A Physiotherapy-Led Emergency Department Guideline (PLEDGE) for Patients Presenting With Low Back Pain: Pre- and Post-Implementation Study

Objective

We evaluated guideline adherence and healthcare utilisation in an emergency department (ED) pre- and post-implementation of a physiotherapy-led low back pain (LBP) guideline and rapid outpatient follow-up service (collectively termed PLEDGE model).

Methods

The PLEDGE model was implemented in a metropolitan tertiary hospital. Data from LBP ED presentations were extracted from electronic medical records for 1 year pre- and post-PLEDGE model implementation. To evaluate guideline-adherent care, the primary outcome was the incidence of any opioid analgesia use. Requests for imaging and pathology were secondary outcomes. To evaluate healthcare utilisation, the primary outcome was the ED National Emergency Access Target (NEAT). Secondary outcomes included ED re-presentations within 28 days, short stay unit (SSU) admissions and ED length of stay (LOS).

Results

Overall, 2732 patients were included (1384 post-implementation). For guideline-adherent care, opioid analgesia (χ² (1, N = 2732) = 17.406, p < 0.001) and pathology ordering (χ² (1, N = 2732) = 6.363, p = 0.012) significantly reduced post-implementation; however, there was no reduction in imaging requests (χ² (1, N = 2732) = 1.859, p = 0.173). With respect to healthcare utilisation, measures of ED NEAT and ED LOS worsened. 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).

Conclusion

Implementation of the PLEDGE model reduced opioid analgesia use, pathology ordering, SSU admissions and ED re-presentations and provided a valuable safety net. ED NEAT worsened, ED LOS increased and imaging requests remained unchanged.