Comparing patient outcomes for care delivered by advanced musculoskeletal physiotherapists with other health professionals in the emergency department—A pilot study

doi:10.1016/j.aenj.2016.06.001

Australasian Emergency Nursing Journal

Volume 19, Issue 4, November 2016, Pages 198-202

https://doi.org/10.1016/j.aenj.2016.06.001 Get rights and content

Abstract

Background

To compare advanced musculoskeletal physiotherapists with other health professionals by measuring outcomes for patients presenting to the emergency department with lower limb soft tissue injuries or acute low back pain.

Methods

A prospective study was conducted (Lower limb soft tissue injury cohort, n = 88), (Acute low back pain cohort, n = 29) at the emergency departments of two urban hospitals. A univariate analysis was completed for a number of outcome measures: Lower Extremity Functional Scale, Roland Morris Disability Questionnaire, imaging requirements, Patient Satisfaction Questionnaire, Numerical Pain Rating Scale and medication use. Data was obtained at discharge, two weeks and six weeks post-discharge.

Results

Advanced musculoskeletal physiotherapists ordered less imaging, had less opioids (lower limb soft tissue injury) administered to patients, and patients’ described equal or more satisfaction when compared to another health professional (p < 0.05). No significant differences were found between groups for functional or pain related outcomes in both cohorts (p > 0.05).

Conclusion

Advanced musculoskeletal physiotherapists are less likely to order imaging, obtain similar outcomes regarding pain medications and display equal or more patient satisfaction when compared to other health professionals for patients presenting to the emergency department with lower limb soft tissue injuries or acute low back pain.

Introduction

Advanced Musculoskeletal Physiotherapists (AMPs) have been established in emergency departments (EDs) for a number of years in Australia. The role of the AMP requires knowledge and skills developed from a clinical governance framework that is based on previous successful models existing both locally and internationally such as in the United Kingdom [1]. Previous studies comparing AMPs to other health professionals have found no significant differences in functional outcomes for patients presenting with peripheral musculoskeletal injuries [2], [3]. In regard to imaging rates, studies differ with one study showing no significant differences in imaging rates between AMPs and other health professionals for patients presenting to ED with fractures [4], yet in another study AMPs were shown to order less imaging than other health professionals for a wide range of musculoskeletal conditions in ED [5]. Patients have also been shown to report greater satisfaction when seen by an AMP compared to another health professional when presenting to ED with musculoskeletal conditions [2], [3], [4], [6], [7].

As part of a government funded project to develop and introduce new AMP roles into a number of EDs, the aim of our study was to assess patient outcomes in an established ED service by comparing AMPs to other health professionals. We also aimed to examine if patient outcomes were similar between groups for musculoskeletal presentations that are both commonly seen and representative of an AMPs caseload. Our research questions therefore were:

1.
Does the AMP improve patient outcomes when compared to other health professionals for patients presenting to ED with either a lower limb soft tissue injury (LLSTI) or acute low back pain (ALBP) in our patient population?
2.
How does an AMP compare to other health professionals when ordering imaging for patients presenting to ED with either a LLSTI or ALBP in our patient population?

Section snippets

Study design

A prospective observational study was conducted using a convenience sample of 88 patients (LLSTI) and 29 patients (ALBP) that presented to one of two major metropolitan hospitals in Melbourne, Australia from September 2012 to January 2013. For each patient cohort, a group assessed and managed by an AMP was compared with a group seen by another health professional in the ED. This included: ED consultant, ED registrar, ED resident or Nurse Practitioner. Ethics approval was received from the

Results

One hundred and twenty eight potential patients were identified as eligible for this study which included eight LLSTI patients and three ALBP patients who initially declined to participate. The study sample therefore comprised 117 patients (n = 29, mean age 36 years, SD 11.4) (ALBP cohort), (n = 88, mean age 34 years, SD 11.7) (LLSTI cohort) that presented to the ED between October 2012 and January 2013. Baseline demographic characteristics are shown in Table 1.

For the ALBP cohort, patients managed

Discussion

Our study found that AMPs ordered less imaging than other health professionals for patients specifically presenting with either a LLSTI or ALBP that was less than three months in duration, and without potential red flags. This is an important finding that is supported by previous literature suggesting imaging is not indicated for ALBP less than 3 months duration and in the absence of red flags [12]. Furthermore, imaging in ALBP without red flags has been reported to show no improvement in

Conclusion

Patients who present to ED with a LLSTI or ALBP are less likely to receive imaging, are equally or more satisfied when seen by an AMP and obtain similar outcomes when receiving pain medications compared to another health professionals. Considering the limitations of this study there may be potential benefits for the patient and healthcare system if AMPs can safely and effectively manage these patients with less imaging in ED. Further research is required to establish if AMPs are obtaining

Provenance and conflicts of interest

The authors declare this work to be original and have no conflict of interest to report.

Funding

Health Workforce Australia provided funding for this study but had no role in study design, analysis, interpretation or drafting of this manuscript. Furthermore the content in this study does not represent the views of Health Workforce Australia.

Meetings

Australian Physiotherapy Association Conference, Melbourne, Australia, 17 October, 2013.

Author contributions

PS and PH conceived and designed the study with pH obtaining research funding. PS, PH and JF supervised the conduct of the study. PS, PH and JS supervised data collection, which included recruitment of patients. JF and AH provided statistical advice on the study design and analysed the data. PS drafted the manuscript and all authors contributed substantially to its revision. PS takes responsibility for the paper as a whole.

Acknowledgements

With thanks to Andrew Corcoran, Rachel Gourlay and Janine Shifman for their assistance with patient recruitment and data collection.

References (17)

S.T. Ball et al.
Do emergency department physiotherapy practitioner's, emergency nurse practitioners and doctors investigate, treat and refer patients with closed musculoskeletal injuries differently?
Emerg Med J
(2007)
M. Sutton et al.
Primary-contact physiotherapists manage a minor trauma caseload in the emergency department without misdiagnoses or adverse events: an observational study
J. Physiother
(2015)
N.F. Taylor et al.
Primary contact physiotherapy in emergency departments can reduce length of stay for patients with peripheral musculoskeletal injuries compared with secondary contact physiotherapy: a prospective non-randomised controlled trial
Physiotherapy
(2011)
R. Chou et al.
Imaging strategies for low-back pain: systematic review and meta-analysis
Lancet
(2009)
S.V. Cantrill et al.
Clinical policy: critical issues in the prescribing of opioids for adult patients in the emergency department
Ann Emerg Med
(2012)
Review Of Primary Contact Physiotherapy Services
(2010)
C.M. McClellan et al.
A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management
BMJ Open
(2012)
C.M. McClellan et al.
Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department
Emerg Med J
(2006)

There are more references available in the full text version of this article.

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Research paperComparing patient outcomes for care delivered by advanced musculoskeletal physiotherapists with other health professionals in the emergency department—A pilot study

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Results

Discussion

Conclusion

Provenance and conflicts of interest

Funding

Meetings

Author contributions

Acknowledgements

Emerg Med J

J. Physiother

Physiotherapy

Lancet

Ann Emerg Med

Review Of Primary Contact Physiotherapy Services

A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management

BMJ Open

Effect of an extended scope physiotherapy service on patient satisfaction and the outcome of soft tissue injuries in an adult emergency department

Emerg Med J

Research paper
Comparing patient outcomes for care delivered by advanced musculoskeletal physiotherapists with other health professionals in the emergency department—A pilot study