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While a few ED-based physical therapy programs have existed for decades, the practice is gaining new converts as emergency clinicians increasingly turn to physical therapy for expertise with conditions ranging from vertigo and orthopedic issues to wounds, vestibular issues, and gait training. Long-standing programs have shown that leveraging physical therapy in emergency medicine can be a financially viable approach with the proper administrative support and guidance.
As patients flock to the ED with orthopedic injuries, vestibular problems, wounds, and gait difficulties, physical therapists are finding themselves increasingly involved in treatment. In fact, it has gotten to the point where a growing number of hospitals are establishing ED-based physical therapy programs, many of which are proving financially viable and greatly appreciated by medical staff.
Proponents of the practice caution that it takes time to build the kind of trusting relationships needed for physical therapists to thrive in an emergency setting. However, these proponents note established programs have shown that not only can such programs pay for themselves if given the time and commitment, they also can deliver cost-savings in some cases for both hospitals and patients.
Some of the oldest ED-based physical therapy programs are in Arizona. For instance, Carondelet St. Joseph’s Hospital in Tucson has stationed physical therapists in the ED since 1998. Carleen Jogodka, PT, DPT, has been tending to patients there for 15 years and has seen the program evolve. “It started off much more protocol-driven ... if someone came in with whiplash, a knee sprain, or vertigo, there was pretty much a protocol of what the therapist would do,” Jogodka explains.
Now, the situation is more fluid. Physical therapists are involved with a much more diverse set of problems, including some trauma, Jogodka notes. “We have lots and lots of wounds, various types of vertigo ... and we are interacting a lot more with hospitalists in making determinations on placement,” she says.
Typically, Jogodka will hear about a patient who could benefit from her services through face-to-face contact with emergency clinicians. “Usually, a physician will just come over to my desk and give me a report on what is happening with the patient,” she says. “Otherwise, bedside nurses are recognizing when there is an issue with a patient; they may be concerned about the patient’s mobility, a wound, or any of the things they have now learned are within our scope of practice.”
Even the paramedics who work as techs in the ED will alert Jogodka when they recognize cases in which physical therapy services could be of benefit, she says. However, with the constant churn of new staff coming into the department, Jogodka has to train residents continually about the services that physical therapists provide, although she often has help in this task.
“There are usually other staff who will also inform new providers coming through on what it is that we do, but we do absolutely still need to be proactive,” she says. “A physical therapist does not necessarily have to be overly aggressive, but rather collaborative and approachable.”
Frequently, Jogodka is involved with patients in the ED who present with low back pain. Jogodka recalls one recent case in which her involvement made a big difference in the patient’s care and disposition. A woman was experiencing such severe symptoms that her family was unable to get her out of bed and into a car. An ambulance brought the patient to the ED, Jogodka explains. “The pain was so severe that she was put on a Foley catheter because she was unable to lift her bottom up to get on a bed pan,” she says.
The staff and the attending physician on duty at that early-morning hour arranged for an MRI, revealing a large, herniated disc in the woman’s back. She was scheduled for surgery the following afternoon. However, when Jogodka arrived to work a few hours after the woman arrived, she inquired about the case, finding that there were no red flags or any neurologic deficits involved — nothing that would suggest that Jogodka should not be involved.
The work consisted of certain exercises with an initial focus on bed mobility and some relaxation techniques. Jogodka recalls that she also may have used some electrical stimulation to distract the nerves. “The woman got to the point where she was able to walk, and she eventually walked out of the hospital ... that afternoon with a scheduled follow-up appointment. The surgery was cancelled, and all the parties were pretty happy,” Jogodka says.
Emergency providers also frequently turn to Jogodka when they see patients with suspected vertigo, which can be quite frightening to patients. “This involves not just treating the vertigo, but also the really hyper aphasia that the vertigo is coming with, and lots of anxiety,” Jogodka says. “I have had patients who were flown in by helicopter because they had vertigo.”
In one case, a woman had attempted suicide because she assumed her symptoms from vertigo were actually a brain tumor. A family member who experienced similar symptoms had been diagnosed with a brain tumor.
“Even when physicians think a diagnosis is probably not positional vertigo, they want to be able to get my input on it,” Jogodka says. “They want to be able to present to the hospital that physical therapy has already seen the patient, and they do not think this is positional vertigo.” The physicians will seek to admit the patient for a different suspected diagnosis, confident that vertigo is not the problem.
The emergency medicine trauma center (EMTC) at Indiana University (IU) Health Methodist Hospital in Indianapolis began using physical therapists in 2002 based on the earlier experience of programs in Arizona like the one at St. Joseph’s Hospital in Tucson. Here, physical therapists are used frequently in cases involving acute orthopedic issues or injuries, gait or balance problems, and vestibular issues, explains Kevin Flint, PT, MBA, a physical therapist in the EMTC at IU Health Methodist Hospital.
“Physical therapists are frequently called to assess and treat varying types of wounds, including burns and traumatic wounds,” he says. “They evaluate most levels of patient acuity and a far-ranging list of diagnoses.” Flint adds that physical therapists work with other clinicians to plan disposition needs and address safety concerns in the geriatric population.
“Upon arrival to the ED, patients are typically triaged to different areas of the ED based on acuity. Then, physical therapy is consulted during the work-up/evaluation portion of their visit,” Flint explains. He adds that staff physicians, residents, medical students, and advanced practice providers all consult with physical therapy services on occasion. “We receive verbal consult orders that are then written into the electronic medical record [EMR],” he says.
The primary benefit that physical therapists bring to the emergency setting is the ability to offer more comprehensive management of patients, according to Michael Brickens, PT, another physical therapist at IU Health Methodist Hospital. “Whether [patients] are critical/acute or non-life-threatening, physical therapists bring a unique skill set and expertise that complements the medical evaluation,” he says.
Brickens explains that the average daily census in the ED is more than 280 patients, so dealing with surges is routine. He notes that physical therapists can help assess orthopedic cases, vertiginous conditions, and chronic and acute wounds. Further, physical therapists work closely with physicians, case managers, and social workers to create safe and appropriate care plans for elderly and underinsured patients. “Specific to mass casualty events, physical therapists have been utilized to assist with musculoskeletal conditions, splinting fractures, and they addressed traumatic wounds and burns,” Brickens adds.
Brickens notes that the ED is staffed with physical therapy coverage from 9 a.m. until 9 p.m. Monday through Friday and from 8 a.m. to 2 p.m. on weekends. “Most major holidays are staffed except Thanksgiving, Christmas, and New Year’s Day,” he says. “We have tried varying hours, but these seem to capture the greatest patient volume and needs of the ED.”
Hospital administrators interested in starting a physical therapy program in their ED should look for physical therapy candidates who offer a strong background in orthopedics, Flint advises. Also, candidates should be well-versed in wound care, vestibular physical therapy, and balance dysfunction, he says.
“Over the past five years, as healthcare has changed, physical therapy has taken an increased role in assisting with geriatric disposition issues that present to the ED,” Flint adds. “A knowledge of services available in the community and levels of care ... has become vital to assisting case management with discharge needs.”
Flint cautions that some newer physical therapy graduates might experience difficulty with the pace and differential diagnosis aspect of working in the ED. “A strong physical therapy candidate should show a high degree of flexibility and ability to triage their daily caseload,” he says. “There is not a set schedule. [Physical therapists] will frequently be called upon to juggle several patients or issues at once.”
Administrators from other hospitals and EDs often visit IU Health Methodist Hospital to review the ED-based physical therapy program with an eye toward possibly starting a similar program in their own facilities. Frequently, their number one concern is reimbursement, Flint notes.
“Through the years, we have done reimbursement audits to ensure that having physical therapy in the ED is viable,” he says. “Reimbursement tends to follow outpatient physical therapy guidelines and requirements, and is separate from the ED reimbursement structure.”
Hospital decision-makers should not just look at the costs associated with maintaining a program, but also the potential cost savings, Flint stresses.
“A physical therapy consult can appear to be utilizing an additional resource, but many times we find that we can avoid an unnecessary admission and assist in appropriate referrals,” he explains. “Physical therapy consults done in the EMTC can often facilitate and expedite the outpatient physical therapy revenue stream.”
To sustain a program properly, it is important for physical therapists and the ED medical staff to develop relationships, Flint says.
“Staff [members] need to trust in the physical therapist’s expertise. Once this occurs, volume can increase exponentially,” he offers. “Physicians and nursing leadership can be [a physical therapist’s] best advocates once [he or she] demonstrates expertise and patient-centered care.”
While an ED-based physical therapy program can be viable in many different types of facilities, it is important to scale the program appropriately.
“Our ED sees nearly 100,000 patient visits per year and sustains 2.5 fulltime physical therapists, providing seven-days-per-week coverage,” Flint says. “Smaller EDs would not adopt this staffing model, but one with 25,000 to 30,000 annual visits could have a successful part-time program.”
Michael Lebec, PT, PhD, a professor in the department of physical therapy and athletic training at Northern Arizona University, has completed numerous research papers on ED-based physical therapy programs and often consults with hospitals that are interested in starting a program.
“I am in contact with a lot of people who do this, and I keep track of who is doing this and to what extent,” he explains. “I would estimate that there are well over 100 [ED-based physical therapy] programs across the U.S. that are doing this in some format.”
Whether a program is successful boils down to the mindset of the providers who work in that setting, and whether hospital administrators are open-minded about the concept, Lebec says. “There are sufficient numbers to pay for the cost of the program as well as generate revenue if you capture sufficient referrals,” he explains. “It’s like anything else, though. It is going to take a little while for providers to wrap their brains around this and to trust the physical therapists.”
Lebec advises hospitals interested in starting such a program to identify both an emergency physician champion and physical therapy champion to lead the effort, and give it some time.
“Don’t expect big numbers in the first few months of the program. Try to forge relationships between the physical therapists and the providers. Make a concerted effort to educate providers on the types of services and patients that physical therapists can help to manage,” he says. “If that is done up front, then you can have much more success.”
Financial Disclosure: Physician Editor Robert Bitterman, MD, JD, FACEP, Nurse Planner Nicole Huff, MBA, MSN, RN, CEN, Author Dorothy
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