Extended scope physiotherapists in the emergency department: one step further

It is a privilege to provide additional commentary on the article by McClellan et al.. The utilization of physiotherapists (PTs) as clinical specialists in the emergency department (ED) is a developing niche which has the potential to enhance patient care. The authors are to be commended for their analysis on this unique practice environment. Their methods of identifying and evaluating the relevant literature are thorough and represent a quality review process. This commentary aims, as the title suggests, to examine the issue of ED utilization of extended scope physiotherapists (ESPs) from an alternate perspective and take the conversation ‘one step further’. The authors make several points worthy of further discussion. The first is with respect to the proposed roles of ESPs in the ED. It is agreed that these practitioners have ‘pre-existing skills in the assessment and diagnosis of musculoskeletal injuries’ and that successful practice in this setting may involve ‘role enhancement’ as compared to typical PT intervention. However, it should be noted that, even without additional training, the knowledge base and focus that PTs bring to this setting may provide expertise above and beyond that traditionally available. Standard PT practice includes providing perspectives on patient education, activity modulation, recommendations for early movement or immobilization, and prescription of appropriate exercises. These important aspects of care are commonly reported as lacking in the routine management of ED patients. Additional research is needed to confirm the value of such added services in improving patient outcomes, but because these approaches are consistent with published practice guidelines their inclusion is justified. Therefore, while some therapists may require specific training to be maximally effective in the ED, physiotherapy, even in its fundamental form may play a role in improving emergency care. The authors’ proposal that ESPs may provide ‘role substitution’ in performing skills presently offered by other practitioners in the ED is also interesting and relevant. The United States’ movement towards a national health care system necessitates that qualified practitioners perform in non-traditional roles when this addresses either shortages or cost savings. Similarly, UK nations offering universal health care must also pursue this trend to sustain desired levels of care for the ever burgeoning population. As stated by the authors, present literature suggests that ‘ESPs can provide a high standard of care at an affordable cost’. It is important to remember that overall cost is not only reflected in immediate dollars spent but also in long term intangibles. Possible benefits of this type include avoiding unnecessary hospital admissions, return visits to the ED, and the progression to a chronic disease state, all of which have been reported as perceived potential advantages of ED PT services. Thus when an added service, such as ED PT, can improve care and subsequently impact long term costs, there is potential for health care savings on a grander scale. Another important consideration surrounding the benefits of a service concerns its perceived value. In this way, the authors’ assertion that ESPs can positively impact patient satisfaction in the ED should not be understated. Though a patient’s perception of an intervention’s proposed benefits should never be the sole basis for its clinical implementation, satisfaction with treatment received takes on an elevated level of importance in the ED. This is because in this setting, patient satisfaction levels are typically abysmal and have been described as a priority that policy makers should attempt to maximize. Though the exact reason for increased satisfaction is not known, it is quite possible that this perception stems from the patient receiving the needed services. Nonetheless, the influence of ESP consultation on ED patient satisfaction is undeniable and provides further motivation for greater implementation of such programs. Another point of further clarification concerns interpretation of the article by Richardson et al. This publication met the authors’ inclusion criteria and was therefore appropriately described in this review. However, critical analysis of this study raises additional considerations regarding conclusions to be drawn from this investigation. The authors correctly shed doubt on the assertion made by Richardson et al., that care provided by ED based ESPs leads to a longer return to normal activity. In addition to using median days for the basis of comparison, subjects with 15 different types of injuries were recruited. Such Correspondence to: M T Lebec, Department of Physiotherapy, Northern Arizona University, P.O. Box 15105, Flagstaff AZ 86001, USA. Email: mike.lebec@nau.edu Lebec Commentaries