Over the past two decades, physical therapists have become key players within U.S. Emergency Departments (ED) in response to an overburdened healthcare system.1 According to the Emergency Medicine Treatment and Labor Act (EMTALA) enacted by the U.S. Congress in 1986, EDs are obligated to provide medical examination, medical stabilization, and if needed, hospital admission or transfer to any individual who requests such services, irrespective of diagnosis, gravity of symptoms, or ability to pay.2 In recent years, ED overcrowding has steadily increased in the U.S. and abroad,3 leading to a decrease in emergency department efficiency, longer wait times, patient and provider dissatisfaction, and higher work-related stress.4
The scope of practice of the ED PT is not consistent across the world.5 In some countries, the Emergency Department physical therapist (ED PT) acts as a primary ED provider and is tasked with triage, ordering of imaging, and medication prescription along with routine treatment and disposition planning.5,6 Within the U.S., EMTALA requires hospitals to designate qualified medical providers to initially evaluate patients in the emergency room, and this list of approved providers does not include physical therapists.2 Therefore, consultation of the ED PT occurs only after being cleared by the referring ED provider.1,6
In the U.S., triage of a patient within the ED is based on the Emergency Severity Index, an algorithm that classifies a patient based on urgency and need. Group 1 and group 5 are defined as the most and least urgent, respectively.7 Most cases seen by ED PTs fall within categories 3 through 5.1 Musculoskeletal diagnoses make up 20% of all ED visits, and they are the most common condition managed by ED PT’s followed by orthopaedic traumas, falls, and vertigo.1,5,8 Given that most patients that present to the ED with musculoskeletal issues and/or pain do not access traditional outpatient PT services due to a lack of referral, personal resolve, or medical coverage, ED PT may be their only opportunity to receive care.8
Preliminary evidence suggests that ED PTs in the U.S. positively impact patients and the overall healthcare systems.1,9 ED PT has been associated with decreased wait times, treatment times, and length of emergency room stays. In addition, ED PT is associated with less inappropriate admissions and diagnostic imaging, resulting in significant cost savings.1,9,10 Older adults that are evaluated by an ED PT following a fall are more likely to be discharged with appropriate placement, thereby avoiding a hospital admission and subsequent ED visits within 30-60 days.10,11 Moreover, patients who receive care from an ED PT report higher rates of satisfaction, significantly less pain upon discharge, reduced use of analgesics, and greater functional improvements compared to standard care.5,12,13
ROLE OF THE ED PT
In addition to improving the overall flow of the emergency department, ED PTs in the U.S. provide non-pharmacological pain management, assist with disposition planning, provide injury prevention training, and facilitate return to function.9,14 As a secondary contact, ED PTs perform bedside evaluations and treatments for any number of musculoskeletal, cardiopulmonary, neurological, vestibular, and integumentary dysfunctions.13 They also perform safety evaluations, prescribe assistive devices, administer wound care, and make recommendations regarding follow-up specialty services and admission disposition.14
THE SKILLS REQUIRED OF THE ED PT
Given the aforementioned duties of an ED PT, they must be proficient in non-pharmacological pain management and advanced clinical reasoning and possess strong communication skills.5,8
NON-PHARMALOGICAL PAIN MANAGEMENT
One of the primary reasons why patients visit the ED is pain management.1 A key variable in the management of acute pain in the ED is selecting approaches that improve pain and function while minimizing prescription opioids.15 The American Academy of Emergency Medicine White Paper on Acute Pain Management encourages the use of non-pharmacological approaches to pain within the Emergency Department, including modalities, dry needling/acupuncture, muscle energy techniques, osteopathic manipulation techniques, softtissue mobilization and exercise, among others.16,17 While patients in the ED often describe exercise as “painful,” “difficult to perform,” and/or simply unnecessary,18,19 evidence overwhelmingly supports the use of movement to optimize function, particularly in the early stages of traumatic and non-traumatic injury.20-22Moreover, according to the literature, patients referred to ED PT expect the use of manual therapy to manage pain.19 Low to moderate evidence supports the use of manual therapy techniques such as mobilization and manipulation for patients with musculoskeletal conditions to improve pain and function.23-26 For example, in patients with sacroiliac dysfunction, joint manipulation has been shown to be more effective than exercise for short-term reduction in pain.27 Interventions including osteopathic manipulations, early mobilization and education help decrease pain in patients presenting to the ED with acute low back pain when compared to control treatment (SMD: -0.39 95% CI: -0.64, -0.13).17 Cervical manipulation, soft-tissue mobilization, and muscle energy techniques have also led to statistically meaningful changes in pain within one hour for patients with mechanical neck pain compared to intramuscular ketorolac.28 Furthermore, emerging evidence highlights the efficacy of direct interventions such as dry needling/acupuncture and softtissue mobilization for the management of acute pain in the ED (SMD: –0.40; 95% CI: –0.67, –0.13).17
Physical therapists employed in the ED are expected to provide insight into the diagnosis and treatment of neuromusculoskeletal conditions for patients of any age, health condition, or stage of injury.8 ED PTs are increasingly becoming valuable members of the ED team, as they have the knowledge and expertise to evaluate and manage complex patients and treat a broad array of neuromusculoskeletal conditions.14,29However, since most ED patients have multisystem involvement, ED PTs must possess the clinical reasoning, medical screening, and differential diagnosis skills to identify red and yellow flags and provide appropriate treatment beyond the musculoskeletal system.8,14,29For example, an ED PT must be able to distinguish mechanical shoulder pain from an infected shoulder joint in the absence of red flags in a homeless man with a history of addiction,30 mechanical low back pain versus a pelvic ring fracture in an elderly woman with a history of falls,31 concussion versus a head bleed in an individual recently involved in an MVA,32 and benign hypoglycemia versus cardiac autonomic neuropathy in an individual with uncontrolled type II diabetes experiencing recurrent episodes of syncope and falls.33
COMMUNICATION & TEAMWORK
Communication is as an essential skill for the ED PT to possess as it is closely linked with teamwork.19,34 Communication and teamwork are well-documented as integral components of the ED that lead to reduced clinical errors and sentinel events, improved diagnosis and treatment efficiency, and reduced wait times.35 Not all medical teams are the same: ED teams are unique within the healthcare system, as both the team members and the work demands are constantly changing.34 ED PTs must therefore be able to adapt to a continuously evolving work environment.33 Moreover, they must be able to relate to a variety of personality types and integrate various healthcare strategies with patient values.34 Finally, ED PTs must be able to communicate to team members and patients, while staying calm and portraying empathy and encouragement.14,19
CHANGE IN TRAINING PARADIGMS
In short, the skill level required for ED PTs exceeds that of an entry-level physical therapist, and the advanced training required by ED PTs remains a topic of debate in the literature.8 Moreover, ED PTs must be able to demonstrate meaningful change in considerably less time due to the lack of patient follow-up with outpatient services.8 Notably, physical therapists considered “experts” value the use of manual skills and touch over technology and equipment for the management of pain.36 Rodeghero et al found that fellowship-trained PTs may have better treatment results in fewer sessions compared to residency-trained physical therapists or those without post-professional residency or fellowship training.37 Resnik and Hart found that clinicians with any form of advanced orthopaedic training such as a board certification in Orthopaedics (OCS), a certification in manual therapy (MTC) or credentials from the American Academy of Orthopaedic Manual Physical Therapy (FAAOMPT) had better outcomes than those without in patients experiencing low back pain.38 Moreover, preliminary evidence suggests that post-professional training or certification may be important in developing improved clinical reasoning39 and communication skills40 required in an ED setting.
Practicing ED PTs require advanced training. Some have even suggested that ED PTs should have a unique residency and fellowship curriculum.8 Then again, maybe its time to rethink “entry-level” physical therapy.
Instead of investing time and money into the advanced-level training necessary to be an effective ED PT, perhaps its time to re-evaluate the Commission on Accreditation in Physical Therapy Education (CAPTE) requirements. Given the projected shortage of physicians over the next 10-15 years,41 a stronger entry-level foundation may be required. Perhaps formal residency training within a specialty of choice should part of the DPT curriculum, thereby elevating clinical reasoning, manual therapy, medical screening and communication proficiency across a broader array of settings. Elevating the standard of entry-level DPT education may give physical therapists a unique opportunity to step-up as physician extenders with a neuromusculoskeletal specialty to truly become the preferred providers and standard of conservative care in the ED setting.
AUTHORSGermaine Hermann, DPT
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Physical Therapist, Eskenazi Health, Indianapolis, IN
Raymond Butts, PhD, DPT, MSc, Dip. Osteopractic
Senior Instructor, American Academy of Manipulative Therapy
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical Therapy
James Dunning, PhD, DPT, MSc, FAAOMPT, Dip. Osteopractic
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Owner, Montgomery Osteopractic Physical Therapy & Acupuncture Clinic
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