Hospital Name: Eastern Health Key contact for this project ( name & details):

1. The Health Roundtable New Zealand Title: Eastern Health PhysiotherapyComparison of different models of providing physiotherapy care for people with simple musculoskeletal injuries presenting to Emergency Department 2 Future role of Allied Health Hospital Name: Eastern Health Key contact for this project ( name & details): Clarice Tang: Clarice.Tang@easternhealth.org.au Nick Taylor: Nick.Taylor@easternhealth.org.au

2. Introduction • Physiotherapists have recognised expertise in the management of musculoskeletal injuries, and these skills are increasingly being utilized in Emergency Departments. • Currently in ED’s there are 2 different models of physiotherapy care. Physiotherapists may work as either primary or secondary contact practitioners. • Primary Contact Physiotherapist (PCP): directly assess and manage patient from triage. • Secondary Contact Physiotherapist (SCP): patients are first assessed by a doctor and then referred for physiotherapy management.

3. Issues encountered in the ED Patient flow • ED presentations are annually increasing, with a 6.2% increase in Victoria from 1999/2000 to 2005/06. • Reducing waiting times in ED is a key objective of health care providers • Developing new service options to cope with increasing demand and reduce waiting times has been identified as a priority in ED care. • Role re-design has introduced nurses and physiotherapists performing expanded roles in ED’s to assist in patient flow.

4. Current evidence on physiotherapy in ED • Some evidence from the United Kingdom supporting the management of musculoskeletal injuries by physiotherapists in ED (McClellan et al 2006; Richardson et al 2005) • But there are no trials comparing primary model of care with secondary model of physiotherapy care

5. Aim of this study • Primary aim: to determine whether PCP management of patients presenting to ED with musculoskeletal injuries resulted in a reduced length of stay compared to patients managed by a physiotherapist after referral by a doctor (SCP) • Secondary aims: were to determine if the two models of care resulted in: • Different level of patient and staff satisfaction • Different rates of re-presentation to ED • Different rates of radiology referrals

6. Method: Design • The study design was a prospective non-randomised controlled trial that was carried out in three ED’s of a large metropolitan health network • Intervention: mode of service delivery • PCP or SCP (non-random based on the day of the week) • Adults with peripheral musculoskeletal injuries were allocated to a single episode of care of primary or secondary contact physiotherapy according to the day of the week.

7. Procedure Patient presented to ED with Musculoskeletal condition/injury and triaged according to Australasian Triage Category Patients assessed to meet inclusion criteria Dependent on the day of the week patient allocated to intervention group Primary Secondary Assessed by doctor Primary Contact Physiotherapy (PCP) Patients completed a questionnaire at the end of treatment. Staff completed survey at conclusion of data collection Secondary Contact Physiotherapy(SCP)

8. Timelines & Resources • Recruitment process was conducted between March 2008- Feb 2009. • All interventions were undertaken within budgetted EFT.

9. Key Outcomes Measures Primary • ED length of stay • Difference between arrival time and departure time (Considine et al 2006, Australasian College of Emergency Medicine 2001) • ED waiting and treatment time Secondary • Number of patient re-presentations • Number of referrals to radiology • Patient satisfaction questionnaire • Staff satisfaction survey

10. Results • 315 patients recruited for the trial. - 7 excluded as required admission - 2 excluded as they were < 18 years of age • 306 patients included in the trial.

11. Demographics

12. Primary Outcomes Measures There was a significant reduction of 60 minutes for patients managed by PCP compared to patients managed by SCP Minutes

13. Results – Secondary Outcomes Referrals to radiology - there was no difference in the number of patients referred for radiology between the PCP (69%) and SCP (77%) groups Number of patient re-presentations – there was no significant difference between PCP and SCP re-presentations.

14. Patient Satisfaction More than 84% of patients from both groups strongly agreed that they were satisfied with the management they received

15. Staff survey on PCP role (n=70) At least 80% of staff were positive about the role, knowledge and skills of PCP for all items in the survey

16. Discussion • Primary contact is a better model of providing physiotherapy for peripheral injuries than seeing a doctor first who then refers to physiotherapy • Reduced LOS and waiting time • No increase in re-presentations • High levels of patient and staff satisfaction

17. Discussion • These results suggest primary contact physiotherapy for this population group could be a more efficient model of care in an ED than the traditional secondary contact model, and more appropriately utilise the skill-set of physiotherapy clinicians working in the ED environment.

18. Discussion Main limitation – non randomised potentially introducing selection bias (younger age of PCP group). Future studies - determine whether primary contact physiotherapy provided advantages compared to having patients solely managed by a doctor( evaluating cost, quality of patient care etc.)

19. Lessons Learnt • Smooth transition of this project was largely due to comprehensive preparation, communication and subsequent buy-in from key stake-holders across the multidisciplinary ED team. • This project is the first step in developing a primary contact role within ED subject to availability of resources. • Investigating Primary Contact Occupational Therapist for hands assessments

20. Acknowledgement • With thanks to: • Fellow research colleagues, and also the physiotherapy clinicians who participated in the data collection • Professor Nick Taylor as lead researcher • Medical and nursing staff at Box Hill, Maroondah and Angliss Hospitals • La Trobe University