MSKTriage – Multidisciplinary working in action
Purpose of triage
The prioritization of care based
on
•
illness
•
Injury
•
Severity
•
Prognosis
•
Resources available
•
Managing patient / healthcare
professional expectation
Types of triage in MSK
•
NHS Telephone triage
•
A&E
•
Multidisciplinary triage services
•
Paper based questionnaire triage : Startback
•
Computerized on line triage
Benefits of triage model
•Waiting list management
•Stratified care approach targeting resources to
demand
•Fits with WAG models of “right place, right person,
right time”
•Reinforcing public health messages
•Multidisciplinary working
Does it work?
•Daker-White et al. designed a randomized clinical trial (RCT) in a British
orthopaedic clinic, comparing APP care to orthopaedic surgeons in training and
found that APPs were as effective as junior doctors to treat patients with
musculoskeletal disorders while ordering less diagnostic tests and reducing direct
medical costs. Patient satisfaction was also higher for the APP care.
•Other studies have looked at diagnostic validity and diagnostic concordance
between APPs and surgeons for patients seen in an outpatient orthopaedic clinic
and have found that for diagnosis and for determining whether patients would
benefit from conservative care or surgical review, agreement may range from
good to excellent (range κ = 0.69 to 1.00) (Aiken et al, 2008, Mackay et al, 2009)
• Treatment recommendations agreement is fair to very good (range κ = 0.52 to
0.70) (Aiken and McColl, 2009)
Cwm Taff ESP CMATS physio experience
Out of 2909 cases seen since Dec 2013
• 386 referred to secondary care for surgical opinion (13.26%)
• 34 referred to rheumatology
• 119 referred to pain clinic
• 937 referred to physiotherapy
• Out of known outcomes of patients referred to secondary
care for surgical opinion over 76% where converted to actual
surgery
Patient satisfaction on Extended Scope Physiotherapy (ESP) Musculoskeletal
triage.
H Welch (Cym Taff NHS Trust), G Paul-Taylor, R John
Physiotherapy Department , Cwm Taf Health Board, Prince Charles hospital, Merthyr Tydfil, Wales
Aims/introduction
Results/graphs/illustration
To evaluate:
•the patient experience of
patients referred to the ESP
•patients’ expectations and
satisfaction of the service
To identify:
•the demographic data of the
patients
Mean age range 40-59 yrs (range
20 -70yrs). 50% >1 year duration of
symptoms.
94% rated the service provided as
good - excellent. 88% of patient’s
reported that they were happy to
be assessed by the ESP.
Graph of patients rating of overall
experience?:
Materials and methods
A prospective audit of 50 new
patients to the ESP service over a
3 month period between Dec
2008 and Feb 2009.
Patients completed an
anonymous self administered
satisfaction survey following
their initial appointment. Data
was analysed with descriptive
statistics.
100%
References
88%
90%
80%
70%
60%
50%
40%
30%
20%
6%
10%
6%
0%
0%
0%
0%
Excellent
Conclusions
The ESP service in Cwm
Taff Health board
achieves a high level of
patient satisfaction.
Good
Average
Poor
Very Poor
Not
Documented
96% agreed they were able to
discuss their treatment openly
with only 10% preferring to see a
Doctor.
Dawson, Ghazi. The experience
of physiotherapy extended
scope practitioners in
orthopaedic outpatient clinics.
Physiotherapy. Vol. 90. 4. 210216.
Poster No. GP149
Triage / Assesment
The key to finding a remedy
to a problem is the accurate
recognition of the problem.
Why is it important??
Failure to correctly identify an appropriate diagnosis
can lead to:•Negative outcomes (Trowbridge 2008)
•Delays in appropriate treatment (Whiting et al, 2008)
•Unnecessary healthcare costs (Dohrenend and
Skillings)
What do we use to triage and
determine care
Three diagnostic questions when addressing a patient
•The first question of diagnosis : are the patients
symptoms reflective of a viseral or serious or
potentially life threatening disorder
•The second question of diagnosis : from where is the
patients pain arising
•The third question of diagnosis: What has gone wrong
with this person as a whole that would cause the pain
experience to develop and persist
Murphy and Hurwitz (2007)
Problems with
diagnostic triage
Can you algorise all conditions?
Mostly done on LBP due to economic cost of condition.
STarT Back
The Keele STarT Back Screening Tool (SBST) is a brief validated tool (Hill et al 2008),
designed to screen primary care patients with low back pain for prognostic
indicators that are relevant to initial decision making.
The STarT Back trial which was recently published in The Lancet (see references)
was designed to compare the clinical and cost effectiveness of a stratified
management approach; allocating patients to different treatment pathways based
on their prognosis i.e. low, medium, or high risk of poor outcome.
The tool helps primary care clinicians (GPs, physiotherapists etc) to group patients
into 3 categories of risk of poor outcome (persistent disabling symptoms) - low,
medium, and high-risk. By being able to categorise patients into these 3 groups,
clinicians are then able to target interventions to each sub-group of patients to help
improve outcome.
Some problems with
interpretation of High risk
High risk does not mean hands off.
High risk means more complex patients and a
higher level of knowledge and skills needed to treat
with a combined psychologically informed hands on
approach (Hill, 2013)
Practical use for STarTBack
GPs (for those patients at low risk of poor outcome) or referral to
primary care physiotherapists who can apply physiotherapy
approaches to addressing pain and disability (for those at medium
risk) and additional cognitive-behavioural approaches to help
address psychological and social obstacles to recovery (for those
at high risk)
. IMPaCT Back study
See STarTback web page for more details
Problem? – can we rely
on objective tests
Limited quality research done on
diagnostician utility of physical
tests
• The majority of clinical special tests of the lumbar
and cervical spine have demonstrated poor
diagnostic value
• Should we think of them as driving decision making
and determining prognosis rather than making a
diagnosis of a superficial condition
• Should we be thinking of them as screening tests
rather than diagnostic tests?
What makes a clinical test a “Best Test”
•Reliable
•Clinical utility
•Validated finding high diagnostic accuracy
Diagnostic accuracy
Sensitivity
Likelihood ratio’s
Percentage of people who test
positive for a specific disease
among a group of people who
have the disease
A value of > or equal to 1 rules in
a diagnosis
Specificity
Percentage of people who test
negative for a specific disease
among a group of people who do
not have the disease
A value closer to 0 rules out
Simple rule
Just remember
High sensitivity and low likelihood ratio to rule out
High specificity and high likelihood ratio to rule in
Luckily
The more serious and sinister the
pathology the more sensitive and
specific the tests get to providing
an accurate diagnosis.
Problem?
Pathologies will present differently according to stage
and chronicity of disorder
Problem?
Patients presentation and radiological findings
often do not correlate.
MR imaging examinations of the lumbar spine frequently reveal
numerous findings, including disk desiccation, height loss, or bulging,
with questionable relevance to patient symptoms. These findings are
common in asymptomatic adults, with prevalence in this group as high
as 90% (boden et al,1990, Jarvik at al, 2001, Jenson et al, 1994)
Moreover, multiple studies have failed to demonstrate clinical benefit
with the use of early MR imaging for LBP compared with radiographs
alone or no imaging at all; furthermore, the imaging results may
negatively affect patients’ sense of well-being (Jarvik,2003, Modic et
al, 2005, Ash et al, 2008)
Can we do anything to reduce anxiety with
abnormal MRI findings
•In patients
•Healthcare professionals
Lumbar MR Imaging and Reporting Epidemiology: Do
Epidemiologic Data in Reports Affect Clinical Management?
Brendan J. McCullough, MD, PhD, , Germaine R. Johnson, MD, ,
Brook I. Martin, PhD, MPH, and , Jeffrey G. Jarvik, MD, MPH
In this study, patients with LBP or radiculopathy were less likely to
receive a prescription for narcotics by primary care providers after
lumbar spine MR imaging if the imaging report included a simple
statement describing the prevalence of common findings in
asymptomatic individuals. Similar trends were observed for repeat
cross-sectional imaging and physical therapy referrals, although the
differences were not statistically significant. Taken together, these
findings suggest primary care providers were more reserved in their
treatment of patients whose MR imaging report included the
statement.
Summary of potential problem :Errors in
diagnosis
•
Confirmation bias
•
Poor diagnostic thinking process
•
Over reliance on objective assessment
•
Non descript conditions that have little or no unique
manifestations
•
Weakness is the clinical tools
•
Bias of reporting of clinical tools in literature and clinical
practice
So what are essential the components of a triage
assessment
•
Well performed history
•
Physical examination
•
Addition tests - bloods / radiological investigations –
if needed
Is there anything else that can help us to
determine pathway of care
Can we use a mechanism based classification of pain
• Can
account for variations in clinical presentation
• use
a cluster of symptoms and signs characteristic to
each category
• Good
consenus of opinion on characteristics of pain
mechanisms (Smart et al, 2009)
research
Smart, Blake , Staines and doody (2009)
Clinical indicators of nociceptive, peripheral
neurogenic and central mechanism of MSK pain : a
Delphi survey of expert clinicians
3 round Delphi of 103 experts.
Nociceptive
Ranked in order of agreement
•
Clear, proportionate mechanical / anatomical nature to agg and easing factors
•
Pain associated with and in proportion to trauma or pathological process or movement /
postural dysfunction
•
Pain localised to area of injury / dysfunction
•
Responsive to simple NSAIDs or analgesia
•
Usually intermittent and sharp with movement / mechanical provocation.
•
May be constant dull ache / throb at rest
•
Associated with other fractures of inflammation
•
Recent onset
Nociceptive clinical
examination
•
Clear, consistent and proportionate mechanical /
anatomical pattern of pain reproduction on
movement / mechanical testing of target tissue
•
Localised pain on palpation
•
Absence of unexpected findings
•
Antalgic
Peripheral neurogenic
•
Pain described as burning, shooting, sharp, aching or electric shock
•
History of nerve injury
•
Pain in associated with other neurological symptoms
•
More responsive to anti epileptic and anti depressants than to NSAID
•
Pain of high severity / irritability
•
Mechanical pattern to agg and easing - load or compression neural tissues
•
Pain in association with other dysesthesia
•
Reports so spontaneous pain
Peripheral neurogenic :
clinical indicators
•
Pain / symptoms associated with tests that load or
compress neural tissue
•
Pain on palpation of neural tissues
•
Positive neurological findings
•
Positive findings of hyperalgesia
•
Ant align posturing of affected body part.
Central pain
•
Disproportionate , non mechanical, unpredictable pattern of pain provocation in response to multiple non
specific agg/easing factors
•
Pain persisting beyond expected tissue healing time
•
Pain disproportionate to nature / extent of injury
•
Widespread non anatomical distribution of pain
•
History of failed interventions
•
Strong association with maladaptive psychosocial factors
•
More responsive to anti epileptic and anti depressants than to NSAID
•
Constant unremitting pain
•
Night pain / disturbed sleep
•
Pain in association with other dysesthesia
•
Pain of high severity and irritability
Central pain : clinical
indicators
•
Disproportionate inconsistent non mechanical non
anatomical pattern of pain provocation in response
to testing
•
Positive findings of hyperalgesia, allodynea and
hyperpathia
•
Diffuse non anatomical area of pain
•
Positive identification of various psychosocial factors
1 :Reasoning of pain as related to
aspects of the physical examination of
patients
•
What am I going to choose in my physical
examination to reproduce it
Tests of nerve trunk
mechanosensitvitiy
Peripheral
neurogenic
Tests of neurological
deficit
LANNS
2: Reasoning of pain related to reasoning
surrounding physio therapeutic or medical
interventions
Advice & Self
management
Therapy &
Rehabilitation
•
How am I going to treat this
Chronic pain
services
surgery
Gp management
Reasoning of pain related to concurrent
thinking concerning a patient's prognosis or
outcome
•
How long it may take to settle
Reasoning of pain related to patient
communication
• How do I communicate with the patient the
management plan and explanation of their symptoms
remember diagnosis is not an event but
a process
Rule out sinister
problems
Identify the
appropriate
location
Identify other
contributors to
the condition
Then matching to
resources
•
Reorganization of services
•
Improved links from secondary to primary care
•
Public health message
•
Training for development for triage posts
•
Psychosocial resources – pain management
programes / pain clinic