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

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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.

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