Effect of an extended scope physiotherapy service on
patient satisfaction and the outcome of soft tissue injuries in
an adult emergency department
C M McClellan, R Greenwood, J R Benger
............................................................... ............................................................... .
An appendix to this paper
has been posted online at
See end of article for
Dr J Benger, Jonathan.
Accepted for publication
1 December 2005
Emerg Med J 2006;23:384–387. doi: 10.1136/emj.2005.029231
Objectives: To evaluate the effect of introducing an extended scope physiotherapy (ESP) service on patient
satisfaction, and to measure the functional outcome of patients with soft tissue injuries attending an adult
emergency department (ED), comparing management by ESPs, emergency nurse practitioners (ENPs), and
all grades of ED doctor.
Methods: The ESP service operated on four days out of every seven in a week in an urban adult ED. A
satisfaction questionnaire was sent to all patients with a peripheral soft tissue injury and fractures (not
related to the ankle) within one week of attending the ED. Patients with a unilateral soft tissue ankle injury
were sent the acute Short Form 36 (SF-36) functional outcome questionnaire, with additional visual
analogue scales for pain, at 4 and 16 weeks after their ED attendance. Waiting times and time spent with
individual practitioners was also measured.
Results: The ESP service achieved patient satisfaction that was superior to either ENPs or doctors. Overall
55% of patients seen by the ESP service strongly agreed that they were satisfied with the treatment they
received, compared with 39% for ENPs and 36% for doctors (p=0.048). Assessment of long-term
outcome from ankle injury was undermined by poor questionnaire return rates. There was a trend towards
improved outcomes at four weeks in those patients treated by an ESP, but this did not achieve statistical
Conclusion: Adding an ESP service to the interdisciplinary team achieves higher levels of patient
satisfaction than for either doctors or ENPs. Further outcomes research, conducted in a wider range of
emergency departments and integrated with an economic analysis, is recommended.
programmes to expand their scope of practice.1It is, however,
essential to demonstrate that individuals who are treating
patients have the necessary skills and competencies to deliver
high quality care.2
An extended scope physiotherapist (ESP) is a physiothera-
pist who has additional skills in assessment, diagnosis, and
management. In the adult emergency department (ED) of the
Bristol Royal Infirmary an ESP is able to autonomously
manage new patient presentations of soft tissue injuries and
associated fractures, request radiographs, prescribe limited
medications, and refer to other services as required. The
addition of an ESP to the interdisciplinary team increases
access to a practitioner with specialist skills for patients and
staff.3Although research relating to the role and effectiveness
of ESPs has been published, this has concentrated on ESPs in
orthopaedic, rheumatology, and spinal outpatient clinics.4–9
There is no published research evaluating patient satisfaction
with ESPs in the ED. However, studies of patient satisfaction
with ENPs have all reported positive outcomes in relation to
communication, education, and care received.10There is little
research concerning the role of an ESP managing an
independent caseload in the ED and the effects on treatment
outcomes, but a recent randomised trial reported that initial
assessment by a physiotherapist led to an increased time
before patients returned to normal activities, compared with
usual ED care.11In the present study we also aimed to
evaluate the effect of introducing an ESP in the adult ED,
comparing three different practitioners: doctors, emergency
nurse practitioners (ENPs), and ESPs.
urses and allied health professionals are increasingly
adopting new roles within the UK National Health
Service, adapting skills and using proactive education
N To compare patient satisfaction between ESP, ENP, and all
grades of doctor in an adult ED.
N To evaluate functional outcome from unilateral soft tissue
ankle injury, comparing management by ESP, ENP, and all
grades of ED doctor.
We undertook this single centre study in the adult ED of the
Bristol Royal Infirmary between September 2003 and April
2004. The Central and South Bristol Research Ethics
Committee approved the study.
The ESP service provided a range of representative early shifts
(8.30 am to 3.30 pm) and late shifts (12.30 pm and 7.30 pm)
on four days out of every seven days of the week. An ESP
independently managed a caseload from arrival to disposal
and was trained to request x rays, prescribe limited
medication, and independently manage patients with per-
ipheral soft tissue injuries and associated fractures. The ESP
service used the same protocols as the other practitioners.
The ED notes relating to all patients attending between 8:30
am and 7:30 pm were reviewed by hand on a daily basis,
Abbreviations: ED, emergency department; ENP, emergency nurse
practitioner; ESP, extended scope physiotherapist; SF-36, Short Form;
VAS, visual analogue scale
seeking patients eligible to be included in either part of the
study (patient satisfaction or outcome from soft tissue ankle
injury). Where available, data were also collected for each of
the three practitioner groups concerning the arrival to
discharge time, arrival to first contact with the treating
clinician and time spent with the treating clinician.
Patient satisfaction questionnaire
A patient satisfaction questionnaire was developed and
piloted in February 2003 (see Appendix 1 online at http://
www.emjonline.com/supplemental/). It was sent to all
patients with a peripheral soft tissue injury or fracture (not
related to the ankle) within one week of attending the ED.
Patients were only sent the questionnaire if they had
attended the ED during a period when the ESP service was
present. This is because patient satisfaction is known to be
strongly associated with waiting time,12which might be
reduced when an ESP was present. The proportion of patients
who reported that they were ‘‘very satisfied’’ with various
aspects of the service was compared between the three
professional groups: ESPs, ENPs, and doctors using a Pearson
x2test. All returned patient satisfaction questionnaires were
scanned using optical character reader Teleform 8.0 software
to automate data entry. A total of 550 patients was required
to detect a change from 30% to 50% in the proportion
responding ‘‘very satisfied’’ (ESP 140 patients, all other
practitioners 410 patients).
Assessment of outcome
For the outcome study, we recruited patients who presented
to the ED with a unilateral soft tissue injury of the ankle and
no associated fracture. We used a well-established functional
outcome questionnaire with proved reliability and sensitivity,
the acute Short Form 36 (SF-36). The acute SF-36 is useful
for comparing general and specific populations, and differ-
entiating between the health benefits produced by different
treatments.13A visual analogue scale (VAS) was added to
measure pain levels at rest and during activity at the time of
completing the questionnaire and before the injury. This
allowed a pre-injury baseline to be established, thereby
optimising the value of the SF-36. Eligible patients were sent
a questionnaire four weeks after their ankle injury. If they
replied to this questionnaire a second identical questionnaire
was sent 16 weeks after the injury.
We analysed the SF-36 and additional VAS using non-
parametric statistics. Both median values with ranges, and
means with standard deviations, are reported to facilitate
understanding and future sample size calculations. Where
statistical comparisons were made we used a Kruskal–Wallis
During the period of the study there were 11 771 minor
injury attendances to the Bristol Royal Infirmary emergency
department. A total of 780 patients were sent patient
satisfaction questionnaires and 489 patients were recruited
to the ankle injury outcome study. The patient satisfaction
Satisfaction was consistently higher for the ESP service than
for either of the other professional groups in all seven of the
domains studied (table 1). Overall, 55% of patients strongly
agreed that they were satisfied with the treatment they
received, compared with 39% for ENPs and 36% for doctors.
The SF-36 questionnaire and VAS were sent to 489
patients. The return rate at one month was 22%, and only
4.5% at both one and three months. Due to the poor return
rate at three months only the one month data are presented
here. The number of valid SF-36 data sets at one month was
91/489 (18.6%). Figure 1 shows total SF-36 scores comparing
ESP, ENP, and doctor. The total number of valid VAS at one
month was 104, and the results from these are summarised
in table 2. Graphical investigation showed the VAS results to
be highly skewed before injury, and slightly skewed after
Both the SF-36 and the VAS show a trend towards
improved pain and function one month after injury in
patients managed by an ESP, compared with management by
an ENP or doctor, but the numbers are small and should
therefore be interpreted with caution.
The waiting time analysis showed that patients managed
by an ESP waited less time to be seen and less time overall
than those managed by an ENP or doctor (table 3). Patients
also spent more time with the ESP than they did with either a
doctor or ENP. Although these results do not reach statistical
significance there is an interesting trend, with patients who
saw an ESP spending 36% of their ED stay with a clinician,
questionnaire, comparing extended scope physiotherapist (ESP), emergency nurse practitioner (ENP) and doctor (all grades)
Percentage of patients who responded ‘‘strongly agree’’ to the individual questions in the patient satisfaction
I felt I received good advice and information about my condition
I was given enough time to ask questions and discuss my condition
I felt confident the member of staff could deal with my condition
I felt confident the member of staff would have got a second opinion if necessary
The member of staff explained the results of the assessment
The member of staff explained what would happen next regarding my injury
Over all I was satisfied with the treatment received
Total SF-36 score
injury, comparing extended scope physiotherapist (ESP), emergency
nurse practitioner (ENP), and doctor (all grades). In this analysis, a
higher number indicates a better health status.
Combined Short Form 36 (SF-36) results at one month after
ESPs in an adult emergency department385
compared with 20% for doctors and 19% for ENPs. In
addition, the overall ED stay of patients who saw an ESP was
reduced. These observations may have a significant impact on
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.14However, many of these initiatives lack good evidence
to support them.15We therefore set out to evaluate the effect
of introducing an ESP service on both patient satisfaction and
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.16There 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
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,11and 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
Our study had several weaknesses. Firstly, it was con-
ducted 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.11
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
This study shows that an ESP achieves higher levels of
patient satisfaction than either doctors or emergency nurse
practitioners in the management of soft tissue injuries and
associated fractures. Much of this may be attributable to
reduced waiting time and increased clinician contact for
patients seeing an ESP, as well as the specialist skills of this
professional group. We failed to demonstrate any significant
difference in the outcome of unilateral ankle soft tissue
injuries, possibly due to poor questionnaire return rates, but a
trend favouring management by an ESP was observed.
Further outcomes research, integrated with a formal eco-
nomic analysis, is required.
Expansion of professional boundaries is being actively
encouraged within the modern NHS, but a programme of
formal evaluation, to provide robust information on which
future decisions can be based, must accompany such
initiatives. This will also ensure that a patient focus is
scope physiotherapist (ESP), emergency nurse practitioner (ENP) and doctor (all grades)
Means and medians of the visual analogue scales for pain and function one month after injury, comparing extended
ESP (n=16)ENP (n=38)Doctor (n=50)
*p valueMean (SD)Median (range)Mean (SD)Median (range) Mean (SD)Median (range)
In this analysis, lower scores indicate reduced pain and increased function.
spent with the patient, and total arrival to discharge time
of patients with minor injuries managed by an extended
scope physiotherapist (ESP) or emergency nurse
practitioner (ENP) or doctor (all grades)*
Comparison of time waiting to be seen, time
Time waiting to be seen
Time spent with patient
Total arrival to discharge time
*All times are mean values and measured in minutes.
386McClellan, Greenwood, Benger
maintained, and that the most appropriate skills are used to
create the optimal interdisciplinary team.
We thank Sue Taylor, Head of Physiotherapy at United Bristol
Healthcare Trust, Mike Paynter, lead Emergency Nurse Practitioner,
Bristol Royal Infirmary Emergency department, and Rebecca
McClellan for their assistance with this study.
C M McClellan initiated the research with the support of R
Greenwood and J Benger. The protocols were designed by all authors.
Data were collected by C M McClellan and analysed by R Greenwood.
The manuscript was drafted by C M McClellan and revised by R
Greenwood and J Benger. The guarantor for the paper is C M
C M McClellan, J R Benger, Academic Department of Emergency Care,
Emergency Department, Bristol Royal Infirmary, Bristol, UK
C M McClellan, J R Benger, Faculty of Health and Social Care, University
of the West of England, Bristol, UK
R Greenwood, Research and Development Department, United Bristol
Healthcare Trust, Marlborough Street, Bristol, UK
This study was supported by the United Bristol Healthcare Trust and
Competing interests: none declared
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ESPs in an adult emergency department 387