- Email: [email protected]
A seven-day physiotherapy service
Journal of Physiotherapy 60 (2014) 179–180
Journal of
PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys
Editorial
A seven-day physiotherapy service Nicholas F Taylor a,b, Nora Shields a,c a
Department of Physiotherapy, La Trobe University; b Allied Health Clinical Research Office, Eastern Health; c Department of Allied Health, Northern Health, Melbourne, Australia
Hospitals and primary healthcare services operate around the clock, 7 days a week. Traditionally, physiotherapy services have operated within business hours from Monday to Friday or, if an out-of-hours service has been provided, it has been a reduced service. However, the health problems of some of our patients can deteriorate if not addressed immediately. In addition, many people with less urgent problems may find it difficult to attend physiotherapy appointments during business hours due to their own commitments or work. Consistent with the principles of patient-centred and family-centred care,1 we have an obligation to provide care for people when they need it and when they are available. This situation, together with the fact that other services and professions in the healthcare system provide care 7 days a week, provides a rationale for a discussion on providing a 7-day physiotherapy service. Some areas of physiotherapy practice have a long tradition of providing services outside of business hours, for example, weekend physiotherapy services for patients with high acuity such as in intensive care units. In the United Kingdom, 97% of intensive care units provide 24-hour access to physiotherapy,2 and in Canada, 97% of intensive care units have weekend physiotherapy services.3 A recent Australian survey found that 80% of acute wards provided physiotherapy on a Saturday.4 Also, physiotherapists working in private practice, often with a focus on treating musculoskeletal problems, have long provided, at least in Australia, services outside of business hours including weekends. Although we were not able to locate data about the extent of the out-of-hours services provided by private practitioners, information about the number of hours worked by physiotherapists in excess of 40 hours a week suggests that these services may be widespread.5 In other areas of physiotherapy practice, out-of-hours services are either much reduced or absent. For example, only 30% of rehabilitation services in Australia,4 and approximately 69% of community hospitals in Canada,6 provide physiotherapy services at weekends. Although 97% of tertiary care hospitals in Canada provide physiotherapy services at weekends, the service is 88% less than during the week, suggesting that only a skeleton staff is employed to address the most urgent cases.3 Furthermore, in some centres, night rosters are covered by the most junior staff, who have the least experience at dealing with unexpected or complex changes in a patient’s clinical condition. The case for advocating increased out-of-hours physiotherapy services would be more compelling if its provision was supported by evidence. Such evidence is starting to emerge. A randomised controlled trial from Australia, for example, found that the provision of additional Saturday physiotherapy and occupational therapy helped adults receiving inpatient rehabilitation to get
better quicker, with benefits in functional independence and health-related quality of life sustained at 6 months after discharge.7 A recent study with comparison to a historical control also found that implementing a multidisciplinary rehabilitation service on a Saturday in Australia improved functional independence.8 A retrospective study in the United States found that a 7-day rehabilitation service including physiotherapy reduced length of stay by 1 day, compared to a 5-day service.9 Studies have also reported a reduction in pulmonary complications for patients with acute spinal injury,10 and the elderly after surgery,11 in an intensive care unit with additional out-of-hours physiotherapy. In other areas of practice, however, the evidence for out-ofhours physiotherapy services is, to date, less convincing. A retrospective study found that introducing a 7-day service after lower-limb joint replacement in an Australian regional hospital did not decrease hospital length of stay.12 A review found that there was no strong evidence to support the provision of out-of-hours physiotherapy services in the areas of orthopaedics, neurology and cardiac surgery.13 One of the difficulties in evaluating the evidence is that so few studies in this area have been randomised controlled trials. The lack of controlled trials is a problem because apart from there being an increased risk of bias in the results, other factors that could influence outcomes, such as the amount of physiotherapy, may not be controlled or accounted for. A key issue in evaluating the effectiveness of out-of-hours physiotherapy services is determining whether the services provided are additional services, or whether they are redistributed from existing Monday-to-Friday services.3 There is strong evidence that providing additional physiotherapy across a range of health conditions and across acute hospital and rehabilitation settings can improve patient outcomes and reduce length of stay.14 Out-of-hours services are one way of increasing the amount of physiotherapy provided to patients. In the context of providing additional physiotherapy services, it has also been reported that rehabilitation inpatients had a different attitude to treatment when services were provided at the weekend; they considered that they were there to work, whereas the attitude of patients receiving a 5-day service was that rest was more important at the weekend.15 Perhaps the key benefit of an outof-hours physiotherapy service is that it provides an opportunity to increase the intensity of therapy provided.7 This benefit may not manifest if the overall amount of physiotherapy is not increased by the redistribution of a 5-day service over 7 days. As a member of a multidisciplinary team, it may be a problem if the physiotherapist is providing out-of-hours service, but the other members of the team are not. For example, in a retrospective study where only the physiotherapy service was increased at the weekend, the physiotherapy length of stay decreased but the
http://dx.doi.org/10.1016/j.jphys.2014.08.004 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
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Editorial
hospital length of stay did not.14 The main issue identified for this discrepancy was that other parts of the health service were not ready for patient discharge. Consistent with this, other allied health professions such as social work and occupational therapy, which are essential to patient management and discharge planning, typically have much lower weekend coverage than physiotherapy.6 This issue of recognising that one area of the health service cannot function effectively at the weekend without having access to other areas of the health service has been more broadly recognised in a discussion about providing a 7-day service in the National Health Service in the United Kingdom.16 Another issue is whether the efficacy of a particular physiotherapy intervention has been established with 5-day or 7-day input. For example, all four trials of inspiratory muscle training to facilitate weaning from artificial ventilation in the intensive care unit have provided the physiotherapist-administered training on a 7-day basis.17,18 If physiotherapists only administer this on a 5-day basis, the gains in respiratory muscle endurance may be reduced or lost during the 60 hours of continuous mechanical ventilation from the last Friday treatment to the first Monday treatment. Even if providing additional out-of-hours physiotherapy services is effective, the issue of who pays remains.19 Are additional physiotherapy services worth the cost? Several studies have investigated the cost-effectiveness of providing additional physiotherapy at weekends. A review of the health economics of providing rehabilitation concluded that it was cost-effective to provide additional rehabilitation therapy for people with stroke or orthopaedic diagnoses.20 Recently, a health economic analysis alongside a randomised controlled trial found that there were likely cost savings in providing additional Saturday rehabilitation to a mixed cohort of inpatients.21 Primarily through a reduction in length of stay, costs to the health service were reduced, even though there was the added expense of employing physiotherapists and occupational therapists at the weekends. One of the challenges is that the part of the health system that accrues the savings may not be the same part that provides the immediate budget for staffing the additional services. A barrier to providing a 7-day physiotherapy service may be the attitudes of physiotherapists and the perceived stress of working out of regular hours. Physiotherapists who are used to working Monday to Friday may be less willing to work at weekends or in the evenings. However, it was found in our trial that there was no difficulty in staffing a Saturday rehabilitation service.7,20 Part of the issue may be in expectations established during training. Including out-of-hours clinical placements during training, similar to nurses and doctors, may lead to positive attitudes and acceptance of working in a 7-day
service. It may also help to structure work schedules to include a day off at the weekend, which can be important in helping health professionals to recover from work stress.22 In conclusion, a 7-day physiotherapy service in some form and in some areas has long been a part of practice. There is now emerging evidence that providing additional out-of-hours physiotherapy services (including at the weekends) can help to improve patient outcomes and be cost-effective. As health professionals providing an important service in the health system, it seems that physiotherapists should be working when other members of the healthcare team are working and at a time that provides care when patients need it. The challenge is to provide evidence in areas of practice where evidence remains scant, and to change the culture and embed the notion that providing additional physiotherapy through a 7-day service can be a routine, beneficial and desirable part of practice. Ethics approval: N/A Competing interests: N/A Source(s) of support: N/A Acknowledgements: N/A Correspondence: Nicholas F Taylor, Department of Physiotherapy, La Trobe University, Australia. Email: [email protected] References 1. Australian Physiotherapy Association. Standard for Physiotherapy Practices 8th edition 2014. Viewed 2 Sept 2014, from https://www.physiotherapy.asn.au/ DocumentsFolder/Resources_Private_Practice_Standards_for_physiotherapy_ practices_2011.pdf. 2. Jones AYM, et al. Physiother Theory Prac. 1992;8:39–47. 3. Campbell L, et al. Physiother Can. 2010;62:347–354. 4. Shaw KD, et al. Physiother Res Int. 2013;18:115–123. 5. New South Wales Health: Physiotherapy Labour Force Profile NSW – 2008. Viewed 2 Sept 2014, from http://www0.health.nsw.gov.au/pubs/2010/pdf/physiotherapy_ 08.pdf. 6. Ottensmeyer CA, et al. Physiother Can. 2012;64:178–187. 7. Peiris CL, et al. BMC Med. 2013;11:198. 8. Hakkenes S, et al. Disabil Rehabil. 2014;early online:1–7. 9. DiSotto-Monastero M, et al. Arch Phys Med Rehabil. 2012;93:2165–2169. 10. Berney S, et al. Physiother Res Int. 2002;7:14–22. 11. Ntoumenopoulos G, et al. Aust J Physiother. 1996;42:279–303. 12. Maidment ZL, et al. Aust Hlth Rev. 2014;38:265–270. 13. Brusco NK, et al. Physiother Theory Prac. 2006;22:291–307. 14. Peiris CL, et al. Arch Phys Med Rehabil. 2011;92:1490–1500. 15. Peiris CL, et al. J Physiother. 2012;58:261–268. 16. Keogh B. BMJ. 2013;346:f621. 17. Moodie L, et al. J Physiother. 2011;57:213–221. 18. Condessa RL, et al. J Physiother. 2013;59:101–107. 19. Flynn P. BMJ. 2013;346:f622. 20. Brusco NK, et al. Arch Phys Med Rehabil. 2014;95:94–116. 21. Brusco NK, et al. BMC Med. 2014;12:89. 22. Drach-Zahavy A, et al. J Adv Nurs. 2013;69:578–589.
Journal of
PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys
Editorial
A seven-day physiotherapy service Nicholas F Taylor a,b, Nora Shields a,c a
Department of Physiotherapy, La Trobe University; b Allied Health Clinical Research Office, Eastern Health; c Department of Allied Health, Northern Health, Melbourne, Australia
Hospitals and primary healthcare services operate around the clock, 7 days a week. Traditionally, physiotherapy services have operated within business hours from Monday to Friday or, if an out-of-hours service has been provided, it has been a reduced service. However, the health problems of some of our patients can deteriorate if not addressed immediately. In addition, many people with less urgent problems may find it difficult to attend physiotherapy appointments during business hours due to their own commitments or work. Consistent with the principles of patient-centred and family-centred care,1 we have an obligation to provide care for people when they need it and when they are available. This situation, together with the fact that other services and professions in the healthcare system provide care 7 days a week, provides a rationale for a discussion on providing a 7-day physiotherapy service. Some areas of physiotherapy practice have a long tradition of providing services outside of business hours, for example, weekend physiotherapy services for patients with high acuity such as in intensive care units. In the United Kingdom, 97% of intensive care units provide 24-hour access to physiotherapy,2 and in Canada, 97% of intensive care units have weekend physiotherapy services.3 A recent Australian survey found that 80% of acute wards provided physiotherapy on a Saturday.4 Also, physiotherapists working in private practice, often with a focus on treating musculoskeletal problems, have long provided, at least in Australia, services outside of business hours including weekends. Although we were not able to locate data about the extent of the out-of-hours services provided by private practitioners, information about the number of hours worked by physiotherapists in excess of 40 hours a week suggests that these services may be widespread.5 In other areas of physiotherapy practice, out-of-hours services are either much reduced or absent. For example, only 30% of rehabilitation services in Australia,4 and approximately 69% of community hospitals in Canada,6 provide physiotherapy services at weekends. Although 97% of tertiary care hospitals in Canada provide physiotherapy services at weekends, the service is 88% less than during the week, suggesting that only a skeleton staff is employed to address the most urgent cases.3 Furthermore, in some centres, night rosters are covered by the most junior staff, who have the least experience at dealing with unexpected or complex changes in a patient’s clinical condition. The case for advocating increased out-of-hours physiotherapy services would be more compelling if its provision was supported by evidence. Such evidence is starting to emerge. A randomised controlled trial from Australia, for example, found that the provision of additional Saturday physiotherapy and occupational therapy helped adults receiving inpatient rehabilitation to get
better quicker, with benefits in functional independence and health-related quality of life sustained at 6 months after discharge.7 A recent study with comparison to a historical control also found that implementing a multidisciplinary rehabilitation service on a Saturday in Australia improved functional independence.8 A retrospective study in the United States found that a 7-day rehabilitation service including physiotherapy reduced length of stay by 1 day, compared to a 5-day service.9 Studies have also reported a reduction in pulmonary complications for patients with acute spinal injury,10 and the elderly after surgery,11 in an intensive care unit with additional out-of-hours physiotherapy. In other areas of practice, however, the evidence for out-ofhours physiotherapy services is, to date, less convincing. A retrospective study found that introducing a 7-day service after lower-limb joint replacement in an Australian regional hospital did not decrease hospital length of stay.12 A review found that there was no strong evidence to support the provision of out-of-hours physiotherapy services in the areas of orthopaedics, neurology and cardiac surgery.13 One of the difficulties in evaluating the evidence is that so few studies in this area have been randomised controlled trials. The lack of controlled trials is a problem because apart from there being an increased risk of bias in the results, other factors that could influence outcomes, such as the amount of physiotherapy, may not be controlled or accounted for. A key issue in evaluating the effectiveness of out-of-hours physiotherapy services is determining whether the services provided are additional services, or whether they are redistributed from existing Monday-to-Friday services.3 There is strong evidence that providing additional physiotherapy across a range of health conditions and across acute hospital and rehabilitation settings can improve patient outcomes and reduce length of stay.14 Out-of-hours services are one way of increasing the amount of physiotherapy provided to patients. In the context of providing additional physiotherapy services, it has also been reported that rehabilitation inpatients had a different attitude to treatment when services were provided at the weekend; they considered that they were there to work, whereas the attitude of patients receiving a 5-day service was that rest was more important at the weekend.15 Perhaps the key benefit of an outof-hours physiotherapy service is that it provides an opportunity to increase the intensity of therapy provided.7 This benefit may not manifest if the overall amount of physiotherapy is not increased by the redistribution of a 5-day service over 7 days. As a member of a multidisciplinary team, it may be a problem if the physiotherapist is providing out-of-hours service, but the other members of the team are not. For example, in a retrospective study where only the physiotherapy service was increased at the weekend, the physiotherapy length of stay decreased but the
http://dx.doi.org/10.1016/j.jphys.2014.08.004 1836-9553/ß 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/).
180
Editorial
hospital length of stay did not.14 The main issue identified for this discrepancy was that other parts of the health service were not ready for patient discharge. Consistent with this, other allied health professions such as social work and occupational therapy, which are essential to patient management and discharge planning, typically have much lower weekend coverage than physiotherapy.6 This issue of recognising that one area of the health service cannot function effectively at the weekend without having access to other areas of the health service has been more broadly recognised in a discussion about providing a 7-day service in the National Health Service in the United Kingdom.16 Another issue is whether the efficacy of a particular physiotherapy intervention has been established with 5-day or 7-day input. For example, all four trials of inspiratory muscle training to facilitate weaning from artificial ventilation in the intensive care unit have provided the physiotherapist-administered training on a 7-day basis.17,18 If physiotherapists only administer this on a 5-day basis, the gains in respiratory muscle endurance may be reduced or lost during the 60 hours of continuous mechanical ventilation from the last Friday treatment to the first Monday treatment. Even if providing additional out-of-hours physiotherapy services is effective, the issue of who pays remains.19 Are additional physiotherapy services worth the cost? Several studies have investigated the cost-effectiveness of providing additional physiotherapy at weekends. A review of the health economics of providing rehabilitation concluded that it was cost-effective to provide additional rehabilitation therapy for people with stroke or orthopaedic diagnoses.20 Recently, a health economic analysis alongside a randomised controlled trial found that there were likely cost savings in providing additional Saturday rehabilitation to a mixed cohort of inpatients.21 Primarily through a reduction in length of stay, costs to the health service were reduced, even though there was the added expense of employing physiotherapists and occupational therapists at the weekends. One of the challenges is that the part of the health system that accrues the savings may not be the same part that provides the immediate budget for staffing the additional services. A barrier to providing a 7-day physiotherapy service may be the attitudes of physiotherapists and the perceived stress of working out of regular hours. Physiotherapists who are used to working Monday to Friday may be less willing to work at weekends or in the evenings. However, it was found in our trial that there was no difficulty in staffing a Saturday rehabilitation service.7,20 Part of the issue may be in expectations established during training. Including out-of-hours clinical placements during training, similar to nurses and doctors, may lead to positive attitudes and acceptance of working in a 7-day
service. It may also help to structure work schedules to include a day off at the weekend, which can be important in helping health professionals to recover from work stress.22 In conclusion, a 7-day physiotherapy service in some form and in some areas has long been a part of practice. There is now emerging evidence that providing additional out-of-hours physiotherapy services (including at the weekends) can help to improve patient outcomes and be cost-effective. As health professionals providing an important service in the health system, it seems that physiotherapists should be working when other members of the healthcare team are working and at a time that provides care when patients need it. The challenge is to provide evidence in areas of practice where evidence remains scant, and to change the culture and embed the notion that providing additional physiotherapy through a 7-day service can be a routine, beneficial and desirable part of practice. Ethics approval: N/A Competing interests: N/A Source(s) of support: N/A Acknowledgements: N/A Correspondence: Nicholas F Taylor, Department of Physiotherapy, La Trobe University, Australia. Email: [email protected] References 1. Australian Physiotherapy Association. Standard for Physiotherapy Practices 8th edition 2014. Viewed 2 Sept 2014, from https://www.physiotherapy.asn.au/ DocumentsFolder/Resources_Private_Practice_Standards_for_physiotherapy_ practices_2011.pdf. 2. Jones AYM, et al. Physiother Theory Prac. 1992;8:39–47. 3. Campbell L, et al. Physiother Can. 2010;62:347–354. 4. Shaw KD, et al. Physiother Res Int. 2013;18:115–123. 5. New South Wales Health: Physiotherapy Labour Force Profile NSW – 2008. Viewed 2 Sept 2014, from http://www0.health.nsw.gov.au/pubs/2010/pdf/physiotherapy_ 08.pdf. 6. Ottensmeyer CA, et al. Physiother Can. 2012;64:178–187. 7. Peiris CL, et al. BMC Med. 2013;11:198. 8. Hakkenes S, et al. Disabil Rehabil. 2014;early online:1–7. 9. DiSotto-Monastero M, et al. Arch Phys Med Rehabil. 2012;93:2165–2169. 10. Berney S, et al. Physiother Res Int. 2002;7:14–22. 11. Ntoumenopoulos G, et al. Aust J Physiother. 1996;42:279–303. 12. Maidment ZL, et al. Aust Hlth Rev. 2014;38:265–270. 13. Brusco NK, et al. Physiother Theory Prac. 2006;22:291–307. 14. Peiris CL, et al. Arch Phys Med Rehabil. 2011;92:1490–1500. 15. Peiris CL, et al. J Physiother. 2012;58:261–268. 16. Keogh B. BMJ. 2013;346:f621. 17. Moodie L, et al. J Physiother. 2011;57:213–221. 18. Condessa RL, et al. J Physiother. 2013;59:101–107. 19. Flynn P. BMJ. 2013;346:f622. 20. Brusco NK, et al. Arch Phys Med Rehabil. 2014;95:94–116. 21. Brusco NK, et al. BMC Med. 2014;12:89. 22. Drach-Zahavy A, et al. J Adv Nurs. 2013;69:578–589.