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_at_freenet.co.uk

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Introduction

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

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Staff

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

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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

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Aims

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

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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

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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

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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)

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Literature Review

• 89 of patients 95 of GPs satisfied with
  physiotherapy treatment (Hockin Bannister,
  1994)
• patients reported a higher level of satisfaction
  after consultation with physiotherapist compared
  to staff grade orthopaedic surgeon (Weale
  Bannister, 1995 Daker-White et al)

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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 patients outcomes
• reduced tendon rupture rates (Peck et al, 2004)

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Method

• Pilot study
• 3 months (n 31)
• 70 of patients discharged directly from
  physiotherapy

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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

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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

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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

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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

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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

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Results
18
Results
19
Results
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Results

• Responses of patients that preferred to see
  consultant (n21)
• required reassurance 13
• unanswered questions 9
• other 1

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Results

• Dissatisfied patients (n7) 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

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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.

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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.

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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.

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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.

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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

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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.

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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

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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 patients 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

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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.

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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.

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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

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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

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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