Process changes

Medicines optimisation for the treatment of spasticity and neuropathic pain led by a Physiotherapist Independent Prescriber

The purpose of this project was to improve medicines optimisation for the management of patients with spasticity or neuropathic pain who attended multidisciplinary specialist neuro outpatient clinics at West Midlands Rehabilitation Centre. The secondary purpose was to identify how much input was required to optimise medication after a change in medication was advised and if this input could be adequately carried out by a Physiotherapist Independent Prescriber.

Historically the Consultant (prescriber) would review and make changes as required to a patient’s medication for managing their spasticity and neuropathic pain.  Patients could contact in case of concerns, however, there was usually no medication follow up initiated by the Consultant between clinic appointments. This was due to limitations on Consultant capacity. Time periods between clinic appointments for each patient could be between 3-12 months depending on the request of the Consultant. This meant that if there were issues with obtaining or taking the medication and the patient did not initiate contact, the issue would not be addressed until the patient returned to clinic.

NICE provides guidance that the prescriber should review the patient with regards to their medication after starting or altering a medication within a timely period. This is important as it ensures that patients receive the right choice of medication for them, at the right dose and right time to benefit their health.

Medication reviews following a face to face appointment do not necessitate a face to face appointment and telephone reviews can be completely adequate.  This is because patient achievement of goals of treatment with medication is primarily identified through subjective assessment. The standard in this project was set that all patients who required a medication change in clinic would be reviewed, on time via telephone consultation(s). The time at which the patient would be need to be reviewed would be dependent on the time period in which the prescriber advised the medication change to occur over.

A musculoskeletal single point of referral in primary care

A single point of referral was implemented in partnership between Allied Health Professionals Suffolk (AHPS) and Norfolk Community Health and Care (NCHC) forming the Integrated Therapy Partnership (ITP). This aimed to standardise the care pathways for musculoskeletal conditions and ensure primary care referrals are processed to the correct provider first time around. This should avoid unnecessary secondary care referrals, where patients are seen in secondary care, receive no treatment and are referred back to community providers. Referrals are triaged by senior physiotherapists. Similar models have been suggested as effective methods of service delivery by the British Orthopaedic Association (Lennox & Karstad, 2013). This was coupled with the implementation of online self-referral for physiotherapy and occupational therapy, where patients were issued advice and exercise within 24 hours. Advice and exercise are issued for patients triaged for physiotherapy through the single point of referral. AHPs are responsible all patient administrative tasks and provide the triaging clinicians. NCHC provide clinical physiotherapy, occupational therapy and orthopaedic triage services. This is contracted to the Norwich and South Norfolk Clinical Commissioning Group and they set key performance indicators for patients being seen. Routine patients to be seen in 28 working days, urgent patients to be seen in 7 days and orthopaedic triage patients to be seen in 14 working days.

Using ANGEL taxonomy to triage referrals in Ceredigion community physiotherapy

To evaluate whether service improvements could be made to our community physiotherapy service through clinical streaming of patient referrals using underlying principles complexity science to consistently deploy the most appropriate member of the physiotherapy team to meet the needs of patients and improve the effectiveness of our service.

Physiotherapy Supported Discharge Service following knee arthroplasty

An audit on length of stay (LOS) for total knee replacement (TKR) patients following surgery highlighted that a number of patients were exceeding their predicted date of discharge (PDD), many due to not achieving traditional physiotherapy goals (90⁰ flexion, < 5 ° extension lack and good quadriceps function), despite being safely mobile and medically fit. This exposes patients to risk of harm due to prolonged stay within an acute hospital environment as well as inefficient utilisation of an in-patient bed. A Physiotherapy Supported Discharge Service (PSDS) had previously been piloted for six months. Phase 2 consisted of permanent service resign, continuing the PSDS and service evaluation.

Oxygen and Non-Invasive Ventilation Pathways in an Adult Cystic Fibrosis Centre

Cystic Fibrosis (CF) is a genetically inherited condition affecting more than 10,000 people in the United Kingdom. A progressive cycle of infection and lung damage occurs. Worsening lung function results in hypoventilation and ultimately leads to respiratory failure that may require supplementary oxygen and/or mechanical support such as Non-Invasive Ventilation (NIV). Guidelines support the use of NIV for nocturnal hypoventilation, hypercapnic respiratory failure and as a bridge to transplant. At the time of development, there were no published guidelines on the use of oxygen therapy in CF and no published pathways on the set up and management of supplementary oxygen or NIV in CF. This special interest report documents the development of separate oxygen and NIV pathways through interdisciplinary working in an adult CF centre.

Objective To develop pathways for supplementary oxygen and the set up and management of NIV in an adult CF centre.

Trial of diagnostic ultrasound in the orthopaedic setting

Historically, provision of MSK Ultrasound diagnostics has been via a referral to Radiology. However, there is increasing evidence that assessment, investigation and initiating treatment at the initial appointment is shown to be cost-effective, increasing patient satisfaction. Utilising this approach also reduces repeated hospital visits for further diagnostics and appointment times for results. The aim of using Point of Care (POC) ultrasound is to enhance the patient experience through instant access to diagnosis, timely implementation of most appropriate clinical pathway and achievement of the optimal outcome in the shortest possible time.

This study aims to investigate the benefits of point of care (POC) and schedule ultrasound clinics using a proof of concepts approach in the orthopaedic setting.

Implementation of a new goal-planning process in an intermediate neuro-rehabilitation unit

It was recognised that the neuro-rehabilitation unit had a length of stay above the national average of 80 days. A new multidisciplinary goal planning process was implemented on the unit with the following aims; reduce length of stay to the national average; reduce the waiting list to 1 week; to consistently achieve greater than 70% patient and family/carer satisfaction.  The impact on the FIM/FAM outcome measure was monitored to ensure there were no adverse effects on patient outcome as a result of implementing the new process.

Developing an evidence-based Making Every Contact Count (MECC) model of practice

Population health and prevention is a major priority of the recently formed Greater Manchester Health and Social Care Partnership and is an area in which physiotherapists can make a positive contribution. The Physiotherapy MSK services within the Bury Care Organisation, have successfully developed a MECC model of practice into their service pathways. This quality improvement, uses evidence based behaviour change principles to support patients in making positive lifestyle changes which can impact on their physical and mental health and wellbeing. It also aims to support Trust staff to become more active and promotes health and wellbeing within the wider communities.

Can Emergency Care Therapies Help to Prevent Avoidable Admissions in the Emergency Department?

The Department of Heath estimate that 62% of hospital bed days are occupied by patients over the age of 65. Of these bed days 2.7 million are occupied by patients no longer needing or not requiring acute care in the first place. Of those who are admitted unnecessarily, the Emergency Department (ED) is often where the decision to admit is made. Furthermore, the longer a patient spends in the ED the longer their associated inpatient stay in the hospital will likely be, with the risk of losing up to 5% of their muscle strength per day.

During May and June 2016 the Emergency Care Improvement Programme (ECIP) reviewed Urgent and Emergency Care at Basingstoke and North Hampshire Hospital (BNHH). This was due to reduced ED performance. BNHH did not have an established dedicated Therapy team in ED, despite national evidence and ECIP recommendations. Therapies are well placed in ED to facilitate early patient discharge and help prevent admission of patients who do not require acute hospital care. The project aimed to eliminate avoidable non-medical admissions to inpatient base ward beds in patients over 65 years presenting to ED at BNHH by September 2017.

Impact of early intervention and rehabilitation on functional decline in patients hospitalised for acute heart failure

Acute heart failure (AHF) is the most common cause of admissions for patients aged 65 and over in the UK. The occurrence of functional decline in elderly adults with hospitalisation for acute illness is well established with decline occurring as early as day 2 of admission. With an average length of stay of 18.7 days, patient age of 71.4 years, and 77.1% of patients having at least one other chronic disease, the patients admitted to the Heart Failure Unit at St George's Hospital are high risk for functional decline throughout their stay. Traditionally these patients would not be seen by a physiotherapist until after their intravenous diuretic treatment was completed. The aim was to assess the impact of early and specialist physiotherapy assessment and intervention on functional decline during hospitalisation of patients with AHF.

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