Reducing pressures on the NHS: the emerging role of the physiotherapist in healthcare reform

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Emergency Care

Training/ Qualifications

Integration of roles requires training at masters level in addition to being signed off as competent. McMillan (2013) reports the role as a challenging varied environment with a high degree of responsibility and that previous MSK experience will assist with the management of what comes literally through the front door. Conditions can include minor head or rib injuries which if dealt with incorrectly can mean dealing with life or death situations (McMillan, 2013). Richard Parris a consultant in emergency medicine is optimistic about the future of physiotherapists in the emergency department: “the physiotherapists are a real asset…we don’t have any hierarchy or boundaries”, however reports that it is not for the faint hearted (McMillan, 2013).

In Australia, emergency physiotherapists must have a minimum of 5 years clinical practice post-graduation including 3 years spent in a relevant specialist area. Additional training or postgraduate study in a relevant clinical area is also desirable (Crane & Delany, 2011). However, there is currently a lack of a clear direct career pathway to get to this position meaning that practitioners are responsible for developing their own range of specialist skills. MSK postgraduate or masters certificates tend to be more directed at outpatient and private physiotherapy roles instead of for use in the emergency department. In Australia, most emergency physiotherapists are undertaking short courses such as plastering, sports, spinal and vestibular to complement their practice.

It has been realised that educational requirements for this sort of role placed within the broader health system network, however, needs to be standardised across settings in order to establish the wider effect of the service. Educational support including onsite training and supervision can be used as part of the programme in addition to certified courses in the absence of specific qualifications however this still means there is a lack of overall structure of training and defines the need for evidence-based regulatory.

Evidence to support

The UK is the worldwide leader in innovative physiotherapy practice (Crane&Delany, 2013). Services are continuously changing to meet the growing and changing patient demands while increasing workforce flexibility (Crane & Delany, 2013). As a result there is an evolving need to provide practitioners with an ethical and evidence-based framework to support changing practice such as the development of the emergency physiotherapist role. Within Australia, career paths are widening for physiotherapists as they try to establish similar counterparts (Crane&Delany, 2013) due to an increasing demand on emergency departments. Some would argue the emergency physiotherapist role has been better suited to the political need to improve patient waiting times rather than patient outcomes, however, Taylor et al. (2011) found that patients with musculoskeletal problems presenting at A&E were just as, if not more satisfied to see a physiotherapist as the first point of contact. Crane and Delany (2013) suggested that musculoskeletal physiotherapists expand their physiotherapy practice in the emergency department by requesting and interpreting radiology results, blood tests,x-rays managing minor wounds and fractures, applying plaster, managing analgesia and referring on to the most appropriate option in an efficient manner. Although predominantly involved with the management of MSK conditions, Anaf and Sheppard (2007) comment on the emergency Physiotherpists role in effectively managing minor chest fractures, whiplash, recent burns limiting functional movement and torticolosis.

Similar to the UK, in Australia Crane and Delany (2013) found that EPs enabled doctors to treat more critical and complex patients faster and reduced overall waiting time through the emergency department. Taylor et al. (2011) found that when operating as primary contact practitioners, patient length of stay could be reduced by up to 59.5 minutes compared with secondary contact practitioners. In the same non-randomised controlled trial, waiting time and treatment time of those attending A&E was also reduced following treatment by an emergency physiotherapist compared to secondary contact. This was thought to be a result of bypassing the initial doctor’s assessment. In addition to reducing the workload of other staff, this system improved patient flow and had no significant impact on re-presentation rate (Taylor et al. 2011) When satisfaction rates were investigated in this study, 85% of patients attending a physiotherapist in the emergency department were satisfied with the treatment they received as were 82% of patients who first saw a doctor followed by a physiotherapist. However, those receiving the primary physiotherapy contact felt things were explained more effectively and that they were given more time to ask questions and discuss their condition (Taylor et al. 2011).

The systematic review conducted by Kilner (2011) analysed the literature surrounding physiotherapists working as emergency practitioners, specifically its effect on health outcomes. Despite the previous findings, this research review did not fully support the engagement of physiotherapists in the emergency care setting. The ‘access block’ (figure. 1) experienced across emergency departments worldwide requires government, economic and societal input overtime with physiotherapists working in emergency departments only a short-term solution to a long-term problem. However, Jogodka and Lebec, (2008) argue the need for mobility and exercise experts in the emergency departments and that when used appropriately, physiotherapists seen here can facilitate healing and prevent secondary complications. Kilner (2011) analysed that emergency physiotherapy affects outcomes on three main levels: system, provider and client. It was determined that although physiotherapists working in A&E were more likely to give advice to patients and arrange for follow up physiotherapy that doctors or nurses working in the same area, at a system and provider level, there is insufficient existing evidence regarding the effects of physiotherapy in A&E. Richardson et al. (2005) for example conducted a randomised controlled trial which failed to establish the cost-effectiveness of such a service. Kilner (2011) agreed that emergency physiotherapy resulted in increased patient satisfaction, decreased waiting times and improved clinical outcomes in the short term, however were not convinced of the reliability of its long term effects.

Injection Therapy

Description

In recent years, physiotherapists have been placed in accident and emergency (A&E) departments to improve patient care, free up hospital beds by preventing unnecessary admissions and target optimal functioning of attendees. Emergency department physiotherapy is incorporated in the umbrella of an extended scope of practice. Clinicians in this area display a considerable depth of academic knowledge, clinical skills and experience and may be involved in providing interventions traditionally beyond the physiotherapy scope of practice (Anaf & Sheppard, 2007).. In addition to frontline emergency physiotherapy practitioners (EPPs), increasingly physiotherapists are being made part of the integrated multidisciplinary team working in A&E and on medical assessment units (CSP, 2011). In Scotland such teams are seen at the Borders General Hospital where the Rapid Assessment and Discharge team are heavily involved in early patient contact, and the Integrated Assessment Team at the Victoria Hospital in Fife who carry out a falls assessment on every patient over the age of 64 attending A&E and assist with safe discharge (NHS Fife, 2014). It is recommended that 80% of patients attending A&E not staying in to be admitted should have length of stay less than 240 minutes (Taylor et al. 2011). These practitioners support medical professionals in assessing patients presenting with musculoskeletal conditions, helping to reduce breaches of this four hour waiting target and excessive delays (CSP, 2011). This allows patients to be assessed and either admitted or discharged home in a timely and safe manner with the appropriate resources in an attempt to prevent future re-admissions. The physiotherapist is also able to liaise with the MDT in deciding if the patient requires further input such as increased care package or community physiotherapy. In August 2013, in response to NHS England’s urgent and Emergency Care Review, the CSP confronted the increased need for physiotherapy services in acute medical departments, including A&E (McMillan, 2013).To meet the growing demands of emergency healthcare, EPPs operate as frontline staff whose role includes the assessment of musculoskeletal conditions, sending for further investigations such as bloods and scans, the management of soft tissue injuries and wounds in addition to educating and advising. This allows for doctors working in the department to focus their attention to more complex acute cases and improves the flow of patients through the system. Frontline physiotherapists are particularly relevant in treating the elderly where admission to hospital is much more likely to result in a consequential spiral of hospital acquired infections, delirium and often reduced functional capacity, resulting in extended stays. An increasing elderly population and patients with two or more long term conditions has recently meant two out of three A&E visits are for those falling into these brackets and with increased access to GP out of hours services since 2004 there has been an additional 4 million A&E attendants (Reesᵃ, 2015). Increases in bed occupancy yet a 6% decrease in bed numbers since 2010 has seen patients being shifted between wards, putting further extension on their length of stay (Reesᵇ, 2015) Historically allied health professionals in A&E were occupational therapists due to their main role in the organisation of discharges. However, with the integration of health and social care advancing multidisciplinary team working, currently in situations such as these, there is an overlap in physiotherapist and occupational therapist roles in order to provide the best possible approach to patient-centred care.

One of our student editors has placement experience with the RAD team at the Borders general Hospital near Melrose. She reports:

“The Rad team which was still being piloted at the time of my placement was made up of one band 6 physiotherapist, one occupational therapist and a further senior physiotherapist with a dual physiotherapy and social care role. Although I was only there for a short period, it was clear the positive effects this set up was having on acute care and I really enjoyed being part of something current and emerging. We aimed to see patients within 12 hours of attending A&E if required, whether that be on the Medical Assessment Unit following admission or if they were discharged home we would contact them via the phone and even go and see them in the community when necessary. The set up of the team enabled interdisciplinary assessments of mobility and functional ability e.g. self-care to occur, providing patients with the appropriate resources and equipment to ensure a safe discharge and reduce the change of future re-admission. In A&E the majority of the patient’s we saw had newly acquired walking aids so time was spent teaching their use and working with the patient to ensure they were able to function optimally and safely in their home environment. We also saw patients who had long term conditions that unrelated MSK problems were now making harder to manage. My favourite aspect of the placement was the variation. One day could be spent in MAU, preparing patients for discharge without any requirement for the team in A&E while other days could be spent solely in A&E or out on home-visits without a hospital ward in sight. This highlighted to me how the profession is changing as we try to move care out into the community. I was aware however of some challenges facing the team. Due to being a pilot the team was still establishing itself across the hospitals, with better knowledge of its purpose in some areas than others. This also meant that here was also no set protocol as to when RAD input was sourced and different methods of triage were being tried and tested over the course of my placement. This finished with the prospect of the RAD team being based in the A&E department to increase awareness. I did not have any doubt however that with a bit of perseverance this would happen.”

In view of this tight window in which to see suitable patients, NHS London Care Commissioning Standards (NHS Healthcare for London, 2011) state that many hospitals have reviewed their A&E services, extending A&E input to cover weekends and extended hours in order to maximise the cost-effectiveness of the service.

Cost Effectiveness

With the average cost of an A&E visit costing the NHS approximately £115 this method of service provision reduces direct costs with similar clinical outcomes (CSP, 2011). The CSP evidence-based briefing found that in 2012-2013 of the 18.3million people that attended A&E, around 21% presented with musculoskeletal (MSK) related injuries, an estimated £440 million worth of healthcare costs. It was recorded that 446000 more people attended emergency departments throughout the UK in 2014 compared to 2013 (Reesᵃ, 2015). Winter 2014-2015 therefore saw huge negative media coverage of A&E provision with increased demand and rises in missed targets with higher reported major incidents (Jenner, 2015; Reesᵃ, 2015). Incapacity in emergency departments was quoted as being “the biggest operational challenge facing the NHS” (Reesᵃ, 2015).In light of this, it is being more accepted that in order to lower the pressures and direct costs of these deficiencies, the skill mix of AHPs should be exploited (Jenner, 2015). If used properly, the abilities of physiotherapists could bring huge benefits in the assessment, diagnosis and treatment of MSK and chronic respiratory exacerbations such as Chronic Obstructive Pulmonary Disorder, in addition to providing vast experience and learning opportunities for the physiotherapists themselves (Jenner, 2015).

Training/ Qualifications

Integration of roles requires training at masters level in addition to being signed off as competent. McMillan (2013) reports the role as a challenging varied environment with a high degree of responsibility and that previous MSK experience will assist with the management of what comes literally through the front door. Conditions can include minor head or rib injuries which if dealt with incorrectly can mean dealing with life or death situations (McMillan, 2013). Richard Parris a consultant in emergency medicine is optimistic about the future of physiotherapists in the emergency department: “the physiotherapists are a real asset…we don’t have any hierarchy or boundaries”, however reports that it is not for the faint hearted (McMillan, 2013).

In Australia, emergency physiotherapists must have a minimum of 5 years clinical practice post-graduation including 3 years spent in a relevant specialist area. Additional training or postgraduate study in a relevant clinical area is also desirable (Crane & Delany, 2011). However, there is currently a lack of a clear direct career pathway to get to this position meaning that practitioners are responsible for developing their own range of specialist skills. MSK postgraduate or masters certificates tend to be more directed at outpatient and private physiotherapy roles instead of for use in the emergency department. In Australia, most emergency physiotherapists are undertaking short courses such as plastering, sports, spinal and vestibular to complement their practice.

It has been realised that educational requirements for this sort of role placed within the broader health system network, however, needs to be standardised across settings in order to establish the wider effect of the service. Educational support including onsite training and supervision can be used as part of the programme in addition to certified courses in the absence of specific qualifications however this still means there is a lack of overall structure of training and defines the need for evidence-based regulatory.

References

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