithms out there that would easily delineate if a patient would benefit from Skilled Physical Therapy Services or if it is safe for nursing to mobilize them.Keeping a patient bedfast for fear of a fall or because nursing simply "doesn't have time" can in no manner be best practice. Neither is the concept of PTs ambulating everyone best practice.We are meant to be complementary professionals providing best patient care.

      Posted by Paula Carroll on 11/22/2014 1:41 PM

    • Susan - mobility is everyone's job. More accurate utilization of PT services would happen if nursing saw mobilization as a priority. This is a large problem , not an individual nurse problem. From education to leadership there needs to be a reset. Consider the cost of a nurse versus a physical therapist leading mobility. Now consider the Cost of a CNA versus a PTA. Cost reduction will drive this - Using physical therapy like a laser as opposed to the shot gun approach.

      Posted by David Ter Borg on 11/23/2014 7:57 PM

    • At one facility (teaching hospital/trauma center): only PTs are "allowed" to mobilize patients, thus nursing and MDs expect PTs to mobilize everyone; imo quality of treatments decline while hours are spent daily performing "total lifts" (because we've given up so much of our practice to other disciplines), and MDs/nrsg get angry if someone is missed. Overtime is sky high. 2nd facility (standard non-profit but HUGE; stroke certified, etc): nrsg gets patients OOB starting in the ICU; only if there are difficulties of some type does PT get consulted. It required initial training/meetings to assure good communication and understanding, but is going smoothly for some time now. Of course PT is consulted for post-op ortho pts at both places.

      Posted by M.L. on 12/12/2014 11:01 AM

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