Over the past 3 weeks during my musculoskeletal placement we have had 4 different supervisors. Having so many different supervisors has been good, as each one teachs differently and has different ideas on what exercises and stretches to give patients. However the other day at prac one aspect of different supervisors that made life challenging was the fact that they all have very different ideas on when to discharge patients.
One particular patient I had been treating for the whole of the 3 weeks, whom had adhesive capusulitis had not been improving at all. I myself felt that maybe the patient would benefit from physio when they were out of stage 1; which is the inflammatory stage. However none of my supervisors discussed discharging her, until this week when as soon as this particular supervisor heard my patients diagnosis and nothing else they said discharge her, we can't do anything for them.
After this comment, I began to question when do we decide to discahrge patients. We have the normal criteria like has the patient improved ? Are they back to pre-injury status ? Or if the patient has fractured something, they get referred somewhere else. But in terms of; if the patient has begun to plataeu when do we say, your not getting better, I think we need to discharge you and refer you back to you GP.
With my patient I introduced the idea of discharge, only to find they became very upset with the idea of having to go back to the doctor, as they were afraid they may require an injection or surgery. To try and relax my patient I said if she hadn't improved by next week, then it would be a month since she had been at physio and had any improvement at all, so discharge from physio would probably be the best option. The supervisor I had at the time said I should of just discharged her that day, but I don't think letting the patient have some ownership of their discharge is such a bad thing to do.
OVERALL IN TERMS OF WHEN DO YOU DISCHARGE PATIENTS IF THEY BEGIN TO PLATEAU, I PERSONALLY WOULD GIVE IT A COUPLE OF WEEKS, DEPENDING ON THE DIAGNOSIS. IF THEY HAVEN'T IMPROVED DURING THIS TIME, I WOULD DO THE SAME AS I DID WITH THE PATIENT ABOVE IF THEY WERE RELUCTANT TO BE DISCHARGED I WOULD INTRODUCE THE IDEA ONE WEEK AND SAY IF THERE IS NO IMPROVEMENT THEN PHYSIO ISN'T REALLY HELPING. THEN DURING THE LAST SESSION GIVE THE PATIENT EXERCISES TO COMPLETE BY THEMSELVES SO THEY DON'T FEEL LIKE YOU HAVE JUST GIVEN UP AND REFER THEM BACK TO THEIR GP OR WHEREVER IT IS THAT THEY COULD GET MORE ASSISTANCE. IF ANYONE ACTUALLY HAS EXACT CRITERIA FOR WHEN TO DISCHARGE PATIENTS LIKE THIS WOULD LOVE TO KNOW THEM?
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3 comments:
ahh, the difficulties of knowing when to discharge a patient... I think your case highlights the importance of asking a patient what their expectations are with regards to physiotherapy and their goals of treatment (set collaboratively with the therapist and patient). These questions should be answered ideally on the day of the initial assessment. A patient should be discharged when these realistic goals have been achieved, keeping in mind the goals should relate to FUNCTION. If these issues are discussed with the patient early on, there are unlikely to be any sudden surprises for the patient when it comes to discharge. For instance, if a patient presents during phase 1 of a frozen shoulder, i would explain to the patient that physio may or may not be helpful at this point, outline what can be offered and explain that if certain goals hadn't been achieved over a certain period, that physiotherapy may not be the best management at that stage.
More generally speaking about discharging patients, we have to remember that it is not realistic for all patients to have recovered to pre-injury status, be 100% pain free etc. Again, this is where goal setting can be helpful. For example, if someone presents with chronic back pain, a realistic goal might be "improve walking tolerance by 50% of current functional level". Once that (and other goals) are achieved, the patient is ready for discharge. And i agree, it the patient is not making the progress you hoped and a better course of action is refer back to the GP, this possibility should be discussed early in the course of treatment.
Ultimately, i agree patients should be involved in their discharge planning. This is facilitated by discussing short and long terms goals early on with regards to treatment and if you suspect the patient may not make reasonable progress (such as stage 1 frozen shoulder), discuss the plan of action early on rather then when it becomes obvious the patient has plateaued.
One other thought.... in patients where its hard to objectively measure improvement, formal outcome measures (questionnaires, scales) can be useful for both the therapist and patient. For instance, i find the following scales useful in clinical practice:
Patient Specific Functional Scale, the quick DASH (disabilities of the arm, shoulder and hand), Upper extremity functional index (UEFI), and Croft Disability Questionnaire.
I think your approach was the best option for this patient as she sounded distressed that physiotherapy wasn't helping her at the time. Your option allowed her to feel like she had some say in her treatment plan, which is important. If she thinks she was discharged too early from physio, then she may end up with negative feelings towards physio. But if she felt like she was involved in the process this is less likely.
Well done, I think you handled the situation well. I have realised that the best way to sometimes deal with a difficult issue such as discharge is to give patients some sense of ownership to the decision making process and it will be much easier on them rather thanjust d/c them on our terms.
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