Sage Journals: Discover world-class research

Abstract

Emergency Departments (EDs) have faced mounting pressures in recent years as greater volumes of patients seek care, many with increasingly complex clinical and social needs. However, the potential contributions of rehabilitation professionals to help alleviate these pressures in the ED are not well understood or leveraged. To address this knowledge gap, the authors conducted a literature review of rehabilitation models of care and the impact of rehabilitation professionals in the ED, as well as an environmental scan to understand rehabilitation models of care across two large regions in Ontario. This article outlines these findings, as well as future opportunities related to leading care and patient flow practices based on rehabilitation models in the ED.

Introduction

Emergency Departments (EDs) across Ontario are facing unprecedented pressures.¹ Multiple factors have contributed to the current ED crisis; prior to the COVID-19 pandemic, Ontario EDs were already under pressure due to an increase in older patients seeking care, many of whom have increasingly complex medical needs.² Reduced health human resources in the hospital and community sectors have also contributed to an exacerbation of patient flow challenges out of hospitals and intensified pressures in the ED. Although unique diversion practices have been implemented in some EDs, the evaluation and spread of these diversion strategies are in the early stages.¹ From a patient care perspective, ED overcrowding leads to delayed treatment,^3,4 poor patient outcomes,³ increased mortality,³ increased inpatient Length of Stay (LOS),³ and increased exposure to error.³

Physiotherapists (PTs) working in the ED primarily assess the mobility and function of patients with musculoskeletal injuries and older adults with frailty. Intervention includes determining the most effective plan to facilitate safe discharge home and recommending and/or educating the patient on the use of mobility aids, if needed.⁵ Occupational Therapists (OTs) in the ED assess patients’ cognitive abilities, functional mobility, and transfers and then recommend ideal discharge locations based on how patients are able to engage safely with activities they need to do at home.⁶

A recent Ontario Health operational guidance document recommended that acute care hospitals consider staffing EDs with rehabilitation professionals to avoid acute care admissions or mitigate functional decline in patients who are admitted, but for whom no bed is available on an inpatient unit.⁷ However, models of care that include rehabilitation professionals as staff who are dedicated to working in the ED have not been widely implemented. To identify potential opportunities that enhanced rehabilitation staffing in EDs could offer, the authors undertook a comprehensive literature review on this topic and conducted an environmental scan in the fall of 2023 to better understand current rehabilitation models of care across nineteen EDs.

Literature review on physiotherapy and occupational therapy in the emergency department

A comprehensive literature review focused on OT or PT in the ED was conducted with the assistance of a librarian based on review articles from 2012 and primary source articles from 2018. Due to a dearth of high-level evidence in the OT literature, the search for literature on OT in the ED was extended back to the year 2000. In addition, to establish a timeline of when research in this area of practice started and grew, the authors also captured the volume of OT or PT ED articles by decade.

The literature worldwide reflecting rehabilitative care in the ED started in the 1960s for PTs and in the 1990s for OTs. Based on a Medline search, PT literature specific to the ED setting worldwide since 1990 was almost ten times greater than OT literature for the same time period. In Canada, the peak growth in the volume of literature for both professions in the ED occurred over the last decade (2010-2019).

The body of literature focusing on the impact of OT or PT in the ED falls into three main categories:

1. Physiotherapists taking on an enhanced role in the ED for musculoskeletal conditions.

2. Occupational therapists and/or physiotherapists providing comprehensive geriatric assessments as part of an interprofessional team.

3. Occupational therapists and physiotherapists, evaluated as discrete professions, working within their scope of practice.

Enhanced physiotherapist role in the emergency department

Different terminologies were observed in the literature describing the roles of physiotherapists in the ED, including “advanced practice,” “extended scope,” “primary contact,” “first contact,” and “direct access.” In these models, PTs do not require a referral from a physician to assess patients; they have a higher level of responsibility and engage in activities for which training comes from outside of traditional PT practice (e.g., diagnostic imaging and pharmacology).^8,9 The use of these various models and terminologies is based on jurisdictional differences in the scope of practice for PTs. For the purposes of this article, these models will be described as enhanced PT roles. These enhanced models of care for PTs in the ED were not found in the OT literature. However, it should be noted that in Alberta, OTs may perform restricted activities such as setting or resetting a fracture for the purpose of splinting, applying fracture braces and performing cranioplasty, reducing dislocation of a joint, and administering diagnostic imaging contrast agents.¹⁰

The body of literature focused on the enhanced PT role in the ED has flourished in the United Kingdom and Australia. In these countries, the enhanced role is specific to the assessment and treatment of patients with low urgency musculoskeletal conditions with no fractures, such as low back pain and neck pain. In Canada, a consistent team of researchers in the province of Quebec has also been conducting research in this area.^8,11–15 This body of literature has produced strong levels of evidence supporting the positive contribution of the enhanced PT role to the healthcare system. A few recent high-level evidence publications on the impact of the enhanced PT role are listed in Table 1. Here are some highlights:

- The literature indicates that enhanced PT roles in the ED have had a positive impact on:

• Patient flow: shorter wait times in ED,^16-20 shorter LOS in ED,^17-20 and fewer hospital admissions.¹⁹

• Patient care: improved access to care,^16,21 improved quality of care,²¹ no adverse events or patient complaints,¹⁷ returned less often to ED,¹³ received more timely analgesia,¹⁸ lower levels of pain,¹³ and used fewer prescription medications.¹³

• Provider experience: reduced workload of other clinicians.¹⁶

- Matifat and colleagues¹⁵ established that there was very good diagnostic agreement between a team of advanced practice PTs and a group of emergency physicians. In addition, moderate agreement was found in advanced practice PT discharge planning practices as compared to ED physicians.¹⁵

- Based on three review studies, the cost analysis outcomes of advanced practice PT roles are currently inconclusive due to methodological heterogeneity.^14,16,22 However, there are two studies currently underway in Canada focused on this topic: one in Quebec and a multi-centre study across three provinces: Quebec, Ontario, and Alberta.^11,12

Table 1.

Literature review summary.

Source	Type of literature	Country of origin	Outcome measure(s)	Conclusion
Enhanced physiotherapist role in the emergency department
Williams et al.,¹⁶ 2019	Narrative review	New Zealand	- Economic evaluation of Advanced Practice Physiotherapist (APP PT) role	Based on the 8 studies reviewing the APP PT role in the ED, this review found the role reduced wait times, improved access to care, and reduced other clinicians’ workload for less serious musculoskeletal conditions. The review also concluded similar patient functional outcomes were achieved when managed by APP PTs as compared to other medical/health professionals in the ED. However, economic evaluations of the APP role in the ED had inconsistent results
			- Wait times in Emergency Department (ED)
			- Access to care
			- Workload of other clinicians
			- Patient functional outcomes
Souter et al.,¹⁷ 2022	Systematic review and meta-analysis	Australia	- Wait time	Based on the 11 studies reviewed, consistent positive results were found regarding extended scope physiotherapist’s clinical effectiveness and safety with the meta-analyses demonstrating significant reductions in wait time and LOS. The results highlighted that extended scope PTs, as additional staff members in the EDs, improved throughput and access to care for patients in lower urgency triage conditions
			- LOS in the ED
			- Patient safety (i.e., reported adverse events, complaints, and missed diagnosis)
Alkhouri et al.,¹⁸ 2020	Prospective, mixed method observations study	Australia	- Wait time	Patients seen by the primary contact physiotherapist (PCP) were associated with a significant reduction in ED LOS by 108 minutes, wait time to treatment by 10 minutes (n = 4 EDs) and time-to-first analgesia by 18 minutes (n = 19 EDs) as compared to those seen through usual care processes. Patients who received care by a physician first followed by a PT (secondary contact model) had a prolonged LOS as compared to other care pathways. High levels of satisfaction with the PCP role were expressed by the ED staff (n = 17 EDs) and patients (n = 19 EDs)
			- LOS in the ED
			- Time to analgesia
			- Patient and staff satisfaction
Sayer et al.,¹⁹ 2019	Retrospective study	Australia	- Wait time	Patients with low back pain seen by the advanced musculoskeletal PT from 3 EDs (n = 360) had significantly shorter ED wait time, shorter ED LOS and fewer admissions as compared to same patient group seen by other clinicians (e.g., physicians or nurse practitioners) (n = 729)
			- LOS in the ED
			- Number of admissions
Kinsella et al.,²⁰ 2019	Observational, comparative, multi-centre study	Australia	- Wait time	A subgroup of patients with musculoskeletal conditions aged 65 or less in the semi-urgent category managed by an advanced musculoskeletal PT (n = 825) from 2 hospitals were found to have a lower wait time and were discharged home more quickly as compared to a matched group of patients seen by other ED staff
Kinsella et al.,²⁰ 2019	Observational, comparative, multi-centre study	Australia	- LOS in the ED
Demont et al.,²¹ 2020	Narrative review	France	- Access to care	Based on a review of 20 studies, the authors concluded that different models incorporating direct access to physiotherapy in the ED provided better outcomes in terms of quality and access to care while maintaining a similar degree of safety. However, the methodology of the studies was of heterogeneous quality. It was also noted that these new models integrating direct access to PT in the ED were not designed to replace the physician and encouraged collaboration between different health professionals
Demont et al.,²¹ 2020	Narrative review	France	- Quality of care
Gagnon et al.,¹³ 2021	Randomized control trial	Canada	- Levels of pain	Patients presenting with a minor musculoskeletal disorder to the ED with direct access to a PT (n = 78) had better clinical outcomes (i.e., lower levels of pain and pain interference at 1 and 3 months following ED visit), returned significantly less often to the ED after 1 month and used less prescription medication both during the ED visit and 1 month following than those in the usual care group. However, the small sample size was identified as a study limitation
			- ED return visit
			- Use of pain medication
Matifat et al.,¹⁵ 2019	Research study	Canada	- Concordance between APP PT and MD	The study found very good diagnostic inter-rater agreement between APP PTs (n = 3) as compared to physicians (n = 37) for patients with musculoskeletal conditions in ED (n = 113). There was a moderate inter-rater agreement for discharge plans, with APP PTs referring significantly more patients to physiotherapy care. High patient satisfaction was reported with no significant differences between providers
Matifat et al.,¹⁵ 2019	Research study	Canada	- Patient satisfaction
Lafrance et al.,¹⁴ 2021	Systematic review and meta-analysis	Canada	- Economic evaluation of APP PT role	Based on a subgroup analysis of 2 ED randomized control trials, this study concluded that the cost of APP PT in the ED working with patients with musculoskeletal injury with no fracture was slightly more expensive than usual medical care. More evidence was needed to evaluate cost benefits of this role due to varying methodology factors that impact on cost analysis
Ferreira et al.,²² 2019	Scoping review	Australia	- Cost	Based on 4 randomized control trials included in 27 reviewed studies, the authors concluded that PTs in the ED managing patients with low urgency musculoskeletal conditions have similar clinical effectiveness and costs as compared to other health providers. However, a lack of robust studies investigating the efficiency and cost-effectiveness of this model of care was identified
Ferreira et al.,²² 2019	Scoping review	Australia	- Clinical effectiveness
Occupational therapists and/or physiotherapists as part of a geriatric interprofessional team in the emergency department
Keene et al.,²³ 2022	Case control study	USA	- LOS in hospital	This study found that patients (ages 65+) assessed by the geriatric medicine assessment team (n = 815) were more likely to be discharged directly from the ED (odds ratio of 2.06); if admitted, hospital LOS was reduced by over 24 hours for an estimated savings of $1.7 million per year. The team consisted of a geriatric emergency medicine-trained advance practice provider (either nurse practitioner or a physician assistant), geriatric care manager, pharmacist technician, and OT
			- Admission rate
			- 30-day ED revisit rate
O’Shaughnessy et al.,²⁴ 2019	Randomized control trial	Ireland	- LOS in the ED	This study analyzed the first 140 patient participants and found the intervention group had a significantly shorter LOS in the ED and lower admission rates after being seen by an interprofessional team [OT, PT, and Social Worker (SW)] in the ED, as compared to usual care
O’Shaughnessy et al.,²⁴ 2019	Randomized control trial	Ireland	- Admission rate
Cassarino et al.,²⁵ 2021	Randomized control trial	Ireland	- LOS in the ED and hospital	This single-site study found patients (ages 65+) in the intervention group (n = 176) experienced significantly shorter ED LOS, lower rates of hospital admission from the ED, higher levels of satisfaction with the ED stay, better function at 30-day and 6-month follow-up, and better mobility and self-care as compared to the control group (n = 177). The intervention group received early assessment and intervention by one or more dedicated health professionals (OT, PT, and SW) on the team. Prior to this study, the dedicated team did not exist and the control group received usual care from medical and nursing staff in the ED
			- Admission rate
			- Patient satisfaction
			- ED revisit
			- Unscheduled hospital admission
			- Mortality
			- Nursing home admission
			- Patient functional status and quality of life
Cassarino et al.,²⁶ 2019	Systematic review	Ireland	- LOS in hospital	Based on 6 studies reviewed, the authors examined the effectiveness of ED-based interprofessional teams providing services to adults aged >= 18 years. The interprofessional teams included two or more of the following: OT, PT, SW, pharmacist, and/or speech and language pathologist. The review found an average 2% reduction in hospital admissions (3 studies), improved referrals to community services for falls (1 study), increased satisfaction with the safety of discharge and with the distribution of staff workload (2 studies), and improved health-related quality of care (1 study). The methodological quality of the studies was mixed
			- Mortality rate
			- Admission rate
			- Patient/staff satisfaction
			- Referral to community
			- ED revisit
			- Quality of life
Cheng et al., 22²⁷ 2024	Retrospective study	Canada	- Admission rate	This single-centre, retrospective, propensity score-matched study found that consultation with a member of an ED interprofessional team including OT, PT, or SW, was associated with a decreased hospital admission rate in older adults aged ≥70 years. The authors also found consultation with a member of this team was associated with a slightly longer ED LOS and subsequent early hospitalization; however, patient mortality rate was not significantly different
			- LOS in the ED
			- 7-day subsequent hospital admission
			- Mortality rate
Goldberg et al.,²⁸ 2020	Randomized control trial	USA	- Fall-related ED visits	This study, conducted in 2 ED urban academic centres, found that intervention group patients (ages =>65) who had a recent fall were less likely to have fall-related ED visits within 6 months as compared control group patients who had a fall. Patients enrolled in the geriatric acute and post-acute fall prevention multidisciplinary intervention protocol received both pharmacist and PT intervention in the ED as compared to usual care (control group)
			- All ED visits
			- Fall-related hospitalizations
			- Hospitalizations
Jordano et al.,²⁹ 2023	Prospective cohort studies	USA	- Time-to-first OT or PT session	This secondary analysis study found increasing OT and PT intensity may reduce delirium duration in older patients in the ED who are admitted to the hospital. The time-to-first OT or PT session was not associated with the delirium duration
Jordano et al.,²⁹ 2023	Prospective cohort studies	USA	- Intensity of OT and PT
Occupational therapists and physiotherapists in the emergency department, evaluated as discrete professions
James et al.,³⁰ 2016	Critical review	United Kingdom	- Varied based on eligible studies, including number of bed days (three studies) and functional status post-OT (one study)	Seven studies in this review focused on OT as a discrete intervention. Three of these reported the number of bed days saved as an outcome of OT intervention. However, the authors concluded that the quality of the papers varied and often lacked sufficient methodological detail for robust review; they thus indicated that research findings can only be generalized with caution. The authors also identified a need for large-scale, well-designed research studies to evaluate the efficacy of occupational therapy within EDs
Omar et al.,³¹ 2023	Nested case control from a larger cohort	USA	- LOS in ED and hospital	This article focused on analyzing OT’s impact on metrics from a geriatric emergency medicine assessment team. Patients who received intervention (n = 576 cases) had a shorter hospital LOS and better outpatient services follow-up 6 months post-discharge as compared to a control group who did not receive OT intervention (n = 258). The ED LOS and 30-day ED revisit rate were not significantly different between the intervention and control groups
			- 30-day ED return rate
			- Outpatient follow-up
Kilner,³² 2011	Systematic review	Australia	- Varied based on studies at the system, provider, and patient level	Based on 11 primary studies, this review concluded that outcomes supporting the impact of the ED PT role at the system and provider levels were limited. However, the review concluded that there was high-level evidence supporting the benefits of the PT role in the ED at the patient level in terms of patient satisfaction, improved pain control, and reduced disability over the short term. The likelihood of methodological bias is high or unknown due to a lack of details
Pugh et al.,³³ 2020	Prospective observational study	USA	- LOS in the ED	Based on 18 months of data, the authors concluded that patients who were assessed by a PT in the ED for musculoskeletal pain (n = 381) had reduced imaging use, reduced likelihood of receiving an opioid prescription, and reduced LOS in the ED, as compared to a control group (n = 143)
			- Imaging rate
			- Opioid administration rate
Kim et al.,³⁴ 2021	Prospective observational study	USA	- Pain-related function	This study found both greater improvements in function and lower use of high-risk medication at 3-month follow-ups for patients who received ED-initiated PT services (n = 43) as compared to usual care (n = 58) for acute low back pain
			- Patient-reported outcome
			- Use of high-risk medications

Occupational therapists and/or physiotherapists as part of a geriatric interprofessional team in the emergency department

This area of research, mostly from Ireland and the United States, also presents strong levels of evidence supporting the benefits of either OT, PT, or both professions as part of a team working with older adults in the ED.

Evidence indicates that including rehabilitation professionals as part of the interprofessional team contributed to cost savings through a reduction in length of hospital stay²³ and had a positive impact on:

- Patient flow indicators: decrease in ED LOS,^24,25 decreased rate of hospital admission,^23,25-27 decrease in hospital LOS,²³ and lower likelihood of ED revisit due to a fall.²⁸

- Patient and provider experience: high patient satisfaction for the ED visit,²⁵ high patient and staff satisfaction with safety of discharge,²⁶ and high staff satisfaction on workload distribution.²⁶

- Patient care: improved referrals to community services for patients post-fall,²⁶ better function at follow-up,²⁵ better quality of life at follow-up,^25,26 and reduction in delirium duration for admitted patients.²⁹

Details of the publications are summarized in Table 1.

A recent randomized control trial design evaluating the role of PT and OT in the ED and patients’ transition to home is noteworthy. This study compares three models of care: usual care with no dedicated interprofessional team in the ED, a comprehensive geriatric assessment in the ED involving an interprofessional team with OT and PT, and a comprehensive geriatric assessment model with an interprofessional team in the ED, in addition to 6 weeks of follow-up including PT and OT visits or phone calls (i.e., ED Plus).³⁵ Although the full study results have not yet been published, the transition to home from the ED model of care, including a self-management program at home involving interprofessional rehabilitation professionals, has demonstrated promising preliminary outcomes on patients’ mobility and quality of life, with decreased ED revisits and rehospitalization.³⁶

Occupational therapists and physiotherapists in the emergency department evaluated as discrete professions

Most of the recent outcome studies on OT or PT roles in the ED were from lower level evidence, primary studies. The quality and focus of publications for OT roles in the ED were varied and often lacked sufficient methodological details for a robust review; therefore, findings reported should be taken with caution.³⁰ These included: bed days saved,³⁰ shorter hospital LOS, and better outpatient follow-up at 6 months post-discharge.³¹

A systematic review study on PTs in the EDs that were not enhanced roles concluded positive patient-level outcomes related to high patient satisfaction, improved pain control, and reduced disability.³² The PT role in the ED was also associated with shorter LOS in the ED,³³ lower use of high-risk medication for low back pain,³⁴ fewer opioid prescriptions for musculoskeletal pain,³³ and less imaging.³³

Details of the studies are summarized in Table 1.

Regional rehabilitation models of care in the emergency department

To further understand current rehabilitation models of care, the authors also conducted an environmental scan in the fall of 2023 across nineteen organizations, some of which have multiple hospital sites. The authors interviewed ED directors and/or rehabilitation leads across three Ontario Health regions and discussed a range of topics, including ED program goals in rehabilitation staffing, ED rehabilitation staff allocation and operations, data indicators tracked, and the challenges encountered and lessons learned when implementing rehabilitation roles in the ED. See Table 2 for participating organizations.

Table 2.

Participating hospitals by Ontario health region.

Ontario health region	Organization
Toronto	Humber River Health
	Michael Garron Hospital
	North York General Hospital
	Scarborough Health Network
	Sinai Health System/Mount Sinai Hospital
	Sunnybrook Health Sciences Centre
	Unity Health Toronto/St. Joseph’s Health Centre & St. Michael’s Hospital
	University Health Network/Toronto General & Toronto Western Hospitals
Central	Georgian Bay General Hospital
	Halton Healthcare
	Mackenzie Health
	Muskoka Algonquin Healthcare
	Oak Valley Health
	Orillia Soldiers’ Memorial Hospital
	Royal Victoria Regional Health Centre
	Southlake Regional Health Centre
	Trillium Health Partners
	William Osler Health System
East	Lakeridge Health

Program goals

Staffing the ED with rehabilitation professionals was for (1) admission diversion only and/or (2) initiating assessment and/or treatment of admitted patients waiting in the ED for an inpatient unit bed. The focus of rehabilitation professionals in the ED for the purpose of admission diversion was to identify patients who could functionally manage in the community with supports (e.g., at home) or be directly admitted to inpatient rehabilitative care if there were no acute medical issues to be addressed. For those patients who were admitted and awaiting an inpatient bed in the ED, rehabilitation professionals not only focused on initiating a functional status assessment but also on preventing functional decline and hospital-acquired conditions such as pressure ulcers or delirium. Anecdotal comments from those interviewed indicated that early assessment and intervention in the ED resulted in shortened lengths of stay on inpatient units, and/or being able to discharge patients directly from the ED.

Rehabilitation staff and operations

Variability was observed in which professions provide services in the ED, how integrated the rehabilitation role is with other staff in the ED, and the hours the ED is staffed with rehabilitation professionals. For multi-site organizations, the rehabilitation staff model may also differ within the same organization. In the majority of the organizations interviewed, physiotherapy tended to be the rehabilitation profession dedicated either full-time or part-time in the ED, particularly if the organization’s primary program goal was admission avoidance. Speech-language pathologists in the ED were identified by only a few organizations and their role was primarily to provide consultation for admitted patients who had experienced a stroke.

Organizations with rehabilitation staff covering the ED on either a consultative basis (i.e., without a dedicated full-time equivalent [FTE]) or dedicated part-time with less than 0.5 FTE consistently identified more challenges in keeping up with the referrals, especially with the current ED pressures. The amount of time rehabilitation staff could see patients in the ED was correlated with the development of their role in this setting and their ability to develop relationships with other ED team members and leaders, which were reported to enhance the interprofessional approach to patient care.

Table 3 lists the observed differences in models of care by categories based on the environmental scan.

Table 3.

Observed models of care based on categories.

Category	Rehabilitative model of care in the emergency department
Program goal	Admission avoidance only
	Early intervention of admitted patients only
	Admission avoidance and early intervention of admitted patients
Profession	Physiotherapist only
	Occupational therapist only
	Both physiotherapist and occupational therapist
	Occupational therapy assistant/physiotherapist assistant involved
	Speech-language pathologist
Staffing model	Consultation model (no full-time equivalent assigned)
	Dedicated staff in the emergency department: Full-time
	Dedicated staff in the emergency department: Part-time
Scope of practice	Case management and/or interprofessional practice approach
Scope of practice	Traditional roles of health professions
Hours of operation	Traditional: 8-hour weekday shift only
	Enhanced time weekday coverage, up to evenings
	Weekend coverage

Lessons learned in emergency department rehabilitation role implementation

Key lessons learned related to the implementation of rehabilitation roles in the ED included:

- Clarity in roles of OT, PT, or occupational therapy assistant/physiotherapist assistant: This process may involve ongoing iterative education of all team members and a sustainability plan in addressing role clarity.

- Importance of relationship building with ED team members and external partners: This is also an intentional, ongoing process. Appreciation of the value each rehabilitation profession can contribute in the ED requires that their roles be integrated within the ED team and care processes.

- Physical environment in the ED: Existing EDs are generally not designed for older adult mobility intervention. A lack of equipment storage and the loss or misplacement of mobility aids were also identified as challenges.

Evaluation and measuring impact

The majority of organizations interviewed that had recently implemented a rehabilitation role in the ED measure the impact of this change by monitoring referral volumes, attendances of rehabilitation professionals and the number of patients admitted or redirected from the ED. Since the interviews were conducted, some organizations monitoring metrics have reported further investments in OT and/or PT coverage in the ED, which reflects the organization’s appreciation of the rehabilitation role’s contribution. For those organizations with longstanding rehabilitation staffing in the ED, quantitative metrics are no longer collected as there is recognition of the value of having dedicated rehabilitation staff in the ED. There is currently no regional strategy to evaluate the impact of OT or PT roles in the ED.

Opportunities

As mentioned, Ontario EDs face significant pressures due to higher numbers of older adults with more complex needs seeking care and waiting for inpatient beds.³⁷ The risks, and even dangers, for older adults within acute care hospitals are clear. Among them are deconditioning, one of the most common reasons for delayed discharge from acute hospitals,³⁸ and prolonged immobility associated with a decline in muscle strength and muscle mass, as well as in physical and cognitive function.^39,40 This highlights the importance of early, targeted rehabilitation intervention, which can reverse functional decline in older adults associated with acute hospitalization⁴¹ and can expedite their discharge, as higher levels of mobility are associated with shorter lengths of stay.⁴²

Given these system pressures and risks for older adults seeking care, there is an opportunity for government to develop policies and funding incentives such as the Pay-for-Results program in the ED⁴³ that will encourage health service provider organizations to develop alternate models of rehabilitative care in EDs that can help alleviate capacity pressures and assist older adults and others in continuing to live well in the community. Based on findings from the environmental scan and literature review, promising models that should be further explored include enhanced roles for rehabilitation professionals, in which they do not require a physician’s referral to assess patients, have a higher level of responsibility, and engage in activities beyond traditional PT and OT scope of practice; and the “transition to home” model in which OTs and PTs are part of a geriatric interprofessional team in the ED and support time-limited follow-up after ED discharge with a self-management program at home.

Rehabilitative professionals in the ED, as additional members of the interprofessional team, have evolved as ED programs are designed to better manage patient flow. These professionals, with promising impacts on patient flow, patient care, and provider experience, complement the skill mix of other professions in the ED. Dedicated rehabilitation staff should be considered as part of a broader strategy to address patient needs efficiently and effectively while helping to alleviate pressures on EDs.

Footnotes

Acknowledgements

We would like to thank Emilia Main, librarian at the University Health Network, for assisting with the literature review search, and Laura Glynn, for proofreading this article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Institutional review board approval was not required.

ORCID iDs

Sharon A. Ocampo-Chan

Charissa Levy

References

Office of the Auditor General of Ontario . Value for money audit: emergency departments. 2023:1-50. https://www.auditor.on.ca/en/content/annualreports/arreports/en23/AR_emergencydepts_en23.pdf. Accessed June 13, 2024.

Health Quality Ontario . Under Pressure: Emergency Department Performance in Ontario. Toronto, ON: Queen’s Printer for Ontario; 2016:1-46. https://underpressure.hqontario.ca/. Accessed June 13, 2024.

Morley

Unwin

Peterson

Stankovich

Kinsman

. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One. 2018;13(8):e0203316. doi:10.1371/journal.pone.0203316

Darraj

Hudays

Hazazi

Hobani

Alghamdi

. The association between emergency department overcrowding and delay in treatment: a systematic review. Healthcare. 2023;11(2):385. doi:10.3390/healthcare11030385

Canadian Physiotherapy Association . The Value of Physiotherapy: Emergency Department. Canadian Physiotherapy Association; 2012. https://physiotherapy.ca/app/uploads/2022/08/cpa_valuept_erdept-en.pdf. Accessed August 9, 2024.

Royal College of Occupational Therapists . Urgent Care: The Value of Occupational Therapy. Royal College of Occupational Therapists; 2015. https://www.rcot.co.uk/sites/default/files/Urgent-Care-report-ILSM-2015.pdf#:∼:text=Occupational_therapists_can_deliver_quality_care_and_cost,at_home_and_maintain_their_health_and_wellbeing. Accessed August 8, 2024.

Ontario Health . Operational direction – rehabilitation and complex continuing care capacity and flow. 2023. https://www.ontariohealth.ca/sites/ontariohealth/files/Operational-Direction-Rehab-and-CCC-July-2023.pdf. Accessed June 13, 2024.

Matifat

Zidarov

Woodhouse

Desmeules

. Advanced practice physiotherapy in Canada: a survey of Canadian physiotherapists. Physiother Can. 2024. doi:10.3138/ptc-2023-0060. Accessed May 24, 2024.

World Physiotherapy . Policy statement: advanced physiotherapy practice. World Physiotherapy. 2023. https://world.physio/policy/ps-advanced-pt-practice. Accessed August 2, 2024.

10.

Government of Alberta . Health Professions Restricted Activity Regulation, Alberta Regulation 2022/2023. Edmonton: Alberta King’s Printer:1-56. https://open.alberta.ca/publications/2023_022. Accessed August 15, 2024.

11.

Matifat

Berger Pelletier

Brison

, et al. Advanced practice physiotherapy care in emergency departments for patients with musculoskeletal disorders: a pragmatic cluster randomized controlled trial and cost analysis. Trials. 2023;24(1):84-812. doi:10.1186/s13063-023-07100-x

12.

Gagnon

Hebert

Guertin

Berthelot

Desmeules

Perreault

. Integration of primary contact physiotherapists in the emergency department for individuals presenting with minor musculoskeletal disorders: protocol for an economic evaluation. PLoS One. 2023;18(9):e0277369. doi:10.1371/journal.pone.0277369

13.

Gagnon

Perreault

Berthelot

, et al. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: results of a randomized controlled trial. Acad Emerg Med. 2021;28(8):848-858. doi:10.1111/acem.14237

14.

Lafrance

Demont

Thavorn

Fernandes

Santaguida

Desmeules

. Economic evaluation of advanced practice physiotherapy models of care: a systematic review with meta-analyses. BMC Health Serv Res. 2021;21(1):1214-1215. doi:10.1186/s12913-021-07221

15.

Matifat

Perreault

Roy

, et al. Concordance between physiotherapists and physicians for care of patients with musculoskeletal disorders presenting to the emergency department. BMC Emerg Med. 2019;19(1):67-610. doi:10.1186/s12873-019-0277-7

16.

Williams

Stotter

Hefford

Warren

Darlow

. Impacts of advanced physiotherapy: a narrative literature review. N Z J Physiother. 2019;47(3):150-159. doi:10.15619/nzjp/47.3.03

17.

Souter

Jones

Sheppard

Crowe

. Extended scope physiotherapists are effective and safe in the emergency department: a systematic review and meta-analysis. Internet J Allied Health Sci Pract. 2022;20(3):1-21. doi:10.46743/1540-580X/2022.2130

18.

Alkhouri

Maka

Wong

McCarthy

. Impact of the primary contact physiotherapy practitioner role on emergency department care for patients with musculoskeletal injuries in New South Wales. Emerg Med Australasia (EMA). 2022;32(2):202-209. doi:10.1111/1742-6723.13391

19.

Sayer

Kinsella

Cary

Burge

Kimmel

Harding

. Advanced musculoskeletal physiotherapists are effective and safe in managing patients with acute low back pain presenting to emergency departments. Aust Health Rev. 2018;42(3):321-326. doi:10.1071/ah16211

20.

Kinsella

Collins

Shaw

, et al. Management of patients brought in by ambulance to the emergency department: role of the advanced musculoskeletal physiotherapist. Aust Health Rev. 2018;42(3):309-315. doi:10.1071/ah16094

21.

Demont

Quentin

Bourmaud

. Impact of models of care integrating direct access to physiotherapy in primary care and emergency care contexts in patients with musculoskeletal disorders: a narrative review. Rev Epidemiol Sante Publique. 2020;68(5):306-313. doi:10.1016/j.respe.2020.08.001

22.

Ferreira

Traeger

Maher

. Review article: a scoping review of physiotherapists in the adult emergency department. Emerg Med Australasia (EMA). 2019;31(1):43-57. doi:10.1111/1742-6723.12987

23.

Keene

Cameron-Comasco

. Implementation of a geriatric emergency medicine assessment team decreases hospital length of stay. Am J Emerg Med. 2022;55:45-50. doi:10.1016/j.ajem.2022.02.027

24.

O'Shaughnessy

White

Smalle

, et al. 106 Optimising early assessment and intervention by health and social care professions in the ED: preliminary Findings from the OPTIMEND RCT. Age Ageing. 2019;48:iii1-iii16. doi:10.1093/ageing/afz102.24

25.

Cassarino

Robinson

Trepel

, et al. Impact of assessment and intervention by a health and social care professional team in the emergency department on the quality, safety, and clinical effectiveness of care for older adults: a randomised controlled trial. PLoS Med. 2021;18(7):e1003711. doi:10.1371/journal.pmed.1003711

26.

Cassarino

Robinson

Quinn

, et al. Impact of early assessment and intervention by teams involving health and social care professionals in the emergency department: a systematic review. PLoS One. 2019;14(7):e0220709. doi:10.1371/journal.pone.0220709

27.

Cheng

Kiss

Coyle

, et al. Diversion of hospital admissions from the emergency department using an interprofessional team: a propensity score analysis. CJEM. doi:10.1007/s43678-024-00760-x. Accessed September 20, 2024.

28.

Goldberg

Marks

Resnik

Long

Mellott

Merchant

. Can an emergency department-initiated intervention prevent subsequent falls and health care use in older adults? A randomized controlled trial. Ann Emerg Med. 2020;76(6):739-750. doi:10.1016/j.annemergmed.2020.07.025

29.

Jordano

Vasilevskis

Duggan

, et al. Effect of physical and occupational therapy on delirium duration in older emergency department patients who are hospitalized. J Am Coll Emerg Physicians Open. 2023;4(1):e12857. doi:10.1002/emp2.12857

30.

James

Jones

Kempenaar

Preston

Kerr

. Occupational therapy and emergency departments: a critical review of the literature. Br J Occup Ther. 2016;79(8):459-466. doi:10.1177/0308022616629168

31.

Omar

Keene

Childers

Cameron-Comasco

. Occupational therapy evaluation within a geriatric emergency department is associated with shorter hospital stay. Acad Emerg Med. 2023;30(Supplement 1):144. doi:10.1111/acem.14718

32.

Kilner

. What evidence is there that a physiotherapy service in the emergency department improves health outcomes? A systematic review. J Health Serv Res Policy. 2011;16(1):51-58. doi:10.1258/jhsrp.2010.009129

33.

Pugh

Roper

Magel

, et al. Dedicated emergency department physical therapy is associated with reduced imaging, opioid administration, and length of stay: a prospective observational study. PLoS One. 2020;15(4):e0231476. doi:10.1371/journal.pone.0231476

34.

Kim

Ciolino

Lancki

, et al. A prospective observational study of emergency department-initiated physical therapy for acute low back pain. Phys Ther. 2021;101(3):pzaa219. doi:10.1093/ptj/pzaa219

35.

Conneely

Leahy

O'Connor

, et al. A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial. Pilot & Feasibility Studies. 2022;8(1):1-14. doi:10.1186/s40814-021-00954-5

36.

Conneely

Leahy

O’Connor

, et al. A physiotherapy-led transition to home intervention for older adults following emergency department discharge: a pilot feasibility randomised controlled trial (ED plus). Clin Interv Aging. 2023;18:1769-1788. doi:10.2147/cia.s413961

37.

Ontario Hospital Association . Ontario Hospitals - Leaders in Efficiency. 2nd ed.; 2024:1-23. https://www.oha.com/Bulletins/OHA-Hospital_Efficiency_Paper_August2024_FINAL.pdf. Accessed September 24, 2024.

38.

Lim

Doshi

Castasus

Lim

JKH

Mamun

. Factors causing delay in discharge of elderly patients in an acute care hospital. Ann Acad Med Singapore. 2006;35(1):27-32. doi:10.47102/annals-acadmedsg.V35N1p27

39.

Falvey

Mangione

Stevens-Lapsley

. Rethinking hospital-associated deconditioning: proposed paradigm shift. Phys Ther. 2015;95(9):1307-1315. doi:10.2522/ptj.20140511

40.

Krumholz

. Post-hospital syndrome-an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. doi:10.1056/nejmp1212324

41.

Martínez-Velilla

Casas-Herrero

Zambom-Ferraresi

, et al. Effect of exercise intervention on functional decline in very elderly patients during acute hospitalization: a randomized clinical trial. JAMA Intern Med. 2019;179(1):28-36. doi:10.1001/jamainternmed.2018.4869

42.

Shadmi

Zisberg

. In-hospital mobility and length of stay. Arch Intern Med. 2011;171(14):1298-1299. doi:10.1001/archinternmed.2011.321

43.

Ontario Health . Hospital Clinical Quality Improvement Update (Issue 3). Spring; 2024. https://www.hqontario.ca/Portals/0/documents/qi/hospital-clinical-qi-update-spring-2024-en.pdf. Accessed September 24, 2024.

Rehabilitation in emergency departments: A regional scan and future opportunities

Abstract

Introduction

Literature review on physiotherapy and occupational therapy in the emergency department

Enhanced physiotherapist role in the emergency department

Occupational therapists and/or physiotherapists as part of a geriatric interprofessional team in the emergency department

Occupational therapists and physiotherapists in the emergency department evaluated as discrete professions

Regional rehabilitation models of care in the emergency department

Program goals

Rehabilitation staff and operations

Lessons learned in emergency department rehabilitation role implementation

Evaluation and measuring impact

Opportunities

Footnotes

Acknowledgements

Declaration of conflicting interests

Funding

Ethical approval

ORCID iDs

References