Audit of back pain/spinal patients - QI Hub audit of back pain - spinal... · From our samples, we estimated an average of more than 1700 back pain/spinal patients attending new outpatient

Musculoskeletal Audit (MSk) - Back pain audit

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Audit of back pain/spinal patients A report on individual hospital data from the Musculoskeletal Audit Interpretive text in blue from Eric Ballantyne (National Clinical Director of the Neurosurgery Managed Service Network, and Consultant Neurosurgeon, Ninewells) on behalf of the 18-Weeks Orthopaedics Task and Finish Steering Group Executive Summary This report summarises a 12-week ‘snapshot’ audit of adult patients attending new outpatient appointments for a back or spinal condition at Scottish hospitals from 13th September to 5th December 2010. The report was commissioned by the Scottish Government’s Orthopaedic Task and Finish Group and addresses the need for basic data on this large group of patients, summarising the variation in pathways and management. MSk Local Audit Co-ordinators collected data from patient case notes, patient information systems, results reporting and referral management systems.

From our samples, we estimated an average of more than 1700 back pain/spinal patients attending new outpatient appointments in Scotland every month (Table 1, Fig. 1). These included 430 appointments run by Orthopaedic units, 390 by Neurosurgery, 560 by MSK-ESP services and 330 by Physiotherapy. Dialogue with local leads suggested these numbers are probably underestimates, and emphasised the difficulty of finding and counting all such patients in the diverse array of service models across the country.

Service models varied markedly throughout the country (Figs. 1, 9 and 10). Some centres have all referrals vetted by medical staff and patients triaged to the appropriate service. In others all vetting and triaging is carried out by an ESP, with only complex cases being sent onwards to Orthopaedics or Neurosurgery. Less than half of patients see a physiotherapist prior to referral (Fig. 7).

Most referrals were from GPs, but Orthopaedic and Neurosurgery units also saw significant numbers of inhouse referrals or referrals from other hospitals (Fig. 2). Altering the pathway to divert patients away from direct referral to Ortho/Neuro will place a further burden onto MSK-ESPs.

16% of all referrals were sent to specialties as ‘urgent’, and although many were downgraded to routine at vetting 5% of all patients still required urgent consultant-led clinic appointments (Fig. 3).

73% of patients had lumbar complaints and 20% cervical complaints (Fig. 4), but 15% of referral letters did not include spinal level on the referral letter.

30% of Orthopaedic and Neurosurgery patients had symptoms for more than a year, and a further 50% for more than three months (Fig. 5), showing how poorly patients are accessing and filtering through the system.

Only 28% of Orthopaedic patients had MRIs or other diagnostics done before their OPA, so a further 36% required diagnostics post-OPA (Fig. 6). For Neurosurgery patients, 69% had diagnostics done before their OPA, but a further 22% required diagnostics post-OPA. Lack of diagnostics at a surgical OPA prevents informed discussion of the role of surgery, so patients will often require further diagnostics and re-appointment, and appropriate treatment will be delayed. Overall the conversion rate to surgery from the first Orthopaedic and Neurosurgery clinic is low at around 20% (Fig. 13). These data confirm how wasteful the new OP clinic resource can be, causing an increase in review appointments to discuss imaging results. Boards should look at the health economics of protocol-based open-access MRI either by GP or MSK-ESP. An alternative may be a one-stop service for triage and diagnostics as has been explored in some units in England.


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In most hospitals the assessment of patients presenting to spinal clinics by medical staff is poorly quantified (Figs. 11, 12). Together with a lack of standardisation, this hampers comparison of patients and outcomes across Boards.

Contents Number of patients Page 3 Referral information Page 6 Source of referral, urgency, spinal level, duration of symptoms Pre-OPA management Page 10

Availability and timing of diagnostics, pre-referral physio, specialties involved pre-referral Grades of staff, vetting and first OPA Page 13 Assessment/scoring tools and BMI Page 15 OPA Outcomes Page 17

Outcomes, diagnosis, further referral RTT section Page 20

Time from referral to OPA including breakdown and delays Appendix: Sources of patients in this report Page 24 Acknowledgements - Local Orthopaedic, Neurosurgery, ESP and Physiotherapy leads fed back constructive comments on earlier drafts of this report. Sadia Majid collated, validated and analysed the data gathered by the team of MSk Local Audit Co-ordinators based in each hospital (see list on http://www.msk.scot.nhs.uk/Coord.html) Comments and queries

Please send comments and queries to either

Jane Campbell 01463 705850 MSk Clinical Co-ordinator [email protected] or

Rik Smith 0131 275 7040 MSk Senior Analyst [email protected]


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Number of patients This audit reports on patients attending a first outpatient appointment (OPA) with a back or spinal problem. Neither return outpatients nor unscheduled care patients were included. Patients under 13 years old were also excluded. The large number of back/spinal patients seen by some hospitals forced us to sample in most cases. As back/spinal patients were seen at three main types of OPA (Orthopaedic, Neurosurgery and MSK OPAs), we attempted to obtain adequate sample sizes for each type of OPA for each hospital. Thereafter samples were largely taken based on surnames, and the overall number of patients sampled depended on the amount of time available to our Local Audit Co-ordinator in each hospital. The number of patients sampled and reported on is presented in Table 1, and more detail of the specific sources of data and sampling regimes are given in the appendix. Unless otherwise indicated in the appendix, these samples have been taken from all known sources of back/spinal patients in a hospital and should be broadly indicative of the management of such patients in your hospital. These samples also allowed us to estimate the total number of new back/spinal patients attending OPAs in each hospital per month by multiplication (Table 1, Fig. 1). A few additional sources of patients were identified after the audit period, and numbers from such sources were added to our estimates accordingly. Discussion of these estimates with local leads often indicated that our estimates were not high enough. There are a number of possible reasons why this might have occurred:

Local estimates may be based on referrals or slots and may include or define ‘New’ OPAs differently from our definition above

Local estimates may include community appointments or patients that Did Not Attend Local Audit Co-ordinators were often dependent on finding appropriate coding when

identifying patients from electronic systems, and this may not always have been consistent In some cases Local Audit Co-ordinators were dependent on receiving notes/letters from

secretaries or clinics rather than being given direct access to complete systems. We were unable to check whether all patients were forwarded

Some of a specialties’ patients may not be included as expected. For example, we have included patients seen by ESPs as being managed by the Orthopaedic service if these patients were initially referred to Orthopaedics and vetted first by medical staff

Estimates in this report are based on a short sampling period and are based on relatively small numbers. Short-term variations such as annual leave and cold-weather suspension of some clinics in late November may have reduced our monthly estimate relative to the norm


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Table 1: Sample size and estimate of total number of patients managed by specialties in each department

Number of patients sampled Estimated per month

Hospital Ortho Neuro MSk -

ESP MSk -

PhysioPain

ServiceTotal Ortho Neuro MSk -

ESP MSk -

Physio Pain

ServiceTotal

Ayr 40 40 19 99 14 38 25 77

Crosshouse 29 28 57 38 45 83

Borders 4 34 38 1 12 13

DGRI / GCH 135 135 70 70

QMH / Victoria 69 24 39 132 30 9 31* 21 91

Forth Valley 15 99 114 5 36 41

ARI / Woodend 59 70 43 172 29 68 21 117

Elgin 33 33 50 50

GRI / Stobhill 50 117 167 23 58 81

WIG / Gartnavel 38 36 74 24 22 46

Victoria Infirmary 10 7 24 41 7 8 29 45

SGH 41 159 6 20 226 30 115 7 24 176

RAH / VOL 27 32 31 90 33 39 37 109

Inverclyde / Dunoon 52 28 80 38 20 58

Raigmore 37 36 40 113 13 13 44 70

Hairmyres 47 34 15 96 17 25 11 53

Monklands 32 31 11 74 12 22 8 42

Wishaw 95 39 5 139 34 47 9 91 RIE / WGH / St Johns

35 123 30 188 83 149 36 268

Ninewells / Stracathro

33 108 73 214 13 41 70 123

Perth 53 53 19 19

Total 737 496 809 254 39 2335 426 385 558 333 21 1723

The audit period for most hospitals was 13th September 2010 to 5th December 2010. Exceptions were GRI/Stobhill (13th Sep to 16th Nov), Gartnavel/WIG (1st Nov to 17th Dec) and ARI/Woodend (4th Oct to 5th Dec)

The multiplicative factor used to obtain a monthly estimate of patients seen depended on what proportion of patients were sampled and varied both between and within hospitals. Details of sources and sampling regimes are provided in the appendix

59 Neurosurgery patients had previously been seen as new OPAs by Orthopaedics, either inhouse or from other hospitals

* Numbers for Fife Physio service are estimated from figures provided by that service - not audited Patients were categorised as being managed by Orthopaedics if the original referral came into Orthopaedics

and was vetted by medical staff, irrespective of whether an ESP or medical staff saw the patient at first OPA. If the referral was sent into the Orthopaedic unit but was vetted and managed by an ESP then the patient will be reported in the ESP category


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Fig. 1: Number and type of back/spinal outpatients by hospital

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Orthopaedics Neurosurgery MSK - ESP MSK - Physio Pain Service


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Referral information As expected most referrals are from GP directly to Physiotherapy and 60% of Neurosurgery and 80% of Orthopaedic referrals are straight from GP. Altering the pathway to divert patients away from direct referral to Ortho/Neuro will place a further burden onto MSK-ESPs. Fig. 2: Source of referral

a) Orthopaedics b) Neurosurgery

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GP Community physioInhouse From other hospital/BoardSelf-referral Other


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Sixteen percent of all referrals were sent to specialties as ‘urgent’. In some sites, particularly those where self referral to Physiotherapy is available, the ‘urgent’ referral criteria for spinal patients is anyone with Low Back Pain (or neck pain) with or without radiating pain; nerve root signs of more than two weeks and less than 12 weeks duration; or those with extenuating circumstances (e.g. a carer struggling to care for dependants). However, after vetting, many of these urgent referrals were sent to routine Orthopaedic or Neurosurgery clinic slots, or to ESP or Physiotherapy clinics. After vetting, an average of 5% of all patients still required urgent consultant-led clinic appointments (9% of Orthopaedic patients and 11% of Neurosurgery patients, Fig. 3). 37% of Orthopaedic patients who were considered urgent after vetting had an OPA within 6 weeks of vetting, compared to 21% of those that were not urgent. Similarly, 87% of urgent Neurosurgery patients were seen within six weeks compared to 22% of those that were not urgent. Fig. 3: Urgency of appointment post-vetting a) Orthopaedics b) Neurosurgery

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There were a marked number of patients (15% across all specialties) who had no spinal level of complaint recorded in the referring letter. After excluding these cases, 73% of all complaints included lumbar problems (Fig. 4). There were also significant numbers (20%) of cervical referrals, especially to Neurosurgery and Physiotherapy. More cervical patients are seen by Physiotherapy than ESP. This may indicate that the cervical pain patients seen by Physiotherapy are true musculoskeletal without radiculopathy. Fig. 4: Spinal level of the complaint a) Orthopaedics b) Neurosurgery

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Cervical ThoracicLumbar Sacral/coccyxMore than one level Not recorded in referring letter

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Fig. 5: Duration of symptoms prior to OPA a) Orthopaedics b) Neurosurgery

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Fig. 5 shows how poorly patients are accessing the system and how slowly they filter through to Orthopaedic and Neurosurgery clinics. Even assuming the ‘not recorded’ patients are seen timeously, that still means 80% of Orthopaedic and Neurosurgery patients have had symptoms for more than three months and, worse still, 30% of the total have had symptoms for more than a year. None of the hospitals perform well here.


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Pre-OPA management There is a huge national variation in access to imaging from primary care and from MSK-ESP (green and grey bars on Fig. 6). Similarly, the rate of diagnostics requested at first OPA (pink bar on Fig. 6) is inversely proportional to the rate prior to referral. Only 28% of Orthopaedic patients had diagnostics (mainly MRIs) done before their OPA, so a further 36% required diagnostics post-OPA. For Neurosurgery patients, 69% had diagnostics done before their OPA, but a further 22% required diagnostics post-OPA. There is little point in a patient being referred to a spinal service without diagnostics as there cannot be an informed discussion of the role of surgery. The patient will often require further diagnostics and re-appointment. Appropriate treatment will be delayed. Boards should look at the health economics of protocol-based open-access MRI either by GP or MSK-ESP. An alternative may be a one-stop service for triage and diagnostics as has been explored in some units in England. Fig. 6: Availability and timing of diagnostics


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In some Boards where GPs do not have direct access to MRI (e.g. A&A) the high numbers of diagnostics carried out prior to attending a first OPA have been requested as a result of ‘in-house’ referrals.


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Less than half of patients see a physiotherapist prior to referral (Fig. 7). The audit was not able to determine whether this was just an assessment or if a course of treatment had been given prior to onward referral. A change in the pathway of management to include a higher proportion of patients seeing a physiotherapist earlier in their condition will require significant augmentation of the workforce. Fig. 7: Physiotherapy received prior to referral


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Community physiotherapy clinic GP surgery

Privately Done, not known where

No prior physiotherapy documented


- - 12

Fig. 8: Specialities involved in patient pathway before referral a) Orthopaedics b) Neurosurgery

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Orthopaedics Neurosurgery MSk (Physio/orthotics)

Rheumatology Pain Service Other

More than one None Not recorded


- - 13

Grades of staff, vetting and first OPA Service models vary throughout the country (Fig. 9). Some centres have all referrals vetted by medical staff and patients triaged to the appropriate service. In others all vetting and triaging is carried out by an ESP, with only complex cases being sent onwards to Orthopaedics or Neurosurgery. Fig. 9: Who first vetted patients post Referral?


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Medical staff ESP Clerical staff

Physio Not vetted Missing data

Where patients are recorded as being vetted initially by clerical staff, all then proceeded to 2nd vetting by a clinical member of staff.


- - 14

Fig. 10: Patient seen at OPA by:


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Consultant Specialist trainee Associate specialist Staff grade

ESP Physio Physio consultant Other

Many consultant clinics will be taken by spinal specialists. Trainees in both Orthopaedics and Neurosurgery get an exposure to spinal outpatients.


- - 15

Assessment/scoring tools and BMI In many hospitals the assessment of patients presenting to spinal clinics by medical staff is poorly quantified (Fig. 11). If there is no standardised documentation of initial symptoms and signs, it will be difficult to make meaningful comparison of outcomes across units. Other specialties such as chronic pain clinics have successfully used pre-visit assessment forms. Fig. 11: Assessment/scoring tools used a) Orthopaedics b) Neurosurgery

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Oswesry Disability Index Other

Oswestry + Other Assessed, method unknown

No assessment documented

Mick McMenemy (project lead for the National MSK Programme) commented that these results highlighted the typical situation across Scotland, i.e. inconsistent use of outcome measures and screening tools. The National MSK Programme includes use of a standard minimum dataset for common conditions such as low back pain. Specifically, the Roland and Morris measure is recommended. Employability status and quality of life (EQ5D) will also be recorded routinely. Standard use of the same outcome measures within a patient’s journey will help identify successful management and effectiveness of services (or not). This will also help ensure that the patient is more likely to be seen at the right time, in the right place by the right person.


- - 16

Many units do not appear to document BMI (Fig. 12). Fig. 12: BMI range a) Orthopaedics b) Neurosurgery

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Underweight (BMI < 18.5) Normal (BMI 18.5-24.9)

Overweight (BMI 25-29.9) Obese I (BMI 30-34.9)

Obese II (BMI 35-39.9) Obese III (BMI > 40)

Not documented


- - 17

OPA outcomes Overall the conversion rate to surgery from the first Orthopaedic and Neurosurgery clinic is low at around 20% (Fig. 13). More patients are referred to diagnostics than listed for surgery. This is wasteful of a scarce resource. Fig. 13: First OPA outcome


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Treatment commenced Treatment to be prescribed by GP

No treatment required Other clockstop

Add to waiting list for treatment Referred for diagnostics

Referred for treatment nurse/AHP Referred to another clinician

Return OPA Other non-clockstop


- - 18

More than half of all patients audited had acute/chronic back pain (Fig. 14). Intervertebral disc disorders were also common, especially amongst patients referred to Neurosurgery.

Fig. 14: Diagnosis made at OPA


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Acute/Chronic back pain Intervertebral Disc disorders

Scoliosis Spinal Stenosis

Spondylosis Other

Not recorded


- - 19

Fig. 15: Where was the patient referred onto?


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Orthopaedics Physiotherapy Pain clinic/pain service

Surgical review (Spinal) Neurosurgery Back pain service

Other More than one specialty Not referred


- - 20

RTT section 75% of 2296 patients with documented length of time from Referral to Outpatient Appointment were seen within 12 weeks (Fig. 16). These data are a snapshot of the service in the last quarter of 2010. At that time at least two of the neurosurgical units and some of the orthopaedic units were running waiting list initiative clinics to comply with incoming RTT legislation. Note, however, that we did not record periods of patient unavailability in this audit. Despite this it would seem that there were patients in most hospitals exceeding 12 weeks waiting time for Orthopaedic or Neurosurgical clinic. Fig. 16: Length of time from Referral to Outpatient Appointment


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aw

All

un

its

Per

cent

age

of p

atie

nts

<=6 weeks 6-9 weeks 9-12 weeks

>12 weeks Missing data


- - 21

Table 2: Average time from Referral to First Vetting

Referral to vetting

Specialty % of patients whose vetting dates was

documented

Number of patients

documented

Mean (weeks

)

% > 1 week

Orthopaedics Ayr 100% 40 0.5 25%

Borders 100% 4 0.2 0%

QMH/Victoria 84% 58 0.2 7%

Forth Valley 0% 0 - -

ARI/Woodend 61% 36 1.3 39%

GRI/Stobhill 100% 50 0.1 2%

WIG/Gartnavel 45% 17 0.1 0%

Victoria Inf 70% 7 0.9 57%

SGH 93% 38 0.5 11%

RAH/VOL 78% 21 0.7 14%

IRH/Dunoon 65% 34 0.6 12%

Raigmore 95% 35 0.2 3%

Hairmyres 94% 44 0.2 2%

Monklands 100% 32 0.2 3%

Wishaw 88% 83 1.9 72%

RIE/WGH/St Johns 71% 25 0.0 0%

Ninewells/Stracathro 29% 7 0.4 0%

Perth 98% 51 0.1 0%

All orthopaedics 80% 582 0.6 18%

Neurosurgery ARI/Woodend 97% 68 0.3 4%

SGH 52% 83 2.4 41%

Raigmore 100% 36 0.2 3%

RIE/WGH/St Johns 65% 80 0.0 0%


All neurology 68% 335 0.7 13%

MSK - ESP Ayr 100% 40 0.3 10%

Crosshouse 100% 29 0.4 0%

Borders 100% 34 0.0 0%

DGRI/GCH 100% 135 0.1 1%

QMH/Victoria 92% 22 0.4 0%

Forth Valley 0% 0 - -

ARI/Woodend 2% 1 1.1 100%

GRI/Stobhill 100% 117 0.1 2%

WIG/Gartnavel 3% 1 0.0 0%


SGH 100% 6 0.0 0%

RAH/VOL 100% 32 0.0 0%

Hairmyres 100% 34 0.2 0%

Monklands 100% 31 0.1 0%

Wishaw 97% 38 3.5 89%

RIE/WIG/St Johns 80% 24 0.0 0%


All ESP 75% 609 0.4 7%

Physiotherapy Ayr 100% 19 0.0 0%

Crosshouse 100% 28 0.0 0%

Elgin 100% 33 0.0 0%


SGH 90% 18 0.0 0%

RAH/VOL 100% 31 0.0 0%

IRH/Dunoon 0% 0 - -

Raigmore 50% 20 0.0 0%

Hairmyres 100% 15 0.0 0%

Monklands 100% 11 0.0 0%

Wishaw 100% 5 0.6 20%

All Physio 80% 204 0.0 0%


- - 22

Table 3: Average times from Vetting to Outpatient Appointment

Vetting to Ready for Allocation

Allocation to Date Offered

Date Offered to OPA attendance

Specialty N Mean

(weeks) % > 8 weeks

N Mean

(weeks) % > 8 weeks

N Mean

(weeks) % > 8 weeks

Orthopaedics Ayr 40 0.1 0% 40 6.2 30% 40 0.6 0%

Borders 4 0.0 0% 4 10.5 100% 4 0.0 0%

QMH/Victoria 58 2.2 2% 69 4.3 0% 69 0.2 0%

Forth Valley 0 - - 15 8.6 47% 15 0.0 0% ARI/Woodend 32 4.8 41% 50 9.4 58% 59 0.3 0% GRI/Stobhill 50 0.2 0% 50 8.9 72% 50 0.2 0% WIG/Gartnavel 17 0.0 0% 38 15.6 84% 38 0.8 3% Victoria Inf 7 0.3 0% 10 9.2 70% 10 1.8 10% SGH 38 0.0 0% 41 10.7 88% 41 0.8 7% RAH/VOL 21 1.3 5% 27 9.0 78% 27 0.5 0% IRH/Dunoon 26 4.5 27% 40 4.1 0% 52 1.2 4% Raigmore 35 0.1 0% 36 9.8 75% 37 0.0 0% Hairmyres 44 0.0 0% 47 10.5 81% 47 1.1 6% Monklands 32 0.0 0% 32 11.9 100% 32 0.4 3% Wishaw 83 6.2 19% 95 3.5 0% 95 0.9 6% RIE/WGH/St Johns 25 0.0 0% 35 12.4 74% 35 0.3 3% Ninewells/Stracathro 7 4.8 14% 33 4.6 9% 33 0.2 0% Perth 51 0.1 0% 52 5.0 2% 53 0.1 0% All orthopaedics 570 1.7 7% 714 7.8 44% 737 0.5 2% Neurosurgery ARI/Woodend 68 0.5 3% 69 9.4 71% 70 0.4 3% SGH 83 0.3 1% 159 12.0 66% 159 0.9 4% Raigmore 36 0.0 0% 36 5.9 11% 36 0.6 6% RIE/WGH/St Johns 80 0.0 0% 123 9.4 80% 123 0.1 0% Ninewells/Stracathro 67 8.0 73% 107 3.9 2% 108 0.1 0% All neurology 334 1.8 16% 494 8.8 52% 496 0.5 2% MSK - ESP Ayr 40 0.1 0% 40 5.7 10% 40 0.6 3% Crosshouse 29 0.0 0% 29 7.8 45% 29 0.1 0% Borders 34 0.1 0% 34 2.6 0% 34 0.4 0% DGRI/GCH 135 0.5 0% 135 2.9 1% 135 0.3 0% QMH/Victoria 22 1.4 0% 24 4.0 0% 24 0.1 0% Forth Valley 0 - - 99 10.7 73% 99 0.5 3% ARI/Woodend 1 3.0 0% 41 11.2 78% 43 0.8 7% GRI/Stobhill 117 0.1 0% 117 8.7 74% 117 0.7 3% WIG/Gartnavel 1 0.0 0% 36 10.6 78% 36 0.4 0% Victoria Inf 7 0.0 0% 7 6.7 29% 7 0.3 0% SGH 6 0.0 0% 6 1.0 0% 6 0.0 0% RAH/VOL 31 0.0 0% 31 1.6 3% 32 0.1 0% Hairmyres 34 0.0 0% 34 11.1 79% 34 0.7 0% Monklands 31 0.0 0% 31 10.2 71% 31 1.5 10% Wishaw 38 2.5 8% 39 3.9 0% 39 1.1 5% RIE/WIG/St Johns 24 0.0 0% 30 14.3 97% 30 1.4 10% Ninewells/Stracathro 58 0.8 0% 73 3.6 0% 73 0.6 1% All ESP 608 0.4 0% 806 6.9 39% 809 0.6 2% Physiotherapy Ayr 19 0.0 0% 19 4.4 0% 19 0.2 0% Crosshouse 28 0.0 0% 28 3.7 7% 28 0.0 0% Elgin 33 0.0 0% 33 1.2 0% 33 0.0 0% Victoria Inf 24 0.0 0% 24 7.9 50% 24 0.0 0% SGH 18 0.0 0% 20 2.4 0% 20 0.0 0% RAH/VOL 30 0.1 0% 30 4.4 17% 31 0.0 0% IRH/Dunoon 0 - - 0 - - 28 0.2 0% Raigmore 18 0.0 0% 19 3.4 0% 40 0.1 0% Hairmyres 15 0.0 0% 15 6.5 53% 15 0.4 0% Monklands 11 0.0 0% 11 3.4 0% 11 0.0 0% Wishaw 5 3.8 0% 5 2.7 0% 5 0.0 0% All Physio 201 0.1 0% 204 4.0 13% 254 0.1 0%


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Fig. 17: First reason for delay to OPA


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Did Not Attend Patient cancelled original appointment

Clinic cancelled original appointment Patient unavailable (includes 'declined appt')

Unknown reason No delay


- - 24

Appendix: Sources of patients in this report

Sampling regime Sampled Estimated /month

Description of data gathered from LACs and other comments

Ayr Ortho 100% throughout 40 14 Mr Muirhead's New Patient and Back Clinic lists

ESP 50% (A-L) 13/9-25/10; 30% (A-F) 26/10-21/11;

stopped 21/11

40 38 All lists from Monaghan and Cowie

Physio 50% (A-L) 13/9-25/10; 20% (A-C) 26/10-5/12

19 25 Went through diary for new OPAs

Crosshouse ESP 30% (A-F) 13/9-21/11; stopped 21/11

29 38 All lists from Reid, McMahon and Robinson (no patients seen by Gardner)

Physio 50% (A-L) 13/9-25/10; 20% (A-C) 26/10-5/12

28 41 Went through diary for new OPAs

Borders Ortho 100% throughout 4 1 Ortho new OPAs with Back Pain – very few – picked up by secretaries, but potential for very few to be missed

ESP 100% throughout 34 12 Specialist Back Pain ESP clinic – all new appointments

DGRI / GCH

ESP 70% (A-M) throughout 135 70 Identified by weekly visits to ESP, looking at outcomes of each appointment

QMH / Victoria

Ortho 100% throughout 69 30 All Ortho/Physio clinics at QMH by Mr Brenkel, Ballantyne, Dunstan, Sharma, Grant, Gray, Lynch and specialist trainees All Ortho/Physio clinics at VHK by Mr Brenkel, Ballantyne, Cook, Dunstan, Cameron, Gray, O’Connor, Short, Lynch and specialist trainees

ESP 100% throughout 24 9 Mr Syme’s Ortho/Spinal clinics at VHK

Physio Not audited 31* Not audited - figures from Fife Physio Service

Pain Service

100% throughout 39 21 All clinics at QMH by Gilbert, Roddan and Timperley

Forth Valley Ortho 100% throughout 28 10 Not verified - staff turnover

ESP 100% throughout 86 31 All ESP clinics at Stirling Royal Infirmary

ARI / Woodend

Ortho 100% from 4/10 to 5/12 59 29 All clinics at WGH for Craig and McNair

Neuro 50% (A-L) from 4/10 to 5/12

70 68 All clinics at ARI for Bhatt, Labrum, Karmel and Al Haddad

ESP 100% from 4/10 to 5/12 43 21 All clinics at WGH for Burt, Quirie and Smith

Elgin Physio 20% (A-C) 13/9-19/10; 30% (A-F) 20/10-5/12

33 50 All clinics held at Dr Gray’s Hospital

GRI / Stobhill

Ortho 100% but stopped 16/11 50 23 GRI - Orthopaedic Clinic - Mr Wheelwright - REWOR4:EW - Every Tuesday

ESP 100% but stopped 11/11 117 58 ESP Clinics as follows: Stobhill - STP72R5:PAM72 - every Monday Stobhill - STP71R5:PAM71 - every Monday, Tuesday and Wednesday GRI - Ortho Physio Tues AM Knee - Every Tuesday GRI - Ortho Physio Back Southside - Every Thursday Used Clinical Portal and Bluespier systems to locate clinics

WIG / Gartnavel

Ortho 100% from 1/11 to 17/12 38 24 Data collected from all the following clinics: ORTREETUE : REEC


- - 25



ORPHARTHA ORPHARTAM ORPHARRET (checked for new patients) MR REECE BACK CLINIC These include Physio and Consultant clinics

ESP 100% from 1/11 to 17/12 36 22 See above

Victoria Infirmary

Ortho 50% (A-L) throughout 10 7 Ortho Back Clinics: Gardner (Monday), Mansbridge (Wednesday); only covered back clinics - possibly missed patients in other OP clinics

ESP 30% (A-F) throughout 7 8 Searched Excel database for new lumbar back and neck patients

Physio 30% (A-F) throughout 24 29 Searched Excel database for new lumbar back and neck patients

SGH Ortho 50% (A-L) throughout 41 30 Ortho Back Clinics: Mohammed (Mon), Carter (Tue/Wed), Patil (Tue), Sherlock (Wed), Meek (Thur), Hullin (Fri); only covered back clinics - possibly missed patients in other OP clinics

Neuro 50% (A-L) throughout 159 115 Patients referred directly to Neuro and those referred from other Ortho to Neuro, Sourced through clinical portal - OPA: entered speciality: Mr Suttner - N/Surgery Tuesday AM; SBR02ESP - ESP Clinic; Waiting List (Thursday) Miss Littlechild - N/Surgery Thursday AM; SBR02ESP - ESP Clinic Mr St. George - GEO - Waiting List (Tuesday); N/Surgery Friday Mr Dunn - N/Surgery Thursday AM Mr Taylor - N/Surgery New Monday AM; SBR02ESP - ESP Clinic Mr Alakandy - N/Surgery Thursday PM; Waiting List Thursday; SBR02ESP - ESP Clinic Mr Barlow - N/Surgery New Monday AM Miss Brown - Adult Tuesday AM Mr Sangra - N/Surgery New Tuesday AM

ESP 30% (A-F) throughout 6 7 Searched Excel database for new lumbar back and neck patients

Physio 30% (A-F) throughout 20 24 Searched Excel database for new lumbar back and neck patients

RAH / VOL Ortho 30% (A-F) throughout 27 33 Referral letters checked on SCI every week for all new patient Ortho clinics at RAH and VOL to identify all 'new' spinal referrals.

ESP 30% (A-F) throughout 32 39 All spinal referrals for ESPs were highlighted in the physio appointment book by the physio department office manager

Physio 30% (A-F) throughout 31 37 All spinal referrals for physios were highlighted in the physio appointment book by the physio department office manager

Inverclyde / Dunoon

Ortho 50% (A-L) throughout 52 38 All patients referred to six consultants by GPs with spinal complaints identified in SCI outpatients. Also included all patients referred to the new back pain clinic.

Physio 50% (A-L) throughout 28 20 Diary pages checked and traced via the physio database

Raigmore Ortho 100% throughout 37 13 Secretaries provided copies of first OPA letters of all spinal/ back patients referred into Ortho Neuro 100% throughout 36 13 All referral letters from Highland to Grampian based Neurosurgery service vetted for patients having an OPA during data

collection period. Included in audit if case notes available following OPA

Physio 2 GP practises covering 20000 of 60000 pts in

Raigmore CHP

40 44 Two GP practises covered where Raigmore-based physiotherapists performed clinics. Physios were asked to inform LAC of any back pain/spinal patients attending for a first Physio OPA at the GP surgery

Hairmyres Ortho 100% throughout 48 17 Some patients identified by staff in Ortho (clinics putting names on sheets, including patients seen by ESPs) The rest of the patients (Physio and Ortho) were identified using clinic lists on PMS system and e-vetting system.

ESP 50% (A-L) throughout 33 25 See above

Physio 50% (A-L) throughout 15 11 Some patients identified by staff in Ortho

Monklands Ortho 100% throughout 32 12 All six consultant new clinics and two associate specialist clinics were checked - casenotes, clinic notes and e-vetting attended clinics


- - 26



ESP 50% (A-L) throughout 31 22 Checked all ESP clinics - casenotes. clinic notes and e-vetting attended clinics

Physio 50% (A-L) throughout 11 8 Physios identified patients for LAC - LAC then used Physio notes

Wishaw Ortho 100% throughout 99 35 All Ortho consultants' new clinics screened, referral letters checked

ESP 30% (A-F) throughout 35 49 All ESPs' new clinics screened, referral letters checked

Physio 20% (A-C) throughout 5 12 Physios asked to complete form after seeing any new spinal referrals

RIE / WGH / St Johns

Ortho 30% (A-F) throughout 35 43 Mr Gibson: Mon & Thur clinics + six extra clinics (30/9, 1/10, 9/11, 18/11, 29/11 & 2/12) Did not audit James Campbell's Ortho patients

Neuro 30% (A-F) throughout 123 149 Mr Fitzpatrick’s clinics (Mon, Tue & Thur); Mr Russell’s clinics (Tue & Thur + 2 pm clinics 5/10 &12/10); Mr Statham’s Wed clinics + extra clinic 18/11/10 + 2 other registrar clinics 13/10 & 10/11; Mr Fouyas’s Friday clinics; Lynn Myles’ clinics on 22/9, 13/10, 20/10 and 17/9; also checked clinics by Prof Whittles and Jerrard Ross

ESP 30% (A-F) throughout 30 36 Vivienne Boyd's clinics @ ERI on Mon, Wed, Thur & Fri; also her extra clinics on 21/9, 26/9, 28/9 & 16/9

Ninewells / Stracathro

Ortho 100% throughout 33 13 Ortho surgeon Mr Valentine, spinal clinic, Mon am, every 2nd week; 4 clinics captured - others cancelled due to annual leave

Neuro 100% throughout 108 41 Neurosurgeons - secretaries copied new outpatient letters to LAC who pulled notes

ESP 50% (A-L) throughout 73 70 ESP Ortho NW - weekly pm clinic Tues - 8 clinics; ESP Ortho NW - every second week Wed pm - 5 clinics; ESP Ortho Stracathro - Tues - 9 clinics; ESP clinic Arbroath - Tues - 10 clinics Printed clinic listings and pulled all new patient notes; not all ESP clinics fully booked

Perth ESP 100% throughout 53 19 Orthopaedic Outpatients checked all elective clinics to ensure no backache referrals ESP spinal clinics Orthopaedic outpatient department Monday pm

Documents

Audit of back pain/spinal patients - QI Hub audit of back pain - spinal... · From our samples, we estimated an average of more than 1700 back pain/spinal patients attending new outpatient