HOW MANY of your patients really need a physical therapy (PT) consult? If you’re like most hospitalists, you may be surprised by how many patients do not.
A study in the September 2021 Journal of Hospital Medicine, for example, found that up to 38% of all PT consults at a Chicago teaching hospital were potentially inappropriate. The research also found that high-mobility patients were more than five times as likely to be discharged home, and that those patients experienced virtually no change in mobility while they were hospitalized.
That may be good news for hospitalists worried about the hit in mobility their patients take while lying around in a hospital bed. But it also presents hospitalists with the distinct challenge of figuring out how to know which patients need PT.
“As a resident, you’re taught to get a PT consult on everybody so you don’t delay discharge.”
~ Maylyn Martinez, MD
University of Chicago
That’s where a new breed of mobility scoring tools comes in. These tools—like the one used in the study—give physicians, nurses and physical therapists a standardized way to both measure and talk about mobility in inpatients.
When is PT not needed?
Hospitalist Maylyn Martinez, MD, the study’s lead author and clinical instructor at the University of Chicago, says she started thinking about PT consults in the hospital after talking to the director of therapy services a couple of years ago.
“The director told me that the physical therapists were spending a lot of time evaluating patients who were essentially as mobile as she and I were, so they didn’t really need the expertise of a physical therapist,” Dr. Martinez says. “According to the director, that was a real drain on her department.”
To find out how much of that drain is unnecessary, Dr. Martinez and her research colleagues used the Activity Measure-Post Acute Care (AM-PAC) mobility score. Based in part on previous research, which found that a score of 42.9 on the AMPAC scale accurately predicts which patients will be discharged home, the Chicago researchers concluded that patients who both had an AM-PAC score of greater than 43.63 and were discharged to home were “potentially inappropriate” for a PT consult. That’s because, she says, “those people have no trouble walking around.”
Researchers found that on admission, the average AM-PAC score for patients was 43.9. Using the threshold of more than 43.63 and a home discharge, the authors concluded that 38% of those who’d received a PT consult probably didn’t need those services. Nearly half of the potentially inappropriate referrals were for patients 65 or younger.
Dr. Martinez acknowledges that the data may be counterintuitive to hospitalists, who have been taught since training to make liberal PT referrals. “This can be shocking to people because it’s so instinctive to order PT for all your patients,” she points out. “As a resident, you’re taught to get a PT consult on everybody so you don’t delay discharge.”
But the study data should put at ease those hospitalists who worry about holding back on PT consults, even for high-mobility patients. Researchers found that only 1.5% of patients who had high-admission AM-PAC scores experienced deconditioning that required discharge to a post-acute setting for skilled PT.
Freeing up PT resources
While University of Chicago researchers used the AM-PAC tool to identify inappropriate PT referrals, the health system also utilizes it to try to ensure that PT services go to patients who really need them.
The University of Chicago started its Project Walk program six years ago, having nurses and therapy services work closely together to assess and improve mobility in inpatients. Nurses use the AM-PAC tool on admission (and then every 12 hours that patients are in the hospital) to assess which patients can benefit from PT services
Developed at Boston University more than 10 years ago, the tool (in its shortened version) uses six questions to help identify which patients need—or don’t need—PT services. Three of the questions ask about difficulties with mobility, while the other three assess how much help patients need with mobility activities.
The university established an AM-PAC score of greater than 43.63 as a threshold for nurses to begin independently mobilizing patients. Dr. Martinez says patients who really benefit from the nursing-driven mobilization program are those who “come in with a score in the lower range of high mobility but were completely in dependent” before they were admitted.
“At some point, they took a hit to their mobility,” she explains, “and they need some help from the nurses to get around.” A PT consult is called for those with a score of 43.63 or less.
One goal of the program is helping patients who are on the fence as to whether they need post-acute care or can go home. “That’s a really big decision in a patient’s life,” she notes. “If they had a few extra sessions with physical therapy, maybe you can get them over the threshold and get them discharged home. But that’s more difficult to achieve if PT is busy spending time with patients who don’t need it.”
On the same page
Dr. Martinez adds that the AM-PAC tool plays another important role in improving patient mobility: It gives all parties involved a standardized scoring system. That standardization helps keep everyone on the same page during discharge planning. “Discussing only their medical issues isn’t good enough,” she notes.
“You need to regularly discuss their mobility as well.” In the last few months, Dr. Martinez says that social workers and case managers have begun talking about mobility scores during interdisciplinary team meetings. “You might hear, ‘Does this patient need a SNF?’ And someone will chime in, ‘Their AM-PAC score is 24, so probably not.’ ”
Looking ahead, Dr. Martinez wants to start collecting data on whether PT consults—and the overuse of them—affects length of stay. “If you’re trying to discharge a patient tomorrow to a nursing home and you ask for a PT consult to get an updated recommendation,” she says, “PT may be tied up with five other patients, some of whom don’t need that service. If we eliminate that wasted time, can we discharge low-mobility patients faster—or even get them home?”
Edward Doyle is Editor of Today’s Hospitalist.
Published in the January/February 2022 issue of Today’s Hospitalist