Article, Physical Therapy

Physical therapy in the emergency department: A new opportunity for collaborative care

a b s t r a c t

Emergency department-initiated Physical therapy (ED PT) is an emerging resource in the United States, with the number of ED PT programs in the United States growing rapidly over the last decade. In this collaborative model of care, physical therapists are consulted by the treating ED physician to assist in the evaluation and treatment of a number of movement and functional disorders, such as low back pain, peripheral vertigo, and various gait dis- turbances. Patients receiving ED PT benefit from the physical therapist’s expertise in musculoskeletal and vestib- ular conditions and from the individualized attention provided in a typical bedside evaluation and treatment session, which includes education on expected symptom trajectory, recommendations for activity modulation, and facilitated outpatient follow-up. Early data suggest that both physicians and patients view ED PT services fa- vorably, and that ED PT is associated with improvement of several important clinical and operational outcomes. Hospital systems interested in building their own ED PT program may benefit from the key steps outlined in this review, as well as a summary of the typical clinical volumes and practice patterns encountered at existing pro- grams around the country.

(C) 2018

Introduction

Emergency departments (EDs) in the United States are increasingly clinical applications“>utilizing physical therapists to meet the acute care needs of their pa- tients. Although frequently positioned in EDs in the United Kingdom and Australia [1], physical therapists have only recently established a footprint in United States (U.S.) emergency departments despite sup- port of this collaborative practice arrangement from the American Phys- ical Therapy Association [1,2]. However, as ED patient volumes continue to rise and the proportion of older adults grows larger, so does the need for innovative and collaborative Health care delivery approaches such as ED-initiated physical therapy (PT). Over the last two decades, a number of hospital systems have therefore integrated physical therapy services into the ED workflow and have documented their experience [3-6]. As of 2014, an estimated 23 hospital systems reported utilizing ED physical therapists, with an average of 1.7 full-time therapists per week [7]. The purpose of this review article is to describe the scope and potential

* Corresponding author at: Department of Emergency Medicine, 211 E. Ontario St, Ste 300, Chicago, IL 60611, United States.

E-mail address: [email protected] (H.S. Kim).

impact of ED PT services, summarize data on the clinical volume and practice patterns of existing ED PT programs, and outline key steps in- volved in building a new ED PT program.

Clinical applications

In the U.S., ED physical therapists work within the traditional model of consultative care to provide bedside evaluation and treatment of patients at the request of the treating ED physician. In a typical consul- tation lasting around 45 min [3], the physical therapist conducts an in- dependent history and physical examination, providing individualized and diagnosis-specific patient education, recommendations for activity and gait modulation, and instruction in therapeutic home exercises.

Notably, the U.S. model of care differs from the international model, in which physical therapists function as the primary ED care provider for lower acuity patients presenting to ED triage with musculoskeletal complaints [1]. Practicing without the need for referral, international ED physical therapists assess and treat patients independently as “extended scope physiotherapists,” and in some instances have the ability to order and interpret imaging and prescribe certain medications [8,9]. Importantly, this review article will focus on the U.S. model of care,

https://doi.org/10.1016/j.ajem.2018.05.053

0735-6757/(C) 2018

musculoskeletal injury“>in which ED physical therapists function in the role of secondary consultants rather than primary contact providers or extended scope physiotherapists.

Acute musculoskeletal injury

With respect to patients presenting with Musculoskeletal problems, ED physical therapists are most frequently consulted for clinical condi- tions relating to Back or neck pain, with some programs reporting more than half of all ED consults being for these reasons [1,3]. Other fre- quent sources of consultation include hip pain, knee pain, and shoulder pain. ED patients benefit from the physical therapists’ unique training and experience in musculoskeletal management, which physicians have acknowledged as a limitation in their medical training [5,10]. This deficiency is not surprising, given that nearly half of all U.S. medical schools do not require curriculum in musculoskeletal medicine [11], and emergency medicine training has traditionally focused on the diag- nosis and management of acute, life-threatening conditions.

In a typical consultation for low back pain, the physical therapist may assist the ED physician in arriving at a more specific diagnosis, such as piriformis syndrome or lumbar radiculopathy, then provide the patient with education on the expected symptom trajectory after ED discharge, instruction on activity modification and home exercise techniques, and counseling on return precautions. Physical therapists also provide patients and physicians with key information needed to navigate the complex system of outpatient referrals, such as the need for a physical referral order, proper insurance coverage, expected fre- quency of visits, and expected content of each outpatient PT session. ED practitioners have cited the added value of this service, which results in a more comprehensive diagnosis and treatment plan than is typically possible single provider encounters and allows for the allocation of phy- sician time to other critical tasks [5].

Initial reports from U.S. hospital systems that have established ED PT services have cited increased provider and patient satisfaction, decreasED wait times, and decreased rates of admission to the hospital for patients with orthopedic conditions [3,4,6]. Although these published narratives fall short of rigorously controlled studies, there are several well-conducted studies in the outpatient setting that point to a potential benefit of early PT initiation in the ED care environment [12-14]. In a randomized controlled trial of early PT initiation for acute low back pain in primary care, patients receiving early PT exhibited greater functional improvement than those receiving usual care [15].

Peripheral Vertigo

During entry-level education, all physical therapists receive formal training in assessing and treating vestibular disorders and must demon- strate competence in these areas to obtain licensure [16]. ED physical therapists are therefore frequently called upon to evaluate patients with peripheral vertigo [5,17]. In a typical consultation for dizziness, physical therapists may utilize their expertise and training in vestibular conditions to identify specific etiologies of peripheral vertigo (e.g. be- nign paroxysmal positional vertigo), provide hands-on intervention as appropriate, instruct the patient in self-directed therapeutic maneuvers, and assess patient safety for discharge. Although physical therapy consultation typically occurs after the treating ED physician has reason- ably excluded pathologic causes of vertigo (e.g. cerebellar stroke), concerning features of the therapist’s exam may prompt the primary ED team to revisit their Initial diagnosis and/or pursue further diagnos- tic testing. Conversely, a PT assessment that is concordant with the treating ED physician’s suspected diagnosis of peripheral vertigo may assist in avoiding unnecessary advanced imaging or unnecessary neu- rology consultation.

The application of ED physical therapy to peripheral vertigo com- plaints may be particularly beneficial due to the prolonged duration of time required to adequately assess patients suffering from severe

dizziness. As ED physicians are inherently tasked with simultaneously managing multiple patients and experience frequent interruptions [18], it is often difficult to complete a detailed vestibular exam involving multiple maneuvers. In hospital systems with ED physical therapy services, ED physicians have cited the tremendous value of physical therapists in that they can provide extended one-on-one time with the patient, educate the patient on vestibular symptoms, and provide instruction on recommended therapeutic maneuvers to perform at home [5]. In addition, having physical therapists capable of dedicat- ing their time and effort in this capacity in the ED may result in an immediate and significant decrease in vertigo symptoms prior to discharge [19].

Gait training and disposition planning

The important role of physical therapists in evaluating patient mobility and home safety has been well documented in the inpatient setting [20,21]. Although this assessment has not traditionally been per- formed in the ED setting, the increasing frequency of inPatient boarding and the aging of the U.S. population have forced ED providers to take on non-traditional roles [22-24]. With this evolution, physical therapists are increasingly called upon to evaluate patients in the ED for home safety and assist in determining a safe patient disposition [7].

In some hospitals, this evaluation has become a vital component of multi-faceted interventions specifically targeted at older patient populations [25]. Several EDs recently collaborated under a Center for Medicare and Medicaid Services Innovation Grant to create a transitional care team for older adults, in which physical therapists are available to provide an advanced assessment of gait and transfer abili- ties when standard screening instruments (e.g. Timed Up & Go test) are not appropriate or are unsafe. Physical therapists may assist in selecting a more appropriate outcome measure in the case of existing patient impairment, and may also determine if any assistive device is re- quired. These multidisciplinary intervention teams, which are led by ED nurses trained in older adult care transitions, have been demonstrated to reduce unnecessary hospital admissions [26].

Beyond older adult care, ED physical therapists may also assist in dis- position planning for unique injury patterns in which standard assistive devices are not feasible – such as a patient with a concomitant ankle fracture and Shoulder dislocation who cannot tolerate the use of crutches. PT evaluation may determine that alternative assistive de- vices, such as a knee scooter, are appropriate and may assist in the pro- curement of such equipment to avoid hospital admission. In scenarios where a PT evaluation determines that a patient cannot be safely discharged home, the reason for admission is well justified and the tran- sition of care from the ED team to the accepting inpatient team is facil- itated. Furthermore, in admitted patients who will ultimately require outpatient Rehabilitation placement, initiation of the PT evaluation in the ED setting may expedite this lengthy process by promptly determin- ing the most appropriate next level of care. Thus, PT evaluation of pa- tient mobility and safety can be of great assistance in disposition planning and has been cited as a significant added value by ED physi- cians with access to PT services [5,27].

Additional intangible impacts

ED physical therapy may have a number of wide-reaching impacts beyond the clinical services described above. Published narratives from hospital systems implementing ED PT programs describe over- whelmingly positive feedback from ED physicians, and a number of small studies have noted increased patient satisfaction with overall care. The provision of PT services in the ED have also been viewed as a potential Non-opioid alternative to pain management, and input from PT evaluations may assist in the avoidance of unnecessary diagnostic imaging, especially among patients with low back pain.

Physician satisfaction“>Patient and physician satisfaction

ED physicians have cited the added value of ED PT in improving overall patient care and in contributing to an improved workflow. In one qualitative study, ED physicians felt that patients were more satisfied when their care involved a physical therapist due to their expertise in diagnosing complex musculoskeletal problems and the extra time that physical therapists were able to spend at the bedside educating patients and answering questions. Not only did this enable patients to better understand their diagnosis and how it related to their symptoms, but also contributed to a feeling of being “plugged into the system quicker” due to facilitated outpatient follow-up [5]. This sentiment was reiterated in a study of ED patients in the United Kingdom, in which patients seen by an extended scope physiotherapist rated higher levels of patient satisfaction than patients seen by a nurse practitioner or physician alone. survey responses noted to be signifi- cantly higher among PT patients pertained to questions about overall satisfaction with care, satisfaction with explanation of diagnosis and expected symptom trajectory, and provision of sufficient time to ask questions [8].

ED PT services may also be of direct benefit to physicians by increas- ing workplace satisfaction and improving overall patient flow. Surveyed ED physicians described a sense of pride in working at a facility that was perceived to be “cutting edge” due to PT availability. Physicians also felt that having an expert in musculoskeletal or vestibular impairment spend extended time at the bedside freed them up to attend to medi- cally unstable patients or troubleshoot issues impeding departmental flow [5]. The establishment of an ED PT program therefore allowed phy- sicians to feel well supported in their overarching task of managing the entire department while ensuring that all of their patients were receiv- ing the best care possible. Perhaps the greatest marker of program sup- port are comments from multiple published narratives indicating that physicians were most dissatisfied that PT coverage was not available during overnight or weekend hours [3,27].

opioid prescribing and low”>Reducing opioid prescribing and low-value diagnostic imaging

Physical therapy has also been suggested as a potential method of pain management, especially given the renewed attention to appropri- ate opioid prescribing in an era of increasing opioid overdose [28,29]. The use of ED PT for pain management is particularly appealing given its frequent application to low back pain – the most common diagnosis for which opioids are prescribed and benzodiazepines are co-prescribed in the ED [30-32]. Although no study has yet to examine opioid prescrib- ing rates among patients receiving ED PT, physicians have identified PT services as a viable alternative to opioid prescribing in the ED setting [4,5,27], and a number of claims-based studies point to lower opioid uti- lization among patients referred to PT in the outpatient setting [33-35]. This is further supported by patient feedback indicating that physical therapy was helpful in managing their painful symptoms [3]. PT inter- ventions such as manual therapy, therapeutic electrical stimulation, and patient education on activity modulation have potential to provide further alleviation of symptoms and lessen the need for Prescription opioids – although a definitive study conducted in the ED setting is needed.

Similarly, physical therapist input may have the indirect benefit of reducing unnecessary diagnostic imaging. ED physicians with access to PT services frequently solicit physical therapist input on whether to obtain advanced imaging [1], and an expert evaluation may reassure physicians that imaging is not required in select clinical scenarios. This may be of particular benefit in patients presenting with atraumatic low back pain, as physicians continue to obtain lumbar imaging despite being a low-value service targeted by the American College of Emer- gency Physician’s “choosing wisely” campaign [36]. A number of stud- ies from the outpatient setting support the potential value of ED PT in reducing unnecessary diagnostic imaging, and further demonstrate

that early PT referral may also reduce additional physician office visits and surgical procedures [37,38]. By reducing downstream utilization of these Health care resources and preventing unnecessary hospitaliza- tions, early initiation of physical therapy in the ED setting may ulti- mately result in cost savings to individual patients, hospital systems, and Accountable Care Organizations alike [39].

Building an ED physical therapy program

Although the number of U.S. hospitals with ED physical therapy ser- vices is modest, this total is rapidly growing and there is likely to be an increased demand for this resource given the benefits outlined above. Hospital systems, and their respective departments of emergency medicine and physical therapy, looking to implement their own ED PT programs may therefore benefit from the previous experience of other national programs and previously described barriers and facilitators of success [3,4,27]. Important steps to program implementation will in- clude engaging with key stakeholders in physical therapy and emer- gency medicine, estimating initial clinical volume and staffing needs, and targeting appropriate personnel for the unique practice environ- ment of the ED.

Engagement with key stakeholders

To our knowledge, the vast majority of existing ED PT programs are administered and funded by departments of physical therapy [7]. Al- though it is technically feasible for an emergency department to hire an in-house physical therapist, it is likely more efficient to utilize the existing infrastructure of a rehabilitation department to provide an ad- ditional consultation service to ED patients. To that end, engagement with physical therapy departmental leadership is a foundational step in establishing an ED PT program and initial discussions regarding esti- mates of clinical volume and staffing needs would be directed towards PT leadership.

Several unique features of ED PT services should be noted during these discussions. Unlike inpatient PT services, which are billed accord- ing to the overall diagnostic related group for the hospital admission, ED PT services are billed at the outpatient level using 97000 series (“Physical Medicine and Rehabilitation”) Current Procedural Terminol- ogy codes for individual professional services provided and therefore contribute marginally to overall visit charges. In a national survey of existing ED PT programs, these services were reimbursed at similar rates by commercial insurers, Medicaid, and Medicare alike [40]. How- ever, it should be noted that Medicare guidelines require all physical therapists to utilize G codes, which consist of a code indicating the patient’s primary initial Functional limitation, a code predicting future functional status, and a final code listing the patient’s status at dis- charge. In other practice settings, the physical therapist is able to work with the patient in achieving this long-term goal through multiple treat- ment sessions, typically over a period of weeks. Achieving some goals may prove difficult when the patient is only seen briefly in the ED. Therefore, ED physical therapists must set goals that can be realistically achieved by the end of one treatment session, such as having the patient demonstrate understanding of an exercise or safety in a specific task.

It will also be critical to gain the support of ED leadership prior to program implementation, given that PT services are provided within the physical space of the ED – likely in patient rooms or hallways. We are not aware of any existing ED PT programs that utilize space outside of the ED (e.g. a rehabilitation gym or clinic) for Patient evaluation and treatment. Conversations with ED leadership will likely focus on the value added from an ED PT service weighed against the Opportunity cost of prolonged patient stays, which may impact ED bED capacity. However, we posit that prolonged lengths of stay likely reflect a delay in initiating the PT consultation request, and a formal workflow for early PT consultation is likely to make this process more efficient.

Finally, it will be important to engage with ED care providers – including resident and attending physicians, nurse practitioners, physician assistants, and registered nurses – to determine if there is support for an ED PT service, given that the current model of consulta- tive care requires initiation by the treating ED care provider. Although it is unlikely that ED care providers would be unwilling to consult PT for specific care needs, early engagement with ED providers in the development of specific protocols for consultation will be essential to ensuring that ED PT is utilized to its maximum potential.

Initial estimates of clinical volume

Most ED PT programs operate during normal business hours (i.e. daytime weekdays) and report a daily average of three to six consults [3,4,27]. The ED PT program at Barnes-Jewish Hospital (St. Louis, MO) employed one full-time equivalent (FTE) physical therapist in 2009 and reported 565 annual PT consults for an annual census of 62,000 visits [3]. The program at Indiana University Methodist Hospital (Indianapolis, IN) employed two FTE physical therapists in 2014 and re- ported 2000 annual PT consults for an annual census of 102,000 visits [27]. The program at Saint Joseph’s Carondelet Hospital (Tuscon, AZ) employed one FTE physical therapist in 2011 and reported 2000 annual PT consults for an annual ED census of 110,000 visits [4]. The experience of these ED PT programs may indicate that consult volume is constrained by the number of FTE physical therapists rather than annual ED census, although notably each program began with 0.5 to 1 FTE and scaled up to their current FTE level as awareness and familiarity of the program grew among ED physicians.

Implementing a new ED PT program will also require estimating the duration of an average PT consultation, as some physicians have expressed concern that PT evaluation may prolong lengths of stay [5,27]. Most programs report that a typical PT evaluation averages 30-45 min [4] with one program reporting an average of 54 min due to periodic interruptions of care in the ED environment [3]. There are no published data on total lengths of stay in ED patients receiving PT consultation, although preliminary data from Northwestern Memorial Hospital (Chicago, IL) indicate that patients with back pain receiving PT had a total length of stay 47 min longer than patients receiving usual care (unpublished data).

In our experience, a significant contributor to this prolonged length of stay is a delay in the timing of PT consultation, as ED physicians fre- quently exhaust other measures (i.e. analgesic medications, diagnostic imaging) prior to involving PT. The longer lengths of stay associated with ED PT could likely be improved with early PT consultation for specific indications, ideally within a formalized workflow. Additionally, any consideration of increased length of stay should be also evaluated in the context of other efficiencies that may be gained in ED operations as a result of PT availability.

Ideal characteristics of an ED physical therapist

Given the unique practice environment of the ED, the decision to hire or assign a physical therapist to an ED PT service warrants attention to specific personality characteristics that will enable success. An ideal ED physical therapist will have good patient communication skills, given the volume of information that patients are likely to receive in a Short period of time from the ED care team. Each ED visit also likely rep- resents the “worst day” in some time for each respective patient, and an understanding of the extreme reactions or emotions elicited from pa- tients will be key. Similar to ED physicians, ED physical therapists must also function as a “jack-of-all-trades” and should therefore have a wide range of clinical skills that can be adapted to address the variety of patient problems encountered in the acute care setting. Finally, it will be important for an ED physical therapist to appreciate the psychosocial contexts that often accentuate or drive patient symptomatology in the emergency care environment.

Conclusion

This review provides support for the use of physical therapy services in the emergency department and summarizes typical clinical volumes and practice patterns of existing ED PT programs. Initial data from these programs demonstrate positive impacts in clinical care and patient and physician satisfaction, citing PT expertise in musculoskeletal and vestib- ular impairments and the added value of extended bedside care and pa- tient education delivered by physical therapists. Hospital systems interested in building ED PT programs may benefit from the key steps of program implementation outlined in this review, and may further benefit from resources provided by the “Emergency Department FoCUS group” maintained by the Academy of Acute Care Physical Therapy [41]. This interest group is committed to sharing best practices, chal- lenges, and research related to the delivery of physical therapy in Acute care settings.

Finally, as the number of ED programs in the U.S. continues to grow, there is a strong need to continue collecting data on the operational characteristics of ED PT programs and the clinical outcomes of patients receiving care. Further data collection and research on this topic will en- able ED physicians and physical therapists to improve this innovative and collaborative relationship and enhance the quality of care delivered to ED patients.

Funding disclosures

HSK is supported by AHRQ K12HS023011.

Prior presentations

None.

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