1. An Alternate Virtual Review Model The Edinburgh Experience
AP for 15 years
AP service provide long term follow up of Primary and Revision hip and knee arthroplasty from 6 weeks post op.
We have 15 clinic sessions per week across NHS Lothian over 3 hospital sites within a 50 mile radius.
Morag E Trayner
Arthroplasty Practitioner
ACPA Norwich 2014

2. Traditional Virtual Review
PROMS posted
Local X-ray
PROMS and X-ray reviewed by Arthroplasty Specialist
Hugill et al 2012 reported the lengthy process to introduce this method, which requires co-ordination and collaboration across hospital and PCT.
This includes hospital and PCT finance along with management, surgeons, AHP, nurses, IT services and patients.
Our arthroplasty service has been established for 17 years.
High volume of arthroplasty patients and out patient attendances. NO capital or new repeat funding was available.
Therefore 2 years ago we took a different approach.
Hugill,L et al JBJS B 2012 vol 94B No. Ix72

3. The Edinburgh Model Drivers for Virtual Review
Criteria for Virtual Review
Process
Audit Results
Reason for Clinical Review
Contact after virtual review
Proportion of caseload
Pros & cons
The Future

4. Drivers for Virtual Review
Increasing demographics 880K – 1.1M (1)
Reduced Resources 3.3 to 2.5 WTE
Pressure to increase clinic capacity
Patient Centred Quality Care
NHS Lothian current population projected to increase from 880K 2012 to 1.1 M 2035
60-74 yr olds increase by 27%
75+ yr olds increase by 82%
25% reduction in AP establishment
Increasing Arthroplasty Population and thus demand on capacity Management were pushing to increase clinic capacity by 50%
As the patients advocate and as part of NMC code of conduct we are responsible and accountable to provide highest quality of.care. Maintain patient centred quality care where needed investing time for quality where needed.
(1) NHS Lothian Workforce Planning 2012/13

5. NHS Lothian Arthroplasty Review Service
This graph shows the year on year increase of arhtroplasty out patient attendances compared to the increasing number of arthroplasties per annum.
50% increase in arthroplastys since 1999 in house. Between Apr 2010 and Jan 2014 a further 403 joint replacements were sourced form the private sector. These patients return to NHS follow up service from 1 year post-op.
Despite the 25% decrease in AP, throughput has continued to increase. This is not sustainable in the long term.

6. Criteria for Virtual Review
2+ years since last review and/or joint Replacement 5yr+
Asymptomatic
No previous x-ray or clinical concerns

7. The Process
All case notes screened by Arthroplasty Practitioner prior to clinic
OPA reminder letter
Attend for OPA
Virtual review letter on arrival
Short questionnaire to complete
X-ray
Return questionnaire to out patient staff
Go home/clinical review
Questionnaire and X-rays reviewed by AP
Patient and GP sent letter
Next OPA/discharge
Screening time mins per week for 15 sessions.
OP nurses cannot make clinical decision to designate patients for virtual review
OPA reminder phrase. OPA may take a different format. Complete questionnaire, have x-ray and go home. Setting expectations traditional face to face review
Questionnaire problems with joint yes/no? If yes give details how long? Getting worse?
Home/clinical
Letter x-rays satisfactory/some changes/ next review.

8. Audit Results 113 72 63.7% 296 197 66.6% Total 409 269 65.8%
Virtual Review Audit
Number of Patients designated as Virtual
Number of Patients had Virtual Review
Percentage
that had Virtual Review
Pilot:
01/05/ /8/12
113 72
63.7%
Audit:
1/9/ /3/13
296
197
66.6%
Total
409
269
65.8%
Pilot included 3 outreach sessions and 4 main base sessions per week. For a 4/12 period.
After fine tuning the process, which included any Yes answer patient offered clinical review at that clinic.
Rolled out to all 15 AP sessions across Lothian. Further Audit
Discuss figures. Consistent 2/3rds designated virtual have this format
With 2-5 yr timescale since last appt it is impossible to predict if patients are symptomatic.

9. Reasons for Clinical Review
During both audits information was collected about the reasons patients had clinical rather than Virtual review.
The two graphs demonstrate which reasons were deemed to be clinically relevant and which were for other reasons.
Clinical:
Majority related to painful Arthroplasty or OA joint
mobility problems
Questions
M.o.M.
Non Clinical:
12 administrative error forms not given to patient
4 patients could not grasp the concept easier just to see
2 objected to the format 2/409 = 0.5% of those designated virtual
1no glasses – no resolved with easy readers
1 rotational staff unfamiliar with virtual review

10. Patients contacted after virtual review
Action
PILOT N=8
6 pain, 1 X-ray chg, 1 Error
AUDIT N=12
4 pain, 7 x-ray chg, 1 extra TJA
Clinical review AP 3 1
Clinical review Cons 2
Early virtual Review 5
Routine virtual review
Phone only
Virtual in error
Over the 11 months of the two audits 20 patients were contacted after having virtual review
Some patients state they have problems, but opt out of clinical review on the day.
20/269 = 7.4%. 10 of which were symptomatic
8/269 who had virtual review were asymptomatic, but had x-ray changes This represents a 3% silent failure rate
After clarification pateitns were happy with joint replacemetn and there were no concerns about the x-rays therefore next virtual review routine timescale

11. Caseload Distribution
Audit Dates
Total OPA
Suitable for virtual review
% of caseload
1/9/12 – 31/3/13
2685
712
26.5%
1/4/13 – 31/3/14
4905
1155
23.6%
Virtual Review Audit
Designated Virtual
Reviewed as virtual
Percentage had virtual review
1/5/12 – 31/313
409
269
65.8%
1/4/13 – 31/3/14
605
418
69%
Whilst conducting both audits, AP recorded data about all patients seen clinically who would be suitable for virtual reviews at next OPA.
Full Clinical picture rather than from OP notes likely to be more accurate allocation at that point in time.
We have continued to record this data full year.
Approx 24% of workload suitable for virtual review.
Consistent 2/3rds of patietns designated as virtual have a virtual review within the Edinburgh model.

12. PROS CONS Equity of access Expedites clinical actions Maintain quality
Increase capacity +5%, But a 25% decrease in AP
Avoids additional OPA
Efficiency within clinics
AP prep time
Travelling distance
Vague answers
Electronic notes
Equity – access to immediate clinical review, avoids delays for patients and 2nd travel time, which cold lead to complaints
Appropriate clinical decisions made on the day
Maintains quality
Management have gained capacity
Avoids additional OPA and impact on capacity
True virtuals can be processed at any stage within the clinic session, minimising dealys for clinical reviews
AP prep time persevere for 3 yrs then regain the time
Extra time to screen patient address
Phone/letter to clarify some answers is counter-productive as it takes longer rthan a clinical review, but necessary for patient safety
Quicker to process case notes than access electronically , but it is the way of the future and will be offset by including Virtual/ clinical review in plan

13. The Future Planned repeat database Streamline clinic templates
Increase capacity within clinics
Proactive management
Explore local x-ray
TRAK patietn admin system – planed repeats on the agenda
This would allow review timescales to be set, but OA only sent 6 weeks in advance.
Impacts on AP workload as all booked pts up to 5 yrs would need to be screened for database entry – clinical decision. Current scoping exercise re manpower
AT preseent unable to predict number of virtuals per clinic, so could adjust templates
By using virtual OPA increase capacity, but still be mindful that 1/3 need clinical review
Currently require advance clinic closures for annual leave, but re-opened clinics not fully utilised. ^ weeks notice for A/L, no re-opening, Gain for clerical staff, but need to send out letters instead of reminders.
Explore feasibility of more local x-rays

14. Questions?
Thank you