EASTER ROSS ORTHOPAEDIC TRIAGE PILOT SUE KING EXTENDED SCOPE PRACTITIONER PHYSIOTHERAPIST COUNTY COMMUNITY HOSPITAL INVERGORDON AUGUST 2009
INTRODUCTION A 12 month pilot project to test out a model of triaging orthopaedic referrals began on June 2nd 2008 The pilot involved 3 GP practices covering a population of 21,600
FUNDING Scottish Government allocated money under the Planned Care Improvement Programme to be used to improve referral rates into hospital NHS Highland chose to use it to fund a pilot of orthopaedic referral triage
NHSH commissioned a project to develop a model of orthopaedic triage which: is primary care based is sustainable encourages improved team working between GPs, Orthopaedics and AHPs gives a better outcome for patients enables better use of consultants time
WHY WAS IT INTRODUCED IN MID- HIGHLAND CHP? Orthopaedic referral pathways introduced 2004 Audits in 2004 and 2005 demonstrated improved referral practice and decreased referrals into orthopaedics When monitoring stopped referrals rose again March 2007 audit showed East Highland locality had the highest number of referrals which did not comply with the referral pathways GPs cited very long physiotherapy waiting-lists as the reason for non-compliance with pathways
THE TEAM Extended Scope Physiotherapist (1 WTE ) Admin support (0.5 WTE) Podiatry 2 days per month Orthotics 1 day per month Orthopaedic consultant running CCHI teach and treat clinics monthly and supporting the ESP Small steering group Kenny Oliver Patient Access Manager
MAIN AIMS OF PROJECT To cut non-pathway compliant referrals to orthopaedics To ensure patients are seen by the most appropriate professional in the shortest possible time involving the least number of trips to hospital To set up a monthly Teach and treat orthopaedic clinic in the locality for GPs / AHPs to attend and learn from an Orthopaedic Consultant To provide specialist physiotherapy advice and an injection therapy service to the pilot practices
AIMS OF PROJECT (cont..) To encourage better communication between GPs, Orthopaedics and AHPs To encourage GPs not to simultaneously refer to orthopaedics and physiotherapy To discourage ordering of un-necessary x-rays To discourage named referrals unless necessary
TRIAGE PROCESS Diagram of patient pathway through triage Number of referrals Method of triage
MUSCULOSKELETAL REFERRAL MANAGEMENT SCHEME IN EAST HIGHLAND LOCALITY Process Patient back to GP treatment unsuccessful GP Consultation (Tain/Alness/Invergordon) Notes: Three data collection systems being used. Red captures information flow into Physiotherapy Triage and allows tracking of the triage outcomes. Blue is captured by PAS. Green is captured by physiotherapy database. Physiotherapy Referrals Routine Adult Orthopaedic Referrals using existing Orthopaedic Referral Pathways Urgent and Paediatric Orthopaedic Referrals Physiotherapy PHYSIOTHERAPY TRIAGE Outpatient Orthopaedic Waiting List Raigmore Clinic Orthopaedic Teach & Teach Clinic @ Invergordon SECONDARY CARE RETURN APPOINTMENTS Patient Advice Leaflet Podiatry "Active" referral Extended Scope Physiotherapist GPS with injection/aspiration skills/orthopaedic interest identified Orthotics
REFERRALS RECEIVED 399 NHS, adult, routine referrals were received from the 3 GP practices. No urgent, or complicated paediatric referrals were accepted, or referrals back to named consultants for patients they had treated before for the same problem.
HOW WERE THEY TRIAGED? Type of Triage Paper Face to Face Telephone Grand Total Grand Total 184 185 30 399 % Grand Total 46.1% 46.4% 7.5%
TRIAGE OUTCOMES Quantitative data
Triage Outcomes Refer to Orthopaedic consultant Refer to Orthopaedic consultant patient request Refer to Extended Scope Physiotherapist Discharged no further action by triage (advice only) Refer to physiotherapy Refer to podiatry Refer to orthotics Patient did not respond to triage invite letter D/C Non-compliant with orthopaedic pathway D/C Dual referral to physiotherapy by GP Grand Total Grand Total 149 5 81 38 27 25 23 16 28 7 399 % Grand Total 37.3% 1.2% 20.3% 9.5% 6.8% 6.3% 5.8% 4.0% 7.0% 1.8%
The data shows that only 38.5% of referrals received through the triage pilot needed to be passed onto orthopaedics i.e. 61.5% were treated in primary care. Following triage and failed initial treatments a further 20 patients have subsequently been referred onto orthopaedics. This means that overall 54.6% of orthopaedic referrals received through the triage pilot were treated in primary care. This can be seen clearly from the graph on the next slide
100 90 80 70 60 50 40 30 20 10 0 TOTAL ORTHOPAEDIC REFERRALS FROM THE 3 GP PRACTICES COVERED BY THE TRIAGE PILOT (NHS, Adult, GP, Routine referrals) FROM JAN 2006 END OF PILOT Jan-06 M ar-09 Feb-06 M ar-06 Ap r-06 M ay-06 Jun-06 Ju l-06 Aug-06 S ep-06 O ct-06 Nov-06 Dec-06 Jan-07 Feb-07 M ar-07 Ap r-07 M ay-07 Jun-07 Ju l-07 Aug-07 S ep-07 O ct-07 Nov-07 Dec-07 Jan-08 Feb-08 M ar-08 Ap r-08 M ay-08 Jun-08 Ju l-08 Aug-08 S ep-08 O ct-08 Nov-08 Dec-08 Jan-09 Feb-09 Ap r-09 M ay-09 Jun-09 Month 55338 55427 55431 Total Referrals YEARLY AVERAGE R eferrals
To investigate possible alternative explanations for the decrease in referrals to orthopaedics, further analyses were carried out to verify that referral rates to rheumatology, rehabilitation and physiotherapy had not risen
TRIAGE OUTCOMES Qualitative data
With the assistance of the Clinical Effectiveness Team we ran 4 separate feedback questionnaires: 1. Patient s feedback on the overall triage and treatment process. 2. Patient s feedback on the Teach & Treat clinics 3. Professional s feedback on the Teach & Treat clinics 4. GP feedback at the end of the pilot Patient feedback was overwhelmingly positive 82% of patients happy to attend a triage appointment first of all 95% either quite or very satisfied with the time taken from referral to treatment. 75% satisfied with the outcome of their triage appointment. 100% felt the teach and treat clinic was in a convenient location GP feedback was difficult to analyse due to poor return rate but was broadly positive
CONCLUSIONS The original aims of the project have been met as evidenced by extensive robust quantitative data collected We have demonstrated a sustainable reduction in orthopaedic referrals (54.6%) from the GP practices involved The Teach and Treat orthopaedic clinics in the locality for the duration of the pilot were very successful We now need to evaluate the triage models potential as a sustainable solution across the rest of Highland
We have seen improved compliance with the orthopaedic referral pathways The service has been widely welcomed by patients and GPs as evidenced by extensive qualitative data collected The ESP physiotherapists role developed to include an advisory role to GPs / AHPs and to undertake complex case management from the general outpatient physiotherapy waiting list as well as to triage orthopaedic referrals, demonstrating best use of available resources and skills
THE FUTURE Funding to continue the triage service for a further 6 months has been granted whilst its long-term future is being considered
For further information please contact: Sue King ESP Physiotherapist County Community Hospital Invergordon IV18 0JR 01349 852496 x7398 sue.king6@nhs.net