Discharge Protocol for Hand Patients Results of Audit. Nicole Glassey Clinical Specialist Physiotherapist Burns & Plastic Surgery Unit Nottingham City Hospital [email protected] Introduction.
An audit to investigate the effectiveness of the policy of discharging hand-injured patients directly from physiotherapy without consultant review
Patient pathway following injury / surgery:
Orthopaedic GP referrals:
Peck et al (2001)
Responses of patients that preferred to see consultant (n=21):
Dissatisfied patients (n=7) were seen in clinic:
i.e. none required further surgical intervention
All patients were given the opportunity at the end of the questionnaire to contact the hospital if they felt they would benefit from any further treatment or if they would like to see their consultant. One patient took advantage of this.
None of the nine patients that had sought further advice or treatment had been referred back to the plastic surgery department.
Response rate 68% - possibility of bias due to the number of non-replies
Of the 7 who were dissatisfied 4 required further treatment - potentially 75 out of 79 replies did not require consultant clinic time.
Based on this, the reduction in clinic waiting lists would be four weeks.
Based on the 115 patients discharged via physiotherapy this reduction would increase to six weeks.
However, it cannot be assumed that those patients who did not reply to the questionnaire did not have any residual treatable problems.
Surgeon has greater experience and knowledge than a physiotherapist - possible that patient would require fewer appointments if reviewed in clinic rather than by the physiotherapist
This data was not examined - it was not felt that the physiotherapy appointments were increased, the clinic appointment was simply omitted if it was deemed unnecessary.
Just over half the patients reported residual problems
However, due to the structure of the questionnaire the identification of these problems was nominal and there was no way of knowing their severity or if further treatment would have been beneficial, without reassessing them.
Physiotherapy discharges are validated against consultant discharges every 3 months
Majority of patients preferring to see consultant, required reassurance.
Provision of reassurance by a consultant may not be the most cost effective method of delivery.
Roland et al (1991) judged 43% of orthopaedic out-patient referrals to be inappropriate but noted that 83% of patients considered them beneficial.
Responsibility of a physiotherapist to identify patients that may benefit from further surgery or from further consultant review is controversial.
The physiotherapists must have the appropriate level of experience.
The consultant must have confidence in the ability of the physiotherapist
Possibility of reduced training for registrars
From this study it can be concluded that:
Further exploration into the potential increase in physiotherapy appointments
Objective investigation into the extent and severity of residual problems
Following this study it was decided that all patients should be given the opportunity to have a clinic appointment at the end of their course of physiotherapy if they feel that they require reassurance from the medical staff. Patients rarely request this.