Comprehensive Summary
This single-center pre-post implementation study evaluated adherence and utilization of a Physiotherapy-Led Emergency Department Guideline (PLEDGE) for patients presenting to the emergency department (ED) with low back pain (LBP). ED patients with LBP the year before and year after PLEDGE implementation were compared through electronic medical record review. Guideline adherence was assessed primarily by opioid analgesia use and secondarily by pathology and imaging requests. Healthcare utilization was measured by the ED National Emergency Access Target (NEAT), which reflects timeliness of care. Secondary outcomes included 28-day ED re-presentations, short stay unit (SSU) admissions, and ED length of stay (LOS). Post-implementation, opioid analgesia use (χ2 = 17.406, p < 0.001) and pathology ordering (χ2 = 6.363, p = 0.012) was significantly decreased, although imaging requests did not change. For healthcare utilization, NEAT performance and ED LOS worsened post-implementation; however, SSU admission (χ2 = 6.356, p = 0.012) and ED re-presentation (χ2 = 4.098, p = 0.043) significantly decreased.
Outcomes and Implications
LBP is one of the most common ED presentations, yet its management remains poor due to lack of clinical guideline adherence and low-value care. This study suggests that implementing a physiotherapy-led ED guideline (PLEDGE) can improve adherence to evidence-based practice by reducing opioid prescribing and pathology ordering, without increasing imaging utilization. Although NEAT performance and ED LOS worsened, 28-day ED re-presentations and SSU admissions decreased. While the single-center, nonrandomized design and bundled nature of PLEDGE limit interpretation of individual components, the findings support physiotherapy-led models as a promising strategy to enhance the quality of LBP care in the ED. Future studies should examine cost-effectiveness, evaluate the appropriateness of imaging and pathology indicators, and clarify hospitalization criteria for LBP patients.