Transforming Hip Screening for Children with …. AJones.pdfTransforming Hip Screening for Children...
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Transforming Hip Screening for Children with Cerebral Palsy An Interdisciplinary Approach Following the Cerebral Palsy Integrated Pathway (CPIP) Anna Jones (Highly Specialist Paediatric Physiotherapist) and Janice Pryke (Lead Reporting Radiographer) Correspondence to: [email protected] or [email protected] The Problem Children with cerebral palsy (CP) are more likely to have hips which migrate or dislocate 1 . This causes pain, reduced movement, less function and poor quality of life 2 . Audit at Dorset County Hospital (DCH) highlighted that none of our children with CP were receiving standardised assessment and surveillance of their hips. The Solution Population-based hip surveillance programmes such as the Cerebral Palsy Integrated Pathway (CPIP) detect hip displacement, resulting in significantly lower incidence of dislocation 1-3 . How to position for hip X-ray 4 X-ray image demonstrating how to measure hip migration percentage (MP) using Reimer’s Migration Indices From this image...... ...... to this image Hip X-ray of child with CP before CPIP positioning in 2013 Hip X-ray of the same child with CP imaged with CPIP positioning in 2017 Parents reported hip X- rays a stressful procedure No standardised feedback from referrer Variability in radiology reporting standards Radiographer limited awareness of importance of accurate positioning for reporting of MP and predictor values Time constraints due to capacity/ demand issues with long wait to be seen Radiographer limited awareness of dealing with spasticity and behavioural issues and no available assistance Radiographer unlikely to know child’s abilities/requirements No dedicated time slots for patients as walk in service Process mapping with team (radiographer, physiotherapist, radiographer, paediatrician) highlighted: Images were of poor quality for measurement purposes and were non comparable Local services were not meeting CPIP standards for MP measurements (3% n= 3) or correct timing of imaging (5% n=4) Retrospective data collected 2014-2016 from notes and X-ray records identified 87 children on caseload with CP (0-19 years) Clinical Audit 2016 Highlighted: (registered number 3595) Excellent patient/parent feedback (45% questionnaire return rate) Patient journey leaflet issued to child/family prior to clinic resulting in less child anxiety when presenting to clinic No radiologist involvement allowing quicker and more cost effective reporting turnaround times The radiographer has additional post graduate training for reporting measurements and making recommendations Database ensures timely imaging, reducing risk of over or under imaging Physiotherapist authorised to request CPIP X-rays, directly freeing up consultant paediatrician time Correct equipment available (e.g. hoist) and child friendly X-ray room Appointed hip X-ray clinic sessions with both CPIP trained radiographer and physiotherapist present The physiotherapist has prior knowledge of patient/carers; has the therapy skills to facilitate optimal positioning of child for the X-ray 61% of children with CP on caseload at DCH had been imaged by April 2019, all following CPIP standards Substantial improvement in X-ray standardisation and quality (criteria met for MP measurement and timing for 100% of those imaged n=65) Re- audit 2018/2019 Highlighted: (registered number 4728) Learning outcomes and reflection Inter-professional working has led to standardised care following CPIP, improving the safety of imaging, better quality of care for children with CP and their families, with excellent service user satisfaction. This interdisciplinary working has forged new relationships across professions breaking down boundaries and has led not only to improved patient care, but also greater job satisfaction. References 1. Hagglund G, Andersson S, Duppe H, et al. Prevention of dislocation of the hip in children with cerebral palsy. The first ten years of a population-based prevention programme. J Bone Joint Surg [Br] 2005; 87-B: 95-101. 2. Soo B, Howard JJ, Boyd R et al. Hip displacement in cerebral palsy. J Bone Joint Surgery (Am) 2006; 88-A: 121-129. 3. Hagglund G, Lauge-Pedersen H, Wagner P. Characteristics of children with hip displacement in cerebral palsy. BM Musculoskelet Disord 2007; 8: 101. 4. Cerebral Palsy Integrated Pathway Scotland (CPIPS) Development Team NHS Scotland.(2015). Course material from: Establishing a UK Wide Patient Management System for Children with Cerebral Palsy, including CPIPS booklet of origins and development, core dataset, clinical assessment. Sheffield Hallam University. Further Work Full CPIP pathway with clinical measures awaiting Trust approval and support. A business case has been submitted Agreement to continue clinic, aiming for 100% compliance by 2020 as predicted in graph above Training of additional therapy and radiography staff required (to ensure permanence of clinic and consistency in positioning for imaging) Training cascaded to adjacent Trusts enabling regional standardisation allowing further scope for expansion 0 10 20 30 40 50 60 70 2016 2018 2019 Percentage Year Percentage of local CP population meeting CPIP standards percentage meeting CPIP standards 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Excellent Good Fair Poor Not stated Percentage Rating Questionnaire Feedback - how does today's experience compare to previous hip x-ray experiences? Current (2019) Previous (2018) Care pathway established following audit findings. Clinic piloted 2017. The Radiographer and Physiotherapist work together to use standardised positioning in order to image the child Graphs Showing Comparison of CPIP Standards at DCH 2016-2019 Acknowledgements: The authors wish to thank our brilliant teams (in particular the hard work of Therapy Assistants Naomi Bevan and Jo Greatorex), and all the amazing children and families we work with.
Transcript of Transforming Hip Screening for Children with …. AJones.pdfTransforming Hip Screening for Children...
Transforming Hip Screening for Children with Cerebral Palsy An Interdisciplinary Approach Following the Cerebral Palsy Integrated Pathway (CPIP) Anna Jones (Highly Specialist Paediatric Physiotherapist) and Janice Pryke (Lead Reporting Radiographer)
Correspondence to: [email protected] or [email protected]
The Problem
Children with cerebral palsy (CP) are more likely to have hips
which migrate or dislocate1. This causes pain, reduced movement, less function and poor quality of
life2. Audit at Dorset County Hospital (DCH) highlighted that
none of our children with CP were receiving standardised
assessment and surveillance of their hips.
The Solution Population-based hip surveillance programmes such as the
Cerebral Palsy Integrated Pathway (CPIP) detect hip displacement, resulting in significantly lower incidence of
dislocation1-3.
How to position for hip X-ray4
X-ray image demonstrating how to measure hip migration percentage (MP) using Reimer’s
Migration Indices
From this image......
......to this image Hip X-ray of child with CP before CPIP positioning in 2013
Hip X-ray of the same child with CP imaged with CPIP positioning in 2017
Parents reported hip X- rays a stressful procedure
No standardised feedback from referrer
Variability in radiology reporting standards
Radiographer limited awareness of importance of accurate positioning for reporting of MP and predictor values
Time constraints due to capacity/ demand issues with long wait to be seen
Radiographer limited awareness of dealing with spasticity and behavioural issues and no available assistance
Radiographer unlikely to know child’s abilities/requirements
No dedicated time slots for patients as walk in service
Process mapping with team (radiographer, physiotherapist, radiographer, paediatrician) highlighted:
Images were of poor quality for measurement purposes and were non comparable
Local services were not meeting CPIP standards for MP measurements (3% n= 3) or correct timing of imaging (5% n=4)
Retrospective data collected 2014-2016 from notes and X-ray records identified 87 children on caseload with CP (0-19 years)
Clinical Audit 2016 Highlighted: (registered number 3595)
Excellent patient/parent feedback (45% questionnaire return rate)
Patient journey leaflet issued to child/family prior to clinic resulting in less child anxiety when presenting to clinic
No radiologist involvement allowing quicker and more cost effective reporting turnaround times
The radiographer has additional post graduate training for reporting measurements and making recommendations
Database ensures timely imaging, reducing risk of over or under imaging
Physiotherapist authorised to request CPIP X-rays, directly freeing up consultant paediatrician time
Correct equipment available (e.g. hoist) and child friendly X-ray room
Appointed hip X-ray clinic sessions with both CPIP trained radiographer and physiotherapist present
The physiotherapist has prior knowledge of patient/carers; has the therapy skills to facilitate optimal positioning of child for the X-ray
61% of children with CP on caseload at DCH had been imaged by April 2019, all following CPIP standards
Substantial improvement in X-ray standardisation and quality (criteria met for MP measurement and timing for 100% of those imaged n=65)
Re- audit 2018/2019 Highlighted: (registered number 4728)
Learning outcomes and reflection
Inter-professional working has led to standardised care following CPIP, improving the safety of imaging, better quality of care for children with CP and their families, with excellent service user satisfaction. This interdisciplinary working has forged new relationships across professions breaking down boundaries and has led not only to improved patient care, but also greater job
satisfaction.
References
1. Hagglund G, Andersson S, Duppe H, et al. Prevention of dislocation of the hip in children with cerebral palsy. The first ten years of a population-based prevention programme. J Bone Joint Surg [Br] 2005; 87-B: 95-101.
2. Soo B, Howard JJ, Boyd R et al. Hip displacement in cerebral palsy. J Bone Joint Surgery (Am) 2006; 88-A: 121-129.
3. Hagglund G, Lauge-Pedersen H, Wagner P. Characteristics of children with hip displacement in cerebral palsy. BM Musculoskelet Disord 2007; 8: 101.
4. Cerebral Palsy Integrated Pathway Scotland (CPIPS) Development Team NHS Scotland.(2015). Course material from: Establishing a UK Wide Patient Management System for Children with Cerebral Palsy, including CPIPS booklet of origins and development, core dataset, clinical assessment. Sheffield Hallam University.
Further Work
Full CPIP pathway with clinical measures awaiting Trust approval and support. A business case has
been submitted
Agreement to continue clinic, aiming for 100% compliance by
2020 as predicted in graph above
Training of additional therapy and radiography staff required (to ensure permanence of clinic and consistency
in positioning for imaging)
Training cascaded to adjacent Trusts enabling regional
standardisation allowing further scope for expansion
0
10
20
30
40
50
60
70
2016 2018 2019
Pe
rce
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Year
Percentage of local CP population meeting CPIP standards
percentage meeting CPIP standards
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10%
20%
30%
40%
50%
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100%
Excellent Good Fair Poor Not stated
Pe
rce
nta
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Rating
Questionnaire Feedback - how does today's experience compare to previous hip x-ray
experiences?
Current (2019)
Previous (2018)
Care pathway established
following audit findings.
Clinic piloted 2017.
The Radiographer and Physiotherapist work
together to use standardised
positioning in order to image the child
Graphs Showing Comparison of CPIP Standards at DCH 2016-2019
Acknowledgements: The authors wish to thank our brilliant teams (in particular the hard work of Therapy Assistants Naomi Bevan and Jo Greatorex), and all the amazing children and families we work with.
