Physiotherapists and Emergency Triage

Introduction

It’s an exciting time to be a Physical Therapist/Physiotherapist (PT). The scope and impact of our role responsibilities practice is constantly evolving; this includes our role in the Emergency Department (ED). Note that this page refers to PTs involved in the triage of arriving patients ED This should be considered an advanced practice of physical therapy. For more information on the role of physical therapists in the emergency department (where patients are admitted), see the page: Emergency Department Physical Therapy (ED PT).

As we all know, it has been controversial for allied healthcare providers to assume new roles and responsibilities that have traditionally been solely attributed to physicians. [1] As the practice of physical therapy has evolved, we have health care facility. As subject matter experts (SMEs) in the musculoskeletal system, we can only intuitively know where the injury is – the emergency room.

Traditionally, emergency rooms have been designed to respond to life-threatening medical emergencies. However, there appears to be an emerging trend of individuals referring to emergency departments for non-life-threatening MSK pain for medical care.

A study involving the United States in 2006-2007 found that of the 61.2 million MSK injuries treated during that period, 30% occurred in emergency departments. [2] The National Ambulatory Care Reporting System of Canada (2014-2015) indicated that the leading reasons for consulting the ED for MSK pain included cervical spondylosis and lumbar region. Emergency departments will benefit from experienced physical therapists with keen clinical reasoning and diagnostic skills.

Suggested Roles and Responsibilities for PTs

• Identify any red or yellow markings (indicating non-MSK conditions)
• Provide advice and activity modification
• Provide therapy (manual therapy aids with taping method)
• Application of recognized Clinical Prediction Rules (CPR)
  • Canadian Cervical Spine Rules
  • Carpal Tunnel Syndrome
  • Cervical Radiculopathy
  • Well 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 patients for further medical intervention (including referral for further PT services if necessary).
• Guaranteed/recommended/increased patient satisfaction due to early intervention

The primary success of the triage process lies on the basis that the patient is treated by the right physician. If the medical complaint can be dealt with in the PT alone, then there is no need for further consultation with a nurse or doctor.

Conversely, if a patient requires medical imaging, medication, or consultation with a specialist, the PT will discuss the case with the nurse or doctor, who will then proceed with the medical investigation.

Where this new character is currently in development:

• Canada 
• Singapore[3]
• Australia[1][4]
• United Kingdom[5]
• Ireland

Clinical bottom line (as stated in the literature)

The Australian emergency physiotherapy department now performs traditional physiotherapy activities in non-traditional settings. The role is compatible with MSK physiotherapy; but there is a degree of comprehensive care that takes predominantly older patients. Impact as an emergency The impact of departmental physical therapy services on health outcomes is unclear, but they support patients’ belief that PT services in the ED have system-wide benefits. [6]

Evidence suggests that early physical therapy intervention is effective in reducing pain and improving satisfaction in emergency department patients with acute low back pain. [4]

Advanced musculoskeletal physiotherapists (AMPs) effectively discharged patients admitted to emergency departments in a timely manner, with no evidence of increased readmissions compared with their medical and nursing colleagues. [7]

There were no significant differences between the proportion of patients undergoing x-rays and the type of clinician. (p = 0.17) There was also no significant difference (p = 0.99) in the proportion of x-ray findings of fractures/dislocations between the different types of clinicians. all fractures and Dislocations were found to have been managed in accordance with written departmental procedures. Therefore, further analysis focused only on soft tissue injuries. For soft tissue injuries, senior residents prescribe analgesia/NSAIDs to more patients than others Clinicians (86% p<0.001). Nurses provided more structural support (bandages, etc.) and ED PTs referred more patients for physical therapy follow-up (9.2% p = 0.031) compared to other clinicians (80% p<0.001) . [8]

A growing body of science supports the role of AMP in emergency departments.

PT Success in the Emergency Department (ED)

• Direct front-line access to physiotherapists (no referral required)
• Serve as an educational subject matter expert (SME) to other clinicians in the department
• Early recognition of yellow/red flags (MSK or whole body)
• Appropriate MSK advice and care for patients during the acute phase of healing
• Prompt referral to outpatient physical therapy services (as appropriate)
• Allows for appropriate clinical intervention for medical emergencies of varying degrees (with appropriate sharing of assessment roles among healthcare providers)
• Expand available limited ED resources [3] as the triage burden is shared (freeing up nurse physician specialists to handle non-MSK Sloan complaints).
• Early access to physical therapy in the ED is associated with reduced pain and disability levels [3]
• A possible healthcare model that could improve emergency department efficiency
• Potential reduction in patient wait time
• May reduce demand for outpatient orthopedic services [3]
• Improve patient satisfaction with early rehabilitation specialists [4]
• Responding to the need for greater workforce flexibility and improved service delivery to meet growing patient demand[5]
• A truly interdisciplinary approach to patient care.

Potential Challenges Ahead

• This position in the ED should be considered an advanced practice, so experienced PTs (advanced musculoskeletal physical therapists (AMPs)) should only be placed in high-velocity EDs [7]
• A Potentially High Stress Work Environment for PTs
• Work in a multi-health care provider environment (must be proficient and comfortable working in teams)
• Required qualifications or scope of practice are not standardized (e.g., may vary by hospital or country)
• Evidence-based regulatory ethics and educational frameworks need to be developed to keep pace with the changing clinical environment and service delivery in emergency departments [5]
• Highlight and implement the ethical understanding as well as the legal and professional knowledge required for this work environment[5]
• Willingness of all clinicians to collaborate and share diagnostic/clinical impression roles
• In smaller EDs, there may be too few MSK patients to justify full-time positions at PTs
• Justify the budget for PT positions 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). Are emergency nurses and physicians among emergency department physiotherapists investigating treating and referring patients with closed musculoskeletal injuries differently? Journal of Emergency Medicine. 24:185–188. doi: 10.1136/emj.2006.039537.
4. Bethel, J. (2005). The role of the physiotherapist in the emergency department: a critical appraisal. emergency nurse. 13(2): 26-31. Farrell, S. (2014). Can Physical Therapists Contribute to Emergency Department Care? Australian Medical Journal 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 emergency departments in Australia. physiotherapy. 96(3):248-56. doi: 10.1016/j.physio.2010.01.002.
6. Lebeck, M.T. & Jogodka, C.E. (2009). Physiotherapists serve as musculoskeletal specialists in the emergency department. Joseph. 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 (7 February 2016).