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Breaking the Mould - Physiotherapy's new advanced role in critical care

Photo: Physiotherapy's new advanced role in critical care
It’s no surprise that Dr Scott Bradley can’t envisage working outside the walls of The Alfred Hospital’s Intensive Care Unit (ICU).

“I can’t imagine working anywhere else and I can’t imagine doing anything else - I find this work very rewarding,” he says.

The Melbourne hospital is not only home to one of the largest ICUs in Australia, with the most complex case mix, it’s also leading the way when it comes to taking physiotherapy to an entire new level of patient treatment and care.

The Alfred is the only known hospital in Australia, and only the second in the world after London’s Guy’s and St Thomas’ Hospital, to have advanced respiratory physiotherapists performing bronchoscopies in ICU.
Last year, the hospital established an advanced scope of practice for senior ICU physiotherapists, enabling them to complete education and training to perform bronchoscopies, a procedure usually reserved for senior respiratory or ICU doctors.

These advanced respiratory physiotherapists are able to insert a bronchoscope into an intubated patient’s airways, enabling them to examine and clear any abnormalities such as secretions and foreign bodies.

Dr Bradley, a senior physiotherapist with more than 23 years’ experience, says the advanced role is an extension of physiotherapy’s respiratory management for critical care patients.

“I think performing bronchoscopies really does play to our strengths - we have excellent physiology and anatomy knowledge of the lungs and of breathing,” he says.

“The advantage of physiotherapists doing bronchoscopies is that we can navigate around the airways really well, we can remove secretions really well, and in addition to that we can then use the findings from the bronchoscopy to help work out what treatments the patients are going to need on an ongoing basis.

“It’s an extra string to the bow in the respiratory management of our patients.”

The advanced respiratory physiotherapists use a bronchoscope; a flexible tube fitted with real-time video equipment, enabling them to view and navigate into different parts of the lungs, all while the critical care patient remains connected to a ventilator.

“What the tube also allows you to do is not only see the airways but it allows you to make impressions of whether the airways are burnt, is there bleeding in the airways, is there infection in the airways?

“It allows you to also try to remove those secretions and probably at a higher level, if there was something sinister like a broken tooth that the patient has aspirated into their airways or some sort of foreign body, it allows you to take those foreign bodies out as well,” Dr Bradley says.

The physiotherapist is then able to determine the next course of action to take, whether it’s positioning the patient to enable the secretions to drain, taking deep breaths through the ventilator, or undertaking the challenging task of getting patients moving out of bed while still connected to the ventilator and breathing tube.

Around 3000 patients each year are admitted to The Alfred’s ICU, ranging from those with sepsis and acute respiratory distress syndrome to those with major trauma injuries and complex major burns.

The role of physiotherapists in critical care has evolved in the past 20 to 30 years, with physiotherapists now assisting patients to regain mobility and improve their endurance as well as helping patients to improve their breathing through respiratory care.

Dr Bradley says he first began exploring the potential for senior ICU physiotherapists to perform bronchoscopies about six years ago while working alongside senior ICU consultant Professor David Pilcher, who had previously worked at the renowned Guy’s and St Thomas’ Hospital.

Realising the advantages of physiotherapists performing bronchoscopies, Dr Bradley and his ICU physiotherapy team then sought support for the move from the hospital, the ICU medical team, the respiratory medical team, nursing colleagues and also, importantly, from their pharmacy colleagues.

“The procedure requires a change in the sedation of the pharmacy management of the patients so that’s relatively easy to do when you’ve got a doctor performing it, because obviously doctors can prescribe,” he says.

“It’s been a bit more challenging when only a nurse and a physiotherapist are in the room at the time that the bronchoscopy is being undertaken.

“Our pharmacy staff have been really fabulous in helping develop a protocol for sedation that we can use during the bronchoscopy - something that can be pre-prescribed by the medical staff and then administered by the nursing staff.”

Equipped with an advanced practice allied health grant from the Victorian Department of Health and Human Services, The Alfred developed a competency standard, credentialing framework and education resources for the advanced role.

As part of the initiative, physiotherapists are taught to recognise and seek assistance for patient safety risks outside the scope of their training.

Dr Bradley says physiotherapists are not performing bronchoscopies on high-risk patients, such as transplant and artificial heart patients.

“Making sure that you choose the right patients I think is important for patient safety and with competence as well,” he says.

Although in its early stages, the advanced respiratory physiotherapy bronchoscopy role has been so well received, The Alfred has begun training experienced ICU physiotherapists with postgraduate qualifications from other hospitals around Australia to perform bronchoscopies.

Dr Bradley says the level of support that he and his ICU physiotherapy team has received from colleagues at The Alfred has been overwhelming, resulting in more opportunities to pursue other advanced practice roles.

“I thought there would be a push back of some resistance but in fact it’s been completely the opposite,” he says.

“This, if anything, has actually increased the teamwork of the professions - between physiotherapy, medical, nursing and pharmacy, and we’re working on other things that we might be able to do down the track.

“It’s reconfirmed the mutual respect we have for each other.”

The ICU physiotherapy team also hopes to develop other advanced modules for physiotherapists, such as performing bedside chest ultrasounds, which now lie outside the scope of practice for physiotherapists.

Dr Bradley is thrilled that The Alfred's ICU is at the forefront of innovative physiotherapy practice.

“I think it’s really good for our up and coming staff to see what sort of role they can play in intensive care,” he says.

“Physiotherapists can be really integral to the patient’s care and the patient’s respiratory management.”

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Karen Keast

Karen Keast is a freelance health journalist who writes news and feature articles for HealthTimes.

Karen regularly writes for some of Australia’s leading health news websites and magazines.  In a media career spanning 20 years, Karen has worked as a senior journalist in newspapers and television. She has covered the grind of daily news and worked as a politics reporter at countless state and federal elections.

Since venturing into freelance writing five years ago, Karen has found her niche in writing about the health sector for editors, businesses and corporations.

Karen has interviewed the heads of peak health organisations in Australia and overseas, and written hundreds of news and feature articles covering the dedicated work of health professionals who tread the corridors of hospitals and health services, universities, aged care facilities and practices, day in and day out.

Follow Karen Keast on Twitter @stylemywords