Risk Management - Placement 2 - 2013

 Situation – Day 3 of my gerontology placement, my supervisor is asked by a stroke physiotherapist to assist her in a treatment session with a patient. She agrees and asks if I would be interested in helping out.

Task – Assist in the transfer of a fully dependent patient from wheelchair to plinth and conduct assessment.

Action – As the patient was fully dependent, my supervisor decided that an angel transfer needed to be used to move the patient from the wheelchair to the plinth. Having transferred a few patients in a similar manner and numerous practice sessions at university I felt I was capable of doing the transfer, but having not transferred a patient in this manner for several months  (and never one that was fully dependent) it was not in the patient’s or my own best interest that I attempt this transfer, even though I was the male of the group and keen to make a good start at the placement. I made my shortcomings known and offered to be the extra pair of hands for wheelchair placement and parts management.  I observed closely as my supervisor (half my size) and the other physio planned their transfer and smoothly lifted the patient to the plinth. Their communication was clear, hand and foot placement was well positioned and the patient was fully controlled at all times. I realized how unprepared I was to be a part of this transfer having not been involved for such a long period. My risk management strategies had allowed me to recognize my deficit in this area and instead of being over-confident I took a step back. I made myself useful but not a nuisance.

Result – The patient was transferred safely and efficiently. This increased the trust that the patient has with the physiotherapist team and ultimately improve long-term treatment outcome. I handled my role safely and kept the area around the physiotherapists clear of trip hazards so that they could focus on the patient. I kept my conversation and questions to a minimum and approached my supervisor at an appropriate time to clarify a few points.

Evaluation – Although I felt I wanted to do more, I made the right call in standing back and observing how two experienced physios did it. Being a visual learner I felt I gained a great deal in seeing the set-up, the communication and the smoothness of the transfer. I did notice, however, that I although I had read through my gerontology notes and mentally rehearsed my transfers and protective behaviours, I was unprepared for a maximal assist transfer.

Strategies – Read up on the various techniques used to transfer patients and know what the patient requirements are when choosing a transfer. Practice the transfer with able bodies (other students or a helpful physio) and plan strategies to improve. Know your limitations in all aspects of physiotherapy and don’t feel inadequate when stating the limit of your knowledge. Patient safety comes first and an injured physio isn’t very useful either. Organise all notes from past placements and place them onto the Sonia server for easy access and mental revision. Use the STARES system to review all transfers to improve their effectiveness.

Initial Entry – Placement 2 2013

 For my next placement I will be on a gerontology ward of a hospital. From the brief and facility notes it appears to be very similar to my second year placement. My expectations of the placement are that I will be will be assessing patient’s mobility status and prescribing mobility aids to rehabilitate them into their normal routines. My biggest concern is that this will be a repetitive type placement and I will not learn a great deal more. This is of course completely unfounded as I left that previous placement well below the level of a professional physiotherapist. This will be my opportunity to make amends and bring my skills to fruition in the area where I hope to specialize.

On my second year placement I was able to manage a large patient load and work semi-independently from my supervisor. I intend to use the first week to familiarize myself with the surroundings, the people and procedures and try to assist as many of the working physios as I can to get an understanding of the assessment style and treatment plans being conducted. From this base I will be able to contribute my abilities to the group.

I had also been a part of team meetings and involved in patient referrals and discharge. I felt I left that placement a little unsure of the procedures and what standards were acceptable to discharge a patient. I hope to improve on these points at this next placement. To do this I will read the patient notes more in-depth to understand where they came from and what aids they were previously using, and what they are expected to be discharged to with their current level of function. Talking this through with the patient and collaboratively goal setting is a skill that I have gained from my previous musculoskeletal outpatient setting and one that I will be incorporating here.

I feel I will have more confidence contributing in team meetings and having discussions about a patient with nursing staff and doctors and be aware that I play an important role in the patient’s management. I have been rehearsing the ISOBAR method of patient hand-over in preparation for this placement, as RITH and community physiotherapy are usually involved post-hospital admission. I am also hoping to present a professional development session to the physiotherapist group, as I would like to put my newly acquired research methods skills to the test. This will be advised by my supervisor as to what will be required.

I feel extremely positive about this placement and know I will make great gains into the field of gerontology physiotherapy and into my clinical reasoning abilities.

Final Entry - Placement 1 2013

I have just completed a five-week placement at a musculoskeletal outpatient clinic in the public sector. My main concern at the start of the placement was needing to present myself at a higher standard and be able to justify any of my ideas. This was, of course exactly the way it was, in a very positive way.

In the first week I found it hard to settle. The major difficulty was taking over the treatment of patients from other students and physiotherapists. There was a great deal of time spent on researching the patients’ conditions and going through their files to make sure nothing was missed. On reflection I found that I overdid this part but it was an important hurdle to overcome.

I found that as you progressed in the workplace and saw more patients, you began to trust other health professionals around you and were able to pick up where they left off. A quick read of a patients last session and a look at their initial assessment was enough to give you a good idea of the patient’s current condition and treatment plan. All the reviewing of anatomy and conditions and treatment algorithms were still easily referenced, but it was much quicker and more effective to quickly read the notes and then speak with the patient and re-confirm some points and goals. Three years of physiotherapy study to back me up, but much more refined and streamlined at the coalface. This was some of the key feedback from the supervising staff at my mid-semester review. Over-thinking the problem can create excessive time-wastage, complicated assessment plans and difficult to follow treatments.

It began to make more sense from this perspective about a patient-centred approach. In lectures it just sounded like the holistic way to treat, whereas in the work environment it is the better way to provide a service the client and in a timely manner.

Time management was always an issue and I found myself cutting the line pretty thin at times. Paperwork and other administrative tasks can pile up if not dealt with in a timely manner. Planning ahead and having a session well thought out and recorded can reduce the need to sit and remember what happened at the end of the day. Having a fellow colleague with administrative skills is also very handy and a good way to learn efficiency (just remember to fill the lolly jar regularly).

The notebook was handy but lasted a very short time. Scrawling on small scrap pieces of paper has never been my thing but it seems writing on the back of my hand as a quick reminder worked more effectively. A big handy file sitting on my desk also worked very well to keep track of admin tasks that needed to be accomplished.

I felt that the first placement of this final year has prepared me for being more efficient in the workplace and that these skills will be passed on to my study methods and other areas of my life in a conscious effort to reduce waste and provide the best outcome possible for the client. My fears about there being a greater expectation were true but it has helped to lift the standard of my work and prepare me for life after graduation.

Communication - Placement 1 - 2013

• Situation

Second week in a musculoskeletal outpatient clinic in the public sector. I had been handed a patient 3-months post Right Total Knee Reconstruction (TKR). The patient was a 65-year-old male with co-morbidities of diabetes (type II) and morbid obesity. I had been conducting a program of Grade III-IV knee mobilizations combined with hydrotherapy once a week. I had had mixed results with the patients knee ROM fluctuating between 75˚-85˚ flexion at the start of a session to achieving just over 90˚ by the end. Extension ROM started the session at -15˚ and ended at around 10˚. The patient had been informed that if he were unable to maintain 90˚ flexion he would need to undergo a manipulation under anesthesia (MUA). The patient had a follow-up appointment with the orthopedic team who measured his range between -20˚ extension and 70˚ flexion. An appointment was made for him to undergo an MUA and the patient rang through to the department to postpone further physio until after the operation. I returned the patient’s call to confirm and get the patient’s feelings on the result. The patient expressed that he thought he was making progress and was unsure about the operation. I gained his consent to discuss his treatment plan and outcome measures with the orthopedic team.  Consent was given and I consulted my supervisor prior to calling orthopedics.

• Task

Phone the orthopedic team to discuss the patient’s progress and find out more about the benefits and disadvantages of an MUA for patients post TKR. I was also to advocate for more time for physio treatment

• Action

After I had consulted the patient and my supervisor, I gathered the patient’s notes and rang through to the orthopedics department. The Consultant was not available and the registrar who had conducted the patient’s assessment was not available either. I left a brief message and returned to other work. A short time later I received a phone call from the Consultant to discuss the patient. I was caught a little unprepared as I had returned the notes to the filing cabinet and the Consultant had a definite tone of being short of time and slightly annoyed. I introduced myself as a physiotherapy student and stated that I was calling in regards to a patient booked for an MUA in a few weeks time (while I hastened my way to the filing cabinet – thank you cordless phone). I read my measurements to the surgeon and discussed the current treatment plan. The surgeon responded with “ There seems to be some discrepancy between my reges measurements and yours.” To which I responded that I was unsure about how they took their measurements (maybe with laser-angles or x-ray measures?) but that I was using a long-arm goniometer. The surgeon responded that his registrar had eyeballed the measurements. There was a long pause. The surgeon then broke the silence by asking if I thought my treatment was doing some good and that there was progress. I said I thought there was progress and the concern was that the patient had co-morbidities that reduced his ability to heal and being immobile in hospital for a few days would be counter-productive.

• Result

The result was that I was able to postpone the MUA and allow the patient more time to heal and gain the necessary knee ROM to effectively ambulate. I recorded the conversation in the patient notes and informed the patient.

• Evaluation

I felt my actions were beneficial to the health of the patient. I had in mind that I wanted to advocate against an MUA in favour of physio treatment and I had achieved that outcome. What I should have done better was had a clear list of points to discuss written out at my desk before I made the initial phone call and taken the time to read some research on MUA’s after TKR so as to sound more informed when discussing the case with an orthopedic consultant.

• Strategies

Plan conversations about cases with other health professionals.

Gather as much information about a case prior to consulting other health professionals involved.

Be prepared to back-up and defend your position if challenged.

Take your time when it is needed, don't be rushed and get flustered by another persons agenda. If it is important, take some time.