Abstract
Background An upward trend in the number of hospital emergency department (ED) visits frequently results in ED overcrowding. The concept of the emergency department observation unit (EDOU) was introduced to allow patients to transfer out of the ED and remain under observation for up to 24 hours before making a decision regarding the appropriate disposition. No study has yet been completed to describe physical therapist practice in the EDOU.
Objective The objectives of this study were: (1) to describe patient demographics, physical therapist management and utilization, and discharge dispositions of patients receiving physical therapy in the EDOU and (2) to describe these variables according to the most frequently occurring diagnostic groups.
Design This was a descriptive study of patients who received physical therapist services in the EDOU of Massachusetts General Hospital during the months of March, May, and August 2010.
Methods Data from 151 medical records of patients who received physical therapist services in the EDOU were extracted. Variables consisted of patient characteristics, medical and physical therapist diagnoses, and physical therapist management and utilization derived from billing data. Descriptive statistics were used to analyze data.
Results The leading EDOU medical diagnoses of individuals receiving physical therapist services included people with falls without fracture (n=30), back pain (n=27), falls with fracture (n=22), and dizziness (n=22). There were significant differences in discharge disposition, age, and total physical therapy time among groups.
Limitations This was a retrospective study, so there was no ability to control how data were recorded.
Conclusions This study provides information on common patient groups seen in the EDOU, physical therapist service utilization, and discharge disposition that may guide facilities in anticipated staffing needs associated with providing physical therapist services in the EDOU.
The emergency department (ED) is a critical entry point in the US health care system for patients requiring immediate care. The National Hospital Ambulatory Medical Care Survey conducted in 2007 reported that EDs in the United States managed 117 million visits annually.1 Of those visits in the ED, 13% of the patients were admitted as an inpatient to the hospital.1,2 Factors such as high patient acuity, hospital bed shortage, increasing ED patient volume, and insufficient ED space have resulted in a growing concern of overcrowding in the ED.3,4 This overcrowding results in increased “waiting time” for patients to see a physician, which has been shown to negatively correlate with patient satisfaction.5,6 The number of ED visits is increasing at a rate of about 1% annually, whereas inpatient bed capacity is declining or remaining static.7 In the United States, there currently is an urgent need to increase ED patient access, safety, and quality of care without increasing costs. The emergency department observation unit (EDOU) was developed as a potential solution to this dilemma.
The average length of stay for a patient admitted to the ED is 5.5 hours versus about 5 days for those admitted as an inpatient.1,8 Hospitals have been facing increased scrutiny for patients whose length of stay is 1 day or less, putting hospitals at risk of payer audits and denials.7–9 This issue has created a cohort of patients whose needs exceed a 6-hour ED visit but who require less than 24 hours of hospitalization.8,9 The origin of observation care or units dates back to the 1960s; however, formal guidelines for this level of care were not established until the late 1980s and early 1990s.7 The Centers for Medicare & Medicaid Services (CMS) first recognized the EDOU as a distinct entity in 2003 by providing payment for 3 common patient diagnostic groups: those with chest pain, heart failure, and asthma.7 The EDOU is ideally used in instances where further diagnostics or intervention are required prior to a conclusive decision regarding the appropriate discharge disposition.7,8,10 The EDOU allows increased time for the clinical decision-making process and improves the efficiency and satisfaction of patient care by providing a middle ground between inpatient admission and discharge-to-home dispositions.2,7,8
The use of EDOUs is expanding throughout the country. Studies indicate that 36% of US hospitals reported using an EDOU in 20072 compared with 19% to 27% between 1989 and 2003.11,12 The increased utilization of EDOUs has resulted in decreased total inpatient admissions, ambulance diversion, and patients leaving the ED prior to being seen, making the EDOU a potential cost-saving strategy for hospitals.13,14 Emergency department observation services have been determined to be a “best practice” by the American College of Emergency Physicians, so these units will most likely continue to expand, as they appear to provide efficiency and quality.15 Additionally, financial penalties for avoidable hospital readmissions are an integral part of the new health care legislation,16,17 and EDOUs may become an increasingly important entity as hospitals attempt to limit these readmissions. Given these impending health care financial changes, EDOUs may be an expanding area of emergency practice where physical therapists will be a part of the health care team.
Physical therapy is currently a part of the health care team in some EDOUs, but the scope of physical therapist practice in this setting has not been described. By contrast, there is evidence to suggest that physical therapists are effective members of the health care team in the ED,18 especially for musculoskeletal conditions.19–21 Physical therapists in the ED have expertise in differential diagnosis of medical conditions from musculoskeletal injuries,22 and physical therapy care in the ED is cost-effective.23 Early introduction of physical therapy reduces pain and improves patient satisfaction in patients with low back pain in the ED.24 It also has been demonstrated that physical therapists effectively treat conditions such as benign paroxysmal positional vertigo in the ED.25 Wait times in overcrowded EDs with physical therapist services have been shown to be reduced because patients with a low triage status can be directly referred for physical therapy, freeing the ED physicians to manage patients with more serious and urgent medical issues.26,27 Additionally, patient satisfaction in the ED has been shown to be the highest when patients are treated by physical therapists rather than nurses and physicians.28 Physical therapists provide detailed instructions28 and better patient education regarding the current diagnosis as well as information pertaining to what they might expect in the future.27
Although there is evidence for the safety, effectiveness, and efficacy of physical therapist practice in the ED, no study has yet described the role and scope of physical therapist practice in the EDOU. A description of current physical therapist practice may increase the understanding and utilization of physical therapist services in the EDOU setting and thus enhance overall patient management. The purposes of this study were: (1) to describe patient demographics, physical therapy management and utilization, and discharge dispositions of those receiving physical therapy in the EDOU and (2) to describe these variables according to the most frequently occurring diagnostic groups of people.
Method
This was a retrospective, descriptive study of patients who received physical therapist services in the EDOU of the Massachusetts General Hospital, a tertiary care facility in Boston, Massachusetts. Variables were extracted from medical records and from the physical therapy department billing database.
Participants
We included patients who received physical therapist services in the EDOU during the months of March, May, and August 2010 and for whom medical and billing records were available. We selected these months in an effort to represent admissions during different seasons of the year. There were no exclusion criteria. A total of 156 patients were identified as receiving physical therapist services in the EDOU in the designated time period. Of these patients, 151 had available medical and physical therapy billing records that were further analyzed.
EDOU Staffing Patterns
The EDOU is staffed by a designated inpatient physical therapy team in addition to their typical service on their specialty unit (ie, orthopedics, neurology). At the time of data collection, members of the adult neurology/pediatric team, as the designated EDOU team, responded to the consults received from the EDOU between the hours of 8:00 am and 4:30 pm, 7 days per week. The nurse case manager for the EDOU prioritized early recognition of patients who may have required physical therapist services to expedite timely referral during physical therapists' work hours. Patients admitted overnight who required physical therapist services were evaluated early the next workday, still within their maximum 24-hour EDOU stay.
Procedure
Data were extracted from the patients' medical records by a physical therapist using a standardized data collection form. At our institution, the inpatient physical therapist service is responsible for responding to EDOU referrals; therefore, inpatient records were reviewed. Variables extracted from the medical record included age, sex, length of stay, discharge disposition, physical therapist diagnoses, and medical diagnoses. Physical therapist diagnoses were identified based on the practice patterns from the Guide to Physical Therapist Practice29 recorded in the physical therapist's note in the medical record. Medical diagnoses were classified according to the leading causes of EDOU admission as identified by a national survey of US observation units completed in 2003.11 Variables extracted from the physical therapy database included time spent on physical therapist evaluation and interventions and the number of physical therapy visits during the EDOU stay. Total census numbers and common medical diagnoses for the EDOU over the same periods of time as the study data were collected from the hospital admissions office.
Data Analysis
Data analysis was conducted using SPSS 17.0 statistical software (SPSS Inc, Chicago, Illinois). Descriptive statistics (eg, frequencies, means) were generated for all variables for the whole sample and for each of the most frequently occurring patient diagnostic groups based on the leading EDOU medical diagnoses. Chi-square statistics and associated standardized residuals were generated to analyze differences in discharge dispositions and physical therapist service referrals across the patient diagnostic groups. Residuals greater than 2.0 were considered significant. A one-way, between-subjects analysis of variance (ANOVA) was conducted to compare the effect of diagnostic group on age, physical therapist evaluation time, and physical therapy total time. Significance for comparisons was set at P≤.05.
Results
Total EDOU admissions were 502, 524, and 517 patients for March, May, and August 2010, respectively. The leading medical diagnostic groups of the EDOU admissions were patients with chest pain (25% average of total admissions over 3 months), syncope and dizziness (9%), and back pain (4%). Physical therapy referrals accounted for 9% to 12% of these monthly admissions. There were, on average, 1.6 referrals per day for physical therapist services from the EDOU. There were 41 referrals in March, 50 in May, and 60 in August. The patient group with the most common medical diagnosis referred for physical therapy were patients with falls without fracture (n=30) followed by those with back pain (n=27), dizziness (n=22), and falls with fracture (n=22). Of the remaining 50 patients, the next most common medical diagnosis was non-fall trauma (n=12) followed by diagnoses such as chest pain, asthma, syncope, head injury, and transient ischemic attack, with each category accounting for 1 to 3 patients each. Physical therapist diagnosis by physical therapy practice pattern was documented in the medical record. Of the 151 records examined, 31 did not include a specific physical therapy practice pattern. Of the remaining 120 records, a single practice pattern was recorded for 116 patients (76.8%), and 2 practice patterns were recorded for 4 patients (2.6%). The most frequently applied practice pattern was 5A (Primary Prevention/Risk Reduction for Loss of Balance and Falling; n=47, 31.1%), followed by 4F (Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders; n=22, 14.6%).
The average age for the whole sample was 67.7 years (SD=17.7). Patients with falls without fracture were the oldest with a mean age of 74.2 years (SD=14.3), and those with back pain were the youngest with a mean age of 61.2 years (SD=17.8) (see Tab. 1 for all descriptive data). A one-way ANOVA showed a statistically significant difference in mean age across the 4 diagnostic groups (F3,97=3.156, P=.028). Post hoc comparisons using the Tukey honestly significant difference test indicated that patients in the falls without fracture group were significantly older than patients in the back pain group (X̅=13.05, SD=4.3). Age was not statistically different among other patient groups. Evaluation time for physical therapy was not statistically different among diagnostic groups. However, there were differences among patient groups on total physical therapy time. Patients with dizziness had the highest total physical therapy time with a mean of 65.7 minutes. A one-way ANOVA on total physical therapy time across the 4 diagnostic groups showed a statistically significant difference in mean total physical therapy time among the groups (F3,97=4.92, P=.003). Post hoc comparisons using the Tukey honestly significant difference test indicated that the mean score for total physical therapy time was significantly longer for the patients with dizziness compared with patients in each of the other 3 diagnostic groups (back pain: X̅=16.61, SD=4.80; falls with fracture: X̅=13.86, SD=5.04; and falls without fracture: X̅=15.19, SD=4.69). There were no differences in total physical therapy time among the other 3 groups. Most patients were seen only once by a physical therapist (n=137 [90.7%]), but a small number were seen for 1 (n=13 [8.6%]) or 2 (n=1 [0.7%]) additional physical therapy visits while in the EDOU. The average length of stay was 38.7 hours (SD=47.6, range=3–43). For those not admitted to acute care, the average length of stay was 22.0 hours (SD=17.3, range=3–168) compared with those who were admitted for acute care who had a mean length of stay of 131.5 hours (SD=56.0, range=48–264). The length of stay for those admitted for acute care includes their acute care stay hours in addition to the EDOU time.
Patient Descriptive Dataa
Physical therapist interventions were classified as shown in Table 2. Of all patients referred for EDOU physical therapist services, 44.4% were provided gait training, 35.1% required bed mobility and transfer training, and 34.4% received functional training. The average time spent per intervention also is provided in Table 2. Frequencies of documented patient education (76.2%) and documented prescription of assistive devices (33.1%) were captured from medical records. The time spent on these interventions could not be determined because they are nonbillable services. Time spent on other aspects of care coordination with the medical team were not recorded in the medical record but were an integral part of physical therapist services in the EDOU.
Leading Billable Interventions by Diagnostic Category
Overall, 105 patients seen by a physical therapist (69.6%) were discharged home from the EDOU. Discharge disposition varied significantly across patient groups (χ2=22.71, df=9, P=.007). More patients than expected in the falls with fracture group were discharged to acute rehabilitation (χ2 standardized residual=3.2). Of the patients who went home, referral for home physical therapist services compared with outpatient services varied significantly across groups (χ2=18.39, df=3, P≥.000). More patients than expected with dizziness were referred for outpatient physical therapist services (χ2 standardized residual=2.1).
One of the roles of the physical therapist in the EDOU is to help determine discharge disposition and the appropriate next level of care for patients who are at risk of extending past the 24-hour observation limit. The first priority of the physical therapist in the EDOU in determining discharge disposition is to determine the patient's ability to mobilize safely with available social supports and environmental constraints. If the patient is not independent or there is not support at home, recommendations are made regarding appropriate level of rehabilitation care. Physical therapy EDOU management also focuses on care coordination with the medical team to provide symptom management (pain medication, antiemetics) to maximize function and promote self-management of the patients' conditions. Finally, physical therapist services in the EDOU provide for referral to appropriate level and timing of follow-up services such outpatient physical therapy. Table 3 includes case examples for each major EDOU medical diagnostic group to illustrate the role of the physical therapist in the EDOU.
Examples of EDOU Episode of Care for Patients Referred for PTa
Discussion
This preliminary descriptive study is the first of its kind to describe physical therapist practice and utilization in the EDOU. Although the role and value of physical therapy in the ED has been investigated,18–21 physical therapist practice in the EDOU has not previously been studied. This study is unique in its investigation of the scope of physical therapy in the EDOU and hence provides information to enhance knowledge and foster the utilization of physical therapist services in this setting.
The overall, leading medical diagnoses of patients admitted to the EDOU in previous available literature were identified as chest pain/circulatory, abdominal pain/gastrointestinal, and respiratory issues.2,11 Massachusetts General Hospital's EDOU leading diagnosis also was chest pain but was followed by syncope/dizziness and back pain. In contrast, in the present study, the patients most commonly referred for physical therapy in this large, inner city academic medical center EDOU were those with falls with and without fractures, back pain, and dizziness. This finding suggests that specific patients are being triaged for physical therapy and that physical therapists may contribute a unique expertise best suited for patients with these types of conditions compared with the most common EDOU medical diagnoses previously reported in the literature. The most often used preferred physical therapist practice pattern (Practice Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling) suggests that safety for discharge to home was the focus of physical therapy intervention for most patients. Physical therapists in the ED have been said to require certain skills to be able to provide efficient care in this setting. The same set of skills also could be believed to be applicable for practicing in the EDOU, as it is essentially an extension of the ED, with the patient acuity being similar. These skills include working with high levels of acute pain and distress,30 emphasizing patient education,30 focusing on reducing unnecessary hospital admissions,30 providing an appropriate discharge plan,31 and maintaining interdisciplinary relationships.31 The current findings also may be helpful in identifying a particular set of clinical evaluative skills that physical therapists should have to plan for staff training and to best serve the typical patients in the EDOU (eg, differential diagnosis and treatment of people with dizziness and vestibular dysfunction, spine and balance dysfunction).
In regard to how physical therapy time was utilized in the EDOU, evaluation time was not significantly different among diagnostic groups; however, this finding may be a reflection of the billing system that allows billing only for up to 30 minutes of evaluation. There were differences in total physical therapy time across patient diagnostic groups, which may be more reflective of the clinical decision making required for various diagnostic groups. The patients with dizziness had the highest total physical therapy time, which may indicate the complex process of differential diagnosis of dizziness, especially in this setting.32 The potential variety of patient diagnoses represented in the dizziness category would require well-developed skills of differential diagnosis and understanding a variety of tests and measures across multiple systems. By the time patients are seen in the EDOU, they likely have already received antivertigo medication such as meclizine, which makes differential diagnosis challenging and often equivocal. Closer cooperation with the ED, especially in regard to medications for the patient with dizziness, and earlier physical therapist intervention may facilitate greater accuracy in diagnosis and clinical management for this group.
Overall, there was a broad range of total physical therapy time billed to patients. Intervention billing focused on functional training activities. This time is reflective of only billable services and does not capture nonbillable services such as patient, family, and caregiver education and care coordination (eg, discharge planning) with other health care professionals. Anecdotally, these nonbillable activities require a significant portion of the physical therapist's time, as the length of stay is so short that much of the physical therapist's time is spent in communicating the physical therapy findings and the appropriate discharge setting and services with the patient and family, physician, nurse, and case manager and providing the patient and family with education about their physical therapist diagnosis, intervention, and referral for further services. Despite the nonbillable nature of these services, they require a high level of expertise, interprofessional interaction and teamwork, and clinical decision making in order to facilitate the most appropriate plan of care.
The aim of the EDOU is to allow for further diagnostics or interventions beyond the initial ED stay, but with the goal of safe discharge to the next appropriate level of care, within 24 hours.7 One of the primary roles of the physical therapist on the interprofessional EDOU team is to advise on discharge disposition and follow-up service referrals. The majority of the patients in this study had a length of stay that was less than 24 hours, requiring only one physical therapy visit. Only 15.2% of the individuals seen in this study were subsequently hospitalized. Although we could not directly compare the hospitalization rates of patients in the EDOU seen by a physical therapist with patients in the EDOU not seen by a physical therapist due to the unavailability of data, the hospitalization rate in this study of patients seen by a physical therapist was favorable compared with 18% to 22.3% hospitalization rates reported in the medical EDOU literature for all patients.2,7,11
This study is the first of its kind to describe physical therapist practice in this unique setting. It is expected that expansion and development of EDOUs will continue in US hospitals. Physical therapists may be a part of the health care team in emergency observation units. Physical therapy managers can use the information gleaned from this descriptive study to identify common diagnostic groups that will likely be seen in these units. This knowledge can be used to provide professional development of the physical therapists working in these units, as they will require expertise in not only acute musculoskeletal management but also assessment and differential diagnosis of patients with dizziness and balance dysfunction. Patient education materials for vestibular dysfunction, back pain, and fall reduction should be developed to increase efficiency for physical therapists working in these units. Physical therapists are part of the acute care health team who may have an increasing role in emergency services. Future studies should focus on clinical decision making of physical therapists in the EDOU, differences in discharge disposition and length of stay for patients who do and do not receive physical therapy, and prevention of readmission through appropriate diagnosis, intervention, and education.
Footnotes
Dr Plummer, Dr Beninato, and Dr Parlman provided concept/idea/research design and consultation (including review of the manuscript before submission). Dr Plummer, Ms Sridhar, and Dr Beninato provided writing. Dr Plummer, Ms Sridhar, and Dr Parlman provided data collection. Dr Plummer, Ms Sridhar, and Dr Beninato provided data analysis. Dr Parlman provided participants and facilities/equipment. Dr Plummer provided institutional liaisons. The authors thank Michael Sullivan, PT, DPT, MBA, and Nancy Goode, PT, DPT, MS, for their guidance and help in collecting the data.
The study was approved by the Massachusetts General Hospital Institutional Review Board.
A poster of this research was presented at the American Physical Therapy Association's Combined Sections Meeting; January 21–24, 2013; San Diego, California. A platform presentation of this research was presented at the Massachusetts Chapter of the American Physical Therapy Association Fall Conference; November 3, 2012; Wellesley, Massachusetts.
- Received January 21, 2014.
- Accepted September 23, 2014.
- © 2015 American Physical Therapy Association
References
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