Extended Scope Physiotherapists Research Articles

Expert clinical consensus in the delivery of hydrodilatation for the management of patients with a primary frozen shoulder : a modified Delphi study.

AimsTo achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation.MethodsWe conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional.ResultsBetween 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating).ConclusionIn the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation.Cite this article: Bone Jt Open 2022;3(9):701–709.

Extended Scope Physiotherapists are Effective and Safe in the Emergency Department: A Systematic Review and Meta-Analysis

Purpose: Extended scope physiotherapists (ESPs) are an innovative approach to service delivery that have emerged in response to increasing pressures on emergency departments (EDs). While previous systematic reviews have suggested that ESPs have a positive impact on ED outcomes, clinical practice recommendations based on limited evidence highlight a pressing need for evaluation studies to truly determine their effectiveness and safety in this setting. Therefore, the objective of this systematic review and meta-analysis was to evaluate the clinical effectiveness and safety of ESPs when delivering services in EDs. Method: Systematic literature searches were conducted using the online databases: Medline (Ovid), CINAHL (EBSCOhost), Scopus, PEDro, Cochrane Library and Informit in October, 2019. Randomised controlled trials (RCTs) or cohort studies investigating the clinical effectiveness and safety of ESPs in EDs in comparison with usual ED medical care providers were eligible for inclusion. Data extraction was completed using a form specifically developed for the study. The quality of each study was assessed using the Crowe Critical Appraisal Tool (CCAT) as well as a subjective assessment of bias, and the level of evidence was graded using the National Health and Medical Research Council (NHMRC) evidence hierarchy. Random-effects model meta-analyses were conducted using Stata (version 16.1). Results: Eleven studies met the inclusion criteria for the systematic review. These studies provided III-1 to III-3 evidence, with quality scores ranging from 50% to 93%. Consistent positive results were found regarding ESP clinical effectiveness and safety with meta-analyses demonstrating significant reductions in wait time (Cohen’s d effect size: -0.54; 95% confidence interval [CI]: -0.64 to -0.45) and length of stay (Cohen’s d effect size: -0.79; 95% CI: -0.86 to -0.72) for patients managed by ESPs. Although, confounding of results by treatment urgency made it difficult to establish a clear causal link between ESP services and outcomes. Conclusion: Although it was not able to be suggested that ESPs are an appropriate substitute for usual ED medical care due to the presence of bias and confounding, the results highlighted that ESPs, as an additional staff member in EDs, improve throughput and access to care for patients in lower urgency triage categories.

P068 Early experience and outcomes of telephone and video consultations in rheumatology during first wave of COVID-19

Background/Aims The 2018 NHS Long Term Plan set a target of reducing face to face (F2F) outpatient visits by a third within 5 years. The COVID-19 pandemic forced departments to implement changes to the delivery of outpatient services at unprecedented speed. Here we present our community-based department’s experience of offering telephone and video consultations to new patients during the first wave of the pandemic. Methods All new patients (excluding those with suspected early inflammatory arthritis or other conditions triaged as urgent) offered an appointment with a consultant or extended scope physiotherapist in the rheumatology service from 11 May 2020 were offered a choice of a telephone or video consultation. Data were collected on the choice of appointment, provisional diagnosis, final diagnosis and need for a subsequent F2F assessment. Surveys to assess patient and staff experience were distributed and analysed. Results Between 11/05/2020 and 24/07/2020, 215 virtual consultations were booked. 124 patients (57.7%) opted for a video consultation and 91 (42.3%) chose a telephone consultation. The 'Did Not Attend' rate was 5.1%. Following the initial assessment, 68% of patients were discharged, 16% were booked for a F2F appointment and 16% required further investigations prior to a management decision. The discharge rates between video (70%) and telephone (65%) consultations were similar. Patients with non-inflammatory conditions such as fibromyalgia, hypermobility and osteoarthritis were more likely to be discharged after a virtual consultation. The staff survey highlighted that most clinicians had no prior experience or training in conducting virtual consultations. However, confidence in these modalities rapidly grew, with the majority of respondents happy to deliver a varying proportion of consultations remotely post pandemic. The first 20 patient surveys returned showed that remote consultations were generally well received. 16 patients (80%) agreed or strongly agreed that the consultation met their needs and was a suitable replacement for a F2F appointment. However, only 60% stated that they would be happy to have remote appointment after the pandemic. Conclusion Telephone and video consultations for rheumatology new patients were successfully adopted during the first wave of the COVID-19 pandemic, particularly for non-inflammatory conditions. Although clinicians had limited experience and training in remote consultations prior to the crisis, most adapted rapidly and would consider continuing with them after the pandemic. The majority of patients were happy with their virtual consultation during the first wave, although were less certain of their acceptability in the future. A further analysis and patient survey is underway to ascertain any differences during the second wave. We propose a hybrid model in the post-pandemic future to offer patients a choice of F2F, telephone or video consultations. Disclosure C. Rao: None. S. Horton: None. E. MacPhie: Other; EM is the secretary of the North West Rheumatology Club, whose regional meetings have been funded by an unrestricted educational grant from UCB and are now sponsored by Abbvie. A. Madan: None. S. Fish: Other; Member of the Heberden Committee.

Inter-professional agreement and collaboration between extended scope physiotherapists and orthopaedic surgeons in an orthopaedic outpatient shoulder clinic \u2013 a mixed methods study

BackgroundExtended scope physiotherapists (ESP) are increasingly supplementing orthopaedic surgeons (OS) in diagnosing patients with musculoskeletal disorders. Studies have reported satisfactory diagnostic and treatment agreement between ESPs and OSs, but methodological study quality is generally low, and only few studies have evaluated inter-professional collaboration. Our aims were: 1) to evaluate agreement on diagnosis and treatment plan between ESPs and OSs examining patients with shoulder disorders, 2) to explore and evaluate their inter-professional collaboration.MethodsIn an orthopaedic outpatient shoulder clinic, 69 patients were examined independently twice on the same day by an ESP and an OS in random order. Primary and secondary diagnoses (nine categories) and treatment plan (five categories, combinations allowed) were registered by each professional and compared. Percentage of agreement and kappa-values were calculated.Two semi-structured focus-group interviews were performed with ESPs and OSs, respectively. Interviews were based on the theoretical concept of Relational Coordination, encompassing seven dimensions of communication and relationship among professionals. A thematic analysis was conducted.ResultsAgreement on primary diagnosis was 62% (95% CI: [50; 73]). ESPs and OSs agreed on the combination of diagnoses in 79% (95% CI: [70; 89]) of the cases. Partial diagnostic agreement (one professional’s primary diagnosis was also registered as either primary or secondary diagnosis by the other) was 96% (95% CI: [91; 100]). Across treatment categories, agreement varied between 68% (95% CI: [57; 79]) and 100%. In 43% (95% CI: [31; 54]) of the cases, ESP and OS had full concordance between treatment categories chosen, while they agreed on at least one recommendation in 96% (95% CI: [91; 100]).Positive statements of all dimensions of relational coordination were found. Three themes especially important in the inter-professional collaboration emerged: Close communication, equal and respectful relationship and professional skills.ConclusionsIn the majority of cases, the ESP and OS registered the same or partly the same diagnosis and treatment plan. Indications of a high relational coordination implying a good inter-professional collaboration were found. Our results support that ESPs and OSs can share the task of examining selected patients with shoulder disorders in an orthopaedic clinic.Trial registrationClinicalTrials.gov Identifier: NCT03343951. Registered 10 November 2017

Spinal triage by extended scope physiotherapists in a diagnostic interface clinic: spinal unit conversion rates from a 12-month service evaluation

Spinal triage by extended scope physiotherapists in a diagnostic interface clinic: spinal unit conversion rates from a 12-month service evaluation

Physiotherapist as an alternative to a GP for musculoskeletal conditions: a 2-year service evaluation of UK primary care data.

Physiotherapists are currently working in primary care as first contact practitioners (FCP), assessing and managing patients with musculoskeletal conditions instead of GPs. There are no published data on these types of services. To evaluate a new service presenting the first 2 years of data. Analysis of 2 years' data of patient outcomes and a patient experience questionnaire from two GP practices in Forth Valley NHS, UK. The service was launched in November 2015 in response to GP shortages. Data were collected from every patient contact in the first 2 years. This included outcomes of appointments, GP support, capacity of the service, referral rates to physiotherapy and orthopaedics, numbers of steroid injections, and outcomes from orthopaedic referrals. A patient experience questionnaire was also conducted. A total of 8417 patient contacts were made, with the majority managed within primary care (n = 7348; 87.3%) and 60.4% (n = 5083) requiring self-management alone. Referrals to orthopaedics were substantially reduced in both practices. Practice A from 1.1 to 0.7 per 1000 patients; practice B from 2.4 to 0.8 per 1000 patients. Of referrals to orthopaedics, 86% were considered 'appropriate'. Extended scope physiotherapists (ESPs) asked for a GP review in 1% of patients. The results suggest that patients with musculoskeletal conditions may be assessed and managed independently and effectively by physiotherapists instead of GPs. This has the potential to significantly reduce workload for GPs as the service requires minimal GP support. The majority of patients were managed within primary care, with low referral rates and highly appropriate referrals to orthopaedics. Patients reported positive views regarding the service.

Ultrasound-guided injections in primary care: evidence, costs, and suggestions for change.

Musculoskeletal (MSK) ultrasound has been used increasingly over the past decade, by non-radiologist hospital doctors, extended scope physiotherapists (ESPs), and to a lesser extent by GPs in primary care, both for diagnostic purposes and to guide therapeutic interventions. The reduction in equipment costs, together with improved image resolution and an increase in educational opportunities, seem to have facilitated these changes. MSK ultrasound is a highly effective diagnostic modality and is regularly used in secondary care to guide MSK interventions including joint and soft-tissue injections. Recent evidence, based on large randomised controlled trials (RCTs) and meta-analyses, demonstrates improved accuracy, efficacy, and cost-effectiveness of ultrasound-guided joint and MSK soft-tissue injections when compared with landmark-guided injections (LMGIs). In 2015 the American Medical Society for Sports Medicine (AMSSM) published a position statement reviewing the current evidence for ultrasound-guided injections (USGIs), focusing on the accuracy, efficacy, and cost-effectiveness of these interventions.1 It demonstrated high-quality evidence that USGIs are more accurate than ‘blind’ or LMGIs and ‘good’ evidence that USGIs are more effective than LMGIs specifically for large joints, inflamed joints, subacromial bursitis, carpal tunnel syndrome, and de Quervain’s tenosynovitis (Figure 1). There was also limited evidence …

Patient-reported outcome measures in advanced musculoskeletal physiotherapy practice: a systematic review.

Advanced practice physiotherapists (APPs), also known as extended scope physiotherapists, provide a new model of service delivery for musculoskeletal (MSK) disorders. Research to date has largely focused on health service efficiencies, with less emphasis on patient outcomes. The present systematic review aimed to identify the patient-reported outcome measures (PROMs) being utilized by APPs. A wide search strategy was employed, including the PubMed, Embase, CINAHL, CENTRAL and PEDro databases, to identify studies relating to PROMs utilized by APPs in MSK healthcare settings. PROMs identified were classified into predetermined outcome domains, with additional contextual data extracted. Of the initial 12,302 studies, 38 met the inclusion criteria. These involved APPs across different settings, utilizing 72 different PROMs and most commonly capturing: Patient Satisfaction, Quality of Life (QoL), Functional Status, and Pain; and, less frequently: Global Status (i.e. overall improvement), Psychological Well-Being, Work ability, and Healthcare Consumption and Costs. The quality of the PROMs varied greatly, with Satisfaction most commonly measured utilizing non-standardized locally-devised tools; the EuroQol five-dimensions questionnaire (EuroQoL-5D) and 36-Item Short-Form (SF-36) cited most frequently to capture QoL; and the Visual Analogue Scale (VAS) to capture Pain. No key measure was identified to capture Functional Status, with 15 different tools utilized. APPs utilized a multiplicity of PROMs across a range of MSK disorders. The present review will act as an important resource, informing the selection of outcomes for MSK disorders, with a view to greater standardization of outcome measurement in MSK clinical practice, service evaluation and research.

Transforaminal epidural steroid injection in lumbar spinal stenosis: an observational study with two-year follow-up

Background context: Transforaminal epidural steroid injection (TFESI) is recognised as a treatment for symptomatic lumbar disc herniation, whilst surgical decompression is generally thought to be the most effective treatment option for lumbar spinal stenosis. There is little available literature examining the effect of TFESI on symptomatic lumbar spinal stenosis.Purpose: To evaluate the use of TFESI as an alternative to surgery in patients with symptomatic stenosis.Study design/setting: An observational study which took place between May 2010 and July 2013. All patients were seen by the Extended Scope Physiotherapist (ESP) injection service.Patient sample: A total of 68 consecutive patients were included. Thirty-one were male and 37 were female. The average age was 75 years.Outcome measures: The primary outcome measure was the avoidance of decompressive surgery.Methods: Patients with radicular leg pain were seen by an ESP in an Outpatient setting. Concordant clinical examination and magnetic resonance imaging were required for diagnosis. Peri-radicular bupivacaine hydrochloride 0.25% (3 ml) and triamcinolone (40 mg) were then injected. Outcome measures were recorded at 6 weeks, 1 year and 2 years.Results: Of 68 patients with spinal stenosis, 22 (32%) had opted for surgery at two year follow-up. Thirty (44%) patients were satisfied with non-surgical management at 2 years, required no further treatment, and were discharged. Of the remaining 24%, nine patients were referred for further injection, four declined surgery but were referred to the Pain Relief Clinic, two still had a similar level of pain but declined surgery and one had died.Conclusions: Our study reports a considerably lower percentage patients opting for surgery than previously demonstrated by the available literature. TFESI is a reasonable treatment for lumbar spinal stenosis and can result in long-term relief from symptoms in a high proportion of patients.

Ultrasound guided musculoskeletal interventions: professional opportunities, challenges and the future of injection therapy

AbstractThe demand for ultrasound guided injections for musculoskeletal presentations has increased in recent years as practitioners and patients seek verification of needle position. Musculoskeletal management pathways regularly include injection therapy for pain relief and are sometimes indicated as a single intervention but may need to be supported by rehabilitation. Workload in radiology departments has expanded in volume and complexity as radiologists perform new interventional procedures that require medical expertise. Innovative responses are required to meet the demand for ultrasound guided musculoskeletal injections; one option is offering appropriate education to musculoskeletal sonographers, enabling them to extend their current scope of practice. The role of the extended scope physiotherapist in the United Kingdom provides evidence that role diversification can produce excellent patient outcomes whilst preserving financial resources. The professional, legal and clinical requirements of extending service provision to include new clinical staff presents challenges that have to be met with strong leadership and the provision of high quality education in ultrasound guided interventions. There are many indicators that the patient experience is enhanced by guiding musculoskeletal injections, and access to this service has impact on patients' confidence in their treatment pathway.

An integrated community team works with the London ambulance service: perspectives on the emerging role of physiotherapists in pre-hospital care

Background: The UK National Health Service’s (NHS) initiative to move more care to the community in order to provide quality and cost-effective intervention has been a key focus of its strategy for over a decade. This has seen the establishment of the integrated community multidisciplinary team (MDT) and the development of further emerging roles for allied health professionals (AHP). Specifically, extended scope physiotherapists (ESP) are now playing active roles as members and leaders of MDTs in emergency, pre-hospital and urgent care settings. Purpose: A new care pathway was established in June 2014 between the London Ambulance Service (LAS) and the Integrated Community Response Service (ICRS) in North West London. It was set up with the philosophy that integrated care teams with enhanced clinical training should be able to successfully manage appropriate acute (but not immediately life-threatening) LAS cases in the community. Methods: Clinical members of the ICRS spent observation days with the LAS and discussions between members took place before ‘going live’ with the pathway. Regular meetings continue to be held with the LAS as part of its ongoing development.Within the system, referrals are received via telephone and discussed with the daily clinical coordinator to determine appropriateness. The ICRS receives referrals 7 days a week between 7 am and 7 pm. Once the referral is accepted, the ICRS responds accordingly within a 2-hour window and provides clinical intervention and management for approximately 7 days. The number of referrals received between June and September 2014 were collected and analysed. The reason for referral, the team members involved, the interventions and the overall outcome of each case were recorded. Results: The number of referrals received from the LAS between June and September 2014 increased by 100%. All patients referred by the LAS and accepted by the ICRS were subsequently assessed and managed in the community by the ICRS clinicians. Inappropriate referrals were declined verbally on the phone. Considering specific case examples, the physiotherapist demonstrated autonomy in assessment, intervention and case management. Conclusion(s): An appropriate LAS case can be referred to an integrated community MDT and managed accordingly. Each patient accepted by the ICRS received interventions from at least three members of the MDT and therefore the direct impact of the physiotherapist alone is unknown. The LAS and the ICRS have successfully demonstrated that they can collaboratively work together in managing acute patients in the community in North West London. Implications: There is an emerging role for physiotherapists in emergency, urgent and pre-hospital care and in response to an appropriate LAS referral. Further research is required into emerging physiotherapy roles. Consideration of merging roles, scope of practice, educational programs and health economics is also required.

The Clinical Effectiveness of the Extended-Scope Physiotherapist Role in Musculoskeletal Triage: A Systematic Review.

Extended-scope physiotherapists (ESPs) are working in musculoskeletal (MSK) triage clinics to assess, diagnose and refer patients for appropriate management. However, there is inadequate appraisal of their clinical effectiveness. The aim of the present systematic review was to appraise the evidence on the diagnostic ability of ESPs in MSK triage, and patient and general practitioner (GP) satisfaction when seen by an ESP in a MSK clinic. CINAHL, AMED, MEDLINE and EMBASE databases were searched from 1989 to February 2014 using the keywords 'physiotherapy', 'extended practitioner' and 'musculoskeletal disease'. Data extraction was compiled using the Centre for Reviews and Dissemination (2009) method. Diagnostic accuracy studies were assessed for methodological quality using the Scottish Intercollegiate Guideline Network (SIGN). Patient/GP satisfaction was assessed using a tool adapted by Desmeules et al. (2012). From 146 studies initially identified, 14 were eligible for review. Only one diagnostic study was of high quality, and satisfaction study scores ranged from 40% to 73%. All studies reported favourable outcomes for ESPs in MSK triage clinics, with ESPs demonstrating a good level of diagnostic ability in comparison with a gold standard such as surgery. In addition, patients and GPs were satisfied with the overall performance and service provided by ESPs. The evidence suggests that ESPs are clinically effective. However, there were methodological shortcomings in the reviewed studies, and further research, using larger sample sizes, multiple locations and comparisons of the same patient cohorts, would strengthen the evidence available to influence future commissioning of these services. Copyright © 2015 John Wiley & Sons, Ltd.

Review article: Emergency department models of care in the context of care quality and cost: a systematic review.

To identify current ED models of care and their impact on care quality, care effectiveness, and cost. A systematic search of key health databases (Medline, CINAHL, Cochrane, EMbase) was conducted to identify literature on ED models of care. Additionally, a focused review of the contents of 11 international and national emergency medicine, nursing and health economic journals (published between 2010 and 2013) was undertaken with snowball identification of references of the most recent and relevant papers. Articles published between 1998 and 2013 in the English language were included for initial review by three of the authors. Studies in underdeveloped countries and not addressing the objectives of the present study were excluded. Relevant details were extracted from the retrieved literature, and analysed for relevance and impact. The literature was synthesised around the study's main themes. Models described within the literature mainly focused on addressing issues at the input, throughput or output stages of ED care delivery. Models often varied to account for site specific characteristics (e.g. onsite inpatient units) or to suit staffing profiles (e.g. extended scope physiotherapist), ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Only a few studies conducted cost-effectiveness analysis of service models. Although various models of delivering emergency healthcare exist, further research is required in order to make accurate and reliable assessments of their safety, clinical effectiveness and cost-effectiveness.

Physiotherapist prescribing in lower back pain: A case study

Changes to legislation have allowed physiotherapists to train as independent prescribers, and the first cohorts qualified in early 2014. Some will be upgrading their supplementary prescribing qualifications, while others will be training for the first time in prescribing. This article discusses the role of the extended scope physiotherapist as an independent prescriber in a specialist musculoskeletal setting. The case study outlines the assessment and treatment of a patient with lower back pain and neuropathic leg pain, and details the prescribing issues involved in the overall management.

The clinical reasoning processes of extended scope physiotherapists assessing patients with low back pain

IntroductionEmploying allied health professionals in extended scope roles has developed relatively recently in health-care. Within physiotherapy, the extended role has provided clinicians with autonomy to use knowledge and clinical acumen to request investigations such as Magnetic Resonance Imaging (MRI) and X-ray as part of the diagnostic process, a practice beyond the traditional scope of physiotherapy. In these advancing roles, little is written about the clinical reasoning processes that clinicians use in managing patients with musculoskeletal pain and knowledge of these processes would advance training for new recruits to this arena. StudyThis qualitative study has explored the processes by which extended scope physiotherapists (ESPs) clinically reason their decisions regarding patients reporting low back pain in a musculoskeletal outpatient setting. The study used a multiple case study design informed by grounded theory methodology, using focus groups (involving ESPs and non-ESPs/musculoskeletal physiotherapists) and semi-structured interviews with a think-aloud method (ESPs only) to investigate these processes. ConclusionsThe themes identified include: prior thinking; patient interaction; formal testing; time; safety and accountability; external and internal factors; and gut-feeling (which challenges current physiotherapy models of reasoning). Extended scope physiotherapists reported experiencing greater stress due to higher levels of perceived accountability, safety requirements and internal drivers for competence than non-ESPs. Further research is indicated to explore the role of gut-feeling in musculoskeletal physiotherapy clinical reasoning.

Orthopaedic triage: cost effectiveness, diagnostic/surgical and management rates

Purpose – The purpose of this paper is to investigate cost effectiveness, diagnostic rates, surgical percentage and appropriateness for orthopaedic referrals and number of patients able to be seen in orthopaedic triage from GP orthopaedic referrals. Design/methodology/approach – The study involved triaging paper referrals for orthopaedic outpatients to an interface service, orthotics or continue normal route. Data were collected on outcome of the interface appointment and outcomes for those patients referred to orthopaedics from the appointment. Findings – The study demonstrated a 27.3 per cent cost saving from the normal orthopaedic route with 86.1 per cent of patients able to be managed by an extended scope physiotherapist (ESP) without requiring orthopaedic assessment. Appropriateness of onward orthopaedic referrals was 80.5 per cent with surgery conversion rate of 75 per cent. Originality/value – Although triage and ESP positions have been studied before, this is the first known study to look at cost effectiveness across the patient pathway despite this being a large reason for the creation of these positions. Further larger studies are required to build upon this base in terms of demonstrating the cost effectiveness of the value of these positions.

Triage of knee pain by an Extended Scope Physiotherapist (ESP) in an orthopaedic clinic: A clinical audit

BACKGROUND: Extended Scope Physiotherapist (ESP) posts have been set up to reduce long waiting lists in orthopaedic clinics. The purpose of this study was to evaluate the activity and outcomes of an ESP clinic within the Irish health care system. The specific aims were to: (i) examine the proportion of patients managed independently by the ESP, (ii) analyse the accuracy of an ESP’s clinical diagnosis, and (iii) to calculate the conversion rate to surgery of patients referred for orthopaedic consultation. METHODS: All knee pain patients referred to the Knee Screening Clinic (KSC) from November 2010 to December 2011 were included in this audit. A prospective audit was carried out in relation to patient demographics, baseline clinical characteristics and a KSC clinical care pathway. Medical records were reviewed retrospectively of patients referred onward for orthopaedic consultation, to investigate their outcomes. RESULTS: 140 patients were included in the study. The ESP independently managed 59.3% of patients. The remaining 40.7% of patients were referred on for orthopaedic surgical consultation. Of these, 84% underwent surgery. ESP clinical diagnostic accuracy was ‘substantial’ (percentage agreement = 88%; = 0.795 (95% CI, 0.58–1.00)). CONCLUSIONS: The majority of patients (59.3%) referred to the orthopaedic clinic did not need to see an Orthopaedic Surgeon. The ESP clinical diagnostic accuracy was ‘substantial’ and the high conversion rate to surgery suggests that appropriate patients were referred on for orthopaedic consultation. The results of this study provide some evidence supporting the role of ESPs in orthopaedic triage.

A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management

ObjectivesTo evaluate the cost effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared with the routine care provided by doctors in an...

Demonstrating clinical quality and cost effectiveness: can extended scope physiotherapists rise to the challenge?

Demonstrating clinical quality and cost effectiveness: can extended scope physiotherapists rise to the challenge?

Direct listing for total hip replacement (THR) by primary care physiotherapists

PurposeThis paper aims to show the results from a pioneering primary care‐based extended scope physiotherapist (ESP) led service, which placed patients directly onto the surgical waiting list of secondary care orthopaedic consultants over a two‐year period.Design/methodology/approachA retrospective data review was performed on all referrals from community‐based ESPs for direct listing at the secondary care hospital between 2 January 2008 and 31 December 2009.FindingsA total of 130 referrals for direct listing were made by the ESP team during the two‐year period. Of these, 127 (98 per cent) went on to undergo a THR. Three patients (2 per cent) did not ultimately have a THR.Research limitations/implicationsThis process has continued over the two years of the direct listing service, with ongoing evaluation and refinement of the pathway, so referral criteria and clinical/administrative pathways have been changed in the light of experience.Practical implicationsPatients who were directly listed did not require a hospital orthopaedic outpatient appointment until attendance at preoperative assessment clinic shortly before their surgery. In addition to the reduction in inconvenience and travelling costs incurred by patients, there was an approximate saving of £145 to the primary care trust per directly listed patient.Originality/valueThe authors believe that this service evaluation is the first publication to show that direct listing by primary care based ESPs is a safe and effective process for some patients requiring primary THR.