The front line
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Physiotherapists work either as frontline emergency physiotherapy practitioners (EPPs) or as part of the multi disciplinary therapy team in A&E and medical admission units (MAUs). They can reduce delays and inefficiencies, prevent unnecessary admissions and enable timely discharge of patients to home or community settings.
EPPs see patients with, mainly, musculoskeletal (MSK) problems independently of medical staff. They undertake activities including expert assessment, requesting and interpreting investigations, managing wounds, soft tissue injuries and fractures, providing advice and treatment, freeing doctors to manage more complex conditions and improving patient flow.(1, 2) Physiotherapists managing MSK injuries have equivalent clinical outcomes and lower direct costs than doctors or emergency nurse practitioners.(3 5)
Attendance at A&E is increasing faster than population growth, and this rate is highest in people over 65.(6)
Size of the problem
- In 2012-13, 18.3million people attended A&E units; 43% were under 30 years old, 24% were aged 60 or over, 21% were admitted to hospital and almost 21% attended for joint, muscle, tendon, ligament and soft tissue injuries.(6)
- The cost per attendance was £115, giving a total cost of over £2,111million of which about £440million relates to MSK injuries.(12)
The clinical risks associated with hospitalisation of older people are clearly documented including loss of function, delirium, and hospital acquired infections.(7) In A&E / MAUs physiotherapists assess and
manage people, including those who have fallen, to avoid unnecessary admission and enable timely discharge to a safe environment with appropriate therapy or social support to prevent re-admission.(2)
For older patients, discharge planning is often a key performance indicator and a large part of the therapist role. It requires close liaison with other team members and rapid decision making to assess if patients can manage at their pre-admission destination, with or without increased health or social care support, or if they require placement for either rehabilitation or interim social care. Arranging community services could include home physiotherapy, increasing an existing care package, falls prevention services
and intermediate care, either in the patient’s home or a residential rehabilitation setting, or providing equipment.(2)
Historically, A&E therapists were occupational therapists (OT) because of their key role in discharge planning.(8)(9) Care and treatment have evolved in the light of changes in demands and expectations of healthcare; currently Physiotherapy and OT roles overlap with teams working closely together, providing interdisciplinary assessments which streamline patient care. For example, many A&E physiotherapists will
assess a patient’s ability to manage personal care tasks and provide basic equipment to enable patients to return home and avoid admission.
Resources for GPs
Patient information leaflets and more at Physiotherapy works: information for GPs
In 2011, the NHS London care commissioning standards,(10) stated that a multi-disciplinary assessment should be made within 12 hours of a patient presenting to A&E, highlighting the crucial role of therapists in preventing unnecessary admissions. Following publication of these standards many hospitals reviewed their A&E therapy services and developed services further, to include extended hours and weekends.
Evidence shows therapy-led services prevent admissions, reduce length of stay and are cost saving.(11)
Physiotherapists in A&E undertake an extensive and advanced role, providing expert assessment, diagnosis and management to a wide range of patients to deliver cost and clinically effective patient centred care. They provide an additional knowledge and skill set to traditional A&E professions to meet the growing demands of emergency healthcare.
Salford Royal NHS Foundation Trust treats 88,500 Accident and Emergency patients per year.
An advanced physiotherapy practitioner post was established in 2010 for people attending A&E with musculoskeletal injuries to provide holistic assessment and treatment for all aspects of their condition.
The role includes ordering and interpreting investigations such as X-rays and blood tests and onward referral for further physiotherapy if required.
Evaluation has shown increased service efficiency and care quality. Patients are provided with immediate access to expert physiotherapy advice and treatment, and waiting times have been lowered. A reduced requirement for more expensive medical staff has resulted in cost savings of £32 per patient - a 60% reduction. Patient flow through A&E has been improved and staff have reported better knowledge sharing between membersof the multi-disciplinary team.(1)
- Advanced practitioner: Accident & Emergency (A&E) and physiotherapy. Case study. http://www.nwwmhub.nhs.uk/media/142869/adp-009-musculoskeletal-emergency... (link no longer available)
- Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing. 2007 Jan;15(1):34-9.
- McClellan CM, Cramp F, Powell J, et al. A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management. BMJ open. 2012;2(6) http://bmjopen.bmj.com/content/2/6/e001092.abstract
- McClellan CM, Cramp F, Powell J, et al. A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management. BMJ open. 2013;3(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3549250/
- Richardson B, Shepstone L, Poland F, et al. Randomised controlled trial and cost consequences study comparing initial physiotherapy assessment and management with routine practice for selected patients in an accident and emergency department of an acute hospital. Emergency medicine journal : EMJ. 2005 Feb;22(2):87-92. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726666/pdf/v022p00087.pdf
- Health and Social Care Information Centre. Accident and Emergency Attendances in England 2012-13. January 28, 2014. http://www.hscic.gov.uk/catalogue/PUB13464
- Arendts G, Fitzhardinge S, Pronk K, et al. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. BMC geriatrics. 2012;12:8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3341184/pdf/1471-2318-12-8.pdf
- College of Occupational Therapists. Occupational therapists working in A&E teams help reduce admissions and re-admissions to hospital. London: College of Occupational Therapists; http://www.cot.co.uk/occupational-therapy-evidence-fact-sheets
- Carlill G, Gash E, Hawkins G. Preventing Unnecessary Hospital Admissions: an Occupational Therapy and Social Work Service in an Accident and Emergency Department. British Journal of Occupational Therapy. 2002;65(10):440-5.
- NHS London. Adult emergency services: Acute medicine and emergency general surgery: Commissioning standards. London NHS London; 2011. http://www.londonhp.nhs.uk/wp-content/uploads/2011/09/AES-Commissioning-...
- Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy. 2013 Jun;99(2):95-100.
- Department of Health. National Schedule of Reference Costs 2012-13 for NHS trusts and NHS foundation trusts. November 2013.https://www.gov.uk/government/publications/nhs-reference-costs-2012-to-2013 [Accessed: 2 December 2014]
The CSP would like to thank Lisa Goodwin Emergency Physio Practitioner(A&E) Homerton NHS; Jenni Harris Physiotherapy Professional Lead, Kettering General Hospital; Jo McLeod Team Leader A&E Therapy Team, Pennine Care Foundation Trust; Jennifer Willis Principal Physiotherapist, St George’s NHS Trust.