Transcript A New Delivery Option - Great Plains SAEM Research Meeting

Physical Therapy in the Emergency Department:
A New Delivery Option
Debra A.McDonnell, PT, DPT
Pamela M. Wendl, PT, DPT
Susan S. Deusinger, PT, PhD
Linda Van Dillen, PT, PhD
Sara Bohall, MS
Robert Poirier, Jr., MD
Great Plains Regional SAEM Research Meeting
September 28, 2013
Elements of a New Service Delivery
Model In The Emergency
Department
The Model: Physical Therapy in the ED
The Subject: Back Pain Study
The Catalyst(s) for the Model
PT in the ED
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Contemporary changes in PT
A vision of interdisciplinary care
Knowledge of prevalent conditions
Openness to innovation
Impending change(s) in health care
The Study
Rationale for Back Pain in the ED
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60-80% of adults experience LBP
$30 billion annual costs
2.5-3 million ED visits annually
Complexity of presentation
Accountability for outcomes
The Study
Purpose and Hypotheses
• Purpose:
Test effectiveness of a new delivery model
for patients presenting to the BJH ED with
back pain
• Hypotheses:
↓ pain and ↑ function
↓ medications, x-rays and 72-hour return
Null effect on Length of Stay (LOS) in the ED
The Study
Design
• Subjects: Adults, chief complaint of back pain
Inclusions: > 18 y/o, non-febrile, speaks English
Exclusions: Pregnant, cognitively impaired, critical
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Personnel: PT/MD/Student research assistant
Group Assignment: PT-First and MD-Only
Pre- and post-testing of pain and function
Analysis of group differences
The Study
Procedural Design
PT-First Group
MD-Only Group
Triage (RN)
Triage (RN)
Consent (PT)
Consent (Student)
Functional Assessment (PT)
Functional Assessment (Student)
Treatment (PT)
Medical Assessment (MD)
Functional Assessment (PT)
Functional Assessment (Student)
Medical Assessment (MD)
Discharge (RN)
Discharge (RN)
Follow-Up (Student)
Follow-Up (Student)
The Study
Data Sources
• VAS (Visual Analog Scale)
Self-report of pain
• FA Test (Functional Assessment Test)
Self-report of symptoms during 12 specific
movements
• HMED (Hospital data base)
Electronic recording of duration of stay in ED, use
of medications and x-rays, and 72-hour return
The Study
Pre- and Post-Tests Measures
• Pain
Self-reported numeric rating of pain on a 0-100 scale
• Symptoms during functional tests
Patient report of whether symptoms increased, decreased or
stayed the same during the following movements, or whether
the movement could not be performed (recorded as NA):
• Turn head to right
• Getting out of bed
• Turn head to left
• Getting out of chair
• Raise arms overhead
• Getting into chair
• Raise right arm overhead
• Forward bend
• Raise left arm overhead
• Return from forward bend
• Getting in bed
• Walking
The Study
Definition of New Variables
• Symptom change
A non-numerical comparison from pre-test → post-test of
self-reported symptoms
Pre-Test
Decreased
Increased
NA
Same
Post-Test
Decreased
Decreased
Increased
Increased
Symptom Change
Same
Improved
Improved
Worsened
The Study
Definition of New Variables
• Percent Improved Symptoms
The number of improved symptoms divided by the sum of
NAs and increased symptoms at the pre-test across all 12
functional tests
Subject
1
2
3
4
# of NA & Increased
Symptoms Pre-Test
5
2
9
10
# of Improved
Symptoms
2
2
8
5
Percent Improved
Symptoms
40%
100%
89%
50%
The Study
Statistical Analyses
• Subject characteristics, LOS, medication, x-ray and 72hour return
– Descriptive and Chi Square tests of HMED data
• VAS Pain Pre → Post
– Mixed Model ANOVA of self-report
• FA Test Symptom Change Pre → Post
– Chi Square to test frequency of symptom changes (worsened,
stayed the same or improved)
– t-test to compare percent change in symptoms in both groups
across all tests of function
The Study Outcomes
Descriptive Statistics
Variable
Gender M (%)
Age
Race
Black
White
Other
Triage
Green/Purple
Gold
PT-First (n=34) MD-Only (n=32)
P-Value
21 (64%)
17 (52%)
.619
38.1 (11.6)
38.7 (12.1)
.838
21 (62%)
12 (35%)
1 (3%)
25 (78%)
5 (16%)
2 (6%)
33 (97%)
1 (3%)
24 (83%)
5 (17%)
.103
.086
The Study Outcomes
X-Ray/Medications
Variable
PT-First (n=34) MD-Only (n=32)
P-Value
X-rays
Yes
No
8 (24%)
26 (76%)
7 (22%)
25 (78%)
1.00
Given Medications
Yes
No
22 (65%)
12 (35%)
23 (72%)
9 (28%)
.603
Given Narcotics
Yes
No
1 (4%)
25 (96%)
7 (23%)
23 (77%)
.056
The Study Outcomes
LOS/72-Hr Return
Variable
PT-First (n = 34)
MD-Only (n = 32) P-Value
LOS Time (minutes)
With PT
Overall LOS
Overall LOS, No Imaging
0:56 (0:09)
4:03 (1:42)
3:47 (1:39)
2:49 (1:11)
2:33 (0:59)
.001
.002
72-hr Return
Yes
No
1 (3%)
33 (97%)
2 (6%)
30 (94%)
.608
The Study Outcomes
VAS (Self-Reported Pain)
80
MD-Only
75
VAS Score
70
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PT-First
p=.019
65
60
55
50
45
40
VAS PRE
VAS POST
The Study Outcomes
FA Test (Symptom change)
Symptom Data
Raise Right Arm Overhead
Worsen
Same
Improved
Getting in Bed
Worsen
Same
Improved
Getting out of Bed
Worsen
Same
Improved
Getting out of Chair
Worsen
Same
Improved
Getting into Chair
Worsen
Same
Improved
Walking
Worsen
Same
Improved
PT-First (n=34)
MD-Only (n=32)
P-Value
0
18
14
5
22
5
.008
0
5
28
1
22
9
.000
1
6
26
3
15
14
.015
0
11
23
4
17
11
.009
0
17
17
3
21
7
.024
1
11
22
3
20
9
.011
Percent Improved Symptoms
The Study Outcomes
FA Test (% Improved Symptoms )
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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MD-Only
p<.001
PT-First
The Study
Limitations
• Potential differences other than baseline characteristics in PTFirst (weekday) and MD-Only (weekend) caseload
• Triage, technology and space allocation issues that affected
LOS measures
• Significant problems contacting patients post-discharge to
determine complaint(s) that can lead to 72-hour return
• Inadequate data collected for:
– Timing and type of MD contact for PT-First group subjects
– Dose and timing of administration of narcotics/medication
– Cost of ED visits and interventions
The Study
Future Directions
• Seek funding to support:
Dedicated research coordinator and space
Formal testing of psychometrics of FA Test
• Refine design to:
Improve notification after triage
Recruit and randomize subjects on weekdays only
Characterize patterns of presenting complaints in the ED
Use 5-day time frame for follow-up
The
Windows of PT Opportunity
• Create routes for more timely intervention,
discharge planning and follow-up in the ED
• Incorporate PT to manage non-life threatening
musculoskeletal conditions seen in Urgent
Care Centers
• Reinforce the value of systematic assessment by PT as an
expected component of care in all venues
• Fully embrace PT as an integral component of interdisciplinary
care across the continuum of health and life
Acknowledgements
WUSM Colleagues:
• Beth Crowner, PT, DPT, NCS
• Tammy Burlis, PT, DPT, CCS
• Robert Deusinger, PT, PhD
• Lawrence Lewis, MD
• Brent Ruoff, MD
BJH Leadership:
• Sharon O’Keefe, RN
• Richard Liekweg, MBA
WUSM PT Students:
• Sharon McMonagle, DPT
• Allie Harris, SPT
• Kristen Waldron, SPT
• Sara Heldman, SPT
• Noelle Peterson, DPT
• Tori Mallow, SPT
• Max Edele, SPT
Funding Sources:
• MPTA Grant (7/2011 – 7/2013)
• Research Division (7/2011 – 7/2012)
• Program in PT