Using Simulation To

Understand Orthopaedic Flow Through Triage

Ekwutosi Chigbo Ezeh

Supervised by Dr Navid Izady16/10/13

University of Southampton

University Hospital Southampton - Solent NHS – ISTC (CARE UK)

Southampton City Clinical Commissioning Group

Background When patients require orthopaedic assessment they

are referred by their GP to an Integrated Medical Assessment and Treatment (IMAT) service for triage to determine the appropriate referral pathway

For orthopaedics, these routes include physiotherapy, podiatry, rehabilitation programmes, pain management services, and community re-ablement services, as well as orthopaedic surgery (three tier system)

Evidence that some patients are routed incorrectly, leading to wastage and poor patient experience

Aims: to identify how patients are referred, then triaged then routed; quantify where patients are initially routed incorrectly and subsequently rerouted; use simulation to test alternative pathway designs

Providers modelled In 2012-13 the Southampton Musculoskeletal

service (including IMATs, physiotherapy, rheumatology and pain management) served 16,000 patients and provided 38,000 outpatient appointments

Southampton City CCG (Tier 1)

NHS Solent (Moorgreen Hospital) – community-based outpatient clinics, physio and reablement (Tier 2)

Independent Sector Treatment Centre at the Royal South Hants hospital (Tiers 2 & 3)

University Hospital Southampton (Tiers 2 & 3)

Many others – highly complex patient flow through different sectors with a multiplicity of providers and over 400 pathways, which were modelled as a series of clinics

Patient flow between providers

Challenges

Limited data available for modelling the whole system (lack of referral numbers; medical conditions recorded; referral destination; no entrance data for cohort)

Significant differences in data across providers

No universal identifiers linking data Appointment scheduling procedures

required to model waiting times, but were not available

Moorgreen Hospital Simul8 Model

160 pathways in total!

Outpatient ClinicsUHS OP Spine Clinic

Appointments Booked New Follow up - No of referrals accepted from GP 488 41.7% - No of referrals accepted from A & E 72 6.2% - No of referrals accepted from other sources 610 52.1% Outcomes of Appointments attended - Discharged from clinic 310 39.6% 522 42.0% - Another appointment booked 472 60.4% 720 58.0% No of Appointments Cancelled - Cancelled by Hospital 267 68.8% 519 66.4% - Cancelled by patient 95 24.5% 173 22.1% - Patient did not attend 26 6.7% 90 11.5%

UHS OP Hand Clinic

Appointments Booked New Follow up - No of referrals accepted from GP 506 52.0% - No of referrals accepted from A & E 132 13.6% - No of referrals accepted from other sources 335 34.4% Outcomes of Appointments attended - Discharged from clinic 157 22.2% 583 30.1% - Another appointment booked 551 77.8% 1,351 69.9% No of Appointments Cancelled - Cancelled by Hospital 174 67.2% 180 31.3% - Cancelled by patient 65 25.1% 225 39.1% - Patient did not attend 20 7.7% 171 29.7%

Solent : Accepted & Cancelled Referrals

Top 95% of pathways in Solent NHS

CLINICNo. of Appts

% of Total

Cumulative %

MGH MSK Physio 6913 29.78% 29.78%

ADC MSK Physio 6567 28.29% 58.07%

MGH MSK SPINAL 1933 8.33% 66.40%

MGH CAS 1813 7.81% 74.21%

MGH MSK HAND 924 3.98% 78.19%MGH MSK LOWER LIMB 914 3.94% 82.13%ADC MSK SHOULDER 650 2.80% 84.93%

ADC MSK SPINAL 649 2.80% 87.72%

ADC MSK FEET 648 2.79% 90.51%ADC MSK LOWER LIMB 504 2.17% 92.69%

MGH MSK FEET 359 1.55% 94.23%MGH MSK SHOULDER 186 0.80% 95.03%

Number of consecutive appointments per pathway

1st Clinic 2nd Clinic 3rd Clinic 4th Clinic 5th Clinic 6th Clinic0

50

100

150

200

250

300

NUMBER OF CONSECUTIVE APPOINTMENTS PER PATHWAY

1 2 3 4 5 6 7 8 9 >10

Clinics VIsited in pathway

no o

f p

ath

ways

Conclusions

Many limitations of model due to data challenges Enhancement of current data available needed to

effectively model this We found less inefficiency in the system than was

perhaps initially perceived by our “client”: the majority of patients are correctly triaged at Tier 1, while 94% of patients referred to Tier 2 attend only the first clinic they are referred to

Despite the data limitations, the modelling process highlighted many key issues for the providers to think about

OR - clinical perspective

Dr Cathy Price

UHS FT

NHS perspective

Are pathways of care

Timely? - treatment delivered within an acceptable waiting period (need to understand rate of deterioration whilst waiting)

Effective? - no bounce around, minimal follow ups

Efficient? - minimal number of follow ups

Commissioning Landscape

Multiple Providers within small geography

Confusing entry criteria

One large teaching hospital

Multiple Signposting “Tier 2” services for GP’s

Collaboration difficult across providers

Commissioned time points for providers to meet to review cases (“virtual clinics”)

Patient experience “confusing”

Clinical effectiveness unclear

Modelling /OR – comments

Brought some clarity on efficiency (minimal follow ups) in Signposting service – pretty efficient

Clinical Effectiveness hard to ascertain within timescale (no follow ups per provider – needed to be accurately agreed )

Model built that allowed for varying scenarios

Concerning number of differing outcomes for patients (400+ pathways )

No easy way to ID patient through whole system i.e. more confident modelling would require this