Trusted NHS Partner from Surgical Appliances to Orthotics
Abstract
A narrative on influencing the change of policies at one of our NHS Partner Trusts with regard to Orthotics and fracture bracing provision.
Introduction
I was employed by A.C Tonks Orthopaedics directly from University. The current Orthotist at The specific NHS Trust was due to retire and in order the spend some time learning hospital policy and how the clinic ran prior to his leaving at the end of August I began employment at the start of May. This meant taking annual leave to graduate in July.
At the time appointments were back to back 15min slots. 9.30 start to 4.30 with 1 hour for lunch. At this time any extras from clinic were expected to be seen along with any ward patients. This was not too much of an issue at the time as orthotic provision could have been said to be quite “traditional”. Leather was the preferred material. It was quite common for there to be 6 or so empty patient slots a day as the demand for a full service was not there.
The previous orthotist decided to take early retirement and so by the end of July I became the lead and only orthotist at the trust.
Evolving the needs of the trust
With quite a bit of spare time and being so keen, fresh from Uni I sought to revolutionise the hospital. I joined the Stroke MDT meeting once a month. I attended the Orthopaedic meeting on several occasions to introduce several different orthotic interventions. For example, an unloader brace for knee OA had never been used in the hospital. The stroke team had never seen a custom AFO.
At the time fracture clinic only used plaster or tubigrip. No fracture braces were employed. They became enlightened. Fracture boots and range of motion knee braces amongst others were introduced.
Referrals picked up. Gone were the days of half empty clinics due to lack of patients. We were only able to cope with half full clinics due to the number of extras. This would include non-urgent insoles assessments would be expected to be seen on the day. Every patient was given 15m appointments be it for a simple insole fitting of KAFO cast.
I hate my clinic running late. Over the years the furthest I’ve gotten behind is 25min and I have no intention of going past that. In order to maintain this, I was forced to leave paperwork until lunch of after clinic. One-day security had to let me out I was so late.
I felt this was a major issue. There had to be a more efficient way of running the clinic and so with BAPO guidelines in hand I met with management who agreed to 20m appointments. This was actually the admin manager for outpatients at the time who aided with this not the clinical manager. Management of Orthotics at the time was minimal to say the least. We had no clinical management. When this was required I was forced to go to the nursing matron of outpatients just through lack of options.
We decided that all referrals would be read by me before giving the patient an appointment at which point it would be decided if a double appointment slot was necessary. If patients did not require to be immediately seen they would be sent an appointment. (see attached 1). I advised to change the start time of the first patient to 9am in order to facilitate the timetable.
In theory things should have become more manageable but fracture bracing had become vogue. All bracing was fitted by myself. A very small portion of nursing staff from fracture clinic would help and some members of plaster room but generally any patient requiring a simple fracture brace would be sent to orthotics.
I ran repeated training sessions over the years but have had constant resistance to change. Most of the nursing staff would now fit a simple wrist brace but not all.
In October 2016 Peacocks won the contract for the specific NHS Trust Partner. The team have been fantastic in providing support to get clinics under control. By year end I will have moved into a new room. No longer situated beside fracture clinic in outpatients. I will move to the main therapy’s block beside Physiotherapy.
With regard to fracture bracing there are 2 benefits to this. Our storage is reducing and so we can no longer hold any fracture bracing. And not being so readily accessible to fracture clinic it improves the need for fracture clinic to provide their own bracing.
Over the last year training sessions have taken place each person in attendance have had to sign to say they feel competent to supply a range of simple braces. Management of each area has been informed they must take control of their own stock and staff. This includes outpatients, A&E, theatres and day procedures. We have weaned off support over the last 2 months to encourage each area to take more responsibility.
To aid the transition I have also changed our referral forms. (See attached.) The previous referral was very basic, it didn’t allow much space for patient history or goals of the referrer. (attached 2) I felt that a problem would arise where patients would continue to be sent to orthotics for fracture braces and without any stock we would be unable to help. It would also look very poor from a patient experience point of view.
I designed 2 new forms. The first for orthotics. (No more surgical appliances yay!!!) (attached 3) As I seen it if I was discussing a patient with a physio for example, the most useful information I could get is any relevant history and what are the goals of orthotic intervention. Secondary to that if the physio had a suggestion to what device they felt was most suitable this could be used as a guide.
For fracture bracing I felt that the simpler the better. The goal being a record of treatment. Who prescribed? What device? Who applied said device and advised the patient on use? This would then be kept in the patient’s hospital notes.
A tick box table of common fracture braces was devised. (attached 4) The theory being if the prescriber required one of these braces the patient should be dealt with in that area. If it was anything other than this they should refer to orthotics on the new referral form on the understanding that the patient would be sent an appointment.
Conclusion
The needs of the trust have greatly changed over the last 5 years. I hope that I have improved on some of the historical systems which were in place. Our waiting list is now on average less than 3 weeks. Friday afternoons are given over to emergency clinic where any urgent patients will be seen. There is a designated slot every day for ward patients. There has been positive response from staff to the new referral forms which are already in use.
