The utility of emergency department physical therapy and case management consultation in reducing hospital admissions

Effects of the delivery of physiotherapy on the treatment course of elderly fallers presenting to the emergency department: Protocol for a randomized clinical trial

The use of physiotherapy (PT) in the hospital emergency department (ED) has shown positive results including improvements in patient waiting time, treatment initiation, discharge type, patient outcomes, safety and acceptability of the intervention by medical staffs. These findings originate from studies that primarily focus on musculoskeletal and orthopaedic conditions. Despite a significant number of people visiting the ED, there is a shortage of literature evaluating PT in the ED for elderly populations. The objective of this study is the evaluate the effect of delivering PT in the ED (versus no delivery) in patients aged 75 and over with 'falls' complaints. The main objective is the evaluate the effect on the discharge disposition (discharge home, hospitalization). Secondarily, we will evaluate the effect delivering PT on patient-length of stay, the number of falls at 7 days after admission to the ED, changes between the initial and final medical decision regarding patient orientation, and medical staff satisfaction. This study will follow a prospective longitudinal design involving participants aged 75 years and over. We plan to recruit a total n = 336 patients admitted to the ED with a 'fall' chief complaint. After consent, participants will be randomized into either the 'PT-group' (receiving a prescription and execution of PT within the ED), or to the 'no-PT group' (no delivery of PT within the ED). The PT intervention will involve a standardized assessment of motor capacities using validated clinical examinations, and the delivery of rehabilitative exercises based on individual needs. Outcomes will be recorded from the patient's medical record, and a phone call at 7 days. A questionnaire will be sent to medical staff. The results of this study will help to determine whether PT might be beneficial for the management of this increasing proportion of individuals who come to the ED. Trial registration: (Trial registration number: ClinicalTrials.gov NCT05753319). https://classic.clinicaltrials.gov/ct2/show/NCT05753319.

Emergency Department-Based Physical Function Measures for Falls in Older Adults and Outcomes: A Secondary Analysis of GAPcare

BACKGROUND AND PURPOSE

Falls are the leading reason for injury-related emergency department (ED) visits for older adults. The Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), an in-ED intervention combining a medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist, reduced ED revisits at 6 months among older adults presenting after a fall. Our objective was to evaluate the relationship between measures of function obtained in the ED and clinical outcomes.

METHODS

This was a secondary analysis of data from GAPcare, a randomized controlled trial conducted from January 2018 to October 2019 at 2 urban academic EDs. Standardized measures of function (Timed Up and Go [TUG] test, Barthel Activity of Daily Living [ADL], Activity Measure for Post Acute Care [AM-PAC] 6 clicks) were collected at the ED index visit. We performed a descriptive analysis and hypothesis testing (chi square test and analysis of variance) to assess the relationship of functional measures with outcomes (ED disposition, ED revisits for falls, and place of residence at 6 months). Emergency department disposition status refers to discharge location immediately after the ED evaluation is complete (eg, hospital admission, original residence, skilled nursing facility).

RESULTS AND DISCUSSION

Among 110 participants, 55 were randomized to the GAPcare intervention and 55 received usual care. Of those randomized to the intervention, 46 received physical therapy consultation. Median age was 81 years; participants were predominantly women (67%) and White (94%). Seventy-three (66%) were discharged to their original residence, 14 (13%) were discharged to a skilled nursing facility and 22 (20%) were admitted. There was no difference in ED disposition status by index visit Barthel ADLs (P = .371); however, TUG times were faster (P = .016), and AM-PAC 6 clicks score was higher among participants discharged to their original residence (P ≤ .001). Participants with slower TUG times at the index ED visit were more likely to reside in nursing homes by six months (P = .002), while Barthel ADL and AM-PAC 6 clicks did not differ between those residing at home and other settings.

CONCLUSIONS

Measures of function collected at the index ED visit, such as the AM-PAC 6 clicks and TUG time, may be helpful at predicting clinical outcomes for older adults presenting for a fall. Based on our study findings, we suggest a novel workflow to guide the use of these clinical measures for ED patients with falls.

Physical therapy consultation in the emergency department for older adults with falls: A qualitative study

Objectives

Little is known about current practices in consulting physical therapy (PT) in the emergency department (ED) for older adults with falls, a practice that can reduce fall-related ED revisits. This qualitative study aimed to understand perspectives of ED staff about ED PT consultation for older adults with falls and fall-related complaints, specifically regarding perceived value and associated challenges and strategies.

Methods

We performed focus groups and key informant interviews with emergency physicians, advanced practice clinicians, nurses, physical therapists, occupational therapists, and technicians who perform ED geriatric screenings. We used rapid qualitative analysis to identify common themes related to decisions to consult PT from the ED, perceived value of PT, and common challenges and strategies in ED PT consultation.

Results

Twenty-five participants in 4 focus groups and 3 interviews represented 22 distinct institutions with ED PT consultation available for older adults with falls. About two thirds of EDs represented relied on clinician gestalt to request PT consultation (n = 15, 68%), whereas one third used formal consultation pathways (n = 7, 32%). Participants valued physical therapists' expertise, time, and facilitation of hospital throughput by developing safe discharge plans and contact with patients to improve outpatient follow-up. Common challenges included limited ED PT staffing and space for PT evaluations; strategies to promote ED PT consultation included advocating for leadership buy-in and using ED observation units to monitor patients and avoid admission until PT consultation was available.

Conclusion

ED PT consultation for older adults with falls may benefit patients, ED staff, and hospital throughput. Uncertainty remains over whether geriatric screening-triggered consultation versus emergency clinician gestalt successfully identifies patients likeliest to benefit from ED PT evaluation. Leadership buy-in, designated consultation space, and formalized consultation pathways are strategies to address current challenges in ED PT consultation.

Direct Access to Physical Therapy: Should Italy Move Forward?

Direct access to physical therapy (DAPT) is the patient’s ability to self-refer to a physical therapist, without previous consultation from any other professional. This model of care has been implemented in many healthcare systems since it has demonstrated better outcomes than traditional models of care. The model of DAPT mainly focuses on the management of musculoskeletal disorders, with a huge epidemiological burden and worldwide healthcare systems workload. Among the healthcare professionals, physical therapists are one of the most accessed for managing pain and disability related to musculoskeletal disorders. Additionally, the most updated guidelines recommend DAPT as a first-line treatment because of its cost-effectiveness, safety, and patients’ satisfaction compared to other interventions. DAPT was also adopted to efficiently face the diffuse crisis of the declining number of general practitioners, reducing their caseload by directly managing patients’ musculoskeletal disorders traditionally seen by general practitioners. World Physiotherapy organization also advocates DAPT as a new approach, with physical therapy in a primary care pathway to better control healthcare expenses. Thus, it is unclear why the Italian institutions have decided to recognize new professions instead of focusing on the growth of physical therapy, a long-established and autonomous health profession. Furthermore, it is unclear why DAPT is still not fully recognized, considering the historical context and its evidence. The future is now: although still preliminary, the evidence supporting DAPT is promising. Hard skills, academic paths, scientific evidence, and the legislature argue that this paradigm shift should occur in Italy.

Physiotherapeutic approach and profile of patients treated in the emergency room surgical unit of a tertiary care hospital in the Federal District

Abstract Introduction The emergency room (ER) is the main entry door for the care of critically ill patients. The inclusion of physiotherapists in these sectors is being consolidated in Brazil. Objective To characterize the physiotherapeutic approach and the clinical-functional profile of patients in the ER surgical unit of a tertiary hospital. Methods This was a retrospective cross-sectional study conducted from August to December of 2020. Clinical and functional data, and the main physiotherapeutic procedures performed, were collected. Analyses were conducted by means of the Friedman and Pearson Correlation tests, using SPSS software v.23. Results The sample included 98 patients, 68% male, mean age of 52 ± 19 years. The most common (64%) physiotherapeutic diagnosis was central nervous system (CNS) deficiency with mechanical ventilation (MV) dependence. The mean time of MV use was 4 ± 5 days. Association (p < 0.05) between MV time and admission in the emergency department (r = 0.972) and between MV time and age (r = 0.330) was identified. The most used physiotherapeutic actions were: suction (69%), lung re-expansion therapy (51%), and bed kinesiotherapy (37%). Conclusion Adult men with CNS-related disabilities were the principal patient profile. The physiotherapeutic action in the surgical emergency unit was diverse, with application of motor and respiratory techniques, and the predominant activity was the management and maintenance of MV.

Abordagem fisioterapêutica e perfil dos pacientes assistidos na unidade cirúrgica do pronto-socorro de um hospital terciário do Distrito Federal

Resumo Introdução O pronto-socorro (PS) tornou-se a principal porta para o início da assistência a pacientes graves. A inserção do fisioterapeuta nesses setores está em processo de consolidação no Brasil. Objetivo Carac-terizar a abordagem fisioterapêutica e o perfil clínico-funcional dos pacientes na unidade cirúrgica PS de um hospital terciário. Métodos Trata-se de um estudo transversal retrospectivo realizado no período de agosto a dezembro de 2020. Coletaram-se dados clínicos, funcionais e as principais condutas fisioterapêuticas utilizadas. As análises foram conduzidas por meio dos testes de Friedman e Correlação de Pearson, utilizando o software Statistical Package for the Social Sciences v.23. Resultados Ao todo, a amostra foi de 98 pacientes, dos quais 68% eram homens, com idade média de 52 ± 19 anos. O principal (64%) diagnóstico fisioterapêutico foi deficiência do sistema nervoso central (SNC) com dependência de ventilação mecânica (VM). O tempo médio de uso de VM foi de 4 ± 5 dias. Houve associação (p < 0,05) entre tempo de VM e internação no PS (r = 0,972) e entre tempo de VM e idade (r = 0,330). As condutas fisioterapêuticas mais utilizadas foram a aspiração (69%), terapia de reexpansão pulmonar (51%) e cinesioterapia no leito (37%). Conclusão Os homens em faixa etária adulta e com deficiências relacionadas ao SNC constituíram o principal perfil dos usuários. A atuação fisioterapêutica na unidade de emergência cirúrgica foi ampla, com emprego de técnicas motoras e respiratórias, das quais a atuação predominante ocorreu no manejo e condução da VM.