Implementation and performance evaluation of an emergency department primary practitioner physiotherapy service for patients with musculoskeletal conditions

The experiences of patients attending the emergency department who were managed by physiotherapists: a person-centred perspective

PURPOSE

The expectation for all clinicians to deliver person-centred practices extends to the growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED). Research on ED patients' experience of this physiotherapy role has yet to consider this through the lens of person-centredness. A qualitative exploration of person-centredness among ED physiotherapists through the experiences of attending patients targeted this knowledge gap to inform future clinical practice.

METHODS

Semi-structured interviews with thematic analysis.

RESULTS

13 interviews were completed with four overarching themes generated: (1) patient experience of the ED; (2) the importance of connection, competence, and time; (3) recognising the benefits of being seen by a physiotherapist in ED; and (4) patient experience of the ED physical environment.

CONCLUSION

Novel contributions from the patient perspective, here, reflected a cognisance of certain environment limitations to PCP, as well as institutional challenges to their personhood, with a suggestion that ED patients anticipated a validation of their visit and valued the educational aspects that the physiotherapists provided. Considering this new knowledge can help ED physiotherapists to be more person-centred.

An evaluation of the effectiveness of an advanced practice physiotherapist in the emergency department setting in Ireland

BACKGROUND

One of the means of easing increased pressure on emergency care worldwide has been the development of advanced musculoskeletal physiotherapy practice in the emergency department setting. This model of care is in its infancy in Ireland.

AIMS

To evaluate the effectiveness of an advanced practice physiotherapist working as a primary contact clinician in the emergency department at St. James's Hospital, Dublin.

METHODS

A three-month retrospective chart review was undertaken for patients assigned the advanced practice physiotherapist as their primary clinician during their emergency department attendance. Three widely accepted measures of quality in emergency medicine were used to evaluate effectiveness, namely, time from attendance to discharge, time from triage to assessment, and unplanned reattendance within seven days.

RESULTS

A total of 129 patients were included in this study. Time from attendance to discharge was significantly less in the APP group (mean 208.5 min, standard deviation 122.4 min) than in the ED group (mean 377.1 min, standard deviation 314.7 min) (mean difference - 168.61 (95% C.I - 191.24- - 145.98)) (p < 0.001). Time from triage to assessment was significantly less in the APP group (mean 72.1 min, standard deviation 51.9 min) than in the ED group (mean 94.1 min, standard deviation 96.5 min) (mean difference - 22.08 (95% C.I - 31.28- - 12.89)) (p < 0.001). The unplanned reattendance rate was 3.9%. No adverse events were identified.

CONCLUSIONS

The findings of this study indicate that an advanced practice physiotherapist can provide a timely, effective, and safe service for patients attending the emergency department with musculoskeletal complaints in Ireland.

Short waits, happy patients and expert care, moving basic musculoskeletal care from the emergency department to a physiotherapist-led diversion pathway

OBJECTIVE

Patients with musculoskeletal conditions (MSKCs) are highly prevalent in ED. This project explores the impact of the pilot phase of a 'diversion pathway', which directed patients with MSKCs from the ED waiting room to an outpatient clinic led by advanced-scope physiotherapists.

METHODS

A prospective intervention study comparing care outcomes between patients in the 'diversion pathway' with usual ED care. The characteristics of patients considered eligible and non-eligible are described.

RESULTS

Between May and December 2022, 1099 patients were diverted. For diverted patients, mean length of stay (LOS) in ED was reduced by 110 (95% confidence interval [CI]: 99-120) min and 4 h rule compliance improved by 19.3% compared to usual ED care. There were fewer patients who 'did not wait' (DNW) with the diversion pathway. The diverted group was young (median age 22 years and 41% paediatric), mostly low urgency, self-referred and arrived by private transport with minor limb trauma. The diversion pathway triage process appropriately identified 182 patients ineligible for diversion. 96.7% of patients reported satisfaction with care received from the diversion pathway. There was no change in ED representation rates for diverted patients.

CONCLUSIONS

A new pathway resulted in reduced LOS, reduced DNW, high patient satisfaction and more people being discharged within 4 h for diverted patients compared to usual ED care. The pathway increased ED capacity, improved key ED performance metrics and safely expedited care delivery for patients.

An exploration of person-centredness among emergency department physiotherapists: a mixed methods study

PURPOSE

There is a growing number of primary contact physiotherapists based in United Kingdom emergency departments (ED) who are expected to deliver person-centred practices. Perceptions of physiotherapists working in these high-pressure environments on person-centredness are currently unknown. A mixed methods exploration of person-centredness among ED physiotherapists targeted this knowledge gap to inform future clinical practice.

METHODS

Online survey and semi-structured interviews followed a convergent mixed methods design with sequential explanatory features. Data sets were analysed separately using descriptive statistics and thematic analysis, respectively, before merged analysis using joint display.

RESULTS

Twenty-six surveys and 11 in-depth interviews were completed. The three overarching themes of ED patients, ED physiotherapists, and ED environment were generated. Themes were integrated and analysed alongside quantitative survey findings. This produced three novel contributions that further our understanding of person-centred practices among ED physiotherapists.

CONCLUSION

ED physiotherapists were mindful of an apparent, yet unspoken struggle between the competing philosophies of biomedicine and person-centredness. The results here support entering a patient's world as a person-centred approach to help navigate the line between what an ED attender wants and the clinical need of their visit.

The effectiveness of allied health and nurse practitioner models-of-care in managing musculoskeletal conditions in the emergency department: a systematic review and meta-analysis

BACKGROUND

Musculoskeletal conditions are the most common health condition seen in emergency departments. Hence, the most effective approaches to managing these conditions is of interest. This systematic review aimed to evaluate the effectiveness of allied health and nursing models of care for the management of musculoskeletal pain in ED.

METHODS

MEDLINE, EMBASE, CINAHL and LILACS databases were searched from inception to March 2023 for published randomised trials that compared the effectiveness of allied health and nursing models of care for musculoskeletal conditions in ED to usual ED care. Trials were eligible if they enrolled participants presenting to ED with a musculoskeletal condition including low back pain, neck pain, upper or lower limb pain and any soft tissue injury. Trials that included patients with serious pathology (e.g. malignancy, infection or cauda equina syndrome) were excluded. The primary outcome was patient-flow; other outcomes included pain intensity, disability, hospital admission and re-presentation rates, patient satisfaction, medication prescription and adverse events. Two reviewers performed search screening, data extraction, quality and certainty of evidence assessments.

RESULTS

We identified 1746 records and included 5 randomised trials (n = 1512 patients). Only one trial (n = 260) reported on patient-flow. The study provides very-low certainty evidence that a greater proportion of patients were seen within 20 min when seen by a physician (98%) than when seen by a nurse (86%) or physiotherapist (77%). There was no difference in pain intensity and disability between patients managed by ED physicians and those managed by physiotherapists. Evidence was limited regarding patient satisfaction, inpatient admission and ED re-presentation rates, medication prescription and adverse events. The certainty of evidence for secondary outcomes ranged from very-low to low, but generally did not suggest a benefit of one model over another.

CONCLUSION

There is limited research to judge the effectiveness of allied health and nursing models of care for the management of musculoskeletal conditions in ED. Currently, it is unclear as to whether allied health and nurse practitioners are more effective than ED physicians at managing musculoskeletal conditions in ED. Further high-quality trials investigating the impact of models of care on service and health outcomes are needed.

Patients report being satisfied with private musculoskeletal physical therapy when therapists educate effectively and facilitate shared decision making

BACKGROUND

Overall satisfaction with physical therapy care can improve patient adherence and active involvement in their management. However, which individual factors most influence satisfaction with private practice physical therapy care is not well established.

OBJECTIVE

To identify which aspects of the private practice musculoskeletal physical therapy experience best delineated "completely satisfied" and "dissatisfied patients".

METHODS

The MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) was used in a cross-sectional design within 18 Australian private musculoskeletal physical therapy practices. The area under the curve (AUC) of receiver operator characteristic curves (ROC) was used to quantify the ability of the individual patient experience questions to classify the global impressions of satisfaction and likelihood to recommend to others.

RESULTS

1712 patients completed the survey (out of 7320 survey recipients - response rate 23%). High scores were identified for overall satisfaction (4.8/5 ± 0.61) and likelihood to recommend (4.78/5 ± 0.67). Individual items relating to education (AUC = 0.839 and 0.838) and shared decision making (AUC = 0.832 and 0.811) were the most accurate indicators of satisfaction and likelihood to recommend to others, respectively.

CONCLUSION

Individual questionnaire items relating to education and shared decision making were the most accurate indicators of satisfaction and likelihood to recommend in patients attending private practice musculoskeletal physical therapy in Australia. Clinicians and educators should focus on developing these skills to encourage an effective therapeutic alliance and promote greater levels of patient satisfaction.

Identifying the activities of physiotherapy practitioners through primary and secondary models of care provided in New South Wales emergency departments

BACKGROUND

Following the introduction of the emergency department (ED) primary contact physiotherapy role, emergency physiotherapy models of care have evolved and are increasingly being adopted in the Australian EDs. This has occurred due to growing ED patient demand and a need for greater workforce flexibility. Since introduction, there has been limited evaluation of the scope of work physiotherapists are providing in Australian EDs.

OBJECTIVES

To identify the activities of ED physiotherapists provided through different models of care in NSW.

METHODS

Prospective observation study in 19 participating EDs conducted over 6 months between September 2014 and April 2015.

RESULTS

The study identified different models of care across participating hospitals where physiotherapists worked independently or in conjunction with a team through a referral service. The individual's scope of work was determined by organisational policy, culture, individual competence, knowledge and skills, and varied significantly between sites.

CONCLUSIONS

These findings could guide both ED work flow and the development of multidisciplinary workforce structures to improve the utilisation of the physiotherapy service in EDs. This will allow for better service levels in hospitals, better access for patients and better use of resources.

[Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: A narrative review]

BACKGROUND

Musculoskeletal disorders are increasing in prevalence, principally due to sedentary behaviors. Strong evidence supports an early need for first-line treatment including physiotherapy. New and innovative models in primary and emergency care have been drawn up and put the physiotherapist's skills to work in early and first-line management of patients with musculoskeletal disorders. The objectives of this review were to identify and describe studies assessing models of care integrating direct access to physiotherapy in primary care and in emergency care for patients with musculoskeletal disorders and to provide perspectives on the application of these two models in France.

METHODS

A literature review was carried out including studies extracted from four scientific databases: PubMed, CINAHL, Embase, and PEDro. The selected articles had to address the clinical effectiveness or efficiency of these models for the provision of care in primary or in emergency care. A narrative literature review method was used. The synthesis deals with the qualitative analysis of the included studies.

RESULTS

Thirty-nine studies were included in this review: 19 on assessment of the direct access to physiotherapy model in primary care and 20 on the direct access to physiotherapy model in emergency departments as concerns patients with musculoskeletal disorders. The studies showed that the different models incorporating direct access to physiotherapy in primary or in emergency care provided better outcomes in terms of quality and access to care while maintaning a similar degree of safety. However, the methodology of the studies included was estimated as being of heterogeneous quality.

CONCLUSION

The studies dealing with the new models for provision of care integrating direct access to physiotherapy in primary care or emergency care impart two lessons: (1) they are not designed to replace the physician; (2) collaboration between different health professionals aimed at improving patients' access to efficient care is to be encouraged. It would be worthwhile to focus upon dissemination factors that would enhance the efficiency of these innovative models in other countries, as in France.

European region of the WCPT statement on physiotherapy in primary care

This statement has been produced by the European Region of the World Confederation for Physiotherapy (ER-WCPT) to promote the role of the physiotherapy profession within primary care, to describe the health and economic benefits to health systems and populations of having a skilled, appropriately resourced and utilised physiotherapy workforce in primary care services, and to illustrate how different models of physiotherapy service delivery are contributing to these health and cost benefits.

Management of patients brought in by ambulance to the emergency department: role of the Advanced Musculoskeletal Physiotherapist

Objective The aim of the present study was to evaluate the role of the Advanced Musculoskeletal Physiotherapist (AMP) in managing patients brought in by ambulance to the emergency department (ED). Methods This study was a dual-centre observational study. Patients brought in by ambulance to two Melbourne hospitals over a 12-month period and seen by an AMP were compared with a matched group seen by other ED staff. Primary outcome measures were wait time and length of stay (LOS) in the ED. Results Data from 1441 patients within the Australasian Triage Scale (ATS) Categories 3-5 with musculoskeletal complaints were included in the analysis. Subgroup analysis of 825 patients aged ≤65 years demonstrated that for Category 4 (semi-urgent) patients, the median wait time to see the AMP was 9.5min (interquartile range (IQR) 3.25-18.00min) compared with 25min (IQR 10.00-56.00min) to see other ED staff (P ≤ 0.05). LOS analysis was undertaken on patients discharged home and demonstrated that there was a 1.20 greater probability (95% confidence interval 1.07-1.35) that ATS Category 4 patients managed by the AMP were discharged within the 4-hour public hospital target compared with patients managed by other ED staff: 87.04% (94/108) of patients managed by the AMPs met this standard compared with 72.35% (123/170) of patients managed by other ED staff (P=0.002). Conclusions Patients aged ≤65 years with musculoskeletal complaints brought in by ambulance to the ED and triaged to ATS Category 4 are likely to wait less time to be seen and are discharged home more quickly when managed by an AMP. This study has added to the evidence that AMPs improve patient flow in the ED, freeing up time for other ED staff to see higher-acuity, more complex patients. What is known about the topic? There is a growing body of evidence establishing that AMPs improve the flow of patients presenting with musculoskeletal conditions to the ED through reduced wait times and LOS and, at the same time, providing good-quality care and enhanced patient satisfaction. What does this paper add? Within their primary contact capacity, AMPs also manage patients who are brought in by ambulance presenting with musculoskeletal conditions. To the authors' knowledge, there is currently no available literature documenting the performance of AMPs in the management of this cohort of patients. What are the implications for practitioners? This study has added to the body of evidence that AMPs improve patient flow in the ED and illustrates that AMPs, by seeing patients brought in by ambulance, are able to have a positive impact on the pressures increasingly facing the Victorian Ambulance Service and emergency hospital care.

Advanced musculoskeletal physiotherapists are effective and safe in managing patients with acute low back pain presenting to emergency departments

Objective The aim of this study was to compare emergency department (ED) key performance indicators for patients presenting with low back pain and seen by an advanced musculoskeletal physiotherapist (AMP) with those seen by other non-AMP clinicians (ED doctors and nurse practitioners). Methods A retrospective audit (October 2012-September 2013) was performed of data from three metropolitan public hospital EDs to compare patients with low back pain seen by AMP and non-AMP clinicians. Outcome measures included ED length of stay, ED wait time, admission rates and re-presentation to the ED. Results One thousand and eighty-nine patients with low back pain were seen during AMP service hours (360 in the AMP group, 729 in the non-AMP group). Patients seen by the AMP had a significantly shorter ED wait time (median 13 vs 32min; P<0.001) and ED length of stay (median 141 vs 175min; P<0.001). Significantly fewer patients seen by the AMP were admitted (P<0.001), and this difference remained after accounting for the difference in triage code between the groups. Conclusions Improved ED metrics were demonstrated in patients with low back pain when managed by an AMP compared with patients seen by doctors and nurse practitioners. What is known about the topic? There is a growing body of literature regarding the role of AMPs in the Australian healthcare system in providing clinical services for patients with musculoskeletal conditions, including settings such as the ED. AMPs have proven to be safe and cost-effective, achieving high patient satisfaction and improved patient outcomes. However, there is little to no information regarding their effect on ED metrics, such as ED length of stay, wait time and admission rates for patients presenting to the ED with low back pain. What does this paper add? This paper demonstrates improved ED metrics for patients presenting to the ED with low back pain when seen by an AMP compared with patients seen by doctors and nurse practitioners. The specific improved metrics for these patients were decreased admission rates, decreased ED length of stay and decreased wait time. What are the implications for clinicians? This paper provides evidence that the AMPs effectively discharge patients admitted to the ED in a timely manner, without evidence of increased readmissions, compared with their medical and nursing colleagues. Support for the role of the AMP within the ED setting is strengthened by these results.

Benefits of Musculoskeletal Physical Therapy in Emergency Departments: A Systematic Review

BACKGROUND

Over the past few decades, physical therapists have emerged as key health care providers in emergency departments (EDs), especially for patients with musculoskeletal disorders (MSKD).

PURPOSE

The purpose of this review was to update the current evidence regarding physical therapist care for patients with MSKD in EDs and to update current recommendations for these models of care.

DATA SOURCES

Systematic searches were conducted in 5 bibliographic databases.

STUDY SELECTION

The studies selected presented quantitative data related to the care of patients with MSKD by physical therapists in an ED setting.

DATA EXTRACTION

Raters reviewed studies and used the Effective Public Health Practice Project Quality Assessment Tool to assess their methodological quality.

DATA SYNTHESIS

Fifteen studies were included. Two studies, 1 of weak and 1 of strong quality, demonstrated that physical therapist care in EDs was as effective as or more effective than usual medical care for pain reduction, and 6 studies of varying quality reported that physical therapist care in EDs was as effective as usual care in EDs in reducing disability. Eight studies of varying quality reported that physical therapist care could significantly reduce waiting time in EDs. Four studies of varying quality reported that physical therapists ordered no more, or even fewer, medical images than physicians. In terms of health care costs, 2 studies of moderate to high quality found no significant differences in costs between physical therapist care and usual care in EDs. Finally, 6 studies of varying quality reported that patients were as satisfied or more satisfied with physical therapist care as with usual medical care in EDs.

LIMITATIONS

The roles of physical therapists in EDs vary depending on the setting, legislation, and training of providers. Only a limited number of high-quality studies were identified.

CONCLUSIONS

Although the quality of the evidence is heterogeneous, physical therapist care for patients with MSKD in EDs may be beneficial.

Consumer preferences regarding physiotherapy practitioners and nurse practitioners in emergency departments - a qualitative investigation

Workforce reform has led to Nurse Practitioners (NP) and Physiotherapy Practitioners (PP) employed in Emergency Departments (ED) to see patients alongside doctors. This qualitative study gathered consumer opinions and preferences regarding NPs, PPs, and doctors, and the attributes desired of them. Twenty-two members of the organization's Consumer Representative Program participated in one of three focus groups which were audio-recorded and transcribed verbatim. Data were subsequently collected using an emergent-systematic design that enabled ideas to be explored and refined in sequential focus groups. Data analysis, utilizing the principles of thematic analysis, identified four themes. First, consumers understand and accept that reform is necessary to improve care, better utilize available resources and create sustainable services. Second, although consumers accept the rationale for employing NPs and PPs, preferences vary regarding who they want as their primary clinician. Some consumers do not mind who provides care as long as they receive the care they need; others believe doctors provide superior care and preferred a doctor; a third group indicated that not everyone who presents to an ED needs to see a doctor and specialized care would be provided by NPs and PPs for certain conditions. Some consumers expressed incomplete or inaccurate understanding of ED staff roles, responsibilities, and skillsets, which influenced their care preferences. Third, consumers identified a core set of desirable staff attributes that apply to everyone irrespective of professional demarcation; all staff should embody these attributes, though the expression of the attributes will vary according to circumstances and the staff member's scope of practice. Fourth, consumers expect effective governance over ED services so that all staff, irrespective of their profession provides safe and effective care. In conclusion, these results can be used by health-care administrators and clinicians to inform workforce reform in EDs, helping to ensure that consumers' opinions and preferences are acknowledged and appropriately addressed.

Why do 'fast track' patients stay more than four hours in the emergency department? An investigation of factors that predict length of stay

OBJECTIVE

Low-acuity 'fast track' patients represent a large portion of Australian EDs' workload and must be managed efficiently to meet the National Emergency Access Target. The current study determined the relative importance and estimated marginal effects of patient and system-related variables in predicting ED fast track patients who stayed longer than 4 h in the ED.

METHODS

Data for ED presentations between 1 July 2014 and 30 June 2015 were collected from a large regional Australian public hospital. Only 'fast track' patients were included in the analysis. A gradient boosting machine was used to predict which patients would have an ED length of stay greater or less than 4 h. The performance of the final model was tested using a validation data set that was withheld from the initial analysis. A total of 27 variables were analysed.

RESULTS

The model's performance was very good (area under receiver operating characteristic curve 0.89, where 1.0 is perfect prediction). The five most important variables for predicting length of stay were time-dependent and system-related (not patient-related); these were the amount of time taken from when the patient arrived at the ED to: (i) order imaging; (ii) order pathology; (iii) request admission to hospital; (iv) allocate a clinician to care for the patient; and (v) handover a patient between ED clinicians.

CONCLUSIONS

We identified the most important variables for predicting length of stay greater than 4 h for fast track patients in our ED. Identifying factors that influence length of stay is a necessary step towards understanding ED patient flow and identifying improvement opportunities.

Review article: Best practice management of common ankle and foot injuries in the emergency department (part 2 of the musculoskeletal injuries rapid review series)

Ankle and foot injuries are the most common musculoskeletal injuries presenting to Australian EDs and are associated with a large societal and economic impact. The quality of ED care provided to patients with ankle and foot fractures or soft tissue injuries is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common ankle and foot injuries in the ED. Databases including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English language articles published in the last 12 years that addressed the acute assessment, management or prognosis in the ED were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 1242 articles, of which 71 were included in the review (n = 22 primary articles, n = 35 systematic reviews and n = 14 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the ankle and foot in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. Following a thorough history and physical examination, including the application of the Ottawa ankle rules, ED clinicians should not only provide a diagnosis, but rate the severity of soft tissue injuries, or stability of fractures and dislocations, which are the pivotal decision points in guiding ED treatment, specialist referral and the follow-up plan.

Primary contact physiotherapy services reduce waiting and treatment times for patients presenting with musculoskeletal conditions in Australian emergency departments: an observational study

QUESTION

Can primary contact physiotherapists reduce waiting and treatment times and facilitate faster discharge in Australian emergency departments?

DESIGN

Data on patients treated by primary contact physiotherapists were collected prospectively and compared with historical and concurrent cohorts of patients treated by other clinicians, using diagnosis and urgency.

PARTICIPANTS

Twenty-nine primary contact physiotherapists, working at 10 sites, treated a total of 14 452 patients with musculoskeletal conditions in triage categories 3, 4 and 5.

OUTCOME MEASURES

Data were analysed for two time periods: baseline (historical control) and implementation (12 to 15 months). A concurrent control cohort within the implementation period was selected using diagnosis (ICD-10-AM) and urgency of treatment (triage category). Waiting time, treatment time, and time to discharge from the emergency department were compared across periods and between cohorts.

RESULTS

Significant differences were found in waiting and treatment times. On average, patients treated by primary contact physiotherapists waited 31minutes less than those treated by other practitioners and had an average treatment time of 108minutes compared with 148minutes. Overall, 93% of patients treated by primary contact physiotherapists and 75% treated by other practitioners were discharged from the emergency department within a 4-hour time period. To address concerns that these results could be due to other differences between cohorts, multiple regression models were used and the results were still significantly in favour of the primary contact physiotherapists.

CONCLUSION

A primary contact physiotherapist model in hospital emergency departments can reduce waiting and treatment times for patients with musculoskeletal presentations, resulting in better performance in achieving discharge within the 4-hour national target. [Bird S, Thompson C, Williams KE (2016) Primary contact physiotherapy services reduce waiting and treatment times for patients presenting with musculoskeletal conditions in Australian emergency departments: an observational study.Journal of Physiotherapy62: 209-214].

Attributes of innovations and approaches to scalability - lessons from a national program to extend the scope of practice of health professionals

The context for the paper was the evaluation of a national program in Australia to investigate extended scopes of practice for health professionals (paramedics, physiotherapists, and nurses). The design of the evaluation involved a mixed-methods approach with multiple data sources. Four multidisciplinary models of extended scope of practice were tested over an 18-month period, involving 26 organizations, 224 health professionals, and 36 implementation sites. The evaluation focused on what could be learned to inform scaling up the extended scopes of practice on a national scale. The evaluation findings were used to develop a conceptual framework for use by clinicians, managers, and policy makers to determine appropriate strategies for scaling up effective innovations. Development of the framework was informed by the literature on the diffusion of innovations, particularly an understanding that certain attributes of innovations influence adoption. The framework recognizes the role played by three groups of stakeholders: evidence producers, evidence influencers, and evidence adopters. The use of the framework is illustrated with four case studies from the evaluation. The findings demonstrate how the scaling up of innovations can be influenced by three quite distinct approaches – letting adoption take place in an uncontrolled, unplanned, way; actively helping the process of adoption; or taking deliberate steps to ensure that adoption takes place. Development of the conceptual framework resulted in two sets of questions to guide decisions about scalability, one for those considering whether to adopt the innovation (evidence adopters), and the other for those trying to decide on the optimal strategy for dissemination (evidence influencers).

Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive, Comparative Analysis Over Time

BACKGROUND

Emergency department (ED) use in the United States is expected to rapidly increase. Nearly half of all ED visits are classified as semiurgent or nonurgent, and many fall into the musculoskeletal category. Despite growing international evidence that patients are appropriately and safely managed by ED physical therapists in a time-efficient manner, physical therapist practice in EDs is not widely understood or utilized in the United States. To date, no studies have reported the impressions of ED physicians about this practice.

OBJECTIVES

The purposes of this study were: (1) to assess ED physicians' impressions of ED physical therapist practice 2 years after practice was initiated and (2) to determine whether physicians' impressions changed 7 years later.

METHODS

All ED staff physicians and medical residents at a level I trauma hospital were invited to complete a survey in 2004 and 2011.

RESULTS

In both years, a majority of physicians reported favorable impressions of ED physical therapist practice. Physical therapists were valued for educating patients about safety and injury prevention, providing appropriate gait training, assisting with disposition planning, and providing interventions as alternatives to pain medication. Many physicians supported standing physical therapist orders for certain musculoskeletal conditions. The most common concern was the additional time that patients spend in the ED for a physical therapist consult.

LIMITATIONS

The results of this study may not reflect the impressions of physicians in all EDs that employ physical therapists.

CONCLUSIONS

Emergency department physicians reported favorable impressions of ED physical therapist practice 2 years and 9 years following its implementation in this hospital. This study showed that ED physicians support standing physical therapist orders for certain musculoskeletal conditions, which suggests that direct triage to ED physical therapists for these conditions could be considered.

Physical Therapists as Primary Practitioners in the Emergency Department: Six-Month Prospective Practice Analysis

BACKGROUND

Increasing pressure on the emergency department (ED) throughout the world has meant the introduction of innovative ways of working. One such innovation is the advanced practice physical therapist (APP) acting as a primary contact practitioner. There has been little research into the role beyond identifying patient satisfaction with management, cost-effectiveness, and time efficiency. In order to give further support and assist in development of an APP service in the ED, an increased exploration of patient caseload demographics, resource utilization, and management outcomes is needed.

OBJECTIVES

The purpose of this study was to provide quantitative data regarding patient demographics, time efficiency, resource utilization, and management outcomes to examine the APP role in the ED.

DESIGN

This was a prospective observational study of practice.

SETTING

The study was conducted in a single ED in Melbourne, Australia.

METHOD

Data collection was conducted over a 6-month period. Patient demographics and diagnoses, assessment times, hospital resource utilization, and discharge destinations were recorded.

RESULTS

One thousand seventeen patients (45% female; median age=34 years, interquartile range=25-52) were managed by the APPs; 89% had conditions triaged as not serious or life threatening, and 97% had musculoskeletal pathologies, with the most common diagnosis being fracture or dislocation. Four-hour length-of-stay targets were met in 95% of the patients. Forty-six percent of the patients seen were managed independently, without any support from medical colleagues. The most frequent discharge destination was a referral back to the primary care physician or to hospital outpatient clinics. When comparing similar diagnostic groups, the APPs were significantly more time-efficient than ED physicians in their patient management.

CONCLUSIONS

This study described in detail the caseload managed by the APP in the ED and identified the role as a valuable asset to an ED, managing a great deal of their caseload independently, safely, and time efficiently.

Evaluation of performance quality of an advanced scope physiotherapy role in a hospital emergency department

Background

Physiotherapists working in advanced and extended scope roles internationally make a difference to workflow, performance targets, and patient satisfaction in areas traditionally served by medicine and nursing.

Aim

To assess the impact of an advanced scope of practice physiotherapist (ASoP-PT) service in a large Australian hospital emergency department (ED) by measuring national service and triage category indicators, patient and staff satisfaction.

Methods

Consecutive patients consulting the ASoP-PT were recruited over 53 weeks following service inception. Descriptions of ASoP-PT activities and patients were collected. Performance was assessed against national ED indicators for length of stay and wait. Patient and staff perspectives were assessed independently by semi-structured interviews. The physiotherapist was formally trained to extended scope of practice including competency in medicines, prescription and application. The legislation prevented him from applying these skills, therefore he worked in an ASoP-PT role in ED.

Results

The ASoP-PT treated on average, 72 patients per month in ten shifts per fortnight, consulting patients aged from 1 to 88 years. Patients largely presented with musculoskeletal problems in triage Categories 4 and 5. There were shorter length of wait and length of stay, when the ASoP-PT was on shift. However overall compliance with national performance targets was similar with and without the ASoP-PT. Staff and patient satisfaction was high, particularly valuing the ASoP-PT’s expertise in musculoskeletal injuries.

Conclusion

The ASoP-PT performed at least as well as other ED health care providers in meeting national triage targets. Had the legislation permitted his independent prescription of medicines, the ASoP-PT could have worked in an extended scope role, and his performance in meeting targets may have been better.

Using programme theory to evaluate delivery of health services: A methodology accessible to clinicians

Background:

With healthcare providers experiencing increasing demand to evaluate clinical service delivery, it is necessary to explore evaluation methodologies that can accommodate the complexities and contextual factors in health-care systems and human systems in general. Methodologies must also be comprehensible to clinicians. Programme theory is one such methodology.

Content:

This paper presents a brief description of programme theory methodology and a case study of the use of this approach in a custom wheelchair seating service for people with spinal cord injury.

Conclusions:

Programme theory is a useful methodology for examining how a service operates and whether it achieves what it sets out to do. It is essential that clinicians challenge and test their assumptions about their services and act on information obtained in order to continuously improve service delivery.

Acupuncture as analgesia for non-emergent acute non-specific neck pain, ankle sprain and primary headache in an emergency department setting: a protocol for a parallel group, randomised, controlled pilot trial

INTRODUCTION

This study aims to assess the feasibility of acupuncture as an add-on intervention for patients with non-emergent acute musculoskeletal pain and primary headache in an emergency department (ED) setting.

METHODS AND ANALYSIS

A total of 40 patients who present to the ED and are diagnosed to have acute non-specific neck pain, ankle sprain or primary headache will be recruited by ED physicians. An intravenous or intramuscular injection of analgesics will be provided as the initial standard pain control intervention for all patients. Patients who still have moderate to severe pain after the 30 min of initial standard ED management will be considered eligible. These patients will be allocated in equal proportions to acupuncture plus standard ED management or to standard ED management alone based on computer-generated random numbers concealed in opaque, sealed, sequentially numbered envelopes. A 30 min session of acupuncture treatment with manual and/or electrical stimulation will be provided by qualified Korean medicine doctors. All patients will receive additional ED management at the ED physician's discretion and based on each patient's response to the allocated intervention. The primary outcome will be pain reduction measured at discharge from the ED by an unblinded assessor. Adverse events in both groups will be documented. Other outcomes will include the patient-reported overall improvement, disability due to neck pain (only for neck-pain patients), the treatment response rate, the use of other healthcare resources and the patients' perceived effectiveness of the acupuncture treatment. A follow-up telephone interview will be conducted by a blinded assessor 72±12 h after ED discharge.

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. The study has been approved by the Institutional Review Boards (IRBs). The results of this study will guide a full-scale randomised trial of acupuncture in an ED context.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT02013908.