I recently treated a 50 year old lady who had bilateral total knee replacements and was discharged to home within a week with only 65 degrees active flexion in both her knees. I spoke to her surgeon regarding her progression post-surgery hoping to prolong her stay in hospital in order to gain a bit more flexion in both her knees and that I would like to keep her for a few more days as she would definitely benefit from further rehab at hospital. However, the surgeon said to me that the ranges in both her knees were important, but it was also important to assess her ability to go up and down the stairs with crutches. Being a physio student, I did not really know how to respond to the surgeon in a better way as I thought I have made myself clear that her current main problem was reduced active range in both her knees. I then approached my supervisor and I was glad that my supervisor stood by my side and agreed that it would be difficult for the patient to continue to gain more range if she was discharged with 65 degrees active flexion in her knees (most surgeons aim for at least 90 degrees active flexion post-TKR at D/C). My supervisor took measurements again on the next day and her knee ranges were still the same. He then spoke to the surgeon and stated his concerns however the surgeon did not feel that it was a big problem and insisted to discharge the patient. My supervisor then told me that we had at least communicated with the surgeon and if that was what the surgeon wanted, we had to follow the plan. He then told me that it would be important to record in the medical notes that “PT spoken to surgeon re: patient’s reduced ROM and surgeon happy to D/C” for medico-legal purposes. I learnt that PT point of view can be easily neglected when discharging a patient and there is not much we can do when the decision is made. I however then arranged an outpatient physio appointment for the patient to receive further physio as soon as possible, hopefully to help improve her knees functions. I also educated the patient thoroughly to make sure that she understands her current main problems and that she needed to work harder without PT supervision and a CPM machine at home.
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I have learnt this year that patient discharge is not always straight forward and requires multidisciplinary understanding and communication. Views between health professionals will vary, and the doctors/surgeons are usually the people who push patiants to be discharged as soon as they are medically stable. Sometimes even though a patient may not be as functional as us PTs would like, they are able to go home with some OT equipment and other care pakages, and a referal for outpatient PT asap and a well explained HEP ect. As long as the pt is safe and all of the above are well set up, a patient should be discharged. The hospital is an acute setting and reducing costs, when able is important to runing an efficient health care system.
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