Physiotherapist-led care cut emergency department stays by an hour for back pain, sprains and simple fractures

A twisted ankle or a sore back is rarely an emergency in the medical sense, but it brings a great many people to emergency departments, and they wait. Hospitals in several countries have responded by putting physiotherapists at the front door to assess and treat such patients themselves. The practice spread before anyone had tested it in a large trial.

That trial has now been done. Published in The Lancet in late August, it randomly assigned nearly 1,500 patients at five Australian hospitals to a physiotherapist or to the usual doctor or nurse practitioner. Those who saw the physiotherapist were out an hour sooner, with no sign that their care was worse and at slightly lower cost.

Why emergency departments are trying physiotherapist-led care

The emergency department (ED) is built for the seriously ill, and it is often crowded. The paper begins with what crowding does: long stays in the emergency department compromise patient safety and health system performance.

Muscle, joint and bone problems, which doctors group together as musculoskeletal conditions, are a large part of the load. Gustavo Machado of the University of Sydney, who led the trial, put a figure on it: “In Australia, more than 1.3 million emergency department visits annually are as a result of a musculoskeletal condition, including back pain, fractures, dislocation and joint injuries, placing considerable demand on already crowded hospitals.” A report from an Australian hospital this year made the same point from the shop floor: musculoskeletal conditions are the most common low acuity ED presentation. Low acuity means not urgent.

The trial’s protocol explains the mismatch. Treating these patients takes time from physician and nursing staff, who are primarily trained and resourced to manage high-acuity patients.

Physiotherapists, known as physical therapists in North America, are trained in exactly these problems. In a physiotherapist-led model, one of them is the first and often the only clinician the patient sees. Such roles are not new. A review in 2019 observed that physical therapists have emerged as key health care providers in emergency departments. One hospital in Western Australia has counted its own experience. Over about ten years, its physiotherapists provided 37,771 individual episodes of care.

What had been lacking was a rigorous comparison. The new paper says of these models that their effects have not been rigorously evaluated in randomized trials.

How the physiotherapist trial was run

The trial, called RESHAP-ED, recruited adults aged 18 years and older at five emergency departments in New South Wales, Australia. They had to have an uncomplicated problem. The paper lists soft tissue conditions, neck and back pain, and fractures or dislocations not requiring a specialist surgical review or an operation.

That filter removed a lot of people. In all, 4219 patients were screened, 2728 were deemed ineligible for inclusion, and 1491 participants were randomly assigned. So about a third of those considered were suitable.

The two groups were nearly equal: 746 assigned to the physiotherapist and 745 to usual care. In the comparison group, usual care meant what the paper calls usual physician-led or nurse practitioner-led care. Sixteen people were excluded after being assigned, and 1475 were included in the analysis (737 in the intervention group and 738 in the control group). Their average age was 40, and men and women were about equally represented.

The trial was pragmatic and open-label. Pragmatic means it tested the service as it would run in ordinary practice. Open-label means nobody was kept unaware of the assignment, which would hardly be possible when the test is who walks into the cubicle.

One measure was chosen as the main one. The primary outcome was length of stay in the emergency department, calculated as time from arrival to discharge. The protocol shows how large a gain the researchers thought worth detecting: the trial was sized to detect a 30 min between-group difference.

None of the 1,475 patients analyzed was lost on that measure. Follow-up for the primary outcome was 100% complete, since arrival and discharge times come from hospital records.

Shorter emergency department stays, by an hour

	Physiotherapist-led care	Usual care
Patients analyzed	737	738
Average time in the emergency department	2.4 hours	3.4 hours
Patients reporting an adverse event	39 of 591 (6.6%)	33 of 555 (5.9%)

The difference was one hour, with a plausible range of 0.8 to 1.2 hours. That is twice the half-hour the trial had been designed to detect, and the narrow range leaves little room for chance.

The university’s account of the results adds detail on where the time was saved. Patients in the physiotherapist group were assessed 40 minutes sooner, and they were three times more likely to be seen within recommended triage timeframes. Triage is the sorting of patients by urgency on arrival, and each category comes with a target time for being seen.

Much of the hour, then, was waiting. The likely reason is the queue. A patient with a sprained wrist sits low in a doctor’s list, behind chest pains and breathing problems. A physiotherapist’s list contains only patients like that one.

Patients noticed. The university says those in the physiotherapist group reported higher satisfaction with their care.

Machado summed up the result. “The trial showed that changing who provides the initial care from doctors and nurses to physiotherapists improved patient satisfaction, reduced the time patients spent in the emergency department, and saved hospitals money,” Machado said.

Safety and cost of physiotherapist-led care

Speed would be a poor bargain if injuries were missed or patients did worse. On the measures the trial took, they did not.

Adverse events were reported by 39 of 591 patients in the physiotherapist group, or 6.6%, and by 33 of 555 in the usual-care group, or 5.9%. That gap is well within the range of chance. An adverse event is any medical problem recorded during a study. The counts are out of roughly 1,150 patients, not all 1,475, which means that about a fifth did not provide this information.

The university reports that other results held up as well, saying the improvements in care did not compromise patient outcomes such as pain, quality of life or adverse events.

The authors’ own summary puts the pieces together. A physiotherapist-led model of care in the emergency department reduced length of stay among patients presenting with uncomplicated musculoskeletal conditions, without compromising health outcomes or safety, and was cost-effective.

On money, the saving per patient was small: about 35 dollars, with a plausible range from about 2 to 69. The trial put the probability that the model is cost-effective at 98.1%.

Scaled up, small savings become large claims. The university projects that the model could save hospitals $19 million annually and release more than 540,000 hours of emergency department capacity each year if implemented across NSW, NSW being the state of New South Wales. That is an estimate built on the trial’s averages, and it assumes the results would hold in every hospital in the state.

How it fits with earlier studies of physiotherapists in emergency care

Earlier evidence pointed the same way and was much thinner.

A systematic review in 2019 gathered what there was. Fifteen studies were included, of varying quality. Eight reported shorter waits with a physiotherapist. On one question that worries hospital managers, whether a different profession would order more scans, the review was reassuring: four studies of varying quality reported that physical therapists ordered no more, or even fewer, medical images than physicians.

That review also flagged why results might not travel. The roles of physiotherapists, it noted, vary depending on the setting, legislation, and training of providers.

A randomized trial did exist, from Quebec City, but it was small, with 78 patients. The intervention group had direct access to a physiotherapist straight after triage and before seeing the doctor. Those patients reported less pain one and three months later, and in the early weeks less prescription medication was used, including opioids.

The Australian trial is nearly twenty times larger than that one and measures something the hospital cares about directly. Its main measure was time, where the Canadian trial’s was pain, and the two tested different arrangements: in Quebec the physiotherapist saw the patient before the doctor, while in Australia the physiotherapist took the doctor’s place.

What the emergency department trial does not show

Rare misses. The serious risk in handing a patient to a different profession is a missed diagnosis, such as a fracture not seen or back pain that turns out to be something else. Such errors are uncommon. A trial of 1,491 patients can show that everyday problems were no more frequent, and cannot say much about events that happen once in a thousand visits.

Patients outside the filter. Two-thirds of those screened were not eligible. The result applies to uncomplicated cases chosen by clear rules. It says nothing about extending the model to more complex injuries.

Blinding. Patients knew who was treating them, and so did staff. Time in the department comes from the clock and is hard to mis-record, though staff who know it is being measured could still work faster. Satisfaction and reported side effects are easier to sway.

Missing safety answers. Adverse-event information came from about four in five participants.

Other health systems. All five hospitals were in one Australian state. What physiotherapists may order, prescribe or decide differs between countries.

Who was involved. The trial was paid for by the Medical Research Future Fund, an Australian government body. The university lists the Australian Physiotherapy Association and the Australasian College for Emergency Medicine among the trial’s partners. The physiotherapists’ association has an interest in the result.

The longer run. The trial measured a visit and its aftermath. Whether patients treated this way do as well months later was not its main question.

Machado argues the case is made. “These findings provide strong evidence for health services to consider physiotherapists as part of the frontline emergency department workforce for people with musculoskeletal conditions,” Machado said.

What a particular injury needs depends on what it is and how severe, which is assessed by their doctor.

In a randomized trial at five Australian hospitals, adults with uncomplicated muscle, joint and bone problems who were managed by a physiotherapist left the emergency department an hour sooner than those given usual care, with similar rates of adverse events, in an open-label study confined to one state and to selected conditions.