Discharge Protocol for Hand Patients Results of Audit

1. Discharge Protocol for Hand Patients Results of Audit Nicole Glassey Clinical Specialist Physiotherapist Burns & Plastic Surgery Unit Nottingham City Hospital nicoleglassey@freenet.co.uk

2. Introduction An audit to investigate the effectiveness of the policy of discharging hand-injured patients directly from physiotherapy without consultant review

3. Staff • One hand consultant • Six plastic surgery consultants • Physiotherapists • CS, S1, S2, Jnr • Occupational therapists • Part time S1 & S2

4. Service • Moderately sized, manageable unit • Continuity of care provided by physiotherapy staff • Physiotherapists manage hand dressings in addition to therapy • Physiotherapists provide static splinting service • Physiotherapy department is based on the ward • A 6 day service is provided during hand take • Both the medical staff and specialist nurses are available at all times

5. Aims • establish whether hand therapists could manage the discharge of hand patients • identify amount of consultant clinic time saved • ascertain level of patient satisfaction

6. Previous Pathway Patient pathway following injury / surgery: • physiotherapy / occupational therapy • consultant clinic at 3 months • only minor operations / injuries not reviewed • one hand clinic per week (new and follow up) • however, consultant available throughout the week to review patients if necessary

7. Disadvantages of Pathway • busy consultant hand clinic • long waiting list for new patients to be seen in consultant hand clinic • some patients had completely recovered by the time they were seen in consultant hand clinic

8. Literature Review Orthopaedic GP referrals: • 27% patients referred to an orthopaedic consultant required physiotherapy (Ross et al,1983) • 40-60% orthopaedic patients could be managed by physiotherapy(Byles & Ling, 1989) • post-graduate study prior & adequate supervision (Hockin & Bannister, 1994)

9. Literature Review • 89% of patients & 95% of GP’s satisfied with physiotherapy treatment (Hockin & Bannister, 1994) • patient’s reported a higher level of satisfaction after consultation with physiotherapist compared to staff grade orthopaedic surgeon (Weale & Bannister, 1995; Daker-White et al)

10. Literature Review Peck et al (2001) • practitioner led hand clinics • reduced waiting times in clinic • reduced consultant workload in clinic • reduced complaints • increased staff morale • improved patient satisfaction • improved recording of patient’s outcomes • reduced tendon rupture rates (Peck et al, 2004)

11. Method Pilot study: • 3 months (n = 31) • 70% of patients discharged directly from physiotherapy

12. Method • patients no longer routinely given a clinic appointment • at discharge from physiotherapy, consultant hand clinic appointment made if necessary • if did not require a consultant hand clinic appointment – patient given discharge advice sheet instructing them to contact the physiotherapist or GP if any further problems

13. Method • letter detailing injury and final outcome sent to consultant and operating surgeon at discharge from physiotherapy • patients that required further surgery or had an unsatisfactory outcome - given a clinic appointment

14. Exceptions • specific patients were always given a clinic appointment due to the necessity for long term monitoring of recovery e.g. nerve repairs, multiple trauma • patients who did not complete their physiotherapy – letter sent to consultant, their decision whether that patient was sent a clinic appointment

15. Subjects • 309 patients were treated over ten months • of those 309 patients, 115 patients were discharged directly from physiotherapy • injuries included flexor and extensor tendon repairs, fractures, infections, fingertip injuries, amputations and crush injuries

16. Subjects • 115 patients sent a questionnaire by the clinical effectiveness department asking for their views • questionnaire was most appropriate method of obtaining data due to large sample size & limitations on resources preventing individual patient reassessment and interview

17. Results

18. Results

19. Results

20. Results Responses of patients that preferred to see consultant (n=21): • required reassurance – 13 • unanswered questions – 9 • “other” – 1

21. Results Dissatisfied patients (n=7) were seen in clinic: • neuroma that did not require surgery but required monitoring • cold intolerance requiring advice / reassurance • decreased rom requiring further exercise • hypersensitivity requiring desensitisation • no residual treatable problems • cancelled appointment • DNA appointment i.e. none required further surgical intervention

22. Results All patients were given the opportunity at the end of the questionnaire to contact the hospital if they felt they would benefit from any further treatment or if they would like to see their consultant. One patient took advantage of this. None of the nine patients that had sought further advice or treatment had been referred back to the plastic surgery department.

23. Discussion Response rate 68% - possibility of bias due to the number of non-replies Of the 7 who were dissatisfied 4 required further treatment - potentially 75 out of 79 replies did not require consultant clinic time. Based on this, the reduction in clinic waiting lists would be four weeks.

24. Discussion Based on the 115 patients discharged via physiotherapy this reduction would increase to six weeks. However, it cannot be assumed that those patients who did not reply to the questionnaire did not have any residual treatable problems.

25. Discussion Surgeon has greater experience and knowledge than a physiotherapist - possible that patient would require fewer appointments if reviewed in clinic rather than by the physiotherapist This data was not examined - it was not felt that the physiotherapy appointments were increased, the clinic appointment was simply omitted if it was deemed unnecessary.

26. Discussion Just over half the patients reported residual problems However, due to the structure of the questionnaire the identification of these problems was nominal and there was no way of knowing their severity or if further treatment would have been beneficial, without reassessing them. Physiotherapy discharges are validated against consultant discharges every 3 months

27. Discussion Majority of patients preferring to see consultant, required reassurance. Provision of reassurance by a consultant may not be the most cost effective method of delivery. Roland et al (1991) judged 43% of orthopaedic out-patient referrals to be inappropriate but noted that 83% of patients considered them beneficial.

28. Discussion Responsibility of a physiotherapist to identify patients that may benefit from further surgery or from further consultant review is controversial. The physiotherapists must have the appropriate level of experience. The consultant must have confidence in the ability of the physiotherapist

29. Discussion Possibility of reduced training for registrars However: • they did not all attend hand clinic previously • they receive a letter from the physiotherapist at discharge detailing the patient’s outcome • they receive regular training from the physiotherapy team • they are encouraged to review their patients recovery during physiotherapy sessions • consultant feels training can be more focused on appropriate patients rather than routine follow up cases

30. Conclusion From this study it can be concluded that: • hand therapists could manage the discharge of one third of these patients • the waiting list was reduced substantially • the majority of patients were satisfied with this method of discharge.

31. Recommendations Further exploration into the potential increase in physiotherapy appointments Objective investigation into the extent and severity of residual problems Following this study it was decided that all patients should be given the opportunity to have a clinic appointment at the end of their course of physiotherapy if they feel that they require reassurance from the medical staff. Patients rarely request this.

32. Developments • Joint consultant & physiotherapist hand clinic • Physiotherapy led follow up clinic for patients being treated by more junior members of the team and patients that require long term monitoring. This service is validated by frequent consultant checks on the advice / treatment given

33. References • Byles SE, Ling RSM, (1989) Orthopaedic out-patients – a fresh approach, Physiotherapy, 75(7): 435-437 • Daker-White G, Carr AJ, Harvey I, Woolhead G, (1999) A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments, Journal of Epidemiology and Community Health, 53(10): 643-650 • Ellis B, Kersten P, (2001) An exploration of the developing role of hand therapists as extended scope practitioners, British Journal of Hand Therapy, 6: 126-130 • Hockin J, Bannister G, (1994) The extended role of a physiotherapist in an out-patient orthopaedic clinic, Physiotherapy, 80(5): 281-284 • Peck FH, Kennedy SM, McKirdy L, (2001) The introduction of practitioner led hand clinics in South Manchester, British Journal of Hand Therapy, 6: 41-44

34. References • Peck FH, Kennedy SM, Watson JS, Lees VC, (2004) An evaluation of the influence of practitioner led hand clinics on rupture rates following primary tendon repair in the hand, British Journal of Plastic Surgery, 57(1): 45-49 • Roland MO, Porter RW, Matthews JG, Redden JF, Simmonds GW, Bewley B, (1991) Improving care: a study of orthopaedic outpatient referrals, British Medical Journal, 302: 1124-1128 • Ross AK, Davis WA, Horn G, Williams R, (1983) General practice orthopaedic outpatient referrals in North Staffordshire, British Medical Journal, 282: 1439-1441 • Weale AE, Bannister GC, (1995) Who should see orthopaedic outpatients - physiotherapists or surgeons? Annals of the Royal College of Surgeons of England, 77(2 Suppl): 71-3