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ORIGINAL STUDIES

The Utilization of Vital Signs During Physical Therapy Evaluation and Intervention After Elective Total Joint Replacement: A Mixed-Methods Pilot Study

Crick, James P. Jr; Smith, Nancy

Author Information
Journal of Acute Care Physical Therapy: January 2021 - Volume 12 - Issue 1 - p 2-11
doi: 10.1097/JAT.0000000000000137
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Abstract

Commonly, physical therapists (PTs) evaluate and both PTs and physical therapist assistants (PTAs) treat patients after orthopedic surgery as a part of routine postsurgical management. Early mobilization following joint arthroplasty has been demonstrated to reduce hospital length of stay, reduce overall use of opioid medication, and decrease risk for postoperative complications.1–3 The most recent estimate of incidence of joint replacement cites that greater than 706 000 elective total knee arthroplasty (TKA) and 465 000 total hip arthroplasty (THA) surgical procedures are conducted yearly in the United States.4 With this incidence, it is also well established that preexisting cardiac and pulmonary disease, in addition to advanced age, is associated with increased morbidity and mortality after total joint arthroplasty.5,6 Furthermore, the potential for acute complications associated with surgery in the older adult population is well established. In patients following TKA, Belmont et al7 demonstrated a 1.6% to 2.1% major systemic complication rate among 15 321 patients. Zarich et al8 demonstrated that increasing age and known coronary artery disease are associated with increasing complications in diabetic patients following peripheral vascular surgery. Further, Berry et al9 concluded that known cardiac, pulmonary, or renal disease is a greater risk factor than age for in-hospital complications in patients undergoing elective abdominal aortic reconstructive surgery. In all of these postsurgical and older adult patients, alterations in vital signs (VS) may be a clinical harbinger of early complications.10–13

Specific to physical therapy in the immediate postoperative period, dynamic changes in hemodynamic status are valuable to assess to ensure safe mobility intervention. Complications could particularly include syncope from hypovolemia or effects of anesthesia, or venous thromboembolism. Thus, assessment of VS provides a window for the clinician to observe the real-time response of a patient to the effect of upright positioning and mobilization shortly after surgery.

Given the potential for complications after orthopedic surgery and current evidence suggesting increased risk for patients who are elderly or with concomitant cardiac or pulmonary disease, close clinical monitoring using VS is recommended.10–13 Because of this recommendation, one consideration is how physical therapy practitioners employ objective measures such as heart rate (HR), blood pressure (BP), and respiratory rate (RR) as valuable tools for clinical decision-making, especially in patients with known cardiac or pulmonary disease. However, current literature suggests that routine utilization of VS occurs less frequently than is recommended,14–18 although a multitude of professional organizations state that routine utilization of VS in clinical decision-making for patients at rest and with activity should be performed.10–13

Literature over the past several years in physical therapy has demonstrated that PTs do not assess VS as frequently as they should. A recent survey study by Severin et al14 revealed that only 14.8% of outpatient PTs assess HR and BP on initial examination for new patients. Self-reported facilitators of this practice included the perceived importance of this assessment while detractors of taking HR and BP included lack of time and lack of perceived importance. Frese et al15 surveyed 387 clinical instructors across various practice settings to determine their self-reported utilization of HR and BP in clinical practice. Although the majority of respondents agreed that analysis of HR and BP should be routinely used in PT screening, 38% and 43% reported that they never assessed HR and BP, respectively, on new patients during the previous 1 week. Similarly, Harris et al16 surveyed 73 practicing PTs in various practice settings regarding their measurement of VS. They concluded that VS were infrequently measured in spite of a general consensus that VS should be assessed as part of routine clinical practice. Further, the authors suggest that practice-setting discrepancies exist with respect to monitoring of VS, with PTs in home health, acute care, and nursing homes assessing VS more frequently. Specific to hospital-based practice, Scherer et al17 analyzed 323 patient care interactions in acutely hospitalized patients to determine the frequency that PTs monitored VS and how this monitoring influenced intervention decisions. Across all interactions reviewed, a mean of 56.3% of patients had HR and BP measured and recorded by the therapist. However, of therapy sessions that included gait training, 66% did not have HR or BP assessed. They suggest that therapists in this study inconsistently used VS in clinical decision-making. This observation is in accord with the findings of Millar et al,18 who observed that PTs were not regularly using HR and BP measurements in evaluations, follow-up appointments, and discharges, including both with activity and at rest. The lack of use of VS in all of these studies is concerning due to the fact that some cardiovascular issues are revealed only with activity even when resting VS are normal.19

While evidence does exist about the use or nonuse of VS in PT practice, 3 gaps exist in the literature. First, the majority of the available evidence for the utilization of VS in PT practice relies on survey report that is subject to potential recall bias. Furthermore, few studies rely on chart review to establish the frequency of VS assessment in the literature. A second gap in the literature pertains to how often VS are taken in the acute care setting with patients who are immediately postoperative from elective total joint replacement. The final gap in the literature relates to examining acute care physical therapy providers' attitudes and inclinations that might explain the use or absence of use of VS as an assessment tool for clinical practice. Therefore, the purpose of the current study was to (1) determine the frequency of VS measurement via retrospective chart review of completed physical therapy sessions, (2) describe attitudes, inclinations, and factors that may influence the measurement of VS by acute care PTs and PTAs on a postoperative orthopedic surgery floor in patients following elective total joint replacement, and (3) provide an explanatory mechanism for the use or nonuse of VS in orthopedic acute care practice.

METHODS

This study was a sequential, mixed-methods observational study with 2 phases. The first phase (phase 1) was quantitative and included primarily chart review, followed by a qualitative phase including interviews with physical therapy practitioners (Phase 2).

Ethics

Before commencing the study, the study protocol was approved by the Naples Community Hospital Institutional Review Board on May 9, 2019. Informed consent was waived for phase 1 of the study, as data collected were deidentified, and not traceable back to the patient file once obtained. Informed consent was obtained for all participants in phase 2.

Phase 1

The study was conducted in a 350-bed community teaching hospital. From chart review, 50 initial evaluations were selected for retrospective evaluation using a sequential purposive sampling method. Patient charts were selected from those patients who had elective TKA or THA procedures during the period of October 1, 2018, until October 13, 2018, at the primary study location. For patient charts to be included in the study, patients had to have an elective TKA or THA, been evaluated by a PT on the day of surgery or the next day following surgery, a continuous stay on the orthopedic surgical floor, an uncomplicated postoperative course (ie, did not require critical care admission nor additional medical specialists' recommendations during this admission), greater than 2 therapy visits during their stay, and a total admission length of stay of less than 4 days. Exclusion criteria for patient charts included patients who had a medically complicated admission, nonelective orthopedic surgical procedures, TKA/THA revision procedures, and bilateral TKA and unicompartmental joint replacement procedures.

Once 50 patient charts had been identified, relevant deidentified data were extracted from the medical charts including type of surgery, patient age and sex, cardiac and/or pulmonary medical history, and which VS, if any, were assessed and documented. Although across the medical landscape VS has routinely referred to HR, BP, RR, and temperature, we focused our results on HR, BP, and RR to align with previous physical therapy literature14,15,18 and due to the relevance to postsurgical physical therapy practice. A random number generator was used to select 20 of the 50 charts to glean data on all subsequent follow-up visits during the same inpatient stay. Only 20 charts were followed throughout the course of their stay for 2 reasons. First, identifying and extracting the data from all of the charts were quite cumbersome. Second, the power requirement to determine a moderate correlation required a total of 29 treatment sessions to be reviewed to determine an r value of 0.50 when α set at 0.05 and β at 0.2. This power requirement was satisfied from the total number of visits examined during chart review. Thus, 50 total initial evaluations were included and 20 of those 50 had all of their subsequent physical therapy encounters also included, for a total of 134 visits.

Phase 2

Once all chart data had been collected, the second portion of the study commenced. Participants for the second part of the study were purposefully selected from PTs and PTAs who were currently practicing at the study location and who had been directly involved in evaluation and/or treatment of the study population. The therapists were selected based upon their involvement in patient care, namely who had treated the greatest number of study patients. From this purposeful sampling, 2 PTs and 1 PTA were selected. Once therapy providers were selected based upon their involvement in patient care, a request to participate in the interview portion of the study was sent via electronic mail to the therapists. The purpose of this portion of the study was to describe attitudes, inclinations, and factors that may have influenced the measurement of VS in this particular practice setting. All 3 agreed to participate and signed an informed consent. Interviews were conducted with the primary investigator in a private location and recorded. A semistructured template was used to facilitate the interview process (Appendix A). Following completion of all interviews, the qualitative data were transcribed with all identifiers removed.

Data Analysis

For phase 1 of the study, descriptive statistics were calculated to describe the patient characteristics including age and sex, number of comorbidities, type of surgery performed, and total number of evaluation/treatment sessions. Comorbidities were coded as the total number of comorbid conditions, which were present for each individual patient. Cardiac and pulmonary comorbidities included in this number were any history of hypertension, coronary artery disease, myocardial infarction, congestive heart failure, cardiac arrhythmia, sick sinus syndrome, cardiomyopathy of any type, cerebrovascular accident, hyperlipidemia, chronic obstructive pulmonary disease, interstitial lung disease, bronchiectasis, pulmonary hypertension, pulmonary embolism, and asthma. Frequency measurements were then conducted to determine the incidence of VS assessment and documentation across the studied period. A point-biserial correlation was used to assess any relationship between the binary nominal variable (VS assessed yes/no) and the interval variable of total number of cardiac and pulmonary comorbidities.

For phase 2 of the study, qualitative analysis of the interview data was conducted via an inductive methodology by initially coding data into small representative codes. These codes were then collapsed into axial codes, and themes were derived from the axial codes. Major themes were identified when all 3 clinicians interviewed had congruent statements that supported the theme. Member checking, data triangulation, peer debriefing, and a rich thick description were used to ensure trustworthiness of qualitative findings.20 After both qualitative and quantitative data were analyzed, qualitative results were corroborated to quantitative findings to provide an explanatory mechanism.

RESULTS

Phase 1

In total, 134 patient encounters were included in the analysis. This included 50 initial evaluations and 84 follow-up sessions. The number of follow-up sessions is greater, as standard care in the study facility is for patients following elective total joint replacement to be evaluated on postoperative day 0, then treated twice daily on postoperative days 1 and 2. In total, 30 of the 84 follow-up sessions (36%) were provided by a PTA. The age of study participants included a wide range from 37 to 92 years of age (SD 11.48) and the sample included 28 female and 22 male patients. The average number of comorbidities was 1.5 (range 0-5, SD 1.27). Among the 50 initial evaluations, VS were assessed and documented in 23 patients (46% incidence), with all 23 assessments including HR and BP values. No instances of RR were documented in our data sample on initial or subsequent visits. Vital sign assessments and documentation by therapists for subsequent visits were 3/20 for visit 2, 2/20 for visit 3, 1/19 for visit 4, 0/15 for visit 5, and 0/6 for visit 6. Among the 134 included physical therapy sessions, VS (HR, BP, and RR values) were assessed and documented in the medical record on only 29 occasions. The point-biserial correlation coefficient between number of comorbidities and whether VS was assessed was +0.016 (no correlation).

Phase 2

In total, 14 physical therapy clinicians directly evaluated or treated patients in the study population (10 PTs and 4 PTAs). Of the 3 practitioners participating in the interview process, the average age was 50 years (range 26-64 years), and they had an average of 19 years in clinical practice (range 2-37 years). The 3 clinicians selected to participate in the interview process were specifically selected, as they alone accounted for 56% of the encounters during the study period for an average of 25 encounters each for these clinicians (vs the remaining 44% of encounters spread across 11 other clinicians).

From the qualitative analysis, 5 major themes were induced from the data. The codes, code groups, and themes had 100% agreement during a peer-debriefing session between the 2 researchers in this study. Member checking also confirmed that all 3 practitioners agreed with the themes as outlined. These themes include (1) therapists perceive that VS should be taken based upon patient-related factors including proximity to surgery and patient-reported symptoms; (2) VS may or may not be necessary to assess based upon patient previous response to intervention, nursing notes, and in asymptomatic patients; (3) multiple barriers exist to the routine utilization of VS in physical therapy practice including lack of immediately available equipment, documentation difficulties, and time constraints; (4) experience plays a role in the decision to use VS; and (5) medical history has importance for measurement of VS.

Theme 1

Supportive statements for the first theme that physical therapy clinicians perceive that VS should be taken based upon patient-related factors including proximity to surgery and patient-reported symptoms were provided by all 3 interviewed practitioners.

For the first part of the theme, related to proximity to surgery, all 3 therapists expressed supportive statements. Therapist 1, who is a PTA (and denoted “PTA1” for further quotations), expressed this notion through the following statement:

Because of the effects of the anesthesia on their breathing. Are they breathing well? Is their BP low because of loss of volume? So you have to contend with all that right after surgery, but by the next morning, those things can resolve, but you have to be aware of any symptomatology.

In congruence to PTA1, a physical therapist (further denoted PT1), stated:

I still think we need to assess the vitals because they've had anesthesia and have had things that alter their BP and all their VS. So we need to make sure we're monitoring them at least on the day of surgery. If their VS are too low, I won't get them up for a walk. If their O2 sats are low, I'll make sure we have oxygen with us when we walk. I make my treatment around whatever the vitals say.

Finally, another physical therapist (further denoted PT2), expressed this theme:

Their hemodynamics are all over the place. A lot of times you will see if they have a lot of pain and it's extremely high, and then if they don't, their fluids are not balanced, it's going to be low. So you need to make sure that you have a baseline because then when you get them up, you want to take it again to make sure that it's not dropping significantly or not increasing significantly, making sure that we're staying in that therapeutic range. I think it's an absolute necessity to do before you get the patient up.

Further statements that support this first theme relate to the patient's symptom presentation. This presentation was alluded to by all 3 therapist providers, and was a promoting factor for VS assessment. In support of this part of the first theme, PTA1 stated, “If they had an incident with a patient passed out in the bathroom because of hypotension or a near miss like that, then I'd be checking it.” PT1 also expressed patient symptoms of, “If they're dizzy, if they're lethargic, if they're nauseous—all the adverse things from surgery and from the anesthesia. Also if they've seemed confused.” This was further endorsed by PT2 who stated:

[The patients'] subjectiveness, like if they are (saying), “I've been feeling a little lightheaded lying in bed” or “I went to the bathroom, and I got dizzy.” So what the patient is telling me, that's going to make me more likely to assess them. Or if I'm looking at the patient and I see that they're starting to sweat or change color in their face, it's going to be a red flag for me to go get a machine to take their vitals.

Theme 2

The second theme expressed by therapists interviewed within the study was that VS may or may not be necessary to assess based upon patient previous response to intervention, nursing notes, and in asymptomatic patients. Supporting statements for this theme are detailed subsequently. PTA1 provided support for this theme when they stated: “I do it as needed. It depends on so many things.” “I won't if there's not a symptomology to cause me concern because some of these they've had the history for years and the doctors aren't going to do surgery on them unless they feel that they're safe to be seen.” Further support for this theme was provided by PT1 when they said: “If on the day of surgery, their VS are stable, the next day if they're not showing any change and I have looked at the nursing vitals, I don't take it at the time.” “If it's not the day of surgery; if it's farther out. If they've been stable the whole time, I won't be doing it.” Finally, PT2 stated: “If they come in and, you know, they don't have a past medical history; they are a young individual who's been active their whole life. You're not thinking of it as much to say, ‘Well maybe I should take your vitals before we get up.’”

Theme 3

A third major theme induced from the interviews is that significant barriers such as equipment availability, documentation-related factors, and to a more limited extent, time are perceived to exist, which limit clinicians in assessing and documenting VS into the medical record. Each of the parts of this theme will be presented subsequently.

Therapist statements related to equipment availability were expressed by all 3 providers interviewed. PTA1 expresses this thought “... you can't find the equipment, but there's always a pulse ox around somewhere, and I take the time and I go find it.” In agreement with PTA1, PT1 stated, “To be quite honest, I hate to say it, but if there was a machine in every room, I probably would use it a whole lot more. But they put all the machines in the post-op room so here it's really hard to find a machine sometimes.” Finally, PT2 endorses the notion of equipment availability:

When I do not decide to take VS it's probably because of lack of equipment available. I'm trying to find a machine, and I know that's not a good excuse, however, in the hospital, it's sometimes very hard to find the appropriate machine. The biggest barrier is equipment availability. Again, not a good excuse to not take the vitals, but when they [the patient] are in the hospital and you can't find it (the equipment) and they [the patient] are very eager or they're not having symptoms, I think that you tend to surpass (sic) it.

For the second part of the theme, related to documentation, participants stated that documentation of VS in the medical record is not always completed. This was related to the VS being normal, not feeling documentation was necessary, or forgetting to document. PTA1 stated:

If the results are within normal limits a lot of times that is what I'll write in the note ... Or if they had complained of dizziness and when I took the BP it was no different or very slightly different or even higher than the one before, I wouldn't even note it ... So I don't always write all the numbers down. I'll just know that things were normal.

Further supporting this part of the theme, PT1 stated: “In [the] recovery room I can get the pre [vitals] but you don't get the post because they leave everything [equipment] off so I tend not to document if I'm not going to have a follow up. I hate to say that but, you know, if you can't show any change, why put it down?” Finally, PT2 stated:

I think this is something that is challenging that I personally need to get better at because I don't always chart directly after my patient, and when you're working with them you don't always have a chance to write it down. Or I'll write it down and then I'll forget. When I have a patient whose BP or HR or oxygen level is abnormal following a surgery, I always document that because I remember it. But whenever my patients have their BP within a functional limit, when they are within functional levels, do I do it 100% of the time? No.

The final factor expressed in this theme is related to time; however, only 2 of the 3 interviewees mentioned time constraints as a relevant barrier to assessment and documentation of VS. PT1 endorses this statement when they say: “It just takes too long when you have a whole caseload of patients.” In congruence to PT1, PTA1 stated: “Time is always an issue, but you adjust your schedule. You have to take care of the patient. That comes first.”

Theme 4

A fourth theme found in this population of therapists was that experience has taught them the value of assessing VS in this population. When therapists were asked if the therapist's utilization of VS has changed with experience, PT1 remarked: “I do it more now than I did before.” PT1 added, “I've seen more patients have adverse problems that if we may be monitored them a little bit closer, we wouldn't have walked them so far or done something that could cause [an adverse event].” Concurring with this thought, PTA1 stated: “I would say I go in with a plan of taking VS every time ... I've had patients pass out on me. Finally, PT2 endorses this theme:

When I first started here, I did not take vitals as much as I do now and I think that came with experience of seeing patients, you know, unfortunately potentially start to pass out and putting them back into bed. And realizing, “Oh man. I didn't take their vitals.” So as I've grown and I've matured during physical therapy, I definitely increased my vitals.

Theme 5

A fifth theme was expressed by the 3 therapists regarding the influence of relevant medical history on their clinical decision-making with respect to VS analysis. PTA1 stated:

Chronic issues. If they've had a-fib chronically; they've had congestive heart failure chronically; they've had chronic kidney disease. Things like that that they have been used to dealing with are not going to be as big an issue for me to deal with unless I see symptoms. So I'm not going to necessarily go right in and start assessing things if it's been a chronic issue.

With response to whether medical history influences the decision to take VS, PT1 remarked, “I definitely agree with that because they can go into a-fib or have cardiac arrhythmias or things because of the anesthesia. You just need to watch them closely.” In response to the same inquiry, PT2 stated, “I would agree because it's kind of in the back of your mind while you're working with the patient, but I still think it's important to take it on all of your patients.”

DISCUSSION

The results of this study suggest that PTs and PTAs may practice in a manner that is inconsistent with their beliefs with respect to the assessment of VS for patients following total joint arthroplasty. These findings are consistent in the PT literature with those of Frese et al15 and Harris et al,16 although this study is unique in that it is specific to the immediate postoperative period when hemodynamic alterations are likely to be more prominent. Among initial evaluations, a 46% incidence of VS assessment is consistent with the results of Scherer et al,17 who found, also in an acute care hospital setting, that a mean of 56.3% of patients had HR and BP assessed by PTs. It is notable, however, that the overall percent utilization of VS across all patient visits in our study, 21.6%, is much lower than the aforementioned 46% taken at initial evaluation. This lower value is consistent with the findings of Millar et al,18 who observed that PTs infrequently assess VS during routine clinical practice. The result that only approximately 1 in 5 treatment sessions overall include VS evaluation while mobilizing patients in the immediate postoperative period after major joint surgery is a cause for concern, especially since cardiovascular abnormalities may only present during activity, even when resting VS are normal.19

A further concern for the decreased use of VS in this study is that individuals who are older than 80 years and who have a history of cardiovascular comorbidities such as coronary artery disease, cardiac stents, myocardial infarction, stroke or transient ischemic attack, poorly controlled hypertension, chronic obstructive pulmonary disease, implanted pacemaker, or a moderate reduction in ejection fraction have individual risk factors for complications and mortality following TKA.21 Although the average age of our sample was 70.24 years, 11 patients of the 50 sampled were 80 years or older at the time of their procedure. Only 4 of these 11 individuals (36%) had VS assessed by the therapist during their acute stay. Furthermore, the average number of cardiac and pulmonary comorbidities was 1.5 diagnoses per patient. Thus, it is reasonable to suggest that many of the patients in our study may have been at increased risk for hemodynamic alterations following their procedure and should have had their VS assessed to determine safety to mobilize in the immediate postoperative period. While no adverse events were documented in the study population during physical therapy evaluation or intervention, there was also typically no method for the therapist to detect an abnormal VS that may have been justification to terminate a therapy visit. That is, without proper assessment of VS during a physical therapy visit, the physical therapy clinician is unable to make objective judgment of the patient response to intervention, nor to refer to appropriate medical or nursing colleagues if VS became abnormal during the visit.

It is important to mention that the interpretation of VS is of most clinical relevance for physical therapy clinicians as opposed to simply the act of recording values into the medical record. Making consideration for normal versus abnormal changes in VS before, during, and after mobilization requires skill and training. This, however, assumes that the data are being collected to allow for interpretation. This study reflects the lack of this initial step, which is necessary, but not fully sufficient, to make inferences about an individual's hemodynamic stability following total joint replacement.

The point-biserial correlation was selected to determine any correlation between the interval variable of total number of comorbidities and the dichotomous variable of whether VS were assessed. The r value of +0.016 suggests essentially no correlation between the number of cardiac and pulmonary comorbidities and the assessment of VS by the therapists in this study population, which is also congruent with participant statements. This finding suggests that, though therapists qualitatively recognize the value of knowing a patient's medical history, it does not necessarily influence their clinical decision-making when determining whether to take VS measurements. Feldman et al22 suggested that PTs are unable to determine whether or not a patient is hypertensive using visual inspection with or without a chart review including medical history. To our knowledge, the incongruence between the stated importance of relevant comorbid conditions and the lack of utilization of VS is a new finding in the physical therapy literature that requires further investigation.

Although all 3 participating therapists agreed that VS were important to assess for all patients following total joint replacement, their practice patterns were not consistent with this. The themes induced from clinician interviews help to elucidate that patient symptoms and proximity to surgery are primary drivers of whether or not a therapist assesses VS. This finding contrasts with generally recommended practice as described by multiple professional organizations, as VS are considered an essential part of practice in all patient encounters.15–18 Furthermore, appropriately intervening by providing monitoring of VS in this patient population is particularly necessary, given the proven benefits of early intervention in this population and the high risk for adverse events with cardiovascular and pulmonary comorbidities.1–3

The physical therapy clinicians further agreed that lack of immediately available equipment was a driving factor in not monitoring VS during mobility sessions. This is a new finding that must be investigated in a larger and more diverse study population to determine whether this is a consistent theme in different patient populations and at different hospitals. Replication of this finding may help guide administrators in improving equipment availability to ensure proper patient assessment and safety.

It is interesting to note that 2 of the 3 therapists remarked that they have increased their assessments of VS, as they have gained more clinical experience. This stands in contrast with the work of Arena et al,23 who found a negative correlation between years of experience and attitude toward the necessity to assess VS in outpatient PTs. Based on our interviews, the increasing use of VS with experience appear to represent an unfortunate experiential learning curve from adverse events. This is a finding that has not previously been described in the literature and was stated by PTs who have a range of clinical experience from 2 to 37 years. This finding has ramifications for educators and clinical instructors working in similar physical therapy settings to properly educate student clinicians in the necessity of proper VS surveillance to avoid adverse events from hemodynamic changes that may be present after surgical interventions.

This study also provides novel insights into PTA practice in the acute care setting. The major themes induced from the qualitative analysis in this study suggest that PTA practice mirrors PT practice when considering the assessment of VS during physical therapy treatments following elective joint replacement. Further research on PTA practice in the acute care setting is necessary to determine whether PTA practice in this particular hospital setting mirrors that in other acute settings.

Limitations

This study is limited in its broad applicability to other facilities or practice settings. The sample size was powered to determine at minimum a moderate correlation (r = 0.50) and thus required a sample size of 29. Although our study included 50 initial evaluations and 134 total patient encounters, it still represents a small overall sample size. Further, the sample was gathered from a single community hospital and a single physical therapy department. It is unknown how generalizable our results are beyond this single institution. This study included interviews with 2 PTs and 1 PTA. Retrospectively, this study would be improved if all of the therapists who were involved in the study period were interviewed. This should be considered in any similar larger studies. Although the qualitative aspect of the study is novel in the physical therapy literature, it is also limited in the small sample size and generalizability. Still, the quantitative data are consistent with other previous research and the qualitative interviews help to explain the inconsistent use of VS in physical therapy practice. Therefore, this study may serve as a pilot for a larger study of multiple centers with increasing numbers of physical therapy practitioners to more definitively determine current practice patterns with respect to VS utilization.

CONCLUSION

This is a unique pilot study that sought to describe the current practice of acute care physical therapy clinicians on a postoperative orthopedic surgery floor in patients following elective total joint replacement with respect to VS utilization. Our results suggest a discordance between the stated value of VS assessment and the actual utilization in practice in this population. Multiple explanatory mechanisms are suggested by physical therapy clinicians and include both subjective and objective factors. It is suggested that experience plays a role in increasing utilization of VS in the early postoperative period, but that comorbid conditions do not. Further studies are needed to further substantiate these results.

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APPENDIX A. Survey and Semistructured Therapist Interview Script

Thank you for your willingness to participate in this semistructured interview. Your participation is completely voluntary and all information and correspondence shared will remain completely confidential. By continuing, you acknowledge that your participation is voluntary and you have authorized your comments to be utilized by the principal investigator for use in this research study including potential presentation and publication.

  1. Please rate on a scale of 1 (not important) to 10 (extremely important) your degree of agreement with the following statements:
    • It is important for physical therapists to assess vital signs in all new patients upon PT evaluation.
    • It is important for physical therapists to assess vital signs on all follow-up patient visits.
    • Reviewing past medical history is necessary prior to physical therapy evaluation and intervention in patients following joint replacement.
  2. Please rate on a scale of 1 (no agreement) to 10 (highly agree) to what degree you agree with the following statements:
    • Taking vital signs influences my clinical decision-making.
    • Elective joint replacement is a low-risk surgery; thus, assessment of vital signs is not necessary.
    • The nursing staff routinely assesses vital signs; thus, it is not necessary for the PT to assess vital signs.
    • I am more likely to take vitals on a patient with a significant cardiac history following a joint replacement.
    • I am more likely to take vitals on a patient with a significant pulmonary history following a joint replacement.
  3. Please explain your clinical rationale for why you do or do not decide to take vital signs on a specific patient following elective total joint replacement.
  4. What barriers do you perceive that reduce your likelihood of assessing vital signs as part of patient management for individuals following elective total joint replacement?
  5. Is there anything specific that may make you more likely to assess vital signs on patients seen following elective total joint replacement?
  6. Is there anything specific that may make you less likely to assess vital signs on patients seen following elective total joint replacement?
  7. Is there anything else that you would like to contribute relevant to this topic?

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