A physiotherapy-led evidence-based pathway for emergency department patients presenting with low back pain improves guideline-adherent care and healthcare utilisation

Rosalie Gan, Caitlin Farmer, Alisha da Silva, Katharine Drummond, Lucinda Marr, John H.Y. Moi, Mark Putland
Purpose:

To determine the effect of implementing a low back pain (LBP) pathway and rapid access outpatient clinic for ED patients with LBP on variability of care, patient flow and safety.

Methods:

This pre- and post-implementation study was performed in a metropolitan tertiary hospital ED in Victoria, Australia, with no existing ED LBP pathway.  The Rapid Access eD Back Assessment Clinic (RADBAC) project was established to implement an ED LBP pathway and RADBAC outpatient clinic.   The ED LBP pathway was formulated after reviewing literature and clinical guidelines by a working group consisting of emergency, neurosurgical and rheumatological doctors, physiotherapists and a consumer.   The RADBAC outpatient clinic was led by advanced practice physiotherapists with support from neurosurgeons when required. Inclusion criteria for the clinic was designed to capture patients with more complex needs and/or at risk of re-presentation.  Referrals to RADBAC were received from ED clinicians for complex LBP patients that were discharged home from ED or the short stay unit (SSU).  Twelve-month pre- and post-implementation (May 2021 – April 2023) data were collected, including short stay admissions, ED re-presentations, investigation ordering, opioid prescriptions, patient safety and satisfaction.

Results:

During the twelve-month post-implementation period (May 2022 – April 2023), 1384 patients with LBP were discharged from ED and 283 patients referred to RADBAC, with a median [IQR] time of 7 [6-11] days to appointment. For guideline-adherent care, the post-implementation group had significantly less opioid prescriptions (χ² (1, N=2732)=17.406, p 0.001) and pathology ordering (χ² (1, N=2732)=6.363, p=0.012) however there was no reduction in imaging requests (χ² (1, N=2732)= 1.859, p=0.173). Regarding healthcare utilisation, post-implementation patients were significantly less likely to be admitted to SSU (χ² (1, N=2732)=6.356, p=0.012) or re-present to ED (χ² (1, N=2732)=4.098, p=0.043) however other healthcare utilisation measures were not improved. The outpatient clinic played a key role in patient safety, identifying five patients with red flags requiring urgent management, and achieved a high level of patient satisfaction.

Conclusion(s):

The implementation of a Physiotherapy-led evidence-based ED LBP pathway with a rapid access outpatient clinic improved the management of LBP patients presenting to ED by decreasing opioid prescriptions, pathology ordering, short stay admissions and representations to ED, and also contributed to patient safety.

Implications:

A physiotherapy-led ED LBP pathway including a rapid access advanced practice outpatient clinic is acceptable to stakeholders and can be an effective strategy in acute hospitals for improving guideline-adherent care and healthcare utilisation.      

Funding acknowledgements:
This study was funded through a $50,000 grant provided by the Royal Melbourne Hospital Foundation.
Keywords:
Emergency department
Low back pain
Advanced Practice Physiotherapy
Primary topic:
Musculoskeletal: spine
Second topic:
Service delivery/emerging roles
Did this work require ethics approval?:
Yes
Name the institution and ethics committee that approved your work:
The study was approved by the Melbourne Health Human Research Ethics Committee, Office for Research
Provide the ethics approval number:
QA2022082
Has any of this material been/due to be published or presented at another national or international conference prior to the World Physiotherapy Congress 2025?:
Yes

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