Interprofessional collaboration may pay off: introducing a collaborative approach in an orthopaedic ward

Abstract

Fast-track hip and knee surgery focuses on optimising pain management, achieving early mobilisation and shortening the length of stay in hospital. These factors make interprofessional collaboration imperative. With the aim of further diminishing the length of stay for patients admitted to an orthopaedic ward for hip or knee replacement and with inspiration from an interprofessional training unit, a daily interprofessional meeting was introduced. At this interprofessional meeting, surgeons, nurses, occupational therapists and physiotherapists used a checklist in discussing barriers and focus areas for discharging hip and knee replacement patients and made joint decisions about which healthcare profession should handle a given task. This interprofessional collaboration was tested in a case control study comparing hospital length of stay in 75 patients treated before introduction of the daily interprofessional meeting with 88 patients treated after the introduction. The result was a significant reduction in the length of stay in hospital in total hip replacement patients (from a mean of 4.1 days (SD 2.1) to 2.7 days (SD 1.4), p?<?0.05) but not in knee replacement patients (from a mean of 3.7 days (SD 1.9) to 3.1 days (SD 1.6), p?=?0.33). So improving interprofessional collaboration by introducing an interprofessional daily meeting may reduce the length of stay in hospital for total hip replacement patients, but further studies are needed to explore the effect in knee replacement patients.     

A comparison of the predictions made by orthopaedic surgeons, nurses and physiotherapists about the rehabilitation problems of fracture patients

Health service staff sometimes are not aware of the psychological and social aspects of patients' rehabilitation problems. This paper compares the accuracy of predictions made by orthopaedic surgeons, nurses and physiotherapists about the rehabilitation problems of a series of fracture patients. Predictions were obtained in the acute orthopaedic trauma wards of one hospital, from members of all three professions, about 26 patients selected as likely to have rehabilitation problems. Follow-up data were obtained from interviews with the patients during the six months after their injury and from the orthopaedic case notes. The orthopaedic surgeons accurately predicted 48 per cent of the problems that occurred, the nurses 26 per cent and the physiotherapists 20 per cent. In their predictions the surgeons discriminated more accurately than the nurses or physiotherapists between the occasions on which problems did and did not occur in the follow-up period. The surgeons were better predictors than the other professions about medical and orthopaedic, work and personal and social problems. Fifty-five per cent of the problems that occurred were predicted by members of one or more professions. If it is desired to base early decisions about treatment or referral in rehabilitation on predictions about patients' likely problems, there is a need to increase the proportion of problems that are accurately predicted, and to increase the ability of predictors to discriminate between the occasions on which problems are and are not likely to occur.     

MRI algorithm for medical necessity for auto accident injured patients

Rationale Magnetic resonance imaging (MRI) is often used as a diagnostic test to evaluate personal injury. However, it increases the health care cost. Therefore, it is important to study the necessity for using MRI. Objective To examine the percentages of MRI ordering between orthopaedic surgeon and non‐surgeon referring health care providers, and to propose an MRI an algorithm to reduce unnecessary MRI for patients with personal injuries. Methods This is a retrospective study. A total of 2000 patients that received a soft tissue injury and did not require surgery between 1 January 2000 and 31 December 2004, were examined. Among them, 1000 patients came directly to one of the authors, an orthopaedic surgeon, and other 1000 were referred to the same surgeon. The percentages of MRI ordered by the author and the referring health care providers are examined. For referred patients, the orthopaedic author re‐examined each patient to determine whether he thought the MRI was necessary. The Chi‐square test and McNemar's test are used for comparisons for the percentages, and confidence intervals are reported. The study examines the overall MRI ordering, and MRI ordering separately for body regions. Conclusions We found that there was a great disparity between the percentages of MRI ordering between the orthopaedic surgeon and the non‐surgeon referring doctors, the orthopaedic surgeon ordered significantly less MRI (P‐values < 0.001). Adopting the proposed algorithm of medical necessity for ordering MRI or considering early referral to an orthopaedic surgeon prior to ordering MRI can significantly reduce the medical cost for these patients.     

Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon – A pilot study

Musculoskeletal impairments affect one-third of the adult population, are one of the major contributors to lost time from work, and account for one-third of a general practitioner's caseload. These injuries respond well to physiotherapy, but access can be limited in a publicly funded health care system. Improved access to physiotherapy occurs in a collaborative model of care in orthopedic clinics however the extent to which the patient receives similar diagnoses and treatment recommendations has not been reported. The purpose of this study was to determine diagnostic concordance and accuracy, and treatment concordance between a physiotherapist and orthopedic surgeons. Twenty-five subjects in an orthopedic clinic were assessed by a physiotherapist and an orthopedic surgeon. Diagnosis and treatment recommendations were made by each separately. These were compared for concordance between professionals and diagnostic accuracy. The physiotherapist and the orthopedic surgeon had 90% concordance in diagnoses of knee and shoulder impairments, and 75% accuracy when compared to definitive diagnostic methods. They had 87% agreement in treatment recommendations, however, the physiotherapist gave three treatment recommendations per patient where the surgeon gave two. In a collaborative care context therefore, this study suggests, that physiotherapists have similar diagnostic capabilities to orthopedic surgeons, and they will enhance the conservative treatment options offered to orthopedic patients.     

The accuracy of primary care teams in diagnosing disorders of the shoulder

Objective The aim of this retrospective, observational study was to determine the accuracy of diagnoses given by a multitude of primary care services to patients referred to an orthopaedic upper limb surgeon with a focus towards shoulder pathology. Methods Records of all patients referred to a single upper limb surgeon over a 1‐year period were reviewed. The diagnosis in the primary care setting was compared with the initial working diagnosis in the specialist clinic and against the final diagnosis following specialist investigation/intervention. Results 114 eligible patients were identified. General practitioners referred 35% of patients, musculoskeletal triage services referred 63% of patients and independent physiotherapists referred 2% of patients. It was found that 37% of patients were not given a diagnosis by the primary care team. When a diagnosis was given, accuracy was 50% (κ = 0.28) when correlated against that given by an orthopaedic upper limb surgeon. Conclusions Our findings suggest that knowledge of shoulder conditions is limited amongst primary care practitioners. There does not appear to be any difference in accuracy between general practitioners and musculoskeletal triage services.     

Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon--a pilot study

Musculoskeletal impairments affect one-third of the adult population, are one of the major contributors to lost time from work, and account for one-third of a general practitioner's caseload. These injuries respond well to physiotherapy, but access can be limited in a publicly funded health care system. Improved access to physiotherapy occurs in a collaborative model of care in orthopedic clinics however the extent to which the patient receives similar diagnoses and treatment recommendations has not been reported. The purpose of this study was to determine diagnostic concordance and accuracy, and treatment concordance between a physiotherapist and orthopedic surgeons. Twenty-five subjects in an orthopedic clinic were assessed by a physiotherapist and an orthopedic surgeon. Diagnosis and treatment recommendations were made by each separately. These were compared for concordance between professionals and diagnostic accuracy. The physiotherapist and the orthopedic surgeon had 90% concordance in diagnoses of knee and shoulder impairments, and 75% accuracy when compared to definitive diagnostic methods. They had 87% agreement in treatment recommendations, however, the physiotherapist gave three treatment recommendations per patient where the surgeon gave two. In a collaborative care context therefore, this study suggests, that physiotherapists have similar diagnostic capabilities to orthopedic surgeons, and they will enhance the conservative treatment options offered to orthopedic patients.     

Kommunikation und Befundaustausch zwischen Hausärzten und Orthopäden bei Rückenschmerzen

Introduction

Low back pain is a frequent reason for consultation in general practice. Many patients are treated in cooperation with an orthopaedic surgeon which requires an effective exchange of information. The aim of this study was to investigate the level of communication between general practitioners (GPs) and orthopaedic surgeons.

Material and methods

In this retrospective observational study referrals from GPs and corresponding response letters from orthopaedic surgeons were analyzed. GPs were asked to provide reasons for referral and to rate the quality of the response letters.

Results

A total of 12 out of 82 GPs from the teaching network of the Medical School of Göttingen participated in the study. Of 911 referrals to ambulatory orthopaedic surgeons within 3 months, 34% (n=312) were referred for low back pain. GPs provided little information beyond a diagnosis on the referral contrary to their self-perception. Most referrals (61%) were initiated by patients and most of them were considered at risk for chronification (72%) by the referring GP. Despite a formal obligation to report back, GPs received a response letter for only one-third (114/312) of the patients. GPs rated most of them as satisfactory, however, 59% were unsatisfied with the treatment recommendations. Only 10% of the letters contained psychosocial details. The information provided in the orthopaedic response letters was heterogeneous and only partly fulfilled the criteria set by the Interdisciplinary Society for Orthopaedic Pain Management.

Conclusion

Incomplete and scant information on referral forms from GPs and a high non-response rate from orthopaedic surgeons suggest that current health care system and referral forms do not promote effective communication about the patient. This might explain the satisfaction of GPs with the orthopaedic response letters despite the lack of information. The GPs dissatisfaction with the treatment recommendations reflects the limited treatment options for chronic low back pain in ambulatory care.     

Influences on individuals with osteoarthritis in deciding to undergo a hip or knee joint replacement: A qualitative study

Purpose. Osteoarthritis (OA) of the hip and knee is one of the major long-term health conditions. At the end-stage of the disease, a hip or knee replacement may be necessary. Yet, deciding to undergo a total joint replacement (TJR) due to OA may be a difficult decision for individuals. We conducted a study to elucidate the factors that influence whether or not individuals with OA decide to undergo a hip or knee replacement.

Method. A qualitative study nested within a longitudinal study (n = 268) that was exploring the management of OA. We interviewed a purposive sample of individuals (n = 27) with OA referred for consideration for TJR.

Findings. Participants were aged 49 to 89 with hip or knee OA. Participants’ decision-making was influenced by (1) symptoms, in particular pain and effect on physical functioning; (2) the opinion of others; (3) a weighing up of risks with benefits and (4) information sources.

Conclusions. Participants with end-stage knee OA were less willing to undergo surgery than those with hip OA. There is a need to provide more treatment options and quality information and advice to individuals to enable informed decision-making.     

Use of autologous blood in support of orthopaedic surgery using a hospital-based autologous donor programme

SUMMARY. The use of autologous blood in support of orthopaedic surgery has been assessed for 296 patients; 150 underwent hip arthroplasty, 69 underwent knee arthroplasty, 37 underwent spinal procedures and 40 underwent miscellaneous operations. Overall, 87% of patients received no allogeneic blood and 23% of the autologous blood collected was not used. For hip and knee arthroplasty, there appears to be an increased willingness to transfuse patients when autologous blood is available, and a decreased proportion of patients receiving more than 3 units for hip arthroplasty and 2 units for knee surgery, when compared with an audit of blood use
when almost all blood used was allogeneic. Wastage of autologous blood in support of spinal surgery was 66%, prompting a review of ordering practices. Assessment of avoidance of allogeneic transfusion by the standard schedule of 3 units for hip arthroplasty and 2 units for knee arthroplasty appears justified by the calculation that collection of an additional unit in each case would avoid allogeneic transfusion in 11 (5%) more patients with the unnecessary collection of 208 units.     

Indications for hip and knee replacement in Sweden

Objectives The aim of this paper was to compare selected indication parameters for patients scheduled for hip and knee replacement at orthopaedic units in Sweden. Methods Swedish orthopaedic clinics performing joint replacement were invited to enrol in the study. The study time was set to 2 years (from June 2006 to June 2008). The study subjects were patients undergoing hip or knee replacement for osteoarthritis (OA). For data collection, we used a Swedish priority criteria tool based on a translation from a form used in Canada with minor changes. The reliability and validity of the Swedish tool were investigated, with good reproducibility. The questionnaires (one for the doctor and one for the patient) were completed during decision making for surgery. Results Eleven hospitals enrolled in the study. In total, 2961 patients were included during the study period. Among these, 1662 were hip replacement patients and 1299 were knee replacement patients. The vast majority of patients undergoing hip or knee replacement had findings indicating severe OA, both clinically and radiologically according to the clinical priority tool. Statistically significant self‐reported problems with pain at rest, walking and impaired activities of daily living were also observed. There were statistically significant differences in reported indications between the hospitals, both for hip OA patients and for knee OA patients. Conclusions A clinical priority criteria tool is a useful means of following changes in indications for certain procedures. It could also contribute to explaining differences in case mix when evaluating clinical outcome and patient satisfaction.     

Physiotherapy screening of patients referred for orthopaedic consultation in primary healthcare – A randomised controlled trial

A large proportion of patients who consult primary healthcare for musculoskeletal pain are referred for orthopaedic consultation, but only a small number of these patients are appropriate for orthopaedic intervention. Experienced physiotherapists have the appropriate knowledge to manage musculoskeletal disorders. The primary aim of this randomised study was therefore to evaluate a screening by a physiotherapist of patients referred for orthopaedic consultation compared to standard practice in primary care.Patients referred for orthopaedic consultation (n = 203) were randomised to physiotherapy screening or standard practice. Selection accuracy for orthopaedic intervention and other referrals were analysed with proportion analysis. Patient views of the quality of care were analysed with Mann–Whitney U-test, waiting time with Independent t-test.There was higher selection accuracy for orthopaedic intervention in the physiotherapy screening group (p = 0.002). A smaller proportion of patients in the screening group were referred back to their general practitioner (GP) (p < 0.001) and a larger proportion to the physiotherapy clinic (p < 0.001) compared to standard practice. The proportion of patients referred for further investigations was significantly lower in the physiotherapy screening group (p < 0.039). Waiting time was shorter in the screening group (p < 0.001). A large proportion of the patients reported no hesitation to attend the clinic for future care, no difference between the groups (p < 0.95).The findings in this study suggest that an experienced physiotherapist effectively can screen patients referred for orthopaedic consultation in primary healthcare.     

Management of osteoporosis in an orthopaedic department: audit improves practice

Patients presenting with an osteoporosis-related fracture are at increased risk of further fractures. We performed a retrospective survey to determine if elderly patients presenting to the orthopaedic unit at Manchester Royal Infirmary with low energy hip or distal radius fractures were being managed appropriately with regards to assessment, investigation and treatment for possible osteoporosis. The initial survey demonstrated that only 16% of elderly female patients with low energy hip fractures and none of those (0%) with distal radius fractures were started on treatment or referred for further investigations for possible osteoporosis. After changes in our practice, 76% (p < 0.00001) of patients with hip fractures and 81% (p < 0.00001) of those with distal radius fractures were investigated, started on treatment or referred to a consultant physician for the management of osteoporosis.     

Investigation of anterior knee pain after total hip replacement: a pilot study

Background and Purpose. There is no previous research to determine if total hip replacement can lead to anterior knee pain. The idea for the present study came from clinical observation of anterior knee pain (AKP) after total hip replacement, and the objective was to investigate anterior knee pain after total hip replacement. Method. The study used a prospective single‐system design with a convenience sample. Six men and seven women were assessed before and at six weeks after total hip replacement for the presence and degree of AKP, using a step‐down test combined with a visual analogue scale (VAS). Measurements were also taken of leg length, hip and knee motion, thigh circumference and hamstring length using previously validated tests. Results. Eight of thirteen subjects had AKP at six weeks post‐operation. Active knee flexion was reduced post‐operation (p < 0.0007), and proximal, mid‐ and distal thigh circumferences were increased (p < 0.0001). Eleven of 13 subjects demonstrated leg lengthening (p < 0.0001), and 10/11 subjects demonstrated a reduction in passive knee flexion (p < 0.002). All biomechanical data were correlated against the VAS. Although none were statistically significant, both decreased active and passive knee flexion, and increased thigh circumference exhibited the greatest trend with the VAS. Conclusions. The results of the present study cannot be compared to other studies, as there are no previous studies on AKP after total hip replacement. Current outcome measures for total hip replacement do not measure for AKP, although it may potentially hinder full functional recovery. Orthopaedic surgeons and physiotherapists need to be aware if this is a possible complication of total hip replacement, and hence further research is required to test external validity. Copyright © 2006 John Wiley & Sons, Ltd.     

Minimizing venous thromboembolic complications in the orthopaedic patient

Venous thromboembolic events (VTE), which include deep venous thrombosis (DVT) and pulmonary embolus (PE), are the most common life-threatening complications associated with orthopaedic surgical procedures. DVT is particularly prevalent in patients undergoing total knee and hip arthroplasty, occurring at a rate of 50 to 60%. In addition, up to 2% of orthopaedic patients receiving pharmacologic prophylaxis still develop PE. Because the majority of candidates for these procedures are older adults with a multitude of comorbid conditions, standard prophylactic practices may not always result in optimal clinical outcomes. Thus, it is important for nurses to have a general understanding of appropriate thromboprophylaxis. This article will provide an overview of the current recommended guidelines and explore the risks and benefits of both pharmacologic agents and adjunctive treatment modalities.     

The experience of physiotherapy extended scope practitioners in orthopaedic outpatient clinics

Objectives Over the last decade there has been an increase in the number of physiotherapists working with an extended scope of practice in the orthopaedic outpatient clinic. There has been a growing feeling within the profession and the literature that these posts are more difficult than first perceived. The purpose of this qualitative study was to look at physiotherapists working in this setting and discover what has been their experience of the role and what recommendations they would make for future practitioners.

Design Qualitative, case study approach.

Setting Scottish National Health Service.

Participants Four physiotherapists working as extended scope practitioners.

Measures Data was collected using tape-recorded semi-structured interviews and investigated five main areas: training, responsibilities, support, satisfaction and recommendations.

Results The results suggested that success and satisfaction in post is dependent on the relationship with the consultant and the medical team; most extended scope practitioners experienced similar difficulties and had the same outstanding training needs.

Conclusions The overall impression from the findings was that although the job can be stressful it is also very satisfying. By ensuring a good relationship with the medical team, providing adequate ongoing training and support, many of the difficulties encountered by the participants could be minimised.     

Comparison of a urine chemistry analyser and microscopy, culture and sensitivity results to detect the presence of urinary tract infections in an elective orthopaedic population

Currently elective orthopaedic patients require a microscopy and culture of urine (MSU) to be performed on admission. Between 70-80% of urine cultures are found to be negative for infection, making this practice costly and time consuming. The purpose of this study was to compare the accuracy of a dip stick urine chemistry analyser (Clinitek 50 machine) with a MSU, to detect the presence of nitrites and/or leukocytes in a group of elective orthopaedic surgical patients. methodology: Using a prospective cohort study design all elective orthopaedic patients who met the study criteria were invited to participate. In total 102 patients undergoing total hip or total knee replacement surgery participated. results: Results showed that the prevalence of urinary tract infections in patients undergoing total knee or hip surgery, was 14%. High specificity and negative predictive values for the detection of bacterial growth by dip stick urine chemical analysis were found, especially when either the presence of nitrites or leukocytes was used as an indicator. conclusion: This study has provided valuable baseline data on the accuracy of using photometry techniques as a screening measure, in the detection of UTI, in a sample of orthopaedic patients. While the Clinitek 50 dip stick urine chemistry analyser did not have high sensitivity in identifying those patients with a UTI, it was specific in identifying those patients who did not have an infection. Given the enormous cost in routine screening of these patients and the impact on nursing resources, use of this analyser could have potential nursing resource and financial benefits.     

High inter-tester reliability of the new mobility score in patients with hip fracture

OBJECTIVE: To assess the inter-tester reliability of the New Mobility Score in patients with acute hip fracture. DESIGN: An inter-tester reliability study. SUBJECTS: Forty-eight consecutive patients with acute hip fracture at a median age of 84 (interquartile range, 76-89) years; 40 admitted from their own home and 8 from nursing homes to an acute orthopaedic hip fracture unit at a university hospital. METHODS: The New Mobility Score, which evaluates the prefracture functional level with a score from 0 (not able to walk at all) to 9 (fully independent), was assessed by 2 independent physiotherapists at the orthopaedic ward. Inter-tester reliability was evaluated using the intraclass correlation coefficient (ICC1.1) and the standard error of measurement (SEM). RESULTS: The ICC between the 2 physiotherapists was 0.98, 95% confidence interval (CI) 0.96-0.99 and the SEM was 0.42, 95% CI -0.40-1.24 New Mobility Score points. No systematic between-rater bias was observed (p>0.05). Patients who were scored differently by the 2 physiotherapists had significantly lower mental scores (p=0.02). CONCLUSION: The inter-tester reliability of the New Mobility Score is very high and can be recommended to evaluate the prefracture functional level in patients with acute hip fracture.     

Soft-tissue Disorders of the Shoulder: A study of inter-observer agreement between general practitioners and physiotherapists and an overview of physiotherapeutic treatment

Objective:

To study the inter-observer agreement between general practitioners (GPs) and physiotherapists in diagnosing soft-tissue shoulder disorders. In addition, to describe the physiotherapy for shoulder disorders in primary care.

Methods:

18 GPs recruited 349 consecutive patients with a new episode of shoulder pain for a follow-up study. Cohen's kappa for diagnostic agreement between GPs and physiotherapists was calculated for a subset of 120 patients who were referred for physiotherapy. The physiotherapists recorded the nature of the physiotherapeutic treatment on standardised forms.

Results:

The overall kappa for the classification of shoulder disorders was 0.31 (95% confidence limits: 0.19, 0.42). Agreement was somewhat better in cases of capsular syndrome (0.48, 95%) confidence limits: 0.30, 0.66), but worse in cases of acute bursitis (-0.03, 95% confidence limits: -0.21, 0.15). Agreement also appeared to be better in patients with a long symptom duration. The physiotherapists most frequently used deep friction massage, exercise therapy and passive mobilisations to treat shoulder pain. Nearly all cases of tendinitis were treated with deep friction massage (97%), whereas the majority of patients with a capsular syndrome were treated with exercise therapy (67%) and passive mobilisation (72%).

Conclusions:

Inter-observer agreement between GPs and physiotherapists was rather low, considering the fact that diagnosis of shoulder pain often has implications for the selection of therapy. Future research should focus on the question of whether inter-observer agreement can be improved and whether different diagnostic categories do, indeed, require different therapeutic strategies.