Katie Kinch MSc (Dist) MCSP, FAPCP and Joyce Cummings

Lead Advanced Practice Physiotherapists (Paediatric Orthopaedics)

Background

Paediatric Orthopaedic service (POS) - redesigned in 2016. The service is now led by two Lead Advanced Physiotherapy

Practitioners (2 WTE, Band 8a) with support from an Advanced Physiotherapy Practitioner (0.3WTE, Band 7), Consultant Paediatric Orthopaedic Surgeons and Consultant Paediatric Radiologists.

The APPs are responsible for the day-to-day running of service

clinic management

vetting and triage of referrals

service improvement, self evaluation and audit.

The APPs also provide leadership in clinical education, quality improvement and quality assurance for the Children and Young People’s Physiotherapy service.

Service includes Secondary surveillance for Developmental

Dysplasia of the infant hip (DDH)

Management of infant foot problems including the management of Congenital Talipes equinovarus (CTEV) following Ponseti protocols

Management of general paediatric orthopaedic conditions

Orthopaedic management of children and young people with neurodisability including the management of focal spasticity

The service does not include urgent, acute musculoskeletal and orthopaedic conditions , acute trauma or the acutely unwell child.

Baby Hip serviceEarly diagnosis and early conservative treatment of DDH is related to more successful outcomes. NHS

Fife operates a selective secondary surveillance programme based on universal clinical hip examination and ultrasound assessment of children with significant risk factors or an atypical clinical examination. Referrals to the Baby Hip service are received from the Maternity Unit via Badgernet or from GPs via SCI Gateway.

Infants are seen for clinical examination and hip ultrasound scan either in the Maternity Unit, prior to discharge, or at a Baby Hip clinic. Urgent referrals, where significant hip instability or hip dislocation is suspected, will be seen, if possible, within 2 weeks. Routine referrals will receive a Baby Hip clinic appointment within 6 weeks.

The experienced physiotherapy team operates a ‘one-stop shop’ service including

expert clinical examination

diagnostic ultrasound scanning

treatment of DDH with Pavlik harness

health promotion

Two Baby Hip clinics are held in the Children’s Unit of Victoria

Hospital each week.

Teaching and training is an integral part of the APP role

Advanced Practice Physiotherapy in Paediatric

Orthopaedics 2017 and 2018

BABY HIP

BIRTHS: 6438

REVIEWS:

REFERRALS: 2532

SINGLE CONSULT:

DDH: 27 Late

presentation:

0

Referred Ortho con:

1

Referred Radiology:

3

Please contact us for

further information:

joycecummings@nhs.net

01592 643355 x 23609

The Advanced Practice physiotherapy

service delivers patient care along the

NHS Fife Infant Hip (DDH) Surveillance

Pathway.

We aim to provide an excellent level of

care including clinical assessment,

investigation using ultrasound ,

diagnosis of hip abnormality and

treatment of DDH.

Baby Hip clinics

Children’s Unit

Victoria Hospital

Kirkcaldy

Fife

photo photo

7.67.68

6.66.6

3.9

7

4.33.7

4.6

0

2

4

6

8

10

2009 2011 2013 2015 2017

Treatment rate per thousand

Treatmentrate perthousand

29 30 30

23 23

14

24

1512

15

02468

101214161820222426283032

200

920

1020

1120

1220

1320

1420

1520

1620

1720

18

Number of infants treated with Pavlik harness

number ofinfantstreated withPavlikharness

Baby Foot serviceThe weekly Baby Foot clinic at Victoria Hospital, Kirkcaldy is a specialist

service for children born with structural foot deformity. Conditions seen include Congenital Talipesequinovarus (Clubfoot), metatarsus adductus and postural moulding of the feet including calcaneovalgus.

The service includes antenatal consultation

diagnostic assessment in the Maternity Unit or clinic

serial casting including Ponseti method

orthotic management.

The APPs work closely with Paediatric Orthopaedic colleagues at Royal Hospital for Sick Children in Edinburgh as babies with CTEV usually require referral for percutaneous tenotomy surgery as an adjunct to casting intervention.

Baby Foot servicePonseti casting Antenatal consultation

Cast removal

Orthotic measurement and fitting

General Out-patient clinic

The service provides out-patient management of non-emergency musculoskeletal conditions affecting young people from birth to the school leaving age. The clinics run weekly at VHK and QMH.

The service includes –

Assessment/diagnosis/management of

non-urgent orthopaedic conditions

ordering of investigations such as x-ray and MRI

health promotion including signposting to local physical activity groups

review and distribution of service user information leading to a reduction in the number of inappropriate referrals

Paediatric Orthopaedic service for

children with neurodisabilityChildren with neurodisability are at increased risk for orthopaedic complications

such as joint contractures, hip displacement and scoliosis.

Clinics offer increased time to cover complex needs related to the CYP’s

orthopaedic management including – timely local reviews, imaging, onward

referral for surgical intervention and focal spasticity

management (assessment and delivery of targeted

Botulinum Toxin-A injections)

Clinics also provide –

Links with Cerebral Palsy Integrated Pathway Scotland (CPIPS) including x-rays

at appropriate intervals

Joint Motor Disorder clinic with Consultant Neurologist from RHSC Edinburgh.

Health promotion including referral to Disability Sport organisations and

appropriate physical activity groups eg RaceRunning and other 3rd sector groups

Impact of APP in General and Motor

Disorder clinics

Paediatric

Orthopaedics

Clinics

Patients referred to

clinic in 2018 = 601

Seen at RHSC

Edinburgh: 25 (CP

– 11, SB – 9*, other

- 5)

CYP with

neurodisability requiring

Orthopaedic review :

194

Consultant review

required = 42 (10%)

Referred to

RHSC = 7**

(1%)

Awaiting

surgery/post

surgery

/surgical

opinion - 11

Surgical

intervention =

4 **(2017/18)

Orthopaedic

Motor Disorder

clinic

*Spina Bifida – all patients are seen within MDT SB clinic at RHSC

Number of patients seen

in Joint MD clinic with

RHSC Neurologist – 40

Seen by Ortho

consultant in

Fife: 0

** does not include referrals to Spinal service

0

2

4

6

8

10

2016 2017 2018 2019

Average waiting time in weeks

Benefits Decreased waiting times through service redesign -

Audit of Orthopaedic clinic referrals - clinics have reduced by 30% since

2016.

Increased capacity

Improved care pathway – patients are seen closer to home and can

have several issues addressed at one clinic rather than several.

Robust links and improved communication have been established

with local therapy teams and tertiary centres

Cost savings –

decreased anaesthetic costs of £123,000 due to service improvements in

Focal Spasticity service (2009 – 2014)

Establishment of career pathway for paediatric physiotherapists

interested in progressing into advance practice roles

Evaluation of service and

service improvement

Focus groups

Semi-structured interviews

Patient survey

2 Stars and a Wish

Care Opinion

Web-address

‘can’t fault, start to finish’

Excellent service, really appreciate it,

really happy’

‘great service’

‘lovely and friendly’

Conclusion

The Paediatric Orthopaedic service can be

successfully managed by Advanced Physiotherapy

Practitioners.

Robust clinical supervision and timely support from

Consultant Paediatric Orthopaedic Surgeons and

Consultant Paediatric Radiologists as required is

essential for safety and clinical governance.

Advanced PracticeAdvanced Practitioner

Level –

Experienced clinical

practitioners with a high

level of skill and

theoretical knowledge.

Will make high level

clinical decisions and

manage their own

workload http://www.ahpadvancedpractice.nes.scot.nhs.uk/media/251474/msk%20framework%20(final).pdf

4 Pillars of PracticeAdvanced Practitioner would be

working towards demonstrating

capabilities within each of

these pillars of practice on

entry to the role.

Each role differs and is likely to

be locally defined.

Differences are likely both

between professions and within

professions – in relation to the

balance of requirements within

each of the pillars of practice.

Career Framework for Health

Learning and

Development

Opportunities – noted

in document.

Post graduate level,

MSc modules

Thanks for listening!

Questions?