Physio At The Front-Line: Physio In A Rural ED

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Osborne Scott
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1 Physio At The Front-Line: Physio In A Rural ED Presented by David Sparshott Dubbo Base Hospital Physiotherapy Department

2 Background Emergency Departments have, in the past, been synonymous with Doctors & Nurses Referral to allied health professionals usually on an on-call basis; these staff already having other ward case-loads.

3 Our Service At DBH the ED was previously serviced by the ICU physiotherapist. With the recent trend of reducing hospital beds and increasing hospital activity: the need to reduce admissions and reduce average length of inpatient stay (LOS) has never been greater. With this trend, ED referrals to physiotherapy have been increasing. Large Metropolitan Hospitals have successfully allocated Physiotherapists to their ED s in an effort to cope with this trend. Why not in the Bush?

4 Increasing Pre-Trial Referrals to ED Average ED Physio Referrals for 12-month Periods: August to July Ave. Number of Referrals per Month Average month Period (Aug-July)

5 Aims Commencement of appropriately timed management for acute patients Completion of mobility assessments and recommendation of appropriate walking aids for at risk patients. Identification and prevention of inappropriate admissions and discharges from the ED Decreasing of workload of medical and nursing staff by assessing and treating soft tissue and bony injuries

6 Methods A physiotherapy position was dedicated specifically to work in the ED unit as part of the normal weekday staff roster in August Duties were to include: Attend ward rounds with the medical staff Treatment of patients in ED, EMU and ambulatory care. Liasing with nursing, ACAT, ALO, and social welfare teams as appropriate. Provide inservices and training to ED staff Keep accurate records for data collection Review records to determine any altered patient outcomes

7 Results Conditions treated Respiratory incl: COPD, pneumonia, atelectasis, chest infections, #ribs, spirometry tests Mobility assessments Back and neck pain Soft tissue injuries hip, knee, ankle, shoulder Application of plasters (also clinical education and feedback to ED staff regarding plastering) Application of slings, braces, collars, crutches Assessment of CVA, #NOF, pre-op abdominal surgery patients prior to admission

8 Conditions Referred ED Physiotherapy Caseload: Aug '05- Jan '06 Mobility n=41 10% Neuro n=17 4% Respiratory n=144 35% Musculoskeletal n=207 51%

9 Musculoskeletal referrals Musculoskeletal Referrals by General Body Area (Aug 05 - Jan 06) Spine n=30 14% Upper Limb n=73 35% Lower Limb n=104 51%

10 Results Staff Satisfaction Staff satisfaction surveys were distributed to ED medical and nursing staff before, during and after the ED physio trial. Results from the survey indicate a significant improvement in the level of staff satisfaction and better patient outcomes Staff indicated that ED physio benefited their work, especially in the area of casting, and in safe discharge of patients over age of 65. They commented on quicker response times, better education of patients and better all round management.

11 Figure 1: Do you feel that patients presenting to ED receive appropriate physiotherapy care? % No answer 60 Always Mostly Sometimes Rarely Never July 2005 September 2005 Date of surveys May 2006

12 Figure 4: Overall how do you find the physiotherapy service to ED? % Jul-05 Average Good Excellent Survey responses Sep-05 May-06

13 Discussion Our ED Physiotherapy Referrals and Occasions of Service (OOS) have dramatically increased since the ED physio has been appointed. (>425% over 12 months) This reinforces our belief that many patients were being missed prior to fulltime physio in ED

14 Fig. 5: ED/EMU REFERRALS TO PHYSIO New referrals Linear (2005) 30 Linear (2006) Linear (2004) 10 0 January February March April May June July August September October November December Average Month

15 Average ED Physio Referrals for 12-month Periods: August to July Ave. Number of Referrals per Month month Period (Aug-July)

16 LOS Hospital Cost saving A Review was conducted to compare the average LOS for respiratory pts admitted to DBH through ED with pneumonia and COPD exacerbations over 3 two-month periods: Aug-September 2004; 2005 and June-July Comparison was also made of admitted respiratory patients who were seen by the ED physio and those not seen. Note: This review did not include patients who were seen by the ED Physio and not admitted.

17 Fig. 7: Respiratory Admissions Average LOS: With ED Physio Vs Without (Aug-Sep 2004 & 2005) LOS (days) days 4.63 days n = days n = without ED Physio 2005 without ED Physio 2005 with ED Physio LOSave DRG-ALOSave

18 LOS Hospital Cost saving For the 31 pts seen by the ED Physio in Aug- Sept 2005, a total of bed-days were saved. This is an LOS reduction of >10% At approx $980 per day per general ward bed, bed-days equates to a financial saving of ~$14,300 for this patient group alone. The cost of employing a full-time physio for this period was ~$11,400. This is a potential saving to DBH of ~$2,900 for the first 2-months of the trial period.

19 Figure 8: Bed Days per 100 admissions with COPD/ Chest Infection Bed Days Occupied Without ED Physio With ED Physio Without ED Physio With ED Physio

20 LOS Hospital Cost saving If the only reason these pts had a shorter LOS was that they saw a physio in ED, then: for every 100 patients admitted with chestinfections/ COPD seen by the ED physio, approx. 47 bed-days could be saved at DBH. In October and November, a further 38 pts were seen by the ED Physio for respiratory conditions prior to admission, potentially saving another bed-days. In the first 6-months of the trial, 142 referrals were seen for respiratory physio intervention. It is difficult to evaluate the impact the ED Physio has had on ED patients who are not admitted. Anecdotally, the effects are extremely positive.

21 Conclusions and the future This ED position has now been approved as a permanent full-time position. The trial has promoted a multi-disciplinary approach and enhanced the understanding of the role of physiotherapy. Early intervention by the physio has improved patient outcomes - patients seen in ED are started earlier on exercise programs. Improved Patient Flow Ward Physio workloads have been reduced What are the most appropriate hours for ED physio??

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