Demand, capacity and flow

The Front of House Team: Enabling and Supporting Discharge from the Emergency Department.

There is an increasing strain being placed all across the NHS systems. Emergency Departments up and down the country are being widely criticised for their performance against the national targets. We also have an aging population often with multiple co-morbidities that often present to the emergency department with both health issues and social care issues. The Royal Stoke Emergency department is one of the busiest in the country. In 2018 it had 111,091 attendances. 30,074. It had a higher than national average attendance to admission rate for over the age of 70. An external body wanted to see if creating a new MDT made up of senior decision makers with a background in the care of frail patients could make a difference.

Improving access to Paediatric Physiotherapy services within a community team - Physiotherapy drop-in screening service

The purpose of establishing the physiotherapy drop in service was:

  1. To improve the appropriateness of referrals being sent to the Physiotherapy department
  2. To provide a universal Paediatric Physiotherapy screening service within the borough for all children and young people
  3. To signpost Children and Young People to the required services or provide information and advice where appropriate

The above purpose links with the aims of the universal service provided by the Physiotherapy department which include: To improve education within the borough about normal development, create free opportunities to develop gross motor skills and educate parents ensuring carryover to the home environment, to highlight the contribution that Physiotherapy can make to the prevention of illness and the promotion of good health through encouraging appropriate physical activity.

Service evaluation of the Anterior Cruciate Ligament Deficient Induction Clinic (ACLD) and Rehabilitation Class.

Historically, at GSTFT, patients with ACL pathology have been managed in weekly exercise classes. Anecdotally, Physiotherapists felt that they were unable to effectively manage both the post-operative and ACL deficient (ACLD) populations due to high class numbers. After an internal service evaluation and audit, a unique ACLD pathway was established to separate the ACLD population, and better manage both ACL cohorts. This included a specific fortnightly ACLD Induction Clinic and ACLD rehabilitation class.

This data collection aimed to:

  • Evaluate the demand for the ACLD pathway, including the new ACLD rehabilitation class, and analyse patient demographics
  • Ensure the ACLD pathway is utilised correctly, by monitoring patients being referred
  • Start analyzing the data and trends of patient attendance and onward management in the ACLD rehabilitation class and begin early root cause analysis.
  • Commence a systematic review around the quality of pre-operative physiotherapy intervention and how this effects outcomes post-operatively, in order to guide the temporality and content of our ACLD rehabilitation class.

Reducing emergency admissions for primary constipation: a pilot study to cut costs in an acute hospital trust.

Constipation is a common condition that impacts quality of life, often causing psychological distress and incurring considerable healthcare costs in terms of unnecessary emergency admissions due to poor management.

Aintree University Hospital offers one of the only Specialist Physiotherapy led healthy bowel clinics (HBC) in the UK that assess, treat and manage patients presenting with functional bowel problems, including constipation. Patients referred into the service are directed straight to HBC and the majority will never see a medic. The service is run solely by Physiotherapists. We can refer for appropriate tests (transit marker studies, defecating proctograms, anorectal physiology and various blood tests). We independently interpret results and decide on appropriate treatment/management. Our service offers specialist assessment, medication management, lifestyle advice, pelvic floor re-education, Posterior Tibial Nerve Stimulation, rectal irrigation and cognitive behavioural therapy. The majority of our patients are managed conservatively as surgery is rarely an option.

From December 2013 to November 2014, Hospital Episode Statistics (HES) data showed that 301 patients were admitted to Aintree University Hospital with a primary diagnosis of constipation, 216 of these through the Accident and Emergency Department (AED), with an average length of stay of 3.3 days. The HBC Physiotherapists recognised that there should be a more cost-effective, efficient way to manage these patients and proposed a new pathway. The pathway allows patients to manage their symptoms in their own home with support from specialist Physiotherapists, enhancing patient dignity. Assessment identified 5 patients with potential red flag symptoms and allowed appropriate onward referral.

Advanced Physiotherapy Practitioner consultation as an alternative to GP consultation for patients with Musculoskeletal Conditions

General Practice is currently experiencing considerable capacity and sustainability challenges. With General Practice carrying out 90% of patient contacts in the NHS and musculoskeletal (MSK) conditions accounting for 10 - 30% of GP appointments it is essential to explore new ways of coping with this demand.

In Midlothian, half the practices were operating with restricted lists as a result of increasing demand: a demand which is predicted to quickly rise as the influx of new housing has resulted in Midlothian being the fastest growing local authority area in Scotland.

The strategic principle of this work is therefore to redirect appropriate patients from General Practice to MSK APP services with the aim of:

•           improving GP capacity.

•           improving patient outcomes.

•           improving the patient experience.

•           being cost effective and efficient.

•           enabling quick and easy access to highly specialised musculoskeletal input.

•           reducing referrals to secondary care, helping throughput and improving the conversion rate to surgery.

A project evaluating integration of a physiotherapy assistant practitioner into consultant led falls clinic and the effect on referrals.

72% of Community Rehabilitation Team (CRT) referrals are generated outside of our NHS Trust. External referrers have no access to our electronic records, and the complexity of local therapy services mean that duplicate and repeat referrals are common. Previous work also highlighted the 'yes' effect of individuals attending outpatient clinics, who consented to onward CRT referrals, but subsequently declined intervention.

This 'Plan, Do, Study, Act' (PDSA) project aimed to evaluate a new way of working to manage both issues. The project was undertaken in a neighbouring trust Consultant Led Falls Clinic (CLFC), identified as high referrer to our service.

Developing a Physiotherapy Foot Surgery Service and Patient Pathway

The foot surgery service was expanded in order to undertake more complex foot surgeries, this required an increase in physiotherapy input. Adaptations were made to our provision of physiotherapy to accommodate patients undergoing complex foot surgeries, patients with multiple co-morbidities and patients with complex social needs. This incorporated developing a robust protocol-led pathway including pre-op education and assessment with the aims of increasing attendance of our pre-op assessments “Foot School” and reducing length of stay (LOS).

Replacing a Retiring Consultant Rheumatologist with an Appropriately Skilled Consultant Physiotherapist.

The role of the Advanced Practice Physiotherapist (APP) has been well established in our Rheumatology team for more than 10 years. However, following the semi-retirement of one of the medical consultants there has been an option to pilot Consultant-level Physiotherapy input to the Rheumatology team. This process of using allied health professionals to replace medics has been called “Practitioner Substitution” and is seen as an important part of improving care and patient outcomes whilst delivering the efficiencies the NHS needs. The aims of the pilot Consultant post were: to independently manage and streamline the pathway for the non-inflammatory / pain service in Rheumatology, to reduce wait times and to ensure a more inflammatory-heavy caseload for the remaining Rheumatology medical team.

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