The president of the Nova Scotia Physiotherapy Association says physiotherapists could play a role in helping the province’s overwhelmed emergency departments but they’ve been overlooked.
“If our full, optimized scope of practice is used, we can unload a lot of the burden on the health care system. But we need to be used,” Monica MacDonald said in an interview.
“In the ER department specifically, we have the capacity to reduce patient wait times, length of stay, the intake of medication, and reduction of pain and disability. Outcomes and overall satisfaction are improved, and there’s less frequent follow up.”
In Québec, a study published in 2021 found that emergency department patients with musculoskeletal injuries/conditions were also less likely to be prescribed opioids, required fewer diagnostic imaging referrals, and were less likely to return to the emergency department for the same issue.
MacDonald said physiotherapists are trained to do “a really thorough job” of triaging patients with musculoskeletal issues and conditions. In both public and private practice, they routinely screen patients to determine whether they can treat them or if they need to be referred elsewhere.
“Say somebody comes in to the ER with an ankle sprain and they’re wondering, ‘Is this a possible fracture?’ Physiotherapists would be very capable of assessing that. Or somebody comes in with low back pain, or if somebody comes in with a mobility issue,” MacDonald said.
“Say they’ve had a fall and there needs to be follow up steps determined. Is this person safe to return home? What are the next steps for them? Those are just some of the possibilities. We would be able to provide education, discharge planning.”
‘Right person, right place, right time’
Physiotherapists working in emergency departments and their successful integration in five Québec hospitals (and counting) is routinely discussed at a national level by physiotherapy association members across the country. MacDonald said they’re trying to use the Québec experience as a model “to push things forward.”
“Some of it is people not knowing. They’ve been talking a lot within the government, within Nova Scotia Health, about right person, right place, right time,” MacDonald said.
“We are the right person for pain management and we are the right person for screening some of these more straightforward musculoskeletal cases…but people don’t necessarily think of coming to us immediately.”
‘Speed access to needed care’
In November the Ontario Physiotherapy Association published an online fact sheet highlighting how physiotherapists working to their full scope and competencies in emergency departments (and other areas) “increase capacity in the health care system and speed access to needed care.”
The document reads, in part:
One of the most common reasons people seek care in EDs is due to musculoskeletal (MSK) disorders or injuries. Due to their expertise in assessment and management of MSK conditions, physiotherapists in the ED can care for patients with soft tissue injuries, minor fractures, mobility and balance problems.
Physiotherapists have been successfully integrated into EDs in many countries, including the United Kingdom, Australia, Singapore, Denmark, and the United States.
MacDonald said the fact her association wasn’t invited to last week’s health care partners summit was a “missed opportunity.”
“Our college was invited, but the physiotherapy association is really who advocates on behalf of the profession and speaks to what is our role, what can we do, where can we expand,” MacDonald said.
“We want first and foremost for physiotherapists to be seen as a key member of the health care team, used to our full scope such as we’ve been seeing with pharmacists, with paramedics being used to their full and even expanded scope,. We would love for the province, Nova Scotia Health, to really use us to our full potential.”
In Nova Scotia, MacDonald said having physiotherapists working in emergency departments has been on the association’s radar since 2009.
Although physiotherapists have provided services to emergency departments in the province, she said their role has typically been more on a consult or on-call basis. In addition, they’re typically confined to doing mobility assessments.
The association wants to let policymakers and patients know that physiotherapists can and want to do more.
“This is something that we’ve been pushing for for a long time, physios in more of a proactive, preventative role,” she said.
“I think if we can get in at this triage level and be able to help from that perspective, that’s huge. We’ve seen it in Québec, so I think it would be great to be able to capitalize on it here as well.”
‘Huge weight off the system’
Although it varies across the country, MacDonald said in Nova Scotia triaging is already within a physiotherapist’s full and current scope.
One thing they’d like to see is more physiotherapists permitted to make diagnostic imaging referrals.
While the act governing the province’s physiotherapists doesn’t restrict them from placing requests for diagnostic imaging, MacDonald said only a few physiotherapists working in rural areas are currently able to make those referrals.
“Say I had somebody come in to see me at a private clinic in the HRM. I’m not able to send them for an X-ray. They would have to then see a physician to get that request before being able to book in for an X-ray currently,” MacDonald said.
“But we’re hoping that if Nova Scotia Health is able to fund that, we would love to be able to refer for that because we think that would be a huge weight off of the system as well.”
Improves emergency department turnover
Following the success of a 2018-19 pilot project in Québec City, the Centre hospitalier de l’Université Laval (CHUL) began offering permanent physiotherapy services in its emergency department as of Oct. 6, 2020.
The initial 2018-19 pilot project saw physiotherapists installed at CHUL’s emergency department to deal with patients presenting with musculoskeletal problems. Those issues accounted for 18% to 25% of all emergency department visits.
In that study, half the group presenting to the emergency department went directly to a physiotherapist, while the other half followed the usual procedure and saw an emergency department physician.
In the physiotherapy group, just 38% of patients needed diagnostic imaging compared to 78% in the control group. The physio groups were also seen on average three hours sooner.
In the first month following the initial visit, there were fewer return visits to the emergency department for the same complaint (0% in the physiotherapy group versus 21% for the control group) fewer opioids were prescribed (13% versus 34%), and far fewer prescription drugs (32% versus 72%).
Today 31 physiotherapists are working at all five of CHU de Québec’s emergency departments, and interest continues to grow.
In the 2021 report, a CHUL emergency department physician said the following (translated from French):
“The presence of a physiotherapist favours the intake of more patients and improves emergency department turnover, particularly in the morning when many patients who arrived during the night must be discharged.”
‘For us, it’s just obvious’
The president of Québec’s physiotherapy association (Association québécoise de la Physiothérapie/AQP) said interest is growing “every month” as more hospitals in that province reach out about the integration of physiotherapists for lower priority patients in their own emergency departments.
“Less imaging, less medication, less redirection to a specialist, and more and more (benefits),” Simon Dalle-Vedove said in an interview.
“This is what opened the eyes of some managers, and they’re like ‘OK, maybe we should consider adding a physiotherapist.’”
As the AQP works to integrate physiotherapists into more emergency departments across that province, Dalle-Vedove said they’re also championing the cause across the country.
“I think since it’s not doctor related or not nurse related or not pharmacist related, it’s thinking outside the box a bit. But for us, it’s just obvious,” Dalle-Vedove said.
“We’re talking about the MSK [musculoskeletal] patients, the lower priorities for sure. We’re not going to have the open fracture in the ED. But those [simpler MSK] cases cost a lot to the government.”
A survey conducted among AQP members a couple of months ago found that of 250 responding physiotherapists from across the province, 95% indicated they were willing to take on emergency department roles.
Dalle-Vedove said they’re hoping for a provincial government call to action that would see physiotherapists in most, if not all, emergency departments.
“There is no mainstream or government recommendation, so it’s all local initiatives,” he said. “And we at the association are helping out as much as we can to make those initiatives a reality.”
‘Take action right now’
Dalle-Vedove said another pilot project is currently underway at several hospitals in Alberta, Ontario, and Québec. The goal is to establish the real costs of patients with musculoskeletal issues either presenting to emergency departments, or not going at all because they fear long wait times.
Those prolonged waits before getting proper care often leads to more problems.
“It’s astonishing how costly it is. To be injured and not having the care at the right time or the right professional just delays the healing process,” Dalle-Vedove said.
“It increases the risk of clinicizing the issue, of (people) being off work for a long time, of being away from all the activity the person is doing. So economically, it’s devastating.”
Dalle-Valdove said at this moment in time, “it’s really, really important” to have physiotherapists in emergency departments. And while studies are important, he said good data already exists and they hope governments act sooner rather than later.
“What we say to governments is, OK. It’s done in other countries and it’s working very well. It’s not like it’s a 50/50 chance. No, no, no. It’s working really well,” he said.
“We’re asking them to take action right now and not always wait on more and more and more studies…Sometimes we feel that they just want to delay things, asking for more information. Take action. We are asking government to take action. We have physiotherapists ready to integrate into those new roles.”
‘Build it and they will come’
The president of Québec’s licensing/regulatory body for physiotherapists and physiotherapy technologists said their integration in emergency departments ultimately pays for itself.
“Having patients seen at the prime time with a good professional with good recommendations and interventions…[means] they’re being made functional again with shorter delays,” Manon Dufresne, president of the Ordre professionnel de la physiothérapie du Québec (OPPQ) said in an interview.
“That’s what’s aimed at within our processes.”
Beyond that, Dufresne said it’s a measure that requires little effort beyond orienting physiotherapists in an emergency department and ensuring they’re comfortable working in that setting.
“These are professionals that are competent and trained already…Things are there. It’s just like they say in that film. Build it and they will come,” Dufresne said.
“The thing here is that we don’t want it to orient people to emergency just to orient them to emergency. But if they have no other resources, we know that they are going to be ending up there.”
‘Something we have to grab’
Dufresne explained that patients presenting themselves at an emergency department with physiotherapists as part of the team will be identified at triage as having musculoskeletal problems.
If they’re deemed lower levels of urgency (typically that means a condition in need of professional care but not life-threatening), they’ll be seen by a physiotherapist.
“Acute injury, pain, decreased range of motion (impeding) the person from doing things. And back pain is always a major condition that we see a lot in the population,” Dufresne said, explaining what patients may be dealing with when meeting with a physiotherapist at an emergency department.
What’s key, she said, is that patients are benefitting in both the short and long term, and their needs are being met as a result of these measures.
Dufresne said other initiatives where physiotherapists could benefit the health care system outside of an emergency department context are also being explored.
“The situation in Québec, and probably elsewhere in Canada, is a lot more mature now than it has been in past years considering what we’re talking about here,” Dufresne said.
“Did the pandemic have something to do with it? I think. But obviously there’s an awareness of what can be done and all of the potential that is there. That is something we have to grab.”