Are Hospitals Over-consulting Physical Therapy?

A regular comment I hear from hospitalist medicine and case management staff is “we are waiting on the PT consult” or “we are waiting for PT to document their recommendations.” 

Physical therapists have experienced many of the same shortages since the COVID-19 pandemic began as the rest of the healthcare industry, with clinicians exiting the hospital setting and many going into alternative work environments for an improved work-life balance. Many hospitals have had to utilize contracted labor or physical therapy assistants (PTAs) for the majority of patient therapy needs, due to the limited PTs being stretched across the inpatient and outpatient hospital-based services to evaluate and treat patients. There are just not enough therapists to meet the demand. However, is such a demand required? Rather than increasing labor costs, should hospitals be asking themselves “are we over-consulting PT?” And is this leading to a delay in patient progression of care, not to mention unrealistic referrals for post-acute care?

In 2021, this topic was reported on by the Society of Hospital Medicine, which found that 38 percent of physical therapy consults were identified as potentially inappropriate. It is a well-known practice for hospitalists to place consults upon admission for PT and occupational therapy (OT), for early assessment and intervention of patients to assess mobility and post-discharge needs, even when there is no medical necessity for such consults. Once consulted, PT and OT are often unable to delete the inappropriate order, and instead will at least complete an initial assessment of the patient to assess their functional and mobility status.

One thing I wonder is if the metric and strong emphasis on fall prevention in hospitals across the nursing discipline and quality departments have created an unintended consequence for our patients and therapists. I often see large signs promoting how many days units have been “free from patient falls.” Patients who experience a fall have a quality report (and often a safety risk report) filed. Although this is an important process, it can still seem quietly punitive for the nursing unit or individual nurse. 

The easiest way to avoid the negative impact of patient falls is to keep patients in bed. In 2019, KFF News and The Washington Post ran an article warning of this exact issue: “Fear of Falling: how hospitals do even more harm by keeping patients in bed.” As if the title wasn’t pointed enough, they went on to note that “hospitals have become so overzealous in fall prevention that they are producing an ‘epidemic of immobility.’”

To identify a patient’s fall risk, we see patients receiving PT and OT consultations for safety and mobility assessments – then the mobility of the patient, unless independently ambulating, is up to the PTAs, who see the patient daily and get them moving. Instead of promoting mobility and walking in between the consults, nursing units place bed alarms on patients. 

From a hospital throughput process, the over-utilization of PT consults creates a large delay, especially for patients under outpatient with observation services (OBS) who are expected to have a quick turnaround, but are now delayed for mobility assessments, regardless if this is a contributing factor to their need for hospital observation services. The result of this consultation is then exacerbated if the therapy assessment recommends post-acute placement, triggering further delays for case management planning and arrangements.

To break the cycle of overutilized therapy consults for PTs who are under-resourced, hospitals should consider tracking the consult utilization of patients resulting in PT signing off on discharges home without services. This data represents a great first step to identify inappropriate consults. 

Dr. Martinez from the University of Chicago recommends patients receive a quick Activity Measure Post-Acute Care (AM-PAC) assessment prior to consulting therapy for patient assessment. Additionally, hospitals have started looking at bringing back patient care technicians and hiring mobility technicians to mobilize patients, rather than relying on the therapy department and supporting the multiple constraints in the nursing divisions.

There is no question that avoiding patient falls is important, but have there been unintended consequences resulting from overutilization of PT and limited patient mobility?