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Service Delivery Innovation Profile

Hospital Employs Emergency Department–Based Physical Therapists, Leading to Improved Quality, Efficiency, and Patient/Physician Satisfaction


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Snapshot

Summary

Carondelet St. Joseph's Hospital uses emergency department–based physical therapists to serve the needs of patients with musculoskeletal complaints. Physical therapists work in the emergency department during daytime hours 7 days a week, contributing to the diagnosis, treatment, and education of patients in cases where physicians request their assistance. Although no formal program evaluation has been conducted, anecdotal reports and internal surveys suggest that the program has improved care (leading to faster recovery and fewer return visits), resulted in more efficient use of hospital resources (including fewer unnecessary imaging tests), and increased patient and physician satisfaction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of anecdotal reports from hospital staff and internal surveys of patients and physicians.
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Developing Organizations

Carondelet St. Joseph's Hospital
Tucson, AZend do

Use By Other Organizations

Flagstaff Medical Center in Flagstaff, AZ, and Clarian Health Systems in Indianapolis, IN, also use full-time PTs in the ED. Virginia Mason Medical Center in Seattle, WA, uses a related model whereby ED physicians make direct referrals to PTs from the ED.

Date First Implemented

1998

Problem Addressed

A significant percentage of patients who go to the emergency department (ED) have nonemergent or relatively minor musculoskeletal complaints. Busy ED physicians do not always have the time, specialized knowledge, or resources to provide the best possible care for these patients. Although physical therapists (PTs) with musculoskeletal expertise can function as a valuable supplement to the care provided by ED physicians, relatively few EDs have them on staff.
  • Many ED patients have nonemergent or relatively minor musculoskeletal complaints: Many ED patients present with musculoskeletal complaints that are not life threatening or major injuries. Often, these patients are experiencing exacerbations of chronic conditions such as back or neck pain, and they come to the ED either because they lack health insurance or the wait to see their primary care physician is too long. Others have relatively minor acute injuries, such as sprained ankles, knees, or backs, that do not require surgery or specialist consultation by an orthopedic surgeon.1
  • Inadequate time and specialized knowledge to provide optimal care: ED physicians, although expert in providing generalized care, may be less efficient than musculoskeletal specialists in treating musculoskeletal problems due to time constraints and a tendency to screen, stabilize, and refer patients rather than provide extensive onsite intervention. For example, ED physicians often immobilize patients by using crutches, casts, cervical collars, and bed rest, even though some of these patients would likely recover more quickly if they started using the injured body part or returned to daily activities sooner. ED physicians also frequently do not give patients detailed instructions on how to treat their injury at home or may not recommend outpatient physical therapy in cases in which the patients would benefit from it.2
  • Unrealized potential of PTs: PTs have undergone intensive training (including learning about established clinical guidelines) on topics such as clinical anatomy and common soft tissue injuries, giving them the expertise and knowledge needed to handle minor musculoskeletal complaints effectively. They are skilled in treatments that help patients recover as quickly as possible, such as spinal manipulation, joint mobilization, therapeutic exercise prescription, and education regarding the PRICE method (protection, rest, ice, compression, and elevation). Moreover, by focusing on a select group of patients, they can be available to provide detailed instructions on self-care, and, if necessary, recommend outpatient physical therapy.3 Despite these potential benefits, few EDs have PTs on staff.

What They Did

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Description of the Innovative Activity

Carondelet St. Joseph's Hospital employs two full-time PTs in its ED, with outpatient PTs providing supplemental coverage during other times. PTs contribute to the diagnosis, treatment, and education of patients with relatively minor musculoskeletal problems, in cases where ED physicians request their assistance. Key elements of the program are described below:
  • Full-time coverage: At least one PT is on duty 7 days a week, from 9 a.m. to 7 p.m. on weekdays and from 11 a.m. to 7 p.m. on weekends. This schedule typically reflects the highest volume times in the ED but can change periodically to accommodate PT staffing availability. Two PTs are dedicated to the ED, while other PTs who normally work in the hospital's outpatient clinic provide supplemental coverage when the dedicated PTs are not available.
  • Functioning as "as-needed" consultants: PTs are integrated into ED care in a manner similar to consulting physicians, such as psychiatrists and orthopedic surgeons. ED physicians see the patient first, then request PT assistance via pager at their discretion. After the PT assesses and treats the patient, interventions are verbally communicated to the physician.
  • Core responsibilities in diagnosis, treatment, and education: When called, PTs spend an average of 40 minutes with each patient (but can spend as much as 90 minutes for those requiring indepth evaluations, such as an elderly person with a history of falls). When time permits, PTs also assist ED nurses in triage. Key areas of PT involvement in patient care include the following:
    • Assistance with diagnoses: ED physicians often collaborate with and seek feedback from PTs in diagnosing patients. This includes soliciting their views on whether imaging tests are likely to be beneficial.
    • Direct treatment: PTs evaluate and treat patients with chronic and acute musculoskeletal pain, with the most common complaints being low back and neck/head pain. Other common complaints treated by PTs include pain in the hip/knee, shoulder, foot/ankle, thorax/rib, and elbow/hand/wrist. PTs also treat patients with vertigo, safety/mobility issues, and acute and chronic wounds.
    • Patient education and instruction: PTs give patients detailed oral and written instructions on how to reduce pain and enhance recovery in the days following their ED visit, covering topics such as effective use of physical modalities, when to begin putting weight on the injured body part, appropriate exercises and/or activity modifications as indicated, and potential complications that should trigger a call to the doctor or return to the hospital.
    • Referrals for outpatient care: When appropriate, PTs explain the benefits of outpatient followup care to patients, providing information on treatment options and instructions on how to contact their insurance company to learn about covered services.

Context of the Innovation

Carondelet St. Joseph's Hospital, a 309-bed facility in Tucson, AZ, offers a full range of hospital services, including a 24-hour ED and an orthopedic and rehabilitation services department. In the late 1990s, hospital leaders noticed that a growing number of ED patients with musculoskeletal complaints were not always receiving prompt or efficient care. At the same time, an internal review stemming from a larger restructuring effort found that outpatient PT services were underutilized. ED physicians occasionally used outpatient PTs on a consulting basis, which led to informal discussions in 1997 about shifting one or more PTs to the ED setting.

Did It Work?

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Results

Although no formal program evaluation has been conducted, anecdotal reports and internal surveys suggest the use of PTs in the ED has improved quality, enhanced efficiency, and increased patient and physician satisfaction.
  • Better treatment: ED clinicians believe the program has helped patients with musculoskeletal problems recover more quickly; reduced use of pain medications (and associated addictions) and return visits to the ED (due to reinjury); and enhanced access to outpatient physical therapy. In addition, ED physicians can now spend more time with patients who are severely ill or injured, thus enhancing their care.
  • More efficient use of hospital resources: Clinicians report that patients are now less likely to receive unnecessary imaging tests or be admitted to the hospital in cases where it is safe for them to return home.
  • Enhanced patient and physician satisfaction: Internal hospital surveys show that overall patient satisfaction has improved since PTs started working in the ED, and that patients who see PTs during ED visits report very high levels of satisfaction. For example, given four choices ("very beneficial," "beneficial," "neutral," and "not beneficial"), 80 percent of patients thought PT-ED services were "very beneficial" and 20 percent felt they were "beneficial." None chose the other categories. Also, ED physicians report that having the PT available has made their job easier and helped them to provide better quality care. A physician survey found 100 percent of ED physicians were "very satisfied" or "satisfied" with the program.

Evidence Rating (What is this?)

Suggestive: The evidence consists of anecdotal reports from hospital staff and internal surveys of patients and physicians.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Initial meetings and research: ED physicians, physical therapists, and senior hospital officials met several times to discuss how the practice could be designed to provide maximum benefit to ED physicians and patients. They also conducted a review of the literature and other research but found no other hospitals using this approach.
  • Training/education: Before launching the pilot of the new practice, a series of meetings were held at which all ED staff (including physicians) were introduced to the concept and advised on how best to use the PTs. One critical element was highlighting areas of physical therapy that are not well known among physicians, such as the treatment of vertigo.
  • Pilot testing: In 1998, the hospital implemented the concept on a trial basis, with PTs covering the ED from 8 a.m. to 4:30 p.m. 7 days a week. During this period, one PT worked full time in the ED while a second divided time between the ED and the outpatient clinic.
  • Program expansion: After the initial trial received positive feedback, the hospital added a second full-time PT in 1999 to enable coverage during early evening hours.

Resources Used and Skills Needed

  • Staffing: The program required no additional staff, as existing PTs were shifted from the outpatient clinics to the ED.
  • Costs: Program expenses were relatively minor, consisting primarily of the purchase of additional supplies.

 

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Funding Sources

Carondelet St. Joseph's Hospital
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Tools and Other Resources

Resources related to integrating PTs in the ED are available through the American Physical Therapy Association (APTA) Web site: http://www.apta.org. APTA members can access resources including a toolkit for those interested in adding PTs to the ED team, and information about a focus group and listserv to enhance communication among individuals engaged in this process.

Adoption Considerations

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Getting Started with This Innovation

  • Choose PTs carefully: Not every PT is well suited to working in the ED. Desirable characteristics include a broad knowledge of musculoskeletal problems; experience working with patients of all ages; a willingness to be flexible and accommodate fluctuations in patient flow; and the ability to work well with physicians in a fast-paced environment. Although experience is important, PTs who have worked for many years in a standard practice setting may not adjust well to working in the ED environment.
  • Establish strong rapport between ED physicians and PTs: Make sure that physicians understand the role of PTs in the ED. Early on, they may be skeptical, believing the involvement of PTs may impede rather than enhance treatment. Overcoming these feelings takes time but can be achieved by emphasizing that physicians do not forfeit the right to see patients before calling in a PT and demonstrating that both patients and physicians benefit from the program.

Sustaining This Innovation

  • Bring in new PTs slowly: Use existing ED-based PTs to mentor new PTs who join the ED staff for several weeks before letting them work on their own.
  • Explain PTs role to new ED physicians: Educate new ED physicians on the role of the PTs and personally introduce the new physician to each PT who works in the ED.

Use By Other Organizations

Flagstaff Medical Center in Flagstaff, AZ, and Clarian Health Systems in Indianapolis, IN, also use full-time PTs in the ED. Virginia Mason Medical Center in Seattle, WA, uses a related model whereby ED physicians make direct referrals to PTs from the ED.

More Information

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Contact the Innovator

Michael Lebec, PT, PhD
Associate Professor of Physical Therapy
Northern Arizona University
Department of Physical Therapy and Athletic Training
PO Box 15105
Flagstaff, AZ 86011
(928) 523-9971
E-mail: mike.lebec@nau.edu

Innovator Disclosures

Dr. Lebec has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Lebec M, Jogodka C. The physical therapist as a musculoskeletal specialist in the emergency department. J Orthop Sports Phys Ther. 2009;39(3):221-9. [PubMed]

Lebec M, Cernohous S, et al. Emergency department physical therapist service: a pilot study examining physician perceptions. Internet J Allied Health Sci Pract. 2010;8(1). Available at http://ijahsp.nova.edu/articles/Vol8Num1/pdf/Lebec%20Final.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.). 

McClellan CM, Greenwood R, Benger JR. Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department. Emerg Med J. 2006;23:384-387. [PubMed]

Richardson B, Shepstone L, Poland F, et al. Randomised controlled trial and cost consequences study comparing initial physiotherapy assessment and management with routine practice for selected patients in an accident and emergency department of an acute hospital. Emerg Med J. 2005;22(2):87-92. [PubMed]

Footnotes

1 Gaieski D, Mehta S, Hollander JE, et al. Low-severity musculoskeletal complaints evaluated in the emergency department. Clin Orthop Relat Res. 2008;456:1987-95. [PubMed]
2 Lebec M, Jogodka C. The physical therapist as a musculoskeletal specialist in the emergency department. J Orthop Sports Phys Ther. 2009;39(3):221-9. [PubMed]
3 Childs J, Whitman JM, Sizer PS, et al. A description of physical therapists' knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: February 03, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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