Training Extended Scope Physiotherapists – Diagnostic Ultrasound in Musculoskeletal (MSK) Clinics
Betsi Cadwaladr University Health Board
When GPs refer patients with musculoskeletal (MSK) problems they are now largely seen by Extended Scope Physiotherapists (ESP’s) specialising in MSK medicine. Some of these cases need further investigation with ultrasound to determine the diagnosis and the nature of their treatment programme. Presently ultrasonography (US) is performed in the Radiology Department by a radiologist or radiographer. The waiting time is about 6-8 weeks. After further delay the patient attends for follow up by the ESP when the diagnosis is made and a suitable treatment programme put into place. This means that such patients have to attend the hospital three times and wait two months for their diagnosis to be made and treatment started.
A comprehensive training programme to up skill ESP’s in US has been designed with the Radiology Department. When the ESP is competent she/he will be able to perform an ultrasound examination when appropriate as part of the initial assessment in the MSK clinic. This means that the patient will receive diagnosis and start treatment at the initial appointment.
At the outset of the project US for MSK cases was performed by radiographers or radiologists in the X-Ray department. We were aware that US is increasingly performed by the clinician who sees the patient in the clinic rather than by X-Ray personnel and set out to investigate how to set this up. We had two ESPs keen to learn US and translate this competence into their clinic. Although at first sight this might seem a simple matter, we were faced with barriers, including capacity for training and funding. It seemed unlikely that our idea would come to fruition.
Analysis / Problem Solving Methods / Approach
Introducing a physio-led US service into a MSK clinic is at first sight simple. Train the physiotherapist, acquire access to a machine and you are set to go.
The reduced capacity within the radiology department proved to be a difficult barrier to overcome. Another factor at play here is that traditionally US has “belonged” to radiology and this project involved transferring the right to perform US to a different profession – physiotherapy.
Our approach to solving this problem was to become Bevan Exemplars and use the influence and status of The Commission to move things forward.
Goals & Targets
The project goal is to set up a “one stop shop” where patients are assessed, have an ultrasound scan if appropriate and a diagnosis and treatment plan made at a single appointment.
To achieve this we need to have an ESP trained to be competent in US and also access to an US machine.
This project is still ongoing. One ESP has completed the theoretical part of the training programme; the other one is to start this in January 2017. Finance to cover the cost of the 6 month practical training and supervision is now available and this will start in 2017.
We are still working on funding for a new US machine.
Interventions and Actions
Becoming a Bevan exemplar and using this to move forward.
- Accepted as Bevan Exemplar (August 2015)
- Attended Bevan Exemplar day, Cardiff (December 2015)
- Attended costings workshop, Bangor (May 2016)
- Identified Betsi Cadwaladr University Health Board (BCUHB) board member responsible for Bevan Exemplars (February 2016)
- Identified present BCUHB board member responsible for Bevan Exemplars (May 2016)
- Meetings with BCUHB Board member
- Funding agreed for radiology training sessions (September 2016)
Training in Ultrasonography
- Visited Telford Hospital to observe an ESP using MSK Ultrasound (March 2015)
- Completion of a diagnostic Master’s module, Keele University (February – April 2016)
Setting up Practical training
- Regular communication with Lead Consultant Radiologist BCUHB West
- Business Case sent to Lead Consultant Radiologist (April 2015)
- Meeting with Lead radiographer (June 2016)
- Meeting to finalise training sessions (November 2016)
- Training sessions to begin (January 2017)
Patients with MSK conditions requiring US will benefit from seeing an US Proficient Extended Scope Physiotherapist (ESP) because:
- Patients attend one rather than three appointments.
- Instant diagnosis and treatment plan.
- The ESP can assess the clinical significance of the findings.
- The ESP will also become competent in using US as a means of targeting their corticosteroid injection more accurately. This will improve the outcome of the injection and reduce referrals to the radiologist who presently carry out these procedures.
- For those patients requiring surgery the reduced diagnostic time will result in earlier referral and earlier surgical intervention if needed, improving outcomes.
- This is a safe cost.
Fit with Prudent Healthcare
This project supports prudent healthcare by making the most effective use of all skills and resources. The introduction of a “one stop shop” approach will avoid multiple hospital appointments and provide immediate diagnosis and treatment. In some patients surgery may be needed and the result of the scan may well avoid conservative treatment which is not going to help. This is an example of only doing what is needed, no more no less.
The project also supports prudent healthcare by achieving health and well-being by co-production. This ‘real time’ method of scanning offers immediate feedback to the patient. It is a very visual and interactive form of imaging, from both a professional and patient perspective. This ensures co-production by immediate information exchange between clinician and patient which will improve the patient’s experience and engagement. This feedback will be reassuring to the anxious patient who is frightened to move the painful joint for fear of causing damage or harm. This fear is often a major barrier, stopping the patient moving freely and naturally which is so important in rehabilitation. Demonstrating that the muscle/tendon is not damaged helps to overcome these concerns and allows the patient to confidently start moving again. This will improve outcomes with conservative management and reduce onward unnecessary referral to Orthopaedic surgeons making most effective use of all skills and resources as well as possibly avoiding doing harm to the patient.
The use of US rather than X-Ray will avoid exposure to radiation thereby doing no harm.
Training physiotherapists to carry out procedures which were previously performed by highly qualified and expensive radiologists will free up their time to carry more complex procedures as well as freeing up one radiology and one MSK ESP appointment slot for other needful cases, which is again making most effective use of all skills and resources.
Part of Cohort Bevan Exemplars 2015-16