Transcript Using Simulation To Understand Orthopaedic Flow Through Triage

Using Simulation
To
Understand Orthopaedic Flow
Through Triage
Ekwutosi Chigbo Ezeh
Supervised by Dr Navid Izady
16/10/13
University of Southampton
University Hospital Southampton - Solent NHS – ISTC (CARE UK)
Southampton City Clinical Commissioning Group
Background

When patients require orthopaedic assessment they are
referred by their GP to an Integrated Medical Assessment
and Treatment (IMAT) service for triage to determine the
appropriate referral pathway

For orthopaedics, these routes include physiotherapy,
podiatry, rehabilitation programmes, pain management
services, and community re-ablement services, as well as
orthopaedic surgery (three tier system)

Evidence that some patients are routed incorrectly,
leading to wastage and poor patient experience

Aims: to identify how patients are referred, then triaged
then routed; quantify where patients are initially routed
incorrectly and subsequently rerouted; use simulation to
test alternative pathway designs
Providers modelled

In 2012-13 the Southampton Musculoskeletal service
(including IMATs, physiotherapy, rheumatology and pain
management) served 16,000 patients and provided
38,000 outpatient appointments

Southampton City CCG (Tier 1)

NHS Solent (Moorgreen Hospital) – community-based
outpatient clinics, physio and reablement (Tier 2)

Independent Sector Treatment Centre at the Royal
South Hants hospital (Tiers 2 & 3)

University Hospital Southampton (Tiers 2 & 3)

Many others – highly complex patient flow through
different sectors with a multiplicity of providers and
over 400 pathways, which were modelled as a series of
clinics
Patient flow between providers
Challenges

Limited data available for modelling the
whole system (lack of referral numbers;
medical conditions recorded; referral
destination; no entrance data for cohort)

Significant differences in data across
providers

No universal identifiers linking data

Appointment scheduling procedures required
to model waiting times, but were not
available
Moorgreen Hospital Simul8 Model
160 pathways in total!
Outpatient Clinics
UHS OP Spine Clinic
Appointments Booked
- No of referrals accepted from GP
- No of referrals accepted from A & E
- No of referrals accepted from other sources
Outcomes of Appointments attended
- Discharged from clinic
- Another appointment booked
No of Appointments Cancelled
- Cancelled by Hospital
- Cancelled by patient
- Patient did not attend
New
Follow up
488 41.7%
72 6.2%
610 52.1%
310 39.6% 522 42.0%
472 60.4% 720 58.0%
267 68.8% 519 66.4%
95 24.5% 173 22.1%
26 6.7% 90 11.5%
UHS OP Hand Clinic
Appointments Booked
- No of referrals accepted from GP
- No of referrals accepted from A & E
- No of referrals accepted from other sources
Outcomes of Appointments attended
- Discharged from clinic
- Another appointment booked
No of Appointments Cancelled
- Cancelled by Hospital
- Cancelled by patient
- Patient did not attend
New
506 52.0%
132 13.6%
335 34.4%
Follow up
157 22.2% 583 30.1%
551 77.8% 1,351 69.9%
174 67.2% 180
65 25.1% 225
20 7.7% 171
31.3%
39.1%
29.7%
Solent : Accepted & Cancelled Referrals
Top 95% of pathways in Solent NHS
CLINIC
No. of
Appts
Cumulative
% of Total
%
MGH MSK Physio
6913
29.78%
29.78%
ADC MSK Physio
6567
28.29%
58.07%
MGH MSK SPINAL
1933
8.33%
66.40%
MGH CAS
1813
7.81%
74.21%
MGH MSK HAND
924
3.98%
78.19%
MGH MSK LOWER LIMB
914
3.94%
82.13%
ADC MSK SHOULDER
650
2.80%
84.93%
ADC MSK SPINAL
649
2.80%
87.72%
ADC MSK FEET
648
2.79%
90.51%
ADC MSK LOWER LIMB
504
2.17%
92.69%
MGH MSK FEET
359
1.55%
94.23%
MGH MSK SHOULDER
186
0.80%
95.03%
Number of consecutive appointments per pathway
NUMBER OF CONSECUTIVE APPOINTMENTS PER
PATHWAY
300
NO OF PATHWAYS
250
200
150
100
50
0
1st Clinic
2nd Clinic
1
2
3rd Clinic
4th Clinic
CLINICS VISITED IN PATHWAY
3
4
5
6
7
8
9
5th Clinic
>10
6th Clinic
Conclusions




Many limitations of model due to data challenges
Enhancement of current data available needed to
effectively model this
We found less inefficiency in the system than was
perhaps initially perceived by our “client”: the
majority of patients are correctly triaged at Tier 1,
while 94% of patients referred to Tier 2 attend only
the first clinic they are referred to
Despite the data limitations, the modelling process
highlighted many key issues for the providers to
think about
OR - clinical
perspective
Dr Cathy Price
UHS FT
NHS perspective

Are pathways of care

Timely? - treatment delivered within an
acceptable waiting period (need to understand
rate of deterioration whilst waiting)

Effective? - no bounce around, minimal follow
ups

Efficient? - minimal number of follow ups
Commissioning Landscape

Multiple Providers within small geography

Confusing entry criteria

One large teaching hospital

Multiple Signposting “Tier 2” services for GP’s

Collaboration difficult across providers

Commissioned time points for providers to meet to
review cases (“virtual clinics”)

Patient experience “confusing”

Clinical effectiveness unclear
Modelling /OR – comments

Brought some clarity on efficiency (minimal follow ups)
in Signposting service – pretty efficient

Clinical Effectiveness hard to ascertain within timescale
(no follow ups per provider – needed to be accurately
agreed )

Model built that allowed for varying scenarios

Concerning number of differing outcomes for patients
(400+ pathways )

No easy way to ID patient through whole system i.e.
more confident modelling would require this