Physical Therapy in the Emergency 11/25/2013

Department: How to Start and Sustain a

Successful Emergency Care PT Service

PHYSICAL THERAPY IN THE

St. Marys Hospital
EMERGENCY DEPARTMENT: HOW TO
START AND SUSTAIN A SUCCESSFUL
EMERGENCY CARE PT SERVICE Part of SSM Healthcare based in St. Louis
320 beds

COMBINED SECTIONS MEETING 2014

Medicare Accountable Care Organization (ACO)
F E B R U A R Y 3 RD- 6 TH, 2 0 1 4 L A S V E G A S , N E V A D A partnered with Dean Clinics
EHR Epic
T U E S D A Y , F E B R U A R Y 4 TH, 2 0 1 4
Physicians contracted through Dean Clinics (except
8:00 AM 10:00 AM
for ED physicians)

SARAH NECHVATAL, PT, DPT

ST. MARYS HOSPITAL MADISON, WISCONSIN

Course Description St. Marys Hospital Emergency Services

1. Describe the development of the PT consultation Average door to doc time is 14 minutes
service in the St. Marys Hospital ED. Bedside registration
2. Review the process and outcome measures of the pilot
Hospital Campus Emergency Department
year of the St. Marys Hospital PT ED project.
Level III trauma center
3. Provide evidence of value of PT in the ED. 29 beds
4. Review which diagnoses and populations are Unit based medical imaging
commonly seen in the ED. St. Marys Sun Prairie Emergency Center
5. Suggest what tools and skills are needed to be an ED Level IV trauma center
PT. 10 beds
6. Offer suggestions on how to start your own PT Laboratory, radiology and helicopter transport

consultation service in your ED. Staffed by Madison Emergency Physicians

Course Objectives St. Marys Hospital Physical Therapy

Upon completion of this course, participants will be 12-13 PT/PTAs on each day (6 Saturday/5 Sunday)
able to: Hours of PT availability 8:30-4:00
1. Explain how PT can add value to an ED. Patients are scheduled in EPIC by Administrative Assistant

2. Collect data before and after implementation of PT Monthly caseload rotations

Pulmonary
in the ED to justify the value of the service.
Neuro
3. Establish a successful ED PT consultation service. Cardiac

4. Sustain a successful ED PT consultation service. Medsurg

Oncology
Ortho
Float

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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

ED PT Care Pathway PT Diagnoses

1. ED PT on Float caseload evals only Back pain (acute or chronic)

2. ED staff identifies appropriate patient Limb pain
3. Enters PT referral in EPIC and calls Float cell Non-surgical fractures
phone to give info
Non-cardiac chest pain
4. PT calls administrative assistant to reschedule
next patient on float load Falls
5. PT arrives within 20 minutes Gait instability
6. PT eval and treat <60 minutes Failure to thrive
7. Coordinate with RN, Physician/PA, Care Vertigo/vestibular dysfunction
Management for D/C planning

Care Management A typical ED visit

Relationship between Care Management and PT is

Triage
vital MD assessment
Medications
Cyndi Benson-Lein, RN Case Manager Imaging (if necessary)

Need for increased Care Management presence in

the ED
Responsible for utilization management
Hospital Admission
Decreasing unnecessary admissions Discharge from ED
Unable to mobilize
Referral back to PCP
Unable to manage symptoms
Finding medical necessity before inpatient admission Referral to outpatient PT with the
OPO stay or potential conversion
symptom as the diagnosis
to inpatient status

Who comes to the ED? What if we could

True emergencies Decrease unnecessary admissions

Losing life
Losing limb(Wilsey et al, 2008) Decrease re-admissions or re-visits to the ED for
Perceived emergencies same diagnosis
~85% of ED patients have non-life threatening injuries(Padgett & Better manage symptoms in the ED
Brodsky,1992)
~11% of ED patients have chronic pain as their C/C (Cordell et al, 2002) Improve patient satisfaction in the ED
Patients with pain feel the need to have objective results to justify
their symptoms (Wilsey et al, 2008) Decreased unnecessary outpatient PCP visits
Frequent visitors Decrease the length of time between ED visit and
Re-admissions or re-visits outpatient PT visit
Use of ED as primary care Decrease time between ED visit and home health
Convenience users services introduction

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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

Project Background Implementation Steps

Opportunity: To practice exceptional stewardship 1. Update the rehab director

by providing the appropriate level of care for our
2. Discuss with PT colleagues
patients in the ED
3. Identify lead PT and a few substitutes
1. Return visits to the Emergency Department (ED) for unresolved 4. Create steering team of stakeholders
symptoms 1. Sarah Nechvatal, PT
2. Extended observation stays 2. Cyndi Benson-Lein, Lead RN Case Manager
3. Inappropriate admissions to hospital 3. Nancy Rung, Rehab Director
4. Theresa Ojala, ED Director
Identifies opportunities for Physical Therapy (PT) and Case 5. Anthony Callisto, MD Medical Director of ED
Management (CM) in the ED 6. Sheryl Krause, RN, Emergency Medicine CNS
7. Deb Dees, ED RN

Implementation Steps

5. Developed care pathway

6. Presentation to the ED physician group
- Pathway
- Narcotics education
7. Presentation to the ED Nursing staff
- Pathway
- Narcotics education
8. Presentations to Rehab and Care Management
Prepared by: 9. Meeting with community resources
- Area outpatient PT clinics and clinic directors
Cyndi Benson-Lein, RN Case Manager - Home health agency schedulers
Sarah Nechvatal, DPT, Physical Therapist 10. Go Live! on November 1, 2010

Goals ED PT Care Pathway

1. Decrease number of observation patients within 1. ED PT on Float caseload evals only

our selected population by 10% over 6 months. 2. ED staff identifies appropriate patient
3. Enters PT referral in EPIC and calls Float cell
2. Decrease observation length of stay within our
phone to give info
selected population by an average of 12 hours over 4. PT calls administrative assistant to reschedule
6 months. next patient on float load
5. PT arrives within 20 minutes
6. PT eval and treat <60 minutes
3. Decrease return visits to the ED within 5 days for
7. Coordinate with RN, Physician/PA, Care
same complaint by 10% over 6 months. Management for D/C planning

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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

Implementation Steps Process Measures

5. Developed care pathway Number of Emergency Department Referrals

During the First Year
6. Presentation to the ED physician group 25
- Pathway 21
20 20
- Narcotics education 20 19
18
17
7. Presentation to the ED Nursing staff 15
16 16 16
- Pathway 15
- Narcotics education ED Referrals
10
8. Presentations to Rehab and Care Management 7 7
9. Meeting with community resources 5
- Area outpatient PT clinics and clinic directors
- Home health agency schedulers 0
Nov Dec Jan Feb March April May June July Aug Sept Oct
10. Go Live! on November 1, 2010

Process Measures Outcome Measures

Number of Emergency Department Referrals Number of Observation Patients within our Selected
During the First Year Patient Population that were admitted through the ED
8 70
7 63
7 60
58 57
6 50 51 52 51 51
49 49 49
47
5 45
43 42 41
43 44
42 41
40
37
4 ED Referrals 35 36

30 31 Previous Year
3 26 Pilot Year

20
2
1 10

0 0
Nov Dec Jan Feb March April May June July Aug Sept Oct

Changes After 1st Month Outcome Measures

Dr. Bell new consultation service Average Observation Length of Stay within our Selected
Be present. Patient Population in Days
Be seen.
Trimmed mean= 1.22
Get in with the nurses.
Dizziness 1.78

Documented in the ED during down time 1.23

Introduced myself to everyone I didnt recognize

Talked with the nursing staff Limb Pain 1.34
Trimmed mean for Pilot
Pilot Year

Made reminder signs for the walls @ each ED phone 1.53 Previous Year

Invited nursing staff into my sessions

Empowering the hospitalists Back Pain 1.42

1.51
Making believersone at a time (Hold the Bucket)
0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00

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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

A Review Lesson on Averages Outcome Measures

3 + 4 + 4 + 26 + 24 + 30 = 91
PT Qualifying Patients Who Return to the ED within 5 days and ED
Patients who are Admitted within 5 days of ED Visit with Same Complaint
12

916 = 15.17 hours 10 10

7 7 7 7

Axis Title
6 6
Previous Year
5
Pilot Year
4 4 4

3 3 3 3

2 2 2

1 1 1 1 1 1

0 0

A Review Lesson on Averages Process Measures

3 + 4 + 4 + 26 + 24 + 30 = 91 35
Number of PT Referrals Throughout the Day
32

916 = 15.17 hours 30 28 29

25 23 23

20 18
3 + 4 + 4 + 26 + 24 + 30 = 80 15 14
17
PT Referrals

803 = 26.67 hours 10

0
8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00

Outcome Measures ED Volume per Hour of Day

Average Observation Length of Stay within our Selected

Patient Population in Days

Trimmed mean= 1.22

Dizziness 1.78

1.23

Trimmed mean for Pilot

Limb Pain 1.34
Pilot Year
1.53 Previous Year

Back Pain 1.42

1.51

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00

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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

ED Volume per Day of Week Process Measures

Discharge Disposition from ED after PT

6.50% 3% 0.50%

11% Home
Inpatient
Observation
SNF
ALF
79%

Process Measures Process Measures

Call to Contact Time Home Services after Discharge Home from ED

Expectation: 20 minutes 50%
45% 43%
Expectation achieved: 80% 40%
35%
Average: 16 minutes and 36 seconds 30% 28%
24%
25%
Treatment Time 20% 18%
Expectation: 60 minutes
15%
10% Percentage of Services
Expectation achieved: 89% 5%
0%
Average: 45 minutes and 12 seconds

Process Measures Process Measures

Chief Complaint Payor

3% 3%
4%
9
13 Medicare
Back Pain 11% Dean
74 Limb Pain Self Pay
40 Falls/Gait Instability
49%
Medicaid/BadgerCare
14% WPS
Vertigo/Dizziness
Misc Worker's Comp
Other insurance
52 16%

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Physical Therapy in the Emergency
Department: How to Start and Sustain a
Successful Emergency Care PT Service
Lessons Learned
1. Make SMART goals after collecting data.
Specific, Measurable, Attainable, Realistic and Timely
2. Data collection always takes longer than expected.
3. Educate the hospitalist group before
implementation.
4. Do a full year for the pilot.
5. Conduct a study group for PTs to review vestibular
and musculoskeletal exam and treatment so that more
PTs feel comfortable in that role
Collecting Outcome Measures
Connect with your ED data analyst (a.k.a. CQI,
information systems)
Data analysts track re-admits or re-visits
Trendstar (billing tool) and HDM are commonly
used programs
We now use Epic instead of HDM
Trendstar has a 1-2 month lag
Connect with medical record ICD-9 coders to
identify ICD-9 codes
Observation Patients: Number & LOS
Observation charge code (instead of inpatient)
Actual vs Billed time
Actual time is the whole time they are
observation
Billed time deducts procedures and
consultations
Only included patients who were observation the
whole time
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11/25/2013
Tracking Return Visits
Same ICD-9 codes
Runs a Re-Admission report (within 5 days)
Return visits: ED visit, D/C from ED, return to ED
Admitted within 5 days: ED visit, D/C from ED, then is admitted
to hospital (through ED or direct admit from outpatient)
Chart Audits to see who could have benefitted from
PT during the first visit to prevent second visit
Include ICD-9 codes in both primary and secondary
diagnoses
Back pain primary diagnosis both visits
Fall with leg pain, return with gait instability primary, secondary
Fracture then readmitted for surgery 3 days later
Why Didnt We
Track for the post-pilot year?
Too time consuming to do chart audits
Other variables were introduced that could affect these outcomes
Audit charts of patient who returned within 30 days?
Too time consuming to do chart audits for that many patients
Would PT intervention one day prevent a return visit to the ED 3
weeks later? Probably not.
Track patient satisfaction?
We didnt think we could do a before and after since the current
practice is randomly survey patients with random diagnoses
St. Josephs Carondelet tracked 80% of patients were satisfied
with the PT service. (Woods, 2000)
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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

Skills and Character Traits Needed Value of PT in the ED

Musculoskeletal exam Enthusiastic PTs are less likely to miss significant knee injury and can
Manual therapy Confident deliver the diagnostic service more cost effectively than
Joint mobs senior house officers(Jibuike et al, 2003)
Active learner
Soft tissue work Patients with acute LBP, with or without referred leg
Flexible pain, had statistically significant reduction in pain and
Modalities increased satisfaction with PT intervention when
Time management
Vestibular assessment compared to control group who received walking training
Lead PT and walking aids only(Lau et al, 2008)
G Code expertise Persistent
Extended scope physiotherapists (ESP) achieve higher
Ability to communicate Good salesperson patient satisfaction with assessment/treatment of
the proper series of events Diplomatic peripheral soft tissue injuries and associated fractures
for a musculoskeletal compared to physicians and emergency nurse
condition practitioners (McClellan et al, 2006)

Resources Needed Value of PT in the ED

High-low table (ED beds) ED physicians perceive PT has value due to increasing the
US/E-stim machine scope of their management options for musculoskeletal
Access to ice and heat modalities pain (an alternative for narcotic use), vestibular
Massage cream
impairments and evaluating mobility of potentially unsafe
patients. Physicians perceive that PTs have reduced their
Exercise library and patient education handouts (ie.
Exercise Pro) workload (Lebec et al, 2010)
Gait belts
Access to stairs/curb step Barnes-Jewish Hospital in St. Louis surveyed ED personnel
DME: crutches, 2ww, youth 2ww, 4ww with seat, who report satisfaction with the PTs management of
standard walker, platform attachments for walker and musculoskeletal pain, contribution to differential diagnosis,
crutches, straight cane, quad cane, manual w/c and discharge recommendations (Fleming-McDonnell et al, 2010)

What does the future hold? Less Money Lost in the ED?

Keep the conversation going with stakeholders Traditional ED care with physician assessment, tests,
Direct Access medications, nursing staff is billed as thousands of
EMTALA (Emergency Medical Treatment and Labor Act) dollars
The right care, the right place (sort of), at the right time The reimbursement does not cover the actual cost
Potential to prevent chronic progression and its high associated
and therefore the ED is a money loser
costs (Lebec & Jogodka, 2009)
PT practices relatively independently cost is mostly
Proving value of PT in the ED
Cost effective care
just PT wages and supplies used during
Increased patient satisfaction treatment(Lebec & Jogodka, 2009)
Improved clinical outcomes

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Physical Therapy in the Emergency 11/25/2013
Department: How to Start and Sustain a
Successful Emergency Care PT Service

Where to Start? References

1. Identify lead PT, lead Case Manager and a few substitutes
2. Identify stakeholders and start the conversation
3. Identify what is important to that individual role (ie.
Administrator)
How will this help the system?
How will this affect FTEs?
Will this prevent readmissions?
Will this increase our outpatient PT referrals? (Is there
opportunity for downstream revenue?)
How will this affect staff satisfaction?
How will this affect patient satisfaction?
4. Meet with data analyst and collect data on whats important
5. Create goals
Lebec MT, et al. Emergency department physical therapist
service: A pilot study examining physician perceptions. The
Internet Journal of Allied Health Sciences and Practice.
2010;8(1):1-12.
Lebec MT, Jogodka CE. The physical therapist as a
musculoskeletal specialist in the emergency department.
Journal of Orthopaedic & Sports Physical Therapy.
2009;39(3):221-9.
McClellan CM, Greenwood R, Benger JR. Effect of an extended
scope physiotherapy service on patient satisfaction and the
outcome of soft tissue injuries in an adult emergency
department. Emergency Medicine Journal. 2006;23:384-7.

Where to Start? References

6. Create your steering team Padgett DK, Brodsky B. Psychosocial factors influencing non-
Lead PT, Case Manager (Social Worker or RN Case Manager), ED
RN, ED physician, ED nursing director, & Rehab Director urgent use of the emergency room: a review of the literature and
7. Create care pathway recommendations for research and improved service delivery.
8. Educate stakeholder groups (pathway & what is important to them) Social Science Medicine. 1992;35(9):1189-97.
ED physicians
Wilsey BL, Fishman SM, Ogden C, et al. Chronic pain
ED nursing
Hospitalists/Internal Medicine
management in the emergency department: a survey of attitudes
Rehab department
and beliefs. Pain Medicine. 2008;9:1073-80.
Care Management department Woods EN. The emergency department: a new opportunity for
Community Resources (home health, outpatient clinics, etc) physical therapy. PT: Magazine of Physical Therapy.
Administration
2000;8(9):42-8.
9. Gather equipment and resources
10. 1 year for pilot period
11. Keep the conversation going with regular meetings/updates with
stakeholders and ask for their feedback

References Questions?

Cordell WH, Keene KK, Giles BK, et al. The high prevalence of pain in sarahnechvatal@gmail.com
emergency medical care. American Journal of Emergency Medicine.
2002;20(3):165-9.
Fleming-McDonnell D, et al. Physical therapy in the emergency
department: development of a novel practice venue. Physical Therapy.
2010;90(3):420-6.
Jibuike OO, Paul-Taylor G, Maulvi S, et al. Management of soft tissue
knee injuries in an accident and emergency department: the effect of
the introduction of a physiotherapy practitioner. Emergency Medicine
Journal. 2003;20:37-9.
Lau PM, Chow DH, Pope MH. Early physiotherapy intervention in an
Accident and Emergency department reduces pain and improves
satisfaction for patients with acute low back pain: a randomised trial.
Australian Journal of Physiotherapy. 2008;54:243-9.

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