Physio On-Call - The 3D Method: Prioritising your week-end list like a pro

by Josh Tipple

Working on the weekend can be daunting for the most experienced of physiotherapists. As an autonomous professional you will be expected to be able to prioritise a workload on a weekend or when a staff member is down. These can be difficult questions, and people can sometimes under/over think the answers. So here is an easy way to split the question into constituent parts.

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When you think about prioritisation questions, think in 3D. Danger. Discharge. Delegation. In that order.

These are your patients who if they are not treated soon will deteriorate. They will generally comprise of your patients who have predominantly respiratory issues that are unmanageable by the nursing staff, these patients will tend to deteriorate very quickly without further input.

Remember you are in a hospital and bed pressures are real. Any panel will look for your ability to appropriately identify discharge patients and show that you understand that it imperative that these patients are not waiting for physiotherapy assessment prior to discharge. Think of the wider NHS climate and how this has a bearing on how physiotherapy help hospitals.

You are coming into a position where you will have assistants and other staff members involved, and you should be able to use them appropriately. Those patients who do not need the close attention or are stable can be delegated to assistants, and these should be available in most teams. Remember that anyone with respiratory symptoms and those that have complex needs may not be appropriate for delegation (shows you understand scope of practice).

For instance, in an interview a question may ask:

You are on a weekend, you have the following patients:

• A patient who requires mobility practice, there have been no worries over their balance since they have been in, the therapist would like the mobility to be maintained over the weekend.
• A new patient who has just had a traumatic THR and they haven’t been moved from bed yet, surgeon reports that the surgery has a been success and no concerns regarding rehab. Nurses are reluctant to move as the patient was not very mobile prior to surgery.
• New patient that has been admitted with COPD and new pneumonia, they are not desaturating, but they are productive. On CXR, they have a left lower lobe pneumonia, on auscultation they are wheezy on expiration, and the patient is visibly distressed in breathing.
• An patient with an elective TKR who has had 3 days of exercise, has been compliant with his exercise regime and has continued with her exercises in bed. The patient has been getting out of bed with therapists and has done everything but the stairs.

In reply, you could argue:

• New patient with COPD and pneumonia DANGER – patient is productive and that means that chest physiotherapy may be appropriate in this instance, wheezy on expiration means that they are likely to have secretions. Therefore, the patient has respiratory symptoms that might respond to physiotherapy input, if we do no treat them, the patient may deteriorate from sputum retention, and the further complications this would cause (chest infection etc…)
• New patient with traumatic THR and haven’t been moved from bed yet DANGER/DISCHARGE – This patient is at risk of deteriorating very quickly should they not mobilise early, they are more than likely elderly and had a long lie when they initially fell. The patient would benefit from a physiotherapy review as soon as possible, if they stay in bed too long they are more prone to chest infections etc…, also they outcomes are generally worse for those patients who do not mobilise day one after their surgery, leading to longer length of stay.
• Patient with TKR, done everything but stairs. DISCHARGE – This patient should have a plan in place to ensure that their rehab goals are met, patients with routine surgical procedures should be on a programme of exercises to ensure that the gains they have already experienced would continue when discharged from the hospital. In practice no discharge will be as straight-forwards as the plan suggests, however in an interview scenario, they are just looking at it theoretically.
• Patient who requires mobility practice to be maintained DELEGATION – this could be a job for the therapy assistants, but be careful over who you are assessing and who you are trusting with the assessment, you must consider the skills of the rehabilitation assistants and their workload. However, this is not a job that requires high level clinical reasoning, patients who are steady and have been risk assessed can be passed on to the rehabilitation assistants.

Here’s a table that might help you with categorising (you can save the picture if you like):

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Acute/Respiratory interview preparation pack