Paediatric orthopaedics: recent achievements and future directionsdocs2.health.vic.gov.au/.../paediatric_orthopaedics.pdf · 2015-05-25 · 58 Paediatric orthopaedics: recent achievements

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Paediatric orthopaedics: recent achievements and future directions


May 2009

60 Paediatric orthopaedics: recent achievements and future directions

Paed_orthopaedics_report_text.indd 60 1/04/09 10:50 AM

May 2009



Published by the Victorian Government Department of Human Services Melbourne, Victoria

© Copyright State of Victoria 2009

This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

This document may also be downloaded from the Department of Human Services website at:

www.dhs.vic.gov.au/ahs/emergency or www.health.vic.gov.au/surgery/

Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.

May 2009.


Paediatric orthopaedics: recent achievements and future directions 59

Physiotherapy-led clinic

Monthly summary report Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Outcome (New patients)

No follow up required

Referred to orthopaedic consultant

Referred to orthotics

Referred to other specialist

OAC R/V

Surgical WL

Referred to physiotherapy

Diagnosis (review appointments)

DDH

TEV

Other

Cast

Total number of casts (new & R/V)

Total number of cast assists

Waiting time (this should be obtained from the administrative database)

Priority 1

Priority 2

Priority 3

Catchment area (recommended to provide on six monthly basis)

Insert postcodes





Other musculoskeletal problems lower limb

Back pain

Spine/scoliosis

Growing pains

Gait problems

Complex other e.g. CP

Age (New patients)

<3m

> 3m <6m

>6m <12m

1 year

2 years

3 years

4 years

5 years

6 years

7 years

8 years

9 years

10 years

11 years

12 years

13 years

14 years

15 years

16 years or more


Paediatric orthopaedics: recent achievements and future directions iii

Message from the Executive Director

The Victorian Government has invested in the health and welfare of children and young people and given high priority to the development of paediatric services across the state.

In 2006 the government released the Framework for paediatric orthopaedic services, which responded to concerns about pressures on paediatric orthopaedic services and identified strategies to build a more sustainable service system into the future.

Over the last two years, the Statewide Paediatric Orthopaedic Advisory Committee has overseen the development and implementation of a range of initiatives to strengthen the capacity of specialist paediatric orthopaedic services and position the system to better respond to complex challenges.

This report, Paediatric orthopaedics: recent achievements and future directions, reviews progress in implementing key recommendations of the 2006 framework and outlines plans for further work over the next two years.

By building on the considerable achievements of the last two years and the inherent strengths of the service system, the future directions identified in this document will help ensure that children with orthopaedic trauma and developmental problems receive the best possible treatment and care.

Paediatric orthopaedics: recent achievements and future directions complements a number of existing Victorian Government policies on child health and welfare. It foreshadows links between the work of the new Paediatric Orthopaedic Advisory Group and other emerging initiatives, such as a proposed new strategic framework for paediatric services in Victoria.

The government is committed to the continued development of paediatric orthopaedic services and to maintaining and strengthening the relationships that been established over the last two years. We look forward to working with service providers to realise the aspirations described in this document.

Lance Wallace Executive Director Metropolitan Health & Aged Care Services


iv Paediatric orthopaedics: recent achievements and future directions





Occasions of service

Attended (new patients)

Attended (review patients)

FTA (new patients)

FTA (review patients)

Total occasions of service

Referral source (new patients)

GP

RCH ED

Internal/external paediatrician

Internal/external orthopaedic consultant

Maternity hospital

Other internal RCH

Other external

Diagnosis (new patients)

Postural variations

Knee conditions

Structural TEV

DDH

Symptomatic flat feet

Postural problems

Toe walking

Toe deformities

Other foot deformities: CV foot, MTA, positional talipes

Other musculoskeletal problems upper limb

Appendix B – Example of monthly summary report




Paediatric orthopaedics: recent achievements and future directions v

Contents

Message from the Executive Director iii

Committee membership vii

1 Introduction 1

1.1 Guiding principles 1

2 Background 3

2.1 Service context 3

2.2 Framework for paediatric orthopaedic services 10

3 Achievements to date 11

3.1 Statewide model of service delivery 11

3.2 Service capacity 13

3.3 New models of care 15

3.4 Workforce development and innovation 16

4 Future directions 21

4.1 Paediatric Orthopaedic Advisory Group 21

4.2 Priorities 2009–2010 21

Appendix 1: Policy and service context for paediatric orthopaedic services 29

Appendix 2: Implementation status of 2006 framework recommendations 31

Appendix 3: Service delineation framework 37

Appendix 4: Framework for development of allied health-led clinics in paediatric orthopaedics 43


vi Paediatric orthopaedics: recent achievements and future directions



1.4.8 DischargeOn discharge from OAC and Orthopaedic Outpatients, a summary report is sent to the referrer outlining the assessment, management and recommended actions.

Referrals remain current for two years. Patients may be re-referred to the OAC as required.

OAC management referral pathway

Triaged to OAC

Assessment

Follow up required(see Box A)

No follow up required:Advice +/- homeexercise program

Discharge from OAC

Box AOptions• Refer to orthotics• Arrange further investigations • Refer to orthopaedic consultant clinic +/- investigations• Refer to physiotherapy• Refer to other specialists• Review at OAC



1.4 OAC process

1.4.1 Management within the OAC clinicAs its name implies, the OAC is intended primarily as an assessment clinic for new referrals. However children with DDH (not requiring surgery) and children with positional and structural foot deformities, including those requiring casting, are usually managed for ongoing review within the OAC. Children with other simple conditions who do not need surgical assessment, but for whom monitoring is necessary, may be booked for review in the OAC (for example: back pain, knee pain) as appropriate.

1.4.2 When no further follow-up is requiredWhere no further follow-up is required, verbal advice regarding the child’s condition is given, generally supplemented by a patient information leaflet. Simple home exercise programs may also given by the physiotherapist within the OAC. Letters are dictated to referrers on the same day, and information leaflets enclosed as appropriate.

1.4.3 When child requires referral to orthopaedic consultantReferral to the orthopaedic consultant for further assessment or management may be made as requested by the physiotherapist. The physiotherapist should organise for appropriate investigations prior to this appointment.

1.4.4 When child requires referral to another specialistThese should be made following consultation with the orthopaedic consultant or registrar. Consultant or registrar signature is required on the consultant referral form.

1.4.5 When other referrals are requiredAllied health referrals (orthotics, physiotherapy, occupational therapy) may be made directly by the physiotherapist using the designated referral card.

New DDH referrals for bracing are seen on the same day by the orthotics department. For all other referrals, appointments are generally arranged by the allied health department for a later date.

Where it is anticipated that the child requires ongoing physiotherapy review and supervision, the child will be referred to the physiotherapy department or community physiotherapy rather than be managed within the OAC.

1.4.6 InvestigationsRequests for radiology/pathology are discussed with the orthopaedic registrar/ consultant and may be made directly, or booked for a later date. Orthopaedic consultant or registrar signature is required on the request form. The physiotherapist may liaise with the consultant to discuss results.

1.4.7 DocumentationDocumentation of the clinic visit is maintained as per RCH documentation guidelines in the child’s medical record.


Paediatric orthopaedics: recent achievements and future directions vii

Current members of the Statewide Paediatric Orthopaedic Advisory Committee are:

Dr Martin Lum Senior Medical Advisor, Access and Metropolitan Performance, Department of Human Services

Mr Andrew Crow Manager, Post Acute Services, Ambulatory and Continuing Care, Department of Human Services

Mr Terry Symonds Manager, Statewide Surgical Services Program, Department of Human Services

Ms Sandra Gates Program Manager, Victorian Paediatric Rehabilitation Service

Prof Kerr Graham Professor of Orthopaedics, Royal Children’s Hospital

A/Prof Leo Donnan Director of Orthopaedics, Royal Children’s Hospital

Ms Michelle Vu Program Manager, Statewide Paediatric Orthopaedics

Mr Adam Horsburgh Director, Monash Sector, Southern Health

Mr Ton Tran Head of Paediatric Orthopaedics, Clayton, Head of Orthopaedics, Dandenong, Southern Health

Mr Rick Angliss Orthopaedic Surgeon, Barwon Health

Mr Chris McCarthy Clinical Program Leader for Surgical Services, Eastern Health

Ms Claire Culley Divisional Director, Surgical Services, Western Health

Dr Donna Henderson Association for Children with a Disability

Ms Penny Green Allied Health (physiotherapist), Eastern Health

Ms Helen Hutchins Nurse Unit Manager, Paediatrics Unit, Peninsula Health

Dr Catherine Marraffa Paediatrician, Royal Australian College of Physicians

Ms Sandy Bell Senior Project Officer, Statewide Surgical Services Program, Department of Human Services

Committee membership


viii Paediatric orthopaedics: recent achievements and future directions

Current members of the Paediatric Orthopaedic Allied Health Subcommittee are:

Ms Margaret Bradshaw (chair) Senior Physiotherapist, Barwon Health

Ms Elizabeth Cashill (retired chair) Director, Allied Health, Melbourne Health

Ms Penny Green Senior Physiotherapist, Eastern Health

Ms Hema Duff Senior Physiotherapist, Peninsula Health


Mr David Harding Senior Physiotherapist, Southern Health

Ms Bernadette Shannon Occupational Therapist, Southern Health

Ms Arlee Hatfield Physiotherapy Manager, Western Health

Ms Prue Weigall Senior Physiotherapist, Royal Children’s Hospital

Ms Nicole Galea Orthotist/Prosthetist, Royal Children’s Hospital

Ms Beverley Eldridge Senior Physiotherapist, Australian Physiotherapy Association




Physiotherapist-led orthopaedic assessment clinic (OAC) guidelines (Royal Children's Hospital)

1.1 New referrals to orthopaedic outpatient clinicsNew orthopaedic outpatient referrals may be mailed or faxed to RCH Outpatients, before being forwarded to the Orthopaedic Outpatient Department for triaging. Some referrals are sent directly to orthopaedic outpatients.

All referrals are dated, and a referral cover sheet attached by orthopaedic outpatient administrative staff on day of receipt. In addition, all referrals are registered by placement on the waiting list.

The first level of triage is conducted by the senior physiotherapists, generally on the same day the referral is received in the orthopaedic department. Referrals that fit the criteria for OAC are triaged directly to the OAC. Referrals that are deemed to require management by clinics other than OAC are passed on to a consultant for second level triage. Where a referral is received that is deemed to require urgent consultation appropriate action is taken to ensure timely evaluation.

1.2 Physiotherapist-led orthopaedic assessment clinic triage guidelines Based on the information provided on the referral, all referrals triaged to the OAC are assigned a clinical priority category. Referrals which are assessed as high priority will then be booked by administrative staff directly.

1.3 OAC - scheduling

1.3.1 OAC clinics run alongside consultant/registrar clinics. One clinic only (8.30am–12.00pm or 1.30 pm–5.00pm) is scheduled for each physiotherapist per day. The time remaining is allocated to non-clinical work. This includes triaging of new referrals, maintaining clinic data, follow-up letters to referrers, research, development of educational materials for families and referrers, professional development, and teaching.

Patients are booked into designated OAC clinics according to a booking template, by orthopaedic outpatient administrative staff. This should generally allow for five new patients (30 minutes allocated) and five review patients (10-15 minutes allocated) per session. One booking per clinic should be left open to allow for scheduling of urgent new patients. All patients are sent a letter informing them of their appointment and that they will be seen by a senior physiotherapist.

Spine assessments are scheduled to coincide with the Consultant Spine Clinic to ensure necessary professional support.

Casting clinics for clubfoot and DDH management are scheduled so that the physiotherapist and consultant may work as a consistent team to ensure professional support, and continuity of care for the patient.

Appendix A – OAC referral guidelines





1. Introduction

This document describes key achievements in the development of paediatric orthopaedic services since the release of the Framework for paediatric orthopaedic services in 2006 and identifies directions for further work over the next two years (2009 and 2010).

The Department of Human Services (the department) commissioned the framework to inform development of a sustainable system of paediatric orthopaedic services in the context of increasing service demand and workforce supply issues.

A time-limited Statewide Paediatric Orthopaedic Advisory Committee was established in March 2007 to provide leadership and advice to the department in implementing key recommendations of the Framework for paediatric orthopaedic services.

The present document is based on consultation with members of the Statewide Paediatric Orthopaedic Advisory Committee and specialist paediatric orthopaedic service providers at the Royal Children’s Hospital, Southern Health and Barwon Health, and relevant areas of the department.

1.1 Guiding principlesConsideration of progress to date and framing of future priorities has taken into account the following principles, which the Framework for paediatric orthopaedic services recommended should underpin planning and delivery of paediatric orthopaedic services:

• Theoverridingobjectiveinplanningpaediatricorthopaedicservicesistoenable the delivery of quality care that achieves an optimal balance between access, safety, effectiveness, appropriateness, efficiency and acceptability to children and their families.

• Whereanacceptablelevelofqualitycanbeachieved,serviceswillbeprovided in local communities.

• Specialistcentreswillprovideprimaryandsecondaryservicestotheirlocalcommunities as well as tertiary services to children and young people and their families from across the state and, where appropriate, interstate.

• Therewillbeanidentifiableservicesystemstructureandlinkageswhichfacilitateappropriate referrals and quality professional interaction between providers.

• Amultidisciplinaryworkforceisrequiredthathastheskills,knowledgeandattitudeto work effectively in responding to the orthopaedic needs of children and their families and that distributes clinical responsibilities within clinical teams to those who are best equipped to meet them.





• waitingtimetobeseenbyanorthopaedicconsultant

• waitingtimetobeseenforreferralstriagedtothephysiotherapy-ledclinic

• numberofnewpatientsseenpermonth

• numberofreviewpatientsseenpermonth.

It is essential to collect baseline data prior to the implementation of the clinic to enable comparisons over time. An administrative database system to record waiting times to be seen, from receipt of referral to date of first appointment for each category of patients in the physiotherapy-led clinic (as well as consultant clinics) should be maintained. A database should be developed to also record the types of patients seen by the physiotherapist, the referral sources, types of intervention and the outcomes (see appendix B for example). Progress reports (with supporting data) should be regularly submitted to the head of orthopaedics.



Infrastructure

• Physicalenvironment

The physiotherapy-led clinic should be located in close proximity to the orthopaedic consultant outpatient clinic.

• Clinicspace

There should be sufficient clinic space for the clinic to run alongside a consultant orthopaedic clinic.

• Administrativesystems

Effective administrative systems are essential to support the booking of outpatient appointments.

• Equipment

The physiotherapy-led clinic has similar equipment needs to an orthopaedic consultant-led clinic. Access to a high-low examination bed, computer and radiology viewing box and plaster room, is required. It should be acknowledged that funding for equipment, such as orthotics, will vary among health services.

Promotion of service

At the OAC, approximately 70 per cent of referrals are received from GPs. Therefore, it is recommended that an education program about the service and referral processes be implemented. This should also include an opportunity to gain feedback from GPs about the referrals and vice versa.

Evaluation Undertaking an evaluation will measure not only what and how well the service is performing, but also informs improvements to the service. Such measures could include (but not be limited to):

• theimpactonpatients

- health, reduced disability and improved quality of life

- parent/patient satisfaction

• theimpactonotherhealthprofessionals

- referring doctor’s satisfaction with service

- number of re-referrals to the clinic from the GPs

- number of referrals to orthopaedic consultants

- number of referrals requiring surgery

- staff retention and turnover

• theimpactonhealth-servicesdelivery



2. Background

This section provides an overview of paediatric orthopaedic services in Victoria and discusses the demands and challenges facing the system. This section also describes the Framework for paediatric orthopaedic services, including its key recommendations.

2.1 Service context‘Orthopaedics’ is concerned with the prevention and treatment of musculoskeletal disorders. ‘Paediatrics’ is concerned with the treatment of infants and children. Paediatric orthopaedic practice encompasses three broad areas:

1. The management of acute trauma and its sequelae.

2. The management of normal variation, postural and ‘packaging’ disorders, and deviations in musculoskeletal development.

3. The provision of highly specialised orthopaedic services to children and young people who have congenital conditions (such as club foot, developmental dysplasia of the hip (DDH), limb deformities and bone dysplasia), neurological and neuromuscular conditions (such as cerebral palsy, spina bifida and muscular dystrophy) and acquired musculoskeletal conditions (such as scoliosis, bone and joint infections, growth disturbance, bone and soft tissue tumours and slipped epiphyses).

The paediatric orthopaedic service system incorporates a large number of providers in hospital and community settings across the public and private sectors. There are two major sub-service systems, as outlined below.

• Acute (emergency) paediatric orthopaedic services. Some emergency services for children who have suffered acute paediatric orthopaedic trauma are provided in community settings (for example, management of sprains and strains by general practitioners) but in the main these services are provided in public hospital emergency departments and inpatient units. Emergency physicians and general orthopaedic surgeons (and general surgeons in some situations where orthopaedic surgeons are not available) provide care to children with moderately complicated injuries. Trauma patients with more complex injuries are referred to specialist paediatric orthopaedic services. Trauma patients with severe or very complex injuries are referred to the Royal Children’s Hospital (RCH), which is Victoria’s designated major trauma centre for children.

• Non-emergency (‘elective’) paediatric orthopaedic services. Assessment and management of otherwise healthy children occurs in a variety of community and hospital settings—for example general practice (GPs), public hospital specialist outpatient clinics1 and maternal and child health centres, plus private hospitals and private consulting rooms. Two Victorian private hospitals (Cabrini and Mercy Private Hospital) provide inpatient care to children requiring more complex orthopaedic care: however, most children with these needs are treated by specialist paediatric orthopaedic surgeons in the public system, as described below.

1. Previously known as outpatient departments.



In accordance with the recommendations of the Framework for paediatric orthopaedic services, three health services—RCH, Southern Health and Barwon Health—have been identified as specialist paediatric orthopaedic services. In addition, following joint surgical appointments between the RCH and Western Health (see page 14), Western Health now has specialised paediatric orthopaedic expertise.

The specialist paediatric orthopaedic services provide general orthopaedic care to children and young people from their local communities and beyond. They also have key leadership roles in complex paediatric orthopaedic clinical care, education and research. They provide sophisticated multidisciplinary services incorporating assessment, surveillance, surgery and rehabilitation services to children and young people with complex needs.

The specialist services each have a different service profile. Both the RCH and Southern Health provide specialised orthopaedic services to children and young people who have congenital conditions, neurological and neuromuscular conditions, and acquired musculoskeletal conditions. Barwon Health provides a range of specialist services for children with conditions such as complex or complicated fractures, talipes, developmental dysplasia of the hip, slipped epiphyses, Perthes disease and spasticity not requiring single event multi-level surgery.2 Western Health provides a range of specialist services for children, including those with complex or complicated fractures, talipes, developmental dysplasia of the hip, slipped epiphyses and Perthes disease.

Orthopaedic surgeons who specialise in paediatric orthopaedics generally undertake at least one year of post-fellowship training in a designated paediatric orthopaedic fellowship position, usually at an international specialty centre. These surgeons have highly specialised skills in low volume, complex procedures specific to children and young people. There are a small number of recognised specialist paediatric orthopaedic surgeons in Victoria, most of whom undertake some adult work in addition to their paediatric practice.

Paediatric orthopaedic services, especially for more complex problems, are best provided through a multi-disciplinary model of care. As well as the surgeon, the team responsible for the patient’s care will include other clinicians (such as physiotherapists, orthotists and prosthetists, nurses and radiolologists) who have skills in dealing both with children and with musculoskeletal problems.

Delivery of paediatric orthopaedic care also requires collaboration with health care professionals who specialise in related areas of medicine—including but not limited to anaesthesia, paediatric medicine, rehabilitation, endocrinology, metabolic medicine, rheumatology, neurology, neurosurgery, developmental disability medicine, emergency medicine and trauma surgery.

2. Single Event Multi-Level Surgery (SEMLS) is the combination of multiple surgical procedures undertaken by two consultant orthopaedic surgeons in one definitive operation.



Until training programs are established, informal learning must be provided to the physiotherapist to ensure competency. This should include opportunity to shadow orthopaedic consultants at outpatient clinics, on-the-job supervised learning, as well as regular informal discussion with consultants and registrars to address clinical concerns and for review of x-rays and other investigations.

Sufficient time should be given for training and achievement of competencies for the physiotherapist and ongoing competencies assessed. To ensure sustainability of the clinic, plans for succession training should be in place.

Implementation

Process

• Targetgroup

Conditions for inclusion and exclusion from the physiotherapist-led clinic should be determined and documented. As a starting point, conditions triaged to the physiotherapist-led clinic may include normal postural variations and simple orthopaedic conditions such as foot and knee pain. More complex conditions, such as DDH or spine conditions should only be undertaken with appropriate consultant support.

• Triage/referralprocess

New triaging guidelines should be established. All patients referred to the orthopaedics outpatient clinic should be triaged according to these guidelines to the appropriate clinic for assessment (refer to appendix A for an example of referral guidelines).

• Clinicschedule

It is essential that each physiotherapist-led clinic session is run alongside an orthopaedic consultant outpatient clinic to ensure that the necessary professional support is provided. This allows timely access to an orthopaedic consultant opinion if required. The following must be determined for clinic sessions:

• numbertobeheldeachweek

• numberofnewpatientsandreviewsforeachsession

• lengthofappointmenttimefornewpatientsandreviews.

Furthermore, when considering the number of sessions per week, appropriate amount of time should be allocated for administration (such as statistics, letter writing) and quality improvement activities.

• Guidelinesforassessmentandmanagement

Agreed clinical guidelines and protocols for management of conditions (including recommended wait times for initial appointment) should be established with the orthopaedic consultants. It is recommended that guidelines be consistent with other health services with physiotherapy-led clinics.



Clinical risk

Clinical risk management is a key component of governance. It involves identifying, analysing and addressing the risks associated with the new role. Clinical risk management strategies could include:

• ensuringappropriatecredentialingandscopeofpracticeforclinicalpractice

• developingprotocolstoclearlyoutlinetheprocessofmanagingpatients

• implementingclinicalauditprocesses

• participatinginperformancereviewanddevelopment.

Knowledge, skills and base qualification

The physiotherapist undertaking the role must be registered with the Victorian Physiotherapists Registration Board. The base qualification is a Bachelor of Physiotherapy or equivalent.

It is recommended that the physiotherapist undertaking the role has at least seven years of postgraduate experience, which must include paediatric orthopaedics.

The competencies required for the advanced practitioner role lie predominantly within the scope of practice of an experienced paediatric orthopaedic physiotherapist. Additional skills required to perform the role, but not specifically taught as part of the undergraduate degree, include:

• patientassessmentandmanagementofcertaincomplexconditions(suchas, club foot and DDH

• castingskills

• radiologyorderingandinterpretation

• triageofpaediatricorthopaedicconditionsreferredtoorthopaedic outpatient clinics.

Due to the advanced clinical reasoning and leadership skills required, this role should be developed as either a Grade 3 or Grade 4 position. This will also help establish a career pathway for physiotherapists working at an advanced scope level.

Education, training and development

Formal education training has not yet been developed. However, an education structure for advanced practice training is recommended to ensure the safe delivery of services and standardised high-quality care. A core competency assessment framework to outline the knowledge, skills and attitudes required for such positions should be developed. Competencies may include expert clinical practice, clinical and professional leadership, education and research.

A six-month academic and clinical education training program for physiotherapists undertaking advanced roles in paediatric orthopaedics was piloted in 2008 at the Royal Children's Hospital (see section 3.4.1).



2.1.1 Challenges for the service systemThe following factors contribute to increased pressure on the paediatric orthopaedic system:

• Thefactthatmanygeneralpractitionersnolongerprovideprimarycaretochildrenandyoung people with simple fractures, and instead refer them to acute health services.

• Atrendforgeneralpractitioners,andpaediatricians—whohavetraditionallymanaged many normal variation, postural and ‘packaging’ disorders and deviations in musculoskeletal development—to refer these children for expert orthopaedic opinion.

• Increasedlevelsofsub-specialisationwithinorthopaedics,meaningthatsomeorthopaedic surgeons now focus on adult patients alone or on specific anatomical areas. In addition, many general orthopaedic surgeons are withdrawing from the care of children. The shortage of orthopaedic surgeons available to care for paediatric patients has been reported elsewhere in Australia and internationally.

As a consequence of these factors, children and young people who previously would have been managed in general acute health services or community settings are being referred more frequently to specialist services at the RCH, Southern Health and Barwon Health.

These challenges occur in a context of increased demand for paediatric orthopaedic services in recent years and, as discussed below, projected continued demand growth.

2.1.2 Influences on future demand for services Factors likely to affect the future demand for paediatric orthopaedic services are discussed below.

• Increased number of children and young people. Recently released population projections for Victoria indicate that, while children and young people will decline slightly as a proportion of the whole population, the actual number of people aged less than 15 will increase by 250,000 between 2006 and 2036.3 Three growth corridors in the metropolitan area (west, north and south-east) will have relatively greater needs for services for children and young people than other areas.

• Prevalence of relevant illnesses and disabilities. While the incidence and prevalence of trauma in children and young people can be assumed (in the absence of any specific evidence to the contrary) to be likely to remain stable, the incidence and prevalence of particular chronic disabling conditions is changing. For example:

- Increasing prenatal diagnosis of a range of genetic abnormalities, and termination of affected pregnancies, may reduce the incidence and prevalence of serious inherited disorders that require specialist paediatric surgical interventions, such as the inherited muscular dystrophies.

3. Victorian Department of Planning and Community Development, Victoria in Future 2008: Victorian State Government Population and Household Projections 2006–2036, DPCD, Melbourne, 2008 www.dpcd.vic.gov.au/ accessed 3 December 2008.



- The rate of neural tube defects has been decreasing since the early 1990s (due to public health efforts to increase consumption of folate by pregnant women and increasing pre-natal diagnosis and termination of affected pregnancies)4 and might decline further after mandatory fortification of flour with folic acid is introduced in September 2009.

- The prevalence of cerebral palsy has been stable over the past 30 years, but there has been no diminution in the number of new cases. During the 1980s there was an increase in the numbers of very low birth weight infants who went on to have cerebral palsy, although this increase has not been sustained in more recent years.5

• Technical innovations, early intervention measures and advances in clinical care. There are many areas in which advances in paediatric orthopaedic care are expected: these include new imaging techniques, procedures (including image-guided and robot-assisted surgery) and equipment (such as intramedullary lengthening devices) that will lead to less invasive surgery. Advances in cancer treatment will allow surgical ‘cure’ of some previously untreatable bone conditions. There is also a potential role for stem cell therapies in the management of some cartilage and bone defects. The likely impact of these innovations on demand and capacity is not known. Some new techniques may substantially reduce demand for inpatient facilities, including theatre time and beds, while others may have the opposite effect. However, demand for specialised paediatric orthopaedic surgeons and other members of the multidisciplinary team, trained in highly complex techniques, is likely to increase as new techniques and procedures become available.

2.1.3 Service activity trends

Paediatric orthopaedic service provision encompasses services delivered to inpatients, in the emergency department or on an outpatient basis. These services may be emergency or as planned elective. Service activity trends reported in this document are for 2005–06 to 2007–08, which corresponds to the period in which the Framework for paediatric orthopaedic services was implemented.

Figures 1 and 2 summarise paediatric orthopaedic inpatient activity between 2005-06 and 2007-08. While overall surgical activity has remained constant there has been some increase in the multiday stay and planned elective separations.

4. Australian Institute of Health and Welfare, Neural Tube Defects in Australia: an Epidemiological Report, Catalogue no. PER 45, AIHW, Sydney, 2008.

5. See N Paneth, T Hong, S Korzeniewski, ‘The Descriptive Epidemiology of Cerebral Palsy’. Clinical Perinatology 33, 2006 pp. 251-267, and SM Reid, A Lanigan and DS Reddihough, ‘Cerebral palsy in Australia: are the rates changing?’ Developmental Medicine and Child Neurology Supplement 113:50, 2008, p.34.



changes required. The lead orthopaedic consultant should work closely with the physiotherapy department to establish agreed clinical, managerial and professional accountabilities. All relevant stakeholders (including outpatient administrative staff) should be engaged during the development and implementation phase of the clinic.

Key staff required to provide a paediatric orthopaedic outpatient service

It is important to acknowledge that an effective physiotherapy-led clinic requires access to a number of key health professionals. These include:

• apaediatricorthopaedicconsultant

• aplastertechnicianwithpaediatricexpertise

• apaediatricnurse

• paediatricalliedhealthprofessionals,suchasorthotists,physiotherapistsandoccupational therapists

• apaediatricdiagnosticimagingservice

• administrativesupport,suchasoutpatientappointmentbookings.

Funding

A funding source for this model of service delivery would be identified by the relevant health service. This may be new or growth funding or from the existing funding allocation.

A funding proposal should be developed following needs assessment, stakeholder consultation and workforce analysis, and should include funding for training and education programs.

Funding for any outpatient clinic is subject to the Victorian Ambulatory Classification and Funding System (VACS). Currently VACS is being reviewed and readers should be cognisant of the fact that reforms to the existing VACS are being investigated.

Scope of practice The scope of practice, both clinical and non-clinical should be clearly defined. Clinical practice includes target population, referral processes to other health professionals and diagnostic imaging referral rights. Non-clinical roles include research, leadership and education.

Governance

Clear lines of responsibilities and accountability to the physiotherapy and orthopaedic departments must be clearly established, recognising the complexity of the scope of practice.



• Feasibility

- Needs assessment

- Consultation with stakeholders

- Key staff required to provide a paediatric orthopaedic service

- Funding

• Scopeofpractice

- Governance

- Clinical risk

- Knowledge, skills and base qualification

- Education, training and development

• Implementation

- Process—what is actually being done in the giving and receiving of care related to paediatric orthopaedic management (for example, target population, triage/referral process, clinic schedule and guidelines for assessment and management)

- Infrastructure—the attributes of the setting in which the clinic occurs (for example: clinic space)

- Promotion of service to GPs and other health professionals.

• Evaluationoftheeffectivenessofthephysiotherapy-ledserviceinmeetingobjectives.

Feasibility

Needs assessment

The establishment of a physiotherapy-led orthopaedic outpatient clinic should be in alignment with the service delineation framework for paediatric orthopaedic services in Victoria. Prior to establishing a clinic, there must be an identified need for such a service. For instance, there may be no existing service or there may be gaps in the present service to which an advanced physiotherapist can add value. It is recommended that an audit of the orthopaedic waiting list be conducted to identify existing waiting times and types of conditions referred. This is an essential step in justifying establishment, and defining the target population for the physiotherapy-led clinic.

Consultation with key stakeholders

It is essential that the proposed service receive the support of the head of orthopaedics and the hospital executive. The establishment of an advisory group to oversee the development and implementation of the physiotherapy-led clinic is highly recommended. An orthopaedic consultant with a significant interest in paediatric orthopaedics should be identified to provide leadership and assist in driving the



Figure 1: Statewide paediatric orthopaedic inpatient separations statewide by length of stay6, 7

Figure 2: Statewide paediatric orthopaedic separations by emergency or elective admission8

6. The short stay category is based on patients staying one night compared with a multi day stay of two nights or longer.

7. Figures are based on a paediatric orthopaedic casemix comprised of 54 diagnostic classifications (AR-DRG, Australian refined–diagnostic related groups) relevant to paediatric orthopaedics. The casemix was developed following consultation with the three specialist paediatric orthopaedic service providers and includes all patients treated by a health service for these DRGs. The patient cohort for the data is aged 0–17 years old.

8. See footnote 7.

3,000

3,500

4,000

4,500

5,000

5,500

6,000

6,500

7,000

2005/2006 2006/2007 2007/2008

Data based on patients 0–17 years old

Sepa

rati

ons

Mulitday

Sameday

Short stay (one night)

Total Paediatric Orthopaedic separations

2005/2006 2006/2007 2007/2008Data based on patients 0–17 years old

Sepa

rati

ons

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

11,000

12,000

Emergency

Elective



Figures 3 and 4 when read together demonstrate that although the level of activity at the Royal Children’s Hospital has reduced, there has been an increase in the complexity of the work over the same period. Activity and complexity at the majority of other health services increased in this period.

Figure 3: Inpatient paediatric orthopaedic separations by health service9

Figure 4: Average WIES weight for paediatric orthopaedic activity by health service10

9. See footnote 7.

10. See footnote 7.

Separations

2005/2006

2006/2007

2007/2008

0 1,000 2,000 3,000 4,000 5,000

Latrobe Regional Hospital

Royal Childrens Hospital

Goulburn Valley Health

Bendigo Health

Barwon Health

Western Health

Southern Health

Peninsula Health

Northern Health

Eastern Health

Austin Health

Ballarat Health Services

WIES Weight




Bendigo Health

Barwon Health

Western Health

Southern Health

Peninsula Health

Northern Health

Eastern Health

Austin Health


2005/2006

2006/2007

2007/2008

0.0 0.2 0.4 0.6 0.8 1.0 1.2



A physiotherapist specialist clinic designed to reduce waiting times for non-urgent, new paediatric orthopaedic referrals was evaluated.20 This retrospective study showed that the median waiting time for non urgent conditions was reduced from 72 weeks to five weeks over a three year period. The success of the clinic was largely due to the close cooperation between the consultant and the physiotherapist, an agreed policy of assessment and management of patients and training the physiotherapist to the surgeon’s work pattern. The authors also noted that educating GP’s about the normal development of the musculoskeletal system in a child and devising a primary care referral protocol may reduce the demand for new paediatric referrals.

Physiotherapy-led clinic model of care

Mission

A physiotherapy-led paediatric orthopaedic clinic provides timely and high quality assessment and primary orthopaedic care for children not generally requiring surgical assessment or intervention. It provides an entry point for orthopaedic assessment and referral to consultant clinics as required.

Core objectives

• Toimprovethequalityoforthopaedicassessment,careandsupporttochildren and their families.

• Toimproveaccesstoorthopaedicassessmentandcareforallchildren,and across all clinics.

• Toreducethewaitingtimeforsemi-urgentandnon-urgentorthopaedicreferrals.

• Toprovideeducationtofamiliesandreferrers.

• Toutiliseandmaximisetheexpertiseofexperiencedorthopaedicphysiotherapists.

• Tostrengthencareerpathwaysforseniorclinicalphysiotherapists,improvejobsatisfaction, retention and career opportunities.

Key steps to establishing a successful physiotherapy-led clinic

Currently there is limited evidence of the best way to introduce allied health led-outpatient clinics, or to educate, support and mentor the allied health professionals in these roles.21

Therefore it is essential to allow ample time for the development phase , and to include detailed consideration of the following:

20. MV Belthur, J Clegg, A Strange, ‘A physiotherapy specialist clinic in paediatric orthopaedics: is it effective?’ Postgrad Medical Journal, 2003, vol 79(938), pp. 699-702.

21. K McPherson, P Kersten, S George et al ‘A systematic review of evidence about extended roles for allied health professionals’, Journal of Health Services Research and Policy, 2006, Vol 11(4), pp.240-7.



ContextThe OAC was developed following the successful implementation of similar services in the United Kingdom, where extended-scope practice is now an accepted part of clinical practice for physiotherapists.

The genesis of the initiative at the RCH was the need to find a way to manage increased numbers of orthopaedic outpatient referrals. The operating environment was already exceedingly busy with around 2,000 outpatient appointments per month. With up to 80-90 new referrals each week, the small paediatric orthopaedic workforce was falling increasingly behind, and children and their families were facing an unacceptable wait for outpatient appointments. The trend to increased specialisation was placing demands on the orthopaedic department that were unsustainable without a change in practice.

In addition, it was recognised that not all referrals necessarily required surgical intervention or assessment, but could be managed by an experienced paediatric physiotherapist with support from the orthopaedic consultant as needed.

Literature reviewThere is a paucity of published literature from Australia on the effectiveness of advanced practice/extended-scope roles for allied health professionals in orthopaedic outpatients. A recent prospective observational study18 investigated the impact, quality and acceptability of a physiotherapist-led screening clinic for patients referred to an adult outpatient orthopaedic department at a major Victorian metropolitan hospital. Nearly two-thirds of patients with non-urgent musculoskeletal conditions referred to the clinic did not need to see a surgeon and were able to be appropriately managed by experienced physiotherapists. The physiotherapist identified the same management plans as the surgeon for 74 per cent of the group. Patients and doctors also reported high levels of satisfaction with the physiotherapist-led service.

Although there is a growing body of published literature overseas supporting advanced allied health roles in orthopaedics, strong research evidence is limited. A randomised controlled trial was conducted19 to evaluate the effectiveness and cost effectiveness of specially trained physiotherapists with that of post fellowship junior orthopaedic surgeons in the initial assessment and management of defined GP referrals to hospital orthopaedic departments. All referrals were screened by the orthopaedic consultant for suitability for inclusion in the study. The trial found that trained physiotherapists were as effective as post-fellowship junior orthopaedic surgeons in the initial assessment and management of new GP referrals to outpatient orthopaedic departments and generated lower initial direct costs.

18. LB Oldmeadow, HS Bedi, HT Burch et al 2007. ‘Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care’. Medical Journal of Australia, vol 186, pp. 625–628.

19. G Daker-White, AJ Carr and I Harvey, ‘A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatients departments’, Journal of Epidemiology and Community Health, 1999, vol 53, pp. 643–50.



Figure 5 summarises paediatric orthopaedic emergency activity between 2005-06 and 2007-08. A number of hospitals—including Bendigo Hospital, Casey Hospital, RCH, Austin Hospital and Sandringham and District Memorial Hospital—have had a significant increase in the number of emergency department presentations.

Figure 5: Emergency department fracture presentations in patients aged 0–16 years by hospital11

The data presented above are based on inpatient or emergency department activity. It is recognised that consulting in specialist outpatient clinics is a significant part of the paediatric orthopaedic workload that is not reflected in these service activity trends. However, because outpatient data is not currently collected in a uniform way that allows comparison across health services, it is not included in this report. The collection of consistent outpatient data is a project being undertaken by the department for all clinical specialities. The planned clinical audit project described on page 26 will develop specific data items relating to paediatric orthopaedic activity in specialist outpatient clinics.

2.1.4 Related policies and service initiatives

The development of paediatric orthopaedic services reflects the State Government’s broader commitment to enhancing the health, wellbeing and safety of Victoria’s children. Appendix 1 describes key policies and service initiatives relevant to the planning and delivery of child health services, including paediatric orthopaedics.

11. Based on fracture presentations, excluding tooth fractures, at Victorian emergency departments. The data, which is captured by the Victorian Emergency Minimum Dataset (VEMD), represents all hospitals that treat children aged 0–16 years old.

Presentation

Latrobe Regional HospitalBendigo HospitalGeelong Hospital

Ballarat Base HospitalSunshine Hospital

Dandenong HospitalCasey Hospital

Royal Childrens HospitalFrankston HospitalNorthern Hospital

Mercy Werribee HospitalMaroondah Hospital

Box Hill HospitalAngliss HospitalAustin Hospital

Sandringham & District Memorial Hospital

Monash Medical Centre

503 522 550609 766 819590 774 717696 752 6441322 1276 1314742 729 635599 620 604845 989 10012452 2618 2681735 732 423983 1106 978456 397 373937 1193 1103492 487 502796 798 711580 640 684523 609 648

0 500 1,000 1,500 2,000 2,500 3,000

2005/2006

2006/2007

2007/2008



2.2 Framework for paediatric orthopaedic servicesThe department released the Framework for paediatric orthopaedic servics in March 2006. The framework, which was developed for the department by Phillips Fox, can be accessed at www.health.vic.gov.au/paediatric-ortho.

The Framework for paediatric orthopaedic services was commissioned at a time when surgeons from the RCH, Southern Health and Barwon were experiencing increased activity levels and had identified problems accessing sufficient operating theatre sessions and other resources. The services were finding it difficult to recruit and retain specialist paediatric orthopaedic surgeons. As well as the lower remuneration relative to adult practice, as mentioned above, the Framework for orthopaedic services noted that workloads and working conditions were contributing to problems in attracting and retaining surgeons.

Although the growing demand for specialist paediatric services—as discussed in section 1—was the impetus for the Framework for paediatric orthopaedic services, the scope of the project was broad. Its overall objective was to develop a service plan for the provision of paediatric orthopaedic services in Victoria.

The report included 35 recommendations intended to inform development of:

• astatewideservicemodel,basedonanoptimalserviceconfigurationandreflectinga balance between access, quality and safety, and efficiency

• increasedcapacityandresponsivenessofspecialistpaediatricorthopaedicservices

• mechanismsforevaluationandmonitoringofserviceperformance

• strategiestoensureasustainableworkforce.

Section 3 discusses the implementation of the framework’s recommendations.



This framework was prepared by Prue Weigall and Michelle Vu, on behalf of the Allied Health Subcommittee of the Statewide Paediatric Orthopaedic Advisory Committee (see page viii for full list of committee members).

IntroductionIt is acknowledged that there is a growing demand for specialist outpatient paediatric orthopaedic services in Victoria. New models of care are needed to make best use of orthopaedic specialist expertise and ensure timely access to care.

Not all referrals to a paediatric orthopaedic outpatient clinic require a surgical opinion. Rather, certain referrals can be managed efficiently and effectively by an experienced senior allied health professional, with support from an orthopaedic consultant as needed. Such allied health professionals are working at an advanced level of clinical practice and have received additional training to undertake this role.

There are many benefits to this new model of care. It can result in improving patient care, create more job satisfaction for practitioners and encourage retention of experienced staff.

The Framework for development of allied health led clinics in paediatric orthopaedics has been produced to assist health services in establishing this model of care within their organisation. The framework draws upon the published literature and brings together the experiences of the recently established Orthopaedic Assessment Clinic (OAC), a physiotherapist-led clinic at the Royal Children's Hospital. However, it is applicable to the establishment of any ambulatory allied health-led clinics in paediatric orthopaedics.

The framework sets out the key steps in establishing a successful physiotherapy-led paediatric orthopaedic outpatient clinic and provides practical advice on implementing the service. The infrastructure and resources required to run the clinic are also outlined in the framework. Appropriate preparation, education and demonstrated competence of the physiotherapist are integral to the success of these clinics. In addition, it is critical that physiotherapy-led clinics are run alongside consultant clinics to ensure that the necessary professional support is provided. A lead orthopaedic consultant with a significant interest in paediatrics should be identified to assist in driving the changes.

The physiotherapy-led service should be underpinned by an evaluative framework. This will assist in determining the impact the physiotherapy-led clinic has had on its intended outcomes and to further improve the service.

This framework should be recognised as a work in progress. As this model of care is implemented in other health services over the forthcoming years, components of the framework will require revision.

Appendix 4: Framework for development of allied health-led clinics in paediatric orthopaedics



Infrastructure and resources Service level

Level I Level II Level III Level IV Level V

Research relating to paediatric orthopaedics

Orthopaedic research Unit × × +/- √ √

Peer review publications × × +/- √ √

Collaborative research framework across all disciplines × × +/- √ √

Leader in translating research findings into clinical practice × × × × √

Education and training

Professorial appointment × × × × √

Other academic appointments related to paediatric orthopaedics (e.g. associate professor, senior lecturer

× × × √ √

Clinical/research paediatric orthopaedic fellowship × × × 1 >1

Leader in paediatric orthopaedic education across all disciplines × × × +/- √

Service organisation

Director/head of paediatric orthopaedics × × × √ √

Full time paediatric orthopaedic consultant presence × × × × √

Designated 24-hour paediatric orthopaedic trauma service × × × × √

Ambulatory allied health-led models of care × × +/- √ √

Family-centred care services √ √ √ √ √

Robust clinical audit information relating to paediatric orthopaedics × × √ √ √

Quality improvement activities relating to paediatric orthopaedics × × √ √ √

Access to paediatric orthopaedic aids and equipment +/- √ √ √ √

Provides specialist outreach services × × × √ √

Transition service × × +/- √ √

Formal links with rehabilitation services and community-based providers √ √ √ √ √

Protocols/guidelines for referral to level III, IV and V √ √ × × ×



3. Achievements to date

Over the last two years, the Statewide Paediatric Orthopaedic Advisory Committee has overseen a range of initiatives to support sustainable development of the paediatric orthopaedic service system. An allied health sub-committee of the committee has also been instrumental in progressing significant pieces of work, such as the workforce development models discussed in sections 3.3 and 3.4.

There has been an impressive level of achievement in a relatively short period of time. Service providers and departmental officers have worked together to address the Framework for paediatric orthopaedic services’ recommendations. Appendix 2 lists the recommendations of the framework and notes progress towards their implementation. Twenty-six of the 35 recommendations have been implemented, and there are varying degrees of ongoing progress towards implementing the remaining nine recommendations.

The remainder of this section provides examples of achievements in the following key areas:

• Statewidemodelofservicedelivery

• Servicecapacity

• Workforcedevelopmentandinnovation

• Newmodelsofcare.

3.1 Statewide model of service deliveryThe development of an integrated approach to the provision of paediatric orthopaedic services was a key recommendation of the Framework for paediatric orthopaedic services.

An important achievement of the Paediatric Orthopaedic Advisory Committee is the increased level of collaboration and cooperation between providers of specialist paediatric services. This includes a joint consultant appointment between the RCH and Western Health. Collaboration between the specialist services and other key health services, such as Eastern Health and Peninsula Health, has also been strengthened through the Advisory Committee.

The creation of a Statewide Paediatric Orthopaedics Program Manager position, based at the RCH, has also facilitated statewide service planning and coordination.

3.1.1 Service delineation framework

The service delineation framework for paediatric orthopaedic services supports the development of a statewide model of service delivery and service planning at individual health services.

The service delineation framework is a tool for describing and planning paediatric orthopaedic services in Victoria. The service delineation framework aims to:



• provideaconsistentandcommonlanguagetodescribeanddifferentiatelevels of paediatric orthopaedic care

• guidehealthservicesinstructuringtheirpaediatricorthopaedicservicesandindelivering high quality and efficient services

• supportdevelopmentofacoordinatedandsustainableservicesystem.

Ensuring patients can access services in a timely manner and in a setting appropriate to their level of need is important in developing systematised approaches to the delivery of health care. This includes making optimal use of limited or specialised resources (high complexity, low volume services), while facilitating treatment of less difficult problems in low complexity settings close to where people live. Service delineation frameworks can be used to support development of system-wide approaches to provision of services. For instance, given the well-established relationship between higher surgical volume and better outcomes for certain procedures,12 and overall resourcing considerations, some services can be provided only at a limited number of sites. Service delineation frameworks promote broad understanding of the roles of different services within a system and support effective referral of patients and communication between providers.

Five levels of paediatric orthopaedic care are described in the service delineation framework. These levels are based on a hierarchy of increasing patient and service complexity, and detail the infrastructure and resources required to provide services at the different levels.

It is intended that the framework will be used by individual health services and at the statewide level to facilitate cooperative service planning and resource allocation.

The service delineation framework is not intended to be prescriptive but rather to guide planning. For example, a health service may have appropriately qualified staff to perform certain procedures at a particular level of care but, due to the limited volume of work, may not satisfy all the infrastructure and resource requirements for that level.

Services should be monitored as part of the health services’ overall clinical governance process. The service delineation framework assumes that health services have in place appropriate policies and guidelines relating to quality of care and patient safety. These include credentialing and granting of clinical privileges to medical staff and auditing of clinical practices.

Table 1 provides a summary description of the levels of paediatric orthopaedic care described in the service delineation framework. Table 2 shows the agreed current designations for the state’s specialist providers. Note that service levels may change over time.

12. GD Murray and GM Teasdale, ‘The Relationship between Volume and Health Outcomes’, Report of Volume/Outcome Sub-Group to Advisory Group to National Framework for Service Change. NHS Scotland, 2005. Accessed on 21 August 2008 at www.sehd.scot.nhs.uk/NationalFramework/Documents/VolumeOutcomeReportWebsite.pdf





Nursing staff

Paediatric orthopaedic nurse unit manager × × × × √

Paediatric orthopaedic clinical nurse educator/facilitator × × × √ √

Care manager × × × √ √

Allied health

Allied health with expertise in paediatric orthopaedics – physiotherapist, occupational therapist, orthotist, social worker and dietician

× × √ √ √

Advanced outpatient paediatric orthopaedic physiotherapist × × +/- √ √

Paediatric specific therapy (e.g. music therapy, educational play therapy) × +/- √ √ √

Other ancillary staff

Paediatric orthopaedic coordinator × × +/- √ √

Plaster technician with experience in paediatric orthopaedics × × √ √ √

Physical facilities

Inpatient care in a designated orthopaedic unit × × × × √

Inpatient care in a general paediatric unit × √ √ √ ×

Paediatric intensive care unit × × × √ √

Family friendly facilities √ √ √ √ √

Telehealth facilities √ √ √ √ √

Family accommodation × × × √ √

Specialist services necessary on site (24-hour access)

Paediatric medical imaging service × × × √ √

Access to other paediatric surgical services (e.g. general surgery) × × +/- √ √

Access to paediatric medical services (e.g. respiratory) × × +/- √ √

Paediatric procedural pain service × × × √ √

Other specialist services necessary on site

Inpatient paediatric rehabilitation team/services × × × √ √

Multidisciplinary paediatric pain management team/service × × × √ √

Paediatric gait laboratory with expertise in reporting × × × × √

Specialist paediatric orthopaedic outpatient clinics × × √ √ √



Orthopaedic condition

Level I

Level II

Level III

Level IV

Level V

Congenital talipes equinovarus (CTEV)

• Newbornscreening& refer to level III, IV or V for management

• Newbornscreening& refer to level III, IV, V for management

• Diagnosis

• Ponsetimethod

As for level III As for level IV plus:

• Syndromicconditions

• Dysmorphicsyndromes

Slipped Upper Femoral Epiphysis (SUFE)

• Diagnosis&referral • Diagnosis

• Pinningofstableand mild slip

As for level II As for level III plus:

• SurgicalMxofunstable and moderate slip

As for level III plus:

• SurgicalMxofunstable and severe slip

Management of bone tumours

Diagnose and referral for appropriate management

As for level I As for level I • Diagnosis

• Benign

As for level IV plus:

• Malignant

Spasticity in children with complex disabilities

× × • BotulinumtoxinA

• Muscle-tendonprocedures


• Boneosteotomies


• Gaitreportingforsurgical decision making

Scoliosis × × × • Diagnosis As for level IV

• Spinalsurgery

3. Infrastructure and resources



Orthopaedic medical staff

Orthopaedic consultant surgeon with recognised fellowship training in paediatrics × × ≥1 ≥2 ≥3

Paediatric orthopaedic fellow × × × 1 >1

Accredited paediatric orthopaedic registrar × × √ √ √

Paediatric orthopaedic resident × × × √ √

Orthopaedic consultant with interest in paediatrics × √ × × ×

Other medical staff

Paediatric rehabilitation specialist × × +/- √ √

Paediatrician × √ √ √ √

Paediatric anaesthetist × × × √ √

Paediatric intensivist × × × √ √



Appendix 3 provides the full service delineation framework. Plans for future work based on the paediatric orthopaedic service delineation framework are discussed in section 4.

Table 1: Paediatric orthopaedic service delineation levels

Level I – Primary care only (emergency care for minor musculoskeletal injuries).

Level II – Primary and secondary services related to uncomplicated paediatric orthopaedic trauma.

Level III – Primary, secondary and limited tertiary specialist paediatric orthopaedic services for emergency and general paediatric orthopaedic elective presentations.

Level IV – Comprehensive primary, secondary and tertiary specialist paediatric orthopaedic services for emergency and paediatric orthopaedic elective presentations. Statewide role in certain specialised elective orthopaedic procedures in collaboration with Level V.

Level V – Full spectrum of primary, secondary and tertiary specialist paediatric orthopaedic services. Statewide role for major trauma and low volume, high complex paediatric orthopaedic services. For example:

•scoliosissurgery

•orthopaediconcology

•managementofcongenitallimbdeficiencies.

Table 2: Current designated levels of care for specialist orthopaedic services

Level III Level IV Level V

Sunshine Hospital (Western Health)

Geelong Hospital (Barwon Health)13

Monash Medical Centre (MMC) (Southern Health)

The Royal Children’s Hospital

3.2 Service capacitySince 2006–07, the State Government has provided over $5.7 million in additional recurrent funding and $0.5 million in one off funding to increase the capacity of the specialist paediatric orthopaedic services.

The RCH, Southern Health and Barwon Health were invited to submit proposals to the department identifying:

• additionalactivityallocationsnecessarytomeetreasonablepaediatric orthopaedic demand

• additionalrecurrentandcapitalfundingnecessarytodevelopanappropriate model of care, in line with the recommendations of the Framework document

• theoutcomestobeachievedthroughprovision of the additional resources.

13. Due to staffing levels, Geelong Hospital is a Level III site. However, it is recognised that the paediatric orthopaedic services provided at Geelong Hospital are consistent with that of a Level IV facility.



3.2.1 The Royal Children’s Hospital Additional funding to the RCH from 2006–07 has supported:

• employmentoftwoadditionalorthopaedicsurgeons,includingtwodualsurgicalappointments between the RCH and Western Health—the first in September 2006 and the second in July 2007.

• establishmentofasurgicalpre-admissionclinicattheRCH.Theclinicallowsstaff to gain relevant health information from the parents about their child prior to surgery and tailor care accordingly. This increases safety and reduces the chance of last minute cancellations or delays. It also provides an opportunity for families to find out exactly what is involved in the surgery and to ask questions. Since the clinic began in 2007, over 444 children with paediatric orthopaedic conditions have been assessed. The preadmission clinic model has now been established for other surgical specialities.

• purchaseofdigitalmobileimageintensifiers

• employmentofaStatewidePaediatricOrthopaedicProgramManager,based at the RCH.

3.2.2 Western HealthIn response to the proposal put forward by the RCH, additional funding was provided to Western Health from 2006-07. This has supported:

• jointorthopaedicconsultantappointmentswiththeRCH(seeabove)

• establishmentofaphysiotherapist-ledpaediatricorthopaedicclinicatWesternHealth (see page 16).

3.2.3 Southern HealthIn October 2007 Southern Health was provided with new recurrent funding for additional service activity and implementation of a new model of care. A Southern Health Paediatric Orthopaedic Steering Committee was established to oversee the new paediatric orthopaedic unit. This enabled:

• appointmentofanewheadofunitforpaediatricorthopaedics

• appointmentofacasecoordinatorforthemanagementofmorecomplexpatients

• employmentofanadditionalpaediatricorthopaedicconsultantsurgeon

• utilisationofanadditionalfive-paediatricorthopaedictheatresessionsperfortnight.This has met the demand of an additional 22 per cent in emergency separations and provided capacity for a 61 per cent increase in elective separations

• additionalspecialistoutpatientservices,including:

- complex care clinic ( a multidisciplinary clinic engaging the paediatric rehabilitation unit)

- introduction of an allied health (physiotherapist) led outpatient clinic

- fracture clinic

- strengthening of developmental dysplasia of the hip surveillance.



Level Description

Level V A Level V facility includes and exceeds the characteristics of a Level IV facility.

It has the capacity to provide non-operative and surgical treatment for the full spectrum of paediatric orthopaedic conditions. It has a statewide referral role for paediatric major trauma and for highly complex, low volume elective paediatric orthopaedic procedures.

There is a full-time consultant paediatric orthopaedic presence at all times. The orthopaedic department provides a 24-hour, seven days a week trauma service by consultants and registrars for paediatric orthopaedics only. The orthopaedic department is staffed by at least three orthopaedic consultants with recognised fellowship training in paediatric orthopaedics who have a substantial fractional commitment to paediatrics (≥0.5 EFT).

In addition to the training of registrars, it offers a number of fellowships in paediatric orthopaedics. Paediatric orthopaedic services are provided by a multidisciplinary highly specialised team, which include clinical nurse coordinators for complex conditions and advanced practitioners. It has a designated paediatric orthopaedic ward. It provides statewide leadership in service delivery models, teaching and research in paediatric orthopaedics.

It has access to a full complement of co-located paediatric sub-specialty services and technology such as gait analysis. It provides a fully integrated paediatric orthopaedic ambulatory care service. It has formal links with Level III and Level IV services for the purposes of referrals and collegiate networking.

2. Client groupThe following table provides a guide to the range of orthopaedic care typically provided at each service delineation level for paediatric orthopaedic conditions. The classifications are based on the complexity of the presenting condition and its management.


Level I

Level II

Level III

Level IV

Level V

Distal radius and ulna fracture

√ √ √ √ √

Supracondylar fracture

• GradeI As for Level I plus:

• GradeII,III

As for level II plus:

• neurovascularcompromise

As for level III As for level IV

Tibial fracture • Undisplaced • Displaced

• Closedreduction

• Openreduction

As for level 2 plus As for level III plus

• Childrenwithcomplex disabilities (e.g. spina bifida)

• Neurovascularcompromise

• AsforlevelIV

Developmental dysplasia of the hip (DDH)


• +/-orthoticMx

As for level I plus:

• Orthoticmanagement

• Diagnosis


• Closed&openreduction






1. Levels of paediatric orthopaedic care

Level Description

Level I A Level I site is predominantly adult-based. A Level I facility is staffed and equipped to manage children presenting to the emergency department with minor musculoskeletal injuries. This may include the management of strains, sprains, undisplaced fractures and simple displaced fractures (e.g. distal radial fractures). Simple manipulation of fractures under appropriate anaesthesia may be undertaken whilst in the emergency department. General practitioners with a special interest in emergency medicine may also perform manipulations.

Paediatric orthopaedic presentations requiring surgery or inpatient care are initially stabilised and transferred to a higher level of service.

No paediatric orthopaedic outpatient clinics are provided.

A Level I facility has formal links with Level II facilities and protocols/guidelines for referrals to Level III, Level IV and Level V facilities.

Level II A Level II facility includes and exceeds the characteristics of a Level I site.

A Level II facility has the capacity for managing a wider range of uncomplicated paediatric trauma presenting to the emergency department when compared with a Level I site.

General orthopaedic surgeons provide management for certain paediatric fractures. These include fractures that do not involve potential or actual neurovascular complications or injuries to the growth plate with high risk of growth arrest. Orthopaedic presentations requiring hospitalisation are admitted to a general paediatric ward/unit. Elective paediatric orthopaedic surgery is generally not provided. Minor surgery such as removal of metal implants/fixation devices may be performed.

A Level II site provides a general fracture and orthopaedic clinic, which children may attend.

It has formal links with Level I facilities and protocols/guidelines for referrals to Level III, Level IV and Level V facilities.

Level III A Level III facility includes and exceeds the characteristics of a Level II facility.

It provides a general paediatric orthopaedic service to its local catchment population. It has the capacity for managing paediatric trauma where appropriate.

It provides some elective paediatric orthopaedic services for its region/catchment area. A consultant orthopaedic surgeon who has undertaken recognised fellowship training in paediatric orthopaedics provides such services.

A Level III site is also staffed by a range of health care professionals with paediatric orthopaedic experience. A Level III site may have joint paediatric orthopaedic appointments with a Level IV or Level V facility.

It has formal links with Level IV and Level V sites for the purposes of referrals and collegiate networking. A Level III facility provides professional leadership within its region. It may have a teaching and research role. It has an identifiable general paediatric orthopaedic outpatient and fracture clinic.

Level IV A Level IV site includes and exceeds the characteristics of a Level III service.

It has a co-located tertiary paediatric service with sub-specialty services. It has a referral role for major paediatric trauma for its region/catchment area and may have a statewide referral role in certain specialised elective orthopaedic paediatric procedures.

The orthopaedic department has a consultant in paediatric orthopaedic surgery who fulfils the role of lead consultant. The orthopaedic department is staffed by at least two orthopaedic consultants who have recognised fellowship training in paediatric orthopaedics and have a substantial fractional commitment to paediatrics (≥0.5 EFT). It has the capacity to manage most paediatric orthopaedic conditions, with highly complex procedures or conditions referred to a Level V facility.

Care is delivered by a multidisciplinary team with expertise in paediatric orthopaedics, including advanced practitioners. It provides and participates in outreach services in partnership with Level I, Level II facilities. It provides leadership in service delivery models, teaching and research in paediatric orthopaedics in partnership with Level V.

It has formal links with paediatric rehabilitation services. It has formal links with Level III and Level V services for the purposes of referrals and collegiate networking.



3.2.4 Barwon Health

Barwon Health received one-off funding in 2007-08 and full-year ongoing funding from 2008–09 for the delivery of additional services. The funding has provided for:

• apaediatricorthopaediccoordinator,responsibleforcoordinatingandsupervisingthe various paediatric orthopaedic clinics (see below), and liaising with general practitioners and other local service providers

• establishmentofDDHandclubfootclinicsand,from2009,aBotoxclinicfora group of patients who currently travel to the RCH for this treatment

• establishmentofaphysiotherapist-ledpaediatricorthopaedicclinic

• purchaseoforthoticsforpatientswithDDHandotherminorequipmenttosupportthe paediatric orthopaedic program.

3.3 New models of careIt is widely acknowledged that new models of care are needed to meet the growing demand for specialist outpatient paediatric orthopaedic services and make best use of existing expertise within the system.

Some key service innovations developed over the last two years are described below.

3.3.1 Allied health-led clinics in paediatric orthopaedics

Not all referrals to a paediatric orthopaedic outpatient clinic require a consultation with an orthopaedic surgeon. The physiotherapist-led orthopaedic assessment clinic (OAC) at the RCH, established in 2005, has demonstrated that certain referrals can be managed efficiently and effectively by an experienced senior allied health professional, with support from an orthopaedic consultant as needed. The clinic has grown rapidly and in 2007-08 provided over 3000 occasions of service. As a result of the OAC, waiting times for semi-urgent referrals triaged to general consultant clinics reduced from three months to two–three weeks. Waiting times for non-urgent referrals triaged to orthopaedic consultant clinics reduced from fifteen months to three months.

The service won a 2007 Victorian Public Healthcare Award for innovation in workforce design and, as noted below, has led to the establishment of similar services at other hospitals.

Based on the success of the physiotherapist-led clinic at the RCH, members of the Allied Health Subcommittee of the Statewide Paediatric Orthopaedic Committee developed the Framework for development of allied health-led clinics in paediatric orthopaedics to assist other health services in establishing this model of care. The framework, which is provided as appendix 4, sets out the key steps needed to develop a successful physiotherapy-led paediatric orthopaedic outpatient clinic and provides practical advice on how to implement the service. It emphasises that the success of these clinics depends on appropriate preparation, education and demonstrated competence of the physiotherapists involved. It is also critical to operate



physiotherapy-led clinics alongside consultant clinics to ensure that the necessary professional support is available.

The benefits of this new model of care are described in the document: these include the potential for improved patient care, greater job satisfaction for practitioners, and better retention of experienced staff.

By the end of June 2009 all three of the health services providing specialist paediatric orthopaedic services and Western Health will have established an allied health-led outpatient clinic. Referral types managed by the clinics include those relating to normal postural variations, and simple orthopaedic conditions such as foot and knee pain. These clinics will also assess and treat more complex conditions such as DDH and clubfoot, in consultation with a paediatric orthopaedic specialist.

The next phase of paediatric orthopaedic service development will include an evaluation of the clinics (see page 27).

3.3.2 Point of care ultrasoundChildren referred for DDH usually require two appointments for the assessment of the condition—one with the radiology department and then a separate appointment with the orthopaedic department. This can result in waiting times for both appointments.

Paediatric orthopaedic services at Barwon Health and the RCH have streamlined this process and now combine the two appointments in one session by having the ultrasound performed at the same time and place as the scheduled orthopaedic consultation. The new process saves time for the patients and their families, provides a multidisciplinary approach to care and allows more children to be seen in the orthopaedic clinic. The model of care also provides an opportunity for education and training of health professionals in the clinical examination of infants for this condition.

3.4 Workforce development and innovationWhen the Framework for paediatric orthopaedic services was commissioned the RCH and Southern Health were experiencing recruitment and retention difficulties for specialist paediatric orthopaedic surgeons, with excessive workloads and difficult working conditions contributing to these problems.

In the last two years, both services have been successful in attracting and retaining additional paediatric orthopaedic surgeons. In addition, the expansion of the allied health-led clinic model (see page 15) has realigned the workload to better reflect available skills and expertise. These factors have contributed to an increased capacity to meet current demand.

Initiatives in place to support new models of care and a stronger multidisciplinary approach to paediatric orthopaedic service delivery are discussed below. However, issues of succession planning for existing paediatric orthopaedic surgeons and the need to increase the number of general orthopaedic surgeons with interest in paediatrics remain a challenge for the future.



Five levels of paediatric orthopaedic care, defined according to the complexity of patient need, are described below.

The framework does not attempt to outline all the services to be provided by health services operating at each level but highlights those that are widely considered to be the core components to provide safe and quality care.

Note that there may be instances where a hospital or health service is functioning between two levels. For example, certain procedures may be being performed by appropriately qualified staff at a designated level, but due to the limited volume of work, it does not satisfy all the core service requirements for that particular level. In such cases, it would be recognised that the health service is transitioning between two levels. The framework, when utilised in conjunction with the other considering factors may highlight that more resources need to be put in place to assist a health service which is in transition to progress to the next level. Alternatively, it may demonstrate a need for the health service to redirect some of its paediatric orthopaedic services.

The service delineation framework assumes that health services have appropriate policies and guidelines relating to quality of care and patient safety. These include credentialing and granting of clinical privileges to medical staff and auditing of clinical practices.

The service delineation framework is not intended to be prescriptive but rather to guide planning and inform governance decisions. For example, a health service may have appropriately qualified staff to perform certain procedures at a particular level of care but, due to the limited volume of work, may not satisfy all the infrastructure and resource requirements for that level.

Appendix 3: Service delineation framework



Recommendation Comment Met/Ongoing

Recommendation 30

That in collaboration with relevant stakeholders including the RCH, Southern Health, the AOA and the RACS, the department’s Service and Workforce Planning Unit reviews the feasibility of initiating a specific paediatric orthopaedic training position.

Ongoing work as required as the service at Southern Health is strengthened and a paediatric orthopaedic medical workforce strategy is developed in 2009 and 2010

Ongoing

Recommendation 31

That the Department of Human Services seeks the support of the Australian Health Ministers’ Advisory Council to resolve the issue of inadequate MBS recognition of specialist paediatric orthopaedic surgery.

Ongoing work as required as a paediatric orthopaedic medical workforce strategy is developed in 2009 and 2010

Ongoing

Recommendation 32

That the RCH, Southern Health and Barwon Health are invited to submit proposals to the Department of Human Services that identify:

• additionalactivityallocationsnecessarytomeetreasonablepaediatricorthopaedic demand

• additionaloperatingandcapitalfundingnecessarytodevelopanappropriatemodel of care according to the recommendations in this report

• theoutcomesthatwillbeachievedthroughtheprovisionofadditionalresources for paediatric orthopaedic services.

Completed, funding provided to all health services to meet this recommendation

Met

Recommendation 33

That the RCH and Southern Health management teams work with the Department of Human Services to review their internal allocations of theatre, inpatient and outpatient consulting resources to various clinical units to ensure that they are based on appropriate criteria including relative clinical need.

Completed/ongoing discussion at annual performance meetings

Met

Recommendation 34

That taking into account the above proposals and reviews, the Department of Human Services makes interim additional activity allocations and provides additional funding to the RCH, Southern Health and Barwon Health to enable the recommendations in this report to be implemented pending incorporation of actual costs into the normal funding formulae.

Completed Met

Recommendation 35

That the allocation of additional activity units to other health services that will be necessary to achieve increased throughput and to improve their self-sufficiency in paediatric orthopaedics occurs via the service planning and resource allocation negotiations that occur between the Department of Human Services and those health services on a regular basis.

Models of outreach to general health services to be developed. Further funding of general health services will be considered as part of outreach models of care.

Ongoing



3.4.1 Advanced practitioner training

The Advanced Paediatric Orthopaedic Physiotherapy (APOP) Training Program responds to the need for a standardised and structured training program for physiotherapists undertaking advanced roles in paediatric orthopaedics.

The training program is the first of its kind in Victoria and creates a strong platform to support the introduction of physiotherapist-led paediatric orthopaedic clinics. It was supported by a grant to the RCH from the Victorian Health Service Management Innovation Council (VHSMIC) Seeding Grants Program.

The goal of the program is to equip participants with the skills, knowledge and attitudes required to commence in the role of a primary care practitioner in paediatric orthopaedics.

The RCH, in collaboration with Western Health, hosted a pilot of the training program between June and December 2008. Six candidates from four health services in Victoria took part in the program. There are now plans to formalise the program into an award course with The University of Melbourne (see page 26).

3.4.2 Training in detection of developmental dysplasia of the hip

Developmental DDH is a condition where an infant’s hip fails to develop properly, resulting in an unstable or dislocated hip. Early detection of DDH is vital, as delayed diagnosis increases the likelihood of the child needing surgical intervention. Infants treated for DDH when they are only a few weeks old have a much better clinical outcome than children with late presentation of the condition.

A new multimedia educational module, funded by a grant from the Office for Children, teaches health professionals the correct method of examination of a child for DDH. The 3D learning tool is directed at health professionals involved in the screening of this condition—including maternal and child health nurses, paediatricians and general practitioners, and is expected to lead to earlier detection of this condition.

The training module also provides tools to enable referral of patients for specialist assessment and treatment where necessary. The allied health-led paediatric orthopaedic clinics (see section 3.3.1) will receive referrals relating to DDH and will be involved in ongoing management of children who have the condition.

The results of a study to evaluate the impact of the education module are described in box 1.

3.4.3 Statewide paediatric orthopaedic allied health survey

In July 2008, a survey of 28 health services in Victoria was carried out to examine the provision of paediatric orthopaedic allied health services and identify any issues and barriers to service provision. There was an overall response rate of 75 per cent. A main reported barrier was a lack of expertise and opportunity for professional development. The results of the survey will be used to develop strategies to improve service delivery.



Box 1: Developmental DDH multi-media education module—evaluation

Aim: To facilitate early diagnosis and referral of children with DDH.

Objectives: To utilise technology mediated learning to:

* increase the clinician’s knowledge of DDH

* increase the clinician’s confidence in all aspects of screening for DDH

* translate improved knowledge and confidence to positive changes in clinical practice.

Method: An innovative education module on DDH was produced using a multimedia DVD format to enhance the learning experience. High quality 3D animation was combined with text, audio and still images to explore the anatomy of the hip, show the pathology associated with DDH, and demonstrate the correct technique for examining the infant hip.

203 maternal and child health (MCH) nurses from 19 municipalities in Victoria (14 metropolitan, five regional) participated in the study. They were surveyed before and immediately after receiving the training and three months after the training.

Results: Change in DDH knowledge: MCH nurses demonstrated significant immediate gains in their knowledge of DDH (95per cent confidence interval: 5.8 to 6.5, p<0.001)

Change in confidence: Self reported confidence, in all aspects of screening of DDH, significantly increased from the pre-test to the three month follow up (p<0.001; see graph).




Recommendation 24

That the Department of Human Services works with the RCH, Southern Health and Barwon Health to:

• reviewtheincidenceoflatepresentationofhipdislocationinnormalinfantsand of hip dislocation in children with moderate-severe cerebral palsy and compare these rates with those experienced in other health systems conduct a feasibility study into implementing best practice screening programs for hip dislocation in normal infants and in children and young people with moderate-severe cerebral palsy.

RCH collaborating with VPDCU to review the reporting of DDH project

Office for Children/RCH multimedia education module

Met

Recommendation 25

That the Department of Human Services in collaboration with the Paediatric Rehabilitation Reference Group and the current managers of post intervention physiotherapy (PIP) services reviews the structure and funding of the ‘PIP Fund’ to ensure that all children who would benefit from post-intervention physiotherapy have timely access to appropriate funding and/or services.

VPRS on advisory committee

RCH review incorporated PIP and recommended management model with RCH

Once PIP management implemented, PIP review to be conducted – managed by continuing care program

Ongoing

Recommendation 26

That the Department of Human Services in collaboration with the RCH and Southern Health reviews the outcomes to date of the transition program and accelerates the program with the aim of achieving effective, timely transition of all adolescent patients from specialist paediatric orthopaedic services to appropriate adult services.

Four clinics established. Evaluation conducted by independent consultants regarding the effectiveness of the clinics and the process of transition.

Met

Recommendation 27

That the RCH management team establishes two new full-time senior positions for specialist paediatric orthopaedic surgeons and that Southern Health management team reviews its paediatric orthopaedic surgical staff structure and considers creating a new full-time position.

Funding provided for additional specialist paediatric orthopaedic surgeons at RCH, Western and Southern

Met

Recommendation 28

That when the RCH recruits an additional paediatric orthopaedic surgeon, a dual appointment is offered to Western Health to enable the development of the paediatric orthopaedic service at Sunshine Hospital.

Dual appointments between RCH and Western funded from 2006-07

Met

Recommendation 29

That the RCH human resources department works with the paediatric orthopaedic service in consultation with the AOA and the department’s Service and Workforce Planning Unit to develop a workforce strategy that addresses issues of appropriate delegation, appropriate structuring of resident and registrar positions, rotation of basic surgical trainees, rotation of orthopaedic registrars earlier in the training program and generally the creation of a training environment that optimises registrars' experiences in paediatric orthopaedics.


Ongoing




Recommendation 16

That the RCH and Southern Health paediatric orthopaedic services work with their respective community advisory committees to further develop their strategies to ensure effective written and verbal communication and engagement of parents and families as partners in care.

Ongoing process of development as consumer focus improves overtime

Met

Recommendation 17

That a RCH and Southern Health paediatric orthopaedic services progress the development of their care coordination models for all children with severe chronic disabilities requiring orthopaedic surveillance or intervention.

Funded positions for CP and scoliosis at RCH, Paediatric Orthopaedic coordinator at Barwon, and care coordinator at Southern Health

Met

Recommendation 18

That the RCH and Southern Health paediatric orthopaedic services incorporate as an integral element of the preparation of children and young people and their families for major orthopaedic surgery a documented care and discharge plan which recognises parents as partners.

Continues to be incorporated into service delivery models

Met

Recommendation 19

That the RCH, Southern Health and Barwon Health adopt a model of specialist paediatric orthopaedic care that incorporates multi-disciplinary outpatient clinics involving, as appropriate, paediatricians, rehabilitation specialists, orthopaedic surgeons and allied health professionals.

Funding at RCH, Western, Southern and Barwon incorporates an allied health-led clinic and multidisciplinary approach to orthopaedic care

Met

Recommendation 20

That the RCH management team works with the paediatric orthopaedic surgeons to ensure that all opportunities are realised to relieve their workload pressures through expanding the multidisciplinary care team as appropriate.

RCH have continued to develop a multidisciplinary approach

Met

Recommendation 21

That the RCH and Southern Health management teams support, resource appropriately and monitor outcomes of physiotherapist-led outpatient clinics.

Physio-led clinics established at RCH and Southern, ongoing monitoring in place.

Met

Recommendation 22

That the RCH and Southern Health management teams review the availability of equipment, including radiological equipment, and the efficiency of administration of their paediatric orthopaedic outpatient clinics to ensure that care delivery systems are streamlined and patient-centred.

Funding for new equipment provided at RCH, Southern and Barwon Health

Met

Recommendation 23

That the Department of Human Services evaluates the feasibility of establishing a dedicated pool of funding within the Aids and Equipment Program for children and young people with disabilities.

Aids and Equipment Program reviewed by the department, program managers consulting with advisory committee in the implementation of review. This is being led by Disability Program

Met



Self reported confidence in DDH screening

Change in clinical practice: The education module had the desired impact of translating improved knowledge into clinical practice. There were statistically significant improvements in:

* clinicians performing the correct clinical examination (p=0.005)

* clinicians interpreting physical signs (p=0.0002)

* inappropriate referrals (p<0.0001)

Feedback from participants: The DVD was rated highly in terms of its clinical relevance, use of graphics and as an educational tool.

Aspects of screening

Perc

enta

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Pre DVD

Post DVD

Three months

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Interpretingfindings






Recommendation 11

That all eligible children and young people from Tasmania and Southern New South Wales who require specialist paediatric orthopaedic care are accorded access on the basis of relative clinical need rather than on the basis of place of residence.

Managed through hospital to hospital transfer Met

Recommendation 12

That the Department of Human Services initiates discussion with its interstate counterparts, particularly New South Wales and Tasmania, with the objective of ensuring that the relevant cross-border agreements provide for reimbursement to Victoria of the full costs of treating interstate paediatric orthopaedic patients.

Managed through the department in collaboration with participating hospitals

Met

Recommendation 13

That the RCH and Southern Health management teams allocate additional outpatient sessions, theatre sessions and administrative resources to their paediatric orthopaedic services and review their infrastructure requirements to ensure that sufficient resources are available to enable the paediatric orthopaedic services to meet reasonably expected demand.

Completed as per funding submission Met

Recommendation 14

That the Department of Human Services consults with its Public Health Group and service providers about the potential to remove unnecessary barriers to the safe and efficient use of image intensifiers in the operating theatre setting.

Public Health Group has been consulted. All persons that use x-ray apparatus in Victoria are required to hold a Use Licence. No exemptions have been given to this condition either in Victoria or any other State in Australia.

Medical specialists that hold a licence may operate fluoroscopy equipment in conjunction with a radiographer. Medical specialists may be licensed to operate mini c-arm fluoroscopy equipment for the imaging of extremities, without a radiographer being present. It is a condition of this type of licence that operating factors must not be able to exceed 80 kVp and 1mA.

In all cases, users of fluoroscopy equipment must undertake an approved course pertinent to the clinical procedures they are involved in.

Approved training course at RCH in 2007.

Met

Recommendation 15

That the Department of Human Services works with all acute general metropolitan health services to ensure they allocate adequate clinical resources for the additional paediatric orthopaedic activity necessary to improve their self-sufficiency significantly.

Service delineation developed and included in this Future Directions document

Met




Recommendation 3

That establishment of this network including consideration and advice on implementation of the initiatives identified above is overseen by a time-limited statewide paediatric orthopaedic advisory committee, led by the Department of Human Services.

Time limited committee established and has met for 18+ months

Met

Recommendation 4

That the Department of Human Services works with the paediatric orthopaedic advisory committee to establish an agreed minimum data set for paediatric orthopaedics.

Agreed minimum data set yet to be developed Ongoing

Recommendation 5

That the Department of Human Services recognises and supports the RCH as a statewide leader in paediatric orthopaedics and provider of general paediatric orthopaedic services to its local catchment population as well as a comprehensive range of specialist paediatric orthopaedic services to a broad catchment population.

The department recognises RCH through service delineation

Met

Recommendation 6

That provision of a small number of highly specialised paediatric orthopaedic procedures is limited to the RCH.

Service profile at RCH supported by the department

Met

Recommendation 7

That the Department of Human Services works with Southern Health to develop its specialist paediatric orthopaedic services with the objective of maximising its local and regional self-sufficiency and enabling it to achieve its potential as a co-provider of statewide services in collaboration with the RCH.

The department has been working with Southern Health since December 2007 to maximise local and regional self sufficiency

Met

Recommendation 8

That the Department of Human Services recognises and supports Barwon Health as a provider of general paediatric orthopaedic services to its local catchment population as well as a range of specialist paediatric orthopaedic services to the population that lives in the Barwon South-Western Region.

The department recognises and supports Barwon Health through additional funding and service delineation

Met

Recommendation 9

That the Department of Human Services recognises and supports all acute general metropolitan health services (other than those in the immediate catchment area of the RCH) and all major regional and sub-regional health services that provide adult orthopaedic services and anaesthetic services for children and young people and that have the clinical infrastructure necessary to provide general paediatric care as providers of orthopaedic services for children and young people who present with uncomplicated trauma.

Demonstrated through service delineation Met

Recommendation 10

That the feasibility of a real-time radiological support service that would enable specialist paediatric orthopaedic surgeons at the RCH and Southern Health to provide timely review and advice on paediatric orthopaedic x-rays from across the state is investigated.

CSIRO telehealth demonstration project completed but feasibility of real time radiology yet to be investigated

Ongoing



4. Future directions

The Statewide Paediatric Orthopaedic Advisory Committee was established to provide leadership and guidance to the Department of Human Services in implementing recommendations of the Framework for paediatric orthopaedic services.

As discussed in section 3, many of the recommendations of the framework report have now been implemented. Collaboration between the department and health services over the last two years, and the increased recurrent funding to specialist paediatric orthopaedic services, has resulted in new resources for specific service development, workforce and model of care innovations.

The development of paediatric orthopaedic services over the last two years is the first stage in progress towards a sustainable service system. The building of specialist service capacity in this initial stage has been essential for the next phase, which will require health services—in consultation with the department—to implement further initiatives to strengthen the responsiveness, quality and effectiveness and coordination of their services.

4.1 Paediatric Orthopaedic Advisory GroupThere is broad support for a continued role for a paediatric orthopaedic group comprising representatives of specialist service providers and the department.

The new Paediatric Orthopaedic Advisory Group will continue to oversee initiatives funded under the first stage of development, and will focus on a series of new projects.

The group will provide a forum for services to identify and collaborate on projects of common interest, and will advise the department on service monitoring and future policy development.

Arrangements for collaboration between paediatric orthopaedic service providers are likely to evolve over time and will align with a proposed strategic framework for paediatric services in Victoria (see appendix 1).

4.2 Priorities 2009–2010Notwithstanding the significant progress to date, some important recommendations of the Framework for paediatric orthopaedic services have yet to be fully implemented. Notably, the framework identified a need for:

• ongoingdevelopmentofanintegratedapproachtoservicedeliveryacrosstherangeof paediatric orthopaedic service providers

• aqualityassuranceframework,includingmonitoringofservicequalityandoutcomes and strategies to strengthen engagement of parents and families as partners in their children’s care

• ongoingprofessionaldevelopmentofthepaediatricorthopaedicworkforce,including education and training programs for allied health, nursing and medical staff at specialist sites.

These issues will be addressed in context of broader challenges facing the system, as discussed in section 2.1.1.



4.2.1 An integrated approach to service delivery

The service delineation framework (see section 3.1 and appendix 3), which defines roles and responsibilities for services offering different levels of care, provides a basis for a more systematised and integrated approach to the provision of services across the state. Figure 6 depicts the envisaged system of care, based on the service delineation framework.

Next steps include work to:

• improvetheappropriatenessandqualityofreferralstospecialistservicesfromgeneral acute health services and community-based providers

• improvecommunicationandlinkagesbetweenspecialistprovidersofpaediatricorthopaedic care

• enablespecialistservicestoprovideclinicalsupportandleadershiptootherhealthservice providers.

The implementation of these next steps will be led by the Paediatric Orthopaedic Program Manager. This position, which was created in 2007, is based at the RCH. The program manager will coordinate key projects with each of the specialist sites and play an important role in strengthening communication and linkages between all the key stakeholders.

Activities that will help develop an integrated approach to the provision of paediatric orthopaedic services are discussed below.

Referral pathways for outpatient servicesDemand for outpatient paediatric orthopaedic consultations remains high and will continue to increase. Currently, the referral process from the community to specialist health services is not ideal. Many of the patients referred to outpatient clinics have conditions that are simply variations of normal development; with growth these conditions undergo spontaneous correction.

General practitioners are usually the first point of contact for parents who are concerned about possible orthopaedic problems in their children. The Paediatric Orthopaedic Advisory Group will support health services to undertake two inter-related projects to provide GPs with information on when and where to refer patients to outpatient clinics for specialist orthopaedic assessment. One project will establish referral guidelines for access to specialist paediatric orthopaedic services, while a second project (discussed in section 4.2.2) will develop and implement a multimedia education module and resource package on paediatric orthopaedics for GPs.

The advisory group will also develop other strategies to improve communication with GPs regarding referral processes. This work will be facilitated by broader initiatives occurring as part of the Victorian Government’s Specialist Clinics (Outpatient) Improvement and Innovation Strategy (OIIS), which include a range of activities to improve the interface between specialist clinics and primary care services.



Appendix 2: Implementation status of 2006 framework recommendations


Recommendation 1

That the following guiding principles are adopted for paediatric orthopaedic services:


• Whereanacceptablelevelofqualitycanbeachieved,serviceswillbeprovidedin local communities.


• Therewillbeanidentifiableservicesystemstructureandlinkageswhichfacilitate appropriate referrals and quality professional interaction between providers.

• Amultidisciplinaryworkforceisrequiredthathastheskills,knowledgeandattitude to work effectively in responding to the orthopaedic needs of children and their families and that distributes clinical responsibilities within clinical teams to those who are best equipped to meet them.

Has informed delivery of services across specialist and participating general health services

Ongoing

Recommendation 2

That a statewide paediatric orthopaedic network is established that incorporates the following initiatives:

• Statewideprotocolsgoverningreferralofpatientsfromgeneralacutehealthservices to specialist paediatric orthopaedic centres.

• Protocolsforcommunicationandcollaborationbetweenthespecialistpaediatric orthopaedic services and community-based providers.

• Protocolstoenableorthopaedicsurgeonsworkinginnon-specialisthealthservices to access timely consultant advice from specialist paediatric orthopaedic surgeons.

• Wherefeasible,establishmentofdual/multipleappointmentsbetweenthe RCH, Southern Health and general acute health services for specialist paediatric orthopaedic surgeons and other health care professionals who have a full-time or substantial fractional commitment to paediatric orthopaedics.

• Establishmentofmechanismstosupport‘orthopaedicsurgeonswithaninterest’ in paediatric orthopaedic services in general acute metropolitan and regional health services to facilitate local leadership, planning, service monitoring and communication with specialist providers.

• DevelopmentofmechanismsbywhichtheRCHandSouthernHealthcanprovide effective professional collaboration and clinical support to those orthopaedic surgeons with dual appointments and those ‘orthopaedic surgeons with an interest’.

• Overtime,supportfortheRCHandSouthernHealthtoestablishvisitingsurgical and allied health consulting services to metropolitan and regional centres.

• Aframeworkforcontinuousmonitoringofserviceadequacyandoutcomes.

• Referralprotocolstobedeveloped

• Communicationprotocolstobedeveloped

• Consultantadviceprotocolstobedeveloped/formalised

• DualappointmentestablishedbetweenRCHand Western Health

• Mechanismtosupportorthopaedicsurgeonswith an interest to be developed

• Modelofprofessionalcollaborationwithorthopaedic surgeons with an interest to be developed

• Visitingservicestobedeveloped

• Frameworkofcontinuousmonitoringofservice adequacy to be developed

Ongoing



Once phases one and two have been completed, it is planned to establish paediatric clinical networks in key areas of speciality. The development of clinical networks16—consisting of linked groups of clinicians, organisations, consumers and stakeholders from primary, secondary and tertiary care working in partnership with the department—was a key outcome of the government’s Health Options Review in 2007. Clinical networks are intended to facilitate clinician engagement in service improvement, focusing on high volume, high-risk clinical services.

Victorian Surgical Services Strategy 2010–2015

The Victorian Government is developing an integrated five-year strategy for emergency and elective surgical services in Victoria’s public hospitals. The strategy will articulate a vision for the future of public hospital surgical services, and identify specific actions to improve surgery access and outcomes.

The strategy will examine how care elements at all stages of the patient journey—from referral by a general practitioner or medical practitioner to discharge, rehabilitation and follow-up—impact on the provision of surgery. It will be aligned with service planning and reform occurring across a number of other areas, including primary care, sub-acute services, outpatient services, critical care and the Victorian State Trauma System.

Capital development

The government’s Metropolitan Health Strategy17 includes two major initiatives for children:

• amajorredevelopmentoftheRCHtomaintainfacilitiesatworldclassstandard

• attheMonashMedicalCentre,reconfigurationandupgradeofemergencydepartment facilities including a dedicated area for children, improved waiting areas and establishment of a short-stay unit of eight beds.

In August 2008 the government announced a $3.5 million package to support a statewide strategy to build capacity and improve access to paediatric intensive care beds. The support package is in recognition of the sustained and increased demand for paediatric intensive care services.

16. See www.dhs.vic.gov.au/ahs/cnsd.htm, accessed 5 December 2008.

17. www.health.vic.gov.au/metrohealthstrategy



Service coordination and communicationStrengthening the links between specialist health services and clarifying their respective roles and relationships with other health services will be a key priority for the advisory group. The service delineation framework will be used as a basis for development of protocols for referrals between services at different service delineation levels of the framework, including between the specialist sites.

Collaboration between the specialist service providers will also be enhanced through networking activities such as:

• anannualmultidisciplinarysymposiumtosharegoodpracticesandinformationonresearch findings, generate ideas for service improvement, and identify strategies to improve collaboration

• sharedtrainingprogramstosupportregistrars,nursingandalliedhealthstaff.

Paediatric tele-orthopaedic support serviceThe Paediatric Orthopaedic Advisory Group will support health services to investigate the feasibility of providing a paediatric tele-orthopaedic support service. This service would enable metropolitan and rural hospitals in Victoria to obtain specialist paediatric orthopaedic consultant advice via video-link technology.

Models of telephone and videoconference consultant support are used successfully in other areas of health care (for example, psychiatry, trauma), both in Victoria and elsewhere. The provision of timely specialist advice to assist with the diagnosis, treatment and management of paediatric orthopaedic conditions could help avoid unnecessary transfer of patients to paediatric specialist hospitals and, where patients do require specialist services, allow for better planning and management of the transfers. The proposed service would also assist in establishing stronger relationships between specialist services and general acute metropolitan and rural health services.

The project will include evaluation of the need for the paediatric tele-orthopaedic support service, analysis of user requirements, and identification of the resources and equipment needed to support the establishment, uptake and continued operation of the service.

The development of a statewide policy framework for telehealth initiatives is a high priority for the department’s new Whole-of-Health ICT Strategy.14

14. www.health.vic.gov.au/ictstrategy



Figure 6. Proposed paediatric orthopaedic service model

Each level of care will be responsible for providing care to their local catchment area as appropriate

Level I Sites

Level II Sites

Primary care providers e.g. GPs

Paediatric orthopaedicspecialist services

Level VRCH

Level IIISunshineHospital

Level IIIGeelong Hospital

Level IVMMC

Inter hospital transferprotocols

Outreach services

Education and referral guidelines



Appendix 1: Policy and service context for paediatric orthopaedic services

a) Key policies relevant to child health services• A Fairer Victoria—the government’s key social policy statement, setting the

framework for tackling disadvantage. It includes priority actions for supporting people with a disability such as early intervention, new skills for young people with a disability, and more respite options, affordable housing and employment opportunities.

• Growing Victoria Together—which includes goals for high quality, accessible services; building friendly confident and safe communities; and a fairer society that reduces disadvantage and respects diversity.

• Every Child Every Chance Reforms—which establish new approaches for helping children who face abuse, neglect or other adverse circumstances. It focuses on early intervention, placing children’s best interests at the heart of all decision making, and greater emphasis on preventing cumulative harm to children and the importance of providing children with stability in their lives.

• Victorian Plan for Improving Outcomes in Early Childhood—which sets out actions to promote and provide early intervention for children including specific actions in the areas of antenatal health, childhood education and care, and workforce development.

• The State Disability Plan 2002-2012—which looks at all aspects of life for people with a disability, including disability supports, health and community services, recreation, education, employment, transport and housing. It recognises that people with a disability have the right to choose the way they want to live and participate in the community. This document sets the vision for re-orienting supports to focus on the individual needs of the person with a disability, positioning the person with a disability as an equal partner rather than a recipient of services.

b) Relevant current initiatives

Strategic Framework for Paediatric Services in Victoria

The Victorian Government is developing a Strategic Framework for Paediatric Services in Victoria to guide planning and delivery of the state’s paediatric health services. The strategy will aim to align paediatric health services with other children’s services, including schools, across both state and local government.

A second phase of the project will define roles and responsibilities between the RCH and the Monash Medical Centre (MMC), Southern Health, in the provision of tertiary paediatric services. These groups are currently meeting to better clarify the roles of the two tertiary children’s services.



Emergency Care Improvement and Innovation Clinical NetworkThe Emergency Care Improvement and Innovation Clinical Network was established to lead innovation and ongoing improvements in the delivery of emergency care in Victoria’s public hospitals. One of its key aims is to support the delivery of consistent, efficient and effective emergency care across the Victorian health system. The management of paediatric fractures has been identified as an issue to be considered by the network. A project to be led by the clinical network in consultation with paediatric orthopaedic services will develop and implement strategies to ensure best practice fracture management.



4.2.2 Workforce development and education

As has been noted elsewhere in this document, there is scope for developing and better using the skills of the paediatric orthopaedic workforce—both specialist and non-specialist—to improve management of demand for services and to attract and retain practitioners in the field.

Online multimedia education module for general practitionersEducation to support primary care providers in the assessment and management of paediatric orthopaedic conditions is needed to improve the quality, appropriateness and timeliness of referrals to specialist paediatric orthopaedic services.

The Paediatric Orthopaedic Advisory Group will oversee the development and implementation of an online multimedia education module and resource package on paediatric orthopaedics for general practitioners (GPs). The RCH, in collaboration with specialist paediatric orthopaedic service providers at Barwon Health, Southern Health, and Western Health, will lead a two-year project to develop the education module and resource package, which will include patient education materials and guidelines for obtaining specialist paediatric orthopaedic opinion. The project will be developed in consultation with GP representatives.

The aim of the project is to ensure that children are managed effectively in their local communities, where appropriate, and referred to paediatric orthopaedic services in a timely manner when this is necessary. The education module and resource package will:

• strengthengeneralpractitioners’knowledgeofpaediatricorthopaedicconditions,and build their confidence and skills in recognising and managing paediatric orthopaedic problems

• empowerparentsandcarersbygivingthemrelevantinformationatappropriatepoints in the care process

• improvecommunicationbetweenGPs’andparentsandcarers

• improvethequalityofreferralstospecialistpaediatricorthopaedicservices.

Development of the specialist paediatric orthopaedic workforceThe Paediatric Orthopaedic Advisory Group will collaborate with relevant organisations to investigate enablers and barriers to the development of a sustainable specialist paediatric orthopaedic workforce. Issues to be explored include education and training, roles, and recruitment and retention.

Credentialling and scope of practice issues may also be considered, with any developments in this area expected to be consistent with relevant departmental policy15 and to engage the relevant program areas within the department.

15. Department of Human Services, Credentialling and defining the scope of clinical practice for practitioners in Victorian Health Services. Melbourne, 2007. www.health.vic.gov.au



Development of the allied health paediatric orthopaedic workforceTwo key initiatives are planned to support the ongoing development of the allied health paediatric orthopaedic workforce.

1. Formalisation of the Advanced Paediatric Orthopaedic Physiotherapy (APOP) Training Program. The RCH has been liaising with the University of Melbourne to formalise the Advanced Paediatric Orthopaedic Physiotherapy (APOP) Training Program as a post graduate qualification. It is anticipated that a specialist certificate in advanced paediatric orthopaedics will be offered to physiotherapists in the latter part of 2009. The ongoing development of this training program will respond to the planned evaluation of the pilot program.

2. Paediatric orthopaedic education seminars. In response to the allied health survey conducted in 2008 (see page 17), a series of paediatric orthopaedic education seminars will be held in 2009 and 2010 for the allied health and nursing professions. The seminars will be held in both rural and metropolitan locations and will focus on particular patient groups.

4.2.3 Quality monitoring and improvement

All health services should have quality assurance and improvement processes in place, including mechanisms for monitoring the outcomes and experiences of patients and their families, and this information should be used to work towards ‘best practice’ service delivery.

Monitoring clinical outcomes and service performance for paediatric orthopaedics will be achieved through the following datasets:

• Analysisandreportingofpaediatricorthopaedicdatacapturedinthedepartment’sVictorian Admitted Episodes Dataset (VAED). (The VAED collects data on all patients admitted to public and private acute hospitals, rehabilitation centres, extended care facilities and day procedure centres in Victoria).

• Collection,analysisandreportingofmoredetailedpatientandservicedatafromspecialist paediatric orthopaedic services.

As discussed below, these datasets will be used as a basis for an audit of paediatric orthopaedic services and for the development of key performance indicators.

Paediatric orthopaedic auditA working group of the Paediatric Orthopaedic Advisory Group will develop and implement the paediatric orthopaedic audit for inpatient and outpatient specialist services. The purpose of the audit is to enable:

• reviewofperformanceacrossandwithinorganisations

• discussionandsharingofinformationabouthowtoimprovethequalityofpaediatricorthopaedic care

• identificationofareasforfurtherinvestigationandactionatalocallevel.



The audit will focus on both inpatient and outpatient data, and will involve:

• developmentofanagreedminimumdatasetthatcanbeusedforapaediatricorthopaedic audit. This includes individual data items/indicators with agreed definitions, standards, coding and sources

• investigationofbarrierstodatacollection

• fieldtestingtheminimumdatasetatspecialistsites

• evaluationandrevisionoftheminimumdataset.

Key performance indicatorsThe advisory group will oversee development of a set of performance indicators to monitor the quality, safety, effectiveness and efficiency of specialist paediatric orthopaedic services.

Evaluation of allied health-led clinicsAs described on page 15, new funding has been provided to establish allied health-led paediatric orthopaedic clinics. Most of these new clinics are in the early stages of development. A statewide evaluation of the clinics will take place in early 2010. The evaluation will focus on waiting times, family satisfaction, referrer satisfaction and workforce satisfaction including both the physiotherapist and consultant.

4.2.4 New models of care

Child and family-focused models of service deliveryThe ongoing development of family/child-focused models of service delivery will be a priority for the advisory group. This approach will be incorporated into new projects and, where evaluations are undertaken, measures will be included to assess the extent to which family/child-focused models of service delivery have been embedded into service design.

Specific actions to strengthen services’ family/child-focus will include the development of a paediatric orthopaedic consumer information website. The internet is an increasingly important source of information for families of orthopaedic patients and their referrers. The planned website will aim to meet the information needs of parents, families and health professionals. The process of developing the website will include collection of information on stakeholder views and needs (including those of families, referrers and specialist services).

Review of the Post Intervention Physiotherapy (PIP) programThe Framework for paediatric orthopaedic services recommended a review of the Post Intervention Physiotherapy (PIP) program. This PIP review will consider:

• themodelofbrokeringprivatephysiotherapyservices

• theclientgroupservicedbyPIP

• theinterfacewiththeVictorianPaediatricRehabilitationService.



Development of the allied health paediatric orthopaedic workforceTwo key initiatives are planned to support the ongoing development of the allied health paediatric orthopaedic workforce.

1. Formalisation of the Advanced Paediatric Orthopaedic Physiotherapy (APOP) Training Program. The RCH has been liaising with the University of Melbourne to formalise the Advanced Paediatric Orthopaedic Physiotherapy (APOP) Training Program as a post graduate qualification. It is anticipated that a specialist certificate in advanced paediatric orthopaedics will be offered to physiotherapists in the latter part of 2009. The ongoing development of this training program will respond to the planned evaluation of the pilot program.

2. Paediatric orthopaedic education seminars. In response to the allied health survey conducted in 2008 (see page 17), a series of paediatric orthopaedic education seminars will be held in 2009 and 2010 for the allied health and nursing professions. The seminars will be held in both rural and metropolitan locations and will focus on particular patient groups.

4.2.3 Quality monitoring and improvement

All health services should have quality assurance and improvement processes in place, including mechanisms for monitoring the outcomes and experiences of patients and their families, and this information should be used to work towards ‘best practice’ service delivery.

Monitoring clinical outcomes and service performance for paediatric orthopaedics will be achieved through the following datasets:

• Analysisandreportingofpaediatricorthopaedicdatacapturedinthedepartment’sVictorian Admitted Episodes Dataset (VAED). (The VAED collects data on all patients admitted to public and private acute hospitals, rehabilitation centres, extended care facilities and day procedure centres in Victoria).

• Collection,analysisandreportingofmoredetailedpatientandservicedatafromspecialist paediatric orthopaedic services.

As discussed below, these datasets will be used as a basis for an audit of paediatric orthopaedic services and for the development of key performance indicators.

Paediatric orthopaedic auditA working group of the Paediatric Orthopaedic Advisory Group will develop and implement the paediatric orthopaedic audit for inpatient and outpatient specialist services. The purpose of the audit is to enable:

• reviewofperformanceacrossandwithinorganisations

• discussionandsharingofinformationabouthowtoimprovethequalityofpaediatricorthopaedic care

• identificationofareasforfurtherinvestigationandactionatalocallevel.



The audit will focus on both inpatient and outpatient data, and will involve:

• developmentofanagreedminimumdatasetthatcanbeusedforapaediatricorthopaedic audit. This includes individual data items/indicators with agreed definitions, standards, coding and sources

• investigationofbarrierstodatacollection

• fieldtestingtheminimumdatasetatspecialistsites

• evaluationandrevisionoftheminimumdataset.

Key performance indicatorsThe advisory group will oversee development of a set of performance indicators to monitor the quality, safety, effectiveness and efficiency of specialist paediatric orthopaedic services.

Evaluation of allied health-led clinicsAs described on page 15, new funding has been provided to establish allied health-led paediatric orthopaedic clinics. Most of these new clinics are in the early stages of development. A statewide evaluation of the clinics will take place in early 2010. The evaluation will focus on waiting times, family satisfaction, referrer satisfaction and workforce satisfaction including both the physiotherapist and consultant.

4.2.4 New models of care

Child and family-focused models of service deliveryThe ongoing development of family/child-focused models of service delivery will be a priority for the advisory group. This approach will be incorporated into new projects and, where evaluations are undertaken, measures will be included to assess the extent to which family/child-focused models of service delivery have been embedded into service design.

Specific actions to strengthen services’ family/child-focus will include the development of a paediatric orthopaedic consumer information website. The internet is an increasingly important source of information for families of orthopaedic patients and their referrers. The planned website will aim to meet the information needs of parents, families and health professionals. The process of developing the website will include collection of information on stakeholder views and needs (including those of families, referrers and specialist services).

Review of the Post Intervention Physiotherapy (PIP) programThe Framework for paediatric orthopaedic services recommended a review of the Post Intervention Physiotherapy (PIP) program. This PIP review will consider:

• themodelofbrokeringprivatephysiotherapyservices

• theclientgroupservicedbyPIP

• theinterfacewiththeVictorianPaediatricRehabilitationService.



Emergency Care Improvement and Innovation Clinical NetworkThe Emergency Care Improvement and Innovation Clinical Network was established to lead innovation and ongoing improvements in the delivery of emergency care in Victoria’s public hospitals. One of its key aims is to support the delivery of consistent, efficient and effective emergency care across the Victorian health system. The management of paediatric fractures has been identified as an issue to be considered by the network. A project to be led by the clinical network in consultation with paediatric orthopaedic services will develop and implement strategies to ensure best practice fracture management.



4.2.2 Workforce development and education

As has been noted elsewhere in this document, there is scope for developing and better using the skills of the paediatric orthopaedic workforce—both specialist and non-specialist—to improve management of demand for services and to attract and retain practitioners in the field.

Online multimedia education module for general practitionersEducation to support primary care providers in the assessment and management of paediatric orthopaedic conditions is needed to improve the quality, appropriateness and timeliness of referrals to specialist paediatric orthopaedic services.

The Paediatric Orthopaedic Advisory Group will oversee the development and implementation of an online multimedia education module and resource package on paediatric orthopaedics for general practitioners (GPs). The RCH, in collaboration with specialist paediatric orthopaedic service providers at Barwon Health, Southern Health, and Western Health, will lead a two-year project to develop the education module and resource package, which will include patient education materials and guidelines for obtaining specialist paediatric orthopaedic opinion. The project will be developed in consultation with GP representatives.

The aim of the project is to ensure that children are managed effectively in their local communities, where appropriate, and referred to paediatric orthopaedic services in a timely manner when this is necessary. The education module and resource package will:

• strengthengeneralpractitioners’knowledgeofpaediatricorthopaedicconditions,and build their confidence and skills in recognising and managing paediatric orthopaedic problems

• empowerparentsandcarersbygivingthemrelevantinformationatappropriatepoints in the care process

• improvecommunicationbetweenGPs’andparentsandcarers

• improvethequalityofreferralstospecialistpaediatricorthopaedicservices.

Development of the specialist paediatric orthopaedic workforceThe Paediatric Orthopaedic Advisory Group will collaborate with relevant organisations to investigate enablers and barriers to the development of a sustainable specialist paediatric orthopaedic workforce. Issues to be explored include education and training, roles, and recruitment and retention.

Credentialling and scope of practice issues may also be considered, with any developments in this area expected to be consistent with relevant departmental policy15 and to engage the relevant program areas within the department.

15. Department of Human Services, Credentialling and defining the scope of clinical practice for practitioners in Victorian Health Services. Melbourne, 2007. www.health.vic.gov.au



Figure 6. Proposed paediatric orthopaedic service model

Each level of care will be responsible for providing care to their local catchment area as appropriate

Level I Sites

Level II Sites

Primary care providers e.g. GPs

Paediatric orthopaedicspecialist services

Level VRCH

Level IIISunshineHospital

Level IIIGeelong Hospital

Level IVMMC

Inter hospital transferprotocols

Outreach services

Education and referral guidelines



Appendix 1: Policy and service context for paediatric orthopaedic services

a) Key policies relevant to child health services• A Fairer Victoria—the government’s key social policy statement, setting the

framework for tackling disadvantage. It includes priority actions for supporting people with a disability such as early intervention, new skills for young people with a disability, and more respite options, affordable housing and employment opportunities.

• Growing Victoria Together—which includes goals for high quality, accessible services; building friendly confident and safe communities; and a fairer society that reduces disadvantage and respects diversity.

• Every Child Every Chance Reforms—which establish new approaches for helping children who face abuse, neglect or other adverse circumstances. It focuses on early intervention, placing children’s best interests at the heart of all decision making, and greater emphasis on preventing cumulative harm to children and the importance of providing children with stability in their lives.

• Victorian Plan for Improving Outcomes in Early Childhood—which sets out actions to promote and provide early intervention for children including specific actions in the areas of antenatal health, childhood education and care, and workforce development.

• The State Disability Plan 2002-2012—which looks at all aspects of life for people with a disability, including disability supports, health and community services, recreation, education, employment, transport and housing. It recognises that people with a disability have the right to choose the way they want to live and participate in the community. This document sets the vision for re-orienting supports to focus on the individual needs of the person with a disability, positioning the person with a disability as an equal partner rather than a recipient of services.

b) Relevant current initiatives

Strategic Framework for Paediatric Services in Victoria

The Victorian Government is developing a Strategic Framework for Paediatric Services in Victoria to guide planning and delivery of the state’s paediatric health services. The strategy will aim to align paediatric health services with other children’s services, including schools, across both state and local government.

A second phase of the project will define roles and responsibilities between the RCH and the Monash Medical Centre (MMC), Southern Health, in the provision of tertiary paediatric services. These groups are currently meeting to better clarify the roles of the two tertiary children’s services.



Once phases one and two have been completed, it is planned to establish paediatric clinical networks in key areas of speciality. The development of clinical networks16—consisting of linked groups of clinicians, organisations, consumers and stakeholders from primary, secondary and tertiary care working in partnership with the department—was a key outcome of the government’s Health Options Review in 2007. Clinical networks are intended to facilitate clinician engagement in service improvement, focusing on high volume, high-risk clinical services.

Victorian Surgical Services Strategy 2010–2015

The Victorian Government is developing an integrated five-year strategy for emergency and elective surgical services in Victoria’s public hospitals. The strategy will articulate a vision for the future of public hospital surgical services, and identify specific actions to improve surgery access and outcomes.

The strategy will examine how care elements at all stages of the patient journey—from referral by a general practitioner or medical practitioner to discharge, rehabilitation and follow-up—impact on the provision of surgery. It will be aligned with service planning and reform occurring across a number of other areas, including primary care, sub-acute services, outpatient services, critical care and the Victorian State Trauma System.

Capital development

The government’s Metropolitan Health Strategy17 includes two major initiatives for children:

• amajorredevelopmentoftheRCHtomaintainfacilitiesatworldclassstandard

• attheMonashMedicalCentre,reconfigurationandupgradeofemergencydepartment facilities including a dedicated area for children, improved waiting areas and establishment of a short-stay unit of eight beds.

In August 2008 the government announced a $3.5 million package to support a statewide strategy to build capacity and improve access to paediatric intensive care beds. The support package is in recognition of the sustained and increased demand for paediatric intensive care services.

16. See www.dhs.vic.gov.au/ahs/cnsd.htm, accessed 5 December 2008.

17. www.health.vic.gov.au/metrohealthstrategy



Service coordination and communicationStrengthening the links between specialist health services and clarifying their respective roles and relationships with other health services will be a key priority for the advisory group. The service delineation framework will be used as a basis for development of protocols for referrals between services at different service delineation levels of the framework, including between the specialist sites.

Collaboration between the specialist service providers will also be enhanced through networking activities such as:

• anannualmultidisciplinarysymposiumtosharegoodpracticesandinformationonresearch findings, generate ideas for service improvement, and identify strategies to improve collaboration

• sharedtrainingprogramstosupportregistrars,nursingandalliedhealthstaff.

Paediatric tele-orthopaedic support serviceThe Paediatric Orthopaedic Advisory Group will support health services to investigate the feasibility of providing a paediatric tele-orthopaedic support service. This service would enable metropolitan and rural hospitals in Victoria to obtain specialist paediatric orthopaedic consultant advice via video-link technology.

Models of telephone and videoconference consultant support are used successfully in other areas of health care (for example, psychiatry, trauma), both in Victoria and elsewhere. The provision of timely specialist advice to assist with the diagnosis, treatment and management of paediatric orthopaedic conditions could help avoid unnecessary transfer of patients to paediatric specialist hospitals and, where patients do require specialist services, allow for better planning and management of the transfers. The proposed service would also assist in establishing stronger relationships between specialist services and general acute metropolitan and rural health services.

The project will include evaluation of the need for the paediatric tele-orthopaedic support service, analysis of user requirements, and identification of the resources and equipment needed to support the establishment, uptake and continued operation of the service.

The development of a statewide policy framework for telehealth initiatives is a high priority for the department’s new Whole-of-Health ICT Strategy.14

14. www.health.vic.gov.au/ictstrategy



4.2.1 An integrated approach to service delivery

The service delineation framework (see section 3.1 and appendix 3), which defines roles and responsibilities for services offering different levels of care, provides a basis for a more systematised and integrated approach to the provision of services across the state. Figure 6 depicts the envisaged system of care, based on the service delineation framework.

Next steps include work to:

• improvetheappropriatenessandqualityofreferralstospecialistservicesfromgeneral acute health services and community-based providers

• improvecommunicationandlinkagesbetweenspecialistprovidersofpaediatricorthopaedic care

• enablespecialistservicestoprovideclinicalsupportandleadershiptootherhealthservice providers.

The implementation of these next steps will be led by the Paediatric Orthopaedic Program Manager. This position, which was created in 2007, is based at the RCH. The program manager will coordinate key projects with each of the specialist sites and play an important role in strengthening communication and linkages between all the key stakeholders.

Activities that will help develop an integrated approach to the provision of paediatric orthopaedic services are discussed below.

Referral pathways for outpatient servicesDemand for outpatient paediatric orthopaedic consultations remains high and will continue to increase. Currently, the referral process from the community to specialist health services is not ideal. Many of the patients referred to outpatient clinics have conditions that are simply variations of normal development; with growth these conditions undergo spontaneous correction.

General practitioners are usually the first point of contact for parents who are concerned about possible orthopaedic problems in their children. The Paediatric Orthopaedic Advisory Group will support health services to undertake two inter-related projects to provide GPs with information on when and where to refer patients to outpatient clinics for specialist orthopaedic assessment. One project will establish referral guidelines for access to specialist paediatric orthopaedic services, while a second project (discussed in section 4.2.2) will develop and implement a multimedia education module and resource package on paediatric orthopaedics for GPs.

The advisory group will also develop other strategies to improve communication with GPs regarding referral processes. This work will be facilitated by broader initiatives occurring as part of the Victorian Government’s Specialist Clinics (Outpatient) Improvement and Innovation Strategy (OIIS), which include a range of activities to improve the interface between specialist clinics and primary care services.



Appendix 2: Implementation status of 2006 framework recommendations


Recommendation 1

That the following guiding principles are adopted for paediatric orthopaedic services:


• Whereanacceptablelevelofqualitycanbeachieved,serviceswillbeprovidedin local communities.


• Therewillbeanidentifiableservicesystemstructureandlinkageswhichfacilitate appropriate referrals and quality professional interaction between providers.

• Amultidisciplinaryworkforceisrequiredthathastheskills,knowledgeandattitude to work effectively in responding to the orthopaedic needs of children and their families and that distributes clinical responsibilities within clinical teams to those who are best equipped to meet them.

Has informed delivery of services across specialist and participating general health services

Ongoing

Recommendation 2

That a statewide paediatric orthopaedic network is established that incorporates the following initiatives:

• Statewideprotocolsgoverningreferralofpatientsfromgeneralacutehealthservices to specialist paediatric orthopaedic centres.

• Protocolsforcommunicationandcollaborationbetweenthespecialistpaediatric orthopaedic services and community-based providers.

• Protocolstoenableorthopaedicsurgeonsworkinginnon-specialisthealthservices to access timely consultant advice from specialist paediatric orthopaedic surgeons.

• Wherefeasible,establishmentofdual/multipleappointmentsbetweenthe RCH, Southern Health and general acute health services for specialist paediatric orthopaedic surgeons and other health care professionals who have a full-time or substantial fractional commitment to paediatric orthopaedics.

• Establishmentofmechanismstosupport‘orthopaedicsurgeonswithaninterest’ in paediatric orthopaedic services in general acute metropolitan and regional health services to facilitate local leadership, planning, service monitoring and communication with specialist providers.

• DevelopmentofmechanismsbywhichtheRCHandSouthernHealthcanprovide effective professional collaboration and clinical support to those orthopaedic surgeons with dual appointments and those ‘orthopaedic surgeons with an interest’.

• Overtime,supportfortheRCHandSouthernHealthtoestablishvisitingsurgical and allied health consulting services to metropolitan and regional centres.

• Aframeworkforcontinuousmonitoringofserviceadequacyandoutcomes.

• Referralprotocolstobedeveloped

• Communicationprotocolstobedeveloped

• Consultantadviceprotocolstobedeveloped/formalised

• DualappointmentestablishedbetweenRCHand Western Health

• Mechanismtosupportorthopaedicsurgeonswith an interest to be developed

• Modelofprofessionalcollaborationwithorthopaedic surgeons with an interest to be developed

• Visitingservicestobedeveloped

• Frameworkofcontinuousmonitoringofservice adequacy to be developed

Ongoing




Recommendation 3

That establishment of this network including consideration and advice on implementation of the initiatives identified above is overseen by a time-limited statewide paediatric orthopaedic advisory committee, led by the Department of Human Services.

Time limited committee established and has met for 18+ months

Met

Recommendation 4

That the Department of Human Services works with the paediatric orthopaedic advisory committee to establish an agreed minimum data set for paediatric orthopaedics.

Agreed minimum data set yet to be developed Ongoing

Recommendation 5

That the Department of Human Services recognises and supports the RCH as a statewide leader in paediatric orthopaedics and provider of general paediatric orthopaedic services to its local catchment population as well as a comprehensive range of specialist paediatric orthopaedic services to a broad catchment population.

The department recognises RCH through service delineation

Met

Recommendation 6

That provision of a small number of highly specialised paediatric orthopaedic procedures is limited to the RCH.

Service profile at RCH supported by the department

Met

Recommendation 7

That the Department of Human Services works with Southern Health to develop its specialist paediatric orthopaedic services with the objective of maximising its local and regional self-sufficiency and enabling it to achieve its potential as a co-provider of statewide services in collaboration with the RCH.

The department has been working with Southern Health since December 2007 to maximise local and regional self sufficiency

Met

Recommendation 8

That the Department of Human Services recognises and supports Barwon Health as a provider of general paediatric orthopaedic services to its local catchment population as well as a range of specialist paediatric orthopaedic services to the population that lives in the Barwon South-Western Region.

The department recognises and supports Barwon Health through additional funding and service delineation

Met

Recommendation 9

That the Department of Human Services recognises and supports all acute general metropolitan health services (other than those in the immediate catchment area of the RCH) and all major regional and sub-regional health services that provide adult orthopaedic services and anaesthetic services for children and young people and that have the clinical infrastructure necessary to provide general paediatric care as providers of orthopaedic services for children and young people who present with uncomplicated trauma.

Demonstrated through service delineation Met

Recommendation 10

That the feasibility of a real-time radiological support service that would enable specialist paediatric orthopaedic surgeons at the RCH and Southern Health to provide timely review and advice on paediatric orthopaedic x-rays from across the state is investigated.

CSIRO telehealth demonstration project completed but feasibility of real time radiology yet to be investigated

Ongoing



4. Future directions

The Statewide Paediatric Orthopaedic Advisory Committee was established to provide leadership and guidance to the Department of Human Services in implementing recommendations of the Framework for paediatric orthopaedic services.

As discussed in section 3, many of the recommendations of the framework report have now been implemented. Collaboration between the department and health services over the last two years, and the increased recurrent funding to specialist paediatric orthopaedic services, has resulted in new resources for specific service development, workforce and model of care innovations.

The development of paediatric orthopaedic services over the last two years is the first stage in progress towards a sustainable service system. The building of specialist service capacity in this initial stage has been essential for the next phase, which will require health services—in consultation with the department—to implement further initiatives to strengthen the responsiveness, quality and effectiveness and coordination of their services.

4.1 Paediatric Orthopaedic Advisory GroupThere is broad support for a continued role for a paediatric orthopaedic group comprising representatives of specialist service providers and the department.

The new Paediatric Orthopaedic Advisory Group will continue to oversee initiatives funded under the first stage of development, and will focus on a series of new projects.

The group will provide a forum for services to identify and collaborate on projects of common interest, and will advise the department on service monitoring and future policy development.

Arrangements for collaboration between paediatric orthopaedic service providers are likely to evolve over time and will align with a proposed strategic framework for paediatric services in Victoria (see appendix 1).

4.2 Priorities 2009–2010Notwithstanding the significant progress to date, some important recommendations of the Framework for paediatric orthopaedic services have yet to be fully implemented. Notably, the framework identified a need for:

• ongoingdevelopmentofanintegratedapproachtoservicedeliveryacrosstherangeof paediatric orthopaedic service providers

• aqualityassuranceframework,includingmonitoringofservicequalityandoutcomes and strategies to strengthen engagement of parents and families as partners in their children’s care

• ongoingprofessionaldevelopmentofthepaediatricorthopaedicworkforce,including education and training programs for allied health, nursing and medical staff at specialist sites.

These issues will be addressed in context of broader challenges facing the system, as discussed in section 2.1.1.






Recommendation 11

That all eligible children and young people from Tasmania and Southern New South Wales who require specialist paediatric orthopaedic care are accorded access on the basis of relative clinical need rather than on the basis of place of residence.

Managed through hospital to hospital transfer Met

Recommendation 12

That the Department of Human Services initiates discussion with its interstate counterparts, particularly New South Wales and Tasmania, with the objective of ensuring that the relevant cross-border agreements provide for reimbursement to Victoria of the full costs of treating interstate paediatric orthopaedic patients.

Managed through the department in collaboration with participating hospitals

Met

Recommendation 13

That the RCH and Southern Health management teams allocate additional outpatient sessions, theatre sessions and administrative resources to their paediatric orthopaedic services and review their infrastructure requirements to ensure that sufficient resources are available to enable the paediatric orthopaedic services to meet reasonably expected demand.

Completed as per funding submission Met

Recommendation 14

That the Department of Human Services consults with its Public Health Group and service providers about the potential to remove unnecessary barriers to the safe and efficient use of image intensifiers in the operating theatre setting.

Public Health Group has been consulted. All persons that use x-ray apparatus in Victoria are required to hold a Use Licence. No exemptions have been given to this condition either in Victoria or any other State in Australia.

Medical specialists that hold a licence may operate fluoroscopy equipment in conjunction with a radiographer. Medical specialists may be licensed to operate mini c-arm fluoroscopy equipment for the imaging of extremities, without a radiographer being present. It is a condition of this type of licence that operating factors must not be able to exceed 80 kVp and 1mA.

In all cases, users of fluoroscopy equipment must undertake an approved course pertinent to the clinical procedures they are involved in.

Approved training course at RCH in 2007.

Met

Recommendation 15

That the Department of Human Services works with all acute general metropolitan health services to ensure they allocate adequate clinical resources for the additional paediatric orthopaedic activity necessary to improve their self-sufficiency significantly.

Service delineation developed and included in this Future Directions document

Met




Recommendation 16

That the RCH and Southern Health paediatric orthopaedic services work with their respective community advisory committees to further develop their strategies to ensure effective written and verbal communication and engagement of parents and families as partners in care.

Ongoing process of development as consumer focus improves overtime

Met

Recommendation 17

That a RCH and Southern Health paediatric orthopaedic services progress the development of their care coordination models for all children with severe chronic disabilities requiring orthopaedic surveillance or intervention.

Funded positions for CP and scoliosis at RCH, Paediatric Orthopaedic coordinator at Barwon, and care coordinator at Southern Health

Met

Recommendation 18

That the RCH and Southern Health paediatric orthopaedic services incorporate as an integral element of the preparation of children and young people and their families for major orthopaedic surgery a documented care and discharge plan which recognises parents as partners.

Continues to be incorporated into service delivery models

Met

Recommendation 19

That the RCH, Southern Health and Barwon Health adopt a model of specialist paediatric orthopaedic care that incorporates multi-disciplinary outpatient clinics involving, as appropriate, paediatricians, rehabilitation specialists, orthopaedic surgeons and allied health professionals.

Funding at RCH, Western, Southern and Barwon incorporates an allied health-led clinic and multidisciplinary approach to orthopaedic care

Met

Recommendation 20

That the RCH management team works with the paediatric orthopaedic surgeons to ensure that all opportunities are realised to relieve their workload pressures through expanding the multidisciplinary care team as appropriate.

RCH have continued to develop a multidisciplinary approach

Met

Recommendation 21

That the RCH and Southern Health management teams support, resource appropriately and monitor outcomes of physiotherapist-led outpatient clinics.

Physio-led clinics established at RCH and Southern, ongoing monitoring in place.

Met

Recommendation 22

That the RCH and Southern Health management teams review the availability of equipment, including radiological equipment, and the efficiency of administration of their paediatric orthopaedic outpatient clinics to ensure that care delivery systems are streamlined and patient-centred.

Funding for new equipment provided at RCH, Southern and Barwon Health

Met

Recommendation 23

That the Department of Human Services evaluates the feasibility of establishing a dedicated pool of funding within the Aids and Equipment Program for children and young people with disabilities.

Aids and Equipment Program reviewed by the department, program managers consulting with advisory committee in the implementation of review. This is being led by Disability Program

Met



Self reported confidence in DDH screening

Change in clinical practice: The education module had the desired impact of translating improved knowledge into clinical practice. There were statistically significant improvements in:

* clinicians performing the correct clinical examination (p=0.005)

* clinicians interpreting physical signs (p=0.0002)

* inappropriate referrals (p<0.0001)

Feedback from participants: The DVD was rated highly in terms of its clinical relevance, use of graphics and as an educational tool.

Aspects of screening

Perc

enta

ge

503 522 550609 766 819590 774 717696 752 6441322 1276 1314742 729 635599 620 604845 989 10012452 2618 2681735 732 423983 1106 978456 397 373937 1193 1103492 487 502796 798 711580 640 684523 609 648

Pre DVD

Post DVD

Three months

0

10

20

30

40

50

60

70

80

90

100

Explanation Appropriate tests Performingexamination

Interpretingfindings



Box 1: Developmental DDH multi-media education module—evaluation

Aim: To facilitate early diagnosis and referral of children with DDH.

Objectives: To utilise technology mediated learning to:

* increase the clinician’s knowledge of DDH

* increase the clinician’s confidence in all aspects of screening for DDH

* translate improved knowledge and confidence to positive changes in clinical practice.

Method: An innovative education module on DDH was produced using a multimedia DVD format to enhance the learning experience. High quality 3D animation was combined with text, audio and still images to explore the anatomy of the hip, show the pathology associated with DDH, and demonstrate the correct technique for examining the infant hip.

203 maternal and child health (MCH) nurses from 19 municipalities in Victoria (14 metropolitan, five regional) participated in the study. They were surveyed before and immediately after receiving the training and three months after the training.

Results: Change in DDH knowledge: MCH nurses demonstrated significant immediate gains in their knowledge of DDH (95per cent confidence interval: 5.8 to 6.5, p<0.001)

Change in confidence: Self reported confidence, in all aspects of screening of DDH, significantly increased from the pre-test to the three month follow up (p<0.001; see graph).




Recommendation 24

That the Department of Human Services works with the RCH, Southern Health and Barwon Health to:

• reviewtheincidenceoflatepresentationofhipdislocationinnormalinfantsand of hip dislocation in children with moderate-severe cerebral palsy and compare these rates with those experienced in other health systems conduct a feasibility study into implementing best practice screening programs for hip dislocation in normal infants and in children and young people with moderate-severe cerebral palsy.

RCH collaborating with VPDCU to review the reporting of DDH project

Office for Children/RCH multimedia education module

Met

Recommendation 25

That the Department of Human Services in collaboration with the Paediatric Rehabilitation Reference Group and the current managers of post intervention physiotherapy (PIP) services reviews the structure and funding of the ‘PIP Fund’ to ensure that all children who would benefit from post-intervention physiotherapy have timely access to appropriate funding and/or services.

VPRS on advisory committee

RCH review incorporated PIP and recommended management model with RCH

Once PIP management implemented, PIP review to be conducted – managed by continuing care program

Ongoing

Recommendation 26

That the Department of Human Services in collaboration with the RCH and Southern Health reviews the outcomes to date of the transition program and accelerates the program with the aim of achieving effective, timely transition of all adolescent patients from specialist paediatric orthopaedic services to appropriate adult services.

Four clinics established. Evaluation conducted by independent consultants regarding the effectiveness of the clinics and the process of transition.

Met

Recommendation 27

That the RCH management team establishes two new full-time senior positions for specialist paediatric orthopaedic surgeons and that Southern Health management team reviews its paediatric orthopaedic surgical staff structure and considers creating a new full-time position.

Funding provided for additional specialist paediatric orthopaedic surgeons at RCH, Western and Southern

Met

Recommendation 28

That when the RCH recruits an additional paediatric orthopaedic surgeon, a dual appointment is offered to Western Health to enable the development of the paediatric orthopaedic service at Sunshine Hospital.

Dual appointments between RCH and Western funded from 2006-07

Met

Recommendation 29

That the RCH human resources department works with the paediatric orthopaedic service in consultation with the AOA and the department’s Service and Workforce Planning Unit to develop a workforce strategy that addresses issues of appropriate delegation, appropriate structuring of resident and registrar positions, rotation of basic surgical trainees, rotation of orthopaedic registrars earlier in the training program and generally the creation of a training environment that optimises registrars' experiences in paediatric orthopaedics.


Ongoing




Recommendation 30

That in collaboration with relevant stakeholders including the RCH, Southern Health, the AOA and the RACS, the department’s Service and Workforce Planning Unit reviews the feasibility of initiating a specific paediatric orthopaedic training position.


Ongoing

Recommendation 31

That the Department of Human Services seeks the support of the Australian Health Ministers’ Advisory Council to resolve the issue of inadequate MBS recognition of specialist paediatric orthopaedic surgery.

Ongoing work as required as a paediatric orthopaedic medical workforce strategy is developed in 2009 and 2010

Ongoing

Recommendation 32

That the RCH, Southern Health and Barwon Health are invited to submit proposals to the Department of Human Services that identify:

• additionalactivityallocationsnecessarytomeetreasonablepaediatricorthopaedic demand

• additionaloperatingandcapitalfundingnecessarytodevelopanappropriatemodel of care according to the recommendations in this report

• theoutcomesthatwillbeachievedthroughtheprovisionofadditionalresources for paediatric orthopaedic services.

Completed, funding provided to all health services to meet this recommendation

Met

Recommendation 33

That the RCH and Southern Health management teams work with the Department of Human Services to review their internal allocations of theatre, inpatient and outpatient consulting resources to various clinical units to ensure that they are based on appropriate criteria including relative clinical need.

Completed/ongoing discussion at annual performance meetings

Met

Recommendation 34

That taking into account the above proposals and reviews, the Department of Human Services makes interim additional activity allocations and provides additional funding to the RCH, Southern Health and Barwon Health to enable the recommendations in this report to be implemented pending incorporation of actual costs into the normal funding formulae.

Completed Met

Recommendation 35

That the allocation of additional activity units to other health services that will be necessary to achieve increased throughput and to improve their self-sufficiency in paediatric orthopaedics occurs via the service planning and resource allocation negotiations that occur between the Department of Human Services and those health services on a regular basis.

Models of outreach to general health services to be developed. Further funding of general health services will be considered as part of outreach models of care.

Ongoing



3.4.1 Advanced practitioner training

The Advanced Paediatric Orthopaedic Physiotherapy (APOP) Training Program responds to the need for a standardised and structured training program for physiotherapists undertaking advanced roles in paediatric orthopaedics.

The training program is the first of its kind in Victoria and creates a strong platform to support the introduction of physiotherapist-led paediatric orthopaedic clinics. It was supported by a grant to the RCH from the Victorian Health Service Management Innovation Council (VHSMIC) Seeding Grants Program.

The goal of the program is to equip participants with the skills, knowledge and attitudes required to commence in the role of a primary care practitioner in paediatric orthopaedics.

The RCH, in collaboration with Western Health, hosted a pilot of the training program between June and December 2008. Six candidates from four health services in Victoria took part in the program. There are now plans to formalise the program into an award course with The University of Melbourne (see page 26).

3.4.2 Training in detection of developmental dysplasia of the hip

Developmental DDH is a condition where an infant’s hip fails to develop properly, resulting in an unstable or dislocated hip. Early detection of DDH is vital, as delayed diagnosis increases the likelihood of the child needing surgical intervention. Infants treated for DDH when they are only a few weeks old have a much better clinical outcome than children with late presentation of the condition.

A new multimedia educational module, funded by a grant from the Office for Children, teaches health professionals the correct method of examination of a child for DDH. The 3D learning tool is directed at health professionals involved in the screening of this condition—including maternal and child health nurses, paediatricians and general practitioners, and is expected to lead to earlier detection of this condition.

The training module also provides tools to enable referral of patients for specialist assessment and treatment where necessary. The allied health-led paediatric orthopaedic clinics (see section 3.3.1) will receive referrals relating to DDH and will be involved in ongoing management of children who have the condition.

The results of a study to evaluate the impact of the education module are described in box 1.

3.4.3 Statewide paediatric orthopaedic allied health survey

In July 2008, a survey of 28 health services in Victoria was carried out to examine the provision of paediatric orthopaedic allied health services and identify any issues and barriers to service provision. There was an overall response rate of 75 per cent. A main reported barrier was a lack of expertise and opportunity for professional development. The results of the survey will be used to develop strategies to improve service delivery.



physiotherapy-led clinics alongside consultant clinics to ensure that the necessary professional support is available.

The benefits of this new model of care are described in the document: these include the potential for improved patient care, greater job satisfaction for practitioners, and better retention of experienced staff.

By the end of June 2009 all three of the health services providing specialist paediatric orthopaedic services and Western Health will have established an allied health-led outpatient clinic. Referral types managed by the clinics include those relating to normal postural variations, and simple orthopaedic conditions such as foot and knee pain. These clinics will also assess and treat more complex conditions such as DDH and clubfoot, in consultation with a paediatric orthopaedic specialist.

The next phase of paediatric orthopaedic service development will include an evaluation of the clinics (see page 27).

3.3.2 Point of care ultrasoundChildren referred for DDH usually require two appointments for the assessment of the condition—one with the radiology department and then a separate appointment with the orthopaedic department. This can result in waiting times for both appointments.

Paediatric orthopaedic services at Barwon Health and the RCH have streamlined this process and now combine the two appointments in one session by having the ultrasound performed at the same time and place as the scheduled orthopaedic consultation. The new process saves time for the patients and their families, provides a multidisciplinary approach to care and allows more children to be seen in the orthopaedic clinic. The model of care also provides an opportunity for education and training of health professionals in the clinical examination of infants for this condition.

3.4 Workforce development and innovationWhen the Framework for paediatric orthopaedic services was commissioned the RCH and Southern Health were experiencing recruitment and retention difficulties for specialist paediatric orthopaedic surgeons, with excessive workloads and difficult working conditions contributing to these problems.

In the last two years, both services have been successful in attracting and retaining additional paediatric orthopaedic surgeons. In addition, the expansion of the allied health-led clinic model (see page 15) has realigned the workload to better reflect available skills and expertise. These factors have contributed to an increased capacity to meet current demand.

Initiatives in place to support new models of care and a stronger multidisciplinary approach to paediatric orthopaedic service delivery are discussed below. However, issues of succession planning for existing paediatric orthopaedic surgeons and the need to increase the number of general orthopaedic surgeons with interest in paediatrics remain a challenge for the future.



Five levels of paediatric orthopaedic care, defined according to the complexity of patient need, are described below.

The framework does not attempt to outline all the services to be provided by health services operating at each level but highlights those that are widely considered to be the core components to provide safe and quality care.

Note that there may be instances where a hospital or health service is functioning between two levels. For example, certain procedures may be being performed by appropriately qualified staff at a designated level, but due to the limited volume of work, it does not satisfy all the core service requirements for that particular level. In such cases, it would be recognised that the health service is transitioning between two levels. The framework, when utilised in conjunction with the other considering factors may highlight that more resources need to be put in place to assist a health service which is in transition to progress to the next level. Alternatively, it may demonstrate a need for the health service to redirect some of its paediatric orthopaedic services.

The service delineation framework assumes that health services have appropriate policies and guidelines relating to quality of care and patient safety. These include credentialing and granting of clinical privileges to medical staff and auditing of clinical practices.

The service delineation framework is not intended to be prescriptive but rather to guide planning and inform governance decisions. For example, a health service may have appropriately qualified staff to perform certain procedures at a particular level of care but, due to the limited volume of work, may not satisfy all the infrastructure and resource requirements for that level.

Appendix 3: Service delineation framework



1. Levels of paediatric orthopaedic care

Level Description

Level I A Level I site is predominantly adult-based. A Level I facility is staffed and equipped to manage children presenting to the emergency department with minor musculoskeletal injuries. This may include the management of strains, sprains, undisplaced fractures and simple displaced fractures (e.g. distal radial fractures). Simple manipulation of fractures under appropriate anaesthesia may be undertaken whilst in the emergency department. General practitioners with a special interest in emergency medicine may also perform manipulations.

Paediatric orthopaedic presentations requiring surgery or inpatient care are initially stabilised and transferred to a higher level of service.

No paediatric orthopaedic outpatient clinics are provided.

A Level I facility has formal links with Level II facilities and protocols/guidelines for referrals to Level III, Level IV and Level V facilities.

Level II A Level II facility includes and exceeds the characteristics of a Level I site.

A Level II facility has the capacity for managing a wider range of uncomplicated paediatric trauma presenting to the emergency department when compared with a Level I site.

General orthopaedic surgeons provide management for certain paediatric fractures. These include fractures that do not involve potential or actual neurovascular complications or injuries to the growth plate with high risk of growth arrest. Orthopaedic presentations requiring hospitalisation are admitted to a general paediatric ward/unit. Elective paediatric orthopaedic surgery is generally not provided. Minor surgery such as removal of metal implants/fixation devices may be performed.

A Level II site provides a general fracture and orthopaedic clinic, which children may attend.

It has formal links with Level I facilities and protocols/guidelines for referrals to Level III, Level IV and Level V facilities.

Level III A Level III facility includes and exceeds the characteristics of a Level II facility.

It provides a general paediatric orthopaedic service to its local catchment population. It has the capacity for managing paediatric trauma where appropriate.

It provides some elective paediatric orthopaedic services for its region/catchment area. A consultant orthopaedic surgeon who has undertaken recognised fellowship training in paediatric orthopaedics provides such services.

A Level III site is also staffed by a range of health care professionals with paediatric orthopaedic experience. A Level III site may have joint paediatric orthopaedic appointments with a Level IV or Level V facility.

It has formal links with Level IV and Level V sites for the purposes of referrals and collegiate networking. A Level III facility provides professional leadership within its region. It may have a teaching and research role. It has an identifiable general paediatric orthopaedic outpatient and fracture clinic.

Level IV A Level IV site includes and exceeds the characteristics of a Level III service.

It has a co-located tertiary paediatric service with sub-specialty services. It has a referral role for major paediatric trauma for its region/catchment area and may have a statewide referral role in certain specialised elective orthopaedic paediatric procedures.

The orthopaedic department has a consultant in paediatric orthopaedic surgery who fulfils the role of lead consultant. The orthopaedic department is staffed by at least two orthopaedic consultants who have recognised fellowship training in paediatric orthopaedics and have a substantial fractional commitment to paediatrics (≥0.5 EFT). It has the capacity to manage most paediatric orthopaedic conditions, with highly complex procedures or conditions referred to a Level V facility.

Care is delivered by a multidisciplinary team with expertise in paediatric orthopaedics, including advanced practitioners. It provides and participates in outreach services in partnership with Level I, Level II facilities. It provides leadership in service delivery models, teaching and research in paediatric orthopaedics in partnership with Level V.

It has formal links with paediatric rehabilitation services. It has formal links with Level III and Level V services for the purposes of referrals and collegiate networking.



3.2.4 Barwon Health

Barwon Health received one-off funding in 2007-08 and full-year ongoing funding from 2008–09 for the delivery of additional services. The funding has provided for:

• apaediatricorthopaediccoordinator,responsibleforcoordinatingandsupervisingthe various paediatric orthopaedic clinics (see below), and liaising with general practitioners and other local service providers

• establishmentofDDHandclubfootclinicsand,from2009,aBotoxclinicfora group of patients who currently travel to the RCH for this treatment

• establishmentofaphysiotherapist-ledpaediatricorthopaedicclinic

• purchaseoforthoticsforpatientswithDDHandotherminorequipmenttosupportthe paediatric orthopaedic program.

3.3 New models of careIt is widely acknowledged that new models of care are needed to meet the growing demand for specialist outpatient paediatric orthopaedic services and make best use of existing expertise within the system.

Some key service innovations developed over the last two years are described below.

3.3.1 Allied health-led clinics in paediatric orthopaedics

Not all referrals to a paediatric orthopaedic outpatient clinic require a consultation with an orthopaedic surgeon. The physiotherapist-led orthopaedic assessment clinic (OAC) at the RCH, established in 2005, has demonstrated that certain referrals can be managed efficiently and effectively by an experienced senior allied health professional, with support from an orthopaedic consultant as needed. The clinic has grown rapidly and in 2007-08 provided over 3000 occasions of service. As a result of the OAC, waiting times for semi-urgent referrals triaged to general consultant clinics reduced from three months to two–three weeks. Waiting times for non-urgent referrals triaged to orthopaedic consultant clinics reduced from fifteen months to three months.

The service won a 2007 Victorian Public Healthcare Award for innovation in workforce design and, as noted below, has led to the establishment of similar services at other hospitals.

Based on the success of the physiotherapist-led clinic at the RCH, members of the Allied Health Subcommittee of the Statewide Paediatric Orthopaedic Committee developed the Framework for development of allied health-led clinics in paediatric orthopaedics to assist other health services in establishing this model of care. The framework, which is provided as appendix 4, sets out the key steps needed to develop a successful physiotherapy-led paediatric orthopaedic outpatient clinic and provides practical advice on how to implement the service. It emphasises that the success of these clinics depends on appropriate preparation, education and demonstrated competence of the physiotherapists involved. It is also critical to operate



3.2.1 The Royal Children’s Hospital Additional funding to the RCH from 2006–07 has supported:

• employmentoftwoadditionalorthopaedicsurgeons,includingtwodualsurgicalappointments between the RCH and Western Health—the first in September 2006 and the second in July 2007.

• establishmentofasurgicalpre-admissionclinicattheRCH.Theclinicallowsstaff to gain relevant health information from the parents about their child prior to surgery and tailor care accordingly. This increases safety and reduces the chance of last minute cancellations or delays. It also provides an opportunity for families to find out exactly what is involved in the surgery and to ask questions. Since the clinic began in 2007, over 444 children with paediatric orthopaedic conditions have been assessed. The preadmission clinic model has now been established for other surgical specialities.

• purchaseofdigitalmobileimageintensifiers

• employmentofaStatewidePaediatricOrthopaedicProgramManager,based at the RCH.

3.2.2 Western HealthIn response to the proposal put forward by the RCH, additional funding was provided to Western Health from 2006-07. This has supported:

• jointorthopaedicconsultantappointmentswiththeRCH(seeabove)

• establishmentofaphysiotherapist-ledpaediatricorthopaedicclinicatWesternHealth (see page 16).

3.2.3 Southern HealthIn October 2007 Southern Health was provided with new recurrent funding for additional service activity and implementation of a new model of care. A Southern Health Paediatric Orthopaedic Steering Committee was established to oversee the new paediatric orthopaedic unit. This enabled:

• appointmentofanewheadofunitforpaediatricorthopaedics

• appointmentofacasecoordinatorforthemanagementofmorecomplexpatients

• employmentofanadditionalpaediatricorthopaedicconsultantsurgeon

• utilisationofanadditionalfive-paediatricorthopaedictheatresessionsperfortnight.This has met the demand of an additional 22 per cent in emergency separations and provided capacity for a 61 per cent increase in elective separations

• additionalspecialistoutpatientservices,including:

- complex care clinic ( a multidisciplinary clinic engaging the paediatric rehabilitation unit)

- introduction of an allied health (physiotherapist) led outpatient clinic

- fracture clinic

- strengthening of developmental dysplasia of the hip surveillance.



Level Description

Level V A Level V facility includes and exceeds the characteristics of a Level IV facility.

It has the capacity to provide non-operative and surgical treatment for the full spectrum of paediatric orthopaedic conditions. It has a statewide referral role for paediatric major trauma and for highly complex, low volume elective paediatric orthopaedic procedures.

There is a full-time consultant paediatric orthopaedic presence at all times. The orthopaedic department provides a 24-hour, seven days a week trauma service by consultants and registrars for paediatric orthopaedics only. The orthopaedic department is staffed by at least three orthopaedic consultants with recognised fellowship training in paediatric orthopaedics who have a substantial fractional commitment to paediatrics (≥0.5 EFT).

In addition to the training of registrars, it offers a number of fellowships in paediatric orthopaedics. Paediatric orthopaedic services are provided by a multidisciplinary highly specialised team, which include clinical nurse coordinators for complex conditions and advanced practitioners. It has a designated paediatric orthopaedic ward. It provides statewide leadership in service delivery models, teaching and research in paediatric orthopaedics.

It has access to a full complement of co-located paediatric sub-specialty services and technology such as gait analysis. It provides a fully integrated paediatric orthopaedic ambulatory care service. It has formal links with Level III and Level IV services for the purposes of referrals and collegiate networking.

2. Client groupThe following table provides a guide to the range of orthopaedic care typically provided at each service delineation level for paediatric orthopaedic conditions. The classifications are based on the complexity of the presenting condition and its management.


Level I

Level II

Level III

Level IV

Level V

Distal radius and ulna fracture

√ √ √ √ √

Supracondylar fracture

• GradeI As for Level I plus:

• GradeII,III

As for level II plus:

• neurovascularcompromise

As for level III As for level IV

Tibial fracture • Undisplaced • Displaced

• Closedreduction

• Openreduction

As for level 2 plus As for level III plus

• Childrenwithcomplex disabilities (e.g. spina bifida)

• Neurovascularcompromise

• AsforlevelIV

Developmental dysplasia of the hip (DDH)


• +/-orthoticMx

As for level I plus:


• Diagnosis


• Closed&openreduction







Level I

Level II

Level III

Level IV

Level V

Congenital talipes equinovarus (CTEV)


• Newbornscreening& refer to level III, IV, V for management

• Diagnosis

• Ponsetimethod




Slipped Upper Femoral Epiphysis (SUFE)

• Diagnosis&referral • Diagnosis

• Pinningofstableand mild slip

As for level II As for level III plus:

• SurgicalMxofunstable and moderate slip


• SurgicalMxofunstable and severe slip

Management of bone tumours

Diagnose and referral for appropriate management

As for level I As for level I • Diagnosis

• Benign


• Malignant

Spasticity in children with complex disabilities

× × • BotulinumtoxinA

• Muscle-tendonprocedures


• Boneosteotomies


• Gaitreportingforsurgical decision making

Scoliosis × × × • Diagnosis As for level IV

• Spinalsurgery

3. Infrastructure and resources



Orthopaedic medical staff

Orthopaedic consultant surgeon with recognised fellowship training in paediatrics × × ≥1 ≥2 ≥3

Paediatric orthopaedic fellow × × × 1 >1

Accredited paediatric orthopaedic registrar × × √ √ √

Paediatric orthopaedic resident × × × √ √

Orthopaedic consultant with interest in paediatrics × √ × × ×

Other medical staff

Paediatric rehabilitation specialist × × +/- √ √

Paediatrician × √ √ √ √

Paediatric anaesthetist × × × √ √

Paediatric intensivist × × × √ √



Appendix 3 provides the full service delineation framework. Plans for future work based on the paediatric orthopaedic service delineation framework are discussed in section 4.

Table 1: Paediatric orthopaedic service delineation levels

Level I – Primary care only (emergency care for minor musculoskeletal injuries).

Level II – Primary and secondary services related to uncomplicated paediatric orthopaedic trauma.

Level III – Primary, secondary and limited tertiary specialist paediatric orthopaedic services for emergency and general paediatric orthopaedic elective presentations.

Level IV – Comprehensive primary, secondary and tertiary specialist paediatric orthopaedic services for emergency and paediatric orthopaedic elective presentations. Statewide role in certain specialised elective orthopaedic procedures in collaboration with Level V.

Level V – Full spectrum of primary, secondary and tertiary specialist paediatric orthopaedic services. Statewide role for major trauma and low volume, high complex paediatric orthopaedic services. For example:

•scoliosissurgery

•orthopaediconcology

•managementofcongenitallimbdeficiencies.

Table 2: Current designated levels of care for specialist orthopaedic services

Level III Level IV Level V

Sunshine Hospital (Western Health)

Geelong Hospital (Barwon Health)13

Monash Medical Centre (MMC) (Southern Health)

The Royal Children’s Hospital

3.2 Service capacitySince 2006–07, the State Government has provided over $5.7 million in additional recurrent funding and $0.5 million in one off funding to increase the capacity of the specialist paediatric orthopaedic services.

The RCH, Southern Health and Barwon Health were invited to submit proposals to the department identifying:

• additionalactivityallocationsnecessarytomeetreasonablepaediatric orthopaedic demand

• additionalrecurrentandcapitalfundingnecessarytodevelopanappropriate model of care, in line with the recommendations of the Framework document

• theoutcomestobeachievedthroughprovision of the additional resources.

13. Due to staffing levels, Geelong Hospital is a Level III site. However, it is recognised that the paediatric orthopaedic services provided at Geelong Hospital are consistent with that of a Level IV facility.



• provideaconsistentandcommonlanguagetodescribeanddifferentiatelevels of paediatric orthopaedic care

• guidehealthservicesinstructuringtheirpaediatricorthopaedicservicesandindelivering high quality and efficient services

• supportdevelopmentofacoordinatedandsustainableservicesystem.

Ensuring patients can access services in a timely manner and in a setting appropriate to their level of need is important in developing systematised approaches to the delivery of health care. This includes making optimal use of limited or specialised resources (high complexity, low volume services), while facilitating treatment of less difficult problems in low complexity settings close to where people live. Service delineation frameworks can be used to support development of system-wide approaches to provision of services. For instance, given the well-established relationship between higher surgical volume and better outcomes for certain procedures,12 and overall resourcing considerations, some services can be provided only at a limited number of sites. Service delineation frameworks promote broad understanding of the roles of different services within a system and support effective referral of patients and communication between providers.

Five levels of paediatric orthopaedic care are described in the service delineation framework. These levels are based on a hierarchy of increasing patient and service complexity, and detail the infrastructure and resources required to provide services at the different levels.

It is intended that the framework will be used by individual health services and at the statewide level to facilitate cooperative service planning and resource allocation.

The service delineation framework is not intended to be prescriptive but rather to guide planning. For example, a health service may have appropriately qualified staff to perform certain procedures at a particular level of care but, due to the limited volume of work, may not satisfy all the infrastructure and resource requirements for that level.

Services should be monitored as part of the health services’ overall clinical governance process. The service delineation framework assumes that health services have in place appropriate policies and guidelines relating to quality of care and patient safety. These include credentialing and granting of clinical privileges to medical staff and auditing of clinical practices.

Table 1 provides a summary description of the levels of paediatric orthopaedic care described in the service delineation framework. Table 2 shows the agreed current designations for the state’s specialist providers. Note that service levels may change over time.

12. GD Murray and GM Teasdale, ‘The Relationship between Volume and Health Outcomes’, Report of Volume/Outcome Sub-Group to Advisory Group to National Framework for Service Change. NHS Scotland, 2005. Accessed on 21 August 2008 at www.sehd.scot.nhs.uk/NationalFramework/Documents/VolumeOutcomeReportWebsite.pdf





Nursing staff

Paediatric orthopaedic nurse unit manager × × × × √

Paediatric orthopaedic clinical nurse educator/facilitator × × × √ √

Care manager × × × √ √

Allied health

Allied health with expertise in paediatric orthopaedics – physiotherapist, occupational therapist, orthotist, social worker and dietician

× × √ √ √

Advanced outpatient paediatric orthopaedic physiotherapist × × +/- √ √

Paediatric specific therapy (e.g. music therapy, educational play therapy) × +/- √ √ √

Other ancillary staff

Paediatric orthopaedic coordinator × × +/- √ √

Plaster technician with experience in paediatric orthopaedics × × √ √ √

Physical facilities

Inpatient care in a designated orthopaedic unit × × × × √

Inpatient care in a general paediatric unit × √ √ √ ×

Paediatric intensive care unit × × × √ √

Family friendly facilities √ √ √ √ √

Telehealth facilities √ √ √ √ √

Family accommodation × × × √ √

Specialist services necessary on site (24-hour access)

Paediatric medical imaging service × × × √ √

Access to other paediatric surgical services (e.g. general surgery) × × +/- √ √

Access to paediatric medical services (e.g. respiratory) × × +/- √ √

Paediatric procedural pain service × × × √ √

Other specialist services necessary on site

Inpatient paediatric rehabilitation team/services × × × √ √

Multidisciplinary paediatric pain management team/service × × × √ √

Paediatric gait laboratory with expertise in reporting × × × × √

Specialist paediatric orthopaedic outpatient clinics × × √ √ √





Research relating to paediatric orthopaedics

Orthopaedic research Unit × × +/- √ √

Peer review publications × × +/- √ √

Collaborative research framework across all disciplines × × +/- √ √

Leader in translating research findings into clinical practice × × × × √

Education and training

Professorial appointment × × × × √

Other academic appointments related to paediatric orthopaedics (e.g. associate professor, senior lecturer

× × × √ √

Clinical/research paediatric orthopaedic fellowship × × × 1 >1

Leader in paediatric orthopaedic education across all disciplines × × × +/- √

Service organisation

Director/head of paediatric orthopaedics × × × √ √

Full time paediatric orthopaedic consultant presence × × × × √

Designated 24-hour paediatric orthopaedic trauma service × × × × √

Ambulatory allied health-led models of care × × +/- √ √

Family-centred care services √ √ √ √ √

Robust clinical audit information relating to paediatric orthopaedics × × √ √ √

Quality improvement activities relating to paediatric orthopaedics × × √ √ √

Access to paediatric orthopaedic aids and equipment +/- √ √ √ √

Provides specialist outreach services × × × √ √

Transition service × × +/- √ √

Formal links with rehabilitation services and community-based providers √ √ √ √ √

Protocols/guidelines for referral to level III, IV and V √ √ × × ×



3. Achievements to date

Over the last two years, the Statewide Paediatric Orthopaedic Advisory Committee has overseen a range of initiatives to support sustainable development of the paediatric orthopaedic service system. An allied health sub-committee of the committee has also been instrumental in progressing significant pieces of work, such as the workforce development models discussed in sections 3.3 and 3.4.

There has been an impressive level of achievement in a relatively short period of time. Service providers and departmental officers have worked together to address the Framework for paediatric orthopaedic services’ recommendations. Appendix 2 lists the recommendations of the framework and notes progress towards their implementation. Twenty-six of the 35 recommendations have been implemented, and there are varying degrees of ongoing progress towards implementing the remaining nine recommendations.

The remainder of this section provides examples of achievements in the following key areas:

• Statewidemodelofservicedelivery

• Servicecapacity

• Workforcedevelopmentandinnovation

• Newmodelsofcare.

3.1 Statewide model of service deliveryThe development of an integrated approach to the provision of paediatric orthopaedic services was a key recommendation of the Framework for paediatric orthopaedic services.

An important achievement of the Paediatric Orthopaedic Advisory Committee is the increased level of collaboration and cooperation between providers of specialist paediatric services. This includes a joint consultant appointment between the RCH and Western Health. Collaboration between the specialist services and other key health services, such as Eastern Health and Peninsula Health, has also been strengthened through the Advisory Committee.

The creation of a Statewide Paediatric Orthopaedics Program Manager position, based at the RCH, has also facilitated statewide service planning and coordination.

3.1.1 Service delineation framework

The service delineation framework for paediatric orthopaedic services supports the development of a statewide model of service delivery and service planning at individual health services.

The service delineation framework is a tool for describing and planning paediatric orthopaedic services in Victoria. The service delineation framework aims to:



2.2 Framework for paediatric orthopaedic servicesThe department released the Framework for paediatric orthopaedic servics in March 2006. The framework, which was developed for the department by Phillips Fox, can be accessed at www.health.vic.gov.au/paediatric-ortho.

The Framework for paediatric orthopaedic services was commissioned at a time when surgeons from the RCH, Southern Health and Barwon were experiencing increased activity levels and had identified problems accessing sufficient operating theatre sessions and other resources. The services were finding it difficult to recruit and retain specialist paediatric orthopaedic surgeons. As well as the lower remuneration relative to adult practice, as mentioned above, the Framework for orthopaedic services noted that workloads and working conditions were contributing to problems in attracting and retaining surgeons.

Although the growing demand for specialist paediatric services—as discussed in section 1—was the impetus for the Framework for paediatric orthopaedic services, the scope of the project was broad. Its overall objective was to develop a service plan for the provision of paediatric orthopaedic services in Victoria.

The report included 35 recommendations intended to inform development of:

• astatewideservicemodel,basedonanoptimalserviceconfigurationandreflectinga balance between access, quality and safety, and efficiency

• increasedcapacityandresponsivenessofspecialistpaediatricorthopaedicservices

• mechanismsforevaluationandmonitoringofserviceperformance

• strategiestoensureasustainableworkforce.

Section 3 discusses the implementation of the framework’s recommendations.



This framework was prepared by Prue Weigall and Michelle Vu, on behalf of the Allied Health Subcommittee of the Statewide Paediatric Orthopaedic Advisory Committee (see page viii for full list of committee members).

IntroductionIt is acknowledged that there is a growing demand for specialist outpatient paediatric orthopaedic services in Victoria. New models of care are needed to make best use of orthopaedic specialist expertise and ensure timely access to care.

Not all referrals to a paediatric orthopaedic outpatient clinic require a surgical opinion. Rather, certain referrals can be managed efficiently and effectively by an experienced senior allied health professional, with support from an orthopaedic consultant as needed. Such allied health professionals are working at an advanced level of clinical practice and have received additional training to undertake this role.

There are many benefits to this new model of care. It can result in improving patient care, create more job satisfaction for practitioners and encourage retention of experienced staff.

The Framework for development of allied health led clinics in paediatric orthopaedics has been produced to assist health services in establishing this model of care within their organisation. The framework draws upon the published literature and brings together the experiences of the recently established Orthopaedic Assessment Clinic (OAC), a physiotherapist-led clinic at the Royal Children's Hospital. However, it is applicable to the establishment of any ambulatory allied health-led clinics in paediatric orthopaedics.

The framework sets out the key steps in establishing a successful physiotherapy-led paediatric orthopaedic outpatient clinic and provides practical advice on implementing the service. The infrastructure and resources required to run the clinic are also outlined in the framework. Appropriate preparation, education and demonstrated competence of the physiotherapist are integral to the success of these clinics. In addition, it is critical that physiotherapy-led clinics are run alongside consultant clinics to ensure that the necessary professional support is provided. A lead orthopaedic consultant with a significant interest in paediatrics should be identified to assist in driving the changes.

The physiotherapy-led service should be underpinned by an evaluative framework. This will assist in determining the impact the physiotherapy-led clinic has had on its intended outcomes and to further improve the service.

This framework should be recognised as a work in progress. As this model of care is implemented in other health services over the forthcoming years, components of the framework will require revision.

Appendix 4: Framework for development of allied health-led clinics in paediatric orthopaedics



ContextThe OAC was developed following the successful implementation of similar services in the United Kingdom, where extended-scope practice is now an accepted part of clinical practice for physiotherapists.

The genesis of the initiative at the RCH was the need to find a way to manage increased numbers of orthopaedic outpatient referrals. The operating environment was already exceedingly busy with around 2,000 outpatient appointments per month. With up to 80-90 new referrals each week, the small paediatric orthopaedic workforce was falling increasingly behind, and children and their families were facing an unacceptable wait for outpatient appointments. The trend to increased specialisation was placing demands on the orthopaedic department that were unsustainable without a change in practice.

In addition, it was recognised that not all referrals necessarily required surgical intervention or assessment, but could be managed by an experienced paediatric physiotherapist with support from the orthopaedic consultant as needed.

Literature reviewThere is a paucity of published literature from Australia on the effectiveness of advanced practice/extended-scope roles for allied health professionals in orthopaedic outpatients. A recent prospective observational study18 investigated the impact, quality and acceptability of a physiotherapist-led screening clinic for patients referred to an adult outpatient orthopaedic department at a major Victorian metropolitan hospital. Nearly two-thirds of patients with non-urgent musculoskeletal conditions referred to the clinic did not need to see a surgeon and were able to be appropriately managed by experienced physiotherapists. The physiotherapist identified the same management plans as the surgeon for 74 per cent of the group. Patients and doctors also reported high levels of satisfaction with the physiotherapist-led service.

Although there is a growing body of published literature overseas supporting advanced allied health roles in orthopaedics, strong research evidence is limited. A randomised controlled trial was conducted19 to evaluate the effectiveness and cost effectiveness of specially trained physiotherapists with that of post fellowship junior orthopaedic surgeons in the initial assessment and management of defined GP referrals to hospital orthopaedic departments. All referrals were screened by the orthopaedic consultant for suitability for inclusion in the study. The trial found that trained physiotherapists were as effective as post-fellowship junior orthopaedic surgeons in the initial assessment and management of new GP referrals to outpatient orthopaedic departments and generated lower initial direct costs.

18. LB Oldmeadow, HS Bedi, HT Burch et al 2007. ‘Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care’. Medical Journal of Australia, vol 186, pp. 625–628.

19. G Daker-White, AJ Carr and I Harvey, ‘A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatients departments’, Journal of Epidemiology and Community Health, 1999, vol 53, pp. 643–50.



Figure 5 summarises paediatric orthopaedic emergency activity between 2005-06 and 2007-08. A number of hospitals—including Bendigo Hospital, Casey Hospital, RCH, Austin Hospital and Sandringham and District Memorial Hospital—have had a significant increase in the number of emergency department presentations.

Figure 5: Emergency department fracture presentations in patients aged 0–16 years by hospital11

The data presented above are based on inpatient or emergency department activity. It is recognised that consulting in specialist outpatient clinics is a significant part of the paediatric orthopaedic workload that is not reflected in these service activity trends. However, because outpatient data is not currently collected in a uniform way that allows comparison across health services, it is not included in this report. The collection of consistent outpatient data is a project being undertaken by the department for all clinical specialities. The planned clinical audit project described on page 26 will develop specific data items relating to paediatric orthopaedic activity in specialist outpatient clinics.

2.1.4 Related policies and service initiatives

The development of paediatric orthopaedic services reflects the State Government’s broader commitment to enhancing the health, wellbeing and safety of Victoria’s children. Appendix 1 describes key policies and service initiatives relevant to the planning and delivery of child health services, including paediatric orthopaedics.

11. Based on fracture presentations, excluding tooth fractures, at Victorian emergency departments. The data, which is captured by the Victorian Emergency Minimum Dataset (VEMD), represents all hospitals that treat children aged 0–16 years old.

Presentation

Latrobe Regional HospitalBendigo HospitalGeelong Hospital

Ballarat Base HospitalSunshine Hospital

Dandenong HospitalCasey Hospital

Royal Childrens HospitalFrankston HospitalNorthern Hospital

Mercy Werribee HospitalMaroondah Hospital

Box Hill HospitalAngliss HospitalAustin Hospital

Sandringham & District Memorial Hospital

Monash Medical Centre

503 522 550609 766 819590 774 717696 752 6441322 1276 1314742 729 635599 620 604845 989 10012452 2618 2681735 732 423983 1106 978456 397 373937 1193 1103492 487 502796 798 711580 640 684523 609 648

0 500 1,000 1,500 2,000 2,500 3,000

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Figures 3 and 4 when read together demonstrate that although the level of activity at the Royal Children’s Hospital has reduced, there has been an increase in the complexity of the work over the same period. Activity and complexity at the majority of other health services increased in this period.

Figure 3: Inpatient paediatric orthopaedic separations by health service9

Figure 4: Average WIES weight for paediatric orthopaedic activity by health service10

9. See footnote 7.

10. See footnote 7.

Separations

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Bendigo Health

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Bendigo Health

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0.0 0.2 0.4 0.6 0.8 1.0 1.2



A physiotherapist specialist clinic designed to reduce waiting times for non-urgent, new paediatric orthopaedic referrals was evaluated.20 This retrospective study showed that the median waiting time for non urgent conditions was reduced from 72 weeks to five weeks over a three year period. The success of the clinic was largely due to the close cooperation between the consultant and the physiotherapist, an agreed policy of assessment and management of patients and training the physiotherapist to the surgeon’s work pattern. The authors also noted that educating GP’s about the normal development of the musculoskeletal system in a child and devising a primary care referral protocol may reduce the demand for new paediatric referrals.

Physiotherapy-led clinic model of care

Mission

A physiotherapy-led paediatric orthopaedic clinic provides timely and high quality assessment and primary orthopaedic care for children not generally requiring surgical assessment or intervention. It provides an entry point for orthopaedic assessment and referral to consultant clinics as required.

Core objectives

• Toimprovethequalityoforthopaedicassessment,careandsupporttochildren and their families.

• Toimproveaccesstoorthopaedicassessmentandcareforallchildren,and across all clinics.

• Toreducethewaitingtimeforsemi-urgentandnon-urgentorthopaedicreferrals.

• Toprovideeducationtofamiliesandreferrers.

• Toutiliseandmaximisetheexpertiseofexperiencedorthopaedicphysiotherapists.

• Tostrengthencareerpathwaysforseniorclinicalphysiotherapists,improvejobsatisfaction, retention and career opportunities.

Key steps to establishing a successful physiotherapy-led clinic

Currently there is limited evidence of the best way to introduce allied health led-outpatient clinics, or to educate, support and mentor the allied health professionals in these roles.21

Therefore it is essential to allow ample time for the development phase , and to include detailed consideration of the following:

20. MV Belthur, J Clegg, A Strange, ‘A physiotherapy specialist clinic in paediatric orthopaedics: is it effective?’ Postgrad Medical Journal, 2003, vol 79(938), pp. 699-702.

21. K McPherson, P Kersten, S George et al ‘A systematic review of evidence about extended roles for allied health professionals’, Journal of Health Services Research and Policy, 2006, Vol 11(4), pp.240-7.



• Feasibility

- Needs assessment

- Consultation with stakeholders

- Key staff required to provide a paediatric orthopaedic service

- Funding

• Scopeofpractice

- Governance

- Clinical risk

- Knowledge, skills and base qualification

- Education, training and development

• Implementation

- Process—what is actually being done in the giving and receiving of care related to paediatric orthopaedic management (for example, target population, triage/referral process, clinic schedule and guidelines for assessment and management)

- Infrastructure—the attributes of the setting in which the clinic occurs (for example: clinic space)

- Promotion of service to GPs and other health professionals.

• Evaluationoftheeffectivenessofthephysiotherapy-ledserviceinmeetingobjectives.

Feasibility

Needs assessment

The establishment of a physiotherapy-led orthopaedic outpatient clinic should be in alignment with the service delineation framework for paediatric orthopaedic services in Victoria. Prior to establishing a clinic, there must be an identified need for such a service. For instance, there may be no existing service or there may be gaps in the present service to which an advanced physiotherapist can add value. It is recommended that an audit of the orthopaedic waiting list be conducted to identify existing waiting times and types of conditions referred. This is an essential step in justifying establishment, and defining the target population for the physiotherapy-led clinic.

Consultation with key stakeholders

It is essential that the proposed service receive the support of the head of orthopaedics and the hospital executive. The establishment of an advisory group to oversee the development and implementation of the physiotherapy-led clinic is highly recommended. An orthopaedic consultant with a significant interest in paediatric orthopaedics should be identified to provide leadership and assist in driving the



Figure 1: Statewide paediatric orthopaedic inpatient separations statewide by length of stay6, 7

Figure 2: Statewide paediatric orthopaedic separations by emergency or elective admission8

6. The short stay category is based on patients staying one night compared with a multi day stay of two nights or longer.

7. Figures are based on a paediatric orthopaedic casemix comprised of 54 diagnostic classifications (AR-DRG, Australian refined–diagnostic related groups) relevant to paediatric orthopaedics. The casemix was developed following consultation with the three specialist paediatric orthopaedic service providers and includes all patients treated by a health service for these DRGs. The patient cohort for the data is aged 0–17 years old.

8. See footnote 7.

3,000

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- The rate of neural tube defects has been decreasing since the early 1990s (due to public health efforts to increase consumption of folate by pregnant women and increasing pre-natal diagnosis and termination of affected pregnancies)4 and might decline further after mandatory fortification of flour with folic acid is introduced in September 2009.

- The prevalence of cerebral palsy has been stable over the past 30 years, but there has been no diminution in the number of new cases. During the 1980s there was an increase in the numbers of very low birth weight infants who went on to have cerebral palsy, although this increase has not been sustained in more recent years.5

• Technical innovations, early intervention measures and advances in clinical care. There are many areas in which advances in paediatric orthopaedic care are expected: these include new imaging techniques, procedures (including image-guided and robot-assisted surgery) and equipment (such as intramedullary lengthening devices) that will lead to less invasive surgery. Advances in cancer treatment will allow surgical ‘cure’ of some previously untreatable bone conditions. There is also a potential role for stem cell therapies in the management of some cartilage and bone defects. The likely impact of these innovations on demand and capacity is not known. Some new techniques may substantially reduce demand for inpatient facilities, including theatre time and beds, while others may have the opposite effect. However, demand for specialised paediatric orthopaedic surgeons and other members of the multidisciplinary team, trained in highly complex techniques, is likely to increase as new techniques and procedures become available.

2.1.3 Service activity trends

Paediatric orthopaedic service provision encompasses services delivered to inpatients, in the emergency department or on an outpatient basis. These services may be emergency or as planned elective. Service activity trends reported in this document are for 2005–06 to 2007–08, which corresponds to the period in which the Framework for paediatric orthopaedic services was implemented.

Figures 1 and 2 summarise paediatric orthopaedic inpatient activity between 2005-06 and 2007-08. While overall surgical activity has remained constant there has been some increase in the multiday stay and planned elective separations.

4. Australian Institute of Health and Welfare, Neural Tube Defects in Australia: an Epidemiological Report, Catalogue no. PER 45, AIHW, Sydney, 2008.

5. See N Paneth, T Hong, S Korzeniewski, ‘The Descriptive Epidemiology of Cerebral Palsy’. Clinical Perinatology 33, 2006 pp. 251-267, and SM Reid, A Lanigan and DS Reddihough, ‘Cerebral palsy in Australia: are the rates changing?’ Developmental Medicine and Child Neurology Supplement 113:50, 2008, p.34.



changes required. The lead orthopaedic consultant should work closely with the physiotherapy department to establish agreed clinical, managerial and professional accountabilities. All relevant stakeholders (including outpatient administrative staff) should be engaged during the development and implementation phase of the clinic.

Key staff required to provide a paediatric orthopaedic outpatient service

It is important to acknowledge that an effective physiotherapy-led clinic requires access to a number of key health professionals. These include:

• apaediatricorthopaedicconsultant

• aplastertechnicianwithpaediatricexpertise

• apaediatricnurse

• paediatricalliedhealthprofessionals,suchasorthotists,physiotherapistsandoccupational therapists

• apaediatricdiagnosticimagingservice

• administrativesupport,suchasoutpatientappointmentbookings.

Funding

A funding source for this model of service delivery would be identified by the relevant health service. This may be new or growth funding or from the existing funding allocation.

A funding proposal should be developed following needs assessment, stakeholder consultation and workforce analysis, and should include funding for training and education programs.

Funding for any outpatient clinic is subject to the Victorian Ambulatory Classification and Funding System (VACS). Currently VACS is being reviewed and readers should be cognisant of the fact that reforms to the existing VACS are being investigated.

Scope of practice The scope of practice, both clinical and non-clinical should be clearly defined. Clinical practice includes target population, referral processes to other health professionals and diagnostic imaging referral rights. Non-clinical roles include research, leadership and education.

Governance

Clear lines of responsibilities and accountability to the physiotherapy and orthopaedic departments must be clearly established, recognising the complexity of the scope of practice.



Clinical risk

Clinical risk management is a key component of governance. It involves identifying, analysing and addressing the risks associated with the new role. Clinical risk management strategies could include:

• ensuringappropriatecredentialingandscopeofpracticeforclinicalpractice

• developingprotocolstoclearlyoutlinetheprocessofmanagingpatients

• implementingclinicalauditprocesses

• participatinginperformancereviewanddevelopment.

Knowledge, skills and base qualification

The physiotherapist undertaking the role must be registered with the Victorian Physiotherapists Registration Board. The base qualification is a Bachelor of Physiotherapy or equivalent.

It is recommended that the physiotherapist undertaking the role has at least seven years of postgraduate experience, which must include paediatric orthopaedics.

The competencies required for the advanced practitioner role lie predominantly within the scope of practice of an experienced paediatric orthopaedic physiotherapist. Additional skills required to perform the role, but not specifically taught as part of the undergraduate degree, include:

• patientassessmentandmanagementofcertaincomplexconditions(suchas, club foot and DDH

• castingskills

• radiologyorderingandinterpretation

• triageofpaediatricorthopaedicconditionsreferredtoorthopaedic outpatient clinics.

Due to the advanced clinical reasoning and leadership skills required, this role should be developed as either a Grade 3 or Grade 4 position. This will also help establish a career pathway for physiotherapists working at an advanced scope level.

Education, training and development

Formal education training has not yet been developed. However, an education structure for advanced practice training is recommended to ensure the safe delivery of services and standardised high-quality care. A core competency assessment framework to outline the knowledge, skills and attitudes required for such positions should be developed. Competencies may include expert clinical practice, clinical and professional leadership, education and research.

A six-month academic and clinical education training program for physiotherapists undertaking advanced roles in paediatric orthopaedics was piloted in 2008 at the Royal Children's Hospital (see section 3.4.1).



2.1.1 Challenges for the service systemThe following factors contribute to increased pressure on the paediatric orthopaedic system:

• Thefactthatmanygeneralpractitionersnolongerprovideprimarycaretochildrenandyoung people with simple fractures, and instead refer them to acute health services.

• Atrendforgeneralpractitioners,andpaediatricians—whohavetraditionallymanaged many normal variation, postural and ‘packaging’ disorders and deviations in musculoskeletal development—to refer these children for expert orthopaedic opinion.

• Increasedlevelsofsub-specialisationwithinorthopaedics,meaningthatsomeorthopaedic surgeons now focus on adult patients alone or on specific anatomical areas. In addition, many general orthopaedic surgeons are withdrawing from the care of children. The shortage of orthopaedic surgeons available to care for paediatric patients has been reported elsewhere in Australia and internationally.

As a consequence of these factors, children and young people who previously would have been managed in general acute health services or community settings are being referred more frequently to specialist services at the RCH, Southern Health and Barwon Health.

These challenges occur in a context of increased demand for paediatric orthopaedic services in recent years and, as discussed below, projected continued demand growth.

2.1.2 Influences on future demand for services Factors likely to affect the future demand for paediatric orthopaedic services are discussed below.

• Increased number of children and young people. Recently released population projections for Victoria indicate that, while children and young people will decline slightly as a proportion of the whole population, the actual number of people aged less than 15 will increase by 250,000 between 2006 and 2036.3 Three growth corridors in the metropolitan area (west, north and south-east) will have relatively greater needs for services for children and young people than other areas.

• Prevalence of relevant illnesses and disabilities. While the incidence and prevalence of trauma in children and young people can be assumed (in the absence of any specific evidence to the contrary) to be likely to remain stable, the incidence and prevalence of particular chronic disabling conditions is changing. For example:

- Increasing prenatal diagnosis of a range of genetic abnormalities, and termination of affected pregnancies, may reduce the incidence and prevalence of serious inherited disorders that require specialist paediatric surgical interventions, such as the inherited muscular dystrophies.

3. Victorian Department of Planning and Community Development, Victoria in Future 2008: Victorian State Government Population and Household Projections 2006–2036, DPCD, Melbourne, 2008 www.dpcd.vic.gov.au/ accessed 3 December 2008.



In accordance with the recommendations of the Framework for paediatric orthopaedic services, three health services—RCH, Southern Health and Barwon Health—have been identified as specialist paediatric orthopaedic services. In addition, following joint surgical appointments between the RCH and Western Health (see page 14), Western Health now has specialised paediatric orthopaedic expertise.

The specialist paediatric orthopaedic services provide general orthopaedic care to children and young people from their local communities and beyond. They also have key leadership roles in complex paediatric orthopaedic clinical care, education and research. They provide sophisticated multidisciplinary services incorporating assessment, surveillance, surgery and rehabilitation services to children and young people with complex needs.

The specialist services each have a different service profile. Both the RCH and Southern Health provide specialised orthopaedic services to children and young people who have congenital conditions, neurological and neuromuscular conditions, and acquired musculoskeletal conditions. Barwon Health provides a range of specialist services for children with conditions such as complex or complicated fractures, talipes, developmental dysplasia of the hip, slipped epiphyses, Perthes disease and spasticity not requiring single event multi-level surgery.2 Western Health provides a range of specialist services for children, including those with complex or complicated fractures, talipes, developmental dysplasia of the hip, slipped epiphyses and Perthes disease.

Orthopaedic surgeons who specialise in paediatric orthopaedics generally undertake at least one year of post-fellowship training in a designated paediatric orthopaedic fellowship position, usually at an international specialty centre. These surgeons have highly specialised skills in low volume, complex procedures specific to children and young people. There are a small number of recognised specialist paediatric orthopaedic surgeons in Victoria, most of whom undertake some adult work in addition to their paediatric practice.

Paediatric orthopaedic services, especially for more complex problems, are best provided through a multi-disciplinary model of care. As well as the surgeon, the team responsible for the patient’s care will include other clinicians (such as physiotherapists, orthotists and prosthetists, nurses and radiolologists) who have skills in dealing both with children and with musculoskeletal problems.

Delivery of paediatric orthopaedic care also requires collaboration with health care professionals who specialise in related areas of medicine—including but not limited to anaesthesia, paediatric medicine, rehabilitation, endocrinology, metabolic medicine, rheumatology, neurology, neurosurgery, developmental disability medicine, emergency medicine and trauma surgery.

2. Single Event Multi-Level Surgery (SEMLS) is the combination of multiple surgical procedures undertaken by two consultant orthopaedic surgeons in one definitive operation.



Until training programs are established, informal learning must be provided to the physiotherapist to ensure competency. This should include opportunity to shadow orthopaedic consultants at outpatient clinics, on-the-job supervised learning, as well as regular informal discussion with consultants and registrars to address clinical concerns and for review of x-rays and other investigations.

Sufficient time should be given for training and achievement of competencies for the physiotherapist and ongoing competencies assessed. To ensure sustainability of the clinic, plans for succession training should be in place.

Implementation

Process

• Targetgroup

Conditions for inclusion and exclusion from the physiotherapist-led clinic should be determined and documented. As a starting point, conditions triaged to the physiotherapist-led clinic may include normal postural variations and simple orthopaedic conditions such as foot and knee pain. More complex conditions, such as DDH or spine conditions should only be undertaken with appropriate consultant support.

• Triage/referralprocess

New triaging guidelines should be established. All patients referred to the orthopaedics outpatient clinic should be triaged according to these guidelines to the appropriate clinic for assessment (refer to appendix A for an example of referral guidelines).

• Clinicschedule

It is essential that each physiotherapist-led clinic session is run alongside an orthopaedic consultant outpatient clinic to ensure that the necessary professional support is provided. This allows timely access to an orthopaedic consultant opinion if required. The following must be determined for clinic sessions:

• numbertobeheldeachweek

• numberofnewpatientsandreviewsforeachsession

• lengthofappointmenttimefornewpatientsandreviews.

Furthermore, when considering the number of sessions per week, appropriate amount of time should be allocated for administration (such as statistics, letter writing) and quality improvement activities.

• Guidelinesforassessmentandmanagement

Agreed clinical guidelines and protocols for management of conditions (including recommended wait times for initial appointment) should be established with the orthopaedic consultants. It is recommended that guidelines be consistent with other health services with physiotherapy-led clinics.



Infrastructure

• Physicalenvironment

The physiotherapy-led clinic should be located in close proximity to the orthopaedic consultant outpatient clinic.

• Clinicspace

There should be sufficient clinic space for the clinic to run alongside a consultant orthopaedic clinic.

• Administrativesystems

Effective administrative systems are essential to support the booking of outpatient appointments.

• Equipment

The physiotherapy-led clinic has similar equipment needs to an orthopaedic consultant-led clinic. Access to a high-low examination bed, computer and radiology viewing box and plaster room, is required. It should be acknowledged that funding for equipment, such as orthotics, will vary among health services.

Promotion of service

At the OAC, approximately 70 per cent of referrals are received from GPs. Therefore, it is recommended that an education program about the service and referral processes be implemented. This should also include an opportunity to gain feedback from GPs about the referrals and vice versa.

Evaluation Undertaking an evaluation will measure not only what and how well the service is performing, but also informs improvements to the service. Such measures could include (but not be limited to):

• theimpactonpatients

- health, reduced disability and improved quality of life

- parent/patient satisfaction

• theimpactonotherhealthprofessionals

- referring doctor’s satisfaction with service

- number of re-referrals to the clinic from the GPs

- number of referrals to orthopaedic consultants

- number of referrals requiring surgery

- staff retention and turnover

• theimpactonhealth-servicesdelivery



2. Background

This section provides an overview of paediatric orthopaedic services in Victoria and discusses the demands and challenges facing the system. This section also describes the Framework for paediatric orthopaedic services, including its key recommendations.

2.1 Service context‘Orthopaedics’ is concerned with the prevention and treatment of musculoskeletal disorders. ‘Paediatrics’ is concerned with the treatment of infants and children. Paediatric orthopaedic practice encompasses three broad areas:

1. The management of acute trauma and its sequelae.

2. The management of normal variation, postural and ‘packaging’ disorders, and deviations in musculoskeletal development.

3. The provision of highly specialised orthopaedic services to children and young people who have congenital conditions (such as club foot, developmental dysplasia of the hip (DDH), limb deformities and bone dysplasia), neurological and neuromuscular conditions (such as cerebral palsy, spina bifida and muscular dystrophy) and acquired musculoskeletal conditions (such as scoliosis, bone and joint infections, growth disturbance, bone and soft tissue tumours and slipped epiphyses).

The paediatric orthopaedic service system incorporates a large number of providers in hospital and community settings across the public and private sectors. There are two major sub-service systems, as outlined below.

• Acute (emergency) paediatric orthopaedic services. Some emergency services for children who have suffered acute paediatric orthopaedic trauma are provided in community settings (for example, management of sprains and strains by general practitioners) but in the main these services are provided in public hospital emergency departments and inpatient units. Emergency physicians and general orthopaedic surgeons (and general surgeons in some situations where orthopaedic surgeons are not available) provide care to children with moderately complicated injuries. Trauma patients with more complex injuries are referred to specialist paediatric orthopaedic services. Trauma patients with severe or very complex injuries are referred to the Royal Children’s Hospital (RCH), which is Victoria’s designated major trauma centre for children.

• Non-emergency (‘elective’) paediatric orthopaedic services. Assessment and management of otherwise healthy children occurs in a variety of community and hospital settings—for example general practice (GPs), public hospital specialist outpatient clinics1 and maternal and child health centres, plus private hospitals and private consulting rooms. Two Victorian private hospitals (Cabrini and Mercy Private Hospital) provide inpatient care to children requiring more complex orthopaedic care: however, most children with these needs are treated by specialist paediatric orthopaedic surgeons in the public system, as described below.

1. Previously known as outpatient departments.





• waitingtimetobeseenbyanorthopaedicconsultant

• waitingtimetobeseenforreferralstriagedtothephysiotherapy-ledclinic

• numberofnewpatientsseenpermonth

• numberofreviewpatientsseenpermonth.

It is essential to collect baseline data prior to the implementation of the clinic to enable comparisons over time. An administrative database system to record waiting times to be seen, from receipt of referral to date of first appointment for each category of patients in the physiotherapy-led clinic (as well as consultant clinics) should be maintained. A database should be developed to also record the types of patients seen by the physiotherapist, the referral sources, types of intervention and the outcomes (see appendix B for example). Progress reports (with supporting data) should be regularly submitted to the head of orthopaedics.





1. Introduction

This document describes key achievements in the development of paediatric orthopaedic services since the release of the Framework for paediatric orthopaedic services in 2006 and identifies directions for further work over the next two years (2009 and 2010).

The Department of Human Services (the department) commissioned the framework to inform development of a sustainable system of paediatric orthopaedic services in the context of increasing service demand and workforce supply issues.

A time-limited Statewide Paediatric Orthopaedic Advisory Committee was established in March 2007 to provide leadership and advice to the department in implementing key recommendations of the Framework for paediatric orthopaedic services.

The present document is based on consultation with members of the Statewide Paediatric Orthopaedic Advisory Committee and specialist paediatric orthopaedic service providers at the Royal Children’s Hospital, Southern Health and Barwon Health, and relevant areas of the department.

1.1 Guiding principlesConsideration of progress to date and framing of future priorities has taken into account the following principles, which the Framework for paediatric orthopaedic services recommended should underpin planning and delivery of paediatric orthopaedic services:


• Whereanacceptablelevelofqualitycanbeachieved,serviceswillbeprovided in local communities.


• Therewillbeanidentifiableservicesystemstructureandlinkageswhichfacilitateappropriate referrals and quality professional interaction between providers.

• Amultidisciplinaryworkforceisrequiredthathastheskills,knowledgeandattitudeto work effectively in responding to the orthopaedic needs of children and their families and that distributes clinical responsibilities within clinical teams to those who are best equipped to meet them.


viii Paediatric orthopaedics: recent achievements and future directions

Current members of the Paediatric Orthopaedic Allied Health Subcommittee are:

Ms Margaret Bradshaw (chair) Senior Physiotherapist, Barwon Health

Ms Elizabeth Cashill (retired chair) Director, Allied Health, Melbourne Health

Ms Penny Green Senior Physiotherapist, Eastern Health

Ms Hema Duff Senior Physiotherapist, Peninsula Health


Mr David Harding Senior Physiotherapist, Southern Health

Ms Bernadette Shannon Occupational Therapist, Southern Health

Ms Arlee Hatfield Physiotherapy Manager, Western Health

Ms Prue Weigall Senior Physiotherapist, Royal Children’s Hospital

Ms Nicole Galea Orthotist/Prosthetist, Royal Children’s Hospital

Ms Beverley Eldridge Senior Physiotherapist, Australian Physiotherapy Association




Physiotherapist-led orthopaedic assessment clinic (OAC) guidelines (Royal Children's Hospital)

1.1 New referrals to orthopaedic outpatient clinicsNew orthopaedic outpatient referrals may be mailed or faxed to RCH Outpatients, before being forwarded to the Orthopaedic Outpatient Department for triaging. Some referrals are sent directly to orthopaedic outpatients.

All referrals are dated, and a referral cover sheet attached by orthopaedic outpatient administrative staff on day of receipt. In addition, all referrals are registered by placement on the waiting list.

The first level of triage is conducted by the senior physiotherapists, generally on the same day the referral is received in the orthopaedic department. Referrals that fit the criteria for OAC are triaged directly to the OAC. Referrals that are deemed to require management by clinics other than OAC are passed on to a consultant for second level triage. Where a referral is received that is deemed to require urgent consultation appropriate action is taken to ensure timely evaluation.

1.2 Physiotherapist-led orthopaedic assessment clinic triage guidelines Based on the information provided on the referral, all referrals triaged to the OAC are assigned a clinical priority category. Referrals which are assessed as high priority will then be booked by administrative staff directly.

1.3 OAC - scheduling

1.3.1 OAC clinics run alongside consultant/registrar clinics. One clinic only (8.30am–12.00pm or 1.30 pm–5.00pm) is scheduled for each physiotherapist per day. The time remaining is allocated to non-clinical work. This includes triaging of new referrals, maintaining clinic data, follow-up letters to referrers, research, development of educational materials for families and referrers, professional development, and teaching.

Patients are booked into designated OAC clinics according to a booking template, by orthopaedic outpatient administrative staff. This should generally allow for five new patients (30 minutes allocated) and five review patients (10-15 minutes allocated) per session. One booking per clinic should be left open to allow for scheduling of urgent new patients. All patients are sent a letter informing them of their appointment and that they will be seen by a senior physiotherapist.

Spine assessments are scheduled to coincide with the Consultant Spine Clinic to ensure necessary professional support.

Casting clinics for clubfoot and DDH management are scheduled so that the physiotherapist and consultant may work as a consistent team to ensure professional support, and continuity of care for the patient.

Appendix A – OAC referral guidelines



1.4 OAC process

1.4.1 Management within the OAC clinicAs its name implies, the OAC is intended primarily as an assessment clinic for new referrals. However children with DDH (not requiring surgery) and children with positional and structural foot deformities, including those requiring casting, are usually managed for ongoing review within the OAC. Children with other simple conditions who do not need surgical assessment, but for whom monitoring is necessary, may be booked for review in the OAC (for example: back pain, knee pain) as appropriate.

1.4.2 When no further follow-up is requiredWhere no further follow-up is required, verbal advice regarding the child’s condition is given, generally supplemented by a patient information leaflet. Simple home exercise programs may also given by the physiotherapist within the OAC. Letters are dictated to referrers on the same day, and information leaflets enclosed as appropriate.

1.4.3 When child requires referral to orthopaedic consultantReferral to the orthopaedic consultant for further assessment or management may be made as requested by the physiotherapist. The physiotherapist should organise for appropriate investigations prior to this appointment.

1.4.4 When child requires referral to another specialistThese should be made following consultation with the orthopaedic consultant or registrar. Consultant or registrar signature is required on the consultant referral form.

1.4.5 When other referrals are requiredAllied health referrals (orthotics, physiotherapy, occupational therapy) may be made directly by the physiotherapist using the designated referral card.

New DDH referrals for bracing are seen on the same day by the orthotics department. For all other referrals, appointments are generally arranged by the allied health department for a later date.

Where it is anticipated that the child requires ongoing physiotherapy review and supervision, the child will be referred to the physiotherapy department or community physiotherapy rather than be managed within the OAC.

1.4.6 InvestigationsRequests for radiology/pathology are discussed with the orthopaedic registrar/ consultant and may be made directly, or booked for a later date. Orthopaedic consultant or registrar signature is required on the request form. The physiotherapist may liaise with the consultant to discuss results.

1.4.7 DocumentationDocumentation of the clinic visit is maintained as per RCH documentation guidelines in the child’s medical record.


Paediatric orthopaedics: recent achievements and future directions vii

Current members of the Statewide Paediatric Orthopaedic Advisory Committee are:

Dr Martin Lum Senior Medical Advisor, Access and Metropolitan Performance, Department of Human Services

Mr Andrew Crow Manager, Post Acute Services, Ambulatory and Continuing Care, Department of Human Services

Mr Terry Symonds Manager, Statewide Surgical Services Program, Department of Human Services

Ms Sandra Gates Program Manager, Victorian Paediatric Rehabilitation Service

Prof Kerr Graham Professor of Orthopaedics, Royal Children’s Hospital

A/Prof Leo Donnan Director of Orthopaedics, Royal Children’s Hospital


Mr Adam Horsburgh Director, Monash Sector, Southern Health

Mr Ton Tran Head of Paediatric Orthopaedics, Clayton, Head of Orthopaedics, Dandenong, Southern Health

Mr Rick Angliss Orthopaedic Surgeon, Barwon Health

Mr Chris McCarthy Clinical Program Leader for Surgical Services, Eastern Health

Ms Claire Culley Divisional Director, Surgical Services, Western Health

Dr Donna Henderson Association for Children with a Disability

Ms Penny Green Allied Health (physiotherapist), Eastern Health

Ms Helen Hutchins Nurse Unit Manager, Paediatrics Unit, Peninsula Health

Dr Catherine Marraffa Paediatrician, Royal Australian College of Physicians


Committee membership


vi Paediatric orthopaedics: recent achievements and future directions



1.4.8 DischargeOn discharge from OAC and Orthopaedic Outpatients, a summary report is sent to the referrer outlining the assessment, management and recommended actions.

Referrals remain current for two years. Patients may be re-referred to the OAC as required.

OAC management referral pathway

Triaged to OAC

Assessment

Follow up required(see Box A)

No follow up required:Advice +/- homeexercise program

Discharge from OAC

Box AOptions• Refer to orthotics• Arrange further investigations • Refer to orthopaedic consultant clinic +/- investigations• Refer to physiotherapy• Refer to other specialists• Review at OAC




Paediatric orthopaedics: recent achievements and future directions v

Contents

Message from the Executive Director iii

Committee membership vii

1 Introduction 1

1.1 Guiding principles 1

2 Background 3

2.1 Service context 3

2.2 Framework for paediatric orthopaedic services 10

3 Achievements to date 11

3.1 Statewide model of service delivery 11

3.2 Service capacity 13

3.3 New models of care 15

3.4 Workforce development and innovation 16

4 Future directions 21

4.1 Paediatric Orthopaedic Advisory Group 21

4.2 Priorities 2009–2010 21

Appendix 1: Policy and service context for paediatric orthopaedic services 29

Appendix 2: Implementation status of 2006 framework recommendations 31

Appendix 3: Service delineation framework 37

Appendix 4: Framework for development of allied health-led clinics in paediatric orthopaedics 43


iv Paediatric orthopaedics: recent achievements and future directions





Occasions of service

Attended (new patients)

Attended (review patients)

FTA (new patients)

FTA (review patients)

Total occasions of service

Referral source (new patients)

GP

RCH ED

Internal/external paediatrician

Internal/external orthopaedic consultant

Maternity hospital

Other internal RCH

Other external

Diagnosis (new patients)

Postural variations

Knee conditions

Structural TEV

DDH

Symptomatic flat feet

Postural problems

Toe walking

Toe deformities

Other foot deformities: CV foot, MTA, positional talipes

Other musculoskeletal problems upper limb

Appendix B – Example of monthly summary report





Other musculoskeletal problems lower limb

Back pain

Spine/scoliosis

Growing pains

Gait problems

Complex other e.g. CP

Age (New patients)

<3m

> 3m <6m

>6m <12m

1 year

2 years

3 years

4 years

5 years

6 years

7 years

8 years

9 years

10 years

11 years

12 years

13 years

14 years

15 years

16 years or more


Paediatric orthopaedics: recent achievements and future directions iii

Message from the Executive Director

The Victorian Government has invested in the health and welfare of children and young people and given high priority to the development of paediatric services across the state.

In 2006 the government released the Framework for paediatric orthopaedic services, which responded to concerns about pressures on paediatric orthopaedic services and identified strategies to build a more sustainable service system into the future.

Over the last two years, the Statewide Paediatric Orthopaedic Advisory Committee has overseen the development and implementation of a range of initiatives to strengthen the capacity of specialist paediatric orthopaedic services and position the system to better respond to complex challenges.

This report, Paediatric orthopaedics: recent achievements and future directions, reviews progress in implementing key recommendations of the 2006 framework and outlines plans for further work over the next two years.

By building on the considerable achievements of the last two years and the inherent strengths of the service system, the future directions identified in this document will help ensure that children with orthopaedic trauma and developmental problems receive the best possible treatment and care.

Paediatric orthopaedics: recent achievements and future directions complements a number of existing Victorian Government policies on child health and welfare. It foreshadows links between the work of the new Paediatric Orthopaedic Advisory Group and other emerging initiatives, such as a proposed new strategic framework for paediatric services in Victoria.

The government is committed to the continued development of paediatric orthopaedic services and to maintaining and strengthening the relationships that been established over the last two years. We look forward to working with service providers to realise the aspirations described in this document.

Lance Wallace Executive Director Metropolitan Health & Aged Care Services


Published by the Victorian Government Department of Human Services Melbourne, Victoria

© Copyright State of Victoria 2009

This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

This document may also be downloaded from the Department of Human Services website at:

www.dhs.vic.gov.au/ahs/emergency or www.health.vic.gov.au/surgery/

Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.

May 2009.





Outcome (New patients)

No follow up required

Referred to orthopaedic consultant

Referred to orthotics

Referred to other specialist

OAC R/V

Surgical WL

Referred to physiotherapy

Diagnosis (review appointments)

DDH

TEV

Other

Cast

Total number of casts (new & R/V)

Total number of cast assists

Waiting time (this should be obtained from the administrative database)

Priority 1

Priority 2

Priority 3

Catchment area (recommended to provide on six monthly basis)

Insert postcodes




May 2009






May 2009