Pugh A, Roper K, Magel J, et al. Dedicated emergency department physical therapy is associated with reduced imaging, opioid administration, and length of stay: A prospective observational study. PLoS One. 2020;15(4):e0231476. Published 2020 Apr 23. doi:10.1371/journal.pone.0231476
Take 5 – 5 Critical Takeaways to Improve your Practice
1. This study is one of the first attempts to quantitatively measure how ED PT impacts use of imaging and opioids during an ED visit and if PT reduces length of stay in the ED.
2. Treating in a primary contact model compared to a secondary contact model is an important transition that the US health system needs to consider in order to reduce health care costs and improve patient satisfaction.
3. ED PT quantitative research is inherently difficult due to a long list of variables that may impact outcomes, as well as the challenge of finding a large cohort.
4. The type of PT intervention provided in the ED matters and may impact the outcomes measured.
5. ED PT in a primary contact model was found to significantly reduce imaging, opioid administration, and ED length of stay.
(Pugh et al, 2020)
Take a Deeper Dive
We have all seen a patient in the ED that comes in with atraumatic back pain or musculoskeletal complaint and are told to see what we can do to help this person. How did this start? Why did they come in today? Have they been here before? Did they get any pain medication already? Are they expecting to get imaging? Did they get here last night or 10 minutes ago? Do they know anything about physical therapy? What can I do for them today? What is my role?
Outside of making the patient feel better, PTs in the ED play an important role in the larger system and in attempting to address major systemic problems like opioid use and reducing healthcare costs.
The study “Dedicated Emergency Department Physical Therapy is associated with reduced imaging, opioid administration, and length of stay: A prospective observational study” by Pugh et. al. attempts to quantitatively answer the question on why and how PTs in the ED matter. Here are the five biggest takeaways from this journal article.
Let’s Break it Down
This study is one of the first attempts to quantitatively measure how ED PT impacts use of imaging and opioids during an ED visit and if PT reduces length of stay in the ED.
In PT research, studies have been done to assess how early PT intervention impacts outcomes for patients with low back pain. However, this was one of the first studies done that is ED specific. Other studies are descriptive and qualitative by nature. Although the PT world is the ruler of it depends, physicians and hospital systems like hard numbers. If and when you start an ED program at your hospital, you need evidence to demonstrate why some of our stakeholders should care, and this study is able to prove it.
Treating in a PT primary contact model compared to a PT secondary contact model is an important transition that the US health system needs to consider in order to reduce health care costs and improve patient satisfaction.
The US model of physician referral and ordered based PT is phasing out as we recognize the role PTs play in primary care, specifically for musculoskeletal complaints. While some patients in the ED certainly require management and services from multiple providers, treating PTs as an ancillary and delayed consult service ultimately leads to longer lengths of stay, among other things (1). Other countries have been modeling PTs as primary contact providers and it’s time for us to get on board and advocate for our role and scope of practice, especially in settings ilke the ED that have patient volume increases annually (cite). Based on the results of this study, PTs in the primary contact model may significantly reduce ED length of stay, opioid administration, and imaging rates.
ED PT quantitative research is inherently difficult due to a long list of variables that may impact outcomes, as well as the challenge of finding a large cohort.
The outcomes of this study are very exciting in the eyes of an ED PT. Any good study also has limitations and this is likely the reason that ED quantitative PT research has not been brought into fruition before. First off, you need a large cohort, and even in this study, one could argue it needed to be larger. Next, no two people that come to the ED are the same, even with the same chief complaint, gender, age, race, and pain score. If no one presents the same, then the PT interventions are going to be different in order to provide the best patient-centered care. One limitation that stood out to me was the fact that the study was done in a relatively homogenous urban area. In this study, 86.6% percent of the PT group is white, 11.8% Hispanic, and 1.6% other, with similar percentages in the control group. I am curious how the outcomes of this study would be impacted by a larger and more diverse cohort.
The type of PT intervention provided in the ED matters and may impact the outcomes measured.
In this study, they used one PT over an 18 month period to assess outcomes for patients who received PT interventions and those that did not for musculoskeletal complaints. Had they used more than one therapist, it is possible the outcomes of the study would be different due to the variables between PT clinicians. Additionally, Keith Roper, the PT for this study was an outpatient PT in rural California prior to working in the ED at the University of Utah. After listening to the journal club, he spoke of his experience providing reassurance and education to patients in the ED. His approach to providing PT intervention for patients with similar chief complaints is calculated and outcomes could be very different if he did not take this very focused approach.
ED PT in a primary contact model was found to significantly reduce imaging, opioid administration, and ED length of stay.
They found all of these things to be statistically significant compared to the patients that did not receive ED PT! So what does this mean for the system? As mentioned earlier, patient volumes in the ED increasingly puts more burden on physicians and APPs to manage patients in a very short amount of time. When the right patients are seen by PTs, throughput may move faster and the cost of the ED stay may go down, which may also lead to better patient satisfaction. Additionally, the opioid epidemic has made us all question our standards of practice and how we can do better for individuals and our society. The CDC estimated in 2017 that 20% of people that are prescribed opioids in the ED will misuse their prescription (2). When early PT intervention in the ED prevents someone from opioid use in the ED, the risk of opioid misuse or addiction may decrease. Finally, imaging in the ED is very expensive compared to outpatient imaging. Not only does a reduction in imaging rates free up space for level 1-3 patients to get care more readily, but it also keeps patients from paying obscene amounts of money for an outpatient procedure or unnecessary imaging.
- Pugh A, Roper K, Magel J, Fritz J, Colon N, Robinson S, Cooper C, Peterson J, Kareem A, Madsen T. Dedicated emergency department physical therapy is associated with reduced imaging, opioid administration, and length of stay: A prospective observational study. PLoS One. 2020 Apr 23;15(4):e0231476. doi: 10.1371/journal.pone.0231476. PMID: 32324821; PMCID: PMC7179851.
- Centers for Disease Control and Prevention (CDC). (2017). Opioid overdose: Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html
- Journal Club recording with Author Keith Roper.