1. Paediatric Orthopaedic MSK Pathways Pamela Holland

2. Background 3000 referrals each year to Paediatric Orthopaedic Services
Prolonged wait of up to 16 weeks for orthopaedic assessment
In patients were assessed at Spire as 'NHS See and Treat'
249 patients resulted in a total 375 consultations at an additional cost of £33 979
If patients require onward referral to other MSK services such as physiotherapy a further wait of weeks for initiation of treatment

3. Aim Reduce patients length of wait for treatment reducing chronicity
Reduce duplication of referrals
Reduce inappropriate referrals to Orthopaedic Services which in time will reduce demand on the service
To improve patient experience and journey by ensuring each patient is seen by the right person at the right

4. Initial Planning
Funding secured from Scottish Government following successful bid to Pump Prime Funding
6 month audit of NP Orthopaedic Clinics to determine focus for pathway development
Knee pathway
Back pathway
Gait pathway
Patient satisfaction of original pathway
Audit: excluded fracture clinic and patients with an underlying neuromuscular diagnosis
278 NP March to August 2015, 155 (56%) of these patients were discharged after assessment with advice, 48 (17%) were referred to physiotherapy
20 (7%) to orthotics16 (6% ) specialist onward referral
12 (4%) surgery, 27 (10%) had ortho follow up appointment
Working diagnosis: 75 gait assessment, 62 joint pain (knee, ankle, hip, shoulder)
32 back pain, 18 pes planus
Patient satisfaction survey using paediatric care measure with additional 2 question regarding their
length of wait. A small sample of 15 patients patients were surveyed. All were found to be happy
with the care they received (good, very good or excellent). Length of wait however varied
considerably with average length of wait for treatment 18 weeks, (min 13 weeks and max wait 22).
Many patients rated this either poor or fair.

5. Engaging Stakeholders
NHSL
Orthopaedic Consultants
Radiology Consultants
Orthopaedic Spinal Consultant
Rheumatology Consultant
RHSC Assistant Service Manager
Medical Record Staff
Patient Information Leaflet Group
E-health team / AHP Informatics Lead

6. Pathway Development
All pathways developed collaboratively by the multi disciplinary team
K:\Paediatric Msk ESP\Pamela\MSK Pathway Re-design\Knee Pathway\Paediatric Orthopaedic Musculoskeletal Knee Pathway.doc
Pathway aim:
Orthopaedic referral received at RHSC – triaged by orthopaedic consultant using pathway flow chart: details urgent and routine orthopaedic patient
other MSK specialities such as rheumatology, orthotics etc
physiotherapy
If referral triaged to physiotherapy, further triaged as urgent or routine and added to MSK waiting list
Each patient has detailed MSK assessment – agreed by the MDT team
To reduce risk detailed red and yellow flags with a specific plan for each clinical finding with onward referral to appropriate service as required
Continue with physiotherapy until discharge

7. Risk Management Detailed competencies within each pathway
Completed IRMER training and competencies
Regular peer review with Orthopaedic Consultant
Ongoing discussion with Orthopaedic consultant when required
Highly experienced physiotherapist

8. Self Management Developed patient information leaflets
Secured opportunity to work jointly with the NHSL Communications Team to develop physiotherapy website
Working with Scottish Government AHP CYP National Lead to develop information for musculoskeletal conditions between the age of for NHS Inform
Rapid access to physiotherapy following changes to self referral

9. Embedding Pathways Small audit of knee and back pathway
37 orthopaedic referrals triaged to physiotherapy
All patients have been assessed with a maximum wait of 10 weeks
6 patients required further investigations of which 4 continued with physiotherapy and 2 have had onward referral to spinal service due to confirmed scoliosis
25 patients have been discharged, 10 ongoing with physiotherapy treatment
Patient satisfaction:
Patient satisfaction: using paediatric care measure – rated as very good or excellent, no concerns
raised about not being assessed by an Orthopaedic Consultant
Length of wait rated much better: either good, very good or excellent
For those patients who waited longer than 6 weeks : wait found to be fair or poor.

10. Savings
Enabled 37 NP Orthopaedic Clinic Appointments to be allocated to other patients
Cost saving £1790 of NHS Consultant time
Additional saving of potential waiting list breaches of £3360
Totalling £5150 during the 19 week audit period
Annually minimum saving of £14,100.
Calculated on 1 consultant session annually costing 10000/year
There for on a weekly session £238.

11. Moving forwards
Continue to develop and embed musculoskeletal pathways throughout NHS Lothian
Investigate if reduced waiting time leads to reduced number of appointment, aim for 6 week maximum physiotherapy wait
Expand collaborative working to include Rheumatology services
Single musculoskeletal referral and triage process for all MSK referrals
Age appropriate care 14 – 16, quantify additional resources required with increasing age range
Secure further funding to enable physiotherapy services to manage increased demand
Increased demand to all services (additional 3000 Orthopaedic outpatient episodes,
- over outpatient 700 physiotherapy episodes)
Increased orthopaedic surgery estimated at 3 – 4 cases/week

12. In Conclusion Pathway development improved MDT working
Streamlined patient journey
Reduced patient waiting times for treatment
Avoided duplication of workload
Reduced inappropriate demand on overstretched Orthopaedic services
Enabled the development of advanced practice in physiotherapy
Ensured each patient is seen by the right person at the right time striving to achieve the Scottish Governments vision of ‘Getting it Right for Every Child’