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jma -> Re: physcial therapy vs chiropractic vs nursing (March 11, 2005 3:37:00 AM)
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Here's an article involving PT's in the ER. Very interesting person to address specific questions to.
"Vol. 12 •Issue 18 • Page 11
* PT on the Front Line
Spend a night with PTs in the emergency room
By Jonathan Bassett
Reggie woke up early one morning and reached for his glasses, just as he had done hundreds of times before. This time, though, a sharp pain knifed through the 65-year-old's wrist, and Reggie was stumped. He had no history of wrist pain, and had played no sports over the last few days that may have aggravated the area.
The pain was severe enough to compel Reggie to his local emergency room, at Carondelet St. Joseph's Hospital in Tucson, AZ. A triage nurse assessed Reggie's situation and transferred him to the attending ER physician, who suspected some type of orthopedic injury and ordered X-rays.
A typical ending to Reggie's story would likely have been that he was placed in a splint, told to make an appointment with his family doctor, and sent home. This may have meant a week or more in pain while waiting for an appointment. But Reggie was fortunate in that Carondelet St. Joseph's has two full-time physical therapists on staff in the ER.
"I saw that his X-rays weren't consistent with any type of musculoskeletal wrist injury," said Jon Davison, PT, staff ER therapist at Carondelet St. Joseph's. "I performed a more extensive evaluation of the wrist, and began evaluating other areas. We detected a lot of tenderness and pain in the cervical area that he hadn't noticed before."
Davison suspected an ulnar nerve irritation, perhaps nerve root compression at the C7-T1 vertebra that might have gone unnoticed otherwise. "I performed some manual treatment of the neck to reduce pain there a bit, and his pain decreased in the wrist soon after," Davison recalled.
Such stories are not unusual to physical therapists working in the ER, but they explain why urgent care and ER physicians fortunate enough to have PTs working alongside them have come to depend upon their expertise. "The ER physicians tell us time and again that they'd be very unhappy if we were taken away," Davison said.
Birth of a Program
Davison and partner Mike Anderes, PT, were therapists at Carondelet St. Joseph's three years ago when inspiration struck. Why not offer PT services in the busy emergency room and urgent care clinics, which were overflowing with patients complaining of conditions that could be served just as well or better by PTs? What followed was the action of cooperative superiors who, along with the hard work and unwavering determination of the two PTs, eventually made their dream a reality.
It started when Anderes, who happened to be treating the mother of an ER physician, approached him with the idea. Anderes was surprised to find out that this physician had already identified such a need, and had actually been pulling PTs out of the outpatient department to help with patient load once or twice a month for years.
"He referred me to the president of the physician group, who happened to have a background in occupational medicine and was very receptive to the idea," Anderes said. All parties agreed to try out a pager system, in which Anderes and another PT would remain inpatient staffers on the acute care floors, but would float down to the ER if a call came in.
The pager system didn't last long. "They began to rely on our orthopedic diagnostic skills fairly quickly, and our opinions on follow-up care," Anderes said. "Because our hospital had a heavy capitation rate at the time, we were called upon to find the appropriate level of care for each patient, instead of just funneling them into the hospital."
Many aches, pains, injuries and critical events occur after hospital hours; this places an even greater strain on staff which is already stretched thin by non-critical patients coming to the ER for primary care because they don't want to wait weeks for a doctor's appointment. And because Carondelet's urgent care unit is only open from 8 a.m. until 11 p.m., all patients coming to the hospital outside of these hourscritical or notwill be diverted into the ER by default. It soon became clear to both ER staff and the PTs at Carondelet that there was an obvious need for full-time, dedicated physical therapists in the emergency room, and an idea was born.
"We're now bridging the gap between injury and a patient's primary care physician," Davison said, adding that handling less severe cases frees up the ER physicians to concentrate on more traumatic and life-threatening ones. "From a PT standpoint, we're dealing with the problem right away, instead of forcing the person to wait for weeks to see a doctor, waiting for a referral, then dealing with what might be an aggravated condition plus secondary sequella because we waited too long."
What Do They Do?
Every patient who enters Carondelet's emergency department is immediately evaluated by a triage nurse. The nurse makes the determination whether the patient requires admission to the ER (life-threatening situations) or the urgent care department (less critical cases). Attending physicians in both environments decide whether the patient requires extensive tests (as in the case of chest pain), immediate surgery or physical therapy.
Davison and Anderes spend most of their time in the urgent care unit, working with patients with musculoskeletal conditions such as low back pain, cervical pain, all types of injury to the ankle, knee, shoulder, elbow, wrist and hand, muscle pulls, strains, fractures and other injuries. In addition, patients with balance deficits, burns, wound care and even tension headaches make up the diverse and constantly growing list of conditions in the PTs' repertoire. "Not to mention anything else the physician would like another set of eyes and hands to evaluate and give a second opinion about," Anderes said.
Generally, a 15- to 20-minute evaluation is followed by some type of intervention, from modalities and manual treatment if pain is a problem, to education and a home exercise program if the problem is less severe. Total visit time hovers around an hour.
"We've established a comfort level and a rapport with physicians," Davison said. "Most of the time they'll look at a patient's history, talk to them for a little bit, and send them our way. We jump right in, and if we find something suspicious or inconsistent, we send the person right back to the physician for more investigation."
Therapists in this area of practice thrive on the unexpected, and must be able to handle multiple patients at once while keeping a cool head. What begins as a slow morning could quickly explode into chaos as weekend warriors start pulling muscles or victims of a motor vehicle pileup are rushed in.
"This is an exciting area of therapy; it's fun, it's unpredictable, and I love it," said Heather Kuklinski, MA, PT, staff ER therapist at Midwest Regional Medical Center in Midwest City, OK. Kuklinski and partner Mandy Garrison, PT, inpatient PTs at the time, made up their minds to start a program from scratch last fall after reading about Anderes and Davison in PT Magazine and meeting with them at the APTA's Combined Sections Meeting 2001 in San Antonio.
Under the advisement of Anderes and Davison, Kuklinski and Garrison pulled ER patient logs and used them to demonstrate to administrators how many patients they could have treated, how the hospital would have been reimbursed for each, and which hours would be the most productive to have them on staff.
"Things moved quickly after that," Kuklinski remembered." The best thing about this experience was the wonderful support of our administration. By March 12 of this year, we were ready to go."
Optimal Marketing Tool
Kuklinski does admit that the early days in the ER were rocky.
"It became very clear to us that first day that nobody down here had any idea what physical therapists did," she remembered. "We didn't see a patient. They just didn't understand what place our interventions had in the ER, or why it was important for us to see them day one. We went home discouraged. And because we had already been replaced on the floor, this was basically our jobs on the line."
The two PTs diligently continued to educate physician and nurse groups on what they could offer. "Reaching the nurses was instrumental, because often they'll be the ones to make suggestions to the doctors, and many times they'll say 'let's let PT try this one.' Just when I started thinking that I should start sending out resumes, things began to pick up." Now, Kuklinski said, those doubting doctors are requesting that the PT program's hours be expanded.
In addition to the physical benefits associated with early PT, patients at Midwest who require a follow-up appointment with the outpatient division, wound clinic or other department receive a referral and appointment card on the spot. "We're able to skip a whole process," Kuklinski said.
All of this translates into a favorable experience from the patients' perspective, which is something every hospital tracks. More than 90 percent of patients surveyed at Carondelet St. Joseph's reported that they were "very satisfied" with their ER physical therapy experience. "This is very much a PR position," Anderes said. "And we're constantly hearing from higher-ups that our patient satisfaction rates are improving because we're here."
But perhaps the biggest beneficiary is the profession of PT as a whole.
"Mike and I each see more than 115 patients a month," Davison said. "That's 230 public contact opportunities to make an immediate and lasting impact on the health of a patient. As these individuals return home or transfer to various levels of care, they bring with them the positive memories of what PT did for them, and educate friends, family, doctors and other patients on what we can provide."
Words of Advice
For those adventurous PTs who may want to explore this career move or launch a program at their hospital, heed the guidance of those that have gone before you.
"Be prepared to prove that you'll be cost-effective," said Kuklinski, whowith the aid of Garrisontracks the progress of every patient they have treated as they move through the care process in order to determine whether the hospital has been reimbursed. "It's a huge project, and we've only completed the first couple of months so far, but we feel this is necessary to justify our being here."
Kuklinski also cautions PTs interested in this area of service that they will not be working office hours. "Just realize that this is not something you can do from 8 to 5, Monday through Friday, with holidays off," said Kuklinski, who (like Anderes and Davison) covers the whole week with Garrison by working two 12-hour shifts, two 8-hour shifts, and alternate weekends. "Also, rewards won't come from seeing long-term progress. For me, though, it's even more rewarding that I'm seeing injuries right after they happen, and I'm able to do something to stop pain and improve function immediately."
The nature of the business inevitably means some down time, and hospital administrators must remember to look at productivity rates as a larger average, since there are bound to be slow days. "For instance, today I might not have five patients. On another day, I might have 25," Kuklinski said.
"You have to find ways to keep yourself productive during these slow spells," Anderes advised. He and Davison will perform literature reviews, work on program development, and oversee the clinical rotations of two or three students a year who are interested in urgent care PT.
Davison and Anderes are also compiling data that they believe will prove that ER patients receiving immediate physical therapy intervention require fewer hospital visits and days off from work, and they plan to present these findings at future conferences. For now, though, they are pleased that hospital administrators are reporting higher patient satisfaction rates, lower patient pain scales, and 100 percent positive feedback from ER and urgent care physicians.
"The biggest complaint in hospital emergency rooms around the country right now is waiting time," Anderes said. "Sometimes we can cut down on that time, sometimes not. But we like to think that we're providing people a higher level of care during the time that they're here. And the results we've had so far confirm that." n
Mike Anderes and Jon Davison established Anderes/Davison Consulting to help emergency room PT programs get started. Reach them at [URL=http://www.backmedic.com]www.backmedic.com[/URL]
Jonathan Bassett is on staff at ADVANCE, and can be reached at jbassett@merion.com
http://physical-therapy.advanceweb.com/common/editorialsearch/viewer.aspx?FN=01sep10_ptp11.html&AD=9/10/2001"
JMA
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