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EDs find physical therapists are an underused asset for musculoskeletal injuries, patient education
Benefits can include a boost in patient satisfaction, better resource allocation
Physical therapists (PTs) are carving a niche for themselves in a small but growing number of EDs. They're doing everything from splinting fractures and taking care of wounds to evaluating cases of low back pain to helping patients with musculoskeletal injuries learn how to use assistive devices.
While there are few d ata gathered to document the value or impact of adding regular PT coverage in the emergency setting, the handful of EDs reached by ED Management that have such coverage certainly don't want to give it up. For instance, Flagstaff Medical Center in Flagstaff, AZ, started putting PTs in its ED in 2004, and now it offers such coverage seven days a week during the unit's busiest hours, between 11am and 7:30pm.
"I don't think we could survive without them anymore," stresses Lindy Turley, RN, BSN, CEN, the director of emergency services at Flagstaff Medical Center in Flagstaff, AZ. "They are such an integral part of our team that it is unfortunate that all EDs don't have them."
These sentiments are echoed by the ED staff at Carondelet St. Joseph's Hospital in Tucson, AZ, where PTs have been providing care in the ED since 1998. Carleen Jogodka, PT, DPT, a board-certified orthopedic specialist, has been manning the ED at Carondelet for the past seven years, but when she was recently out for maternity leave, the ED physicians were not happy. "It really throws them for a loop when we are not there," says Jogodka. "They have become dependent on bringing us in on cases."
Given the high percentage of ED cases that involve musculoskeletal complaints, proponents of putting PTs in the ED stress that they can improve patient care, boost patient and physician satisfaction, and move to a more efficient use of hospital resources, such as imaging, for example. But they also emphasize that not all PTs are ideally suited to work in the ED, and that effective use of PT resources requires ongoing education and outreach to the clinical staff. (See initial steps for starting a PT program in the ED, below.)
Improve the patient experience
Michael Lebec, PT, PhD, an assistant professor of physical therapy at Northern Arizona University in Flagstaff, is working with colleagues to assemble data and information about using PTs in the ED so that more programs will be developed. Lebec, who worked in Carondelet's ED before turning his attention to academics, is convinced that many EDs could reap significant benefits from making use of the specialized expertise that PTs offer.
"Usually when patients come in with an orthopedic or musculoskeletal problem ... they will typically receive meds from the physician and get a few X-rays to make sure there is nothing that is seriously wrong," says Lebec. "The PT can come in and give them a more specific diagnosis, tell them what they should and should not be doing at work, show them exercises they can do to help manage their problem independently, and give them a whole bunch of education that they don't normally get."
The result of this more comprehensive approach to care is that patients are less likely to need a repeat visit, and they are much more satisfied with their care, stresses Lebec. "Typically in the ED, patient satisfaction is abysmal because patients wait a really long time and they feel like they don't get much treatment for what they are there for," says Lebec. "When a PT is involved, they feel like they are getting more for the time they are spending there and, in some cases, the PT can actually improve throughput and decrease wait times." The result, stresses Lebec, is a much better experience for the patient, which is what all EDs strive for, he says.
Further, there is a financial case for putting PTs in the ED, adds Lebec. "What we are finding is that in most cases PT services are being reimbursed just as well, if not better, in the ED as in all other inpatient or outpatient settings," says Lebec. "So you're getting paid, and you're making a profit for the services provided."
Consider the benefits of patient education
Methodist Hospital in Indianapolis, IN, has been using PTs in the ED for eight years, explains Lindsay Anderson, MSN, ACNP-BC, who is a member of the trauma team at Methodist. "We use the PTs often to splint fractures when the traumas arrive to the trauma bay," she says. In addition, PTs often provide gait training, balance assessment, and they also work with patients on pain control, adds Anderson. "They can do electrical stimulation, they can do ice, and they can use tape."
A PT is on staff in the ED from 9am to 9pm every day, says Anderson, and she emphasizes that there is no pushback to the approach from other clinicians; quite the contrary. "We really like it. Our patients get a lot of education, and they know what to do when they leave the hospital," she says.
The patient education component is an important aspect of what PTs bring to the emergency setting, adds Lisa TenBarge, PT, DPT, who is largely responsible for implementing the PT program in Flagstaff Medical Center's ED. "The people who come to the ED, 25% to 28% of them have musculoskeletal injuries, and that is our area of expertise," stresses TenBarge. "We are looking at what are going to be the barriers to getting patients back to their normal function. That is a little bit different than what you normally see in the ED, which is to get them stabilized and send them on their way."
However, TenBarge points out that most PTs are not accustomed to working in emergency settings, so finding good candid ates for an ED program can be difficult. "The PTs who work in outpatient clinics are used to seeing patients who can walk and talk," she says. "We are used to seeing patients who can't get up off of a stretcher, so it is a different level of acuity than most PTs are used to dealing with."
Establish a designated place for PTs
In addition, the PTs who are most successful in an ED setting are those who are able and willing to continually make sure the other clinicians understand what they have to offer, stresses Lori Pearlmutter, PT, MPH, the director of therapy services at Flagstaff Medical Center. "The PT working in the ED needs to do constant marketing, and not a lot of people like to do that," she says. "They also need to communicate to patients that physical therapy is something they can refuse, but point out what benefits it provides as well."
Such skills are particularly important in teaching hospitals where there is a constant rotation of new clinicians in and out of the ED who may have no experience in working alongside PTs, says TenBarge. However, she emphasizes that once you establish relationships with the clinicians on staff, they can turn into your most ardent advocates. "The clinicians I have been working with for seven years know very well how to use me," she says. "The physicians know we are going to spend more time with their patient, talking about their problem and how to manage it, and it allows them to really focus on the higher-acuity patients who are way outside our realm."
It helps to have regular visibility in the ED. For example, for the past two years, Jogodka has had a desk adjacent to where the psychiatric assessment team and case management are stationed. "Clinicians know where they can find us," says Jogodka.
It is also important to have regular PT coverage throughout the ED's busiest times, adds Turley. While it won't make sense for most EDs to have PTs on staff around the clock, consistent, daily coverage is nonetheless critical, she says. "If you don't have PT coverage for a couple of weeks, then the clinicians will forget to use them when the PTs are there," says Turley. "Have a designated spot and a designated staff that [clinicians] can work with as much as possible."
Editorial note: Lebec, TenBarge, and colleagues have been working to assemble a toolkit for those interested in starting a PT program in their ED. They anticipate that the materials will be made available through the American Physical Therapy Association website by this spring. The web site address is: www.apta.org.
Michael Lebec, PT, PhD, Assistant Professor of Physical Therapy, Northern Arizona University, Flagstaff. E-mail: firstname.lastname@example.org.