An audit of the use of risk stratification for low back pain chronicity in an acute hospital physiotherapy out-patient department

Objective of Study:... [ view full abstract ]

Objective of Study:                                                                                                                                        

NICE G.L. 59 ‘Low back pain and sciatica in over 16s: assessment and management’ (2016) 1.1.2 states: Consider using risk stratification (for example, the STarT Back risk assessment tool) at first point of contact with a healthcare professional for each new episode of low back pain with or without sciatica to inform shared decision-making about stratified management.

This study audited the use of risk stratification using the STarT Back risk assessment tool (SBT) during first contact/ assessment of low back pain patients in an acute hospital physiotherapy out-patient department.

Method:

• An initial sample of low back pain patient charts (n=23) was randomly selected from an out-patient database and analysed to establish a baseline percentage that used a STB.

• In-service training (IST) was provided to highlight updated sections of NICE G.L. 59 (2016) and highlight the role of risk screening in the management of low back pain as advocated therein. Risk screening was promoted as a required precursor to establishment of evidence-based ‘matched’ stratified care pathways.

• To further facilitate use of the SBT, departmental lumbar spine assessment templates were amended to include ‘Risk Rating’ in ‘Problem lists’ and both SBT and assessment templates were printed on blue paper. 

• Following provision of IST and documentation changes, a second sample of charts (n=22) was randomly selected to analyse the number of charts that used a SBT.

• The percentage of charts that had used the SBT in first and second chart samples was compared.

• To promote additional use of the SBT, a ‘reminder’ email was then circulated to all staff.

• Following circulation of the ‘reminder’ email, a third random sample of charts (n=21) was selected.

  Results:  

  Prior to provision of in-service training four percent of low back pain patient charts in a randomly-selected sample contained SBT at point of first contact.  Following in-service training and changes to departmental documentation this figure rose to fifty percent. Subsequent circulation of a reminder email to all staff to use SBT resulted in a further two percentage improvement in usage.

  Conclusions:  

  In spite of in-service training promoting its usage and the advocacy of NICE GL 59 (2016), under-utilization of low back pain risk stratification at first point of contact by Physiotherapy out-patient staff is evident.  This has implications for both efficacy and efficiency in the management of low back pain within the department. 

  A questionnaire will be circulated to relevant members of staff to ascertain why this continues to be the case and also elicit staff views on risk screening. Results of this survey will inform future targeted interventions to improve compliance with SBT usage. This will both align clinical practice with the best available evidence for management of LBP and also optimize efficiency of physiotherapy service delivery into the future.

References:

Low back pain and sciatica in over 16s: assessment and management. NICE guideline [NG59] Published date: November 2016

Hill, J., Whitehurst, D., et al (2011) Comparison of stratified primary care management for low back pain with current best practice (STartBack): a randomised controlled trial. The Lancet, Published online September 29, 2011 DOI: 10.1016/S0140-6736(11)60937-9 1

Ethical Approval:

Not required.