The rehab services of Physical Therapy, Occupational Therapy, and Speech Language Pathology (PT/OT/SLP) are areas of emerging practice in the emergency department (ED). These specialty consult services can provide ED physicians with valuable, nuanced assessments for the older adults that will assist in determining a safe discharge plan. PT and OT interventions in the ED have been shown to decrease hospital admissions and readmissions, increase patient satisfaction, and decrease cost. Rehab specialists provide physicians with an expanded scope of management options that can greatly enhance the care of patients in the ED.
Key points
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Physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) can assist in determining a safe discharge plan for older adults with complex disposition problems.
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PT in the emergency department (ED) has been shown to decrease length of stay, admissions, opioid administration, and unnecessary imaging and to increase patient satisfaction.
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SLP in the ED can identify dysphagia in at-risk patients such as those with stroke, aspiration pneumonia, and frailty.
Introduction
Although Rehabilitation Medicine has long been a pivotal part of inpatient care, it has been slow to take hold in the emergency department (ED) setting. As recently as 2010, Physical Therapy (PT) in the ED was being described as a novel practice. In 2018, Occupational Therapy (OT) in the ED was described as a “nascent field” that is “only beginning.” There is a paucity of literature describing Speech Language Pathology (SLP) services in the ED. Given the high volume of older adults in the ED with complex disposition problems, the roles of PT/OT/SLP can be of particular value. Their input regarding whether the patient can be safely discharged home or needs admission to the hospital is relatively well understood. However, rehabilitation medicine expertise also includes the diagnosis and treatment of gait and balance disorders, musculoskeletal injuries, impaired cognition, and dysphagia. It has been observed that elders sustaining injury from a fall rarely have formal fall risk assessment in the ED. Miller and colleagues found that in older adults presenting with a fall and subsequently discharged home, gait was assessed only 10.2% of the time, balance 4.1%, lower extremity range of motion 4.9%, lower extremity strength 2.0%, cognition 26.1%, vision 2.0%, and ability to perform activities of daily living 7.3%.
Excluding these elements in the evaluation of older adults in the ED is a missed opportunity to prevent additional injuries, decrease ED recidivism, and improve safety and patient/family satisfaction. Consider, for example, the traditional model where one might splint the wrist after a fall, do a “road test,” and discharge the patient. Compare with an integrated model where one might also learn that the patient needs additional outpatient help with PT or medication management for a safe discharge from the ED.
Background
Integration of PT in the ED setting was described in the literature as far back as the 1990s in the United Kingdom (UK). In the time since then, the international model for PT in the ED has evolved in countries such as Australia, Canada, and the UK where physical therapists (PTs) are fully integrated and work as primary providers, caring for lower acuity patients with musculoskeletal complaints presenting to the ED. In these countries, at some locations, PTs assess and treat patients independently and are able to order and interpret imaging as well as prescribe certain medications. , Studies have shown that for patients with musculoskeletal disorders, there is often agreement between ED physicians and PTs with respect to care plans. In addition, when patients are seen by PT in the ED, there is an associated reduced length of stay and wait times.
PT/OT/SLP services in the United States (US) are still considered novel, and the model of care varies significantly from the international model. In the US, rehabilitation services are secondary consult services, relying on a physician’s referral to initiate care. The role of PT in the ED in the US was first described around 2000. The body of literature has grown since that time, examining perceptions, length of stay, readmissions, patient satisfaction, rates of imaging, opioid use, and cost. For example, in 2011 the American Physical Therapy Association (APTA) published “Incorporating Physical Therapy in the Emergency Department: A Toolkit for Practitioners.” The APTA “promotes physical therapy as a professional service in the emergency care environment” and at the same time recognized that developing a PT program in the ED is a daunting task. The toolkit provides a roadmap for building a program, but unfortunately, the utilization of PT services in the ED remains limited.
Research on OT in the ED is in its infancy. , To date, studies have examined OT’s perspectives on working in the ED, hospital admission rates, and readmission rates. International studies have shown that patient admissions to the hospital are reduced with the use of OT services.
Speech-language pathologists (SLPs) are specialists in dysphagia, and their evaluations can be valuable in determining a safe disposition plan for older adults where oropharyngeal dysphagia is a major concern. Functional oropharyngeal dysphagia affects up to 84% of patients with Alzheimer’s disease and more than 50% of elderly institutionalized patients. , Oropharyngeal dysphagia and aspiration are also prevalent findings in elderly patients with pneumonia, and an SLP assessment should be considered.
Role of physical therapy
PT practice in the ED has been developed around the world, and the body of literature continues to grow supporting the value of this service. Studies have shown that PT intervention in the ED can lead to decreased wait and treatment times , decreased admission rates, increased patient satisfaction, decreased opioid administration, decreased cost of unnecessary tests and services such as diagnostic imaging, and improved patient function and outcomes. , , , A qualitative study by Lebec and colleagues shows that many ED physicians recognize the benefits of PTs in the evaluation of ED patients. Specifically, PTs are seen as having more functional clinical knowledge of musculoskeletal injuries than ED physicians, as reported by the physicians. In addition, ED physicians feel PTs complete clinical tasks that would have otherwise been delegated to patient care technicians, nurses, or other providers; this is seen as time saving and helps with department throughput. , ,
In the ED setting, PTs commonly manage conditions that affect the lumbar and thoracic spine (39%–43%) and injuries of the neck or cervical spine (12%–18%), hip and/or knee (11%–17%), shoulder (8%–9%), foot/ankle (7%-9%), and hand, wrist, or elbow (∼3%). In addition, PTs are trained in lower extremity and spine bracing as well as neurovestibular assessment and treatment and should be considered as a specialty referral service in these areas as well ( Table 1 ).
| Physical Therapy (PT) | Occupational Therapy (OT) | Speech-Language Pathology (SLP) |
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