When physiotherapist Piers Truter APAM had a chance encounter in 2020 with a mother waiting in the emergency department (ED) at Perth’s Fiona Stanley Hospital to get a cam boot for her son’s injured ankle, an idea began to form in his mind. 

‘There has to be a more efficient way to manage this sort of thing,’ he mused.

Piers happened to be shadowed that day by the hospital’s allied health director, Kellie Blyth, a common practice in the teaching hospital to improve services and communication across the facility. 

Piers and Kellie began ruminating about how this seemingly simple request had cost the mother and son hours of their time and the Western Australian public health system two ED visits—this was the second time they had been to the hospital. 

‘Surely there must be a simpler way to help such people and make better use of valuable hospital ED resources and time,’ Piers and Kellie pondered.

‘This woman brought her son to the ED for a cam boot and waited while patients with more acute needs were seen first. 

'I said to her, “Okay, just come in; bring your son.” We fitted the cam boot and five minutes later they were gone. 

'It was so straightforward,’ Piers says.

And with that, the seed was sown for an ED pathway that would divert people with selected musculoskeletal conditions to see a physiotherapist in an outpatient clinic.

The first steps

Generated by that simple interaction, an innovative new program is now underway in the Rockingham General Hospital ED. 

It is breaking down barriers, challenging norms and, more crucially, streamlining treatment and saving health dollars. 

In just a few short years, the idea of running a diversion pathway in a hospital ED—in which selected patients with musculoskeletal conditions are instead treated in outpatient clinics by advanced scope physiotherapists— has gone from a light bulb moment to a reality that is valued as much by hospital executives and staff as it is by patients.

Piers holds multiple roles. 

He is an advanced scope physiotherapist in the ED at Fiona Stanley Hospital, an advanced scope physiotherapist and clinical lead in the Rockingham General Hospital ED, a Future Health Research and Innovation Fund Fellow, a senior lecturer in the School of Health Sciences at the University of Notre Dame Australia and a principal allied health adviser to the Chief Allied Health Office.

To start realising his vision, Piers and his team first set up a diversion pathway at Rockingham General Hospital ED. 

The pathway was piloted at Rockingham General and Fiona Stanley hospitals in 2020; however, it was paused at the latter hospital due to the COVID-19 pandemic. It is proposed to recommence there later this year.

At Rockingham General Hospital, though, the pathway has been an outstanding success. 

By the end of the first year of the pilot program, it had become permanently funded. 

By the end of 2024, some 10,000 patients with musculoskeletal conditions had been seen and treated expeditiously, with significant cost savings to the hospital. 

In November 2024, the diversion pathway won the WA Health Excellence Award in Patient-Centred Care.

Piers Truter.

The success of the program led to Piers being awarded a WA Health Future Health Research and Innovation Fund fellowship to evaluate the Rockingham General Hospital diversion pathway and consider how it might be expanded across Fiona Stanley Hospital and Peel Health Campus in Mandurah (also managed under the umbrella of the Western Australian Government’s South Metropolitan Health Service).

‘We did some service evaluation and realised that in a secondary ED in Perth, the percentage of people coming in with a musculoskeletal complaint that a physio could see was about eight to nine per cent. 

'If 65,000 people present to a secondary hospital ED, such as in Rockingham, a physio can see approximately 5000 of those people every year.

‘Our economic analysis indicated that at a tertiary hospital, the percentage lowers to six per cent but the actual number of people presenting to ED is higher and 6500 of those patients can be seen by a physio,’ he says. 

‘In a smaller ED, such as Peel Health Campus, the proportion increases to approximately 12 per cent of people presenting to ED.’

Part of the reason for the pathway’s success, Piers says, lies in the backing of a solid foundation of research and public-facing projects and the creation of a completely new IT system, including customer management and workflow systems that generate medical notes. 

However, the stand-out feature has been the speed at which patients can be seen by an advanced scope physiotherapist, have imaging taken if required, then be treated and discharged.

‘When it’s not too busy it’s possible to attend to patients within 20 minutes. 

'Our average is about 50 minutes but we often see people quicker than that; there are fluctuations,’ Piers says. 

‘They literally walk from the ED, get an X-ray on the way if they need it and then they’re straight into seeing somebody.’

Piers says the ability to see patients quickly has also captured some of the people who might present to the ED and wait a while before becoming frustrated at the time delay and leaving untreated. 

This scenario was one of the biggest barriers to accessing care identified during a public-facing World Café session conducted with the Rockingham community as part of taking the project off the drawing board and into the hospital ED.

‘This project has always [been viewed] from the perspective of the patient. 

'Too often patients are judged for coming to ED because it’s not appropriate. 

'But the truth is that every patient who has come to ED has made the decision to go there and we have to honour the fact that they’ve made that decision,’ Piers says. 

‘Often they’re making that choice because they think their options are limited.’

Funding considerations

Initially the pilot project was funded through three blocks of six-month funding from the Western Australian Government’s
Emergency Department Innovation Fund. 

Piers says that by the end of the second block of funding it was clear the program would require two things to be ongoing: permanency for current and future advanced scope physiotherapists and for the hospital to take over funding.

‘We approached the hospital executive team, who then took over the funding so we could appoint people to permanent positions.

'The reason everyone had the confidence to continue to invest in us is due to our strong research program on this subject. 

'We had fantastic data collection, which we’re able to feed back to all of our stakeholders,’ he says.

Research study backing

The strong foundation of research has helped drive the program forward. 

Piers and colleagues have four published works specifically on the diversion pathway, including a health economic analysis demonstrating its effectiveness. 

The model returns more than $2 million a year in timesaving for the Rockingham General Hospital ED, proving its financial viability.

‘We modelled all the surrounding emergency departments and this is a cost-effective model in all of them,’ Piers says. 

‘The next step is for us to roll out this process across South Metropolitan Health Service EDs and then more broadly across Western Australia.’

Overcoming challenges

One of the biggest challenges in implementing the diversion pathway has been staffing. Before the project, Rockingham General Hospital had no advanced scope physiotherapists.

Piers and fellow advanced scope physiotherapist Pippa Flanagan recruited and trained an entire workforce, which was a significant hurdle. 

There are now 10 advanced scope physiotherapists employed to work within the diversion pathway.

‘We had to design a competency assessment framework and a structured supervision model to ensure quality and efficiency,’
Piers says. 

‘It takes about 18 months from when a physio starts training until they become fully independent in the role.

'Recruitment and retention strategies have been crucial to making this sustainable.

‘We had to accommodate all of our recruitment, training, supervision and mentorship processes into the model and we had to design a competency assessment framework to go with this process as well. 

'But once we got the workforce and we got over the training period, it became a very good pathway,’ Piers says.

‘We had a really good executive at the hospital who understood that it would take time to get the results, so they were patient and confident enough to give us funding to move forward. 

'Our program is as successful as it is today because of that.’

Patient feedback

The patient satisfaction rate for the diversion pathway is an outstanding 96.7 per cent. 

Patients endorse all aspects of care including communication, quality and patient-centred decision-making.

‘We’ve collected more than 2500 patient satisfaction surveys and the results are consistently high. 

'We report these to hospital executives on a monthly basis to maintain transparency and ensure quality care,’ Piers says.

The collaboration with emergency medical staff and other departments, including radiology, has also been instrumental in the pathway’s success. 

‘We’ve built strong relationships with medical teams at both Fiona Stanley and Rockingham General hospitals, which have been critical in ensuring seamless patient care,’ Piers says.

The road ahead

The success of the diversion pathway has paved the way for further innovations. 

Piers and his team are now working on expanding the model to include a telehealth component to improve accessibility in rural and remote areas.

‘We already have a physiotherapy-led virtual fracture clinic at Fiona Stanley Hospital that services the entire southern part of Western Australia, with patients from Margaret River, Albany and Esperance. 

'The next step is integrating telehealth into our diversion pathway model, allowing local physiotherapists to be guided by our advanced scope team,’ Piers says.

Beyond musculoskeletal conditions, there is also the potential to expand the model to other patient groups. 

‘Something like 40 per cent of people who come into the ED could be treated by relevant specialists instead. 

'We’ve focused on musculoskeletal issues because that’s what we know, but the same model could be applied more broadly,’ Piers says.

His ultimate vision?

‘I’d love to take this model out of hospitals and into the community—maybe even set up a clinic in a shopping centre. 

'The feedback from the Rockingham community is that they don’t want to go to a hospital if they don’t have to. 

'If we can provide high-quality care in more accessible locations, we’ll be reducing hospital footfall while improving the patient experience.’

The diversion pathway has already won multiple awards. 

It’s clear that this physiotherapy-led approach is revolutionising emergency care in Western Australia—and potentially beyond.

Scan the QR code for an interview with Piers Truter.