Description:
In a class debate on the subject of the roles of various AHPs and their
relative importance in establishing and running a healthcare system isolated
from outside support, my classmates and I found ourselves hard-pressed to
justify the necessity of PTs in such a setting, rating doctors and nurses as
more important for seeing to what were perceived as more crucial needs, such as
triage and support for serious acute patients.
A conversation post-debate also mentioned a PT position in an emergency
ward, which prompted some jokes from all, myself included, as none of us were
able to comprehend the necessity of a PT in such a setting.
Shortly after, I saw my observational placement at
an acute care ward for unscheduled surgical patients, seeing for the first time
the possibilities of PTs contributing to patient care in an acute care setting
by restoring post-surgical patients to levels of mobility sufficient to
discharge to lower levels of care and free up ward beds for other acute
patients.
Feelings:
Placement was an eye-opener to me as, prior to it, I was under the impression
that physiotherapy rehabilitation was strictly confined to sub-acute settings,
ie. following recovery from surgery and other active short-term interventions. At the time, I could not imagine a PT playing
any role in the rehabilitation of a patient at any time before at least onset
of consolidation.
I was to learn, once a fracture was surgically
reduced and fixated, loading should begin as soon as possible to maximally
stimulate healthy remodelling.
Departmental policy mandated mobilisation within 24 hours of surgery
where possible, which seemed highly aggressive compared to what I had learned
in Atkinson(2005), in which most
case studies of serious fractures of the hip and femur recommended
weightbearing begin a matter of around 6 weeks post-reduction and fixation.
Evaluation:
As mentioned above, I was initially apprehensive of participating in what
seemed to me to be a highly aggressive course of treatment, particularly given
the frail and usually aged nature of the patients, not to mention the
inevitable discomfort and pain they were in so soon post-trauma, which was only
aggravated by mobilisation. However,
once I was reassured by the senior therapists on the team that the patients
were in no danger and would not only benefit personally from such treatment but
also benefit others by freeing up highly in-demand beds, I was glad to
participate in any way I could.
Though my time at the department was relatively
short, I could see from comparing patient notes that patients who had high
participation in early mobilisation tended to have shorter stays than patients
who were chronically immobile.
Furthermore, they tended to come to terms with their pain and discomfort
better, reducing its impact on them and enabling them to sooner attain levels
of mobility qualifying them for discharge from the ward.
Analysis:
Postoperative
weight-bearing in stabilised hip fracture patients has been observed to achieve
an average of 51% full weight-bearing one week post-surgery in one cohort of 37
patients with early post-operative mobilisation and as high
as 100% full weight-bearing in another
cohort of 186 patients, neither with any significant
incidence of re-injury or other complications.
Having been told by the department of the high cost of bed days in the
acute ward, I researched this amount and found it to vary between £364.61-367.85/bed-day
nation-wide, and cost an average £12000-15000
per patient admission in Lothian.
Conclusion: Early post-operative
mobilisation to the limit of patient tolerance stands to maximise patient
recovery, enabling faster processing of patients waiting for acute beds. Less time spent in acute care will likely
result in lower per-patient expenditure also, as each patient will occupy a
lower number of resource-intensive acute care bed days. Furthermore, this is a role that PTs are
uniquely suited to fill, given their expected professional role as specialists
in mobilisation and therapeutic exercise.
By taking on this role, PTs will spare doctors and
nurses to focus on their respective areas of patient care. From the above, I have come to understand that
PTs have a significant role to play in acute care, managing efficient and fair
distribution of public healthcare expenditure by maximising patient discharge
rates from resource-intensive levels of care.
Works Cited
Atkinson, K.,
Coutts, F. & Hassenkamp, A.-M., 2005. Management of Fractures. In: Physiotherapy
in Orthopaedics. Edinburgh: Elsevier, pp. 89-133.
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