Physiotherapists and Emergency Triage

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Introduction

It is an exciting time to be a physiotherapist / physical therapist (PT). Our roles, responsibilities, scope of practice and impacts are evolving; which includes our role within the emergency department (ED). Please note that this page addresses PTs being involved in the TRIAGE of patients arriving at the ED, this should be considered as an advanced practice in physiotherapy. For more information on the role of physiotherapists within the emergency department (patient's already admitted), see the page: emergency department physical therapy (ED PT). 

It is no secret that there is a long history of controversy with allied health care providers undertaking new roles and responsibilities, which have traditional been solely attributed to physicians. As the practice of physiotherapy evolves, so do our roles and responsibilities within hospitals and health care institutions. As Subject Matter Experts (SMEs) on the musculoskeletal system, it is only intuitive that we be where the injuries are - which is the emergency department.  

Emergency departments have traditionally been designed to address medical life threatening emergencies. However, there seems to be an emerging trend for individuals to consult EDs for non-life threatening MSK pain in order to gain access to health care.

A study involving the United States between 2006-2007 found that 30% of the 61.2 million MSK injuries treated during that period occurred in the ED. The National Ambulatory Care Reporting System in Canada (2014-2015) suggests that the leading reason to consult an ER for MSK pain includes cervical and lumbar regions. Emergency departments would benefit from an experienced physiotherapists with sharp clinical reasoning and diagnostic skills. 

Suggested Roles & Responsibilities of a PT

• Identify any red or yellow flags (indicating a non-MSK condition)
• Provide advice and activity modification
• Offer a treatment (taping, modalities, manual therapy, assisted devices)
• Application of accepted Clinical Prediction Rules (CPRs)
  • Canadian Cervical Spine Rules
  • Carpal Tunnel Syndrome
  • Cervical Radiculopathy
  • Well's Criteria: CPR for Deep Vein Thrombosis
  • Meniscal Pathology
  • Ottawa Ankle Rules
  • Ottawa Knee Rules
  • Pittsburgh Knee Rules
  • Pulmonary Embolism 
  • Rotator Cuff Pathology
  • Subacromial Impingement

• Refer the patient for further medical intervention (including a referral for further PT services as necessary).
• Reassurance / advice / increased patient satisfaction due to early intervention

The fundamental success of the triage system relies on the basis that the patient is treated by the appropriate clinician. If the medical complaint can be addressed solely with the PT, then there is no need for further consultation with a nurse or physician.

If by contrast, the patient requires medical imaging, medication, or a specialist consult, the PT will discuss the case with the nurse or physician, who will then continue the medical line of inquiry.

Where is this new role presently being developed:

• Canada 
• Singapore
• Australia
• United Kingdom
• Ireland

Clinical Bottom Line (What's being said in the literature) 

Australian emergency department physiotherapists currently perform traditional physiotherapy roles in a non-traditional work environments. The role is aligned with MSK physiotherapy; however, there is a degree of holistic care involved, particularly for elderly patients. The effect that an emergency department physiotherapy service has on health outcomes is not known, but their is support that patients believe that PT services in the ED has system-wide benefits.

There is evidence that early physiotherapy intervention is effective with reducing pain and increasing satisfaction for patients with acute low back pain in an Emergency Department.

Advanced musculoskeletal physiotherapist (AMPs) effectively discharge patients admitted to the ED in a timely manner, without evidence of increased readmissions, compared with their medical and nursing colleagues.

There was no significant difference between the proportion of patients sent for x ray and the type of clinician. (p = 0.17) There was also no significant difference between the proportions of x rays found to have fractures/dislocations with each type of clinician (p = 0.99). All fractures and dislocations were found to have been managed following the written departmental protocols. Consequently, further analysis was for soft tissue injuries only. For soft tissue injuries, senior house officers gave more patients analgesia/ non‐steroidal anti‐inflammatory drugs compared with other clinicians (86%, p<0.001). Nurses gave more structural support (bandages, etc) compared with other clinicians (80%, p<0.001) and PTs in the ED referred significantly more patients for physiotherapy follow‐up (9.2%, p = 0.031).

There is emerging scientific support for AMPs have a role to play in Emergency Departments.

The Successes of a PT in an Emergency Department (ED)

• Direct, front-line access to a physiotherapist (no referral required)
• Acting as the educational Subject Matter Expert (SME) for other clinicians within the department
• Early identification of Yellow / Red Flags (MSK or Systemic)
• Appropriate MSK advice and care given to the patient during the acute phase of healing
• Timely referral to outpatient physiotherapy services (as deemed appropriate)
• Allows for appropriate clinical intervention for various degrees of medical emergencies (appropriately sharing the evaluation roles among health care providers)
• Stretches the available finite ED resources, as there is a sharing of the triage burden (liberating nurses, doctors, specialists for non-MSK complaints).
• Early access to physiotherapy in ED is associated with reduced pain and disability levels
• A possible health care model that can increase the efficiency of emergency departments
• A potential decrease in wait times for patients
• A potential decrease the demand on outpatient orthopedic services
• Increased patient satisfaction for early access to rehabilitation specialist
• Aresponse to a need for greater workforce flexibility and improved service provision to meet growing patient demand
• A truly interdisciplinary approach to patient care.

Potential Challenges Ahead

• Such a position in the ED should be considered advanced practice and therefore experienced PTs  (advanced musculoskeletal physiotherapist (AMP)) should only be put in a high-tempo EDs
• Potentially high-stress work environment for PTs
• Working in a multi-health care provider environment (must be proficient and comfortable with team work)
• No standardization of required qualifications or scope of practice (can vary from hospital to hospital, or country to country, for example)
• The need to develop evidence-based regulatory, ethical and educative frameworks to keep pace with the changing clinical environment and service delivery in EDs
• Highlighting and implementing the ethical understanding and legal and professional knowledge which are required for this work environment
• Willingness of all clinicians to cooperate and share the diagnostic / clinical impression role
• Within smaller EDs, there may be too few MSK patients to justify a full time position for a PT
• Justifying the budget for a PT position in the ED

Additional Resources

1. Canadian Physiotherapy Association (CPA): https://physiotherapy.ca/sites/default/files/valuePT/cpa_valuept_erdept-en.pdf 
2. https://healthtimes.com.au/hub/physiotherapy/8/guidance/kk1/physiotherapy-in-the-emergency-department/685/
3. Ball, S.T.E., Walton, K., & Hawes, S. (2007). Do emergency department physiotherapy Practitioner’s, emergency nurse practitioners and doctors investigate, treat and refer patients with closed musculoskeletal injuries differently? Emerg Med J . 24:185–188. doi:10.1136/emj.2006.039537.
4. Bethel, J. (2005). The role of the physiotherapist practioner in emergency departments: a critical appraisal. Emerg Nurse. 13 (2): 26-31. Farrell, S. (2014). Can physiotherapists contribute to care in the emergency department? Australas Med J. 7(7): 315-317. doi: 10.7748/en2005.05.13.2.26.c1185.
5. Kilner, E., & Sheppard, L. (2010). The ‘lone ranger’: a descriptive study of physiotherapy practice in Australian emergency departments. Physiotherapy. 96(3):248-56. doi: 10.1016/j.physio.2010.01.002.
6. Lebec, M.T., & Jogodka, C.E. (2009). The physical therapist as a musculoskeletal specialist in the emergency department.  JOSPT. 39 (3): 221-229. doi:10.2519/jospt.2009.2857.
7. CIHI (2016). Emergency and Ambulatory Care. Retrieved from: https://www.cihi.ca/en/types-of-care/hospital-care/emergency-and-ambulatory-care (07 Feb 2016).