THE WINSTON CHURCHILL MEMORIAL TRUST OF AUSTRALIA. Report by Katherine Rundus 2012 Churchill Fellow

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1 THE WINSTON CHURCHILL MEMORIAL TRUST OF AUSTRALIA Report by Katherine Rundus 2012 Churchill Fellow The Mr and Mrs Gerald Frank New Churchill Fellowship to explore and investigate new strategies and innovative treatment for patients with hand injuries. I understand that the Churchill Trust may publish this Report, either in hard copy or on the internet or both, and consent to such publication. I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of any claim or proceedings made against the Trust in respect of or arising out of the publication of any Report submitted to the Trust and which the Trust places on a website for access over the internet. I also warrant that my Final Report is original and does not infringe the copyright of any person, or contain anything which is, or the incorporation of which into the Final Report is, actionable for defamation, a breach of any privacy law or obligation, breach of confidence, contempt of court, passing-off or contravention of any other private right or of any law. Signed Dated Katherine Rundus

2 Index Page Introduction 3 Programme 4 Acknowledgements 5 Executive Summary 6 List of Abbreviations Chelsea and Westminster Hospital 7 8 The London Hand and Wrist Unit 12 The Royal London Hospital 14 The Pulvertaft Hand Centre: The Royal Derby Hospital Skåne University Hospital: Department of Hand Surgery The Kleinert Kutz Hand Care Centre Stanford University Hospital and Clinics: Hand Therapy Rehabilitation Clinic Recommendations 27 References 28 2

3 Introduction When trauma or disease reduces ones ability to use their hands, the adverse affect on their productivity and quality of life are far reaching. Occupational Therapists specialising in hand and upper limb rehabilitation are well positioned to make a positive impact on the lives of such people. Faced with population growth and the changing demographics of our community, hand therapists are challenged to ensure they continually meet the demands of the community and ensure that they are delivering the best possible care to their patients in a cost effective and timely manner. This Churchill Fellowship aims to investigate potential hand and upper limb rehabilitation methods and strategies, which once implemented, will improve the journey and quality of life of patients with hand injuries. To achieve this outcome, seven internationally renowned Hand and Upper Limb Clinics were visited and focus was given to three broad areas of patient care including access, treatment and discharge. Innovative techniques and methods were observed, providing insight into how therapists can continue to improve the lives and outcomes for patients with hand injuries. While health care delivery across the countries visited varied greatly, elements of international rehabilitation approaches can be applied to Australian practice. A summary of experiences and strategies observed during this fellowship that would be beneficial to Australian Hand and Upper Limb practice has been included at the end of each clinic summary, as well as a final list of recommendations for practice. 3

4 Programme England: 1. Chelsea and Westminster Hospital: Hand Therapy Clinic London, England. 2. The London Hand and Wrist Unit: Platinum Medical Centre London, England. 3. The Royal London Hospital: Hand Therapy Clinic London, England. 4. The Pulvertaft Hand Centre: The Royal Derby Hospital Derby, England. Sweden 5. Skåne University Hospital: Hand Surgery Department Malmo, Sweden. USA 6. Kleinert Kutz Hand Care Centre: Louisville, KY. 7. Stanford Hospital and Clinics: Hand Therapy Rehabilitation Clinic Redwood City, CA. 4

5 Acknowledgements I would like to thank the Winston Churchill Memorial trust for providing me with this remarkable opportunity. My sincere thanks to Mrs New and her late husband for not only supporting this fellowship, but for their ongoing support of the Winston Churchill Memorial Trust. It is through their generous and ongoing support that many Australians are provided with this truly wonderful experience, and the opportunity to give back to the Australian community. I would like to acknowledge the Occupational Therapy Department at Sir Charles Gairdner Hospital (SCGH) for their support and encouragement throughout this experience. My thanks to the Occupational Therapists (OTs) and Physiotherapists (PTs) who generously shared their time, knowledge and skills with me. Finally I would like to thank my partner Brendan for embarking on this experience with me along with our eight month old twin girls Amelia and Jessica. 5

6 Executive Summary Fellow details: Kate Rundus, Senior Occupational Therapist, SCGH Project description: To explore and investigate new strategies and innovative treatment for patients with hand injuries. Highlights Visiting purpose built facilities where Hand Surgery, Nursing and Hand Therapy are not only co-located, but exist as a single Hand Unit. The generosity of therapists was overwhelming, as was their eagerness to share ideas on assessment and treatment. Observing therapist led clinics that are changing and improving the way patients access hand therapy assessment and treatment services. Lessons learnt 1. Therapists are improving patient outcomes and reducing costs and waiting times by altering care pathways through therapist led clinics for assessment and treatment of hand injuries. 2. While the exact format varies between hospitals, therapist led clinics are being run to target two streams of patients. a) For selected elective conditions, therapist led clinics can: reduce waiting time to initial reviews; allow trial of non-operative treatment; and fast track urgent cases to Consultant Hand Surgeons. b) For selected trauma diagnoses, therapist led clinics can: improve the patient journey by reducing unnecessary contact with the system and reduce the occasions of service (OOS) required to reach definitive diagnosis and treatment; and make appointments available for patients requiring a Surgical review. 3. Such clinics are being run by Clinical Specialists or Extended Scope Practitioners (ESP). Acting beyond ones scope of practice (e.g. therapist ordering MRI or giving injections) can be a contentious issue in Australia, however we don t need to extend the scope of practice to recognise the role experienced therapists can play in improving patient care. Even without extending ones scope, therapists can still improve patient care, treatment provision and the cost of services, purely by reviewing and addressing access and referral issues. 4. Varied treatment approaches were observed to treat the same condition. Reviewing these treatment approaches is worthwhile to ensure that the best available treatment option is utilised that is cost effective whilst not compromising patient care. 5. Reviewing and improving the method by which patients are discharged can enhance patient flow and improve access for patients waiting review and treatment. Implementation: Disseminate results with key stakeholders at SCGH. Present recommendations at both local and national conferences including the Australian Hand Therapy Association s Annual Conference. 6

7 List of Abbreviations CTS CMCJ ED EMG ESP FTE GP MRI NCS OA OT OCTR OPC ORIF PDC PT ROM SCGH Carpal tunnel syndrome Carpometacarpal joint Emergency Department Electromyography Extended scope practitioner Full time equivalent General Practitioner Magnetic resonance imaging Nerve conduction study Osteoarthritis Occupational therapist Open carpal tunnel release Outpatient clinic Open reduction and internal fixation Plastics dressing Clinic Physiotherapist Range of motion Sir Charles Gairdner Hospital 7

8 Chelsea and Westminster Hospital 1. General Clinic Information The hand therapy unit consists of OTs and PTs working in an open-plan treatment environment. Therapy services are located next to the operating theatres, with the Outpatient and Plastic Dressing Clinic (PDC) located on the floor above. Outpatient clinics Consultant Hand Surgeons run daily closed trauma clinics in the Outpatient Department with up to three therapists in attendance. Therapists treat patients on a walk in basis and then re-book patients into the Therapy Department for follow-up. Appointment Allocation Non-urgent referrals from the Hand Surgery Department are put onto a waitlist and seen within 6-8 weeks. A senior therapist manages the waitlist and has three timeslots a week to review referrals and make appointments. 2. Referral and Access Outlined below are two initiatives utilised to improve patient access to services. These include a Consultant Hand Therapy Clinic targeting referrals for elective and non-traumatic hand injuries, and a volar plate and mallet clinic targeting Emergency Department (ED) referrals. a) Consultant Hand Therapy Clinics A Consultant Hand Therapist working in the role of an ESP runs this clinic twice a week. This clinic is primarily for the assessment of elective or nontraumatic hand injuries. Administration The clinic is run independently from the Therapy Department. Organisation of appointments, retrieval of medical notes and correspondence with referring doctors is completed by the secretary for the Surgical Directorate. Dictated letters are outsourced to an external company for completion. Referral and Appointments Referrals are received primarily from General Practitioners (GP) and are seen within 18 weeks. The ratio of new to follow up appointments is 1:2. Patients are commonly referred with (but not exclusive to) trigger finger, ganglions, osteoarthritis (OA) of the thumb carpometacarpal joint (CMCJ) and wrist pain. Acting within an extended scope of practice The Consultant Hand Therapist is able to request imaging including x-ray, ultrasound, magnetic resonance imaging (MRI), electromyography (EMG) and nerve conduction studies (NCS). Following assessment the therapist is able to refer for injection under ultrasound, to hand therapy or to Consultant Hand Surgeons. The Hand Surgery Team does not follow up patients unless referred on by the Consultant Hand Therapist. This therapist works autonomously taking on the governance of these patients. 8

9 b) Volar plate and Mallet Finger Clinic This clinic is run once a week by a senior therapist (not an ESP) and has been running since January This clinic is for the assessment and initial treatment of volar plate and mallet finger injuries. Administration: This clinic is run independently of the Therapy Department. Organisation of appointments and retrieval of medical notes is completed by the secretary for the Surgical Directorate. Referral and Appointments: Referrals are received from the ED. Patients referred into this clinic are assessed by the therapist and all follow up is provided in the Therapy Department. Patients are not reviewed by the Hand Surgery Department unless deemed necessary by the senior therapist. Future: The future of this clinic was discussed including the potential expansion of this role to include further diagnostic groups including metacarpal fractures, central slip injuries and ulnar collateral ligament injuries of the thumb. Example of Patient Pathway Referral from Doctor in ED ê Therapist Led Volar Plate and Mallet Finger Clinic ê Initial Review: 30 Minutes Assessment History Clinical Assessment Review X-rays Treatment Splint Education Exercises í î Ongoing Hand Therapy Hand Surgery Referral 9

10 Literature Box 1: Within England many therapists are changing the throughput of patients via therapist led clinics. Katsoulis, Rees and Warwick (2005) report outcomes of a therapist led mallet finger clinic similar in nature to the clinic observed at Chelsea and Westminster. Initial diagnosis is made by a doctor (commonly from ED) and while a specialist therapist provides subsequent care, the medical governance of the patient remains with the medical team (Katsoulis et al 2005). The components of training or experiences that quantifies a specialised therapist is not reported upon. The outcome for these patients is not compromised, and the change in work pattern has allowed consultants to review more specialised and complex cases (Katsoulis et al 2005). 3. Treatment a) Diagnostic Exclusions Post-operative therapy is not routinely provided to the following diagnostic groups: open carpal tunnel release (OCTR), nail bed repairs and digital nerve repairs. b) Hand Practitioner Clinic (post-operative trauma patients) A post-operative clinic is run once a week by a Clinical Specialist OT working in the role of an ESP and is co-run with a Nurse Practitioner. This clinic is for follow-up review of post-operative trauma (i.e. tendon and nerve repairs) Administration: The clinic is run independently of the Therapy Department. Organisation of appointments and retrieval of medical notes is completed by the secretary for the Surgical Directorate. Referral and Appointments: Patients are routinely provided with this appointment six weeks post operatively. Acting within an extended scope of practice: The role of providing follow-up post-operative care is considered to be acting within an extended scope of practice as the therapist is taking on the responsibility of follow-up medical care. Patients do not routinely see the Consultant Hand Surgeon or medical team other than their first post-operative appointment. Literature Box 2: Peck, Kennedy, Watson and Lees (2004) discuss the value of therapist led clinics in the post operative care of selected diagnoses of hand trauma patients. Improved patient outcomes are reported with reduced tendon rupture rates, improved attendance and improved compliance with post-operative regimes (Peck et al 2004). Such clinics have reduced the waiting time for consultant reviews and allowed improved throughput through outpatient clinics whilst still providing a high standard of care (Peck et al 2004). 10

11 Application and Considerations: Shared Administration: Having the administration of therapist led outpatient clinics completed by the Outpatient Department takes the responsibility of the daily running of the clinic away from the therapist so they can focus on patient care. It helps to formalise the process to enable such clinics to be process dependent, rather than dependent on the individual in the position. Recognition: The development of Clinical Specialists and ESP roles provides recognition of the specialist skills and experience of senior therapists. It provides greater opportunities for career progression and has the potential to assist with staff retention. Trauma Pathways: By reviewing care pathways for closed trauma (volar plate and mallet injuries as above) there is the potential to improve the patient journey (reduce the OOS to reach a desired outcome) and reduce the cost of care provision. Consideration should be given to the role of an experienced therapist in triage in PDCs. Elective Pathways: By reviewing the care pathway for diagnostic specific elective conditions (Trigger finger/ thumb CMCJ OA) there is the potential to provide earlier access to non-surgical management and better patient outcomes. 11

12 The London Hand and Wrist Unit - Platinum Medical Centre 1. General Clinic Information The London Hand and Wrist Unit is a private hand therapy team with five clinics in London. The team is comprised of both OTs and PTs and is managed by a combined Therapies Manager. There are no junior therapists, and all therapists are employed as Senior Clinicians or Clinical Specialists. Physical Layout The Hand Therapy team is co-located with the Hand Surgeons, and operating theatres are located on the floor above. As well as an open treatment area there are two private treatment rooms including custom made treatment tables. All staff have access to computer tablets to review pertinent information including patient x-rays and appointment diaries. Research The clinic has established a database to record patient data to assist with audit and research. All therapists must enter information at time of discharge for all patients. Information includes but is not limited to the following: Date of Injury Date or surgery Diagnostic information OOS DASH (Disability of the Arm, Shoulder and Hand Outcome Measure) PRWE (Patient rated wrist evaluation) Clinical Specialists The team is comprised of two therapists employed as Clinical Specialists who are required to take the lead with clinical issues. The Clinical Specialists are recommended to have a minimum of five years specialised experience in the field of hand therapy, experience in clinical audit, recognised training in validated courses and be accredited therapists of the British Association of Hand Therapists (or working towards this). Their duties include: managing and updating clinical pathways to ensure the delivery of evidence based practice; liaison with surgeons regarding ongoing clinical management and decisions related to patient care and practice; providing clinical direction for the department; and marketing of the unit and profession. 2. Referral and Access The team receives referrals from Consultant Hand Surgeons, GPs or individuals can self refer. Walk-in appointments are available during the times of Consultant clinics. All new patients are allocated a one hour appointment. One reported benefit of having a longer initial appointment is that it affords therapists the opportunity to input appropriate information for future clinical audits. 12

13 Application and Considerations: Clinical Specialists versus ESP: This clinic does not have therapists in the role of ESP, however they do have Clinical Specialists. The development of such roles provides recognition of the specialist skills and experience of therapists, as well as representation to external parties of the high quality and experience of staff. Research: Consider the development of a database to assist with audit and research. 13

14 The Royal London Hospital 1. General Clinic Information The hand therapy team is comprised of OTs and is located in a combined Therapies Department with a shared administration area. There is a combined Therapies Manager who manages across all therapy divisions and sites. Physical Layout The Therapy Department is located next door to the Orthopaedic Consultant Clinics. With the recent move to a new hospital building, the Plastic Surgery Department is no longer co-located with the Therapy Clinic (currently still located in the old hospital building). The Hand Therapy Clinic has one large open treatment area, there are two private treatment rooms and a group treatment area that includes an administrative area for therapists. Appointment Allocation All new patients are allocated a one hour appointment and follow up appointments are allocated 30 minutes. Patients are not routinely seen on the day of referral and new referrals received from the Outpatient Clinics (OPC) are triaged and allocated according to urgency. 2. Referral and Access Referrals received from GPs are seen in an ESP clinic that is outlined in detail below. All other referrals are received from internal sources including the Plastic Surgery and Orthopaedic Department. ED referrals are sent straight to the Orthopaedic and Plastic Surgery Department. a) ESP Clinic This clinic is run twice weekly by a Clinical Specialist OT working in the role of an ESP. This clinic is for assessment and treatment of elective or nontraumatic hand injuries. Literature Box 3: The views of Hand Surgeons working with ESPs were explored in a survey by Ellis and Kersten (2002). They report the need for ESP clinics emerged in response to changing government legislation and directives that aimed to reduce waiting times for patients and improve consultant workloads. Expressed by some respondents was the opinion that ESPs could treat patients as effectively as consultants and that it allowed personal development for therapists (Ellis and Kersten 2002). Concerns about the evolving roles of ESPs included inappropriate extension of roles, exposure to litigation and that the quality of service provision is dependent on the person in the role (Ellis and Kersten 2002). 14

15 Administration The clinic is run independently from the Therapy Department. The organisation of appointments, retrieval of medical notes and correspondence with referring doctors is completed by the secretary for therapy services. GPs are able to directly book appointments on a shared booking system. Referral and Appointments Referrals are received from GPs and are seen within 18 weeks. Patients are commonly referred with (but not exclusive to) carpal tunnel syndrome (CTS), trigger finger, de Quervain s tenosynovitis, ganglions, OA and wrist pain. This clinic is seen as a one stop shop. In one appointment the patient receives assessment, non-operative treatment (injection, splinting), education, exercises and then is either discharged back to the GP or referred on to a Hand Surgeon. A follow up appointment is arranged if investigations are ordered to review results and plan definitive treatment. Acting within an extended scope of practice The ESP is able to request imaging including x-ray, MRI, EMG and NCS. Following assessment, the ESP therapist is able to administer injections, refer to therapy or to Consultant Hand Surgeons. This therapist works autonomously, taking on the governance of these patients. Example of Patient Pathway for CTS GP Referral ê Therapy ESP Clinic ê Initial Appointment Assessment - History - Phalen s +/- EMG/ NCS Treatment - Splint +/- Injection - Tinel s - Boston Carpal Tunnel Syndrome Questionnaire - Education í ê î Discharge to GP Follow Up Review - post investigations Referral to Hand Surgeon 15

16 Literature Box 4: Warwick and Belward (2004) report on the implementation of a therapist led carpal tunnel clinic. The clinic was established secondary to increasing demand on the Hand Surgery Department and with the recognition that surgical outcomes are less successful with longer symptom duration (Warwick and Belward 2004). Following three years of implementation, the reported benefits of the therapist led clinic were considered to be saving consultant time, improving the quality of patient care and improved data collection for future research (Warwick and Belward 2004). 3. Follow-up and discharge All trauma patients can be discharged from the hospital at the discretion of the therapist. There are no set criteria for discharge or time frame dictating when discharge should occur by. At the point of discharge, a letter is sent to the patients GP. Application and Considerations: Elective Pathways: By reviewing the care pathway for diagnostic specific elective conditions (CTS/Trigger finger/thumb CMCJ OA) there is the potential to provide earlier access to non-surgical management and improve patient outcomes. Allocation of Appointments: Trauma and post operative patients are not seen on the day of referral, but triaged and allocated an appointment based on priority, allowing greater control over daily appointments. Review of appointment allocation (triage versus walk in appointments) is recommended to ensure clinics are meeting the needs of the patients within the defined allocated daily appointment slots. Discharge: Review of discharge guidelines for criteria led discharge would be beneficial to ensure the process facilitates streamlined discharge that does not compromise patient care. 16

17 Pulvertaft Hand Centre: The Royal Derby Hospital 1. General Clinic information The Hand Therapy team is comprised of both OTs and PTs with a combined Therapies Manager. They have 16 full time equivalent (FTE) employees including Therapy Assistants. Physical Layout The hand therapy clinic is located in a purpose built Specialist Hand Care Centre. The ground floor is comprised of the Outpatient Consultant Clinic (Orthopedic and Plastic Surgeons) and the Hand Therapy Department, with a shared reception area in the centre. The operating rooms are located on the floor above. This close proximity allows for excellent communication between the medical, nursing and therapy teams and rather than isolated departments, all specialties are combined as a cohesive team. There is one large open treatment area, one large group treatment area, five individual treatment areas as well as a staff administration office. All rooms have access to computers on which therapists are able to review x-rays. There is a hand therapy library and an education room that has video links to theaters. Outpatient Clinics Consultant Hand Surgeons run daily clinics. Approximately four therapists have an open clinic diary (no planned appointments) so they can treat all walk-in patients during this time. Therapists have access to theatre lists and are able to communicate with administration staff to request post-operative follow up appointments. Research There is a dedicated research team. This includes a full time research coordinator (Radiologist) and a dedicated research Fellow (senior doctor). Three therapists are allocated research time every week totaling approximately 20 hours. Within this time therapists are involved in data collection for cross centre research projects or departmental research. Writing application for grants for research is completed within this time. 2. Referral and Access The team runs ESP clinics daily that receive referrals from both internal (ED) and external (GP) sources. Within these clinics the ESP also runs postoperative review clinics as outlined below. a) ESP Clinics The ESP post is the equivalent of one FTE made up of two practitioners, a PT and an OT. These clinics have been running since 2006 and when introduced had backfill to cover the loss of therapist from the clinic. The therapist s positions were upgraded to reflect the specialised skills required to complete the role. Clinical Pathways have been developed for all conditions seen in this clinic. Checklists and structured documentation exists for the extended roles taken on by the therapists. 17

18 Literature Box 5: The development of standardised assessment forms and well developed care pathways, agreed upon by the Hand Surgeons is discussed by Rose and Probert (2009) in their development of therapist led clinics for CTS and thumb CMCJ OA. Their newly developed pathway was able to reduce the demand for outpatient appointments, reduce waiting times to first appointment and provide earlier access to non-operative treatment for this patient group (Rose and Probert 2009). Through the trial phase of their project they were able to establish that not only are therapists effective in diagnosing and developing appropriate treatment plans for CTS, but also other conditions, some of which include ganglions, de Quervain s and trigger finger (Rose and Probert 2009). Administration Organisation of appointments, retrieval of medical notes and correspondence with referring doctors is completed by the combined Hand Centre s administrative team. The importance of adequate geographical and administrative resources and support, as is seen within this clinic, is further supported by Rose and Probert (2009). Therapists document directly into the medical notes. Referral and Appointments The clinic covers patients from 3 areas. a) ED Referrals: 15 minute appointment (usually within 2-3 days of referral) Common conditions include: - Volar plate - Mallet finger - Thumb injuries - Closed central slip injuries - Distal phalanx fracture - Closed 5 th metacarpal neck fractures b) Post operative follow up: 15 minute appointment Common conditions include: - Flexor tendon injuries - Extensor tendon injuries - Dupuytren s contracture c) GP referrals: 30 minute appointment Common conditions include: - CTS - de Quervain s - Trigger Finger - Thumb CMCJ OA - Cubital Tunnel Syndrome Acting within an extended scope of practice The ESP is able to request imaging including x-ray, ultrasound and computed tomography (CT) scans. They can additionally complete injections for CTS, trigger finger and de Quervain s tenosynovitis. Patients seen within this clinic are not seen by the Hand Surgery team unless referred on by the therapist. The therapists work autonomously taking on the governance of these patients. Consultant clinics are running next door and so patients can be referred on, or cases discussed with the medical team if required. 18

19 Literature Box 6: The diagnostic groups deemed suitable for review in a therapist led clinic varied between institutions. Branstiter and Sandford (2010) report on an extended scope clinic for acute traumatic wrist injury where patients were directly referred to a hand therapy led clinic from the ED. The implementation of this clinic has lead to an improved shortened patient pathway that optimizes patient outcomes (Branstiter and Sandford, 2010). 3. Treatment a) Wrist groups Distal radius fractures are not routinely managed in the Hand Therapy Department. Following open reduction and internal fixation (ORIF), patients are routinely seen by a ward therapist and followed up in the Orthopedic OPC where they are provided with an off the shelf wrist brace. If deemed necessary at this review, patients can then be referred to a wrist group run in the Hand Therapy Department. The wrist group is attended by a PT, an OT and 1-2 therapy assistants. The therapy assistant runs the group and the PT/OT complete assessments, joint mobilisation and range of motion (ROM) exercises. Referral and Appointments Patients are commonly referred into this group three weeks post ORIF or six weeks post non-operative management of distal radius fracture. Patients attend twice weekly for one hour sessions with a maximum of 10 patients in a group. Patients are reviewed after 6 sessions and may attend for between six to ten weeks. Administration The clinic is run by the Therapy Department and administration completed by the combined Hand Care Centre administration team. 4. Follow up and discharge Therapists can discharge all conditions without the need for review by a Consultant Hand Surgeon. There are no diagnostic exclusions. Patients can be given an open review for six months. If patients require review they can be re-referred to the hand therapy clinic by their GP. A standardised GP discharge letter is provided at discharge. 19

20 Application and Considerations: A combined Hand Care Team: Where possible hand therapy services should be co-located with the Hand Surgery Department, Plastic Dressing and OPCs. Having one location for all services improves the patient journey, reduces lost time and improves communication between departments. While close physical proximity is arguably an important starting block, the combination of all disciplines as a single Hand Unit as seen here, moves beyond this. It provides a more meaningful integration where the focus is able to move beyond the individual discipline, to shared accountabilities and outcomes. Defining the role: When implementing new services or roles (ESP or therapist led clinics) having well defined and agreed upon care pathways for all diagnostic groups is essential. By defining the boundaries of therapists practice and service provision, it ensures such services are replicable and that all clinics and processes are well established and not reliant on the person in the role. Elective Pathways: By reviewing care pathways for diagnostic specific elective conditions (CTS/Trigger finger/thumb CMCJ OA) there is the potential to provide earlier access to non-surgical management. Trauma Pathways: By reviewing care pathways for closed trauma there is the potential to improve the patient journey (reduce the OOS to reach a desired outcome) and reduce the cost of provision of care. Consideration should be given to the role of an experienced therapist in triage in the PDC. Group versus Individual Therapy: A review of the utilization of therapy assistants and group therapy should be considered. This should address OOS to achieve desired outcome, therapist input required to monitor progress, training needs of therapy assistants and the optimal number of patients required to make groups a viable treatment approach. Discharge: Review of discharge guidelines for criteria led discharge would be beneficial to ensure the process allows streamlined discharge that does not compromise patient care. Consideration should be given to whether discharge occurs at the time optimal outcome is achieved or be defined by time since injury. Research: Consideration should be given to the development of a research post across Hand Surgery and Hand Therapy. Having allocated research time in a therapists case load in this clinic has lead to involvement in multiple research projects and publication of results. 20

21 Skåne University Hospital : Department of Hand Surgery 1. General Clinic Information The hand therapy clinic is located in a purpose built six story Hand Surgery Department. The hand therapy department is located on the fourth floor, with operating theaters, nursing, hand specific inpatient wards and OPC located on the floors above and below. This close proximity allows for excellent communication between the medical, nursing and therapy teams and rather than isolated departments, all specialties are combined as a cohesive team. Clinic structure Both OTs and PTs staff the clinic. There are additionally Rehabilitation Assistants and a Social Worker (in total 12 FTE). Therapists do not have shared competencies meaning that certain tasks can only be completed by one profession. An example of this would be the treatment of extensor tendon injuries where an OT would complete the splint and a PT would complete the exercises. With concurrent nerve injury and repair the OT would complete sensory assessment and treatment. Physical Layout OTs and PTs are paired together and have their own treatment room with computers to access relevant patient information as well as complete digital notes. There is a quiet room for sensory assessments, a group treatment area, and a separate area for work simulation. Some patients may be seen twice a day, or come for intensive periods of hand therapy and so there is also a patient lounge. 2. Referral and Access All patients seen in the Hand Therapy Clinic are referred by the Consultant Hand Surgeons. 3. Treatment Approaches Assessment following nerve repair Researchers at the department developed the Model instrument for outcome after nerve repair (Rosen and Lundborg 2003). This assessment documents progress, evaluates outcomes and can assist in planning rehabilitation objectives. The assessment covers three domains including sensory recovery, motor recovery and pain (Rosen and Lundborg 2003). 21

22 Application and Considerations: A combined Hand Care Team: Where possible hand therapy services should be co-located with the Hand Surgery Department, Plastic Dressing and OPCs. Having one location for all services improves the patient journey, reduces lost time and improves communication between departments. While close physical proximity is arguably an important starting block, the combination of all disciplines as a single Hand Unit moves beyond this. It provides a more meaningful integration where the focus is able to move beyond the individual discipline, to shared accountabilities and outcomes. Sensory Assessment: Review of assessment procedures for never repair and consideration of the use of the Model instrument for outcome after nerve repair is recommended. Having a standard time frame and assessment procedure for sensory recovery can improve consistency of documentation across therapists and ensure assessment not only tracks individual improvement but assists in treatment planning. 22

23 Kleinert Kutz Hand Care Centre 1. General Clinic Information The Hand Therapy Clinic, a part of the Christine M. Kleinert Institute is comprised of 18 therapists working over five locations. Staff includes PTs, OTs, Therapy Assistants and Orthotists. The hand therapy team runs alongside the Kleinert Kutz Hand Care Centre that is comprised of 12 Hand Surgeons. Physical Lay out The primary facility in downtown Louisville is located over three floors and contains the operating theaters, Consultant rooms, OPC and the Therapy Department. Radiography is based within the clinic having the benefit of improving the patient journey by reducing lost time. 2. Referral and Access This is a privately run, not for profit clinic that services patients who are privately insured, workers compensation as well as those covered by Medicare. Patients are referred to the hand therapy clinic by Consultant Hand Surgeons of the Kleinert Kutz Hand Care Centre. All patients require a prescription for splints and therapy that are directed by the referring Surgeon. The frequency of visits is dictated by insurance. 3. Treatment Protocols The treatment protocols outlined below are based on discussions held with the Surgeons and therapists with whom I spent time and do not necessarily reflect the practice or preferences of the entire clinic. OCTR: The Surgeon observed did not routinely refer to therapy post OCTR. Within the OPC the doctor or nurse provides an off the shelf wrist brace that is worn for four weeks post operatively. While the patient was not followed up in therapy they would have at least two OPC appointments with the Surgeon. Volar Plate: The Surgeons preference was for immobilization in an off the shelf splint for three weeks for PIPJ volar pate injuries with avulsion fractures. Metacarpophalangeal Joint (MCPJ) Arthroplasty: Within the first 1-3 weeks post operatively the patient is placed in a plaster of paris cast with a dynamic outrigger. This is then replaced with a thermoplastic dynamic extension splint. Dupuytren s Contracture: Following both fasciectomy and collagenase injections, patients are placed in a volar forearm based thermoplastic splint. Flexor Tendons: Patients are commonly placed in a fiberglass cast. Although not used by all surgeons, the Kleinert protocol utilizing dynamic flexor traction is utilized for flexor tendon repairs. 23

24 Observation of Orthotist: I had the opportunity to trial different techniques of fiberglass and thermoplastic splinting including: fiberglass flexor tendon hoods with dynamic flexion traction; dynamic splinting outriggers with radial pull for MCPJ arthroplasty; and proximal interphalangeal joint extension splinting. 4. Follow-up and discharge Patients are routinely followed up by the Consultant Hand Surgeon post operatively and then referred on to therapy. The referring Surgeon completes the discharge of patients. Application and Considerations: Physical environment: Where possible hand therapy services should be colocated with the Hand Surgery Department, Plastic Dressing and Outpatient Clinics. Having one location for all services improves the patient journey, reduces lost time and improves communication between departments. Therapy or Doctor follow-up? : The cost of achieving desired outcome following OCTR: Review of post operative OCTR is recommended to review the OOS and cost required to achieve a desired outcome. This should include comparison of cost of referral to therapy post operatively to Consultant only follow-up. Treatment: Share alterative approaches to: - fiberglass bracing for flexor tendon injuries; - dynamic extension splinting with radial pull for MCPJ arthroplasty; and - therapy and splinting post collagenase injections for Dupuytren s contracture. 24

25 Stanford University Hospital and Clinics: Hand Therapy Rehabilitation Clinic 1. General Clinic Information The Hand Therapy Clinic is comprised of Certified Hand Therapists working in an open treatment environment. The hand therapy team is located with the Consultant Hand Surgeons in their Redwood City Centre. There are nine Hand Surgeons each with two nurses, and 7.8 FTE Hand Therapists including therapists who cover the wards in the main hospital. There is additionally a full time Plaster Technician and Nurse Practitioner that completes postoperative dressings and follow up of defined diagnostic groups. 2. Referral and Access This is a not for profit clinic that services patients who are privately insured, workers compensation as well as those covered by Medicare and Medicaid. Either Consultant Hand Surgeons or GPs refer patients to the hand therapy clinic. All patients require a prescription for splints and therapy that are directed by the referring Doctor. The frequency of visits is dictated by insurance or Medicare. 3. Treatment Protocols OCTR: Patients are not routinely referred to therapy for post-operative care. Elbow Splinting: Therapists within the clinic do not fabricate elbow splints. These are provided by a vendor who provides the splint and any follow up required. This includes dynamic and static progressive splints for the elbow and forearm. Dupuytren s Contracture: Following collagenase injections night splinting is provided for on average three months. Therapists report to monitor for oedema and blisters at injection site. CMCJ Arthroplasty: Surgeons utilise the mini tightrope procedure. Post-operative therapy includes a plaster or thermoplastic long thumb spica splint for two weeks. Following this active ROM is introduced and the splint is only utilised for night time or heavy activities. Trigger Finger: A senior therapist is completing research on the use of a dorsal hand based splint for trigger finger. 4. Follow-up and discharge Patients are routinely followed up by the Hand Surgeon post operatively and then referred on to therapy. The referring Surgeon completes the discharge of patients. 25

26 Application and Considerations: Physical environment: Where possible hand therapy services should be colocated with the Hand Surgery Department, Plastic Dressing and Outpatient Clinics. Having one location for all services improves the patient journey, reduces lost time and improves communication between departments. Therapy or Doctor follow-up? : The cost of achieving desired outcome following OCTR: Review of post operative OCTR is recommended to review OOS and cost required to achieve a desired outcome. This should include comparison of cost of referral to therapy post operatively to Consultant only follow-up. Treatment: Share alternative approaches to: - splinting for trigger finger; - therapy following mini-tightrope procedure for CMCJ arthroplasty; and - therapy and splinting following collagenase injection for Dupuytren s contracture 26

27 Recommendations 1) Develop the role of therapists as Clinical Specialists. The role of Clinical Specialist should be implemented in Hand and Upper Limb Therapy. This can assist in improving patient outcomes and optimise the cost effectiveness of service provision. Thoughtful consideration needs to be given to the roles that define the practice of a Clinical Specialist and what separates them from senior therapists or the practice of ESPs. 2) Two streams of Clinical Specialists within Hand Therapy. Within a public hospital setting the role of therapists as Clinical Specialists could be effectively split between two streams of patients trauma and elective. a) Clinical Specialist - trauma lead: The trauma lead would provide clinical direction for trauma patients. This would include review of clinical pathways and implementation of therapist led clinics for trauma patients. b) Clinical Specialist - elective lead: The elective lead would provide clinical direction for elective patients. This would include review of clinical pathways and implementation of therapist led clinics for non-traumatic hand disorders. 3. Implement therapist led clinics for selected closed trauma diagnoses. Following discussion with the Plastic Surgery Department, identify diagnostic groups suitable for therapist led clinics. Such conditions could include ED referrals for volar plate injuries and mallet finger injuries. Detailed care pathways for designated diagnosis should be developed. 4. Implement therapist led clinics for selected elective diagnoses. Following discussion with the Plastic and Orthopaedic Departments, identify diagnostic groups of elective hand disorders suitable for therapist led clinics. Conditions should include diagnostic groups that would benefit from nonoperative treatment prior to a review by a Consultant Hand Surgeon such as CTS, de Quervain s, Trigger Finger and thumb CMCJ OA. 5. Cost effective service provision. The clinics visited differed in the treatment approaches utilized for the following conditions; OCTR, nail bed repairs, digital nerve repairs and distal radius fractures. This included providing no therapy, consultant only review post operatively or group therapy. Review of current patient pathways would be of benefit to ensure our methods are cost effective whilst still optimizing patient outcomes. 6. Discharge Process: A review of guidelines for criteria led discharge is recommended to ensure a streamlined approach that does not compromise patient care. This should review if discharge should be defined by the time since injury or when an optimal outcome is achieved. 7. Combined Hand Care Team: Where possible hand therapy services should be co-located with Hand and Upper Limb Surgeons, Nursing and OPCs. Further to this, combining all disciplines into a single Hand Unit provides a more meaningful integration where the focus is able to move beyond the individual disciplines, to shared accountabilities and outcomes. 27

28 References 1. Branstiter G, Sandford G. (2010). Extended Scope Hand Therapist Led Acute Traumatic Wrist Injury Clinic. Journal of Hand Therapy, 23 (4), e Ellis B, Kersten P. (2002). The Developing Role of Hand Therapists within the Hand Surgery and Medicine Services: an Exploration of Doctors' Views. British Journal of Hand Therapy, 7(4), Katsoulis E, Rees K, Warwick D.J. (2005). Hand Therapist-led Management of Mallet Finger. The British Journal of Hand Therapy, 10 (1), Peck F.H, Kennedy S.M, Watson J.S, and Lees V.C. (2004) An evaluation of the influence of practitioner-led hand clinics on rupture rates following primary tendon repair in the hand. The British Association of Plastic Surgeons, 57, Rose R, Probert S. (2009). Development and implementation of a hand therapy extended scope practitioner clinic to support the 18 week initiative. Hand Therapy, 14, Rosen B, Lundborg G. (2003). A new model instrument for outcome after nerve repair. Hand Clinics,19, Warwick D, Belward P. (2004). Hand Therapist Carpal Tunnel Clinic. British Journal of Hand Therapy, 9 (1),