The foot surgery service was expanded in order to undertake more complex foot surgeries, this required an increase in physiotherapy input. Adaptations were made to our provision of physiotherapy to accommodate patients undergoing complex foot surgeries, patients with multiple co-morbidities and patients with complex social needs. This incorporated developing a robust protocol-led pathway including pre-op education and assessment with the aims of increasing attendance of our pre-op assessments “Foot School” and reducing length of stay (LOS).
Feedback from physiotherapists, physiotherapy assistant practitioners, the consultant and nurses was gathered on the existing service and what could be done to improve this. From this information, a series of Plan Do Study Act (PDSA) cycles were implemented to gradually make changes to the service. Firstly, a protocol was developed to guide clinicians in how patients should be progressed and what footwear was required. This was then refined further after learning was gained from the initial implementation. The pre-op assessment “Foot School” was changed from ad hoc referrals to a blanket referral to increase attendance to above 70%. This was linked with our inpatient service, outpatient follow up clinic and onward referral system to complete the pathway. A physiotherapist was allocated to work alongside the existing nurse-led and consultant-led follow up clinics to progress patients' mobility. Referrals to local MSK services were undertaken by the physiotherapy team rather than the consultant to increase compliance.
Median average Foot School attendance per month was increased from ~33% to 73% (as of Feb 19). This achieved the target of 70% which is in line with our arthroplasty pre-op target of 70%.
It was identified that Non-Weight Bearing (NWB) patients who attended Foot School, who were identified as most likely to require a longer admission, were found to have a decrease in their LOS compared to those that did not attend. Of the 41 patients that were NWB, 13 had poor mobility post-op. The nine that attended Foot School had a LOS ranging from 1-2 days. The four that did not attend Foot School had a LOS ranging from 2-14 days.
Over 90% of referrals to local MSK services were made on time (based on the protocol). Although no previous data is available for comparison, anecdotally all staff felt that fewer referrals were being missed or delayed.
A physiotherapy assessment (at the time of the patient being listed for surgery) can have a significant impact on LOS. This enables patient's mobility, expectations, co-morbidities and social needs to be identified, and where possible, addressed prior to admission for surgery. It allows for referral to occupational therapy and patient transport services at an earlier date to reduce these factors delaying discharge.
Cost and savings
No additional costs were required. Estimation of savings from the decrease in LOS were not undertaken.
All of our patients that undergo foot surgery that will result in an altered weight bearing status are referred to Foot School. The demand on clinician time on day of surgery is reduced as most of the assessment is completed prior to admission. A band 6 physiotherapist is assigned to the follow up clinic for progression.
Top three learning points
No additional funding was required
This work was presented at Physiotherapy UK 2019.
Please see the attached Innovations poster below.
For further information about this work please contact Ewan Sharp.
Langley G., Moen R., Nolan K., Nolan T., Norman C. and Provost L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers.