A wide range of new initiatives in the ED, such as “see and treat” and “streaming”, have been advocated as ways of improving waiting times without reducing the quality of care.14
However, many of these initiatives lack good evidence to support them.15
We therefore set out to evaluate the effect of introducing an ESP service on both patient satisfaction and clinical outcomes.
Our patient satisfaction study showed strong support for an ESP service. This superior satisfaction may reflect the appropriate use of a physiotherapist's skills, and satisfaction may itself be a good indicator of quality of care.16
There are, however, many other important factors to consider. Patients who were managed by an ESP spent almost twice as much time with the treating clinician, and the more time a practitioner spends with a patient the more satisfied they are likely to be. In addition, the overall ED stay of patients who saw an ESP was reduced. These factors alone will have a powerful influence on patient satisfaction, and it is therefore unclear how much of the improved satisfaction was due to the reduced stay and increased attention, and how much was due to the unique skills of an ESP.
Patients may have preconceived ideas about treatment by different members of the interdisciplinary team, which may also be influenced by previous experiences or education. Patients are frequently managed by a single member of the interdisciplinary team (ENP, doctor, or ESP), and will receive different levels of information depending on experience, personality, time pressures, and the communication skills of the practitioner. Patients who saw an ESP felt they received significantly better advice about their condition, were given time to ask questions, and received a clear explanation of the results of their assessment, as well as the management plan. All of these factors are important when educating and empowering patients to recover effectively from soft tissue injuries. These factors may also explain the increased time spent with the physiotherapist, and also suggest that ESPs may be less “efficient” than other practitioners in terms of the number of patients seen and treated within a set period of time.
The SF‐36 and VAS failed to show any statistically significant difference in the outcome of patients who attended the ED with unilateral soft tissue ankle injuries. The return rate of the questionnaire was much lower than expected, undermining the comparisons made. However, despite the small number of patients there is a trend for management by an ESP to be associated with reduced pain, improved physical function, and improved general health status one month after injury. This is in contrast to the recently published study of initial physiotherapy assessment in an ED,11
and is difficult to reconcile. Our results are inconclusive and based on smaller numbers, but do not support the idea that ESP management has an adverse effect on outcome. Differences in training and competencies, or patient case mix may also be relevant and deserve further study.
Our study had several weaknesses. Firstly, it was conducted in a single centre, and the wider applicability of our findings is unknown. Secondly, it also evaluated the work of a single ESP, and it is therefore impossible to say to what extent the findings are attributable to one individual, or to all ESPs in general. Finally, the observational methodology employed is less robust than the randomised design employed by Richardson et al
The ED is unlikely to benefit from more than one or two whole time equivalent ESPs within an interdisciplinary team, mainly because ESPs are not as versatile as ENPs or ED doctors. This specificity of treatment limits the number of patients that they can see (20–30% of all patients attending our adult ED), but they are capable of managing a specific minor injuries “stream” with good throughput, high patient satisfaction, and clinical outcomes that may be superior to current practice.