Physical Therapy in the Emergency Department : A New Delivery Option

1. Physical Therapy in the Emergency Department: A New Delivery Option Debra A.McDonnell, PT, DPT Pamela M. Wendl, PT, DPT Susan S. Deusinger, PT, PhD Linda Van Dillen, PT, PhD Sara Bohall, MS Robert Poirier, Jr., MD Great Plains Regional SAEM Research Meeting September 28, 2013

2. Elements of a New Service Delivery Model In The Emergency Department The Model: Physical Therapy in the ED The Subject: Back Pain Study

3. The Catalyst(s) for the ModelPT in the ED Contemporary changes in PT A vision of interdisciplinary care Knowledge of prevalent conditions Openness to innovation Impending change(s) in health care

4. The StudyRationale for Back Pain in the ED 60-80% of adults experience LBP $30 billion annual costs 2.5-3 million ED visits annually Complexity of presentation Accountability for outcomes

5. The StudyPurpose and Hypotheses • Purpose: Test effectiveness of a new delivery model for patients presenting to the BJH ED with back pain • Hypotheses: ↓ pain and ↑ function ↓ medications, x-rays and 72-hour return Null effect on Length of Stay (LOS) in the ED

6. The StudyDesign • Subjects: Adults, chief complaint of back pain Inclusions: > 18 y/o, non-febrile, speaks English Exclusions: Pregnant, cognitively impaired, critical • Personnel: PT/MD/Student research assistant • Group Assignment: PT-First and MD-Only • Pre- and post-testing of pain and function • Analysis of group differences

7. The StudyProcedural Design PT-First Group MD-Only Group Triage (RN) Triage (RN) Consent (PT) Consent (Student) Functional Assessment (PT) Functional Assessment (Student) Treatment (PT) Medical Assessment (MD) Functional Assessment (PT) Functional Assessment (Student) Medical Assessment (MD) Discharge (RN) Discharge (RN) Follow-Up (Student) Follow-Up (Student)

8. The StudyData Sources • VAS (Visual Analog Scale) Self-report of pain • FA Test (Functional Assessment Test) Self-report of symptoms during 12 specific movements • HMED (Hospital data base) Electronic recording of duration of stay in ED, use of medications and x-rays, and 72-hour return

9. The StudyPre- and Post-Tests Measures • Pain Self-reported numeric rating of pain on a 0-100 scale • Symptoms during functional tests Patient report of whether symptoms increased, decreased or stayed the same during the following movements, or whether the movement could not be performed (recorded as NA):

10. The StudyDefinition of New Variables • Symptom change A non-numerical comparison from pre-test → post-test of self-reported symptoms

11. The StudyDefinition of New Variables • Percent Improved Symptoms The number of improved symptoms divided by the sum of NAs and increased symptoms at the pre-test across all 12 functional tests

12. The StudyStatistical Analyses • Subject characteristics, LOS, medication, x-ray and 72- hour return – Descriptive and Chi Square tests of HMED data • VAS Pain Pre → Post • Mixed Model ANOVA of self-report • FA Test Symptom Change Pre → Post • Chi Square to test frequency of symptom changes (worsened, stayed the same or improved) • t-test to compare percent change in symptoms in both groups across all tests of function • Chi-Square Tests to compare groups

13. The Study OutcomesDescriptive Statistics

14. The Study Outcomes X-Ray/Medications

15. The Study OutcomesLOS/72-Hr Return

16. The Study Outcomes VAS (Self-Reported Pain) * p=.019

17. The Study Outcomes FA Test (Symptom change)

18. The Study Outcomes FA Test (% Improved Symptoms ) p<.001 *

19. The StudyLimitations • Potential differences other than baseline characteristics in PT-First (weekday) and MD-Only (weekend) caseload • Triage, technology and space allocation issues that affected LOS measures • Significant problems contacting patients post-discharge to determine complaint(s) that can lead to 72-hour return • Inadequate data collected for: • Timing and type of MD contact for PT-First group subjects • Dose and timing of administration of narcotics/medication • Cost of ED visits and interventions

20. The StudyFuture Directions • Seek funding to support: Dedicated research coordinator and space Formal testing of psychometrics of FA Test • Refine design to: Improve notification after triage Recruit and randomize subjects on weekdays only Characterize patterns of presenting complaints in the ED Use 5-day time frame for follow-up

21. TheWindows of PT Opportunity • Create routes for more timely intervention, discharge planning and follow-up in the ED • Incorporate PT to manage non-life threatening musculoskeletal conditions seen in Urgent Care Centers • Reinforce the value of systematic assessment by PT as an expected component of care in all venues • Fully embrace PT as an integral component of interdisciplinary care across the continuum of health and life

22. Acknowledgements WUSM Colleagues: • Beth Crowner, PT, DPT, NCS • Tammy Burlis, PT, DPT, CCS • Robert Deusinger, PT, PhD • Lawrence Lewis, MD • Brent Ruoff, MD BJH Leadership: • Sharon O’Keefe, RN • Richard Liekweg, MBA WUSM PT Students: • Sharon McMonagle, DPT • Allie Harris, SPT • Kristen Waldron, SPT • Sara Heldman, SPT • Noelle Peterson, DPT • Tori Mallow, SPT • Max Edele, SPT Funding Sources: • MPTA Grant (7/2011 – 7/2013) • Research Division (7/2011 – 7/2012) • Program in PT