Referral and pathways for surgically managed Carpal Tunnel Syndrome patients: guidelines and current practice

Transcription

1 Referral and pathways for surgically managed Carpal Tunnel Syndrome patients: guidelines and current practice A Report from the Musculoskeletal Audit on behalf of the Scottish Government The information in this report is intended to be used for improvement purposes. Please treat the material and any indication of the results as restricted. The information has been collected through the MSK Audit by local MSK Audit co-ordinators based in each hospital. These statistics have not been through the official statistics quality assurance process but have been subject to the MSK Audit s own quality assurance process. Interpretive text in blue from Mr David Lawrie (Consultant Orthopaedic and Hand Surgeon, Aberdeen Royal Infirmary/Woodend Hospital) and John Nugent (GP and Clinical Director North West Sector Glasgow City CHP). This report from the Musculoskeletal (MSk) Audit looks at current practice and how this relates to the referral and pathway guidelines for Carpal Tunnel Syndrome (CTS) patients who underwent carpal tunnel release surgery between 31 st October 11 and 23 rd January 12. These guidelines were issued in May 11 and are available at The audit collected information on clinical elements and Referral to Treatment (RTT) timing information along the pathway. The RTT elements have been reported on separately in a report called Referral to Treatment Pathways for Surgical Carpal Tunnel Syndrome Patients. The audit only included patients treated surgically. A separate audit of patients treated conservatively was undertaken in 1 and can be found at This report is intended to be used, in conjunction with local data, to help managers and clinicians identify opportunities where referral and pathway processes could potentially be improved. It is not intended to be used to make judgements about current performance but rather to stimulate further investigation to understand where the opportunities for improvement exist. Contacts David Lawrie - Consultant Orthopaedic and Hand Surgeon (David.Lawrie@nhs.net) John Nugent GP and Clinical Director North West Sector Glasgow City CHP (jnugent@nhs.net ) Rik Smith MSK Audit Analyst (rsmith11@nhs.net) Jane Campbell MSK Audit Co-ordinator (Jane.Campbell7@nhs.net) Kate James Orthopaedic Services Improvement Project Manager, Scottish Government (Kate.James@scotland.gsi.gov.uk ) - - 1

2 Summary and Key Findings The 18 Weeks RTT Orthopaedic Services Task and Finish Group worked with specialist hand surgeons to develop pathway guidelines for Suspected Carpal Tunnel Syndrome (CTS). These guidelines were published in May 11 on the RTT website (see link on Page 1). The pathway guidelines advise primary care about the criteria for referral, conservative treatment that can be tried prior to referral and pre-referral tests (e.g. Phalen s test, Tinel s sign) that can be undertaken. They also include recommendations on the information required in referral letters to ensure patient journeys and treatment pathways can be managed as efficiently as possible. The Musculoskeletal (MSk) Audit collected referral and pathway data from CTS patients who underwent carpal tunnel release surgery between 31 st October 11 and 23 rd January 12 across Scotland. The referral period for these patients coincided with the release of the pathway guidelines, giving a benchmark against which future improvement can be assessed. 88% of referrals for CTS were from primary care (Table 1). Although 35% of patients did have some documented pre-referral interventions, 65% did not (e.g. NSAIDs, wrist splints; Fig. 6). Boards are encouraged to consider how to increase awareness and provide easy access for GPs on their desktop to the Suspected CTS referral guidelines. This will hopefully improve the amount of conservative treatment tried prior to sending to secondary care for surgical intervention. The quality of the information provided by GPs in the referral letters received in each hospital varied greatly (Figs. 1-4). In some sites, work has been undertaken with colleagues in primary care to provide guidance on referral management of suspected CTS, which has resulted in a positive impact on the quality of referring letters. 68% of patients had no clinical tests documented in the referral letter (Table 2, Fig. 8). It is not clear why so few simple clinical tests had been carried out/documented prior to referral. Video links could be added to Board intranets to show how to carry out the pre-referral clinical tests. There is an opportunity to significantly improve the efficiency of vetting to the right professional first time, and therefore remove un-necessary steps/delays from the pathway. To achieve this requires referrals to contain the information recommended in the pathway guidelines; the patient s symptoms, duration, pre-referral tests undertaken and conservative management measures already in place. For example, there would be an opportunity to vet straight to Nerve Conduction Studies (NCS), including whether to a technician or neurophysiologist, prior to first outpatient appointment (OPA) and to vet to one-stop clinics. Although all patients included in this audit were treated surgically and therefore can be deemed as appropriate referrals, further dissemination and increased awareness of the referral guidelines throughout primary care could streamline the pathway and reduce the waiting for future patients. This would also enable patients to follow an appropriate conservative management or surgical pathway. Boards are recommended to consider: If a NCS service is provided, how the overall capacity should be allocated. For example, whether protocol driven GP access to NCS would improve the patient journey overall. Will it appropriately prevent even a small number of referrals from being necessary, or simply provide an investigation earlier in the process, resulting in a shorter RTT time but not a shorter overall patient journey from GP consultation to treatment? The use of neurophysiology technicians working in an extended role, with the support of a clinical neurophysiologist, at one-stop CTS clinics. This can allow results to be provided at the first clinic appointment and can significantly reduce the number of steps in the journey and the patients Referral to Treatment (RTT) time

3 Although it is entirely appropriate for straightforward, clear cut clinical presentations of CTS to proceed to surgery without Nerve Conduction Studies, it is also generally accepted that when assessing patients with CTS all clinicians should have access to timely NCS. The audit showed that the longer the average length of time that hospitals had to wait for NCS, the less likely they were to request NCS for their patients (n=17 hospitals, r=-.52, p=.3). Boards should consider whether there is a need for NCS guidelines detailing the criteria for which patients would benefit from NCS. There are also options for triaging appropriately to either a technician or neurophysiologist depending on patient symptoms. Clinicians should also consider whether there is a need to bring patients back for a review appointment following NCS or whether a letter or phone call could suffice in some circumstances. PROMS and Patient Experience measurement can provide very useful improvement information that enables clinicians and managers to ensure that good patient outcomes are achieved and that the pathway is patient centred. It is not clear why PROMs/Patient Experience information is still not being routinely gathered (Fig. 15) despite the implementation of the Quality Strategy and this area being highlighted as a Priority Area for Action. The report also contains analysis of the rate of CTS procedures per head of population by Board (Fig. 16). This shows a significant variation and clinicians are encouraged to consider reasons for the variation and whether a reduction in the variation is clinically appropriate

4 Contents: Inclusion of patients Page 5 National Referral Guidelines Page 6 Demographics Page 6 Interventions in primary care Page 6 Quality of referral letter Pages 7-8 Signs for referral to secondary care Page 9 Other information available at referral Pages 1-12 Specialty involvement Page 13 Triage Page 13 Diagnostics Pages Secondary care Page 16 PROMs/Patient Experience measurement Page 17 CTS procedures rates per head of population Page

5 Inclusion of patients All patients listed for an elective carpal tunnel release were included, apart from planned or follow-up operations on the patients other hands in the same episode of treatment. MSk Local Audit Co-ordinators collected data from patient case notes, patient information systems, results reporting and referral management systems. Referral letters were not audited if they related to a previous operation, e.g. the second of two planned operations on both hands. All data in this report are reported by unit (hospital) where the patient was referred. The total number of referrals identified and available in each unit is listed in Table 1. 88% of available referral letters were from GPs (Table 1). 47% of referrals were made before or during May 11 when the guidelines were circulated, and a further 39% in the next three months post-release. The data presented here therefore represents a snapshot of surgical CTS patients whose average referral date coincided with the release of the guidelines. Analysis of the data indicates that the reporting of symptoms, interventions or testing by GPs did not change significantly in the short periods included in this dataset before and after the release of the guidelines. We therefore treat the data as one sample, giving a benchmark for future improvement towards full implementation of the guidelines. Table 1: Number of patients and percentage of referral letters available Hospital Total number of patients included Number of referral letters available No referral letter or letter not available* Number (%) of available referral letters that were from GPs N % N % % 34 89% % 1 67% % 22 81% % 33 89% /Gartnavel % 83% /Stobhill % 22 81% % 68 97% % 49 84% % 13 76% % 52 9% % 96 85% 4 4 % 34 85% % 21 84% /Garrick % 47 87% % 51 96% % 24 92% % 14 93% % 61 88% * e.g. seen/diagnosed at OPA for another condition, or no referral letter in notes The rest of this report excludes the 7% of cases where there was no referral letter or the letter was unavailable (Table 1). We do, however, include the 12% of cases that were referred from sources other than GPs (Table 1)

6 National Referral Guidelines National Referral Guidelines were issued in May 11 and are available at These guidelines advise GPs of criteria for referral, conservative treatment that can be tried prior to referral and pre-referral tests that can be undertaken. They also include recommendations on the clinical information that would be useful to include in the referral letter. Demographics Sixty-eight percent of the 697 patients whose referral letters were audited for this report were female, and the overall mean age was 58 (median 57, interquartile range 46-68). None of the females were pregnant. Twenty-seven (4%) patients had trauma to the affected hand. In sixteen cases trauma had been more than a year previously, five had been 6-12 months previously and six had trauma within six months of referral. Six percent of patients were NIDDM diabetics and 9% IDDM diabetics. Seven percent had a history of thyroid disorder. Sixty-seven (1%) patients had a history of neck problems, mostly for over a year (41 of 52 cases documented; 6 cases for -6 months, 5 cases for 6-12 months, remaining 15 cases duration not documented). Interventions in primary care Altogether 35% of audited patients had documented interventions (analgesia/nsaids or wrist splints) prior to referral. Those who had trauma to the affected hand were less likely to have had pre-referral interventions than those who had not (15% versus 36%, p=.2). Patients with thyroid problems had slightly higher rates of pre-referral interventions (47% versus 35%, p=.8). There was no evidence that those with neck problems or diabetics were more likely to have had pre-referral interventions. Although 35% of patients did have some documented intervention, 65% did not. Boards are encouraged to consider how to increase awareness and provide easy access for GPs on their desktop to the Suspected CTS referral guidelines. This will hopefully improve the amount of conservative treatment tried prior to sending to secondary care for surgical intervention. Recent work in Greater Glasgow and Clyde Health Board suggests that GPs are starting to use these pathways when making referrals, and often when discussing next steps with patients

7 Quality of referral letter Sixty-three per cent of referral letters recorded the duration of symptoms (Fig. 1), 98% documented whether the symptoms were unilateral or bilateral (Fig. 2), and 71% recorded whether symptoms were constant or nocturnal (Fig. 3). Fifty percent of referral letters mentioned all three (Fig. 4). Fig. 1: Percentage of referral letters recording duration of symptoms Percentage of referral letters recording duration of symptoms Fig. 2: Percentage of referral letters recording site of symptoms (unilateral or bilateral) Percentage of referral letters recording site of symptoms Fig. 3: Percentage of referral letters recording the constancy of symptoms (constant or only nocturnal) Percentage of referral letters recording constancy of symptoms

8 Fig. 4: Overall quality of referral letters recording of duration, symptoms and site Duration, symptoms and site Duration and site Other combination Symptoms and site Site only None recorded Although some referral letters did not provide detail relating to the categories above, some may have included the information that the patient had symptoms consistent with a diagnosis of CTS In some sites, work has been undertaken with colleagues in primary care to provide guidance on referral management of suspected CTS, which has resulted in a positive impact on the quality of referring letters. This aids the secondary care clinician to determine if the criteria for referral into secondary care are met and the most appropriate next stage of the patient journey, without having to interrupt/stop that journey to ask for further information

9 Signs for referral to secondary care Patients who have constant symptoms, symptoms present for at least six months, or thenar muscle wasting should be referred to secondary care. 76% of referral letters mentioned one or more of these signs (Fig. 5). Only eleven (2%) letters indicated that none of these signs were present. The remaining 22% of referral letters did not mention either the constancy or duration of symptoms, so had insufficient detail to allow a judgement on whether or not the referral criteria were met. There is an opportunity to significantly improve the efficiency of vetting to the right professional first time, and therefore remove un-necessary steps/delays from the pathway, if all referrals contained the suggested information; the patient s symptoms, duration, pre-referral tests undertaken and conservative management measures already in place. For example, there would be an opportunity to vet straight to Nerve Conduction Studies (NCS) (including whether to a technician or neurophysiologist) prior to first OPA and to vet to one-stop clinics. Fig. 5: Percentage of referral letters documenting criteria for referral into secondary care Total Constant only Thenar wasting only Other combination None of the above > 6 months only Constant and > 6 months Insufficient documentation All light blue, dark blue, grey, green and black bars on this figure indicate referral documentation containing appropriate criteria for referral into secondary care - - 9

10 Other information available at referral Previous diagnosis of CTS 77% of patients did not have any previous (hospital-confirmed) diagnosis of Carpal Tunnel Syndrome mentioned in the referral letter.13% of letters mentioned a previous diagnosis of Carpal Tunnel Syndrome on the same hand and 1% a previous diagnosis on the opposite hand. Three patients (.4%) had a diagnosis on both hands previously. 9% of those that had a previous diagnosis of Carpal Tunnel Syndrome were diagnosed within the previous six months, 12% were diagnosed 6-12 months prior to referral, and 71% more than a year before referral (8% were unknown). Prior interventions 22% of patients had documented analgesia/nsaids prior to referral, and % had wrist splints applied (Fig. 6). In the 72% of referrals that documented the length of time that analgesia/nsaids had been tried, 56% had been given analgesia/nsaids for less than 6 months, 19% for 6-12 months and 26% for over a year. The length of time that wrist splints had been tried was documented for 62% of patients. Of these 43% of patients had tried wrist splints for up to 6 months, 21% for 6-12 months and 36% for over a year. Fig. 6: Pre-referral interventions Analgesia/NSAIDs Wrist splints Both No documented interventions - - 1

11 Duration of symptoms Fig. 7 shows how long patients had CTS symptoms prior to referral into secondary care, although in some cases they may have had symptoms for some time before presenting to the GP and it is not always clear if the GP has included this in their documentation re duration of symptoms. Fig. 7: Duration of symptoms Percentage of referral letters Total < 1 month 1-6 months 6-12 months >1 year Not recorded 73% of the 15 patients who had symptoms of Carpal Tunnel Syndrome for less than a month prior to referral had documented interventions prior to referral. In contrast only 36% of those who had symptoms for 1-6 months prior to referral had documented interventions, increasing slightly to 39% of those who had symptoms for 6-12 months, and 46% of those who had symptoms for more than a year. It is not clear whether these figures reflect early presentation of patients with more severe symptoms to GPs, earlier referral of more severe symptoms by GPs or lack of documentation of more dated interventions, or some combination of these possibilities. Site of symptoms 51% of patients had unilateral CTS symptoms, 47% bilateral. For the remaining 2% site was not recorded. Constancy Of the 71% of referral letters that documented constancy of symptoms, 9% of patients had constant symptoms. Of the remaining 52 (1%) patients with nocturnal-only symptoms, relief by shaking was only mentioned in 21 (4%) referral letters: 16 patients symptoms were relieved by shaking and five patients symptoms were not. Thenar muscle wasting 7% of referral letters indicated wasting of the thenar muscles

12 Pre-referral testing Table 2: Proportion and results of pre-referral testing % of patients tested % of those tested that were positive or had APB weakness Phalen s test % 73% Tinel s sign 26% 67% APB Weakness 7% 43% 14% of patients had one of these tests documented as having been undertaken prior to referral, 14% had two undertaken and 4% had all three undertaken. The remaining 68% of patients had no documented tests undertaken prior to referral. The percentage of each type of testing carried out varied widely between hospitals (Fig 8). Phalen s test varied from 7-44% between hospitals, 15-52% for Tinel s sign test and -35% for APB weakness checks. Fig. 8: with documented pre-referral tests carried out All tests undertaken Phalen's & Tinel's Phalen's only Tinel's only APB weakness only Other combination No tests undertaken It is not clear why so few simple clinical tests had been carried out/documented prior to referral. If these simple tests were standard practice prior to referral this would significantly improve vetting and ensure that patients were put on the correct pathway much sooner. It is hoped that this change in practice could be supported by wider dissemination and increased awareness of the referral guidelines (e.g. by Boards putting them on their intranet. Video links could be added to show how to carry out these clinical tests)

13 Specialty involvement Most hospitals carpal tunnel patients were treated by Orthopaedics. Lothian patients, however, were mainly treated by Plastics. 27% of Aberdeen patients were treated by Neurosurgery. In the treatment of CTS is also carried out by Plastics and Neurosurgery (22 patients during audit period, 23% of carpal tunnel release operations), but these patients were not included in the audit. Nine per cent of audited patients had more than one specialty involved, either at referral or later in the pathway. Fig. 9: Specialty involvement Total Orthopaedics Neurosurgery Plastic surgery Multi-specialty Triage Pre-referral test results versus pathway (direct to surgery or via NCS) Nationally, there was little indication that pre-referral test results influenced whether patients were initially seen by more senior staff or whether they followed a particular pathway (pre-referral NCS ordered, NCS ordered at first OPA or no NCS see Fig. 13). Only six patients had post-referral pre-opa diagnostics testing undertaken. As commented in the signs for referral to secondary care section on page 9, there are opportunities to increase the efficiency of the patient s journey if these pre-referral tests were undertaken, documented in the referral letter and acted upon by those vetting in secondary care

14 Diagnostics Not all hospitals have the facility to undertake Nerve Conduction Studies on site.,,, and carry out all or most of their NCS on site. Some hospitals provide NCS within the Board but at another site (e.g. Lothian, St Johns patients are sent to WGH). All other hospitals have an arrangement with another Board for the undertaking of NCS. Fig. 1: Timing of NCS * Prior to referral At first OPA No NCS Between referral and OPA After first OPA Although the data in this audit does not show a significant number of NCS at first appointment in Woodend, during the time of the audit the NCS machine in the one-stop clinic was out of use for a short period Fig. 11: Staff carrying out NCS at or after OPA Neurophysiologist Other medical staff Technician Not known Note:,,,, and percentages are based on small samples (4-1 patients)

15 Fig. 12: Time from ordering NCS to when they were carried out weeks 4-8 weeks 8-12 weeks weeks >24 weeks Not known Note:,,,, and percentages are based on small samples (4-1 patients) For a more detailed analysis of journey stages and stage times see report titled Referral to Treatment Pathways for Surgical Carpal Tunnel Syndrome Patients. Analysis was undertaken to determine whether use of pre-referral NCS affected the overall referral to treatment time (RTT) for patients. Pre-referral NCS did reduce overall RTT by 4 weeks on average in hospitals that regularly receive patients with pre-referral NCS (e.g. and parts of GG&C). It is noted, however, that has long waits for post-referral NCS and some of the longest waits from NCS being performed to post-ncs review. Boards are recommended to consider: If a NCS service is provided, how the overall capacity should be allocated. For example, whether protocol driven GP access to NCS would improve the patient journey overall. Will it appropriately prevent even a small number of referrals from being necessary, or simply provide an investigation earlier in the process, resulting in a shorter RTT time but not a shorter overall patient journey from GP consultation to treatment? The use of neurophysiology technicians working in an extended role, with the support of a clinical neurophysiologist, at one-stop CTS clinics. This can allow results to be provided at the first clinic appointment and can significantly reduce the number of steps in the journey and the patients Referral to Treatment (RTT) time. At Woodend Hospital, after a trial period, a business case was accepted for the purchase of their own machine for one-stop carpal tunnel clinics. This has considerably reduced the RTT time and the number of steps in the patient journey

16 Secondary care Fig. 13: Path from outpatient appointment to surgery Listed at first OPA - NCS same-day or earlier Listed when NCS reviewed - return OPA Listed after single review, no NCS Listed at first OPA - no NCS Listed when NCS reviewed - phone/letter or on day Listed after multiple reviews Although it is entirely appropriate for straightforward, clear cut clinical presentations of CTS to proceed to surgery without Nerve Conduction Studies, it is also generally accepted that when assessing patients with CTS all clinicians should have access to timely NCS. The audit showed that the longer the average length of time that hospitals had to wait for NCS, the less likely they were to request NCS for their patients (n=17 hospitals, r=-.52, p=.3). Boards should consider whether there is a need for NCS guidelines detailing the criteria for which patients would benefit from NCS. There are also options for triaging appropriately to either a technician or neurophysiologist depending on patient symptoms. Clinicians should also consider whether there is a need to bring patients back for a review appointment following NCS or whether a letter or phone call could suffice in some circumstances

17 PROMs/Patient Experience measurement Fig. 14: Pre-op secondary care scoring scored Yes No Not known 15% of patients had pre-op scoring performed. Pre-operative scoring in this context means for PROMs purposes (e.g. DASH, Boston Questionnaire). Scoring systems in use to help determine patient pathway (e.g. whether there is an indication for referral for NCS) were not included. Fig. 15: Patient sent post-operative questionnaire scored PROMs Patient experience None Not known were known to send patient experience questionnaires to 25-5% of all admitted orthopaedic patients, although these were not specifically identified for the audit. PROMs and Patient Experience measurement can provide very useful improvement information that enables clinicians and managers to ensure that good patient outcomes are achieved and that the pathway is patient centred. It is not clear why PROMs/Patient Experience information is still not being routinely gathered despite the implementation of the Quality Strategy and this area being highlighted as a Priority Area for Action

18 CTS procedures rates per head of population Fig. 16: Total carpal tunnel procedures per 1, population by Board of Residence Cases per 1, population A&A Borders D&G GG&C Grampian Highland Lanarkshire Lothian Orkney Shetland Tayside WI Source: SMR1, discharges during financial year 1/11 Fig. 16 shows a considerable variation in the rate of CTS procedures per head of population by Board as calculated from SMR1 data (not MSk Audit data). Clinicians are encouraged to consider reasons for the variation and whether a reduction in the variation is clinically appropriate