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

Identifying competencies for an advanced practice physiotherapy role within an interprofessional chronic pain clinic

BACKGROUND

Advanced practice physiotherapy (APP) models of care have shown success in access, safety, satisfaction, and care quality for musculoskeletal pain conditions in various settings. Yet, there is a gap in defining competencies for physiotherapists to be the initial point of contact for people with chronic pain. This study aims to identify and agree upon the competencies necessary for a physiotherapist to fulfill the role of an APP in an interprofessional chronic pain clinic.

METHODS

Three focus groups were conducted using a Nominal Group Technique and a modified Delphi process. Consensus on the competency, defined as agreement by ≥ 75% of participants, was sought.

RESULTS

Twenty-three experts (17 healthcare providers and six individuals with chronic pain) participated in the focus group discussions. Twenty completed the follow-up Delphi surveys. Ten essential competencies for an APP role in interprofessional chronic pain clinics were identified and achieved consensus: 1) use an evidence-based approach to practice; 2) communicate effectively with the patient; 3) perform a comprehensive assessment; 4) determine pain-related diagnoses; 5) develop therapeutic relationships; 6) provide appropriate care; 7) support patients through transitions in care; 8) collaborate with members of the interprofessional team; 9) advocate for the needs of the patients; and 10) use a reflective approach to practice.

CONCLUSION

This study identified ten competencies essential for physiotherapists to fulfill an APP role within interprofessional chronic pain clinics. These competencies serve as a foundation for informing a training program and future research evaluating the effectiveness of the APP model in this setting.

Is clinician reported practice in Western Australian emergency departments aligned with direct discharge pathway protocols for minor self-limiting fractures? A multi-centre professional survey

OBJECTIVE

To determine ED clinician's current management for five common minor self-limiting fractures (MSLF) and evaluate practice against evidence-informed direct discharge pathway (DD) protocols.

METHODS

A survey was provided to doctors, nurse practitioners and advanced scope physiotherapists working in seven metropolitan, public health EDs in Perth, Australia. The relative odds of ED location (e.g. which facility) and clinician level factors (e.g. country of initial training, years of ED experience, profession) on recommending care completely consistent with evidence informed direct discharge pathway protocols were estimated.

RESULTS

Two hundred sixty-two clinicians completed the survey. There was variability in practice across all sites, with most reported care assessed at 60%-76% consistency with individual elements of DD care provision. Highest consistency was seen in lower limb immobilisation and DVT prophylaxis. Lowest consistency was seen in weight bearing advice, pain management and (boxer's) fracture reduction and immobilisation. There were very low levels of complete consistency, ranging from 9% (boxer's fracture) to 25% (radial head fracture). Two factors were associated with increased odds of completely consistent care: (i) clinician experience working in ED, with greater duration of practice associated with increased odds ratios (OR range, 1.6-3.3); and (ii) profession, where advanced scope physiotherapy was associated with increased odds ratios (OR range, 3.2-25.0).

CONCLUSIONS

Survey results suggested system wide variation in ED fracture management practice and target areas for service improvement. Avenues for service improvement could include hospital wide agreed management plans for specific fractures and support for less experienced clinicians.

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.

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.

How can scope of practice be described and conceptualised in medical and health professions? A systematic review for scoping and content analysis

BACKGROUND

The term scope of practice (SOP) refers to the limits of a health professional's knowledge, skills and experience and reflects all tasks and activities they undertake within the context of their professional role. Inconsistency in definitions of SOP contributes to uncertainty and confusion regarding professional practice boundaries and potentially impacts societal access to safe, effective and efficient healthcare options. The aim of this paper is to understand the conceptual diversity that may exist in terminology used to describe medical, nursing/midwifery and allied health SOP within an Australian practice context exemplar.

METHODS

A systematic review for scoping and content analysis of SOP definitions and concepts, involving inductive thematic analysis and synthesis of published and grey literature.

RESULTS

The initial search strategy yielded 11,863 hits, of which 379 were suitable for inclusion. Data coding identified various SOP terms and definitions and the emergence of six, conceptual elements underpinning the theoretical construct. These were subsequently proposed as a preliminary conceptual model ('Solar') to explain how the six conceptual elements may be applied across various professions, clinical settings and jurisdictions to better understand and address current and evolving SOP issues.

CONCLUSION

The findings of this study highlight limited consistency in SOP definitions and terminology within a single jurisdiction, and the conceptual complexity of the underlying theoretical construct. Further research is required to build on the proposed 'Solar' conceptual model and create a universal SOP definition across jurisdictions, to enhance understanding of the importance of SOP to workforce policy, clinical governance, service models and patient outcomes.

Assessing the feasibility of a clinical trial to evaluate an advanced practice physiotherapy model of care in chronic pain management: a feasibility study

BACKGROUND

Chronic pain management is challenging for health systems worldwide. Clinical practice guidelines recommend interprofessional chronic pain management, but chronic pain clinics often have lengthy wait-lists. Advanced practice physiotherapists (APP) in orthopedic clinics and emergency departments have provided effective care and reduced wait times. The purpose of this study is to determine the feasibility of a clinical trial to evaluate the effects of integrating an APP into a chronic pain clinic setting. The primary objectives are as follows: (1) determine the feasibility of implementing trial methods by evaluating participant recruitment rates, retention, and assessment completion; (2) determine the feasibility of implementing the APP model of care by monitoring care provided and treatment fidelity; and (3) assess contextual factors that may influence implementation of the APP model of care by exploring the perspectives of patient participants and healthcare providers related to the model of care.

METHODS

This will be a single-arm feasibility study with embedded qualitative interviews to assess contextual factors influencing implementation by exploring participant and provider perspectives. Approximately 40 adults with chronic musculoskeletal pain referred for care at an interprofessional chronic pain clinic will be invited to participate in the feasibility study. Approximately 10-12 patient participants and 5-10 health professionals from the interprofessional team will be interviewed using an interpretive description approach. The APP model of care will involve participants seeing a physiotherapist as the first point of contact within the interprofessional team. The APP will complete an initial assessment and make care recommendations. Outcome measures planned for the full trial will be reported descriptively, including pain severity, pain interference, health-related quality of life, psychosocial risk factors for chronic pain, treatment satisfaction, perceived change, healthcare utilization, and healthcare costs over one year.

DISCUSSION

This study will inform plans to implement a full-scale study to evaluate the impact of an APP model of care in an interprofessional chronic pain management program. The results of the full study are intended to inform stakeholders considering this model to improve patient-centered and health system outcomes in interprofessional pain management program settings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05336903 (Registered April 5, 2022).

Influence of Initial Health Care Provider on Subsequent Health Care Utilization for Patients With a New Onset of Low Back Pain: A Scoping Review

OBJECTIVE

The aim of this research was to examine the scope of evidence for the influence of a nonmedical initial provider on health care utilization and outcomes in people with low back pain (LBP).

METHODS

Using scoping review methodology, we conducted an electronic search of 4 databases from inception to June 2021. Studies investigating the management of patients with a new onset of LBP by a nonmedical initial health care provider were identified. Pairs of reviewers screened titles, abstracts, and eligible full-text studies. We extracted health care utilization and patient outcomes and assessed the methodological quality of the included studies using the Joanna Briggs Institute checklist. Two reviewers descriptively analyzed the data and categorized findings by outcome measure.

RESULTS

A total of 26,462 citations were screened, and 11 studies were eligible. Studies were primarily retrospective cohort designs using claims-based data. Four studies had a low risk of bias. Five health care outcomes were identified: medication, imaging, care seeking, cost of care, and health care procedures. Patient outcomes included patient satisfaction and functional recovery. Compared with patients initiating care with medical providers, those initiating care with a nonmedical provider showed associations with reduced opioid prescribing and imaging ordering rates but increased rates of care seeking. Results for cost of care, health care procedures, and patient outcomes were inconsistent.

CONCLUSIONS

Prioritizing nonmedical providers at the first point of care may decrease the use of low-value care, such as opioid prescribing and imaging referral, but may lead to an increased number of health care visits in the care of people with LBP. High-quality randomized controlled trials are needed to confirm our findings.

IMPACT

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, may help reduce opioid prescription and selective imaging in people with LBP. The trend observed in this scoping review has important implications for pathways of care and the role of nonmedical providers, such as physical therapists, within primary health care systems.

LAY SUMMARY

This scoping review provides preliminary evidence that nonmedical practitioners, as initial providers, might help reduce opioid prescription and selective imaging in people with LBP. High-quality randomized controlled trials are needed to confirm these findings.

Health-Related Quality of Life of Patients Presenting to the Emergency Department with a Musculoskeletal Disorder

Background

Musculoskeletal disorders (MSKDs) are among the most disabling and costly non-fatal health conditions. They may lead to long-term consequences such as chronic pain, physical limitations, and poorer quality of life. They also account for a significant proportion of emergency department visits, representing between 18% and 25% of all visits, depending on country.

Purpose

To assess the health-related quality of life of patients presenting to the emergency department with a MSKD, to convert their answers to utility scores and to explore the association between diverse socio-demographic and clinical variables and patients’ health-related quality of life.

Patients and Methods

This is an analysis of cross-sectional data obtained during the baseline assessment performed as part of a 6-month pragmatic randomized controlled trial conducted in an academic emergency department. We included patients aged 18–80 years with a minor MSKD. The main outcome measures were health-related quality of life (five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and utility scores (−0.148 – worse than death, 0 – dead, 0.949 – perfect health) measured with the EQ-5D-5L. Possible associations were explored by comparing scores across subgroups based on certain socio-demographic (eg, age, gender, triage score) and clinical factors (eg, pain interference on function, pain intensity) and with reference values using descriptive statistics (mean, median), rankFD ANOVAs, and χ² tests.

Results

Sixty-nine participants completed the EQ-5D-5L. Mean and median utility scores were, respectively, 0.536 (95% CI: 0.479–0.594) and 0.531 (IQR: 0.356–0.760). Participants with higher levels of pain (<4/10: 0.741, 95% CI: 0.501–0.980; 4–7/10: 0.572, 0.500–0.644; >7/10: 0.433, 0.347–0.518) or pain interference on function (<4/10: 0.685, 95% CI: 0.605–0.764; 4–7/10: 0.463, 0.394–0.533; >7/10: 0.294, 0.126–0.463) presented significantly lower utility scores. No significant differences were found for other socio-demographic characteristics.

Conclusion

In patients with MSKDs who present to the emergency department, higher levels of pain or pain interference are associated with decreased health-related quality of life. These findings need to be confirmed on a larger scale.

Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial

OBJECTIVES

The objective was to evaluate the effects of direct-access physiotherapy on patients presenting with a musculoskeletal disorder (MSKD) to the emergency department (ED) on clinical outcomes and use of health care resources.

METHODS

We conducted a randomized controlled trial in an academic ED in Québec City, Canada. We included patients aged 18 to 80 years with minor MSKD. The intervention group had direct access to a physiotherapist (PT) in the ED immediately after triage and prior to physician assessment, and the control group received usual care by the emergency physician without PT intervention. The key variables included clinical outcomes (pain, interference of pain on function) and resources use (ED return visit, medications, diagnostic tests, additional consultations). They were analyzed using descriptive statistics and compared between groups using two-way analyses of variance, log-linear analysis, and chi-square tests.

RESULTS

Seventy-eight patients suffering from MSKDs were included (40.2 ± 17.6 years old; 44% women). For the primary clinical outcome, participants in the PT group (n = 40) had statistically lower levels of pain and pain interference at 1 and 3 months. In terms of resource use, participants in the PT group returned significantly less often to the ED. At baseline and 1 month, less prescription medication was used, including opioids, but there were no differences at 3 months. Although over-the-counter medication was recommended more at baseline in the PT group, there were no differences in use at 1 month, and the PT group had used them less at 3 months. There were no differences between groups at follow-up for imaging tests, other professionals consulted, and hospitalization rates.

CONCLUSION

Patients presenting with a MSKD to the ED with direct access to a PT had better clinical outcomes and used less services and resources than those in the usual care group after ED discharge and up to 3 months after discharge.

Cross-sectional UK survey of advanced practice physiotherapy: characteristics and perceptions of existing roles

Background/aims

Few studies have investigated the characteristics of advanced practice physiotherapy in the UK to evaluate current context and implementation. The aim of this study was to understand how advanced practice physiotherapy is implemented in the UK.

Methods

A cross-sectional online descriptive national questionnaire was developed, using a previous survey and literature, comprising 33 closed, Likert-scale and open questions. Data analysis was undertaken using frequencies and thematic analysis. All 646 members of the Advanced Practice Physiotherapy Network were invited to participate.

Results

A total of 142 (22% response) reported 13 job titles; 40% had experienced ≥1 title change; most (50.7%) preferred ‘advanced practice physiotherapist’. High level job satisfaction was identified but barriers prevent fulfilment of the four advanced practice physiotherapy pillars: clinical practice, leadership and management, education and research. High level clinical skills and facilitating patient pathways were key to role differentiation. Problems included lack of support, inconsistency between responsibility and reward, and no consistent framework for advanced practice physiotherapy roles.

Conclusions

Advanced practice physiotherapists are largely satisfied, but significant variation exists in titles and implementation of roles. A consistent advanced practice physiotherapy framework is required.

Extended scope of practice audiology in the ENT outpatient clinic - a pilot study

OBJECTIVE

To investigate the feasibility of using an extended scope (ES) audiology service to provide care to non-urgent adult patients waiting for an Ear Nose and Throat (ENT) appointment.

DESIGN

Based on suitability criteria developed by the Audiology and ENT departments, an internal review of the ENT wait list identified patients who would be suitable for an ES audiology clinic.

STUDY SAMPLE

220 non-urgent patients on the ENT wait list with hearing loss and/or tinnitus.

RESULTS

A total of 220 patients were transferred from the ENT wait list to the ES audiology clinic: 200 (90.9%) were seen by the ES Audiologist and 20 (9.1%) patients self-discharged or did not attend the appointment. Out of the 200 patients seen, 175 (87.5%) were assessed, managed and discharged without the need for input from an Otologist. The remaining 25 (12.5%) patients needed an Otologist's input.

CONCLUSION

This study has demonstrated the feasibility of an ES audiology clinic in a tertiary teaching hospital. Of those seen by ES audiologist, 87.5% were discharged from the ENT wait list without medical intervention. This model may represent an effective alternative pathway for lengthy outpatient waiting list management whilst providing patients with timely access to care.

Development of nurse practitioner metaspecialty clinical practice standards: A national sequential mixed methods study

AIM

To achieve profession-wide consensus on clinical practice standards for six broad Australian nurse practitioner specialty areas (termed metaspecialties).

DESIGN

Sequential mixed methods with initial interpretive study (Interpretive Phase) followed by modified three-round Delphi study (Survey Phase).

METHODS

Participants from all Australian jurisdictions were recruited. Main eligibility criterion was current endorsement as a nurse practitioner for 12 or more months. Interpretive Phase comprised in-depth interviews of purposeful sample of nurse practitioners to identify clinical care activities and practice processes. Six sets of draft clinical practice standards relevant to six previously identified metaspecialties were developed. Outcome informed Round 1 of Survey Phase (six nested web-based Delphi surveys), with draft standards reviewed profession-wide. Responses comprised scoring using Likert scales to calculate content validity indexes for individual standards with qualitative responses supporting decision-making. For Rounds 2 and 3, participants rated relevancy of original or revised standards after consideration of individual and group feedback. The study was conducted 2014-2017.

RESULTS

Interpretive Phase: Analysis of interview data with 16 nurse practitioners provided 75 draft standards. Survey Phase: 221 nurse practitioners completed Round 1 (20% of then eligible Australian nurse practitioners). Weighted respondent retention was 92%. Seventy-three standards were validated, with final content validity indices of 92-100%. Scale-level indices were 98%, strongly validating metaspecialty taxonomy.

CONCLUSION

A research-derived, professionally endorsed suite of nurse practitioner clinical practice standards was developed. This provides a broad clinical learning structure with metaspecialties guiding nurse practitioner student clinical education.

IMPACT

The clinical practice standards and metaspecialty taxonomy strengthen nurse practitioner clinical education and professional development nationally and internationally. These novel study methods and findings are applicable to advanced specialty roles in other health professions.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

[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.

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.

Large variability found in musculoskeletal physiotherapy scope of practice throughout WCPT and IFOMPT affiliated countries: An international survey

BACKGROUND

Advanced practice physiotherapy (APP) rights are part of the evolution of the Physical Therapy profession. To date, no study has investigated musculoskeletal APP rights within the World Confederation for Physical Therapy (WCPT).

OBJECTIVE

To investigate musculoskeletal APP rights for physical therapists worldwide and examine the relationship between level of education (entry and post-professional) and direct access for countries that are vs. are not members of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT).

DESIGN

Cross-sectional study with descriptive and exploratory online surveys.

METHODS

An electronic survey-based descriptive and exploratory investigation was conducted. We assessed variability between WCPT member organizations descriptively and the strength of the relationships among the number and types of APP rights with: (1) country affiliation to IFOMPT; (2) entry-level professional degree; (3) post-professional training; and (4) direct access.

RESULTS

Some countries reported having the right to practice all 20 APP rights while others reported no APP rights. Countries with IFOMPT member organization countries displayed fair correlation (r_s = .48, p < .03) between entry-level physical therapy degrees and number of APP rights. IFOMPT member organization countries were less likely to require post-professional training for direct access and manipulation.

CONCLUSION

APP rights for countries with direct access were significantly higher than for countries without direct access. IFOMPT member organizations demonstrated higher APP rights prevalence and were less likely to require post-professional training to obtain the right to direct access and perform manipulation.

Medicines management activity with physiotherapy and podiatry: A systematic mixed studies review

OBJECTIVE

Making best use of existing skills to increase service capacity is a global challenge. The aim was to systematically review physiotherapy and podiatrist prescribing and medicines management activity, including evidence of impact on patient care, levels of knowledge and attitudes towards extended medicines role.

METHODS

A search of MEDLINE, CINAHL, and Cochrane databases, using terms to identify prescribing and medicines management across a range of roles, was conducted from January 1985 to May 2016 for physiotherapy, and January 1968 to May 2016 for podiatry. Hand searching of citations and databases from professional organisations was undertaken. Data were extracted and analysed descriptively, and quality appraised by 2 reviewers using the mixed methods appraisal tool.

RESULTS

1316 papers were identified, and 21 included in the review. No studies were identified that reported prescribing and no studies specific to podiatry met the inclusion criteria. Physiotherapists were highly involved in administering medicines, providing medicines advice, and recommending new medicines. Patient satisfaction, cost and outcomes were equivalent when comparing physiotherapist-led injection therapy to traditional care. Pharmacology knowledge was variable and unmet training needs identified.

CONCLUSION

Medicines management practices were identified in physiotherapy and positive outcomes of extended scope physiotherapy. There was a lack of evidence regarding podiatric practice. Review of educational preparation for medicines management is recommended along with evaluation of medicines management practice.

Patients' and healthcare professionals' experiences and perceptions of physiotherapy services in the emergency department: a qualitative systematic review

BACKGROUND

Worldwide, emergency department (ED) attendances and admissions to acute care have increased significantly. Many EDs are adding physiotherapists to their team thereby allowing doctors to see more cases that are 'urgent'. This is a move away from the 'traditional' physiotherapy service whereby the ED team refers patients to an outpatient physiotherapy service sometimes resulting in significant delays. Internationally, there is no agreed consensus on the role or value of ED-based physiotherapists.

AIM

The objective of this review was to retrieve, critically appraise and synthesise the evidence from studies relating to patients' and healthcare professionals' experiences and/or perceptions of physiotherapy services in the ED.

METHOD

This is a systematic review (SR) synthesising qualitative studies, which have considered patients' (population 1) and healthcare professionals' (population 2) experiences and/or perceptions (outcomes) of ED physiotherapy services (exposure). A comprehensive systematic search, limited to English language articles, was undertaken on seven electronic medical databases (Medline, EMBASE, CINAHL, AMED, BNI, PubMed and PEDro) for the period January 2006 to October 2016. Grey literature was identified using Google Scholar, reference lists and website searching. The Critical Appraisal Skills Programme (CASP) qualitative checklist was used to appraise all included studies. All studies were data extracted and quality appraised by two reviewers to enhance rigour and reduce bias.

RESULTS

A total of 2163 studies were screened, 10 received full-text review and 7 studies were included in the final review. Six of the studies originated in Australia and one from the USA. The themes that emerged were as follows: Patients and healthcare professionals view ED-based physiotherapists as having (1) expert clinical skills and (2) an educational role. There is role confusion and lack of integration of the ED-based physiotherapist within the ED team.

CONCLUSION

This review adds an in-depth human perspective to the current ED physiotherapy literature, which provides insight into how ED healthcare services and physiotherapy services specifically should be developed and delivered in the future. The knowledge from this review has implications for future education programmes, as well as development of both new care pathways and physiotherapy clinical roles. Research into ED-based physiotherapy services is predominantly quantitative. Despite the newness of the ED physiotherapy role, this review reveals that the provision of physiotherapists within EDs contributes value to both patients and staff. However, the dominance of Australian research means it is uncertain how it translates to the UK or elsewhere. There needs to be further UK-based research.

Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review

QUESTION

What are staff and patients' perceptions of physiotherapists working in the emergency department (ED)?

DESIGN

Systematic review of qualitative studies.

PARTICIPANTS

Staff working in EDs and patients presenting to the ED and managed by ED physiotherapists.

OUTCOME MEASURES

Perceptions of ED staff and patients were synthesised using a three-stage thematic analysis consisting of extraction, grouping (codes), and abstraction of findings.

RESULTS

Eight studies, which had sought the perceptions of 138 patients and 122 ED staff members, were included. Three main themes emerged: role of physiotherapists in the ED, positive perceptions of ED physiotherapists, and concerns about physiotherapists in the ED. Patients and ED staff both considered physiotherapists to be experts in musculoskeletal care. The role of ED physiotherapists was seen as providing thorough patient education, non-pharmacological pain management and activity resumption, especially through exercise therapy. Having broad knowledge to assess and treat different health conditions was seen as facilitating the work of physiotherapists in the ED. Patients and ED staff felt that ED physiotherapists had good interpersonal communication skills. ED staff expressed concerns regarding the additional time that physiotherapists spent with patients. Some patients felt that performing exercises in the ED was inappropriate and painful.

CONCLUSIONS

ED physiotherapists were mostly well accepted by patients and ED staff, and their work was perceived to improve the ED. Concerns included restricted availability, lack of awareness of the role undertaken by physiotherapists in the ED, and increased treatment time in some settings. [Ferreira GE, Traeger AC, O'Keeffe M, Maher CG (2018) Staff and patients have mostly positive perceptions of physiotherapists working in emergency departments: a systematic review. Journal of Physiotherapy 64: 229-236].

Advanced musculoskeletal physiotherapy: Barriers and enablers to multi-site implementation

OBJECTIVES

Advanced musculoskeletal physiotherapy (AMP) services are a safe, effective model of care, but without broad-scale healthcare implementation to date. The aim of the present study was to identify the barriers and enablers to implementation of 12 AMP services from the perspective of clinical staff.

METHODS

In a qualitative study, 12 participants (physiotherapists), from 12 different healthcare networks (seven metropolitan, three regional, two rural), were included. Their departments implemented AMP services (orthopaedic postoperative joint replacement review, n = 10; general orthopaedic, n = 1; emergency, n = 1; and neurosurgery n = 1) over a 12-month period. Participants completed a structured survey specifically designed for the study. Thematic analysis was used, with themes mapped to the validated Theoretical Domains Framework.

RESULTS

Nine major themes emerged from the data regarding barriers and enablers to the implementation of the AMP services from the perspective of clinical staff. These were: demand/capacity; model of care; the organization; stakeholders; communication; planning and processes; evaluation; workforce; and learning and assessment framework. Important enablers included engagement and buy-in from key stakeholders and medical staff, and well-established AMP learning frameworks for training and operational frameworks. Barriers included competitive funding environment, and issues that hindered effective communication. The knowledge, skills, availability, motivation and experience of the advanced musculoskeletal physiotherapists had a large impact on the implementation.

CONCLUSIONS

The study identified a number of factors that should be considered for successful implementation of AMP services across healthcare services or wider healthcare networks.

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].