Abstract
Background Emergency department (ED) use in the United States is expected to rapidly increase. Nearly half of all ED visits are classified as semiurgent or nonurgent, and many fall into the musculoskeletal category. Despite growing international evidence that patients are appropriately and safely managed by ED physical therapists in a time-efficient manner, physical therapist practice in EDs is not widely understood or utilized in the United States. To date, no studies have reported the impressions of ED physicians about this practice.
Objectives The purposes of this study were: (1) to assess ED physicians' impressions of ED physical therapist practice 2 years after practice was initiated and (2) to determine whether physicians' impressions changed 7 years later.
Methods All ED staff physicians and medical residents at a level I trauma hospital were invited to complete a survey in 2004 and 2011.
Results In both years, a majority of physicians reported favorable impressions of ED physical therapist practice. Physical therapists were valued for educating patients about safety and injury prevention, providing appropriate gait training, assisting with disposition planning, and providing interventions as alternatives to pain medication. Many physicians supported standing physical therapist orders for certain musculoskeletal conditions. The most common concern was the additional time that patients spend in the ED for a physical therapist consult.
Limitations The results of this study may not reflect the impressions of physicians in all EDs that employ physical therapists.
Conclusions Emergency department physicians reported favorable impressions of ED physical therapist practice 2 years and 9 years following its implementation in this hospital. This study showed that ED physicians support standing physical therapist orders for certain musculoskeletal conditions, which suggests that direct triage to ED physical therapists for these conditions could be considered.
The number of individuals seeking care in emergency departments (EDs) is increasing at a considerable rate. Between 2000 and 2011, the number of ED visits in the United States rose by 26%,1,2 and this trend is expected to continue with implementation of the Affordable Care Act.3–5 Paradoxically, nearly 30% of hospital-based EDs have closed since 1990,6 contributing to overcrowding, longer wait times, increased risk of adverse events, and poor patient satisfaction.7–9
According to data from the Centers for Disease Control and Prevention, nearly half of all ED visits can be classified as semiurgent (35%) or nonurgent (8%).2 Despite efforts to reduce the use of EDs for conditions that could be managed at other facilities, such as urgent care centers or outpatient facilities, nonurgent ED visits have continued to rise.10,11 A large percentage of these conditions include sprains and strains, superficial injuries and contusions, intervertebral disk disorders, and other back problems.12,13 Many of these conditions are acute, and there is strong evidence that providing early intervention results in better oucomes.14–22 Physical therapists are well trained to evaluate and manage many of these conditions.23 With increasing numbers of patients seeking care in EDs for nonurgent musculoskeletal conditions, physical therapists have the knowledge and skills required to play an increased role in the primary care of patients and to help mitigate overcrowding and improve time efficiency in the current ED environment.
The earliest literature defining physical therapist practice in the ED was published in 199624,25 with descriptive studies originating from the United Kingdom. This practice was first described in the United States in 200026 and was identified as an “emerging practice” by the American Physical Therapy Association.27 Although physical therapist practice in the ED has become more widely known and accepted after 15 years, it remains poorly understood.28 No current data exist to indicate how many EDs in the United States employ physical therapists on a full-time basis, but empirical evidence from ED physical therapist special interest group meetings held at national physical therapy conferences suggests that this number is quite small.
Although few studies specific to ED physical therapist practice have been published, there is strong evidence that patients are highly satisfied with physical therapist services in this setting.20,29–36 There is some evidence to suggest that patient wait times can be diminished,25,31,33,37–42 patient education is enhanced,33,34,43,44 diagnostic tests are reduced,41 and referral to appropriate outpatient services is improved.45–47 Other perceived benefits include avoiding inappropriate admissions,28,42,44,45,48 providing appropriate early intervention,20 and freeing ED physicians for treatment of patients with more critical conditions.28,31,44,46
In the United States, patient care in the ED is currently overseen and directed by physicians. Physical therapists function as secondary practitioners and require referrals from medical doctors to examine and treat patients. Because ED physicians have a “big picture” perspective of emergency medical care and work closely with physical therapists as part of the interprofessional ED team, they are well suited to provide feedback on physical therapist services in the ED. As physical therapist practice in the ED grows and evolves, it is important to hear physicians' impressions on physical therapist practice in the ED to determine whether support for the practice exists, whether physical therapist services are considered valuable to patients and the ED team, and whether there are aspects of physical therapist practice that can be improved or expanded.
Two studies28,37 have described aspects of ED practitioner satisfaction with ED physical therapist services. Fleming-McDonnell and colleagues37 collected written feedback from ED personnel and found positive comments about physical therapist management of musculoskeletal pain, provision of follow-up services, and contributions to diagnostic and discharge processes. However, the authors did not provide information about the number or types of ED practitioners who offered this feedback. Lebec and colleagues28 conducted a qualitative study examining perceptions of ED physical therapist services from 11 ED physicians. Responses were globally favorable within 3 main themes identified through individual interviews: value of ED physical therapist consultation, challenges associated with an ED physical therapy program, and ED physical therapist characteristics.
No studies could be identified that have described ED physician impressions of ED physical therapist services quantitatively, nor has there been a comparison of these impressions over time. Therefore, the purposes of this study were: (1) to assess ED physician impressions of ED physical therapist practice shortly after the program's inception and (2) to determine whether these impressions changed over a 7-year period.
Method
Description of Hospital and ED Physical Therapist Practice
All data were collected at Indiana University–Methodist Hospital (IUMH), a level I trauma center located in Indianapolis, Indiana, affiliated with the Indiana University School of Medicine. The IUMH ED is a 72-bed facility that includes an 8-room “fast track” or urgent care area dedicated to patients with low acuity. The ED also has a separate 19-bed observation unit.
The IUMH ED has roughly 102,000 patient visits on an annual basis. Patient care within the primary area of the IUMH ED is the responsibility of ED staff physicians employed by IUMH. Many of these physicians supervise medical residents in their first, second, or third year of residency. Patient care in both the fast track area and the observation area is managed by nurse practitioners, although they are overseen by the staff physicians.
Physical therapist practice in the IUMH ED began in 2002 with one full-time physical therapist who covered the hours of 10 am to 7 pm, Monday through Friday. In 2005, the days and hours of physical therapy coverage were expanded considerably when a second full-time physical therapist and several per diem physical therapists were added. Current coverage occurs Monday through Friday from 9:30 am to 9:30 pm and on weekends from 8:00 am to 2:00 pm. The ED physical therapists evaluate more than 2,000 patients annually, with all ages represented. Roughly 60% of conditions managed are categorized as musculoskeletal, with the remaining 40% of conditions being neurological, burns and wounds, cardiopulmonary, vestibular, or a combination.49
Study Design
This was a survey-based, descriptive study that incorporated content analysis. Participants included ED staff physicians and ED medical residents. The surveys were administered at 2 time points, 7 years apart. The first survey was conducted in 2004, 2 years after physical therapist practice in the IUMH ED had been established. The second survey, identical to the first, was conducted in 2011, 9 years after this physical therapist practice was established.
Participants
Participants for both the 2004 and 2011 surveys were recruited as a sample of convenience from available email lists of all IUMH ED staff physicians and medical residents. These lists were provided by a hospital administrator. An email was sent by the author (S.J.F.) to all potential participants. This email included an introductory statement outlining the purpose of the study, a statement that participation in the anonymous survey implied consent, an option to ask questions prior to completing the survey, and a link to the survey. In addition, the email contained information that a hard-copy version of the survey would be available in a designated ED physician workstation. Practitioners were discouraged from completing both the electronic version and the hard-copy version of the survey. In 2004, 16 (53.3%) of 30 staff physicians and 13 (40.6%) of 32 medical residents completed the survey. In 2011, 21 (63.6%) of 33 staff physicians and 12 (33.3%) of 36 medical residents completed the survey. At both times the survey was offered, there was no provision made to ensure that participants had referred patients to an ED physical therapist.
Survey Instrument
The survey utilized in this study (eAppendix) was constructed in 2004 by the study author with input from the ED physical therapist and the IUMH rehabilitation director. In addition, the survey was evaluated by a research consultant in a physical therapy program at a local university. Neither a reliability study nor a pilot study was feasible because the survey items were very specific to experience with ED physical therapist practice. In 2004, IUMH was the only hospital in the state or region that employed a physical therapist in the ED. Had medical staff been asked to participate in a pretest-posttest reliability assessment or a pilot study of the survey, this would have diminished the already small available pool of participants for the study. To maintain consistency, the survey was identical in both years that it was offered.
The survey consisted of 16 items, most of which required the participant to select one or more options from a list provided. Globally, the survey sought to determine participant impressions of, concerns about, and general comments on physical therapist practice in the ED. To address these global concepts, the survey included specific questions on participants' referral patterns, concerns about physical therapist consults adding time or cost to ED visits, views of physical therapists' roles and skills in the ED, support for standing orders for musculoskeletal conditions, and suggestions for expansion or improvement of physical therapist services in the ED. Some survey items allowed participants to provide clarifying comments (such as specifying what was meant if the option “other” was selected), and the final 2 items were open-ended and allowed participants to provide written comments. The electronic and hard-copy versions of the survey were identical. The electronic version of the survey was administered using Zoomerang (MarketTools Inc, San Francisco, California). The survey was open for a total of 4 weeks in both 2004 and 2011.
Data Analysis
Descriptive statistics were used to summarize categorical survey responses. Between-group comparisons for categorical data were conducted with chi-square tests (P≤.05) using IBM SPSS version 19.0 (IBM Corp, Armonk, New York). Content analysis is a research tool used to determine the presence of certain words or concepts within texts or sets of texts.50 In this study, quantitative content analysis was used to identify, group, and quantify comments from the open-ended questions. Using the concepts assessed in the survey as a general framework, comments from the participants were categorized, and like comments were tallied to indicate the frequency of their presence in the participants' responses. Quantification was not conducted to infer meaning through interpretation of the participants' responses but rather to explore usage and to understand the contextual use of words and phrases.51
Results
Information about the ED staff physicians and medical residents who participated is presented in Table 1. There were no significant differences between years of ED employment or method of survey completion when comparing staff physicians who participated in 2004 versus those who participated in 2011. There also were no significant differences in year of residency or method of survey completion when comparing the medical residents who participated in 2004 versus those who participated in 2011.
Participant Informationa
For all survey items, there were no significant differences in responses between staff physicians and medical residents in 2004 or 2011 or in responses between the 2 years. Therefore, to simplify data presentation, staff physician and resident responses were combined for each year (Tab. 2). Nearly all participants reported having referred at least one patient to an ED physical therapist in both 2004 (96.6%) and in 2011 (97%). In both years, the most common reasons for referral to an ED physical therapist were musculoskeletal conditions, gait training, and pain (both acute and chronic), whereas the least common reasons for referral were cardiopulmonary and neurological conditions. Of the practitioners who did refer patients to ED physical therapists, all but one in each year were satisfied with the outcome. The reason for dissatisfaction reported in both cases (both from staff physicians) was that the ED physical therapist was not available at the time the physician sought to refer a patient.
Survey Resultsa
Concerns About Referring Patients to ED Physical Therapists
In both 2004 and 2011, additional time in the ED was more of a concern when physicians considered an ED physical therapist referral as compared with added cost or whether the patient had insurance. In 2004, slightly more than one-third of the respondents reported concerns about added time, and this number increased to more than 40% by 2011. Concerns about added cost also were reported by roughly one-third (31.3%) of the respondents in 2004, but this number decreased to 25% by 2011. Neither of these changes between 2004 and 2011 were statistically significant, with P=.796 for concerns over added time and P=.578 for concerns about added cost. Both years the survey was offered, there was little reported concern related to patients' insurance status when considering a referral to an ED physical therapist.
Value-Added Services of ED Physical Therapists
When asked what components of ED physical therapist service were considered most valuable, the following 3 items were rated as most valuable in both 2004 and 2011: (1) provide specific instructions regarding the proper and safe use of assistive devices; (2) provide interventions that are an alternative to pain medication; and (3) educate patients regarding injury prevention, safety, and body mechanics with daily activities. The item rated least valuable in both years was: assist in identifying drug-seeking patients.
Practitioner Best Suited
Participants were asked which ED practitioner was best suited to provide various services. Choices included: physician, nurse practitioner, registered nurse, or physical therapist. In both 2004 and 2011, participants indicated that physical therapists were the best-suited ED practitioner to provide gait training with an assistive device and to educate patients regarding injury prevention. In 2004, physicians were identified as the practitioner best suited to determine a patient's ability to return to work or school. By 2011, physical therapists were identified as the ED practitioner best suited for this task.
Standing Orders
The survey asked participants to indicate whether they would support a standing order for various musculoskeletal conditions (by body region). By definition, a standing order would indicate a physical therapist referral for a given condition, regardless of other patient variables (including acuity, desire to be seen by a physical therapist, or medical stability). When comparing results from 2004 to 2011, there was generally greater support in 2011 for standing orders for all body regions, although the differences were not statistically significant. The body region that showed the greatest increase in support included neck injury or pain (increase of 20.1%; P=.194), while support for a standing order for wrist or hand injury or pain remained the same.
Open-Ended Questions
Content analysis of the comments from the 2 open-ended questions led to categorical groupings, as shown in Table 3. For the item asking participants to provide comments regarding expansion or improvement of physical therapist services, the most common responses in both 2004 and 2011 were the request for additional physical therapy coverage (days, hours, and personnel). In 2004 physical therapy coverage was 45 hours per week (9 hours each weekday), and comments indicated this coverage should expand to weekends and more hours overall. By 2011, physical therapy coverage had expanded to 72 hours/per week (12 hours per day on weekdays; 6 hours per day on weekends), and comments indicated that coverage during all hours of ED operation (24/7) would be welcomed. Related to expanding coverage, participants suggested in both 2004 and 2011 that expediting the process of ordering physical therapist consults and decreasing the time patients wait for a physical therapist consult to be initiated were areas for improvement.
Responses to Open-Ended Questionsa
Participants also were asked to provide general comments about physical therapist services in the ED. In both 2004 and 2011, a majority of these comments were favorable toward current physical therapist practice or offered further suggestions for advancing physical therapist practice in the ED. Participants generally indicated that physical therapists are a positive asset to the ED, and the skills that physical therapists offered in the area of disposition planning and as a viable alternative to pain medication were specifically mentioned. In 2004, several participants indicated that they would like additional training or information about the services that physical therapists could provide, although no participants mentioned this desire for additional training or information in the 2011 survey. Frequently mentioned was the need to improve time efficiency through direct triage to physical therapy, establishing a designated physical therapy area in the ED, or finding other ways to decrease patient wait time.
Discussion
Physical therapist practice in the ED setting remains poorly understood. Although this practice has been established for at least 15 years in the United States, published descriptions of the practice or evidence of its benefit are scarce. This study, to our knowledge, is the first to capture and quantitatively analyze physicians' impressions of physical therapist practice in the ED. It shows that physicians had positive perceptions of physical therapist practice in the ED and considered physical therapists a valuable asset to the interprofessional ED team at 2 years and again at 9 years after physical therapist practice was initiated in the ED. These findings are similar to the findings of 2 prior studies28,37 that reported aspects of practitioner satisfaction with ED physical therapy.
Physicians in this study specifically indicated that physical therapists are the ED practitioners best suited to select and train patients in proper use of assistive devices and to provide patients with safety and prevention education. Emergency department physical therapists also were appreciated for providing assistance in the areas of patient evaluation and differential diagnosis, disposition planning, and providing interventions that are an alternative to pain medications. This finding is consistent with the views of ED physicians reported in a qualitative study by Lebec and colleagues28 that showed 3 primary areas of value of the physical therapist consult in the ED: (1) value for the patient (improved quality of care and patient education), (2) value to the ED physician (physical therapists are often able to provide appropriate patient care that is outside a physician's scope of practice), and (3) value to the ED itself (improved efficiency and workflow and improved patient satisfaction).
In the current study, the most common concern noted by staff physicians and medical residents alike, both in 2004 and 2011, was the added time a patient might spend in the ED when a physical therapist referral was made. The survey question did not differentiate whether there was more concern about the time a patient might need to wait until a physical therapist was available or whether the concern related to the time required for the actual physical therapist examination and intervention. Both are certainly possibilities. The IUMH ED offers 72 hours of physical therapy coverage per week, believed to be one of the highest in the United States, yet this coverage only allows one physical therapist covering the ED at any given time. Thus, when multiple referrals are received in rapid succession, it necessitates that some patients will have longer wait times. Employing additional physical therapists and having more than one physical therapist on shift during the busiest times are possible solutions to this problem, and these were common requests mentioned in the open-ended survey questions.
Some of the challenge specific to increased wait time likely also relates to the time a patient spends waiting on a physician for examination. It is not uncommon for patients to occupy an ED bed for several hours prior to an ED physical therapist receiving a request for a consult. Once the consult request is received, physical therapists may need time to finish with other patients before initiating a new physical therapist examination or intervention.
The current study showed that fewer than one-third of ED physicians are concerned with the added cost that patients incur when physical therapist services were added to standard ED care. For all patients seen in the ED at IUMH, physical therapy is billed as an outpatient service. Thus, costs for the ED visit will be higher when physical therapy is an added service. What is currently unknown is: (1) whether direct triage of appropriate patients to an ED physical therapist would result in lower costs and (2) whether there is an ultimate cost savings as a result of physical therapy intervention. Specific to the latter, although further study is needed, it has been suggested that physical therapy intervention in the ED may lead to decreased costs when considering the entire episode of care for any given condition or injury.29,34,46–48,52 Some of the suggested mechanisms of this cost savings include providing early and appropriate injury-specific intervention, referral to appropriate outpatient services, reducing diagnostic tests, educating patients and families about condition management, reducing return visits to the ED for the same condition, and preventing unnecessary hospital admissions.
Recent studies38,41,42 have demonstrated that patients with low-severity musculoskeletal conditions spend significantly less overall time in the ED when directly triaged to physical therapy. Although direct access to physical therapists is available to patients in the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires “hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination.”53 Although the law does allow hospitals to designate nonphysician practitioners as qualified to perform this screening examination, that is not typically practiced at hospitals across the United States. Thus, patients seen at EDs in the United States are not able to see a physical therapist without a prior medical examination. Until physical therapists are able to see patients autonomously in the ED, as our advanced-practice physical therapist colleagues in the United Kingdom, Ireland, Canada, and Australia are able to do,30,42,54 it will be difficult to perform high-quality studies directly comparing the benefits of ED physical therapist practice with those of standard medical care.
The current study indicates that a higher percentage of physicians and residents supported standing physical therapist orders for musculoskeletal conditions in 2011 than in 2004. Although this support is encouraging, it is acknowledged that not all patients with musculoskeletal conditions seen in the ED are appropriate for physical therapist examination and intervention. When this survey was created in 2004, direct access to physical therapist services was not prevalent, and physical therapist practice in the ED was in its infancy. At the time, therefore, the thought that physical therapists might be afforded the opportunity to practice independently in the ED was an ambitious goal but not very realistic. Thus, the survey question focused on support for standing physical therapist orders following an assessment by a medical practitioner. Much has changed, however, in the 11 years since this survey was created and first offered. It is encouraging that several physicians mentioned the possibility of direct triage to physical therapists for certain conditions in open-ended comments on the 2011 survey. As evidenced by 2 recent studies in Australia,41,42 physical therapists are well suited to independently manage certain conditions or injuries in the ED in a safe and time-efficient manner. As the demand on EDs continues to grow in the United States, and as evidence of the physical therapist's value and effectiveness in the ED expands, it is perhaps time to consider moving toward a model that encourages direct triage of certain conditions to physical therapists in this setting.
Limitations
This study was not without limitations. Potential participants were contacted via an available list of all ED staff physicians and all ED medical residents. It is possible that some ED physicians were inadvertently excluded. The response rates for staff physicians were 53% and 64% for the 2004 and 2011 surveys, respectively, so not all physicians' impressions were captured. Similarly, the response rates for medical residents were 41% for the 2004 survey and 33% for the 2011 survey. However, physicians and medical residents who worked night shifts in the ED were included as potential participants, which may have affected the survey response rates because those physicians did not typically interact with physical therapists.
Favorable impressions may have been the result of voluntary response bias if those with more positive experiences with ED physical therapy were more likely to respond to the survey. Nonresponder bias also was possible if practitioners who did not utilize physical therapist services in the ED opted not to complete the survey.
In addition, the survey created for this study was not assessed for reliability prior to its use. Although the author (S.J.F.) consulted with an academic research consultant to create the survey and to diminish any confusion or hidden bias in the survey questions, it was determined that a reliability study was not feasible when the survey was created in 2004 due to the unique nature of physical therapist practice in this setting and the lack of a similar setting to conduct such a study.
Finally, because physical therapist practice in the ED is relatively rare in the United States, generally poorly understood, and quite variable from hospital to hospital, the results of this study cannot be generalized to all EDs that employ physical therapists.
In conclusion, the current study demonstrates that staff physicians and medical residents who practice at IUMH have positive impressions of physical therapist practice in the ED. In addition, their impressions remained consistent after a 7-year time span. Although there is some concern about the added time and cost a patient may incur when physical therapy is added to a patient's ED care, these concerns seem to be offset by the value of physical therapist services recognized by physicians and residents.
This study is important in that it supports a relatively new but growing area of physical therapist practice. These results provide valuable information for physical therapists, medical practitioners, and hospital administrators who may be considering implementing or expanding physical therapist practice in this setting.
Footnotes
Dr Fruth provided concept/idea/research design, data collection, and project management. Both authors provided writing and data analysis. Dr Wiley provided consultation (including review of manuscript before submission).
The authors thank Michael Brickens, PT, for his assistance with survey creation, communication with hospital administration and physicians, and manuscript review prior to submission. They thank Emily Slaven, PT, PhD; Nathan Gentry, PT, DPT; Lindsey Hahn, PT, DPT; Amanda Baker, PT, DPT; and Michael Schaumberg, PT, DPT, for their assistance with data collection and analysis for the 2011 survey.
- Received May 26, 2015.
- Accepted March 29, 2016.
- © 2016 American Physical Therapy Association
References
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