Allied health advanced clinical practitioners have the potential to develop innovative, responsive, and efficient models of care in a range of healthcare environments, including the emergency department. Piers Truter is an advanced scope physiotherapist (ASP) who strongly believes the best model of care for patients with musculoskeletal conditions in an emergency department (ED) is made possible by the skills of ASPs.¹ Since 2016, Piers has worked beyond his clinical roles as a health system innovator.

He was engaged in the establishment of the advanced scope physiotherapy ED services at the Saint John of God Midland Hospital and Gold Coast University Hospital, and more recently, he developed a physiotherapy-led ‘virtual fracture clinic’ providing orthopaedic telehealth fracture care at Fiona Stanley Hospital. In December 2021, he was awarded a WA Department of Health (DoH) grant to divert patients from the Emergency Department to a novel outpatient physiotherapy clinic. This diversion pathway is now permanently funded at Rockingham General Hospital and moves patients with musculoskeletal conditions from the ED waiting room to the ASP-led ED musculoskeletal diversion clinic.

The clinic is staffed by ASPs, supported by senior physiotherapists with outpatient and ED experience, and manages typical physiotherapy patients as well as providing comprehensive fracture care including plastering and thermoplastic splinting. Piers' clinic team  increases the Rockingham General Hospital ED clinical capacity by 250-300 patients per month; from a patient perspective, this means wait times are reduced on average by about two hours to around 50 minutes.

Earlier this year, Piers presented A novel model of advanced physiotherapy practice: Diverting patients from the emergency department directly to an outpatient clinic at the 15th National Allied Health Conference in Perth, discussing his findings that the clinic significantly reduces crowding in the emergency department, provides excellent care and is cost effective. We spoke with Piers about his work innovating novel models of care at Fiona Stanley Hospital (FSH) and Rockingham General Hospital.

How do you define your role as an advanced scope physiotherapist?

I'm a primary contact practitioner, so when I'm working clinically, the responsibility for looking after the patient sits with me. In the ED context, I can self-select a patient, provide care, order imaging and undertake necessary procedures, and discharge them home, autonomously. I can manage patient care independently, which is not generally how allied health work in hospitals. Usually, allied health in hospitals are secondary contact practitioners and operate on a referral basis for a medical practitioner who holds governance for that patient.

How was the virtual fracture clinic set up for WA Department of Health?

The model of virtual fracture clinics (VFC) comes from Europe, and the concept is that there are some fractures where patients don't actually need surgery, they don't really need more care—what they need to do is understand their injury and effectively self-manage it.

That model of care is gaining favour in Europe. So I thought given the good evidence for that, we could try doing something like it at Fiona Stanley. The concept makes sense to hospitals and patients, which is why there are also virtual fracture clinics at Logan, Townsville, and in Western Health in Melbourne.

The VFC operates by moving patients with simple fractures off the orthopaedic trauma list. The advanced scope physiotherapists contact that patient by TeleHealth and let the specialists focus on patients with complex injuries who may need surgery. We manage patients with self-limiting injuries and help patients to self-manage and understand their problem. They never make footfall in the hospital, which of course during COVID was quite useful, because we didn't change our practice at all.

Let's talk about the model of care offered by the ED musculoskeletal diversion clinic

We received funding from the WA DoH emergency department innovation fund for an 18 month pilot, and we were able to demonstrate proof of concept with experienced clinicians from the Fiona Stanley Hospital ED ASP team in the first six months.

It was obvious from the start that the main challenge to establishing a sustainable clinic was going to be workforce. We developed a training program which allowed us to train from scratch an entirely local workforce, and we were so successful that the South Metropolitan Health Service executive and the Rockingham Hospital executive permanently funded our clinic. That funding is really important for attracting talent, because clinical innovation, with practitioners working to the full extent of their scope, requires experienced and well-trained clinicians.

As of mid-2023, the clinic sees about 250 to 300 patients a month, not the kind of figures we were getting in our start-up phase. This has a measurable impact on the emergency department, with patients leaving the ED so the next patient moves up in the queue. Diverted patients move to the lower stakes environment of outpatients where they can receive expert care with the diversion clinic team. That's the piece that's essential: having suitably trained and credentialed primary contact practitioners to take over the role of ED with these minor injuries.²

I think a message which I'm really keen to get out is (we didn't know this before we started, but now we do), most EDs have a cohort of patients that would sustain the establishment of a diversion clinic. We've demonstrated that you can train local staff to do it; even if you don't have a primary contact physiotherapy workforce, you can develop your own. It is a sustainable model, which has a measurable impact on the performance of the ED, and [I feel that] we've reached the point where it'd be worth a lot of hospitals considering this model as part of their own emergency department.

How do you recruit allied health clinicians for a primary contact practitioner pathway?

That's the big question facing us. Developing a primary contact practitioner means we need to have a defined and agreed upon—ideally national—strategy for saying these people have the appropriate qualifications, they've got the appropriate training, they've got the appropriate competencies, and therefore they form part of this workforce—there is a big piece of work to be done to do that so that we have the ability to recognise these people, and so they can move between health services without having to start all over again. Right now, it's all very siloed.

When you started the ED musculoskeletal diversion clinic, how did your medical practitioner colleagues react?

When we started they didn't understand why we were there, and then they realised that in our niche area, we are very effective at treating patients with musculoskeletal conditions; we're effective diagnosticians, we understand the conditions well, we provide comprehensive management plans, and we use less imaging.

Over time, we have become a respected and integral workforce of our host ED. In many EDs, nurse practitioners perform a role where they see musculoskeletal patients. There's no doubt they can see them and there are many rural settings where a nurse practitioner is more effective due to their larger scope of practice. For patients with musculoskeletal conditions in good sized ED, ASPs may be the most efficient workforce, simply because we have considerably more education, training and experience with this patient group.³

Let's just put it in context: nurse practitioners are fantastic wound managers because they've had years of training to manage wounds; physiotherapists have had years of musculoskeletal training. All of the ASPs in WA have a clinical Master's degree and significant experience managing musculoskeletal patients—so of course we're better at it, we're literally more expert. My own experience working in the Fast Track area of several EDs is that working as a team, ASPs and NPs can make a fantastic team. The ASPs focus on the musculoskeletal and the nurse practitioners move into the boundaries of their scope, seeing patients with eye injuries, gynae complaints, wounds, and managing unwell people. Then you get this really efficient workforce with nurse practitioners and advanced scope physiotherapists and doctors working together with each person, seeing where the expertise lies. It's the best model of care in the ED in my opinion.

How do you think the pandemic helped shape attitudes to the roles played by AHPs in keeping people out of hospital?

I think there was downwards pressure from hospital executives, rather than AHPs trying to give upwards pressure, to avoid footfall in the hospital. So any process that would keep people at an arm's length who didn't necessarily need hospital care, that could be cared for through other pathways... I think there was a real willingness at that time to explore those pathways. Whereas before, there wasn't necessarily the same drive to do it; top-down pressure is a lot more effective than bottom-up pressure.

How integral do you feel innovation is to improving allied health care outcomes?

One thing to know is that a lot of the things we already do have value, so we need to keep doing the things that we do well. We don't necessarily need to innovate everywhere, however I don't think that most allied health operate anywhere near their full scope—we need innovation in the space of: 'what are allied health capable of contributing beyond what they already contribute?' To drive that, we need a strategic desire from health services at a [state] level, and then we need significant funding change within the health area to acknowledge those novel or advanced scope roles for allied health; many projects fail to get up, because the current funding model of allied health does not support advanced practice or recognise the impact they have.

Piers, any final thoughts as an advanced scope physiotherapist?

We need more ASPs! If anybody wants to come to Rockingham, we would love to have you. We've got a great training program. We've got kangaroos in the car park. It's a beautiful part of the world. Piers Truter is a Senior Lecturer at University of Notre Dame School of Physiotherapy, and practices advanced scope physiotherapy at The Fiona Stanley Hospital and Rockingham General Hospital. Follow Piers on LinkedIn | Join the Advanced Practice Collective, a Community of Practice for advanced allied health practitioners with an interest in continuing professional development and peer group discussion. | Join us for the Advancing Practice Across Australia Summit on Wednesday, March 6, 2024 at the Ann Harding Conference Centre, University of Canberra. This in-person event is a unique opportunity to connect with healthcare leaders and expand your knowledge of advanced clinical practice for the Allied Health, Nursing and Midwifery workforce.

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