Clinicians' Commentary

A friend of yours has had her lung resection for cancer scheduled for the Friday afternoon before a long weekend. Will this surgery date have an impact on her outcome following surgery? A review of Campbell et al.'s study¹ suggests that the day of surgery may affect the provision of early intervention by physiotherapists in Canadian hospitals.

Campbell et al. present a picture of the provision of weekend physiotherapy (PT) care in university-affiliated tertiary-care hospitals (i.e., those with at least one intensive care unit) across Canada. Their cross-sectional, nationwide telephone survey was conducted between March and July 2008. Their interesting findings include the fact that all but one of the hospitals surveyed provided weekend PT services. There was a significant (88%) decrease in the PT services provided over the weekend; on average, 3.4 physiotherapists per physiotherapy assistant (PTA) per facility were on staff over weekends and statutory holidays. The researchers also found that, on average, each physiotherapist visited approximately 12 patients per day (range: 1–28 patient visits). The most common criteria for the provision of weekend PT services intervention were (a) risk of patient deterioration due to cardiorespiratory problems or early postoperative problems and (b) mobility assessment required for patient discharge over the weekend. In general, PT service provision tended to decrease slightly from Saturday to Sunday in terms of numbers of physiotherapists, numbers of PTAs, and hours worked.

On a positive note, the authors found that there has been an increase in PT services since Heck's 2001 study,² from 83% to 97% of facilities providing weekend PT in the Greater Toronto Area. There also seems to be a slight increase from previous studies in the number of physiotherapists working on Saturday.^2,3 It is difficult to determine whether this trend reflects changes across Canada.

Several factors influence whether weekend PT services are offered and the types of services provided, including the history of practice in a particular setting, physiotherapists' perspectives on the role of PT interventions in weekend coverage, lack of existing strong evidence in favour of weekend PT service, the specific location or region of the country in which the setting is located, and the financial resources available.

Most physiotherapists probably entered their PT programme with the idea that PT is a 9-to-5, 5-days-a-week career. But does this truly describe optimal physiotherapy practice? Probably not. In most cases, individuals have no control over when they are injured, get sick, undergo surgery, or experience deterioration in their condition. Many individuals need to be seen when they are acutely ill,⁴ which means that they may need PT assessment or intervention outside “standard” hours or on weekends. It is time to accept that there is a definite role for PT outside of the regular Monday-to-Friday business hours for some of our patients. Although more students in recent years may have a better understanding of the scope of the profession, they may not see this role modelled in the classroom and clinical settings. How do physiotherapists discuss weekend work with students? We are not helping either our future colleagues or the profession if we do not expose students to the complete scope of the profession. We cannot expect other members of the health care team to accept the importance of our role during “non-business” hours if we ourselves do not accept it first. Students entering the profession need to be made aware of this fact, to have it ingrained in their curriculum and in their clinical experience. Many schools and clinical sites have wisely included weekend shifts in their clinical placement experiences (i.e., if the supervising physiotherapist is working over a weekend, then the student will do the same).

Campbell et al. allude to the fact that there is a scarcity of supporting evidence for the effectiveness of weekend PT services.¹ They comment on two studies that have shown a significant decrease in the length of stay (LOS) where weekend PT services were provided to patients following a stroke⁵ and to those who underwent total hip or knee arthroplasty.⁶ A systematic review examining the effects of additional PT outside of regular work hours found few rigorous studies.⁷ The authors did suggest that in one study,⁸ in a critical-care setting with overnight PT coverage, there was a decrease in LOS and reduced pulmonary complications.

Since this systematic review,⁷ other studies have been published that need to be considered when examining the evidence related to weekend and evening provision of PT services. Early PT intervention for patients with femur fractures has been shown to decrease hospital LOS: Pendleton et al. found that patients seen by a physiotherapist more than 1 day after surgery for femur fractures stayed an average of 1 day longer than those who received PT within the first postoperative day.⁹

A recent Cochrane systematic review by Rotter et al. looked at the effects of clinical pathways on professional practice, patient outcomes, LOS, and hospital costs in in-patient settings.¹⁰ For the purpose of the review, a clinical pathway was defined as a structured multidisciplinary care plan that details essential steps in the care of patients with a specific clinical problem. A total of 27 studies involving 11,398 participants met the eligibility and quality criteria for inclusion. There was no evidence of differences in readmission to hospital or in-hospital mortality. LOS was the most commonly employed outcome measure; most studies reported significant reductions. Overall, the authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively affecting LOS or hospital costs. Certainly, over the last decade the use of clinical pathways in facilities with certain patient populations has resulted in changes from 5-days-a-week to 7-days-a-week coverage by physiotherapists. There may not be a significant change in LOS for many patients with complex injuries or illnesses, as there are many other factors that influence this outcome. Brusco has described the use of LOS as a primary outcome measure as a two-edged sword;⁷ there can be confounding effects on patient LOS, and the provision of additional PT care is just one component of a multifactorial equation that affects LOS. For example, LOS in an ICU setting may be affected by bed availability, staffing issues, and other factors affecting patients' conditions on which physiotherapy may have no influence. Thus, we need to expand our search to include other outcome measures that are affected by our care.

Preventing admissions to hospital is also a significant goal for health care in Canada. The few studies of PT services in the emergency department have suggested that PT can help prevent the need for admission, reduce pain, and improve patient satisfaction.^11,12 This setting requires 7-days-a-week service in order to provide optimal care and potentially decrease costs to the system.

Evidence alone is not always enough to influence administrators or policy makers. Landry has suggested that political decision making is not inherently a rational process;¹³ policies are not always driven by data and research findings. Rather, he suggests, we need to “tell them a story”—for example, we need to tell a policy maker that the lack of PT care during weekends and evenings could have a direct impact on the care that his or her own family members would receive in a hospital setting. Advocating with administrators and policy makers will help to secure funding for these services.

In many cases, limited financial resources represent one of the most significant barriers to weekend and evening PT service. Cost-effective models of PT weekend service need to be integral to any plan. McAuley et al. found that approximately 30% of patients seen on weekends could have had their care provided by a physiotherapy assistant.³ Developing sound criteria and ensuring that the appropriate member of the PT weekend team provides the right treatment will help to contain costs for this service. Preventing admissions through the emergency department will also aid in decreasing costs to the hospital during weekends.

The Canada Health Act states that “continued access to quality health care without financial or other barriers will be critical to maintaining and improving the health and well-being of Canadians.”^14(p.1) It also states that the primary objective of Canadian health care policy is “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”^14(p.5) Thus, a patient who has his surgery on Friday has every right to receive equivalent care to his roommate whose surgery took place on Monday.

Decter and Grosso suggest that health care services, like real estate, have a lot to do with “location, location, location.”¹⁵ Canadians may have a “universal health care system, in which every resident and citizen is entitled to medicare, but we do not have a system in which the services and products to which we are entitled are the same from coast to coast.”^15(p.xxi) This was certainly evident in Campbell et al.'s study,¹ which found that weekend PT services differed across the country.

What can we do to ensure that our friend having lung surgery on the Friday before a long weekend receives the care she needs to ensure a good outcome? First, we need to be strong advocates with fellow physiotherapists, physiotherapy students, and colleagues in hospitals and with our politicians. It is important not only to collect the evidence but also to tell the stories of how a friend is affected by having limited or no physiotherapy intervention on the weekend.

How often have you heard, “That's not how we do it here”? One of the foundations for the PT Vision 2020 is “leadership through accountability,” which means being responsible for individual or organizational actions and decisions and accepting their consequences.¹⁶ Being reflective practitioners, both at the individual and at the professional levels, is key to advancing as physiotherapists and as a profession. We should not be so mired in the past that we cannot look to the future and move the profession forward with the goal of providing optimal and safe patient care.

The Canadian Physiotherapy Association's Position Statement on Access to Physiotherapy Services (February 2006) states that “all Canadians deserve timely and reliable access to physiotherapy services regardless of venue.”¹⁷ Is this truly happening for individuals who are in hospital over the weekend?