The concern about the triage system came about as many
patients were on waiting lists for 3 months with no intervention at
all. (Anecdotally) many patients stopped activities in fear that
they may make their condition worse, or continued doing
activities that were detrimental.
At present in our hospital system we have a physio working in
fracture clinic, where specific advice and exercises can be given
whist patients are waiting for their appointment (usually in 3-4
days from an appointment with the consultants in fracture clinic).
>From repeated audits, this has shown to decrease treatment time
and speed up recovery and prognosis. The pre- assessment clinic
has arisen from this model.
>My concern would be, which exercises would you give them
without an evaluation
>first? It could be a liability issue if they either perform the
exercise
>since they haven't been taught and injure themselves, or if the
>How often do you get a diagnosis on the presription that is not
accurate?
The pre-assessment takes the form of a scaled down
subjective/objective assessment, where a probable diagnosis is
made by the physio. If the patient is is need of urgent Rx they will
be taken out of the triage system and treated imediately. These
patients include:
1. Current episode less than 6/52, acute, or acute on chronic.
2. Pts off work from current episode less than 6/52, and aiming to
return in the near future.
>Is the advice written down? Memories are notoriously poor at
first visits. What is the >purpose of "general" exercises?
Any exercises given are written down in a Physio Tools-type
format, and all are performed by the patient with supervision of
the physio. "General" exercises are classed as: SLR, IRQ, active
assisted shoulder flex, capsular stretches, etc. The purpose is to
enable pts, as oppose to disabling them.
Any posture, manual handling advice is written down on pre-
printed sheets, with sections highlighted appropriately. Any other
specific advice asked for by the pt is not written down. The whole
process takes 45 minutes.
>Am I mistaken, or are you explicitly stating that people with
problems for prolonged periods >do not deserve the same
considerations of care that people with more recent complaints
>might receive? What is your rationale?
Yes. The current system of acute and chronic pt lists already
exists, with the acutes getting far earlier Rx than the chronics.
This is currently decided on what the GP/ consultant writes on the
referal card - a wholely unfair system as a recent audit at our
department showed that 30% of all pts referred, the physio
disagreed with the diagnosis from the doctor, and 40% had no
mention of acuteness.
>If they do this for months and nothing happens then you
examine them and decide on >specificity of exercise, can you
convince them that it is worthwhile to persevere? Specific
>exercises require a thorough assessment, guidance and
practice.
I think that is a very valid point, and one we need to address.
Specific exercises of the McKenzie/ ANT are obviously not
applicable in this case, as there is no follow-up to re-assess and
modify.
The psycological factor is an important one. The patients are sent
a letter explaining the pre-assessment clinic and that they will be
given advice to manage their condition whilst on the waiting list
(they are not told that they will jump the queue if their need is
assessed to be great enough). I recently attended a seminar on
Motivational Interviewing techniques, which is very in the
empowerment of the pt camp, and letting them decide if they are
ready to change a behaviour - be it to tkae up exercise, or
become more active, or whatever. On that basis, the pts who
actually attend for the clinic will be ready to change, and willing to
do something about it (or appear as if they do). Pts in this state
would surely respond to stretches, strengthening and advice - as
this is surely the basis of the majority of all physiotherapy.
I do not want to appear really defensive of this new protocol, so
please do not take it that way. I just feel that I did not explain
myself cleary in the first email. I hope this addresses your
concerns, and sorry it's so long ;>
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