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Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
PHYSICAL THERAPY IN THE
EMERGENCY DEPARTMENT: HOW TO
START AND SUSTAIN A SUCCESSFUL
EMERGENCY CARE PT SERVICE
11/25/2013
St. Mary’s Hospital
 Part of SSM Healthcare based in St. Louis
 320 beds
COMBINED SECTIONS MEETING 2014
F E B R U A R Y 3 RD- 6 TH, 2 0 1 4 – L A S V E G A S , N E V A D A
 Medicare Accountable Care Organization (ACO)
partnered with Dean Clinics
 EHR – Epic
T U E S D A Y , F E B R U A R Y 4 TH, 2 0 1 4
8:00 AM – 10:00 AM
 Physicians contracted through Dean Clinics (except
for ED physicians)
SARAH NECHVATAL, PT, DPT
ST. MARY’S HOSPITAL – MADISON, WISCONSIN
Course Description
1.
2.
3.
4.
5.
6.
Describe the development of the PT consultation
service in the St. Mary’s Hospital ED.
Review the process and outcome measures of the pilot
year of the St. Mary’s Hospital PT ED project.
Provide evidence of value of PT in the ED.
Review which diagnoses and populations are
commonly seen in the ED.
Suggest what tools and skills are needed to be an ED
PT.
Offer suggestions on how to start your own PT
consultation service in your ED.
Course Objectives
Upon completion of this course, participants will be
able to:
1. Explain how PT can add value to an ED.
2. Collect data before and after implementation of PT
in the ED to justify the value of the service.
3. Establish a successful ED PT consultation service.
4. Sustain a successful ED PT consultation service.
Property of Sarah Nechvatal, not to be
copied without permission.
St. Mary’s Hospital Emergency Services
 Average “door to doc” time is 14 minutes
 Bedside registration
 Hospital Campus Emergency Department
Level III trauma center
29 beds
 Unit based medical imaging


 St. Mary’s Sun Prairie Emergency Center
Level IV trauma center
10 beds
 Laboratory, radiology and helicopter transport


 Staffed by Madison Emergency Physicians
St. Mary’s Hospital Physical Therapy
 12-13 PT/PTAs on each day (6 Saturday/5 Sunday)
 Hours of PT availability 8:30-4:00
 Patients are scheduled in EPIC by Administrative Assistant
 Monthly caseload rotations
 Pulmonary
 Neuro
 Cardiac
 Medsurg
 Oncology
 Ortho
 Float
1
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
11/25/2013
ED PT Care Pathway
1.
ED PT on Float caseload – evals only
2. ED staff identifies appropriate patient
3. Enters PT referral in EPIC and calls Float cell
4.
5.
6.
7.
phone to give info
PT calls administrative assistant to reschedule
next patient on float load
PT arrives within 20 minutes
PT eval and treat <60 minutes
Coordinate with RN, Physician/PA, Care
Management for D/C planning
PT Diagnoses
 Back pain (acute or chronic)
 Limb pain
 Non-surgical fractures
 Non-cardiac chest pain
 Falls
 Gait instability
 Failure to thrive
 Vertigo/vestibular dysfunction
Care Management
A typical ED visit
 Relationship between Care Management and PT is
vital
 Cyndi Benson-Lein, RN Case Manager
 Need for increased Care Management presence in
the ED
 Responsible for utilization management
Decreasing unnecessary admissions
 Finding medical necessity before inpatient admission

Who comes to the ED?
 True emergencies


Losing life
Losing limb(Wilsey et al, 2008)
 Perceived emergencies

~85% of ED patients have non-life threatening injuries(Padgett &

~11% of ED patients have chronic pain as their C/C (Cordell et al, 2002)
Patients with pain feel the need to have objective results to justify
their symptoms (Wilsey et al, 2008)
Brodsky,1992)





Frequent visitors
Re-admissions or re-visits
Use of ED as primary care
Convenience users
Property of Sarah Nechvatal, not to be
copied without permission.
Triage
MD assessment
Medications
Imaging (if necessary)
Hospital Admission
•Unable to mobilize
•Unable to manage symptoms
•OPO stay or potential conversion
to inpatient status
Discharge from ED
•Referral back to PCP
•Referral to outpatient PT with the
symptom as the diagnosis
What if we could…
 Decrease unnecessary admissions
 Decrease re-admissions or re-visits to the ED for
same diagnosis
 Better manage symptoms in the ED
 Improve patient satisfaction in the ED
 Decreased unnecessary outpatient PCP visits
 Decrease the length of time between ED visit and
outpatient PT visit
 Decrease time between ED visit and home health
services introduction
2
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
11/25/2013
Project Background
 Opportunity: To practice exceptional stewardship
by providing the appropriate level of care for our
patients in the ED
1.
2.
3.
Return visits to the Emergency Department (ED) for unresolved
symptoms
Extended observation stays
Inappropriate admissions to hospital
Implementation Steps
1.
Update the rehab director
2. Discuss with PT colleagues
3. Identify lead PT and a few substitutes
4. Create steering team of stakeholders
1.
2.
3.
4.
 Identifies opportunities for Physical Therapy (PT) and Case
5.
Management (CM) in the ED
6.
7.
Sarah Nechvatal, PT
Cyndi Benson-Lein, Lead RN Case Manager
Nancy Rung, Rehab Director
Theresa Ojala, ED Director
Anthony Callisto, MD – Medical Director of ED
Sheryl Krause, RN, Emergency Medicine CNS
Deb Dees, ED RN
Implementation Steps
5.
6.
Developed care pathway
Presentation to the ED physician group
-
7.
Presentation to the ED Nursing staff
-
8.
Prepared by:
9.
Cyndi Benson-Lein, RN Case Manager
Sarah Nechvatal, DPT, Physical Therapist
Decrease number of observation patients within
our selected population by 10% over 6 months.
Pathway
Narcotics education
Presentations to Rehab and Care Management
Meeting with community resources
-
Area outpatient PT clinics and clinic directors
Home health agency schedulers
10. Go Live! on November 1, 2010
Goals
1.
Pathway
Narcotics education
ED PT Care Pathway
1.
ED PT on Float caseload – evals only
2. ED staff identifies appropriate patient
3. Enters PT referral in EPIC and calls Float cell
2. Decrease observation length of stay within our
selected population by an average of 12 hours over
6 months.
3. Decrease return visits to the ED within 5 days for
same complaint by 10% over 6 months.
Property of Sarah Nechvatal, not to be
copied without permission.
phone to give info
4. PT calls administrative assistant to reschedule
next patient on float load
5. PT arrives within 20 minutes
6. PT eval and treat <60 minutes
7.
Coordinate with RN, Physician/PA, Care
Management for D/C planning
3
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
11/25/2013
Implementation Steps
5.
6.
Number of Emergency Department Referrals
During the First Year
Developed care pathway
Presentation to the ED physician group
25
Pathway
Narcotics education
-
7.
Process Measures
Presentation to the ED Nursing staff
-
0
10. Go Live! on November 1, 2010
7
Nov
Dec
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
Number of Observation Patients within our Selected
Patient Population that were admitted through the ED
70
7
63
60
6
58
ED Referrals
3
47
45
43
40
4
57
52
51
50
5
42
49
49
49
42
51
41
37
36
35
51
44
43
41
Previous Year
31
30
Pilot Year
26
2
20
1
10
0
16
Outcome Measures
Number of Emergency Department Referrals
During the First Year
7
18
17
16
7
Process Measures
8
16
15
5
Area outpatient PT clinics and clinic directors
Home health agency schedulers
-
21
19
ED Referrals
10
Presentations to Rehab and Care Management
9. Meeting with community resources
8.
-
20
15
Pathway
Narcotics education
-
20
20
Nov
Dec
Jan
Feb
March
April
May
June
July
Aug
Sept
Oct
0
Outcome Measures
Changes After 1st Month
 Dr. Bell – new consultation service
Be present.
 Be seen.
 Get in with the nurses.
Average Observation Length of Stay within our Selected
Patient Population in Days

 Documented in the ED during down time
Trimmed mean= 1.22
Dizziness
1.78
1.23
 Introduced myself to everyone I didn’t recognize
 Talked with the nursing staff
Limb Pain
Trimmed mean for Pilot
1.34
 Made reminder signs for the walls @ each ED phone
Pilot Year
1.53
Previous Year
 Invited nursing staff into my sessions
 Empowering the hospitalists
Back Pain
1.42
1.51
 Making believers…one at a time (Hold the Bucket)
0.00
Property of Sarah Nechvatal, not to be
copied without permission.
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
2.00
4
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
11/25/2013
A Review Lesson on Averages
Outcome Measures
 3 + 4 + 4 + 26 + 24 + 30 = 91
91÷6
PT Qualifying Patients Who Return to the ED within 5 days and ED
Patients who are Admitted within 5 days of ED Visit with Same Complaint
12
= 15.17 hours
10
10
9
Axis Title
8
7
7
6
7
7
6
Previous Year
5
Pilot Year
4
3
2
4
4
3
3
3
2
2
1
1
1
1
1
1
0
0
A Review Lesson on Averages
 3 + 4 + 4 + 26 + 24 + 30 = 91
91÷6
= 15.17 hours
Process Measures
Number of PT Referrals Throughout the Day
35
32
30
25
 3 + 4 + 4 + 26 + 24 + 30 = 80
80÷3
= 26.67 hours
23
20
15
29
28
17
23
18
PT Referrals
14
10
5
0
8:00
Outcome Measures
9:00
10:00 11:00 12:00 13:00 14:00 15:00
ED Volume per Hour of Day
Average Observation Length of Stay within our Selected
Patient Population in Days
Trimmed mean= 1.22
Dizziness
1.78
1.23
Limb Pain
Trimmed mean for Pilot
1.34
Pilot Year
1.53
Back Pain
Previous Year
1.42
1.51
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
1.80
Property of Sarah Nechvatal, not to be
copied without permission.
2.00
5
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
11/25/2013
Process Measures
ED Volume per Day of Week
Discharge Disposition from ED after PT
6.50% 3%
0.50%
11%
Home
Inpatient
Observation
SNF
ALF
79%
Process Measures
Process Measures
 Call to Contact Time
 Expectation: 20 minutes
 Expectation achieved: 80%
 Average: 16 minutes and 36 seconds
Home Services after Discharge Home from ED
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
 Treatment Time
 Expectation: ≤ 60 minutes
 Expectation achieved: 89%
 Average: 45 minutes and 12 seconds
43%
28%
24%
18%
Percentage of Services
Process Measures
Process Measures
Chief Complaint
13
Payor
4%
9
74
40
Back Pain
Limb Pain
Falls/Gait Instability
Vertigo/Dizziness
Misc
52
Property of Sarah Nechvatal, not to be
copied without permission.
3% 3%
11%
49%
14%
16%
Medicare
Dean
Self Pay
Medicaid/BadgerCare
WPS
Worker's Comp
Other insurance
6
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
11/25/2013
Lessons Learned
1. Make SMART goals after collecting data.

Specific, Measurable, Attainable, Realistic and Timely
2. Data collection always takes longer than expected.
3. Educate the hospitalist group before
implementation.
4. Do a full year for the pilot.
5. Conduct a study group for PTs to review vestibular
and musculoskeletal exam and treatment so that more
PTs feel comfortable in that role
Tracking Return Visits
 Same ICD-9 codes
 Runs a Re-Admission report (within 5 days)


Return visits: ED visit, D/C from ED, return to ED
Admitted within 5 days: ED visit, D/C from ED, then is admitted
to hospital (through ED or direct admit from outpatient)
 Chart Audits to see who could have benefitted from
PT during the first visit to prevent second visit
 Include ICD-9 codes in both primary and secondary
diagnoses
Back pain – primary diagnosis both visits
Fall with leg pain, return with gait instability – primary, secondary
 Fracture then readmitted for surgery 3 days later


Collecting Outcome Measures
 Connect with your ED data analyst (a.k.a. CQI,
information systems)
 Data analysts track re-admits or re-visits
 Trendstar (billing tool) and HDM are commonly
used programs


We now use Epic instead of HDM
Trendstar has a 1-2 month lag
 Connect with medical record ICD-9 coders to
identify ICD-9 codes
Observation Patients: Number & LOS
 Observation charge code (instead of inpatient)
 Actual vs Billed time
Actual
time is the whole time they are
observation
Billed time deducts procedures and
consultations
 Only included patients who were observation the
whole time
Property of Sarah Nechvatal, not to be
copied without permission.
Why Didn’t We…
 Track for the post-pilot year?


Too time consuming to do chart audits
Other variables were introduced that could affect these outcomes
 Audit charts of patient who returned within 30 days?


Too time consuming to do chart audits for that many patients
Would PT intervention one day prevent a return visit to the ED 3
weeks later? Probably not.
 Track patient satisfaction?
We didn’t think we could do a before and after since the current
practice is randomly survey patients with random diagnoses
 St. Joseph’s Carondelet tracked – 80% of patients were satisfied
with the PT service. (Woods, 2000)

7
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
Skills and Character Traits Needed
 Musculoskeletal exam
 Enthusiastic
 Manual therapy
 Confident
Joint mobs
 Soft tissue work

 Modalities
 Vestibular assessment
 G Code expertise 
 Ability to communicate
the proper series of events
for a musculoskeletal
condition
 Active learner
 Flexible
 Time management
 Lead PT
 Persistent
 Good salesperson
 Diplomatic
Resources Needed
 High-low table (ED beds)
 US/E-stim machine
 Access to ice and heat modalities
 Massage cream
 Exercise library and patient education handouts (ie.
Exercise Pro)
 Gait belts
 Access to stairs/curb step
 DME: crutches, 2ww, youth 2ww, 4ww with seat,
standard walker, platform attachments for walker and
crutches, straight cane, quad cane, manual w/c
What does the future hold?
11/25/2013
Value of PT in the ED
 PTs are less likely to miss significant knee injury and can
deliver the diagnostic service more cost effectively than
“senior house officers”(Jibuike et al, 2003)
 Patients with acute LBP, with or without referred leg
pain, had statistically significant reduction in pain and
increased satisfaction with PT intervention when
compared to control group who received walking training
and walking aids only(Lau et al, 2008)
 Extended scope physiotherapists (ESP) achieve higher
patient satisfaction with assessment/treatment of
peripheral soft tissue injuries and associated fractures
compared to physicians and emergency nurse
practitioners (McClellan et al, 2006)
Value of PT in the ED
 ED physicians perceive PT has value due to increasing the
scope of their management options for musculoskeletal
pain (an alternative for narcotic use), vestibular
impairments and evaluating mobility of potentially unsafe
patients. Physicians perceive that PTs have reduced their
workload (Lebec et al, 2010)
 Barnes-Jewish Hospital in St. Louis surveyed ED personnel
who report satisfaction with the PT’s management of
musculoskeletal pain, contribution to differential diagnosis,
and discharge recommendations (Fleming-McDonnell et al, 2010)
Less Money Lost in the ED?
 Keep the conversation going with stakeholders
 Traditional ED care with physician assessment, tests,
 Direct Access
medications, nursing staff is billed as thousands of
dollars
 The reimbursement does not cover the actual cost
and therefore the ED is a “money loser”
 PT practices relatively independently – cost is mostly
just PT wages and supplies used during
treatment(Lebec & Jogodka, 2009)
EMTALA (Emergency Medical Treatment and Labor Act)
 The right care, the right place (sort of), at the right time
 “Potential to prevent chronic progression and its high associated
costs” (Lebec & Jogodka, 2009)

 Proving value of PT in the ED
Cost effective care
Increased patient satisfaction
 Improved clinical outcomes


Property of Sarah Nechvatal, not to be
copied without permission.
8
Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
Where to Start?
Identify lead PT, lead Case Manager and a few substitutes
Identify stakeholders and start the conversation
3. Identify what is important to that individual role (ie.
Administrator)
11/25/2013
References
1.
 Lebec MT, et al. Emergency department physical therapist
2.
service: A pilot study examining physician perceptions. The
Internet Journal of Allied Health Sciences and Practice.
2010;8(1):1-12.
 Lebec MT, Jogodka CE. The physical therapist as a
musculoskeletal specialist in the emergency department.
Journal of Orthopaedic & Sports Physical Therapy.
2009;39(3):221-9.
 McClellan CM, Greenwood R, Benger JR. Effect of an extended
scope physiotherapy service on patient satisfaction and the
outcome of soft tissue injuries in an adult emergency
department. Emergency Medicine Journal. 2006;23:384-7.
How will this help the system?
How will this affect FTEs?
 Will this prevent readmissions?
 Will this increase our outpatient PT referrals? (Is there
opportunity for downstream revenue?)
 How will this affect staff satisfaction?
 How will this affect patient satisfaction?


4.
5.
Meet with data analyst and collect data on what’s important
Create goals
Where to Start?
6.
7.
8.
9.
10.
11.
Create your steering team
 Lead PT, Case Manager (Social Worker or RN Case Manager), ED
RN, ED physician, ED nursing director, & Rehab Director
Create care pathway
Educate stakeholder groups (pathway & what is important to them)
 ED physicians
 ED nursing
 Hospitalists/Internal Medicine
 Rehab department
 Care Management department
 Community Resources (home health, outpatient clinics, etc)
 Administration
Gather equipment and resources
1 year for pilot period
Keep the conversation going with regular meetings/updates with
stakeholders and ask for their feedback
References
 Cordell WH, Keene KK, Giles BK, et al. The high prevalence of pain in
emergency medical care. American Journal of Emergency Medicine.
2002;20(3):165-9.
 Fleming-McDonnell D, et al. Physical therapy in the emergency
department: development of a novel practice venue. Physical Therapy.
2010;90(3):420-6.
 Jibuike OO, Paul-Taylor G, Maulvi S, et al. Management of soft tissue
knee injuries in an accident and emergency department: the effect of
the introduction of a physiotherapy practitioner. Emergency Medicine
Journal. 2003;20:37-9.
 Lau PM, Chow DH, Pope MH. Early physiotherapy intervention in an
Accident and Emergency department reduces pain and improves
satisfaction for patients with acute low back pain: a randomised trial.
Australian Journal of Physiotherapy. 2008;54:243-9.
Property of Sarah Nechvatal, not to be
copied without permission.
References
 Padgett DK, Brodsky B. Psychosocial factors influencing non-
urgent use of the emergency room: a review of the literature and
recommendations for research and improved service delivery.
Social Science Medicine. 1992;35(9):1189-97.
 Wilsey BL, Fishman SM, Ogden C, et al. Chronic pain
management in the emergency department: a survey of attitudes
and beliefs. Pain Medicine. 2008;9:1073-80.
 Woods EN. The emergency department: a new opportunity for
physical therapy. PT: Magazine of Physical Therapy.
2000;8(9):42-8.
Questions?
[email protected]
9