Development of a Hip/Knee Pathway between Primary and Secondary Care

Authors:  Aisling Brennan1,3, Caitriona Ní Shé1, Sarah O’Driscoll1, Elaine Barker1, Joe Malone2, Conor McNally2. Institutions:    1Tallaght Hospital, Tallaght, Dublin 24 ... [ view full abstract ]

Authors:  Aisling Brennan^1,3, Caitriona Ní Shé¹, Sarah O’Driscoll¹, Elaine Barker¹, Joe Malone², Conor McNally².

Institutions:    ¹Tallaght Hospital, Tallaght, Dublin 24

                        ²PCCC Dublin South West, Tallaght, Dublin 24                         ³National Clinical Programme for Rheumatology

Objectives:

Hip and Knee referrals are the most common General Practioner (GP) referrals to the Musculoskeletal (MSK) Triage service within the Department of Elective Orthopaedics in Tallaght hospital. Between 2012-2014, 74% of patients with non-traumatic hip and knee pathology were discharged at their MSK Triage clinic visit.  Fifty nine percent of these patients were referred to physiotherapy after their triage appointment.  Therefore, the need for these patients to be referred to secondary care is questionable. Physiotherapy is recommended for these patients prior to considering invasive intervention^1,2. The objective was to establish a care pathway for these patients between Primary, Community and Continuing Care (PCCC) and secondary care.

The aims of this pathway were to:

1) Provide timely access to physiotherapy for patients;

2) Improve access for patients who require further investigations/specialist opinion;

3) Streamline care between primary and secondary care services.

Methods:

In November 2015 a care pathway for patients presenting to GPs with non-traumatic hip or knee pain was devised and established between the MSK Triage Service in Tallaght Hospital and Dublin South West (DSW) physiotherapy department. All patients residing in DSW were eligible for referral to this pathway. GPs in DSW were encouraged to refer patients to PCCC physiotherapy in the first instance. Patients would access PCCC physiotherapy within 6 weeks of GP referral. Any patients who the PCCC physiotherapist deemed appropriate for onward referral would be seen at the MSK Triage Clinic within one month of referral.  

• The pathway and associated information was sent to all GPs in DSW
• The pathway was presented at both the Tallaght Hospital GP Liaison Committee meeting and at a DSW GP Education Forum.

The total number of hip and knee referrals received to the MSK Triage service from DSW GPs was compared between May-July 2015 and 2016.  The number of DSW PCCC physiotherapy referrals from GPs was also reviewed.

 Further promotion of the pathway was done in late 2016.  This included:

• a joint presentation at a GP Study day in Tallaght Hospital,
• individual feedback to GP’s referring to MSK Triage without prior referral to PCCC physiotherapy and
• Promotion of the rapid access to PCCC physiotherapy in DSW. 

Referral rates were reviewed again from Jan-March 2017.

Results:

The percentage of hip and knee referrals from DSW GPs to DSW PCCC Physiotherapy service has increased since the implementation of the pathway from 33% (n=10 December 2015) to 63% of total musculoskeletal referrals (n=30 October 2016).

Accordingly the percentage of referrals from DSW GPs to MSK Triage services has reduced from 46% (May-July 2015) to 44% (May-July 2016) and further again to 30% (Jan-March 2017).

Conclusions:

This initial data shows promising results that GPs in DSW are increasing their utilisation of physiotherapy services in primary care. There percentage of hip and knee referrals from DSW GPs to MSK triage services has demonstrated a downward trend since the implementation of the pathway.

Future developments include introducing this pathway to other primary care areas or other orthopaedic areas.

References:          ¹ The American College of Rheumatology (ACR) guidelines (2012)

² NICE guidelines (2014)

Ethics:  Ethical approval was not sought.