Physical Therapists Can Improve Patient Safety in Hospitals

One of the "failure modes" in preventing hospital-acquired venous thromboembolism (VTE) - a blood clot - is that risk assessment is not routine or standardized.

Physical therapists who treat post-surgical patients can provide screening to diagnose this problem in high-risk patients. Screening rules, such as the Wells' Criteria can aid the physical therapist in diagnosing a blood clot.

But, one physical therapist cannot create a culture of safety.

To create a culture of safety in preventing hospital-acquired infections the Agency for Healthcare Research and Quality has sponsored a Comprehensive Unit-based Safety Program (CUSP). The CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms.

The program features: evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, engagement of leadership, and tools to improve teamwork among doctors, nurses, and other members of the health care team.

The CUSP uses a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses and hospital leaders.

Step 1 Staff are educated on the science of safety.

Step 2 Staff complete an assessment of patient safety culture. Safety is everyones' responsibility - we as physical therapists cannot continue to defer our responsibility to physicians on the "sharp end" of healthcare.

Step 3 A senior hospital executive partners with the unit to improve communications and educate leadership. Staff (MDs, nurses, PTs, etc) need to know we have support from the top.

Step 4 Staff learn from unit defects. These defects get reported by staff members unafraid of personal attacks.

Transparency, like in the airline industry, celebrates the reporting of medical errors as the opportunity to learn and improve. Instead, in healthcare, we've had a habit of "naming, blaming and shaming" people who make mistakes. A broken tort system of punitive legal redress is the product of these habits.

Step 5 Staff use tools, including checklists and electronic decision support, to improve teamwork, communication, and other systems of work.

Clinical decision support tools, with reminder pop-ups, prompts and suggestions can help physical therapists provide guideline-adherent care.

The most common preventable cause of hospital death is VTE.

"Over 1 year, a 300-bed hospital that lacks a systematic approach to VTE prevention can expect roughly 150 cases of hospital-acquired VTE.
Approximately 50 to 75 of those cases will be potentially preventable because of missed opportunities to provide appropriate prophylaxis.
Approximately five of those patients will die from potentially preventable PE."

Highly focused initiatives using these five principles have achieved success in reducing preventable infections, such as central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections, and ventilator-associated pneumonia, in intensive care units (ICUs) and other hospital units.

Healthcare leaders can address the growing rate of blood clots by attacking this problem with teams of providers implementing a standardized approach.

Doctor Happy and the Silent Treatment

A new study highlights an old problem in medicine that leads to patient harm.

A new study from VitalSmarts, the American Association of Critical-Care Nurses and the Association of Peri-Operative Registered Nurses (AORN) called The Silent Treatment describes several categories of "undiscussables" in medicine:

• Dangerous shortcuts
• Incompetence
• Disrespect

As I shared here, even physical therapists are subject to events that lead to the silent treatment.

Teams of healthcare workers in the future will need to learn positive ways of influencing each others' behavior but not bullying, yelling or disrespectful behavior.

The silent treatment happens anytime communications between physicians and other workers break down. "Other workers" can include nurses, physicians' assistants, physical therapists or even clerical people. My experience with a particular orthopedic surgeon falls under the "disrespect" catagory.



Acoording to the American Association of Critical-Care Nurses (AACN):

"More than half say disrespect prevented them from getting others to listen to them or respect their professional opinion, and only 16 percent confronted their disrespectful colleague."

My story goes like this:

The orthopedic surgeon called me two weeks after the patient's operation. I had seen the patient once, or maybe twice, at that point, for rehabilitation of his full-thickness rotator cuff repair. The patient was on the standard six week protective protocol, passive range-of-motion only and pendulum exercises at home.

The incision was still swollen and tender. Motion, even passive motion, was quite painful. The patient was still having trouble sleeping at night. Therapy consisted of maybe 20 minutes of passive mobility in six directions, the aforementioned pendulum exercises followed by electrical stimulation and ice.

I got called in the middle of the work day by the physician who we'll call Dr. Happy. When I picked up the phone, Dr. Happy practically yelled,

"Tim! What the hell are you doing letting my patient get stiff?"

I knew better than to argue. "He's still very sore, Dr. Happy" I said.

Dr. Happy continued, "You'd better improve internal rotation! He can't get his arm up his back! He's going to get a frozen shoulder!"

"We won't let that happen, Dr. Happy!" I said.

That might have been enough - a sharply worded reminder to improve joint motion - except for what came next.

"You like my referrals - don't you?". It wasn't a question.

"Yes sir!" I said, dreading what I knew was to follow.

"You'd better not let him freeze up or I won't send any more referrals to your clinic!" growled Dr. Happy

The question is not whether Dr. Happy was justified in chewing my butt, or whether my patient actually was stiffening up (he wasn't).

The questionable behavior is Dr. Happy's abusive, disrespectful and bullying attitude that, unfortunately, was not seen as abnormal in the culture of American medicine.

Nowadays, hospital safety is changing as a result of checklists, computerized decision support tools and new surgical protocols. But, these new tools won't create a safe culture as long as people disrespect each other to enforce a culture of silence.

Tools don't create safety, people create safety.

The culture of silence is beginning to change.