Physiotherapist-led emergency care cut an hour off length of stay

Design

open-label pragmatic randomised controlled trial with economic evaluation, 5 emergency departments, intention-to-treat linear mixed-effects model

Population

1,475 adults with uncomplicated musculoskeletal presentations, mean age 40.1 years

Primary outcome

emergency department length of stay, arrival to discharge

Effect

2.4 h vs 3.4 h, difference −1.0 h (95% CI −1.2 to −0.8); adverse events 6.6% vs 5.9% (P = 0.72); cost −$35.10 (−69.0 to −1.7)

RESHAP-ED was an open-label pragmatic randomised trial across five emergency departments in New South Wales. It enrolled 1,491 adults presenting with uncomplicated musculoskeletal problems — soft tissue injuries, neck and back pain, and fractures or dislocations not needing orthopaedic review or surgery — and randomised them 1:1 to physiotherapist-led care or usual physician- or nurse-practitioner-led care. Follow-up for the primary outcome was complete.

Mean length of stay was 2.4 hours against 3.4 — a reduction of 1.0 hour (95% CI −1.2 to −0.8). Adverse events were 6.6% against 5.9% (P = 0.72). Costs were lower by $35.10 per patient (95% CI −69.0 to −1.7), with a 98.1% probability of cost-effectiveness.

An hour per patient across a category that fills a large share of every emergency department is an unusual finding: interventions that shorten stay usually do it by moving work elsewhere or by accepting more risk, and this one did neither. The transferable element is the eligibility rule rather than the staffing model — it worked because someone defined precisely which presentations do not need a doctor, and set them on a separate track from arrival. That definition is what any department adopting this has to write for itself.

• Define the eligible presentations explicitly before changing who sees them — the rule is the intervention
• Keep the exclusion for anything needing orthopaedic review or surgery; that boundary is what kept harm flat
• Measure length of stay for the eligible group specifically, not department-wide, or the effect disappears into the average
• Confirm local scope of practice for imaging requests and analgesia prescribing before implementing

Why it matters

It is a length-of-stay reduction that did not come from shifting work downstream or accepting more risk.

Don't overread it

Five Australian departments with a tightly defined eligible group — the result belongs to that group, not to emergency musculoskeletal care in general.

The statistics, in plain English

A one-hour mean reduction with an interval of 0.8 to 1.2 hours is both precise and large for a service-delivery trial. The adverse event comparison (6.6% vs 5.9%, P = 0.72) shows no signal of harm, but a trial of 1,475 patients cannot exclude a rare serious miss — that reassurance would need a much larger sample.

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