Advocacy

Basic Medical Screening is a Necessity for ALL Patients

I was recently engaged in a Twitter discussion regarding the necessity of taking “vital” signs in our patients.   I want to highlight several reasons why we should be taking, and monitoring basic vitals (HR, BP) in each of our patients.

1. It has been developed as a Standard of Care.  Taking vital signs is an essential component of every new patient exam as documented in the Guide to Physical Therapist Practice. From a legal standpoint, the Guide establishes a standard of care for all physical therapists and physical therapist assistants, and in any case of incident, if you can not demonstrate that you were following a Standard of Care, you increase your legal liability.  The APTA has provided several resources on this topic here.

2. Assessing vitals at baseline only, does not give us enough information.  I suspect we need to screen vitals in each of our patients, on each of their visits.  This can be performed easily by a PT or PTA, and the values can be used in determining a progression of care, or necessity of referral.  The APTA has provided in its resources to Physical Therapists: Heart-Health Screenings, as published by the AHA.   The AHA’s recommendations for BP are as follows:  If an individual is 20 years or older, blood pressure should be assessed at every healthcare visit (notice the terminology;  not “medical” visit) or at least every 2 years if blood pressure is less than 120/80mmHg.   Again, when we look at Standard of Care, for legal defensibility, the APTA has provided this resource for Physical Therapists.  We better take note.

3. Patients who seek are care in outpatient facilities, may have underlying pathology .     A 4-year retrospective analysis of 14,970 participants, found that younger participants received a diagnosis of hypertension slower than older counter-parts.  Early detection of heart-disease is key in it’s management and simply suspecting the patient does not have underlying pathology, when they may, is very poor professional practice.   Just remember: we have no way for determining if a patient has high blood pressure, without truly measuring it.  Don’t “suspect” a patient has “good” vitals, without truly checking.

4. To be recognized as Direct Access providers, we must accept responsibility for that individuals well-being.  As we move towards a practice of increased autonomy, we also move towards a practice of increased liability.  We can no longer fall back upon the idea, “the physician should have caught that…”.   We need to accept responsibility for our patients health.  At a minimum, we are responsible for  screening for any potential pathology that may necessitate a referral.

 

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13 replies »

  1. I disagree . I haven’t time to give my full reasons but suffice to say for most general outpatients work i feel that further emphasising biomedical pathology when the overwhelming majority of patients overmedicalsied benign pain syndromes may send people down the wrong path . sure checking pulses for example are easy to do and having an awareness of red flag issues and when a person simply does not feel well should prompt further referral. I have had a few patients this year who are either not around or now have Ca diagnosis . There is no physio exam or basic testing that would have picked any of this up and none of the questions i am supposed to ask would have either . I already have screeds of useless questions i am supposed to ask for simple problems in the clinic . Make good links with GP’s have an awareness of the medical issues (good idea to get ward experience and to have seen ill people for example) but being responsible and testing takes us further down the biomedical line . I think its much more relevant to have more awareness of the demographics of benign pain and develop communication /counselling skills myself !

  2. Thanks for your views Ian. I am not sure where you practice, but in the United States:

    1. Medical Screening is a Standard of Care. Meaning it is professionally recommended by our association (increasing our liability if we ignore this and something does happen)
    2. PTs can treat patients without a medical referral (state permitting). You may be a point of entry for the patient, making screening ever more important.
    3. In the United States, we do not have the legal ability to diagnose CA, or other major medical pathology (this would be practicing medicine without a license). We do have the legal obligation to screen for medical pathology that is outside our realm of care though.

    Do you test reflexes, Ian?

  3. Joe,

    Screening is important in everything we do as physical therapist; however, part of screening is not simply taking VS. As an out-patient PT, I look at the patient, listen to his or her complaints, take a look at the subjective intake which includes screening question re: risk factors and familial history, and complete an objective examination, If, at any point of any of that, my index of suspicion is raised, then yes, absolutely VS that include HR, BP, O2, and ABI are taken as indicated. Do you take PT/INR, HGB, HCT, sub-max VO2, etc too? Where do you draw the line on that?
    But Joe, what of this situation: Active 25 year-old male, acute knee pain, no personal hx or familial hx of CV risk factors, no complaints of temperature changes, nothing suggestive of compartment syndromes or vascular integrity loss or this situation: 35 year-old active female triathlete with wrist pain after a sprint-tri? What is the clincial utility in measuring VS each and every time for those patients, even if you see each patient 1x/week or less? Why are you looking for a zebra among horses? Do you think defensive practice in the sense you are advocating is reasonable? How’d that work for physicians and MRIs….? If so, before you place your hands on each and every patient, each and every time you see the patient, you do check VS, re-check all your ligamentous and stress tests to each region of complaint, carry out special tests and neurological exam? Or, if the patient reports a change in status, do you re-assess then? Where do we draw the line on this?
    I get the importance of VS and screening; however, I don’t agree with the assertion to carry these out EVERY time we encounter a patient in the out-patient setting that does not have risk factors, suspicious complaints, negative change in status, etc.

    • Thanks for the response Austin. In neither situation you provided, can I determine if those individuals have hypertension or abnormal heart rates. In the example of the male, you only support my notion of the article I linked in the post above. Please correct me if I am wrong in my analysis.

      I am curious how you developed your model of screening to screen (pre-screen)? It appears you first look for risk factors prior to screening basic vitals (you screen for CV risk factors, temperature changes, compartment syndrome and vascular integrity) and then determine if you will check someone vitals upon this? Did you learn this in school or your fellowship training—just curious where this was taught?

      The practice of basic vital screening can take 30 seconds. It is very reasonable. It is very necessary. And it is advocated within our profession. I am not looking for zebras; I am looking for very basic variables that could predict more serious medical complications.

      • Hi Joe,

        Please understand I’m not advocationg for NEVER checking VS but rather disagreeing with the blanket statement and absolutism of the notion of ALWAYS checking VS. Agreed? Where my disagreement lies is the assumption that, in an out-patient setting, in a patient without any CV complaints/previous history/family history/(-) subjective intake/(-) objective/otherwise no index of suspicion whatsoever, VS MUST be checked every visit. And, there’s a lot more to above: is the patient obese, asthma, sedentary, tobacco use, smoker (of anything), admits to use of illicit drugs, generally appears ashen or ill….in those cases, and there are many more clinical scenarios, then yes, VS are taken on eval and with ANY intervention. But in my clinical practice, not EVERY patient EVERY time. What is the point of continually checking VS EVERY visit for otherwise healthy patients with MSK complaints? What are you looking for, other than to practice defensively? I’d argue you are looking for zebras in these cases b/c what exactly is changing in these patients in the time between visits?
        Do you check Sharp-Purser with non-traumatic neck pain every time you touch the patient’s neck? That test takes less than 30 seconds too, but I’d argue the clinical utility and appropriateness for that test in that case (that is, re-testing) is just not there.
        Screening = index of suspicion + clinical reasoning + critical thinking. VS screening is reasonable, yes, but not necessary EVERY TIME with EVERY patient, IMO.

        Thanks for dialogue and insights, both here and on Twitter, and the opportunity to air my perspective!

        Respectfully,
        Austin Sheldon PT, DPT

  4. Excellent post Joe. Taking vitals at every examination has been a practice of mine for a while, and I’ve recently started doing it more often and am beginning to do regularly at every visit. I honestly hadn’t though of the standard of care/liability issue, but that’s an excellent point. I look at it from the point of view that I’m the main healthcare professional that is seeing that particular patient the MOST often, so I owe it to track vitals incase anything is present. There may be an underlying condition that arises that if we miss, may not be discovered until their next MD visit, whenever that may be.

    I’ve started looking at it like I look at intervention selection: pros vs cons/risks vs reward. Pros of checking vital sign: Doesn’t take much time at all, it can only benefit the patient, as well as the liability issue/standard of care addressed above. Cons of checking vitals: I got nothing.

    If we’re going to be direct access practitioners, there’s certain things that we should be checking and responsible for.

  5. Good job on this Joe and worth bringing up. I have enjoyed reading the comments from others with good points for and against.

    Personally, I will admit I need to do a better job at taking vitals during initial evaluations and just as others mentioned above, I typically do not do it unless the subjective history / medical history entices me to. Working a rural environment, I think ~50% of my patients have DM and HTN. We see lots of unhealthy patients unfortunately…but these are the ones you want to help catch. They check up with their PCP every 6 months or so, but I do see myself as an extender of PCP to an extent…for their MSK complaints but to refer out if outside my scope. It has been many times that I’ve referred back due to vitals.

    I have always utilized vitals as a risk profile for determining if symptoms are arising from mechanical vs non-mechanical origin, especially neck/head pain. It assists in differential diagnosis and gives me an overall picture of the condition. I always ask how long someone has been diagnosed with HTN and how well it is managed with medication (or diet/exercise).

    To answer some of the other comments, I do not know where to draw the line in regards to taking vitals, but I will say personally I would start with blood pressure and if a concern, go on to RR, HR, etc.

    H

  6. Great post Joe, and great discussion – a discussion which gets more and more important as the profession, and medical science, develop. With greater autonomy comes greater responsibility. Reliance on GP screening is an absolutely out-dated construct. Screening can be so quick and so informative. Here’s something we wrote to get the profession engaged in the same conversation:

    https://drive.google.com/file/d/0B9M5BmP2G474TC15Vjdvb1BRcWs/edit?usp=sharing

    Great work

    Roger

    • Roger,

      Excellent paper. Thank you for posting the article here. All cases presented within your paper are all cases in which I personally would have taken VS d/t patient complaints, area of susipicion, referral source, and PMH.
      I’m curious on your thoughts as to the ALWAYS, ALL THE TIME, with EVERY patient being advocated here though? Reasonable AND necessary? No matter the dx, the area of complaint, and no matter previous measurements? Where do you stand on this?

      Thank you,
      Austin Sheldon PT, DPT

  7. Hi Austin, thanks for your comments. You have a great point and I think this is the sticking point. UK guidance seems to be a little different from the USA. I’m a great advocate of a reasoned approach, and if there are suggestions early on in the history which might generate a ‘red flag’ hypothesis, then go for it. Our argument is that there are probably more red flags which present as MSK than we think, early non-ischemic signs of stroke are a good example, presenting as headache and neck pain in young “healthy” people. The idea of screening for all, all the time seems to be based on a different premise: that general health signs might be a good thing to monitor in response to PT interventions. I think this should be made clear, in that it is a different argument from differential diagnosis. The two notions overlap to a degree, but I think we should be clear what we are talking about when we have these discussions.

    I don’t think we can establish a “right” or “wrong” way at this point, but having discussions like this can only serve to help.

    Cheers
    Roger

  8. I have been working with a 78-yr old female with a history of controlled HTN with no significant changes in medications in the last 5 years. She has returned home after 4 months of short-term rehab after a severe episode of cellulitis and deconditioning – no recent cardiac issues. Last Monday, she presented without complaint of palpitations, chest pain, shortness of breath, etc – her HR was approx. 150 BPM. It was my 7th visit with her (the 13th with the agency). This week, her HR became irregular with a pulse between 120 and 140 – again, without additional symptoms. In the last 12 days, she has been to the cardiologist 3 times, and her meds have been changed twice.

    As for the time spent – it is something that becomes part of the ritual. I explain to my patients on the first visit what they can expect in each subsequent visit; they don’t mind my taking their BP/HR real quick while we converse about their progress, how they are moving, etc. This can be done easily during conversation – after all, I am only assessing whether they are in a range that is typical for them +/- 10 to 15 with BP, +/- 8 to 10 with HR. If everything checks out, I move on. If I have any doubts I slow down and double check.

    If you are, however, confident that every patient who walks into your clinic is an A+ historian and that their ‘presentation’ on any given day is necessarily representative of their condition, I don’t know what to tell you. Personally, I rarely took VS when I worked in the outpatient setting, but my eyes have since been opened and I would never put my patient’s lives (or my own license) at risk in the same (naive) way as I once did.

    (places 2 pennies in the jar, steps away from soap box)

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