Transcript The impact of triage on management of referrals to a pain

The impact of triage on
management of referrals to a pain
service
Cathy Price
FPM Spring Meeting Newcastle 2010
Triage…
• A system used to allocate a scarce commodity,
such as food, only to those capable of deriving
the greatest benefit from it.
French, from trier, to sort, from Old French
The Problem – Soton in 2002
pain cannot be managed
Dodgy thinking had lead to
dodgy expectations
50,000 care population-endless waiting list for
specialist medical care
Demand v capacity
Government Pilots - Shifting Care
Closer to Home
Our Health Our Car Our say: large patient survey –
waiting times/ease of access most important
6 areas pilots started 2002
• Orthopaedics
• ENT
• Surgery
• Gynaecology
• Urology
• Dermatology
Review started 2006 & 18 week target introduced
Local Health Board’s expectations of
Orthopaedic service?
end the scatter gun effect for MSK referrals
and doctor shopping
Local access
Informed choice
Greater emphasis on pain managament
Overview
19th March 2009
Keys to success
• High quality staff with clear roles and skills
• Effective team working
• As clear a picture as possible of the person
being triaged
• Decision support tools to enable accurate
signposting
• Validated questionnaires
• Easy access to investigations
Barriers to Change
• Professional :
– knowledge low in primary care
– Lack of confidence in non medical staff by doctors
• System:
– Lack of joined upness
– Unclear care pathways
• Data:
– Routine hospital data lacked sufficient detail
Challenges
• “the rise and fall of the MPTT”
• British Orthopaedic Journal 2006
Professional - 1
• Knowledge low in primary care
– General Practitioners unable to select accurately
patients for physiotherapy versus more skilled
assessment lad to long queues
• Solution:
– Administrators telephone questionnaire
– 33% redirected within the service
Professional 2 - Improving clinical
decision making - Decision Tools
• Pain Team unclear as to who to triage where
Psychosocial factors scored – crude scale
– Supported by: BDI/PainDetect/Bradford Needs
Questionnaire
• MSK spinal assessment team:
– Pain Catastrophising Scale
– Pain self efficacy questionnaire
– MRI using informed decision making tool – MBUR
6
Professional - – Physiotherapists not
recognising psychosocial barriers
• Keele tools
Psychosocial obstacles to recovery – enhanced package –
CBT practitioners
Explanations – coaching/pain relief
Reassurance , pain relief
High
risk
Medium risk
Low risk
http://www.keele.ac.uk/research/pchs/pcmrc/dissemination/tools/startback
• University run courses on “yellow flags”
• Extended scope practitioner modular course
System- Role of spinal surgery in care
pathway
• Direct access to spinal surgery – confusing
– Review of NICE guidance by Public health
priorities committee – spinal surgery LOW
PRIORITY.
– Spinal surgeons agreed to end direct access for
non emergencies 2010
– Map of Medicine pathway for spines
Decision Aids reduce rates of
discretionary surgery
RR=0.76 (0.6, 0.9)
O’Connor et al., Cochrane Library, 2009
16
OA Knee - Some Screen Shots
17
18
19
Lack of” joined upness”
• Shared record systems
– Paper notes
– Hampshire Health care record
– PACS - picture archive system
Data
• Large spreadsheets to measure processes
• Development of secondary user services data
• Kaiser system
Assurance
• Audit commission asked to review servicereported excellent outcomes
• Nominated site for Department of health
review of “care closer to home”
the estimated cost of the Orthopaedic Choice
service was 39% less than the £2,840,916 which
would have been incurred if all the referrals had
been seen by secondary
care providers.
Outcomes MSK triage - 2009/10
• Mixture of Physiotherapists, Occupational
therapists, podiatry, General practitioners
– 3865 referred to MSK Triage
– 1.2% referred to surgery
Outcomes Pain Triage
• Nurse.Physiotherapist.Occupational therapist +
doctors at end – all referrals screened by medical
staff according to locally agreed criteria
• 1500 referred - pop: 50,000
– c. 850 seen by MDT
– 150 – re-referrals – problem solving session
– 500 advice /further investigation not the right time
• Hospital care criteria : ED admissions, Strong
opioids, dependency on medical model, under
other services c 250 patients p.a.
Overall Outcomes of Assessment for Level
of Need
19% community care
47% other pathway
34%
Complex care
management
User Surveys
• 88% felt the assessment process was
about right
• 75% were satisfied with the outcome of
assessment
• A small number were unclear as to the
next step
Case Mix
City PCT
Hampshire
PCT
National
Musculoskeletal pain
89
80
70
Pain Intensity
25
27
23
Pain impact scale
47
47
44
depression score (Beck)
29
25
?
Duration > 2 years
85
80
80
Other solutions?
• STEPS – Stephanie Davies Perth
introduction of self care programme removed
people from the waiting list in 45%
• Clark AJ, Beauprie I, Clark LB , Lynch M: A
triage approach to managing a waiting list.
Pain Research Management 2005; 10:3:155-7
– 600 triaged
– 26% benefitted by written recommendations
alone to primary care
Conclusions
• The magnitude of chronic pain can be
managed by careful clinical and administrative
processes
• Multiple barriers require careful solutions
• These systems are fragile and require
excellent data and auditing.
References
JOINT WORKING? An audit of the implementation of the
Department of Health’s musculoskeletal services
framework ARMA June 2009
Department of Health, A joint responsibility: doing it
differently – the musculoskeletal services framework, 12
July 2006
NHS Institute Delivering Quality and Value Focus On:
Musculoskeletal Interface Services NHS Institute for
Improvement 2009
Shifting care from hospitals to the community: a review of
the evidence on quality and efficiency. B. Sibbald, R.
McDonald . M. Roland. J Health Serv Res Policy
2007;12:110-11