Extended Scope Physiotherapists are Effective and Safe in the Emergency Department: A Systematic Review and Meta-Analysis

Purpose: Extended scope physiotherapists (ESPs) are an innovative approach to service delivery that have emerged in response to increasing pressures on emergency departments (EDs). While previous systematic reviews have suggested that ESPs have a positive impact on ED outcomes, clinical practice recommendations based on limited evidence highlight a pressing need for evaluation studies to truly determine their effectiveness and safety in this setting. Therefore, the objective of this systematic review and meta-analysis was to evaluate the clinical effectiveness and safety of ESPs when delivering services in EDs. Method: Systematic literature searches were conducted using the online databases: Medline (Ovid), CINAHL (EBSCOhost), Scopus, PEDro, Cochrane Library and Informit in October 2019. Randomised controlled trials (RCTs) or cohort studies investigating the clinical effectiveness and safety of ESPs in EDs in comparison with usual ED medical care providers were eligible for inclusion. Data extraction was completed using a form specifically developed for the study. The quality of each study was assessed using the Crowe Critical Appraisal Tool (CCAT) as well as a subjective assessment of bias, and the level of evidence was graded using the National Health and Medical Research Council (NHMRC) evidence hierarchy. Random-effects model meta-analyses were conducted using Stata (version 16.1). Results: Eleven studies met the inclusion criteria for the systematic review. These studies provided III-1 to III-3 evidence, with quality scores ranging from 50% to 93%. Consistent positive results were found regarding ESP clinical effectiveness and safety with meta-analyses demonstrating significant reductions in wait time (Cohen's d effect size: -0.54; 95% confidence interval [CI]: -0.64 to -0.45) and length of stay (Cohen's d effect size: -0.79; 95% CI: -0.86 to -0.72) for patients managed by ESPs. Although, confounding of results by treatment urgency made it difficult to establish a clear causal link between ESP services and outcomes. Conclusion: Although it was not able to be suggested that ESPs are an appropriate substitute for usual ED medical care due to the presence of bias and confounding, the results highlighted that ESPs, as an additional staff member in EDs, improve throughput and access to care for patients in lower urgency triage categories.