London Patient Choice Project

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London Patient Choice Project
London Patient Choice Project Lumbar Discectomy
Care Pathway 17/12/2003
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Orthopaedics Patient ( Clinical ) Pathway
Principles and Standards
Patient Identification
Pre - Operative

• Operative Assessment
• These visits will commence at 800 AM with an MRI
  scan followed by examination by the Resident
  Medical Officer. Findings will then be presented
  to the specialist surgical team.
• Notes, MRI scans X-rays available (scans
  x-rays need to be less than 6 months old)
• Personnel required
• Surgeon (with special interest which would enable
  performing the surgery), and Nurse
• Tests Urinalysis, ECG, B/P, Height, Weight,
  Bloods (FBC, UEs), Chest x-ray, MRSA.
• Consent
• Anaesthetic assessment (by anaesthetist or nurse
  trained in anaesthetic assessment)
• Individual patient education (including smoking
  cessation where appropriate)

• All patients who have been on the waiting list
  for the agreed procedures for 4 months and 2
  weeks and are registered with a London GP (PCT)
  are eligible to be offered Choice EXCEPT patients
  in the following groups
• Known MRSA/Active Tb
• MI or Cardiac Surgery within last 6 months.
• Pregnant
• Under 16 years old
• Current renal dialysis
• ASA 3 or above (if known)
• Taking warfarin

• Principles
• Clear responsibility for ongoing treatment in the
  best interests of the patient.
• Need to work together to provide a high quality
  experience for patients.
• Minimal reasons for excluding patients from being
  offered Choice - No cherry picking by the
  provider.

• BestPractice Guidelines/Standards
• Action on Orthopaedics
• Good Practice in consent Implementation guide -
  DOH (March 2001)
• Royal College of Anaesthetists Guidelines -
  including guidelines for Pre-Admission. (2000)
  Raising the Standard.
• ASA guidelines on physical status.

• There are 6 possible outcomes from this visit -
  local arrangements to accommodate track these
  outcomes MUST be in place.
• Fit for surgery but requires up to date
  investigation.
• Patient fit for surgery, wishes to proceed (at
  RT) date of operation agreed with patient.
• Patient fit for surgery or temporarily unfit for
  surgery but wishes to have surgery/further
  treatment at OT.
• Patient decides not to proceed with surgery.
• Patient is temporarily unfit for surgery - will
  require treatment at OT or by GP prior to
  returning to RT for operation.
• Patient not suitable for surgery at any time.
• A clear record must be kept of the clinical
  reasons which prevent patients progressing to
  surgery - these outcomes will be audited by the
  LPCP team.
• The RT consultant must also write to the OT
  consultant with the clinical findings if the
  patient does not progress for clinical reasons.

• Procedures
• Lumbar discectomy
• (for prolapsed intervertebral discs)
• Which includes -
• Microdiscectomy
• Laminectomy
• Discectomy
• Associated procedures
• Decompressions
• Fusions

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Elective Joint (Hip and Knee) Replacement
Orthopaedics Patient ( Clinical ) Pathway
Planning for Discharge
Peri-Operative
Post Operative
Follow up Rehabilitation
The first follow up appointment will be at the
Receiving Trust 6 weeks after surgery Any
complications arising from the operation within
3 months will be treated by the RT. If treatment
is ongoing at 3 months it will continue at the RT
until the patient can be discharged. If the
patient presents after 3 months with a new
complaint, the GP, in discussion with consultant
colleagues if necessary, will decide whether the
patient should be referred to the OT or the RT.
Any emergencies should be treated at the
nearest available facility and then referral
arrangements made as appropriate. If required,
follow up physio/occupational therapy
arrangements will depend on local network
arrangements - see local section of pathway.
However, the patient remains the responsibility
of the RT until discharged by the
consultant. Patient outcomes must be audited and
results documented. A report on the initial group
of patients from Lewisham who choose to attend
Ravenscourt Park will be required by LPCP. Longer
term measurement of outcomes would be
recommended.

• As per the Royal College of Surgeons and British
  Orthopaedic association guidelines Action on
  Orthopaedics.
• Surgeon - certificate of completion of Surgical
  Training
• -consultants on GMCs Specialist Register
• Workforce
• Ultra clean air theatres (dedicated usage)
• Record keeping as per guidelines
• Monitoring of case mix
• These procedures are usually performed under
  general anaesthetic.

These procedures are usually performed as day
surgery or short stay (1 to 5 nights) Post-operati
vely the patient should be monitored for any
neurological deterioration (lower extremity
weakness or numbness). The usual post anaesthetic
procedures should be followed. The patient should
be seen by the surgeon prior to discharge. The
patient should be given written information on
what to expect post operatively and guidance on
what and what not to do to promote recovery. The
RT must provide the patient with a 24 hour
emergency contact telephone number on discharge.
It is not anticipated that complex discharge
planning will be required for this group of
patients. However, if a patient does present
with more complex needs, then there must be
liaison between RT and OT and a treatment plan
agreed.
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Patient Choice System PCA Process
Pre Operative
Principles Standards
Patient Identification

• IT System Implications
• Recording op dates etc from RT so that
• system can be kept up to date to facilitate
• patient questions.
• Reporting systems developed - template on web
  link
• for Trusts to complete on a daily or weekly
• basis.

Patient Choice System
RTs will need to provide specific information
about Operative Assessment Operating Schedules,
I.e. day, date, time, surgeon etc. It is
particularly likely for these procedures that
more slots will be required for Operative
Assessment than for operation to allow for
patients who will not proceed to surgery.
Information about RTs for patients being offered
Choice - PCA file

• Operations should take place within 4 weeks of
  the pre-operative assessments and can be booked
  into Choice capacity by the RT. However.
• The outcome of the pre-assessment, including the
  guaranteed date for surgery and details of any
  treatment required before surgery MUST be
  communicated to the OT, GP and PCA team for
  reasons of clinical governance, accurate waiting
  list management and complete patient tracking. If
  patients receive treatment at OT or by GP in
  preparation for surgery, RT PCA team must be
  made aware of progress via reporting/patient
  tracking mechanism.
• It is also anticipated that if relatively simple
  treatment would render the patient fit for
  surgery, then it should be carried out at the RT.
  
• The date for surgery MUST be arranged with the
  patient at the Operative Assessment visit - the
  patient MUST NOT just be sent an appointment by
  letter at a later date.
• RTs are recommended to use Integrated Care
  Pathway documentation (which should commence at
  the pre-operative assessment) to facilitate both
  accurate contained record keeping at the RT and
  comprehensive return of information to the
  Originating Trust.
• The patient notes should stay at the RT until the
  episode is completed unless they are specifically
  required for other purposes at the OT.

• Complete set of notes from OT to RT - robust
  local systems for safe transfer including named
  person who is responsible for whereabouts of the
  notes at each Trust.
• Appropriate x-rays/scans (less than 6 months old)
• OT RTs to establish operational teams with
  clear roles and responsibilities.
• OT will need to log patients excluded from Choice
  and the reason why against the exclusion criteria.

Rigorous quality assurance process prior to Go
Live to ensure operational capacity of
participating Trusts - see separate documents.
Patient expectation to be managed from validation
through to offer of Choice as the outcome of the
Operative Assessment may not be surgery at an
earlier date.
Stage 1 Outpatients Stage 2 Pt. Waiting Stage 3
Choice Offered Stage 4 Choice Accepted
PCA Process
Stage 5 Pre-Operative Assessment, Surgery
Discharge
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Elective Joint (Hip and Knee) Replacement
Patient Choice System PCA Process
Planning for Discharge
Peri-Operative
Post Operative
Follow up Rehabilitation
Patient Choice System

• PCA Evaluation Learning
• Patient Tracking /
• Reporting Cycle

To ensure a level of equity in Patient Choice,
local systems must be known and comply with the
timelines of the pathway There are elements of
patient care that could be shared between the OT
and RT in the best interests of the patient. A
copy of the discharge plan should be sent to the
Originating Trust.
Copy of RT notes/Integrated Care Pathway to be
returned to Originating Trust with the original
notes and x-rays. Outcomes of the completed
episode must be reported via Choice template to
OT and PCAs. A discharge letter should be sent
to the patients GP in the usual fashion.
PCA Process
Stage 5
Stage 5
Stage 5
Stage 6 Follow Up
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Local/Sector Arrangements (Buddying) Lewisham
Hospital and Ravenscourt Park
Principles Standards
Pre Operative
Patient Identification
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Local/Sector Arrangements (Buddying)
Planning for Discharge
Peri- Operative
Post Operative
Follow up Rehabilitation
Lewisham Head of Occupational Therapy - Tricia
McMenamin. 020 8333 3037. Email
tricia.mcmenamin_at_uhl.nhs.uk Social Services
contact - Janet Higgins. 020 8314 8637. Email
janet.higgins_at_lewisham.gov.uk Greenwich Home
loan equipment (temporary) (PCT Borough) -
Community Stores - Alan Piper 020 8836 6393/6391.
Fax - 020 8836 6399 (830 to 1700) Home
Adaptations (permanent) (Borough) - Adaptations -
Bill Brittain 020 8854 8888 (900 to 1730.
Fridays close at 1630) Bexley (Queen Marys
Sidcup) Occupational Therapy - Helen Wilson 020
8302 2678 Ext 3151 Social Services OT - Judith
Bird - Contact via Helen Wilson Southwark Home
loan equipment (temporary)/ Physiotherapy -
Stephanie Edwards (Adult Therapy) 020 7771 3361
(900 to 1700) email _at_ southwarkpct.nhs.uk Home
adaptations (permanent)- Social Services OT - 020
7525 399695 Bromley Home loans (all) (PCT)
Thelma Morley 01689 853339
Agreed that Originating Trust or local primary
care therapies would treat patients if they
required further visits after discharge -
indications are that numbers will be manageable.
Lewisham Senior Physiotherapist - Denise
Christie. 020 8333 3000 Bleep 065 GSTT Head of
Therapies - Sue Waters Greenwich Community
Therapy/Physiotherapy (PCT) - Team Leader - Marta
Aujeet 020 8836 6377 Fax [phone] (830 to
1630) Bexley (Queen Marys, Sidcup) Physiotherap
y - Shan Lythgoe 020 8302 2678 Ext
4539 Bromley Physiotherapy - Evelyn Benfield -
01689 853339