The U.S. Preventive Services Task Force recommends screening for high blood pressure in adults 18 years of age and older. Both the American Physical Therapy Association and American Occupational Therapy Association websites reveal the importance of monitoring vitals. Logic dictates that anyone who provides interventions which impacts vitals should take baseline measurements and monitor the impact of physical interventions.
In consideration of the upcoming change to the Patient-Driven Payment Model, the patient with a primary cardiac diagnosis or cardiovascular related comorbidities is someone we’re likely to see in short-term rehab. Therefore, clinical guidelines and monitoring should be part of the physical and occupational therapist’s common practice.
It takes leadership to change a culture
At Centrex Rehab, we believe clinical tips are only part of the path to success. Frankly, we expect that our rehab professionals know what to do and what is expected when it comes to vitals monitoring. Success is based on whether leadership is willing to set expectations AND therapists are willing to be accountable — instead of shrugging off monitoring vitals because of whatever the reason may be.
As part of the leadership team in a post-acute care organization, we see physicians and nurse practitioners order tests and make adjustments based on reported vitals monitoring.
Survey reports inadequate vitals monitoring
The July 8, 2019 edition of PT in Motion reported on the survey titled: “Survey of PTs Reveals Significantly Inadequate Rates of BP and HR Measurement.” In our opinion, though this survey was of outpatient physical therapists, we need to insure vitals monitoring occurs throughout the continuum of care. In an effort to improve consistency, the Cardiovascular and Pulmonary Section of the APTA has had a social media campaign of #VitalsAreVital and has several educational videos on the topic. Some key survey results include:
- Low percentage of consistent blood pressure (BP) and pulse rate (PR) monitoring of patients with cardiovascular disease
- Most commonly reported barriers to BP and PR screening were lack of time (37%) and “lack of perceived importance” (36%)
- Respondents with higher percentages of patients with or at risk for cardiovascular disease (CVD) tended to perform the screenings more often, as did PTs who had completed a residency or fellowship training program and clinicians with more than 20 years of experience
Meaningful clinical tips
We’d like to share a few clinical tips and resources that may be helpful in getting more therapists to monitor vitals:
- Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs (4th and 5th editions) – The American Association of Cardiovascular and Pulmonary Rehabilitation textbooks offer a wealth of clinical information and propose a model of cardiac care in the post-acute arena with a strong continuum of care between acute and outpatient cardiac rehabilitation. There is also information on risk stratification of patients so they receive appropriately challenging interventions.
- OMNI Rate of Perceived Exertion (RPE) – This tool is a valid and researched tool for self-reported exertion directly correlated to the BORG RPE without the proprietary associated costs.
- Tanaka Age Related Target Heart Rate Maximum – Setting this variable helps to maintain a safe but effective heart (pulse) rate when providing various interventions taxing the cardiovascular system. The “Tanaka” model compensates for the error associated with the 220 – age formula, which underestimates the exercising heart rate for older adults and overestimates for the younger person.
- Staying Current – Advancement of medical interventions such as the left ventricular assist device (LVAD) helps create partnerships with acute care providers and LVAD suppliers so we better understand this technology and serve our patient population.
As we all know, data is only as good as the person and collection/interpretation process.
The following table indicates reasons for common errors with measuring blood pressure (references for this include: Pickering, et. al. in “Circulation; O’Brien et. al. in the Journal of Hypertension; and Ferese from Cardiopulmonary Physical Therapy Journal).
|Patient Conditions||Blood pressure measurements can appear higher:|
|A full bladder||by 10-15 mmHg|
|An unsupported back||by 5-10 mmHg|
|Unsupported feet||by 5-10 mmHg|
|Crossed Legs||by 2-8 mmHg|
|Cuff over clothing||by 10-40 mmHg|
|Unsupported arm||by 10 mmHg|
|A conversation or is talking||by 10-15 mmHg|
Though more clinical tips could be included, we believe the tips included here are the most “vital” ones. We’d love to hear yours as well—so please feel free to share them in a comment.
Kristy Wikum, MS, CCC-SLP has more than 25 years of management experience as CEO/ President of Centrex Rehab and former executive director at Augustana Therapy Services. Clinical Physical Therapy Specialist Matthew Mesibov, PT, GCS is responsible for providing clinical support to the physical therapists and physical therapy assistants at Centrex Rehab.