Development of Botulinum Toxin-A service in Fife, Scotland

Purpose

I wanted to highlight the cost savings gained following a review and change of service delivery to children with focal spasticity in a district general hospital.  The purpose of the review and change was to improve the service we provided to children and their families in terms of timeliness on intervention, proximity to home and follow-up with known clinicians. 

Although the data is from 2014, we continue to inject less that 10% of our children under a general anaesthetic compared to 78% in 2009.

This service is led and delivered by a physiotherapist working in an extended role – initially Clinical Specialist, now Advanced Physiotherapy Practitioner with support from Orthopaedic and Neurology consultants.

50% reduction in general aneasthetic
for children receiving BoNT-A injections.
2009 78% GA
2011 21% GA
2012 onwards <25% GA
A cost saving of almost £83,700
between 2010- 2013

Approach

Annual reviews of the clinic carried out until the end of 2013 illustrated cost savings through reduction in the number of children having the injections done under GA.

A patient satisfaction survey was performed at the end of 2011 with the aims to ensure that parents/carers were satisfied with their child receiving injections under topical anaesthetic, and to enable decisions to be made on what aspects of the clinic could be improved on.

 

Outcomes

The driving reason for the development of the topical injection clinic was to improve the service for children and their families when receiving BoNT-A injection as capacity issues within the children’s ward regularly restricted the number of patients listed.

BoNT-A is delivered through intra-muscular (IM) injection and often requires more than 1 injection to effectively target all the identified muscles. IM injections can be painful.  Preventing distress to the child/family was paramount as was ensuring accuracy of injection.  As a result, the majority of children required a general anaesthetic (GA) to receive the injections.

Reviewing the service with the view to perform most of the injections under topical aesthetic/sedation has significantly reduced number of children requiring a GA. In 2009, 78% (N= 35) children required a GA for their injections.  In 2011, only 21% (n =10) required a GA.  Since 2012, this number has remained under 25% of total annual injections requiring a GA.

From our survey, 15 out of 26 responded (58%).12 out of 15 parents (80%) felt they were either very well or well prepared for the injections under topical anaesthetic. No parent felt they were very badly prepared.

As for the child being prepared, nine out of 12 parents (60%) felt their child was either very well or well prepared for the injections under topical anaesthetic with the remaining six parents feeling the preparation for their child was fine. No parent felt their child was badly or not well prepared.

In terms of how well the child tolerated the injections under topical anaesthetic, 10 out of 15 (67%) of parents said very well or well. Only one parent felt their child did not tolerate the injections well. No parent felt their child reacted very badly.

Children were supported by the Play Specialist in seven out of the 15 episodes (47%). Six of the seven families felt that this support was either very helpful or helpful. The remaining family felt that the support was fine.

All parents/carers stated that they would allow their children to have further injections under topical anaesthetic although in the comments section one parent stated she would prefer her child to have a GA in the future.

Cost and savings

In 2009 anaesthetic costs were £31,500 (based on each child costing £900 when they went for a GA to have their BTX-A injections) 78% went for GA (35 GA/ 10 Topical anaesthetic (TA))

in 2010 it was £18,900, 51% for GA (21 GA/ 20 TA)

in 2011 it was £9,000, 21% for GA (10 GA/ 35 TA/ 3 none)

in 2012 it was £12,600, 25% for GA (14 GA/ 39 TA/ 2 none)

in 2013 it was £9,000, 21% for GA (10 GA/ 34 TA/ 4 none)

The number of children requiring an injection remained static

between 2009-2013. If 78% of children going for injection had received a GA the costs would have been as follows:

2010 - £28,900 (saving of £9,000)

2011 - £33,300 (savings of £24,300)

2012 - £38,700 (savings of £26,100)

2013 - £ 33,300 (savings of £24,300)

This savings continues with only 3 children in both 2014 (7%) and 2015 (12%) having injections under GA.

Implications

The CSPT has now established a BoNT-A clinic within Fife. The service is now more easily accessible for children and families and the need for children to undergo a GA for focal management of spasticity has been reduced. The patient experience is enhanced with fewer waits on the day and less likelihood of cancellation.

The cost saving to the organisation is considerable even when only taking into account the cost of anaesthesia and not the cost the Paediatric Orthopaedic Physician.  As the CSPT is also able to inject independently as of June 2014, this has further freed up the time of the Paediatric Orthopaedic Physician to focus on other areas of the Paediatric Orthopaedic service.

Top three learning points

What did you learn from doing the project?

1. Reviewing systems and looking for a ‘better way’ is often achievable and brings additional benefits. In attempting to improve the experience of children going for BoNT-A, we were able to make cost savings to the organisation.  Demonstrating not only the cost savings but the parent satisfaction has ensured that the clinic is ongoing

A cost savings of almost £83,700 between 2010- 2013 as a secondary consequence to improving the child and families experience is significant. This information has been shared at local, national and international levels through conferences and poster presentations. 

2. Further developments, such as the APP injecting independently has also freed up time for the Paediatric Orthopaedic Physician. This ability of the CSPT to inject independently highlights the ability of physiotherapists to work at advanced practice levels.

3. Collaborative working between all agencies and professionals also is of great benefit.  The support from nursing has been invaluable and their offer of assistance to support Entonox/sedation has allowed us to further improve the service we are able to offer children and families. Nursing staff on the ward were already involved in using Entonox/sedation for other children and they extended their service to assist us.

Fund acknowledgements

This work was unfunded.

Additional notes

 Updated by the author in November 2018. First published on the database in 2016. 

The authors of this work may be contacted at: k.kinch@nhs.net

Ade-Hall R.A, Moore A.P (2000) Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy (Review). Cochrane Database of Systematic reviews, Issue 1. Art. No.: CD001408. DOI: 10.1002/14651858.CD001408.

Berweck S, Schroeder A.S, Fletzek U.M, Heinen F (2004) Sonography-guided injection of botulinum toxin in children with cerebral palsy. The Lancet, 363:249-250.

Chin,T.Y, Nattrass G.R, Selber P, Graham H.K (2005) Accuracy of Intramuscular Injection of Botulinum Toxin A in Juvenile Cerebral Palsy A Comparison Between Manual Needle Placement and Placement Guided by Electrical Stimulation. Journal Pediatric Orthopedics, 25(3):286–289.

Heinen F, Molenaers G, Fairhurst C, Carr L.J, Desloovere K, Valayer E.C, Morel E, Papavassiliou A.S, Tedroff K, Pascual-Pascual S.I, Bernert G, Berweck S, Di Rosa G, Kolanowski E, Krageloh-Mann I (2006) European consensus table 2006 on Botulinum toxin for children with cerebral palsy. European Journal of Paediatric Neurology, 10:215-225.

Katchburian L, Cawker S, Coombe S, Kinley E, Shaw R, Wiggans L, Will E (2008) Evidence-based Guidance for Physiotherapists.  The use of Botulinum Toxin in Children with Neurological Conditions. Association of Paediatric Chartered Physiotherapists.

Koman L, Mooney J, Smith B.P, Goodman R.N, and Mulvaney T (1993) Management of Cerebral Palsy with Botulinum-A Toxin: Preliminary Investigation. Journal Pediatric Orthopedics, 13(4):489-494.

Molenaers G, Desloovere K, Fabry G, De Cock P (2006) The Effects of Quantitative Gait Assessment and Botulinum Toxin A on Musculoskeletal Surgery in Children with Cerebral Palsy. Journal of  Bone & Joint Surgery, 88-A(1): 161-170.

Royal College of Physicans, British Society of Rehabilitation Medicine, Chartered Society of Physiotherapy, Association of Chartered Physiotherapists Interested in Neurology.  Spasticity in adults: management using botulinum toxin.  National guidelines. London: RCP,2009.

Westfhoff B, Seller K, Wild A, Jaeger M, Krauspe R (2003) Ultrasound-guided Botulinum toxin injection technique for the iliopsoas muscle, Developmental Medicine & Child Neurology 45: 829-832.