vital sign assessment

VITAL SIGN ASSESSMENT

SELF-REPORTED VITAL SIGN ASSESSMENT

IN PHYSICAL THERAPY

______________________________________________________________________________

An Independent Research

Presented to

The Faculty of the Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor of Physical Therapy

______________________________________________________________________________

By

Clint G. Harrison

2017


APPROVAL SHEET

This Independent Research

is submitted in partial fulfillment of the requirements for

the degree of

Doctor of Physical Therapy

Clint G. Harrison

Approved: May 2017

Ellen Donald, PhD, PT

Committee Chair

Kathleen Swanick, DPT, MS, OCS

Committee Member

The final copy of this Independent Research has been examined by the signatories, and we find

that both the content and the form meet acceptable presentation standards of scholarly work in

the above mentioned discipline.


Acknowledgements

There are so many to thank for their ongoing support of this research project & during my

continued education towards a Doctorate of Physical Therapy degree. First and foremost, I need

to thank my committee Chair, Dr. Donald, & committee member, Dr. Swanick, for the opportunity

to work on this research project and their help and guidance along the way. Important data has

been and will be used for further understanding with this area of practice in physical therapy, help

other research projects, used as a reference, and other purposes to further improve patient care in

the physical therapy profession.

Paying respects to your loved ones for their role is of the utmost importance. Each one of

these Family Members, Co-Workers, & Friends have helped me be the person I am today. I love

them all and appreciate what each has done to make my life what it is. The following are in

alphabetical order (by last name) and there are many others not specifically mentioned that have

made an amazing impact as well:

Jack Anderson, Erika Banks, Stewart Buckingham, Mary & David Chen, John & Tyler

Dam, Anne Marie Dorsa, Rashel & Dennis Dube, Angelina Ford, Dawnell Glunz, Kathy Harriman,

Ron & Sandy Harrison, Ruth & Denzel Harrison, Shelby Jones, Tylor Laflan, Dan & Emily Lavin,

Joseph Muffoletto, Betty & LaVern Nosal, John Snyder, John & Billie Walker, All of my nieces,

my nephew, aunts, uncles, cousins, friends that are my family, and anybody that has made an

influence.

I would like to thank all of the faculty, professors, clinical instructors, and every patient I

have worked with that have made a profound impact on my life and educational endeavors. To

add, multiple beautiful animals have and continue to be in my life that make lasting impressions.

I am so very thankful to have you All in my life and in my heart, God Bless!!!

VITAL SIGN ASSESSMENT 1

Table of Contents

Abstract…………………………………………………………….…………………………...….3

Introduction…………………………………………………………...………...……………….…4

Review of the Literature………………………………….…………………….……………….…5

The Vital Signs………………………………………….………...………………….…5

Vital Sign Assessment………………………………….…………………………….…6

Cardiovascular Disease…………………………………………...………………….…7

Hypertension………………………………………………………...……………….…9

Vital Sign: Blood Pressure……………………………………....……………….……10

Vital Sign: Heart Rate……….…………………………….………....………….…….11

Vital Sign: Pulse Oximetry…………………………………….…………...…………11

Physical Therapy Education and Vital Sign Assessment…………….…….…………12

American Physical Therapy Association………………………….…….……….……13

Individual State Practice Laws…….…………………………….…...……….………14

Pilot Survey…………………………………………………...………………………15

Research Questions and Hypotheses…………………………….……………………………….16

Methods………………………………………………………………………………….......……17

Research Design and Instrumentation…………………………....…………...………17

Access to Subjects and Sampling Plan……………….………….……………………18

Data Collection………………………………………………….…….………………18

Results…………………………………………………………………………………….………19

Part I-Demographic Information……………….………….……….………....………19

Part II-Practice Behaviors & Beliefs………………....……………….…….………...23

Discussion……………………………………………………….……………….……………….27

Conclusion…………………………………………………….………………………………….32

References………………………………………………………….………………….…….……34


Appendices……………………………………………………….……………………….………38

A: Question 6b-Open Ended Responses, Synopsis/Report………….………….……….38

B: Question 22-Open Ended Responses, Synopsis/Report……………………………...40


Abstract

Introduction. The purpose of this study was to determine how often physical therapists

(PTs) assess the vital signs of heart rate (HR), blood pressure (BP), and oxygen saturation (SpO2)

throughout the United States, and if there are key factors that may affect the assessment of these

vital signs. Review of Literature. In previous research (Peters, 2014), it was shown that there

are a variety of reasons why the assessment of vital signs is routinely used by some therapists and

not by others. Research Questions and Hypotheses. This research aimed to determine the

particular reasons why or why not HR, BP, and SpO2 are assessed, and if differences occur

between unrestricted vs. restricted direct access states. Methods. An online survey was

developed and piloted prior to distribution. All 50 physical therapy state associations and the

District of Columbia were contacted for the opportunity for their membership to participate. Of

those associations that expressed interest to participate, an email with a link was sent to that state

association once approved by the Institutional Review Board (IRB). Results. Data of 286

anonymous respondents were included in the analysis with representation from 24 states with a

distribution across most practice areas and settings. There were 60% unrestricted and 32.5%

restricted direct access practicing states. Ninety-eight percent of respondents are somewhat

confident to extremely confident with taking HR, BP, and SpO2 and 91% are able to assess these

vitals within 1-6 min. However, respondents only regularly (>75% of the time) measured vital

signs of HR 39%, BP 37%, and SpO2 30% during initial evaluations. During intervention

sessions, even less, with HR 31%, BP 26.5%, and SpO2 22%. Discussion. Various reasons were

provided for the lack of regular assessment of vital signs with patients. A statistically significant

association was noted between frequency of measurement of vital signs by participants and the

nature of the direct access in the State of licensure, with a higher frequency of measurement in

states with restricted direct access. Conclusion. Insight was gained in patterns of assessment of

vital signs as well as rationale behind therapists’ decisions to use these critical measures.

Continued research will help inform practice and maximize patient safety.


Introduction

Chronic conditions and noncommunicable diseases are dominating health systems across

the globe, and physical therapists will be engaging patients in health promotion and disease

management for many years to come (Knight, Werstine, Rasmussen-Pennington, Fitzsimmons, &

Petrella, 2015). No health-related condition affects American lives more than heart disease.

According to the Center for Disease Control and Prevention, the leading cause of death in the

United States is heart disease, at a rate of 611,105 in the year 2013 (Leading Causes of Death,

2015). Pulmonary hypertension is commonly associated with, and is a major risk factor for,

coronary artery disease (Lowe et al., 2011). Hypertension is responsible for doubling all-cause

mortality, while tripling the number of stays in the hospital, as well as, morbid complications

(Lowe et al., 2011).

Physical therapists are responsible for ensuring the safety of each patient being treated,

and measuring vital signs allows clinicians to screen for undiagnosed conditions, monitor existing

conditions, and facilitate safety through prevention (Peters, 2014). Exercise interventions utilized

by PTs have the potential to be harmful if the patient is not being properly monitored (Grunig et

al., 2012). The monitoring, through assessment of vital signs to be discussed in this research

includes blood pressure (BP), heart rate (HR), and pulse oximetry (SpO2). It is recommended that

these vital signs should be utilized routinely by all practicing physical therapists in order to screen

for heart-related conditions, as well as other conditions.

This exploratory survey research gathered information on the use of these key vital sign

measurements in various physical therapy settings. Based on prior research (Peters, 2014), there

is strong suspicion currently practicing American physical therapists do not assess patients’ vital

signs regularly. This idea was evidenced in the work of J. Peters (2014), which focused on the

patterns of utilization of vital sign measures of therapists in the State of Florida. Peters found that

a majority of practicing physical therapists were not measuring vital signs during each visit


because of a lack of time, or simply the perception of these measures not being important for

certain patient population (Peters, 2014).

Physical therapists have broadly become more autonomous as direct access practitioners,

and share the role of primary care professionals with other health care practitioners. With

physical therapy being a doctoring profession and having direct access to patients, it is essential

to assess vital signs for patient safety and be consistent with APTA standards of care. As part of

expanding the parameters of responsibility of physical therapy practice, this issue needs to be

studied to inform practice.

Review of the Literature

The Vital Signs

Clinical medical practitioners face patients with illness, disability, and suffering on a

daily basis (Yuen & Irwin, 2005). It is the role of a physical therapist to ascertain a patient’s

current physical condition, in addition to determining a proper PT diagnosis when seeing a new

patient. A physical therapist must first monitor the patient’s vital signs in order to achieve a

baseline report upon which to measure and compare future readings, during and after exercise.

Baseline measurements should be determined to understand whether the patient is appropriate for

exercise, and is responding appropriately to an intervention (Graham, & Clark, 2011). There are

numerous vital sign applications, found in research literature, that may be utilized in various

physical therapy settings. Included among these are the four traditional vital signs, which consist

of heart rate, blood pressure, temperature, and respiratory rate (Cretikos et al., 2008). Pulse

oximetry can be added to this fundamental list, since it has increasingly become an essential tool

in the modern practice of emergency medicine (Sinex, 1999).

The use of other standardized tests and assessments, along with vital sign administration,

can provide a better interpretation of overall health. Walking speed reflects both functional and

physiological changes, and can be a discriminating factor in determining potential for

rehabilitation, which also aids in the prediction of falls with the fear of falling (Fritz & Lusardi,


2009). Prevalence of emotional distress is a screen to identify patients in need of psychosocial

support (Bultz & Johansen, 2011). Dynamometrically measured grip strength was shown to be

associated with a greater likelihood of premature mortality, the development of disability, and an

increased risk of complications or prolonged length of stay after hospitalization or surgery

(Bohannon, 2008). Health literacy as a vital sign could result from a quick screening test for

limited literacy in primary health care settings (Weiss et al., 2005). Aerobic exercise testing

allows for the manifestation of physiologic abnormalities that are not readily apparent during the

collection of resting data (Arena, Myers, & Guazzi, 2010). Finally, sleep has been referred to as a

potential vital sign since many people often sleep no more than five to six hours a night, even

though studies show that most people need between seven to eight hours (Wilson, 2005).

This research is specifically focused on three aspects of vital sign assessment. These

three are blood pressure, heart rate, and pulse oximetry. It is the position of this research that all

three applications must be given before, during, and after all exercise treatments performed by the

patient to provide best practice by the physical therapist.

Vital Sign Assessment

In general, healthcare services that utilize vital signs, will reflect the state of personal

health and aid in the detection and prevention of cardiovascular disease (Kim & Kim, 2012).

Performing vital sign assessment properly, utilizing reliable procedures/techniques, interpreting

the findings accurately, and applying appropriate clinical judgement when deciding if the patient

should proceed with treatment/exercise is of the utmost importance by PTs. In a study designed

to determine whether the taking of vital signs in a clinical setting is reproducible, two trained

technicians assessed the vital signs of 140 patients in an acute setting with medical complaints

(Edmonds et al., 2002). The results of this study showed that even among properly trained

individuals who knew they were being watched and recorded, inter-observer variability still

indicated a limited reproducibility. Whereas the heart rate assessment was a difference of 10% to

15%, and not drastically important for that clinical assessment, the diastolic and systolic blood


pressure measurements were a difference of 20% to 25%. These differences in measurement

could become dangerous when they become near abnormal values (Edmonds et al., 2002).

Vital signs can be very useful predictors of mortality for patients who were admitted to

the hospital. In a retrospective study from the Wake Forest University School of Medicine

Institutional Review Board, the intent was to examine the association of critical vital signs that

occurred at any time during the hospital stay, and not just at the time of admission (Bleyer et al.,

2011). The researchers obtained 1.15 million individual vital sign determinations, and discovered

that if the patient presents with critically abnormal vital signs, it is associated with a high

mortality rate. However, early detection of these signs presented an opportunity to lower the

mortality rate (Bleyer et al., 2011).

A recent review of vital sign assessment literature showed that age of the patient may

alter the results from the analysis. The review found that in older, frailer patients, the results of

single point measurements of vital signs have less sensitivity in discovering cardiovascular

disease (Chester & Rudolph, 2010). In order to increase the sensitivity of the tests, serial vital

sign assessments should be made. However, regardless of this fact, the most important discovery

for clinical purposes is that while vital signs may change with age, the individual reference

alteration is the most important warning sign, and will require additional testing to determine the

pathological process (Chester & Rudolph 2010).

Cardiovascular Disease

According to the Center for Disease Control and Prevention, one quarter of all reported

deaths are a result from heart disease in the United States, on an annual basis. Nearly 370,000 of

the 611,105 heart related deaths, had the most common form of heart disease, which is coronary

heart disease (Heart Disease Fact Sheet, 2015). Cancer is the second leading cause at 584,881

deaths, while chronic lower respiratory diseases are listed third at a rate of 149,205 deaths. A

cerebrovascular accident (stroke) ranks fifth at 128,978 deaths after unintentional injuries and

accidents (Leading Causes of Death, 2015).


There are 26.6 million adult Americans with a diagnosis of heart disease, which is 11.3%

of that population (Heart Disease, 2015). The range of major clinical heart disease conditions

include: stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary

heart disease, heart failure, valvular disease, and peripheral arterial disease (Mozaffarian et al.,

2015). As the first and fifth leading causes of death in the United States, heart disease and stroke

occur in approximately 30% of adults aged 18 years and older (Prevalence of Hypertension and

Controlled Hypertension — United States, 2007–2010, 2013).

The existence of avoidable deaths reflects poorly upon the healthcare system. Every year

the mortality rate shows a certain portion of avoidable deaths due to a lack of timely and effective

medical care. One measure of the health of Americans, deaths from treatable conditions, still does

not compare well with rates in other industrialized countries (Nolte & McKee, 2008). The

assessment of risk factors due to cardiovascular disease is crucial in the successful treatment of

cardiovascular disease resulting in patient death. In a recent study, national vital sign statistics

were analyzed from 2001 to 2010. The results showed that avoidable deaths (resulting from

ischemic or chronic rheumatic heart disease, stroke, or hypertensive disease in patients 75 years

old or less) were estimated at over 200,000 in the United States in 2010 (Schieb, 2013). The

overall death rate utilizing these parameters was generated as: 60.7 deaths per every 100,000

people, with the conclusion being that one quarter of these deaths are avoidable (Schieb, 2013).

Heart disease is the leading cause of death for both women and men in the United States,

with males being more than half of the reported deaths (Heart Disease Facts, 2014). Men suffer

coronary heart disease and heart failure more than women, while women are more susceptible to

hypertension and diabetes, suggesting that cardiovascular risk factors have a different impact on

cardiovascular events and mortality in males and females (Zhang et al., 2012). Differences hold

as well for a population advancing in age. In the last stage of lifespan, men suffer more left

ventricular systolic dysfunction and abnormally affected lipoproteins in the blood, while women

are much more susceptible to malnutrition, hyperglycemia, and arrhythmia (Zhang et al., 2012).


Hypertension

A critical measure, to determine a patient’s cardiovascular health status, that a physical

therapist should assess is blood pressure. High blood pressure (hypertension), is the force of

blood pushing against the walls of the patient’s arteries, and remains at that high level for an

extended period of time (High Blood Pressure Fact Sheet, 2014). Since physical therapists now

play an important role as primary health care providers, the accurate measurement of blood

pressure is critical for making the appropriate clinical decisions (Frese et al., 2011).

Hypertension is the most common primary diagnosis in the United States, with 22% of

individuals unaware that they are hypertensive. Hypertension is also a major risk factor for renal

failure, stroke, and coronary heart disease (Frese et al., 2011).

One in every three Americans has high blood pressure, which places the physical therapy

patient at a fairly high risk of heart disease and stroke (High Blood Pressure Fact Sheet, 2014).

From the year 2011 through the year 2012, 32.5% of non-institutionalized adult Americans aged

20 and over had a diagnosis of hypertension (National Center for Health Statistics, 2015). The

total cost of high blood pressure on the United States is 46 billion dollars, which includes the

costs of health care services, missed days at work, and medication (High Blood Pressure

Frequently Asked Questions, 2015). These facts clearly show the high level of importance that

blood pressure readings have during every visit a patient has in every physical therapy setting.

The effects of respiratory and exercise training on exercise capacity was associated with a

significant improvement in quality of life. Aerobic Exercise training in patients with severe

hypertension provides beneficial psychological and physical effects, leading to an enhanced and

healthier quality of life (Mereles et al., 2006). However close monitoring must occur during this

training to provide safe care of patients.

In a recent study, it was determined that the use of taking BP was crucial over just doing

visual inspection alone or in conjunction with the patients past medical history (PMH) to

determine the accuracy of patients’ hypertensive status. Of the 68% participating patients who


had a BP reading in the pre-hypertensive or hypertensive range the visual inspection and use of

PMH group would have only taken BP 9% of that time. It was concluded by the researchers that

physical therapy clinicians were unable to predict the hypertensive status with accuracy unless

they took the vital sign assessment of BP (Feldman, et al. 2016).

Vital Sign: Blood Pressure

Vital sign measurement and assessment are of great importance during the physical

therapy exam and review of symptoms for patients who present with and without

cardiopulmonary disease; for purposes of establishing a baseline status, a response to exercise,

and for future exercise prescription (Frese, Frick, & Sadowsky, 2011). Hypertension is a major

health problem and is relevant to physical therapy because relatively small reductions in blood

pressure can result in decreased risk for stroke and myocardial infarction (Taylor, Dodd, &

Damiano, 2005). In the majority of hypertensive patients, no particular cause for abnormal blood

pressure is evident (primary or essential hypertension). In contrast, in the minority of patients

with secondary hypertension a specific underlying cause is responsible for the elevated blood

pressure (Ott, Schneider, & Schmieder, 2013).

Standardizing the blood pressure measurement technique through training, is crucial

during physical therapy education and clinical practice (Frese et al., 2011). In a study at

Quinnipiac University, the physical therapy faculty received reports from their students in clinic

that the clinicians whom they work for do not follow standard protocols for routinely measuring

blood pressure with their patients. A study was conducted to assess whether there is a population

of hypertensive patients, regularly attending physical therapy sessions, that could be undiagnosed

with hypertension, or otherwise use poorly controlled antihypertensive medications (Kasinskas,

Wood, & Koch, 2011). Out of 87 patients screened for hypertension, 27 were classified as

hypertensive, and 27 were classified as pre-hypertensive (Kasinskas, Wood, & Koch, 2011). That

was almost 2/3 of those patients (62%), which again demonstrates why blood pressure screening

in the outpatient clinic is imperative.


Vital Sign: Heart Rate

The average resting heart rate for most individuals is 60-80 beats per minute, while there

is typically a lower reading for physically fit people, and higher scores are found in the aged and

sedentary populations (Target Heart Rates, 2013). It is important for the physical therapist to

know the patient’s heart rate, especially when placed on an exercise program. Maximal heart rate

is one of the most commonly used values in clinical medicine and physiology, and is utilized as a

basis for prescribing exercise intensity in both rehabilitation and disease prevention programs

(Tanaka, Monahan, & Seals, 2001). Every patient is different, and every exercise program is

tailored for each individual. The physical therapist needs to dose a proper exercise regimen based

on the patient’s heart rate. It is pivotal that the physical therapist maintains knowledge of their

patient’s heart rate throughout the exercise program. Heart rate can be affected by numerous

factors, including a patient’s age, medical condition (such as fever), medications currently taking

(such as beta blockers), and their current fluid retention (Elliot & Coventry, 2012).

A survey was mailed with a 43% return rate from clinical instructors and students

working in a variety of practice settings. The purpose of the 11-item survey was to determine if

heart rate and blood pressure were taken in these practice settings (Arena, 2009). The results

showed that the clinical instructors in the outpatient setting either never or seldom assessed the

patient’s vital signs. Additionally, only 37% of clinicians believed that measuring heart rate and

blood pressure was important, while 87% of students believed it to be important (Arena, 2009).

While it is promising that the students were interested in taking vital signs, the actual practice of

the vital sign assessment is tremendously low.

Vital Sign: Pulse Oximetry

The pulse oximeter is an extremely reliable and valuable clinical tool that is easy to use

(Elliot & Coventry, 2012). The World Health Organization defines a pulse oximeter as a medical

device that monitors the level of oxygen in a patient's blood, allowing for intervention if dropped

below a safe level (Pulse oximetry, 2014). The pulse oximeter device is critical for use in


intensive care, hospital settings, operating rooms, and emergency care. Pulse oximeters are also

utilized in outpatient physical therapy clinics to provide a noninvasive way to maintain the

estimated oxyhemoglobin saturation of blood in the patient’s arteries, which in turn may diagnose

hypoxemia (Mengelkoch, Martin, & Lawler, 1994). In a comprehensive Cochrane Review, five

eligible studies were discovered that showed that pulse oximetry can detect hypoxemia and other

related events (Pedersen, Møller, & Pedersen, 2003).

Pulse oximetry is now a ubiquitous and essential tool of modern medicine, and the pulse

oximeter, like any basic tool, must be used properly (McMorrow, & Mythen, 2006). To work

properly and effectively, the pulse oximeter requires adequate peripheral blood flow; for example,

anemia may provide a misreading since the patient might have a lowered potential to carry

oxygen in the blood, and the pulse oximeter could provide a misreading on the hemoglobin level

measurement (Elliot & Coventry, 2012). Pulse oximetry however, can be very useful in alerting

the physical therapist of a change in the patient’s condition.

Physical Therapy Education and Vital Sign Assessment

Physical therapy education is now at the Doctorate level in the United States and

standards of care continue to rise. Therefore, when a patient presents with undiagnosed

hypertension, and the physical therapist fails to measure vital signs, they place both their patient

and their license at considerable risk. This is not only because most patients with hypertension

are asymptomatic, but also because 50% of the American adult population has an underlying

chronic medical condition. Additionally, 66% of American adults are overweight or obese,

creating additional health risks (Graham & Clark, 2011). Aerobic capacity and the ability to

perform physical activities may be hindered by obesity, which may have implications for physical

therapists' interventions (Racette, Deusinger, & Deusinger, 2003). Consistent with the role as

autonomous practitioners, physical therapists should take a primary health care role of baseline

vital signs on every new patient and monitor vital signs during exercise (Graham & Clark, 2011).


With all the education and ability to provide vital sign assessments quickly and with ease,

Physical Therapists are still showing a low frequency of taking the vital signs of their patients.

Observational research was conducted in an outpatient setting where 74 patients were seen for

either an initial evaluation, follow-up, or discharge. Only two times during the initial session, and

one time during a follow-up session, was HR and BP taken. Of these 74 patients, 19 (26%) were

diagnosed with hypertension. This lack of patient care increases the risk for the PT that a patient

will have a cardiac event in their office, while under their care (Millar et al. 2016). This study is

limited as it analyzed practice at only one location, but it still contributes to the evidence of the

lack of vital sign assessment compliance among physical therapists.

American Physical Therapy Association

The American Physical Therapy Association was founded to increase the quality of life

for patients through the advancement of physical therapist practice, education, research, and by

improving the public’s awareness and comprehension of physical therapy's role in the United

States’ health care system (About Us, 2014). As mentioned, unrestricted direct access is a prime

goal for the organization, so much so that they placed the idea firmly in their Vision 2020

strategic plan, which states:

“By 2020, physical therapy will be provided by physical therapists who are

doctors of physical therapy, recognized by consumers and other health care

professionals as the practitioners of choice to whom consumers have direct

access for the diagnosis of, interventions for, and prevention of impairments,

activity limitations, participation restrictions, and environmental barriers related

to movement, function, and health.” (Vision 2020, 2014)

Physical therapists are well-educated and licensed health care professionals who can aid

patients in reducing pain levels and improve or restore mobility, ideally without expensive

surgery and often reducing the need for long-term use of prescription medications, which can

carry heavy side effects. Physical therapists also instruct patients on ways to prevent or manage


their condition so that they will achieve long-term health benefits (Who Are Physical Therapists,

2014). Physical therapists typically evaluate each patient, and then develop a plan, utilizing

techniques to treat and promote movement, the reduction of pain, the restoration of function and

mobility, and to avoid disability. They also work with patients through the development of

fitness and wellness encompassing programs, for people who are already considered healthy and

wish to enhance their active lifestyle. State licensure is a requirement for each state in which a

physical therapist practices (Who Are Physical Therapists, 2014).

According to an American Physical Therapy Association press release dated October 28,

2009, APTA President R. Scott Ward, PT, PhD, addressing the International Summit on Direct

Access and Advanced Scope of Practice, said the following:

“[W]e heard evidence from around the world that clearly demonstrates that direct

patient access to physical therapists is appropriate for all Americans. The

findings of this conference confirm that the legislation allowing patients to access

physical therapists without a referral -- legislation that currently exists in 44

states -- is worth pursuing in all states and at the federal level.” (Direct Access

Summit, 2009)

Direct access and patient self-referral specifically mean that the patient has the power and

ability to utilize physical therapy as the first choice for wellness programs and rehabilitation,

without the need of a referral from their physician (Direct Access Summit, 2009).

Individual State Practice Laws

For purposes of this research, the focus will remain solely with one aspect of healthcare;

that being the specific assessment of vital signs in all areas of physical therapy practice across the

entire United States of America. Current physical therapy practice laws are created and regulated

by each individual state. This can encompass a variety of limitations and freedoms in the ability

to practice physical therapy. All 50 states in the US have direct access to practice physical

therapy. However, the therapist is the one who is ultimately responsible for providing best


practice in the screening process of patients who may have conditions that negatively impact their

response to interventions (Graham & Clark, 2011).

There are a variety of limitations within states regarding direct access. These limitations

may include the patient first obtaining a referral to see the physical therapist or that there may be

a requirement from certain states that the therapist must have spent a specific amount of time in

school, with a minimum level of education first attained by the therapist, for that patient to then

visit. There are currently 18 states with unrestricted direct access listed by the American Physical

Therapy Association, signifying that the patients in those states can have direct access to a

physical therapist, without any stipulations (American Physical Therapy Association, 2016).

Vital sign assessment is an important component of the delivery of PT services. With this

added responsibility of patients accessing PT services directly, physical therapy practice must

include the routine assessment of vital signs to ensure patient safety and to contribute to the

identification of health risks.

Pilot Survey

A pilot study was conducted by J. Peters titled Self-Reported Use of Vital Signs in the

Adult Outpatient Physical Therapy Setting (Peters, 2014). As the title indicates, he focused his

research on the assessment of vital signs in outpatient settings. The survey assessed the

frequency of HR, BP, and SpO2 measurement in the six months prior to taking the survey,

physical therapist’s beliefs about the importance of measuring vital signs, their specific reasons

for not measuring vital signs, and information pertaining to the demographics of the respondents.

He received cooperation with, and was able to place the 16 question survey on the website of the

State of Florida’s Physical Therapy Association. After 21 days of availability, data from 45

respondents was then collected and analyzed (Peters, 2014).

The outcomes reported by the study cited physical therapists’ difficulties with the

measurement of vital signs for specific reasons. For example, only 28.9% of the respondents

reported that their clinic had a policy regarding the measurement of vital signs. Additionally,


66.7% reported that 81-100% of their case load over the last 6 months involved patients whose

primary problems were musculoskeletal in nature, and not related to issues deemed necessary for

the assessment of vital signs. Almost half of the respondents believed it was “extremely

important” to measure vital signs (HR n=20; BP n=21; SpO2 n=18) on patients with a

cardiovascular condition, but few believed it was “extremely important” to measure vital signs on

each patient during every visit (HR n=4, BP n=4, SpO2 n=3). The most frequently chosen

responses for not assessing vital signs were, “not important for my patient population” (40.0%;

n=18) and “lack of time” (22.2%; n=10) (Peters, 2014).

Peters’ results were able to point out the disparity between the guidelines put in place by

the American Physical Therapy Association, and actual physical therapy practice concerning the

assessment of vital signs in the State of Florida. He concluded that physical therapists are

responsible for the safety of each patient that they treat, and that it is important for vital signs to

be assessed by clinicians for undiagnosed conditions for monitoring existing conditions, and for

facilitation of safety through prevention (Peters, 2014). While Peters was able to establish a

baseline view of vital sign assessment in one state, this current research study was able to expand

his 2014 pilot study to multiple states throughout the U.S. to achieve a much more broad-based

and national view on the assessment of vital signs in all physical therapy settings.

Research Questions and Hypotheses

This survey-based research study sought to answer two research questions. The first

research question is: at what level of frequency do physical therapists assess vital signs (BP, HR,

SpO2) with their patients? The hypothesis was that physical therapists assess vital signs (BP,

HR, SpO2) at a frequency that is significantly less than every patient visit. To further consider

the role of direct access in practice, the second research question was: what is the relationship

between the frequency of physical therapists’ assessment of vital signs and the level of restriction

of patient direct access? The hypothesis was that there will be a greater frequency of assessment

of vital signs (BP, HR, SpO2) among physical therapists in states with unrestricted access than in


states with restricted access. It was believed that physical therapists take on a greater primary care

role in these states and therefore have an increased responsibility to monitor patients vital signs.

Methods

Research Design and Instrumentation

A survey was designed to encompass the subject of a physical therapist’s role in patient

primary care, and attempted to illustrate a way to show the current level of importance that the

physical therapist places on the assessment of vitals in the setting they work.

This research project, using an online survey format, was an observational, non-

experimental, quantitative, & cross-sectional study. The survey evaluated participants’

demographic data, clinical practice for recording vitals (BP, HR, SpO2), why vitals may not be

taken with every patient visit, beliefs with the autonomous progression of the physical therapist

field and the importance for physical therapists to take vitals (BP, HR, SpO2) with having more

direct access to patients. The survey was web-based research tool using Check Box™ software.

There was a total of 22 questions and consisted of a combination of open-ended and multiple

choice. It took approximately 10 minutes to complete this survey. Participants remained

anonymous through the use of a numbered code assigned to the data collected that associates the

subject with the results.

The survey was fully developed after a thorough search of scholarly articles pertaining to

the purpose & research questions. Four members of the Florida Gulf Coast University Doctor of

Physical Therapy faculty, three student physical therapists, and three members of the public not

associated with the physical therapy profession, reviewed the survey for content and readability

before finalization, securing Institutional Review Board approval, and uploading to state physical

therapist association websites. Due to the survey being uploaded to the participating state

physical therapist association sites, both members and non-members for that state association

could potentially take the survey. Information was available on the website to inform subjects

about the confidentiality and security of their personal data. All the data obtained through this


study was stored on a flash drive and stored under lock and key in the committee chair’s office on

Florida Gulf Coast University campus for the 3-year required period in compliance with the

Institutional Review Board. After this time period the flash drive will be destroyed.

Access to Subjects and Sampling Plan

The online survey was utilized that allowed respondents to fill out the survey

anonymously. All 50 physical therapy state associations and the District of Columbia were

contacted via phone giving them the opportunity for their members to participate. Of those that

responded back, an additional email was sent with the Online Survey Consent form with details

about the study, and the need for each Association to send a response email stating that state

association’s willingness to participate.

Once IRB approval was obtained, the researcher contacted each association via phone the

email was sent with the survey link. It was also discussed that the state association could decide

how to disperse the online survey link. Follow up contacts were made with each participating

association after 2-4 weeks, via phone and email, to request a second distribution of the survey

link to increase the response rate.

Response rates were monitored throughout the study to ensure that any technical errors

were perceived and resolved. Participants were given full disclosure of the nature and purpose of

the study through an informed consent letter that was part of the online survey. Participation was

voluntary and anonymous, with the submission of the survey implied informed consent.

Data Collection

An approximate 6-week window was given for each association to participate, with the

overall the availability from May-November 2016. The total number of states that expressed

willingness to participate totaled 29, these included: Alabama, Arizona, Arkansas, California,

Connecticut, Delaware, Florida, Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland,

Massachusetts, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New York, North

Dakota, North Carolina, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Vermont,


Washington, & West Virginia. The District of Columbia physical therapy association expressed

willingness to participate as well.

Results

Part I-Demographic Information

Once data collection was ended, there were 286 participating respondents to the online

survey. Of the 29 states and District of Columbia that participated in this research project, 22 of

those states had at least 1 response. An additional 2 states were represented although the

associations of that state did not participate. In total, the respondents to this survey represented

24 states. Table 1 represents the states with the highest number of respondents.

Table 1

Respondents Primary Practicing State

State Frequency (%) of the Respondents

California 29 10.14

Florida 20 7.00

Iowa 103 36.01

New York 16 5.60

Nebraska 14 4.90

North Dakota 37 12.94

West Virginia 21 7.34

Other States 46 16.07

Total 286 100

Respondents were asked for their practice area and more than one answer was allowed.

Table 2 shows the most common practice areas chosen by the respondents. While

orthopedic/musculoskeletal and geriatrics represented the majority of areas in which respondents

practiced, the data represented all categories of practice.


Table 2

Respondents Areas of Practice

Area of Practice Frequency (%) of Respondents

Orthopedics/Musculoskeletal 179 62.59

Geriatrics 123 43.01

Adult Neurological Rehab 63 22.03

Cardiovascular & Pulmonary 46 16.08

Sports Physical Therapy 31 10.84

Other 91 (N/A)

The following table shows the patient populations with which the respondents provided

care. Again, respondents were provided the opportunity to respond to all patient populations

currently in their caseload. Table 3 includes the most common patient populations that were

reported. Once again, the respondents represented a broad spectrum of the patients commonly

seen in physical therapy practice.

Table 3

Patient Population Type

Patient Population Type Frequency % of Respondents

Musculoskeletal 165 61.12

Neurological 52 19.92

Cardiovascular 18 8.65

Pulmonary 14 7.41

Metabolic 9 5.36

Integumentary 3 1.89

Lymphatic 0 0


The current practice settings of responding PTs are found in the table below. Respondents

were able to choose more than one practice setting if applicable. These settings represent the most

common areas in which physical therapy is practiced throughout the US.

Table 4

Current Practice Setting

Practice Setting Frequency (%) of Respondents

Hospital Based Outpatient 87 30.42

Physical Therapy Owned 76 26.57

Acute Care Hospital 66 23.08

Home Care Agency 39 13.64

Skilled Nursing Facility 28 9.8

Other 51 17.83

Respondents were asked about the payor mix for their caseload in the past 6 months for

Medicare, other insurance, and private pay. The majority of respondents described their payor as

being made up of Medicare and other insurance, with 61% reporting that 1-25% of their patients

were private pay.

Respondents were asked if there was a policy regarding measurement/recording of vital

signs in the setting they work. Of the 285 that answered this question, 223 respondents (78.25%)

said ‘No’ and 62 respondents said ‘Yes’ (21.75%). For those that responded ‘Yes’, they were

given the opportunity to explain in more detail. Appendix A discusses the open-ended responses

and categorizes certain commonalities between the respondents.

Responses to the participants initial/entry level of PT degree is shown in the table below,

with a representative mix of Bachelor, Master, and DPT educated therapists.


Table 5

Entry Level Physical Therapy Degree

Degree Frequency Percentage of respondents

Certificate 27 9.44

Bachelors 73 25.52

Masters 80 27.97

DPT 106 37.06

Total 286 100

When asked for the highest-level degree earned, better than half of the respondents

indicated that they earned a DPT (Table 6). A total of 257 (90.81%) respondents answered ‘No’

and 26 (9.19%) answered ‘Yes’ if they had completed a residency and/or fellowship.

There were 213 (74.74%) respondents that answered ‘No’ and 72 (25.26%) answer ‘Yes’

if they had an American Board of Physical Therapy Specialty certification (ABPTS).

Table 6

Highest Degree Earned

Degree Frequency Percentage of respondents

Bachelors 39 13.78

Masters 59 20.85

Doctorate (Clinical/DPT) 156 55.12

Post-Professional doctorate 17 6.01

PhD/DSc 12 4.24

Total 283 100

Forty-seven percent of respondents were licensed for 0-15 years with 34% reporting

licensure for 16-30 years. The remaining 20% were licensed for over 30 years. Of the 286


respondents, 14 (4.90%) said ‘No’ & 272 (95.10%) said ‘Yes’ with being members of the

American Physical Therapy Association. Of those that said ‘Yes’, the length of membership

distribution was consistent with the length of licensure across the sample.

Part II-Practice Behaviors and Beliefs

This section of the survey asked the respondents specific questions about practice

behaviors and beliefs with the key vital signs this research focused on (HR, BP, and SpO2).

Also, respondents were asked questions regarding direct access in their state, Medicare and

assessing vital signs, and an open-ended question for additional comments.

The following results in this section answers the first research question ‘at what level of

frequency do physical therapists assess vital signs (HR, BP, and SpO2) with their patients’?

The first survey question in this section asked how often in the past 6 months have

respondents measured HR, BP, and SpO2 during the initial evaluation. The following table

shows the frequency of respondents assessing these vitals greater than 50% of the time during the

initial evaluation.

Table 7

Initial Evaluation: Respondents Reporting that they Assess HR, BP, and/or SpO2 greater than

50% of the time

Vital Sign Frequency Percentage of Respondents

Heart Rate 119 44.57

Blood Pressure 113 42.33

SpO2 93 34.97

Respondents were asked how often in the past 6 months have they taken BP, HR, and

SpO2 during treatment sessions. The following table shows the frequency of respondents

assessing these vitals greater than 50% of the time during their treatment sessions.


Table 8

Every Treatment Session: Respondents Reporting that they Assess HR, BP, and/or SpO2 greater

than 50% of the time




SpO2 83 31.20

Utilizing a Likert scale, respondents were asked their beliefs with the level of importance

for certain vital sign measurements being dependent on certain patients/conditions. The tables

below represent respondents’ level of importance as “somewhat” or “extremely important”.

Table 9

Assessment of Vitals on Certain Patients Some of the Time: Somewhat or Extremely Important




SpO2 237 89.10

Table 10

Assessment of Vitals on Patients with a History of Cardiovascular Disease each visit: Somewhat

or Extremely Important


Heart Rate 226 84.65%

Blood Pressure 218 81.65%

SpO2 201 75.85%

Heart Rate 91 34.08


Note. SpO2 on all patients each visit – not included on web survey


The most common reasons respondents expressed they did not take vital signs is in the

table below with frequency and percentage of the total responses.

Table 11

Most Common reasons for Physical Therapists to not assess vitals

Reason Frequency Percentage of Respondents

Not Important for My Patient

Population

104 41.77

Lack of Time 75 30.12

Vitals are measured by other

staff members at my clinic

67 26.91

Equipment not available 38 15.26

Other 63 (N/A)

The amount of time respondents expressed it took them to assess vitals is shown in the

table below, with frequency and percentage of the total responses.

Table 12

Average Time to Assess Vitals: HR, BP, & SpO2

Average Time Frequency Percentage of respondents

1-3 minutes 153 56.88

4-6 minutes 111 41.26

7-9 minutes 3 1.12

9+ minutes 2 <1

Total responses 269 100

Of the 265 respondents that answered the question regarding if they would recommend a

patient’s vitals be taken more often if there was someone else that could assess them, 112


(42.26%) said ‘No’ & 153 (57.74%) said ‘Yes’. Of the 268 respondents that answered the

question about living in a restricted or unrestricted state, 161 (60.07%) said they lived in an

‘unrestricted’ state, 87 (32.46%) said they lived in a ‘restricted’ state, and 20 (7.46%) said they

were ‘unsure’. For respondents who reported ‘unsure’, data was coded using reported state of

practice to record level of restriction of direct access for the respondent.

The second research question stated: ‘What is the relationship between the frequency of

physical therapists’ assessment of vital signs and the level of restriction of patient direct access?’

Analysis of the association between the variable of level of restriction of direct access and each of

the reported frequency of assessing vital signs during the initial evaluation and treatment sessions

was conducted. Strong and statistically significant associations were identified for each variable

with the level of restriction of direct access. The table below provides the Chi-Square and Phi

values for each relationship.

Table 13

Relationships Between State Direct Access Level and Vital Sign Assessment Frequency

Chi-Square Df p-value Phi (p)

IEHR 687.12 18 .000 1.049 (.000)

IEBP 674.45 16 .000 1.039 (.000)

IESpO2 653.21 16 .000 1.022 (.000)

TSHR 692.15 16 .000 1.052 (.000)

TSBP 695.45 16 .000 1.055 (.000)

TSSpO2 645.41 16 .000 1.016 (.000)

Note. IEHR=Initial Evaluation Heart Rate, IEBP=Initial Evaluation Blood Pressure,

IESpO2=Initial Evaluation Pulse Oximetry, TSHR=Treatment Session Heart rate,

TSBP=Treatment Session Blood Pressure, TSSpO2=Treatment Session Pulse Oximetry.

To learn more about respondents’ attitude about practicing under direct access, they were

asked ‘How confident do you feel working as a physical therapist under Unrestricted Direct

Access?’ The responses indicated a high level of confidence in practice (Table 15).


Table 14

Confidence with working as a Physical Therapist under Unrestricted Direct Access

Confidence Level Frequency Percentage of respondents

Not confident at all 0 0

Somewhat not confident 5 1.86

Neutral 21 7.81

Somewhat confident 85 31.60

Extremely confident 158 58.74

Total responses 269 100

With recent changes in Medicare requirements to measure vital signs such as

height/weight and blood pressure, it was of interest whether these changes had an effect in

therapists’ measurement of the three vital signs of interest in this study. Eight-seven responded

‘No’ and in regard to the question if recent Medicare requirements associated with patient

outcomes and payment for performance had any effect on their frequency of assessing vital signs.

Respondents were provided the opportunity to express any additional comments, so an

open-ended question was asked at the end of the survey. These 78 responses were compiled and

categorized by common themes and are included in Appendix B. The common themes to the

open-ended question responses included that vital sign measurement is important for all patients,

important for certain age groups, important for only certain patient types, only important for when

patients are exercising, are typically done by other health professionals, or are not done because

of time or lack of reliable equipment.

Discussion

This research, utilizing an online survey, was able to obtain 286 respondents to answer

questions to help understand how current practicing PTs from varying backgrounds assess vitals

around the U.S. Participants represented a mixture of PTs with varying years of experience, but


almost half of the respondents have worked as a PT for 0-15 years of experience. Almost all the

respondents to the survey reported being APTA members with varying years of membership and

more than half of the respondents have been members between 0-15 years.

Twenty-two state associations demonstrated interest in participating in the distribution of

the survey. Not all states were willing/able to participate for various reasons or researcher was

not able to get a hold of a representative after multiple attempts. There was skewed

representation for the states that did participate. The 7 states with the most frequency of

respondents represented 83.92% of total responses.

Respondents represented a variety of practice settings and patient types with the majority

working in outpatient settings with musculoskeletal and geriatric patient populations. This is

consistent with the previous study by Peters (2014) and may be representative of the distribution

of physical therapists within practice. It is less clear if there are differences in the behaviors and

beliefs of therapists in other practice settings and with other populations as they were less

represented in the sample.

The data indicates a lack of policy for vital sign assessment in the clinical facilities

represented in the sample. Policy for vital sign assessment was reported to be none for greater

than ¾ of the respondents showing a lack of focus on this aspect of patient care in many physical

therapy settings. This seems to show a similar pattern as the pilot study on vital sign assessment

in outpatient PT settings, by Josh Peters (2014) for the state of Florida, where policy for vital

signs is <30% according to responses. This present study does not seem to show a

comprehensive understanding of vital sign policy across all practice settings, due to the outpatient

setting being the most represented in the sample.

Most of the respondents were highly educated, with the initial degree being at the

graduate level for almost two-thirds of them (either masters or doctorate), and an even greater

number earning a clinical or academic doctorate as their highest degree. Most responders to the

survey did not express having a specialty certification (ABPTS) or that they completed a


residency or fellowship. Of those that do hold a specialty certification most have either an

orthopedic or geriatric ABPTS. There seems to be a pattern of similarity with the majority who

responded with having a specialty ABPTS and the majority of respondents reporting their area of

practice being in orthopedics/musculoskeletal and/or geriatrics. The respondents with geriatric

ABPTS demonstrated higher support in taking HR, BP, and SpO2, as they reported they would

with over half of their patient population during initial evaluations. Therapists with an orthopedic

ABPTS reported they were of lesser support of taking HR, BP, and SpO2, as they reported they

would not assess these vitals with over half of their patient population during the initial

evaluation. This may be due to the PT respondents reasoning regarding their patient population

they work with and feelings about this. The most common reasons that geriatric specialty

certified respondents expressed for why vitals are not measured was that either their patient was

young and medically stable or that others measure the vital signs already at other medical visits.

Orthopedic specialty certified respondents expressed that it was not important for their patient

population and approximately one-third expressed a lack of time. The results are similar and

appear to support the pattern of results found in the pilot study by Peters (2014). Although other

areas of practice may have differing reasons for why vital signs are not assessed, these data

provide insight into the similar reasons of why a PT may or may not take vitals.

Data were able to address the research questions for this study. The hypothesis for the

first research question is supported with the current research. Results indicate that vital sign

assessment of BP, HR, and SpO2 occur at a frequency significantly less than every patient visit.

The results for assessment of SpO2 for initial patient visit and following treatments were less than

for HR and BP. A technical error did not allow for the collection of data on frequency of SpO2

measurement during regular treatment sessions. Most respondents expressed that they did not feel

that taking vital signs of HR and BP for all patients all the time was important. More expressed

that it was important to take vital signs of HR, BP, and SpO2 during initial evaluation than for

every treatment visit, but even taking vitals at initial evaluation occurred less than half the time


for the respondents’ patient caseloads in the past 6 months. Again, HR and BP was measured

more than SpO2. There was similarity in that a majority of the respondents do feel that taking

vitals of BP, HR, and SpO2 are important for some patients some of the time and for patients with

cardiovascular known diseases, supporting Peters (2014) findings.

As mentioned earlier, many respondents who participated in this online survey, reported

that assessing vitals was dependent on their patient population, which was the top reason for why

these vital signs are not taken. Also, lack of time or others are taking the vital signs were

frequent reasons to why HR, BP, and/or SpO2 are not taken. It is important to highlight that

asked about the time it would take to assess vitals, over half of the therapists said it would take

one to three minutes to assess and almost all said it would take between one and six minutes. It

appears that almost all respondents would take less time than one billable unit, which is eight

minutes (Jannenga, 2016), to assess vitals.

Secondly, this research attempted to investigate the relationship between state direct

access to physical therapy and the frequency of measurement of vital signs. The data did not

support the hypothesis for research question two. The hypothesis was that there will be a greater

frequency of assessment of vital signs (BP, HR, SpO2) among physical therapists in states with

unrestricted access than in states with restricted access. There was statistically significant

relationship between the variables of level of direct access and frequency of measuring vital

signs, with a greater frequency of respondents in restricted direct access states measuring HR, BP,

and SpO2 than therapists in unrestricted direct access states during both initial evaluations and

during treatment sessions. Additionally, there was close to two-times more respondents that live

in unrestricted vs. restricted states according to the survey results. Due to a smaller sample size

of under 300, generalization of these results and conclusions are limited. Future research is

necessary to get a firm understanding of vital sign assessment with unrestricted and restricted

states.


Lastly, Medicare reimbursement was the greatest for the respondents to this survey

followed by other insurance providers. Very few providers had private pay in their payor mix. A

majority of the responding PTs do not feel that Medicare requirements associated with patient

outcomes and payment for performance are affecting their frequency of assessing vital signs. It

will be important to continue to monitor how reimbursement shapes the practice of physical

therapist in these health monitoring measures.

When asked if the responding PTs would have their patients’ vitals assessed more often if

there was a qualified person to assess them, there were mixed feelings about this with ~15% more

saying ‘yes’ than ‘no’.

This study gathered further information regarding the thoughts, feelings, and practice of

vital sign assessment through the inclusion of an open-ended question. Of the 78 respondents that

remarked to this question, certain trends were noted. The most frequent responses, as discussed

in the results, were: Vital sign assessment is important for all patients; vital sign assessment is

important but limited by time/equipment and/or availability/reliable supply issues; vital sign

assessment is important especially for cardio/pulmonary compromised patients; and vital sign

assessment is important for certain patients (e.g., past medical history/symptoms). One can see

the diversity in the comments but also the cohesiveness. All of these responses attest that vital

signs are important, but the difference lies with which patients and how often. Although most

PTs do not feel assessing vitals is important every patient visit, many PTs do. As patients in all

practice settings continue to have more comorbidities, there may be a shift in PTs practice of the

measurement of these vital signs.

There are a few limitations to this study. First, by using an internet-based survey, not

everyone is willing to take a survey online, with some people being more comfortable with other

methods (e.g., paper or phone surveys). Second, distribution of the survey was reliant on state

physical therapy associations. Most of the physical therapists obtaining the online survey were

likely to be members of that association. Not all of the state associations were willing to


participate, some expressing that it would be too much to take on every research project from

around the country so they only take projects from within the state. Some of the states did not

respond which decreased the geographic representation of the survey results. Also, each state

association participating was allowed to disperse the survey as they saw fit. State associations

were provided a variety of methods: email blast, placing on the website, to sending it out in a

news-letter. It is not fully known how each state dispersed the survey and how many times they

dispersed the survey. This may have had an effect on the number of responses from each state.

Obtaining input from physical therapists not associated with state association would have been

difficult to achieve due to the privacy of contact information for licensed physical therapists.

Continued analysis of the data obtained in this research project will be important to

determine the various relationships that may exist. Further data collection in states and practice

areas that are underrepresented may improve the understanding of the practice of vital sign

assessment across all areas of practice. Due to many respondents utilizing other methods of vital

sign assessment, having research focused on different vital sign assessment (e.g., BMI, pain,

temperature, RR) or in combination with the vitals researched in this project would be beneficial.

The responses from the open-ended questions may inform further research. Many

therapists expressed that an older population would require vital sign assessment more than a

younger population. Future research that specifically focuses on vital sign assessment among the

older adult population would be beneficial to determine how often vital signs are assessed in this

higher risk population, and how many negative medical events are lessened by detection of

cardiac pathologies.

Conclusion

Vital sign assessment among many health care providers allows the practitioner to

develop an initial plan of action for patient care and identify serious health issues in patients.

These measures are quick, easy, and objective methods to determine a patient’s general health

status. Physical therapists are well educated to both measure and interpret the findings of these


measures within their role as primary care providers. This research provides a better

understanding of vital sign assessment among physical therapists in various regions around the

U.S. Further research will continue to add to the understanding of practice.

Assessing vitals is not just pertinent for patient care that treatment session, but may

provide valuable insight on that patient’s current status, which may be known or unknown.

Physical therapists being primary health care providers need to be part of the health care team in

identifying signs of pathology in patients. Physical Therapists are able to provide valuable

information regarding vital sign assessment that will inform physicians, nurses, rehabilitation

specialists, and other health care providers. Increasing the comprehensiveness of patient care and

communication between health care providers benefits both patients and the health care system.

As mentioned previously, cardiovascular disease is the number one cause of death among

people in the United States. Vital sign assessment utilizing HR, BP, and SpO2 may show warning

signs that could save a persons’ life. This practice is not just for the immediate treatment session,

but could also be a key indicator for some complication that may warrant a referral or

communication with that patient’s physician’s office. As many respondents in this survey

mentioned, by assessing vitals, some of their patients’ lives were saved because they contacted

that patient’s physician about an abnormality with their patients’ vitals.

It can be questioned if are vital sign assessments should just be taken at one treatment

session or is this a measure that should be regularly assessed for rapid detection of underlying

pathology. These measures, once done regularly, were not reported to be difficult or time

consuming to assess, based on survey results. Once part of routine practice, these objective

measures can provide insight for each patient’s cardiovascular health and prevention of further

health events.


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Appendices

Appendix (A): Question 6b-Open Ended Responses, Synopsis/Report

In total, question 6b (Please Describe the Policy) received 52 responses of the total 285

responses to Question 6a. Question 6a (Does your clinic have a policy regarding the

measurement/recording of vital signs? Yes or No) had 62 responses that marked ‘Yes’. This

survey only allowed a participant to respond to 6b if they marked ‘Yes’ for 6a.

Most of the responses expressed vital sign assessment was done, mandatory, highly

expected, should do, etc. Since this research study did not get actual organization policy

documents, the complete understanding is not going to be fully understood. It still gives valuable

information to how the PT profession is currently regarding vital sign assessment, for example,

out of the 285 that responded to Question 6a, 21.75% of the respondents marked ‘Yes’ that their

organization had a policy on vital sign assignment. The participants that marked ‘No’

represented 78.25% of the respondents; there are multiple reasons why a respondent marked

‘No’, further research would need to be conducted to determine these specifics.

The researchers grouped the 52 responses into the following categories, based off of the

survey participants’ responses to question 6b:

• Are required to take ‘Vitals’ during the evaluation and during proceeding treatment

sessions: 22

• Required during evaluations but at their discretion for subsequent patient treatments:

12

• Evaluations and treatments of patients were at the therapists’

discretion/recommended by organization but not mandatory: 5

• Vitals are required to take for all company pre-work screens, but at therapist

discretion for other patients based on PMHx and symptoms: 2

• Had to report the ‘pain’ vital sign only: 1


Appendix (A): Question 6b-Open Ended Responses, Synopsis/Report (continued)

• Acute Care Patients needed vitals to be monitored: 1

• Computer Updates: 1

• Pre-employment vital sign assessment tests: 1

• All Medicare patients’ vitals are to be taken at evaluation and at PT discretion during

treatments & all non-Medicare is at PT discretion during evaluation and during

treatments but encouraged: 1

• All Medicare patients’ height and weight are recorded for BMI but they do not take

HR or BP: 1

It was difficult to determine which vital signs, specifically, the respondents to this survey

are required, expected, highly encouraged, recommended, deemed appropriate, etc. at their

organization of employment. A few mentioned specifics, but not enough to where clarifying

would gain any realistic understanding, as a whole, for this research project, in regard to vital sign

assessment. Health care providers know that vital signs encompass multiple items used to assess a

patient’s health status. Each vital sign helps the health care provider, and for the purpose of this

research project, the Physical Therapist health care provider to determine pathological conditions

of their patients or lack there-of. The survey respondents, whom did not clarify in their responses,

may have been referring to this research projects focus of the three vital signs BP, HR, and SpO2,

but the researchers are not assuming that, since the respondents did not specify!


Appendix (B): Question 22-Open Ended Responses, Synopsis/Report

Of the 78 relevant responses (not reporting respondents saying, N/A, No, or other

responses similar) the researchers found that 19 of the 62 respondents (31.1%) that answered

‘Yes’ to question 6a (Does your clinic have a policy regarding the measurement/recording of vital

signs?), made it to the end of the survey and responded to question 22. The remaining 59

respondents to question 22 marked ‘no’ to question 6a. There were 206 participants that marked

‘no’ to question 6a, so 28.6% of those respondents made additional comments to this question.

The responses obtained for this question have been categorized based off the

interpretation of what the participating responders shared. Some shared one thought others shared

multiple thoughts. A person that shared multiple thoughts will be included in all the categories

that they shared in their response. Below are frequency of responders and categories of this open-

ended question’s responses set up by the researchers:

• Vital sign assessment is important for All patients: 17

• Vital sign assessment is important but time/equipment availability/reliable supplies

issues: 12

• Vital sign assessment is important especially for cardio/pulmonary compromised

patients: 11

• Vital sign assessment is important for certain patients (e.g., Past Medical History,

Symptoms): 10

• Vital sign assessment is important for certain age groups (e.g., older vs. younger

population): 8

• Vital sign important due to Physical Therapists being active/exercising patients: 8

• Vital sign assessment in certain settings are not as important unless signs/symptoms

due to other staff (e.g., nurses) and/or machines take them: 7

• Vital sign assessment depends on the setting a Physical Therapist works: 5


Appendix (B): Question 22-Open Ended Responses, Synopsis/Report (continued)

• Educators & clinicians should teach the importance of vital sign assessment more: 4

• Vital sign assessment in OP settings is lacking: 4

• Physical Therapists under-utilize this aspect of care: 3

• Vital sign assessment important at least during the initial evaluation of a patient: 3

• Vital sign assessment is important as it could find an abnormality that could help a

patient’s quality of life/save their life: 2

• Important with helping Physicians with patient care: 2

• Important to educate patients to self-assess their own vitals as well: 2

• If I had a PT tech I would do it more regularly: 2

• Only response was that they take Rate of Perceived Exertion: 1

• Vital sign assessment is bothersome to certain patients: 1

• Importance of vital sign assessment and justifying services/progress made: 1

• Respondents expressed that in addition to the one’s mentioned in the study the

following are also important:

o Temperature (Temp): 1

o Temp & Pain: 1

o Temp and Respiratory Rate (RR): 1

o Walking Speed & Weight for certain patients (e.g. Congestive Heart Failure): 1

o RR & pedal pulses: 1

o Bruits & Cardiac/Lung sounds when appropriate: 1

• Should be done regularly but am an older clinician and feel that other older clinicians

would be less likely to as well: 1

• Physical Therapy is a Doctoring Profession: 1



• Measure Vitals with Rest & Activity as well as assist Medical Doctor with diagnosis

and medicine changes that make significant improvement in patients’ lives: 1

• Patients are unable to see the physician as regularly, Physical Therapists are their

more regular line of health care: 1

• Specifically mentioned that Blood Pressure and Heart Rate as Important: 1

• Need Physician approval for SpO2: 1

• Physical therapists should be able to assess SpO2 without physician approval as some

non-respiratory patients whose O2 saturation may drop need that type of assessment:

1

• Important of All practice settings: 1

• Imperative for unrestricted direct access: 1

• Use of subjective vital sign assessment more (e.g., facial features, breathing patterns):

1

• Do not rely on heart rate as much as RPE due to many patients taking beta-blockers:

1

• Should be more consistent with taking vitals on patients: 1

• Uncertainty with what to do if the numbers of a patient’s vitals are bad, do I send

them home or monitor them: 1

• May not bring in axillary equipment for vital sign assessment in a patient’s room

with infection control issues: 1

• Vital sign assessment is in a Physical Therapists scope of practice, if we do not do it

then we are essentially giving up that part of our practice: 1

• Others do it so I don’t have to: 1



• Work in a program with patients who have chronic illnesses so I take them regularly:

1

• Document what the machines or nurse document as this facility has policies that

certain machines be utilized to take vitals, but these are limited (3 machines per 25

patients): 1

• As physical therapist professionals, we should be able to make up our own minds

when vital sign assessment should be taken with patients: 1

• Important to assess vitals due to what physical therapists do to the lungs, heart, and

oxygen consumption, plus need to be confident with vital sign assessment: 1

• The leaders in the settings that physical therapists work need to have the vital sign

assessment tools readily available: 1

• Need to review vital sign assessment skills: 1

• Needed cleared guidelines for all physical therapists on vital sign assessment: 1

• More physical therapists should take vitals more often: 1

• Recent APTA or Cardiology Association guidelines, not sure which, say that it is safe

to work with patients that have a Blood Pressure that is higher than I am comfortable

with: 1

In addition to the above responses to vital sign assessment certain responders made other

remarks about vital sign assessment, physical therapy practice, and patient care. These remarks,

show variances in practice patterns, shed insight to other issues/concerns that may need to be

addressed with further research to help improve physical therapists’ autonomy, practice setting,

and/or patient care:



“The pay for performance and value based purchasing system essentially discriminates

against those really ill or physically challenged. That is providers will be financially

penalized for not making good outcomes and so have negative reason to accept and service those

individuals.”

“I unfortunately just had to terminate a DPT student on final affiliation for multiple

reasons, lack of monitoring vital sign responses to treatment & interventions being one of them.”

“Vital signs…can be very helpful for getting patients with cardiovascular and pulmonary

histories more visits (in outpatient) or an increased length of stay (inpatient).”

“Although my state…has restricted DA, I am a hospital-based PT and we are still bound

by a decades-old regulation called Title 22, which requires us to have Dr. Diagnosis and signed

plan of care. So, essentially in my setting, I cannot yet practice DA.”

“It is dangerous to not measure vital signs in each patient.”

“Physical therapists are part of the Professional Continuum of Care needed for providing

and achieving optimal patient care.”

“It is an essential part of good practice. In diabetic patients, I also ask for recent blood

glucose readings or ask the patient to test before exercise.”

“With a non-verbal population it is more than necessary to be able to constantly be

‘reading’ and being sensitive to physical cues via clinical observation, including but not limited to

the following: energy level fatigue…respiratory rate…respiratory pattern use of diaphragm, use

of accessory muscles, changes in lips, skin, fingers.”

“What about PTs reconciling meds like beta blockers? That is equally important as well.”

“Should be done but not sure some of the old dogs…me included will change willingly.”

“Temperature and respiration should be included. In direct access/primary care you will

encounter patients with infections that have Msk referral.”

“Find that many times the wrong size cuff is used or done to quickly to obtain accurate

information.”

“I see lots of young athletes. I do not regularly take a BP on these patients. When I see

older adults, I ALWAYS take BP.”

“Typical patient is a 0-3 year old child in a home or an older school child…training

parents/school staff on activities. Typically this does not warrant vital sign assessment. I do have

one baby with some heart issues and parents and I both watch vital signs closely.”

vital sign assessment

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