Wednesday, March 11, 2020 Study: Even in After-Hours Settings, Seeing a PT First for MSK Conditions in the Emergency Department Saves Time, Reduces Opioid Prescriptions An Australian study found that when patients' primary ED contact was with a PT, treatment times, orthopedic referrals, and analgesic prescriptions decreased — all in an after-hours setting, and with most PTs having no prior ED experience. In this review: Emergency department after-hours primary contact physiotherapy services reduce analgesia and orthopedic referrals while improving treatment time. (Australian Health Review, February 2020)Abstract The Message The beneficial role PTs can play in emergency departments is fairly well-established in research, but now a study from Australia takes that support even further, with authors finding that even in after-hour settings, patients with musculoskeletal issues whose primary contact was with a PT tended to leave the ED with fewer orthopedic referrals and opioid prescriptions than did those for which the PT was a secondary contact, all in less time than for patients who were seen by another professional first. And those improvements were accomplished with a cohort of PTs who, with one exception, had no prior ED experience. The Study Researchers analyzed data from an Australian ED that treated patients between 4:30 and 8:30 p.m. from a Saturday through a Tuesday, focusing on patients who presented with a musculoskeletal or orthopedic diagnosis. Those patients, just over 1,000 included in the study, were divided into two treatment groups — one group that saw a PT as primary contact, and a control group of patients whose first contact was with an ED medical officer and only later with a PT. Authors of the study then compared rates of referral for orthpedic consultation, prescriptions for analgesics (defined as "any restricted medication requiring a script from a medical officer, primarily opioid-based medication"), and overall treatment times. A total of 12 physiotherapists provided ED services. Overall professional experience among the PTs ranged from three to 16 years, but only one had prior ED experience. Findings Orthopedic referrals. Among patients in the primary PT group, 36.7% were referred for orthopedic consultation in the ED; the rate was 57.1% among the secondary PT group. Just over 48% of patients in the primary PT group were referred to an orthopedic clinic after discharges from the ED, compared with 69.4% among the control. Analgesic prescriptions. In all, 16.2% of the primary PT patients received prescriptions for analgesia on discharge. That rate rose to 24.7% among patients in the secondary PT group. Treatment times. The percentage of patients discharged from the ED or admitted to the hospital within four hours — a goal in the Australian health care system — was 89.6% for the primary PT group. Fewer patients in the secondary PT group, 64.4%, were treated within that four-hour window. Why It Matters Authors of the study characterize the findings as not just consistent with previous research but also ones that "build on" earlier studies by demonstrating "similar outcomes … using an ED PCP [primary care physiotherapist] workforce consisting of less-experienced physiotherapists than in previous studies, and in an after-hour setting." More From the Study Researchers believe the findings reflect well on the diagnostic abilities of PTs in the ED, writing that the study "supports the notion that [PTs] may be more confident than ED medical officers with diagnostic accuracy for musculoskeletal and simple orthopaedic presentations, as well as in establishing an effective treatment regimen that may not require orthopaedic consultation." They add that the reduced analgesia rates suggest that "either patients managed by ED PCPs require less analgesia in general or that ED PCPs seek non-pharmacological forms of analgesia to manage soft tissue injuries." Authors also pointed out that the results were achieved by PTs without previous ED experience, a detail that "suggests that even physiotherapists without prior ED experience can provide a safe effective service." Keep in Mind … The researchers acknowledge a few limitations to their study, primary among them that the control group was composed of patients with secondary contact with a PT, a factor that could necessitate longer overall treatment times or point to more complex presentations. Still, they argue, the study was limited to patients with an ICD-10-AM diagnosis code, which mitigated some of those potential confounders, making them "highly unlikely" to explain the magnitude of differences noted in outcomes. Authors also acknowledge that the particular study setting — a hospital ED with after-hours radiology and orthpedic services on-site — may make generalizing findings more difficult, and they advise that "confirmation of findings of this study across a range of ED settings and times would be beneficial." Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. 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