Physiotherapists and Emergency Triage

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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 emergency department physical therapy (ED PT), click here.  

Introduction

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

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.