Proof of Concept Trial of Diagnostic Ultrasound in the Orthopeadic Triage Setting

Citation: Morgan G.E., Welch H., Jenkins D., Wroe L.M. (2018) Proof of Concept Trial of Diagnostic Ultrasound in the Orthopaedic Triage Setting.Open Science Journal 3(1) Received: 18 September 2018 Accepted: 2 February 2018 Published: 25 March 2018 Copyright:© 2018 This is an open access article under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The author(s) received no specific funding for this work Competing Interests: The author have declared that no competing interests exists. Purpose: This study aims to investigate the benefits of Point of Care (POC) ultrasound and Scheduled Ultrasound Clinics using a Proof of Concept approach in the orthopaedic triage setting. Materials and Methods: The trial ran for a six week period sourcing all patients referred to the orthopaedic triage service. The trial collected three measurable outcomes i.e. two Patient Reported Outcome Measures: MSK-HQ and The Care Measure, and a Proof of Concept clinician survey via Survey Monkey. These were completed by the clinicians and patient cohort during the scheduled clinic and POC clinical contact. Results: A total of 135 patients received a diagnostic ultrasound scan over the six week trial period. 34 patients received a diagnostic ultrasound scan from the Extended Scope Practitioner (ESP) Physiotherapist in a Scheduled Care setting. 101 patients received a diagnostic ultrasound scan from the ESP Podiatrist in orthopaedic triage over the six week period (74 in Scheduled care clinics and 27 at Point of Care). The outcome measure suggest that patients recieved a rapid diagnosis (n.135), implementation of appropriate treatment pathway (86.36%), a positive impact on Referral to Treatment (88.55%), appropriate implementation of conservative treatment (91.11%) and had excellent co-production during the trial with an 88% average CARE Measure Score. The MSK-HQ results suggested a wide variety of muscuoskeletal conditions were asseessed during the trial with a mean MSK-HQ score of 27.6 with a Standard Deviation of 12. Open Science Journal Research Article Open Science Journal – March 2018 2


Introduction
Diagnostic ultrasound has been thought of as a rapid, accurate, repeatable, non-expensive, noninvasive and without the risk of radiation [1].It has been used to focus clinical questions, improve differential diagnosis and direct patients to the most suitable treatment [2].However there is a need to define the benefits of appropriate use and, limit any unnecessary imaging and its consequences [3].It is becoming accepted practice for ultrasound diagnostics to expand beyond the borders of Radiology departments due to the evolving nature of clinical practice and the requirement of prudent healthcare principles [4,5].The Clinical Musculoskeletal Assessment Triage Service (CMATS) is an orthopaedic triage service that assess primary care referrals into secondary care orthopaedic clinics.Assessment supported by appropriate imaging can often be utilised to ensure the implementation of the right pathway for patients at the earliest opportunity.
Historically, provision of MSK Ultrasound diagnostics has been via a referral to Radiology.However, there is increasing evidence that assessment, investigation and initiating treatment at the initial appointment are shown to be cost-effective and increase patient satisfaction [6].Utilising this approach also reduces repeated hospital visits for further diagnostics and appointment times for results.The aim of using Point of Care (POC) ultrasound is to enhance the patient experience through instant access to diagnosis, timely implementation of most appropriate clinical pathway and achievement of the optimal outcome in the shortest possible time.to this utilised the ultrasound equipment in a POC setting.The patient caseload was sourced from the orthopaedic triage pathway.

Materials and Methods
Patients were allocated to the scheduled ultrasound scan clinics prior to the trial and the scanning clinics were populated.The trial ran for a six week period.
This study utilised three measures to assess the benefits of diagnostic ultrasound service provision.The outcome measures are outlined in the following section and include Clinician Input data on Survey Monkey (Fig. 1), and patient questionnaires (The CARE Measure (Fig2) and MSK-HQ (Fig. 3)).

Results
The total number of patients who received a scan in this study were 135, of which 45% were New Assessments and 55.55% Follow Ups.The total number from ESP Physiotherapist planned scanning session was 34, and the total number from ESP Podiatrist planned scanning session was 74.The total number of patients who received a scan at Point of Care was 27.The average number of of scans per week was 22.5.For the six week period 267 patient contacts were made in the orthopaedic triage setting by the ESP Podiatrist and 101 of these recieved an ultrasound scan.Results from each measure are indicated below.

Survey Monkey clinician survey
Results obtained from the Survey Monkey clinician survey for the period of the study (Fig a ).A total of 135 patients recieved a diagnostic ultrasound scan over the six week period.83.36% of scans resulted in a change of patient pathway, suggesting the diagnostic ultrasound scan identified an appropriate pathway for the patient.The largest amount of scans completed were of the foot and ankle due to the ESP Podiatrist utilising the diagnostic ultrasound at POC and the number of scheduled scanning clinics.A small number (8.15%) of patients recieved a rapid referral to orthopaedics referral following their ultrasound scan.A significant number of scans resulted in appropriate implementation of conservative treatment, allowed the provision of specific advice / empowerment and ensured better co-production, improved patient decision making and a positive impact on referral to treatment (Fig a ).

MSK-HQ Results
The MSK-HQ is a validated musculoskeletal health questionnaire which measures key health domains i.e. pain severity, physical function, work, fatigue, emotional health, physical activity, independence, understanding, confidence to self manage and overall impact.The highest possible outcome score for MSK-HQ is 56, the least outcome being 0 [7].
The study population had a mean MSK-HQ score of 27.6 which is almost a 50% reduction in MSK health domains.This is indicative of a population of significant MSK health issues affecting not only physical but emotional and general wellbeing.
The study population had a standard deviation (Standard Deviation P) of MSK-HQ scores of 12.This is indicative that the sample scores have high variance and the mean score results are an inaccurate representation of the population scores.There is therefore great variability of the MSK-HQ scores within the population sampled suggesting a wide variety of MSK condition sampling within the study.(See There was no significant correlation between MSK-HQ scores and amount of physical activity measured as a component of the MSK-HQ questionnaire.The Mean daily Physical Activity level of the measured population was 1.67 days which is less than the recommended weekly physical activity recommendations recommended by the World Health Organisation [7].However, the standard deviation of the population measured was 12 which is indicative of a varied spread of physical activity within the population.

The Care Measure Outcome
The CARE measure (Consultation And Relational Empathy Measure) is a person-centered process measure that was developed and researched at the Departments of General Practice in Glasgow and Edinburgh Universities supported by the Scottish Government.The CARE Measure is a quick (10 questions), clear and easy to complete patient-completed questionnaire.It measures empathy in the context of the therapeutic relationship during a one-onone consultation between a clinician and a patient.Originally developed and rigorously tested for use by General Medical Practitioners, it has since been successfully used by other medical staff, allied health professionals and nurses.

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Conclusion
It is recognised that appropriate use of ultrasound has the potential to improve quality of care but robust clinical governance is required to ensure that procurement and deployment of equipment is appropriate, service provision is evidence based and delivered by qualified and competent clinicians.Patients are the primary benefactors of POC ultrasound with improved diagnostic accuracy, faster and appropriate implementation of treatment pathways and demonstrating excellent co-production with the patient population.Radiology is also a cobenefactor with the likely reduced referral rates to the service.
The results of this study suggest that POC ultrasound in orthopaedic triage has a positive outcome on the patient care pathway and experience.
Three clinicians attained a PGCert in Diagnostic Musculoskeletal Ultrasound (Consortium for the Accreditation of Sonographic Education Accreditedhttp://www.case-uk.org/) in 2015 and subsequently supported by Cwm Taf University Health Board Radiology Department underwent a 12 month mentorship programme.Two of these clinicians were directly involved in the trial.An Extended Scope Practitioner (ESP) Physiotherapist participated in one clinical session per week of a scheduled ultrasound clinic.An ESP Podiatrist participated in two clinical scheduled scanning sessions per week and in addition Conclusion: Results from clinician sourced Survey Monkey data, The CARE Measure and MSK HQ suggest that POC ultrasound and Scheduled care clinics offer a positive benefit for the patient's care pathway, are beneficial clinically and suggest adequate demand for the service.

Fig
Fig b: MSK-HQ Scores Standard Deviation Results of The Care Measure indicate an average "Excellent" score of 88% of patients.Suggestive that an excellent therapeutic relationship was measured and experienced by the patient.