Friday, 28 October 2016

Auditorium, Kolling Institute, Royal North Shore Hospital

Musculoskeletal Network

Forum 2016

#MSKF16

1

Musculoskeletal Network Forum 2016

Overview

The Agency for Clinical Innovation (ACI)

works with clinicians, consumers and

managers to design and promote better

healthcare for NSW.

We provide expertise in service redesign

and evaluation, specialist advice on

healthcare innovation, initiatives including

clinical guidelines and models of care,

implementation support, knowledge sharing

and continuous capability building.

Our Clinical Networks, Taskforces and

Institutes provide a unique forum for people

to collaborate across the NSW Health

system. By bringing together leaders from

primary, community and acute care settings

we promote an integrated health system.

Audience

This event brings together doctors, nurses,

allied health professionals and managers

that work in NSW health services,

consumers contributing to ACI networks,

researchers, private health service

providers, consumer organisations, and

others who are interested in advancing

musculoskeletal health in Australia.

Photographs

Photographs taken at this event may be

published by the ACI for internal and /or

external promotion, education or research

purposes. If you do not wish your

photograph to be taken please notify Robyn

Speerin.

Aims

The Forum aims to share with all delegates the

progress of the Musculoskeletal Network in

supporting improved health care services and

outcomes for people living with musculoskeletal

conditions. Service sites, implementation groups

and researchers will present their progress and/or

outcomes that relate to the work of the

Musculoskeletal Network.

Musculoskeletal Network Manager

Robyn Speerin

Musculoskeletal Network Manager

0429 925 518

robyn.speerin@health.nsw.gov.au

#MSKF16

.

1

Schedule of Event

Friday 28 October 2016

8.00 am Registration / Tea and Coffee served

8.30 am Housekeeping

Robyn Speerin, Manager ACI Musculoskeletal Network

Welcome to Country

Nathan Moran, Chief Executive Metropolitan Local Aboriginal Land Council

Session 1 Chair: Dr Gabor Major, Co-Chair Musculoskeletal Network; Director

Rheumatology, Royal Newcastle Centre

9.00 am Welcome to Northern Sydney Local Health

Lee Gregory, A/Chief Executive Northern Sydney Local Health District

9.05 am Opening

A/Professor Brian McCaughan; Chair, ACI and CEC Board

9.10 am

Developing the Model of Care for the Management of People with Acute Low

Back Pain

Dr Chris Needs, Co-Lead, ACI Acute Low Back Pain Working Group; Rheumatologist, Royal

Prince Alfred Hospital, Sydney Local health District

9.20 am

Official launch of the Model of Care for the Management of People with Acute

Low Back Pain

The Honourable Justice Peter Garling RFD SC; Judge of the Supreme Court of NSW;

Commissioner of the Special Commission of Inquiry into Acute Care Services in NSW 2008

9.40 am Short Break

9.45 am Overview of the Musculoskeletal Network 2016

Matthew Jennings, Co-Chair Musculoskeletal Network; Director Allied Health, Liverpool

Hospital, South Western Sydney Local Health District

9.55 am Reflections of the Musculoskeletal Primary Health Care Initiative

Professor Lyn March, Lead Musculoskeletal Primary Health Care Initiative; Rheumatologist,

Royal North Shore Hospital, Northern Sydney Local Health District

10.05 am

Implementing the Musculoskeletal Primary Health Care Initiative in

Murrumbidgee

Narelle Mills, Manager Quality & Pathways, Murrumbidgee Primary Health Network

10.25 am

Mid North Coast Musculoskeletal Primary Health Care Initiative:

Demonstrating the role of Primary Care in delivering integrated responses to

common musculoskeletal conditions

Sharyn White*, Fiona O’Meara, Martin Cushing, Northern NSW Primary Health

Network

10.45 am Feedback and Discussion

2

11.00 am Morning Tea

Session 2 Chair: Matthew Jennings

11.30 am

Key Principles of the Model of Care for the Management of People with Acute

Low Back Pain

Dr Chris Needs, Co-Lead ACI Acute Low Back Pain Working Group; Rheumatologist, Royal

Prince Alfred Hospital, Sydney local Health District

11.45 am Development of a Coordinated Back Pain Management Program

Rodger Laurent for the Royal North Shore Hospital Back Pain Steering Committee;

Rheumatologist Northern Sydney Local Health District

12.00 pm

Back and Neck Pain Triage Physiotherapy Service - Proof of Concept Trial -

Ambulatory Care

Trish Schlotfeldt, Back and Neck Triage Physiotherapist, Musculoskeletal Initiative; Northern

Sydney Local Health District

12.15 pm Feedback and Discussion

12.30 pm Lunch

1.30 pm Session 3 - Concurrent Sessions

Auditorium Wallace Freeborn Room

Chair: Chris Barnett Chair: Matt Jennings

1.30 pm

Is a Fracture Liaison Service cost-

effective? Gabor Major*, Fiona Niddrie, Ayano Kelly, Rod

Ling, Andrew Searles, John Attia, Elizabeth

Holiday & Nik Bogduk; Royal Newcastle Centre

NSW

Evidence for and variation in acute care

processes for knee and hip arthroplasty

surgeries Mayer M, Naylor JM*, Mills K, Harris IA, Badge H,

Adie S

Whitlam orthopaedic Research Centre, South

Western Sydney Local Health District

1.45 pm

Secondary fracture prevention

needs to happen in the country too

- the first two and a half years of the

Coffs Fracture Prevention Clinic Sandy Fraser*, Fracture Liaison Coordinator &

Peter Wong, Rheumatologist; Coffs Harbour

Health Campus NSW

Quality Improvement project to find ideal exercises for patients in the acute phase after total knee replacement (TKR) surgery Alan Domansky-Chung, Surgical Ward Senior

Physiotherapist , Coffs Harbour Health Campus Mid

North Coast Local Health District

2.00 pm

RNSH Osteoporosis Refracture

Prevention Service Lillias Nairn, Fracture Liaison Coordinator;

North Shore Ryde Health Service, NSW

Inpatient rehabilitation versus hybrid

home program after knee arthroplasty: a

randomised controlled trial Mark A. Buhagiar*, Justine M. Naylor, Ian A. Harris,

Wei Xuan, Friedbert Kohler, Rachael Wright and

Renee Fortunato

3

2.15 pm

A Combined Randomised and

Observational Study of Surgery for

Fractures In the distal Radius in the

Elderly (CROSSFIRE) Andrew Lawson* & Ian Harris for The

CROSSFIRE Study Group

“Kneed to Improve" - Physiotherapy and

the Joint Replacement Journey Genevieve Langron* & Marie March, Orthopaedic

Physiotherapists; Blacktown Mt Druitt Hospitals,

Western Sydney Local Health District

Auditorium

Session 4 Chair: Dr Gabor Major

2.35 pm

Poster

Implementing the model of care for the NSW Paediatric Rheumatology

Network – diagnostics and implementation

Anne Senner,* Jeff Chaitow, Davinder Singh-Grewal, Cathy Lovell, Robyn Speerin, &

Christie Graham; Sydney Children’s Hospital Network & Agency for Clinical Innovation

2.40 pm

“I wish we had this when my daughter was diagnosed”

Development of Resources to Support Patients and Families with Rheumatic

Disease

Anne Senner,* Jeff Chaitow, Kate Faber, A. Ford, Christie Grahame, Debra Grech, Cathy

Lovell, Davinder Singh-Grewal, Robyn Speerin, & P. Weigand

2.55 pm

Improving transition for young people with rheumatology conditions, a work in

progress

Lynne Brodie,* Jane Ho, Jeff Chaitow, Geraldine Hassett, Fiona Niddrie, Gabor Major,

Damien McKay, Angela Myles, Helene Rickard, Davinder Singh-Grewal, Fiona Tickle &

Dawn Vernon

3.10 pm

Physiotherapy involvement within the Paediatric Rheumatology Clinic:

Implementation of ACI guidelines

Fiona Tickle* & Carolyn Young; Paediatric Physiotherapy Team, Liverpool Hospital,

Liverpool, NSW

3.25 pm Feedback & Discussion

Session 5 Chair: Matt Jennings

3.40 pm Presentation of the Lyn March Award 2016

3.45 pm Wrap Up / Next Steps / Evaluation / Close at 4pm

4

Abstracts

Optimising health while waiting for surgery – implementing a musculoskeletal model of

care in the primary care setting

Narelle Mills*, Murrumbidgee Primary Health Network; Catherine Maloney, Murrumbidgee Local Health

District; Murrumbidgee MSK Joint Steering Committee

The ageing population in Australia combined with increasing rates of obesity and inactivity will see the

rates of osteoarthritis and elective joint replacement continue to rise. The NSW Osteoarthritis Chronic

Care Program (OACCP) Model of Care is an evidence based, multidisciplinary, chronic care approach to

addressing this burden.

The Murrumbidgee OACCP is an integrated approach between primary care, private physiotherapists,

specialists and acute care, for patients waiting for joint replacement surgery. A Physiotherapy Provider

Panel enables participants in rural areas to access care as close to home as possible with around 70%

of the assessments being completed by the panel. OACCP services are provided across 12

communities with a mix of private and local health district providers. Measures include function, pain

and quality of life, removal from the wait list, escalation of surgery, length of stay, and discharge

destination.

Over the two years, 476 patients were recruited to the program with 422 (89%) completing an initial

assessment. Of those attending for an initial assessment, 27% had a BMI ≥35 (morbidly obese), with

only 19% reporting having accessed a physiotherapist and 7% a dietitian prior to going on the wait list for

surgery. Three monthly assessments leading up to surgery have shown improved outcomes for

patients, with some removed from the waitlist as no longer requiring surgery. A significant decrease in

length of stay was achieved for those proceeding to surgery along with an improvement in the rate of

discharge to home.

Outcomes from this pilot will help to inform changes required to improve access to conservative

management in primary care.

Your notes:

5

Mid North Coast Musculoskeletal Primary Health Care Initiative: Demonstrating the role

of Primary Care in delivering integrated responses to common musculoskeletal

conditions

Sharyn White*, Fiona O Meara, Martin Cushing; North Coast Primary Health Network delivered the

project, in partnership with the NSW Agency for Clinical Innovation, the Mid North Coast Local Health

District and General Practices

Background

The Mid North Coast region on NSW is an area of 11,324 with a population of 208 000 people and 21%

of the population are aged over 65 years. The population is spread between regional centres and rural

locations, with limited public transport which limits access to specialist services.

Aim:

The Mid North Coast Musculoskeletal Initiative aimed to demonstrate the use of ACI MSK Models of

Care in Primary Care settings, providing access to best practice management of common

musculoskeletal conditions in their usual general practice.

Intervention

Three micro projects were implemented

• Primary Care Osteoarthritis Program

• Primary Care Osteoporosis Refracture Prevention pilot study

• Musculoskeletal Primary Care Collaborative

Each project was supported by a HealthPathway, which translated the ACI models of care for primary

care implementation.

Conclusion

Primary care offers a significant untapped resource in the management of common musculoskeletal

conditions

• MBS alone does not provide a viable source of funding for access to allied health

• There is significant opportunity to engage General Practice in proactive management of

Osteoporosis and re-fracture prevention

• If there is proactive identification of fragility fractures, there is significant opportunity to engage

General Practice in management of Osteoporosis and re-fracture prevention

Your notes:

6

Development of a Coordinated Back Pain Management Programme R Laurent for the Royal North Shore Hospital Back Pain Steering Committee, Royal North Shore Hospital, St Leonards, Sydney, 2065 Background Non-surgical back pain patients are managed by several groups within our hospital and there was poor coordination between treating Health Professionals. We have developed a programme to improve the management of non-surgical back pain. Aims The aims were to develop a simple admission policy, reduce inpatient length of stay, provide an educational booklet, commence a multidisciplinary back pain clinic, reduce spinal surgery waiting lists and ensure patients are seen in the correct clinic. Interventions and Outcomes All non-surgical back pain was admitted under Rheumatology. This reduced time the Emergency Department spent trying to find an admitting team. The length of stay was reduced by an increase in physiotherapy staff so that physiotherapy could be given on the day of admission. An educational booklet on managing back pain was produced and used to help educate patients about how they can manage their back pain. Back pain management guidelines have been prepared for General Practitioners with contact numbers of relevant specialist services. A multidisciplinary back pain clinic, managed by a physiotherapist and rheumatologist was established, particularly for patients seen in the Emergency Department who require early follow up, recently discharged inpatients and acute problems. A process was developed to allocate patients referred to the surgical clinics to the appropriate clinic. Conclusion Co-ordination of established services and ensuring patients are allocated to the appropriate service, can improve management of back pain with minimal increase in costs.

Your notes:

7

Back and Neck Pain Triage Physiotherapy Service - Proof of Concept Trial - Ambulatory Care Trish Schlotfeldt MSc Physiotherapy; Royal North Shore Hospital, NSW, Sydney, Australia The use of a triage therapist to manage back and neck pain and identify patients that require a surgical opinion is well described in the literature. All patients referred to the ambulatory orthopaedic spinal clinics are triaged to attend either the orthospinal clinic (approximately 52% of patients) or the physiotherapy back and neck pain service (45%). Approximately 3% are mistriaged and are redirected to the correct service. All patients that are triaged to attend the physiotherapy assessment receive a full musculoskeletal assessment, their type of back or neck pain is classified and a clear path is established in partnership with the patient. Patients are also offered practical advice related to self-management of their condition. If necessary, they were referred to other service providers, e.g. local physios, dietician, hydrotherapy, chronic pain clinic. If at this assessment, it was identified that the patient did in fact require an orthopaedic spinal surgeon consultation, this was expedited. Of the patients that attended the physiotherapy assessment, approximately 22 % required a surgical opinion. The waiting time to be seen in the orthospinal clinic has been decreased from 325 days (range 50 – 679) to less than 75 days. The average time to be offered an assessment appointment with the triage physiotherapist is 14 days or less. The time to be seen by the physiotherapist and then the orthospinal surgeon is approximately 60 days or less. This is proving to be an effective method of decreasing the waiting list times and offering the patients a more timely and holistic intervention.

Your notes:

8

Is a Fracture Liaison Service cost-effective?

Gabor Major*, Fiona Niddrie, Ayano Kelly, Rod Ling, Andrew Searles, John Attia, Elizabeth Holiday &

Nik Bogduk; Royal Newcastle Centre NSW

Background/Purpose

Services that actively seek out and identify patients with fractures following a minimal trauma injury have

been promoted as the most effective means of addressing the wold wide increasing incidence of

osteoporotic fractures. Implementation however has been hampered by the paucity of information about

the cost effectiveness of this approach

Methods

Design: To undertake a detailed costing of operating a fracture liaison service (FLS) and compare the

total direct cost of re-fracture management of a cohort of patients (n=515) processed over a 6 month

period, and followed for 3 years with the refracture management costs of a contemporaneous cohort of

patients (n=414) seen at a hospital without a FLS.

Determination of costs: Components of the care and entered as a cost centre in a microcosting model

created in a Microsoft® Excel workbook. All cost centres were linked to a summary page to enable

comparison between the FLS and Usual Care. Sensitivity analyses were conducted by adjusting

parameters where there was no observed data. Cost of labour, infrastructure and consumables were

calculated from the relevant public sources. Medical consultations, investigations and treatments costs

were derived from reference tables of the Australian Medical and Pharmaceutical Schedules of Benefits.

Costs of re-fracture management were derived from published costing of fracture treatments in Australia.

Health inflation calculations for 2015/16 were done with reference to the Total Health Price Index and

Industry Wide Index (AIHW).

To allow comparison of the different cohort sizes the FLS costs were spread over 3 years and given for

every 1,000 patients processed.

Results

Table 1: Component costs of FLS per 1000 patients processed

Cost Centre /Activity Cost ($ AUS)

Reviewing emergency department records $30,143 Contacting patients $42,732 Clinical assessment and treatment $364,707 Follow up $23,018 Total $468,601

Table 2: Comparison of costs of treatment between a hospital with a fracture liaison service (FLS) and

usual care (Per 1,000 patients)

Re-fractures over 3 years

Total Cost Saving

(n) ($AUS) ($AUS)

Hospital with FLS 150 $2,883,937 Usual Care (incurs no additional cost)

212 $3,421,653 $537,716

5% of Usual Care patients treated 212 $3,518,584 $634,648 15% of Usual Care patients treated 212 $3,712,447 $828,510

Conclusion

From the perspective of the health system a FLS generates a significant gain, in opportunity costs with a

rounded net positive of effect of $540,000 - $830,000 per 1,000 patients processed.

9

Secondary fracture prevention needs to happen in the country too - the first two and a half years of the Coffs Fracture Prevention Clinic Fraser S1*, Wong PKK1,2,3 1. Coffs Harbour Health Campus; 2. Mid-North Coast Arthritis Clinic, Coffs Harbour; 3. UNSW Rural Clinical School, all in Coffs Harbour, NSW 2450. Background Bone health issues are often not addressed following fragility fracture. Most interventions addressing this gap are at major tertiary referral centres. Aim To report the initial two and a half years’ experience of one of the first Fracture Liaison Services in regional Australia. Intervention Patients aged ≥50 years with a fragility fracture who presented to Coffs Harbour Health Campus (CHHC) July 2012 to December 2014 were identified by a Fracture Liaison Coordinator (FLC) and seen by a Rheumatologist in Fracture Prevention Clinic (FPC). Patients discharged from the FPC were contacted via telephone by the Rheumatologist on one occasion 12 months later to discuss bone health and to assess medication adherence. Outcomes An appointment in FPC was offered to 222 patients but declined by 56 patients. N=166 patients were seen in FPC. Forty percent (n=66/166) had a prevalent fragility fracture but only 12% (n=8/66) were on bone protective therapy (BPT). Eighty-two percent (n=136/166) were commenced on BPT. Of the 55 patients discharged from FPC with sufficient follow-up time to allow contact at 12 months, 60% (n=33/55) required bone health advice during the follow-up telephone call 12 months later. Of the 31 patients commenced on BPT, 65% (n=20/31) said they were adherent with medication. Conclusion A FLC, committed clinician and supportive hospital environment were all that was required for an effective Fracture Liaison Service in a regional hospital. The number of patients who declined an appointment suggested the implications of a fragility fracture were often not appreciated.

Your notes:

10

RNSH Osteoporosis Refracture Prevention Service

Lillias Nairn, Fracture Liaison Coordinator North Shore Ryde Health Service Background There is strong evidence that the refracture risk following osteoporotic or minimal trauma fracture

(MTF) is high. Despite this, multiple national and international studies reveal low rates of screening for

bone fragility and treatment initiation among people after MTF. Osteoporotic Refracture Prevention

(ORP) services in Australia and overseas have repeatedly demonstrated significant reductions in

refracture rates among people who use such services compared to those who do not. The RNSH ORP

Service has been developed as part of a district wide service which is currently being extended to

establish a smaller ORP service at Ryde Hospital.

Aim

The aim of the service is to reduce the refracture rate among people over 50 years of age, living in the RNSH catchment, who have sustained a MTF. Intervention The ORP Service represents best practice, being based on the Agency for Clinical Innovation ORP model of care (MoC). Key elements of this MoC include active MTF case identification by a Fracture Prevention Coordinator who has responsibility for case coordination, access to essential investigations, medical specialist (Endocrinology or Rheumatology) consultations and referral to health and community services such as Falls Prevention programs. Patients are followed up at 6 and 12 months after the Specialist consultation to determine refracture

rate, adherence to osteoporosis medications and uptake of referrals, and change in Patient Reported

Outcome Measures (PROMs). Further evaluation of the service is planned by implementation of Patient

Reported Experience Measures (PREMs).

Innovations

An electronic screening tool has been developed which ensures a high level of accuracy in active case

identification. In addition electronic ORP forms are being developed which will be integrated into the

electronic medical records.

Outcomes Preliminary data representing the service activity and outcomes to date will be presented.

Your notes:

11

A Combined Randomised and Observational Study of Surgery for Fractures In the distal

Radius in the Elderly (CROSSFIRE)

Andrew Lawson* and Ian Harris for The CROSSFIRE Study Group

A multi-centre RCT including almost thirty sites in Australia and NZ. The administering institution is The

Whitlam Orthopaedic Research Centre. The study is funded with an NHMRC grant.

Background

Distal radius fractures are the commonest fractures seen in the hospital setting, with incidence

increasing in the elderly population due to increasing falls incidence and increasing prevalence of

osteoporosis. The direct costs of osteoporotic wrist fractures have been estimated to be over $130

million dollars per year in Australia. With trend increasing toward use of surgical fixation (volar plate

fixation), this cost is expected to increase disproportionately

The evidence gap is that no one has tested volar plate fixation as used in Australia. The evidence-

practice mismatch arises from a perceived benefit from volar plating. The reality is that best evidence is

that it doesn’t help in elderly population. Given that there is no clear benefit to surgery, the higher cost

and the risks associated with surgery can’t be justified. This creates a strong potential to change

practice and policy.

Aim

The primary aim is to determine the comparative effectiveness of operative treatment versus non-

operative treatment for adults aged 65 years and older with displaced distal radius fractures in a

multicentre randomised controlled trial. The secondary aim is to compare safety and cost effectiveness

of the two treatments in this same patient population.

Interventions

The study compares the outcomes of two standard forms of treatment of distal radius fractures 1.

Operative treatment with volar locking plate fixation and 2. Non-operative treatment with closed

reduction and cast immobilisation. Eligible patients are invited to participate in the RCT whereby their

treatment is randomised to operative or non-operative. If they decline to participate in the randomised

arm of the trial, they are invited to participate in the observational arm.

Participants will be treated within two weeks of their injury with post-procedure review at two weeks. As

part of the study, participants will be followed up at 3 and 12 months, 2, 5 and 10 years.

Outcomes

This study is at recruitment phase. The primary outcome will be PRWE at 12 months and secondary

outcomes will include measures of QOL, pain, disability, complications, radiographic measures and

therapy utilisation.

Conclusions

If the study finds that operative treatment (plating) is not superior to non-operative treatment (casting), it

will strengthen the existing evidence for non-operative treatment for these fractures and therefore

influence and change clinical practice. If the study finds plating to be superior, and it is found to be

cost-effective, it will provide high quality evidence to support the current practice of plate fixation.

Your notes:

12

Evidence for and variation in acute care processes for knee and hip arthroplasty surgeries Mayer M, Naylor JM*, Mills K, Harris IA, Badge H, Adie S Whitlam orthopaedic Research Centre, SWSLHD Background Inconsistencies in care contribute to unnecessary variation in treatment costs and outcomes. Aims To identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) those for which routine use is supported by high-level evidence, and; ii) whether surgeon use aligns with the evidence. Methods Part 1: Systematic search of electronic library databases for systematic reviews, meta-analyses, and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use or not were extracted by independent assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons from 19 hospitals. For each intervention, frequency of use per surgeon was summarized using caterpillar plots. Surgeon-specific routine and not routine use was defined as use in ≥ 90% and ≤ 10% of their patients, respectively. Results Tranexamic Acid: Routine use recommended; 26% used it routinely. Indwelling urinary catheterisation: Routine use supported; 58% used it routinely. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 34% used it routinely for TKA, 29% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 80% used it routinely for TKA, 92% used it routinely for THA. Cryotherapy: Routine use not supported; 48% used it routinely for TKA, 30% used it routinely for THA. Continuous passive motion (TKA): Routine use not recommended; 74% of surgeons did not use it routinely. Patella resurfacing (TKA): Routine resurfacing not recommended; 38% of surgeons routinely resurfaced the patella. Conclusion Recommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations, thus, it is unclear whether further evidence alone would lessen unwanted practice variation.

Your notes:

13

Quality Improvement project to find ideal exercises for patients in the acute phase after total knee replacement (TKR) surgery Alan Domansky-Chung, Surgical Ward Senior Physiotherapist , Coffs Harbour Health Campus Mid North Coast Local Health District Aim Quality Improvement (QI) Project to find ideal exercises for patients in the acute phase after total knee replacement (TKR) surgery Method A pictorial sign with minimal wording, placed upon patient’s bedside table immediately upon admission to the ward post-operatively (Figures 1 & 2). In-services (Physiotherapy, Surgical nurses, Acute Pain Service) discouraging previous long-standing culture of waiting for physiotherapy review prior to instigating any movement. Feedback 6 months after Project initiation used to modify the Physiotherapy post-operative approach. Results Medical Record auditing revealed average patient knee range of motion (on discharge) the same as for 1 year period prior to the Project. Education and re-assurance provided by Physiotherapists found to be more effective than any particular exercise prescription. Shorter average hospital length of stay (LOS) 0.3 days for unilateral TKR patients and 3.2 days for bilateral TKR patients. Decreased number of patients hospitalised for knee manipulation under anaesthetic (MUA) due to poor knee movement at follow-up with surgeons (after introducing a “new approach” of Physiotherapy intervention). Number of pre-operative Physiotherapy exercise sessions does not appear to correlate with length of hospitalisation including inpatient rehabilitation.

Conclusion The sign has re-assured patients about the painful experience after TKR surgery and also empowered them to initiate basic movements which assist in their functional recovery. Exercise prescription is no longer necessary, as the new approach of Physiotherapy intervention has been more effective, focussing on education and re-assurance. Cost of stationary for signage (and staff education) minimal when compared with cost savings in reduced hospital length of stay and reduced admissions for MUA.

Your notes:

14

Inpatient rehabilitation versus hybrid home program after knee arthroplasty: a randomised controlled trial Mark A. Buhagiar*, Justine M. Naylor, Ian A. Harris, Wei Xuan, Friedbert Kohler, Rachael Wright and Renee Fortunato; South Western Sydney Local Health District

Background Formal rehabilitation programs, including inpatient programs, are often assumed to be required after total knee arthroplasty (TKA) to optimise patient recovery. With the exception of comparisons with domiciliary services, no randomised trial has compared inpatient rehabilitation to any outpatient-based program. Aim To determine if 10 days of inpatient rehabilitation followed by a hybrid home program provided greater improvements in mobility, function and quality of life compared to a hybrid home program alone following TKA. Intervention In this multicentre, two-arm parallel randomised, controlled trial conducted at sites within the SWSLHD and SESLHD, participants who underwent a primary TKA were randomly assigned to receive either 10 days of hospital inpatient rehabilitation (HI) followed by usual care (an eight-week hybrid home program delivered by physiotherapists) or usual care at home (HO). Eligible people who declined randomisation, but consented to follow-up, formed an observational arm, receiving usual care. The primary outcome was mobility measured at 26 weeks post-surgery. Outcomes 165 patients were randomised (HI, n = 81; HO, n = 84) and 87 constituted the observational group. There was no significant difference (p=0.53) in the six-minute walk test between HI (mean 394.8m, SD 96.8) and HO groups (mean 395.9m, SD 118.4) nor in patient-reported pain and function, quality of life and time off work. There were also no differences in outcomes between those who received usual care in the observational arm and the HO group. Conclusion Inpatient rehabilitation does not provide participants with a superior level of recovery across a range of outcomes following TKA when compared to a home program. Your notes:

15

NB: The two following abstracts will be presented as one titled “Kneed to Succeed … Kneed to

Know”

“Kneed to Succeed”- Group Physiotherapy after Knee Replacement

Genevieve Langron*, Physiotherapist and Marie March, Physiotherapist (Orthopaedics)

Blacktown Mt Druitt Hospitals (BMDH), Western Sydney Local Health District

Background

The Blacktown Mt Druitt Outpatient Physiotherapy Department is a high-demand service and received

approximately 2800 referrals in 2015. Post-operative total knee replacement (TKR) is the second most

commonly referred condition, with approximately 120 referrals received in 2015. Current evidence

suggests that group based physiotherapy is equally as effective for TKR as the one-to-one model that

was current practice (Ko et al 2013, Naylor et al 2012), hence prompting our service redesign for this

cohort.

Aim

Our goal was to improve efficiency of outpatient physiotherapy treatment post TKR by 50% within 4

months.

Intervention

We used Clinical Practice Improvement Methodology to design a weekly TKR group, which includes

assessment, education and individual client exercises. Clients who are slow to progress are also given

the option of extra one-on-one sessions to ensure optimal outcomes are achieved for every client.

Outcomes

The average time spent treating post-operative TKR clients reduced by 59% throughout a three month

period. Despite a 17% increase in number of TKR referrals over 1 year, the total time spent by therapists

reduced by approximately 21 hours/month and achieved an annual labour efficiency cost saving of

$10,500. Client satisfaction remained consistently high, with formal post-program feedback results

showing 100% patient satisfaction with the quality of physiotherapy received. 100% of patients also

agreed that they enjoyed their exercises and felt confident performing exercises at home.

Conclusion

Group physiotherapy is an effective and efficient treatment for patients following TKR surgery in

Blacktown and Mt Druitt Hospitals.

16

“Kneed to Know”- Physiotherapy Education before Knee Replacement

Marie March*, Physiotherapist (Orthopaedics) and Genevieve Langron, Physiotherapist

Blacktown Mt Druitt Hospitals, Western Sydney Local Health District.

Background

Current systematic reviews do not support routine physiotherapy education for patients before knee

replacement (Ayden et al 2015, McDonald et al 2014). However, physiotherapy staff spent 475 mins per

month delivering an ad-hoc, one-to-one service in this patient group. Therefore, a redesign of our service

was required to reflect current physiotherapy evidence and to improve staff efficiency.

Aim

Our aim was to decrease physiotherapy service time spent per pre-admission patient by 50% to 15

minutes per patient over a 6 week period at Mt Druitt Hospital.

Intervention

We implemented a service redesign in 2016 based on Clinical Practice Improvement methodology. This

was the second project aiming to improve the TKR journey, after the 2015 project “Kneed to Succeed”

focused on outpatient physiotherapy after TKR. Our new service is a weekly class for patients and carers

delivered by a junior physiotherapist. The content outlines the TKR procedure, expectations before and

after surgery, knee exercises, and discharge planning. A collaborative team including occupational

therapy, specialist nursing and consumer representation across inpatient and community sectors

contributed to this content.

Outcomes

Physiotherapy time spent per pre-admission patient reduced from 29 mins to 8 mins (71% improvement)

after the implementation. 100% of patients were satisfied with the service. Concurrent increases in

inpatient physiotherapy time were seen during this period. System efficiency was improved by

streamlining the referral process to physiotherapy straight from the bookings department.

Conclusion

Class-based physiotherapy education is an efficient way of delivering physiotherapy education before

joint replacement while maintaining patient satisfaction.

Your notes:

17

NSW Paediatric Rheumatology Network

Model of Care Project – Diagnostics and Implementation

Anne Senner,* Jeff Chaitow, Davinder Singh-Grewal, Cathy Lovell, Robyn Speerin, & Christie Graham;

Sydney Children’s Hospital Network & Agency for Clinical Innovation

In 2013 the Agency for Clinical Innovation (ACI) launched the Paediatric Rheumatology Network Model

of Care. In 2015, ACI and Sydney Children’s Hospital Network (SCHN) developed a partnership to

implement the NSW Paediatric Rheumatology Network Model of Care by funding a project officer to

implement the model of care. Utilising the Redesign Methodology, the project has undertaken key

Diagnostics which has led to Solution Design and Implementation. The Steering Committee comprised

of clinicians, consumers, non-governmental support agencies and broad representation from

government agencies guided the implementation of the Model of Care. Phase 1 of the project

concentrated its efforts on the largest single patient group in the speciality, patients with Juvenile

Idiopathic Arthritis (JIA). This paper will detail the results of the diagnostic work, which identified

inequities in both uveitis surveillance and intra-articular injections. Designing solution for implementation

was initiated for some of the key areas as well has highlighting other areas for future work needed to the

Model of Care. In addition diagnostics related to the patient journey, benchmarking the paediatric

rheumatology service was critical data point when designing solutions. Successes of the project will be

highlighted.

“I wish we had this when my daughter was diagnosed”

Development of Resources to Support Patients and Families with Rheumatic Disease

A. Senner,1* J. Chaitow,1,5 K. Faber,3 A. Ford,1 C. Grahame,5 D Grech,1 C. Lovell,1 D Singh-Grewal,1,5,6

R. Speerin,2 P. Weigand1

Sydney Children’s Hospital Network,1 Agency for Clinical Innovation,2 Arthritis NSW,3 Myositis

Association Australia4, John Hunter Children’s Hospital,5 Liverpool Hospital6

In 2015, the Agency for Clinical Innovation and Sydney Children’s Hospital collaborated on a project to

implement the Model of Care for the NSW Paediatric Rheumatology Network. One of the key outcomes

of this project was the development of resources for patients and families with rheumatic diseases. This

presentation will describe patient resources that have been developed through the collaboration of

clinicians and key stakeholders, including non-government agencies and consumers. The aim of these

resources is to provide accurate information to patients and families (consumers) which has been either

created and/or recommended by the paediatric rheumatology multidisciplinary team. The consumers for

each project were consulted about content, which was then included in the resource. The two main

projects were the development of a video resource title “What is Juvenile Dermatomyositis: A resource

for Patient and Families diagnosed with JDM” and the development of the Paediatric Rheumatology

Network, NSW Website. This paper will describe the projects and promote the resources to the wider

rheumatology community.

Your notes:

18

Improving transition for young people with rheumatology conditions, a work in process

Brodie L.,1* Ho, J.,2* Chaitow, J.,3 Hassett, G.,4 Niddrie, F.,5 Major, G.,5 McKay, D.,4 Myles, A.,1 Rickard,

H.,4 Singh-Grewal, D.,3,4, Tickle, F.,4 Vernon, D.1 1 Agency for Clinical Innovations; 2Trapeze, Sydney Children’s Hospital Network; 3 Paediatric

Rheumatology, Sydney Children’s Hospitals Network; 4 Department Rheumatology, Liverpool Hospital; 5Department of Rheumatology, John Hunter Hospital;

Transition support for young people with chronic illnesses /disabilities in NSW has improved significantly

over the past decade but there is still a long way to go before it becomes embedded into clinical practice.

There is still a tendency to view transition as an event involving the actual move to adult services, rather

than a planned process that empowers young people and their families over several years to be active

partners in decisions that will impact on their future healthcare.

NSW has two funded transition services that work together to improve the process - Trapeze for patients

of the Sydney Children’s Hospitals Network and the ACI Transition Care Network for patients outside the

SCHN. They work collaboratively to facilitate evidence based transition processes that take a

comprehensive, developmentally appropriate approach to preparing and supporting the young person

and family.

Young people with rheumatic disease need to be linked into a range of services other than just

rheumatology. There is evidence that morbidity increases in young adults who are in the process of

transitioning.(1) In a population of adolescents with rheumatic disease, an increase in active disease and

flare ups were noted. (2) Speciality transition clinics to support these young people are now being

developed within John Hunter and Liverpool Hospitals and SCHN. This paper will provide an overview of

NSW Transition services and outline the new clinic initiatives. A young person with juvenile arthritis who

has been a long term patient of paediatric care will provide their perspective of transition.

1. Watson AR. (2000). Noncompliance and transfer from paediatric to adult transplant unit. Pediatric

Nephrology, 14:469-72

2. Stringer E, Scott, R, Mosher D, MacNeill I et al. (2015) Evaluation of a Rheumatology Transition

Clinic. Pediatric Rheumatology, 13:22

Your notes:

19

Physiotherapy involvement within the Paediatric Rheumatology Clinic: Implementation of

ACI guidelines

Fiona Tickle* and Carolyn Young*

Fiona.tickle@sswahs.nsw.gov.au, Carolyn.young@sswahs.nsw.gov.au

Paediatric Physiotherapy Team, Liverpool Hospital, Liverpool, NSW Australia.

Background

A need for specialist multidisciplinary paediatric rheumatology services and access to trained

physiotherapists and occupational therapists in regional and rural areas of NSW has been highlighted

within the Agency for Clinical Innovation guidelines (2013). Recommendations included that education of

this group of health professionals can have favourable outcomes for patient care and for creating

regional networks of care that are particularly important in rheumatic diseases.

Aim

To use the ACI recommendations as a guide for improving educational opportunities for staff and

provision of multidisciplinary services for patients within the South Western Sydney region.

Intervention:

1) Physiotherapy involvement within the Paediatric Rheumatology clinic at Liverpool Hospital.

2) Coordination of educational opportunities for local clinicians.

3) Development of resources, referral pathways and communication throughout the regional

network.

Outcomes

1) Every child who attends the Paediatric Rheumatology clinic at Liverpool now has access to a

Paediatric Physiotherapist trained in Rheumatology. They may receive assessment, education on

their condition, advice regarding activity modification , exercise and onward referral.

2) 54 allied health staff attended an educational day on management of Rheumatological conditions

in the Paediatric Population.

3) During the last 9 months 146 children have attended the Rheumatology clinic with 61 (42%)

identified as requiring direct physiotherapy input. Fourteen have been referred directly to therapy

services throughout the region with ongoing support offered to therapists.

Conclusion

The Physiotherapists’ involvement within the Paediatric Rheumatology Clinic at Liverpool Hospital

alongside the coordination of an educational day, has enabled children with Rheumatological conditions

to access specialist multidisciplinary management close to home in line with ACI guidelines.

Your notes: