Impacts of Physiotherapy Services in a Quebec Emergency Department

Impacts of Physiotherapy Services in a Quebec Emergency Department - Randomized Clinical Trial

Emergency departments (ED) in several countries integrated physiotherapists in order to reduce wait times for patients with musculoskeletal disorders (MSKD). These initiatives have indeed reduced wait times, length of stay, time waited before seeing a professional and the prescription of unnecessary consultations and diagnostic tests. In Canada, such initiatives are marginal and their effects have not been studied.

The objectives of the project are to evaluate the effects of physiotherapy management of patients with MSKD in ED compared to usual practice on clinical course of patients, use of services and resources, and waiting time and length of stay in ED. The hypothesis is that patients presenting with a MSKD to the ED with direct access to a physiotherapist will have better clinical outcomes and that use of services, waiting time, and length of stay are going to be inferior to those of the EP group.

Study Overview

• Status: Completed
• Conditions: Musculoskeletal Diseases; Musculoskeletal Pain; Musculoskeletal Injury
• Intervention / Treatment: Other: Direct access to a PT

Detailed Description

Background and rationale: Emergency departments (ED) in several countries integrated physiotherapists, which led, for patients with musculoskeletal disorders (MSKD), to a reduction in wait times, length of stay, time waited before seeing a professional and the prescription of unnecessary consultations and diagnostic tests. Furthermore, early access to physiotherapy is associated with a decrease in pain and psychological symptoms and decreased risks of developing persistent pain. In Canada, such initiatives are still marginal and their effects have not been studied.

Objectives: Evaluate the effects of direct access physiotherapy management of patients with MSKD in the ED compared to the usual management by the emergency physician on clinical course of patients (pain, quality of life and disability) and use of services and resources at one and three months, and waiting time and length of stay in the ED.

Methods: A randomized controlled trial is currently in progress at the Centre hospitalier de l'Université Laval (CHUL). Two groups of 50 participants each are recruited over a six months period: one group with direct access to a physiotherapist (PT) in the ED and one control group with the usual access care to the emergency physician. Data is extracted from the patients' medical record, administrative data from the ED, self-administered forms given to the patients during their ED stay and either electronic or phone follow-ups (1 and 3 months). Data will be analysed using descriptive (demographic and clinical profiles) and inferential statistics (repeated ANOVA between groups across time points and Student T tests for independent samples).

Importance of potential findings for MSK health: ED overcrowding causes prolonged lengths of stay, increased rates of patient leaving without being seen, increased medical errors, increased mortality among ambulatory and non-ambulatory patients and decreased patient satisfaction. This project will measure the effects of integrating PTs into the ED in a Canadian hospital setting and help identify ways to improve the current services offered to patients with a MSKD presenting to the ED. Direct access to PT may improve musculoskeletal health outcomes and support positive patient experience.

• Study Type: Interventional
• Enrollment (Actual): 78
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Quebec
    • Québec, Quebec, Canada, G1V 4G2
      • Centre Hospitalier de l'Université Laval (CHUL)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Triage category 3, 4 or 5
• Discharged home with a minor MSKD after ED care
• Able to consent
• Able to understand French and to complete the questionnaire either verbally or in writing

Exclusion Criteria:

• Major MSKD requiring urgent care
• Presence of a red flag or an unstable clinical condition
• Living in a long-term care facility

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
NO_INTERVENTION: Emergency Physician Group; Usual care by the EP without the intervention of the ED PT.
EXPERIMENTAL: Physical Therapist Group; Direct access to a PT in the ED immediately after triage and prior to physician assessment.	Other: Direct access to a PT; Direct access to a PT in the ED immediately after triage and prior to physician assessment.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Level of Pain: Numeric Pain Rating Scale	Scale ranging from 0 to 10 where 0 means no pain at all and 10 means the worst pain ever.	Baseline, 1 and 3 months
Pain Interference on Function: Brief Pain Inventory	List of 10 items (work, sleep, general activity, etc.) represented on a scale ranging from 0 to 10 where 0 means "Does Not Interfere" and 10 means "Completely Interferes". Subscales are averaged and the resulting score is out of 10. A higher score means a higher interference of pain on function.	Baseline, 1 and 3 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Catastrophizing: Pain Catastrophizing Scale	List of 13 items (thoughts and feelings about pain) represented on a scale ranging from 0 to 4 where 0 means "Not at all" and 4 means "All the time". Subscales are summed and the resulting score is out of 52. A higher score means a higher tendency to catastrophise pain.	Baseline
Interventions received by the participants : Standardized Form	Form were every intervention received by the patient was checked as a "Yes" or "No" answer. (Advice, medication, technical aids, referral to another health professional, etc.)	Baseline, 1 and 3 months
Diagnostic Tests : Standardized Form	Form were every diagnostic test received by the patient was checked as a "Yes" or "No" answer. (X-ray, MRI, CT Scan, ultrasound, etc.)	Baseline, 1 and 3 months
Consultations with Another Health Professional : Standardized Form	Form were every consultation being prescribed to the patient was checked as a "Yes" or "No" answer.	Baseline, 1 and 3 months
Satisfaction: Visit-Specific Satisfaction Instrument	List of 7 items (Answers to your questions, Technical skills of the healthcare provider, etc.) represented on a scale ranging from 1 to 5 where 1 means "Excellent" and 5 means "Poor". Subscales are transformed in results out of 100 (1 = 100% and 5 = 0%), averaged and the resulting score is out of 100%. A higher score means higher satisfaction.	Baseline
Wait Time	Difference between beginning of the intervention and time of arrival between groups during their ED visit	Baseline
Length of Stay	Difference between departure time and time of arrival between groups during their ED visit	Baseline

Collaborators and Investigators

• Sponsor: Rose Gagnon
• Collaborators: CHU de Quebec-Universite Laval; Laval University; Integrated University Health and Social Services Center of the Capitale-Nationale
• Investigators: Principal Investigator: Rose Gagnon, MPT, MSc(c), Laval University

Publications and helpful links

General Publications

• Gagnon R, Perreault K, Berthelot S, Matifat E, Desmeules F, Achou B, Laroche MC, Van Neste C, Tremblay S, Leblond J, Hebert LJ. Direct-access physiotherapy to help manage patients with musculoskeletal disorders in an emergency department: Results of a randomized controlled trial. Acad Emerg Med. 2021 Aug;28(8):848-858. doi: 10.1111/acem.14237. Epub 2021 Apr 16.

Study record dates

Study Major Dates

• Study Start (ACTUAL): September 10, 2018
• Primary Completion (ACTUAL): June 27, 2019
• Study Completion (ACTUAL): June 27, 2019

Study Registration Dates

• First Submitted: July 2, 2019
• First Submitted That Met QC Criteria: July 3, 2019
• First Posted (ACTUAL): July 5, 2019

Study Record Updates

• Last Update Posted (ACTUAL): October 28, 2020
• Last Update Submitted That Met QC Criteria: October 26, 2020
• Last Verified: October 1, 2020

More Information

Terms related to this study

• Keywords: Health services; Health care access; Professional practices
• Additional Relevant MeSH Terms: Pathologic Processes; Pain; Neurologic Manifestations; Disease Attributes; Muscular Diseases; Emergencies; Musculoskeletal Pain; Musculoskeletal Diseases
• Other Study ID Numbers: MP-20-2019-4307

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No