Wound Debridement

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Is wound debridement within the scope of practice of a physical therapist and; if so, may a physical therapist assistant do wound debridement?

The Physical Therapy Board of California (Board) (name change effective January 1, 1997) was requested to address the issue of physical therapists performing sharp debridement of nonviable tissue in relation to their scope of practice. The issue was discussed at the February 3, 1995, meeting of what was then named the Physical Therapy Examining Committee (Committee). The position of the Board on this issue is as follows.

Dorland's Medical Dictionary, 27th edition, defines debride as "To remove foreign material and contaminated or devitalized tissue, usually by sharp dissection."

The scope of practice of physical therapy is defined in Section 2620 of the Business and Professions Code as follows:

"Physical therapy means the art and science of physical or corrective rehabilitation or of physical or corrective treatment of any bodily or mental condition of any person by the use of physical, chemical, and other properties, heat, light, water, electricity, sound, massage and active, passive, and resistive exercise, and shall include physical therapy evaluation, treatment planning, instruction, and consultative services. The use of roentgen rays and radioactive materials, for diagnostic and therapeutic purposes, and the use of electricity for surgical purposes, including cauterization, are not authorized under the term "physical therapy" as used in this chapter, and a license issued pursuant to this chapter does not authorize the diagnosis of disease."

A physical therapist is not authorized to sever or penetrate any viable or living tissue, except as provided in section 2620.5 in order to perform a neuromuscular evaluation.

Debridement is performed by the use of sharp instruments including, but not limited to, scalpel, scissors, forceps or tweezers. Debridement of devitalized tissue is not to be confused with surgical debridement, which is to be performed by a physician and includes the removal of both devitalized and vitalized tissues. Physical therapists by education and training should be able to differentiate between necrotic, nonviable tissue, and viable tissues.

It is the official position of the Physical Therapy Board of California that, with appropriate training, physical therapists can perform debridement of nonviable tissue. Furthermore, it is the position of the Board that physical therapists may utilize sharp instruments such as scalpels, scissors, forceps, tweezers and other appropriate instruments to perform debridement.

The Board's official position on debridement is primarily based on the evolution of physical therapists' involvement in wound care management. Wound care management is also included in the evaluative criteria for accreditation of physical therapist programs by the Commission on Accreditation in Physical Therapy Education, American Physical Therapy Association. Wound care management includes debridement, as it has become an accepted treatment protocol over many years. Debridement, like many other procedures, originated in the clinical setting rather than the academic setting. The theory of wound care and the skills to effectively and safely perform debridement are currently identified in the academic setting, while the opportunity for students to apply and perfect the techniques of debridement exists in the clinical setting. In fact, according to a survey conducted by the Santa Clara Valley Medical Center, of 159 responding California acute care facilities, over 90% indicated debridement was performed by their physical therapy staff.

The Physical Therapy Board of California was also requested to address the issue of properly supervised physical therapist assistants performing debridement of nonviable tissue.

Section 2620 (above) defines the practice of physical therapy referring to the various modalities authorized by the issuance of that license.

A physical therapist assistant is a person who is approved, by the Board "to assist in the provision of physical therapy under the supervision of a physical therapist who shall be responsible for the extent, kind and quality of the services provided by the physical therapist assistant." (Section 2655, subd. (b).)

Section 2655.7 provides:

"Notwithstanding the provisions of Section 2630, a physical therapist assistant may assist in the provision of physical therapy service provided the assistance is rendered under the supervision of a physical therapist licensed by the Board."

There are no other provisions in the practice act which set forth a scope of practice for physical therapists or otherwise detail the modalities which an assistant may utilize in their practice. While the regulations adopted by the Board set forth requirements for the adequate supervision of physical therapist assistants, they do not otherwise address a scope of practice for assistants. Thus, the only mention of the authorized practice of a physical therapist assistant is set forth in the language of Section 2655.7 above.

The applicable statute (Section 2655) does not reveal any limitation on the practice of a physical therapist assistant by task, however, they, along with the Physical Therapy Regulations, limit the practice of the assistant by the supervision required by a licensed physical therapist. In Title 16 Cal. Code Reg. Section 1938.44 the Board has set forth specific supervision requirements for practice by physical therapist assistants.

Section 2655.7, authorizes that a physical therapist assistant may assist without limitation a supervising therapist in the provision of physical therapy services which the supervisor himself or herself may perform. It is clear from reading both Sections 2630 and 2655.7 that the general licensure requirements for the practice of physical therapy do not apply to the physical therapist assistant who is approved by the Board and appropriately supervised by a licensed physical therapist. Thus, the general purpose of the statutes authorizing the approval and utilization of physical therapist assistants appears to be to allow the licensed therapist to use the assistant in all aspects of physical therapy practice with the condition that the assistant be appropriately supervised when providing such assistance.

As it has been determined that a physical therapist assistant may assist the licensed therapist in any physical therapy services without limitation, subject to adequate supervision by the licensed physical therapist, the physical therapist assistant in accordance with the Physical Therapy Practice Act and the Physical Therapy Regulations may, with appropriate training, perform debridement.

Therefore, the Board concludes that with appropriate training, debridement may be performed by a physical therapist and may be delegated to a properly trained physical therapist assistant.

Note: This document is not a declaratory opinion of the Physical Therapy Board California.

Adopted by the Physical Therapy Examining Committee on February 3, 1995