University of Wisconsin–Madison ⋅ Medical College of Wisconsin
WMJ

Early Access Physical Therapy: Utilizing Physical Therapists in Urgent Care and Emergency Settings

Jeff Hartman PT, DPT, MPH; Sarah Nechvatal, PT, DPT; Bringa Johnson, PT, DPT, OCS, GCS

WMJ. 2024;123(2):74-75,77

Download full-text pdf.

During the 1990s and into the 2000s, emergency departments (ED) in Wisconsin were burdened with increasing numbers of annual visits and rising wait times to see a physician. Similar to other states, patient satisfaction was decreasing, and patient safety was a concern.1 Conditions such as acute or severe musculoskeletal pain and dizziness were treated with medications, and it was not unusual for patients to return for symptom management while they waited for an appointment with their primary care physician.2 This costly and inefficient use of health care forced hospitals to explore creative solutions, such as utilizing nurse practitioners and physician assistants.3 These physician extenders provided much-needed answers to some of these challenges, but it wasn’t enough.

Similar challenges existed in other parts of the world, and countries such as Australia and the United Kingdom (UK) began utilizing physiotherapists as first-contact providers in their EDs and urgent care centers. This novel idea was successful, and researchers began to produce evidence demonstrating the benefit of providing physical therapy in the ED. For example, they demonstrated that physiotherapists could reduce wait and treatment times compared to other providers when addressing musculoskeletal conditions.4

The practice of utilizing physical therapy in the ED came to the United States in 1998, and by 2010, it was estimated that 15 facilities had full-time physical therapists working in the ED. Researchers were able to demonstrate high physician, physician extender, and patient satisfaction,5 and they were able to repeat clinical findings similar to those found in Australia and the UK. This evidence acted as a catalyst for more EDs and urgent care centers to adopt the practice. By 2020, it was estimated that the total number of EDs that staffed physical therapists had tripled. Many believe this number continues to rise at a similar rate today.

In 2010, SSM St Mary’s Hospital in Madison, Wisconsin, was one of the first early adopters of this model in the state. It is now estimated that Wisconsin has approximately 30 EDs and urgent care centers that have physical therapy consultation services (APTA Wisconsin, unpublished data, 2023). Additionally, the Wisconsin Chapter of the American Physical Therapy Association (APTA) has a formal committee called the “Early Access PT Coalition” that is advocating for physical therapists in EDs and urgent care centers throughout the state, making Wisconsin a leader within the United States for this area of practice.

THE ROLE AND BENEFIT OF EARLY ACCESS PHYSICAL THERAPY

With the transition to the entry-level doctoral degree in the mid-1990s, the physical therapist’s scope of practice within the United States expanded. The addition of pharmacology, radiology, and advanced pathology to the standard curriculum has allowed physical therapists to screen for life-threatening “red flags,” which increases their utility in early-access emergency and urgent-care settings.6 In the ED, physical therapists typically see level III to level V patients and can be called for a level I or level II to assist the care team with splinting or other procedures before transportation to surgery. A physical therapist in these settings provides immediate access to a physical therapy evaluation and treatment for a large spectrum of conditions and situations (see full-text pdf for Table). The goals of providing physical therapy services include collaborating with the medical team for diagnostic clarity, plan of care development, and direct intervention aimed at symptom management and mobilization.7 Additionally, physical therapists can offer education to the patient and family, assist the care team in discharge planning, and assist in the coordination of community resources. A significant contribution of physical therapists is the ability to provide the patient and family with a better understanding of the situation and offer reassurance, often aiding in the reduction of stress and anxiety.7 Providing physical therapy services in the ED not only helps the patient and family, but research has demonstrated it helps the entire care team5 and decreases the overall cost of care for symptom management.8

Additional benefits of emergent and urgent access to physical therapy are as follows:

  • Increases patient and care team satisfaction5
  • Reduces unnecessary hospital admissions9
  • Reduces outpatient observation patients in the hospital9
  • Decreases risk of fall-related revisits to EDs10
  • Decreases the burden of primary care physician care/follow-up11
  • Decreases unnecessary referrals to specialists8
  • Reduces the need for imaging12
  • Reduces use of medications12,13

Various staffing models exist across the country, including full-time physical therapists who spend most of their day – 8 to 12 hours – in the ED, including weekends. Physical therapists working either in the acute care or outpatient settings within the same hospital systems also can provide on-call physical therapy services in the ED. Other models that have been utilized are diagnosis-specific, in which the physical therapists are only consulted for one or two diagnoses, such as acute neck and back pain, wound care, vestibular disorders, or falls. Other models focus more on people groups, such as the geriatric population.14 The type of model used often depends on ED patient volume and mix and the priorities established by department leadership.

CONCLUSIONS

Emergency departments and urgent care centers in Wisconsin face many of the same challenges as 2 decades ago and are trying to find alternative solutions to situations such as opioid distribution and pain management, falls, and clinician burnout. Some have found creative solutions to these challenges, while others have been slow to adopt evidence-based solutions, such as early access to physical therapy services. For over 20 years, it has been shown that physical therapists can work effectively and efficiently within the health care team to assist with the diagnosis, treatment, and discharge planning for a wide variety of pathologies and situations, yet having a physical therapist as a part of the interdisciplinary emergency team is recognized only in a small percentage of Wisconsin facilities. The vision of the APTA Wisconsin is for early access to physical therapy to become the standard of care throughout the state. To achieve this, the APTA Wisconsin Early Access Coalition is poised to partner with leaders within the ED and urgent care center community to advocate for this new standard and provide resources and consultation upon request. Growing the interprofessional emergency and urgent care environments to routinely include physical therapy would further establish Wisconsin as a leader in health care and benefit all who are involved in emergent and urgent care – especially the patients.

REFERENCES
  1. Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997-2007. JAMA. 2010;304(6):664-670. doi:10.1001/jama.2010.1112
  2. Jones MR, Viswanath O, Peck J, Kaye AD, Gill JS, Simopoulos TT. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther. 2018;7(1):13-21. doi:10.1007/s40122-018-0097-6
  3. Hooker RS, McCaig L. Emergency department uses of physician assistants and nurse practitioners: a national survey. Am J Emerg Med. 1996;14(3):245-249. doi:10.1016/S0735-6757(96)90167-9
  4. Bird S, Thompson C, Williams KE. Primary contact physiotherapy services reduce waiting and treatment times for patients presenting with musculoskeletal conditions in Australian emergency departments: an observational study. J Physiother. 2016;62(4):209-214. doi:10.1016/j.jphys.2016.08.005
  5. Fruth SJ, Wiley S. Physician impressions of physical therapist practice in the emergency department: descriptive, comparative analysis over time. Phys Ther. 2016;96(9):1333-1341. doi:10.2522/ptj.20150306
  6. Kim HS, Strickland KJ, Mullen KA, Lebec MT. Physical therapy in the emergency department: a new opportunity for collaborative care. Am J Emerg Med. 2018;36(8):1492-1496. doi:10.1016/j.ajem.2018.05.053
  7. Incorporating Physical Therapist Practice in the Emergency Department: A Toolkit for Practitioners. American Physical Therapy Association. Accessed May 26, 2023. https://cdn.ymaws.com/www.aptaacutecare.org/resource/resmgr/communications/emergency_toolkit_final.pdf
  8. Walk M, Mehta A, Bhoja K, Frei C, Du L. Integrating a physical therapist into the urgent care team: an administrative case study of collaborative seamless, and cost-effective care pathway for neuromusculoskeletal problems. Phys Ther J Policy Adm Leadersh. 2015;15(2): J1-J13.
  9. Gurley KL, Blodgett MS, Burke R, Shapiro NI, Edlow JA, Grossman SA. The utility of emergency department physical therapy and case management consultation in reducing hospital admissions. J Am Coll Emerg Physicians Open. 2020;1(5):880-886. doi:10.1002/emp2.12075
  10. Goldberg EM, Marks SJ, Resnik LJ, Long S, Mellott H, Merchant RC. Can an emergency department-initiated intervention prevent subsequent falls and health care use in older adults? A randomized controlled trial. Ann Emerg Med. 2020;76(6):739-750. doi:10.1016/j.annemergmed.2020.07.025
  11. Morris CD, Hawes SJ. The value of accident and emergency based physiotherapy services. J Accid Emerg Med. 1996;13(2):111-113. doi:10.1136/emj.13.2.111
  12. 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. doi:10.1371/journal.pone.0231476
  13. Thackeray A, Hess R, Dorius J, Brodke D, Fritz J. Relationship of opioid prescriptions to physical therapy referral and participation for Medicaid patients with new-onset low back pain. J Am Board Fam Med. 2017;30(6):784-794. doi:10.3122/jabfm.2017.06.170064
  14. Dresden SM, Lo AX, Lindquist LA, et al. The impact of Geriatric Emergency Department Innovations (GEDI) on health services use, health related quality of life, and costs: protocol for a randomized controlled trial. Contemp Clin Trials. 2020;97:106125. doi:10.1016/j.cct.2020.106125
Author Affiliations: Department of Family Medicine and Community Health, Doctor of Physical Therapy (DPT) Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Hartman); UW Health-University Hospital, American Family Hospital, Madison, Wisconsin (Nechvatal); Fort Therapy and Sport, Fort HealthCare, Fort Atkinson, Wisconsin (Johnson).
Corresponding Author: Jeff Hartman, PT, DPT, MPH, assistant professor, Department of Family Medicine and Community Health, Doctor of Physical Therapy Program, University of Wisconsin School of Medicine and Public Health, 5110 Medical Sciences Center, 1300 University Ave, Madison, WI 53706; phone 608. 265.9781; emaail jahartman@wisc.edu; ORCID ID 0000-0002-8369-3142.
Funding/Support: None declared.
Financial Disclosures: Dr Nechvatal reports receiving honorariums to present at conferences regarding emergency physical therapy practice and payment for co-teaching a continuing education course on this topic.
Share WMJ