Triage with Tele (TWT): early brief intervention for children's physiotherapy

Sarah Roberts Team Lead Children’s Physiotherapist


Aneurin Bevan University Health Board

Background

Variations in gait (walking pattern), foot posture and gross motor development (e.g. sitting, standing, walking) are very common in young children. Parents look forward to their children reaching developmental motor milestones such as walking, however if there is any variation from what the parents and family feel is normal this can generate a huge amount of concern and anxiety.


Most of these developmental differences are normal and do not usually require intervention, however parents often seek answers as to why their child is developing in a way they think is abnormal. In seeking answers, parents and Primary Care Practitioners may seek a specialist referral into a Children’s Physiotherapy Service.


Gait, foot and mild gross motor delay related problems are sometimes difficult to fully describe by both referring health professionals and families.


The current referral system within ABUHB Children’s Physiotherapy is via written referral. A written referral often does not help the triaging physiotherapist to fully understand the presentation of the difficulty and its impact on the child. This results in appointment being offered in most cases.


In 2018-2019, 18% (164) of all patients placed on the ABUHB Children’s Physiotherapy waiting list for an appointment only needed to be seen once and were then discharged. These patients would have sat on a routine waiting list for up to 14 weeks prior to being seen. During this time families can become more anxious and have an expectation that physiotherapy treatment is required for their child’s problem.

Project Aims


  • To use a ‘virtual first’ triage approach via the Attend Anywhere Video consultation platform.

  • To enable visual contact with a child and family in the referral triage process allowing early exchange of information, guidance and advice to help relieve any parental anxiety and possibly reduce the need for a face to face appointment.


  • Reduce the amount of children attending unnecessary appointments.

  • Reduce waiting list times and release physiotherapy capacity to see children with the greatest need.

  • Give early advice to those that require further assessment enhancing care.

  • Provide early support and reassurance for parents/carers and manage expectations that physiotherapy is needed for their child’s problem.

  • Enable early referral onto other services if required e.g. podiatry

  • Empower self-management.

  • Reducing time taken out of school and /or work for children and parents to attend and travel to appointments.

Challenges

  • The global Covid-19 pandemic resulted in the project start date being delayed by 6 months, due to redeployment and other clinical priorities. With clinical and administrative staff self-isolating and/or shielding it was sometimes difficult to book appointments in a timely way.

  • Poor family internet access/ connection and lack of confidence of some families using IT equipment. Although only 1 patient who was offered a Video Triage appointment was unable to accept the appointment as they had no internet access at home.


  • More difficult for single adult households to be able to video child while encouraging them to do activities that we asked them to do. Some verbal feedback given from a parent ‘I feel it is a 2 person job’.

  • As we are unable to carry out a hands-on assessment via video, face to face assessment is still required for some patients. Some parents remained anxious and needed to be seen again to offer further reassurance, although all felt the triage video call was very helpful.

Key Outcomes

Over a 3 month period, 46 patients met Triage with Tele (TwT) criteria, 36 attended for an appointment. 18 of these did not require a further physiotherapy assessment.


Of the 36 who attended, 24 undertook a patient satisfaction questionnaire. 100% were satisfied with the appointment.


Feedback from parents is included below.


‘Convenient’
‘Gave piece of mind’
‘Able to be seen sooner’
‘Put my mind at ease immediately’
‘Easy to do’
‘Unexpected that everything could be done in a video that could also be done face to face, very pleased with this fact’
‘Felt it was as good as if face to face’
‘Appreciated that my husband was able to join in from work too, on a 3 person call’
‘Good for my child to be seen in his own surroundings’
‘Easier to attend when have other children’
‘I have health problems, it takes a lot of time to get to Childrens Centre as need to take 2 buses and need to arrange childcare’
‘Less anxiety as seen so quickly’
‘No travel’
‘The physio listened to my concerns and history of my child and his milestones, was thorough and felt reassured’
‘Really happy, clear and explained properly, took time to listen to our views and leaflets were sent via email in minutes’

  • Average waiting time for a triage appointment from referral received was 19 days compared to a maximum of 98 days to wait for first physio contact if on a routine waiting list.

  • Average time for video and non-video time for each patient was 33 minutes, compared to a 1 hour appointment that would be given for a face to face assessment. Over the 36 patients seen this has saved 15 clinical hours over the 3 months.

  • 501 patient travel miles were saved and 21 hours of patient travel time.

  • 3 patients following video triage required urgent physiotherapy intervention and 1 required an urgent referral to Orthopaedics, from the written referral information given, would not have known needed urgent intervention was required.


Next Steps

  • Further parent experience evaluation of how beneficial the initial triage video consultation was for children who required a full physiotherapy assessment.

  • Look into offering triage sessions outside of normal hours e.g. evenings, one parent commented ‘I would have preferred an out of school hours appointment’

  • Explore having a broader criteria for early triage video calls, as it is felt that other cohorts of Children’s Physiotherapy referrals could benefit from this brief early intervention.

  • Possible development of an Advice Line/ Drop in Clinic for families and professionals to give verbal advice, guidance and discuss if a referral is required.

  • Implementation of a self-referral process enabling even earlier advice and education to empower patients and families to self-manage as early as possible in referral process.

Our Exemplar Experience

Being a Bevan Exemplar has given me confidence to pursue a project idea and make it happen. I am so grateful for the support and guidance offered to me from being part of the programme.

Bevan With Thanks


Huge thanks to members of the Children’s Physiotherapy team in ABUHB who helped with the delivery and evaluation of this project. These include Armanda Rees Van-Wolferen, Kerri Harris, Zoe Derham-Luckwell, Sam Edwards, Cherie Lamont and Kirsty Lightowler. Also a big thankyou to Cherie Lamont, Charlotte Lamont and Danielle Farrington for their lovely artwork and to Louise Leach and Margaret Manton for their support and guidance.

Bevan Exemplar Showcase 2021

Contact

Sarah.Roberts5@wales.nhs.uk