Physical Therapists in the Emergency Department

Findings indicated that these physicians found ED physical therapy services to be of value to themselves, to their patients, and to the department as a whole and described specific manners in which such consultations improved emergency care. Implementation and maintenance of the program, however, presented various challenges.

Emergency Department Physical Therapist Service: Removing Barriers and Building Bridges

• Michael T. Lebec PT, PhD
• Lisa TenBarge PT, DPT
• Carleen Jogodka, PT, DPT, OCS
• Michael Brickens, PT

To start, a brief introduction of who comes into the emergency department. Fewer and fewer are coming via ambulance, even fewer by life flight. People are using the ED in new and different ways. For example, many have non-urgent and non-life threatening conditions.

The average wait is upwards of 1 hour, with the average length of stay in the ED upwards of 4 hours. The ED physician spends an average of 11 minutes on direct care. That time includes research, orders, and making referrals.

Patient satisfaction with ED care is generally low. Management of common musculoskeletal, pain, and soft tissue injury complaints is varied and poor. Individuals are routinely given cervical soft collars for neck pain, immobilization including CASTS and or instructions for non-weight bearing for ankle sprains, and MULTIPLE days of bed rest for low back pain.

What do the PATIENTS want? Answers, instructions, and to feel better!

What do the patients receive? Imaging. Medications. Prescriptions. No follow up.

The fact of the matter is this that more and more individuals are utilizing the ER as their primary stop for health conditions. By the time they seek care these conditions are more chronic and less well controlled. Thus, more and more people seen in the ED are not necessarily in an emergent state. And, I believe, more and more would benefit from the skills of a physical therapist.

Now, I also believe physical therapist’s can play a vital role in deciding when imaging of musculoskeletal conditions is and is not necessary. Further, the treatment they provide may (again my belief) decrease imaging, medication prescription/usage, and decrease re-visit rates for the same complaint. And maybe, just maybe, if we plug these people into physical therapy sooner their conditions (pain, chronic medical diagnoses, etc) will be better managed and controlled. And, I think, that all links back to the Physical Therapist’s Role in Health, Wellness, and Prevention as per Healthy People 2020.

The data that does exists suggest that having PT’s in the ED results in decreased wait time and increased patient satisfaction. [Unfortunately, much of the data on PT’s in the ED has been obtained outside the United States.] At the large, academic hospital I practice high priority is placed on “patient satisfaction.” [However, flawed that concept may be. Refer to Patient Satisfaction is Useless Part I and Part II on the Evidence In Motion Blog]. Further, wait time in the ED is directly related to the costs for that department. Therefore, decreasing wait time is a very real way to decrease costs. Not surprisingly, wait time is inversely related to patient satisfaction. So, already those are two powerful take home points regarding the positive effects PT’s ARE ALREADY having in the ED already. But, what does the future hold?

In expanding PT services in the ED, we can look to other sources of evidence and data to support PT treatment of individuals in the emergency department:

• PT Management and Evidence for Specific Musculoskeletal Conditions
• Outcomes when PT is involved earlier in care of painful episodes
• Outcomes when PT is delayed
• Future healthcare costs with advanced, and over, imaging
• PT’s Knowledge and Decision Making In Medical Screening and Diagnosis

Specifically, there is evidence supporting specific PT approaches to common orthopaedic conditions such as low back pain, neck pain, knee pain, ankle sprains, etc. Also, there are innovative practice models where physical therapists are involved earlier in care providing FRONT end intervention for painful episodes. Virginia Mason (out of my hometown of Seattle) received a lot of publicity even a Wall Street Journal Article for their model of sending patients with work related musculoskeletal complaints to a PT FIRST. They decreased costs by over 50% (!!!) and decreased time away from work.

Future Research and Data Tracking

• Readmissions
• Time between ER visits
• Medication Prescription and Usage
• Imaging Utilization and Costs
• Falls and Injury from Falls

The talk was very interesting, and I think this practice area will continue to grow. It actually reminds me of the growth of early mobility and rehabilitation of individuals in intensive care units. I also think there is really good research and data from other areas of practice supporting not only the treatment PT’s can provide, but also our training, decision making, and skills in medical screening and aiding in diagnosis. Not to mention, I did not even mention fall risk screening and intervention, splinting, wound care, assistive device recommendations, and aiding in discharge planning.

Where will physical therapy go next?

Resources

1. Physical Therapists in the Emergency Department: Development of a Novel Practice Venue. Physical Therapy. March 2010.
2. The Physical Therapist as a Musculoskeletal Specialist in the Emergency Department. Physical Therapy. March 2009
3. Emergency Department Physical Therapist Service: A Pilot Study Examining Physician Perceptions Internet Journal of Allied Health Sciences and Practice. 2010.