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SICK PARADE: IT’S PROBABLY NOT WHAT YOU THINK

A.L. Ager

 

Imagine an emergency department (ED) where true interdisciplinary cooperation happens, where clinicians and not overly territorial of their fields of practice, and where patients can directly access the health care professional they need. A multi-disciplinary triage system? Welcome to the concept of sick parade.

While they coined the term “sick parade,” the concept is not exclusive to the military. Hospitals around the world, notably in Australia, the United Kingdom, the United States, and perhaps even some parts of Canada are beginning to recognize the benefits of having a well-oiled interdisciplinary team at the helm of a font-line emergency department.

 

How it works

Sick parade is the military medical triage system that occurs every morning, usually between 0700-0930 for patients with acute ailments. Military members can go directly to the hospital, where they will be quickly screened by a triage nurse. If their signs and symptoms appear to be musculoskeletal (MSK) in nature, they are referred directly to the physiotherapist (PT).

The PT assigned to sick parade will be responsible for the medical screening of the patient. Once the obvious red and yellow flags have been addressed and the source of discomfort continues to present itself as an MSK disorder, the physiotherapist can:

  • Provide advice
  • Offer a treatment
  • Refer the patient for further medical intervention (including a referral for further PT services, of course!)

This is a proactive approach to putting out acute MSK fires, and can perhaps even help interrupt the chronicity process. Speaking from experience, the sick parade process allows the PT to intervene at a very early stage of healing and to offer proactive advice to patients, even those who await further intervention.

The physiotherapist is part of a tightly knit and patient-centric team and has an evaluation station directly within the triage environment. As such, the PT has direct access to the physician-assistant (PA), the nurse practitioner, and even the doctor or specialist.

The fundamental success of the triage system relies on the basis that the patient is treated by the appropriate clinician. If the medical complaint can be addressed solely with the physiotherapist, then there is no need for further consultation with a physician.

If by contrast, the patient requires medical imaging, medication, or a specialist consult, the PT will discuss the case with the physician, who will then continue the medical line of inquiry.

Military sick parade has been around for years and is arguably ahead of its time. But it doesn’t have to be a “military marvel.” This model can easily (and I would argue should) be applied to civilian hospitals.

 

The Successes of a PT in an Emergency Department (ED)

  • Direct, front-line access to a physiotherapist
  • Acting as the educational Subject Matter Expert (SME) for other clinicians within the department
  • Appropriate MSK advice and care given to the patient during the acute phase of healing
  • Timely referral to outpatient physiotherapy services (as deemed appropriate)
  • Allows for appropriate clinical intervention for various degrees of medical emergencies (appropriately sharing the evaluation roles among health care providers)
  • A possible health care model that can increase the efficiency of emergency departments
  • A potential decrease in wait times for patients
  • A cost effective approach for the triage system, liberating physicians for appropriate and often life threatening cases
  • A truly interdisciplinary approach to patient care

 

The Potential Challenges of a PT in an ED:

  • Requires an efficient and experienced physiotherapist with sharp clinical reasoning skills on the front-line (Advanced Physiotherapy Practice)
  • Willingness of all clinicians to cooperate and share the diagnostic / clinical impression role (which I believe we can all agree is often a point of friction)
  • Within smaller EDs, there may be too few MSK patients to justify a full time position for a PT
  • Justifying the budget for a PT position in the ED

Emergency departments have traditionally been designed to address medical life threatening emergencies. However, there seems to be an emerging trend for individuals to consult EDs for non-life threatening MSK pain in order to gain access to health care.

A study involving the United States between 2006-2007 found that 30% of the 61.2 million MSK injuries treated during that period occurred in the emergency room (ER) (Pitts et al. 2008). The National Ambulatory Care Reporting System in Canada (2014-2015) suggests that the leading reason to consult an ER for MSK pain includes cervical and lumbar regions. As subject matter experts on the MSK system, shouldn’t we be where the action is?

What remains exciting about the health care system is its continuously evolving nature. The role of a physiotherapist has drastically changed over the years, after sprouting from nursing roots during the two World Wars.

Historically, physiotherapists were not able to offer clinical diagnosis; we were to simply follow the “doctor’s orders”.

Currently, we are leaning forward and offering clinical impressions, exploring the possibilities of prescribing basic medications, and requesting medical imaging (with the proper qualifications).

Isn’t it about time that the emergency department infrastructure evolved, too?

If you are fortunate enough to work in a progressive health care establishment that has already put the wheels in motion to include physiotherapy in the triage equation, please let us know about your experiences.

If you wish you open a dialogue about the current obstacles facing the concept of a PT within the ED, we would like to hear from you as well!

This is not a new concept, but one that still struggles to gain traction. Should this be our next legislative challenge in Canada?  I’m game, if you are.

 

For further reading on the subject, I strongly recommend:

Ball, S.T.E., Walton, K., & Hawes, S. (2007). Do emergency department physiotherapy Practitioner’s, emergency nurse practitioners and doctors investigate, treat and refer patients with closed musculoskeletal injuries differently? Emerg Med J . 24:185–188. doi: 10.1136/emj.2006.039537

Bethel, J. (2005). The role of the physiotherapist practioner in emergency departments: a critical appraisal. Emerg Nurse. 13 (2): 26-31.

Farrell, S. (2014). Can physiotherapists contribute to care in the emergency department?Australas Med J. 7(7): 315-317.

Kilner, E., & Sheppard, L. (2010). The ‘lone ranger’: a descriptive study of physiotherapy practice in Australian emergency departments. Physiotherapy. 96(3):248-56.

Pitts, S.R., Niska, R.W., Xu, J., & Burt, C.W. (2008).  National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. Natl Health Stat Rep. 2008;7:1–39.

Lebec, M.T., & Jogodka, C.E. (2009). The physical therapist as a musculoskeletal specialist in the emergency department.  JOSPT. 39 (3): 221-229.

CIHI (2016). Emergency and Ambulatory Care. Retrieved from: https://www.cihi.ca/en/types-of-care/hospital-care/emergency-and-ambulat... (07 Feb 2016).