Historically, at GSTFT, patients with ACL pathology have been managed in weekly exercise classes. Anecdotally, Physiotherapists felt that they were unable to effectively manage both the post-operative and ACL deficient (ACLD) populations due to high class numbers. After an internal service evaluation and audit, a unique ACLD pathway was established to separate the ACLD population, and better manage both ACL cohorts. This included a specific fortnightly ACLD Induction Clinic and ACLD rehabilitation class.
This data collection aimed to:
- Evaluate the demand for the ACLD pathway, including the new ACLD rehabilitation class, and analyse patient demographics
- Ensure the ACLD pathway is utilised correctly, by monitoring patients being referred
- Start analyzing the data and trends of patient attendance and onward management in the ACLD rehabilitation class and begin early root cause analysis.
- Commence a systematic review around the quality of pre-operative physiotherapy intervention and how this effects outcomes post-operatively, in order to guide the temporality and content of our ACLD rehabilitation class.
Data was manually extracted from our electronic patient records (PIMS, EPR and e-noting) and stored in an Excel spreadsheet over a 10 month period, where it was structured for further analysis.
The ACLD pathway enabled better utilisation of the ACLR rehabilitation class, reducing the number of incorrect referrals into this post-operative class from 36% to 7%, as well as a reduction in waiting time to < 1 week. The ACLD Induction clinic has seen 91.76% New Patient slot utilisation, with an 80.77% attendance rate. 91% of these referrals were appropriate, with Orthopedics being the dominant referral source. Of the patients in ACLD Induction clinic, 79.7% were referred to the ACLD rehabilitation class and 13.6% were discharged with self-management. Of those patients who are referred to the ACLD rehabilitation class, 63% did not attend and 47% attended 0-2 sessions (average 2.68 sessions). The ACLD rehabilitation class has had 76% utilisation of its NP and FU slots. The average non-attendance rate was 25%.
This pathway has been effective in allowing better management and more immediate access to our services for the ACLR cohort. The ALCD Induction clinic has shown good utilisation. The main pathway for these ACLD patients is into the ACLD rehabilitation class which has shown moderate utilisation. A high DNA rate of ACLD Induction clinic patients has been identified, with a high drop-out rate after 0-2 sessions.
Without root cause analysis, it is unknown why there is low ACLD rehabilitation utilisation and a high DNA rate. Are patients receiving sufficient education and advice and are happy to continue independently? Or, is it due to an impending surgery date?
Cost and savings
The post-operative ACL class waiting time reduced from 2 weeks to <1 week, due to a reduction in incorrect class usage/referrals (from 36% to 7%).
There were no set up or running costs for this project.
This service evaluation and development has been momentous in allowing better management of our post-operative ACL population at GSTFT, and to begin specific, individualised and evidence based rehabilitation of our ACLD cohort. Literature highlights the value of pre-operative rehabilitation. However, further questions can be asked around its quality, prescription and content. Questions that we hope to answer through our systematic review to further guide rehabilitation in this area.
Top three learning points
The author provided two learning points.
Unfunded. Special thanks to the Physiotherapy Outpatients team at GSTFT for their ongoing support with this service evaluation project.
This work was presented at Physiotherapy UK 2019
For further information about this work please contact Hannah Bundy.