Carpal Tunnel SyndromeCarpal Tunnel Syndrome

A clinical audit of the local service

Dr Elena NikiphorouDr Adam YoungSuzanne Jenkins (Research Assistant)

BackgroundBackground

Incidence: 1 per 1000 people/year

Prevalence: 3% population

Gender/age: commoner in F 4:1, peak 45-54 in F, increases with age in M

Pathogenesis: compression of median nerve within the carpal tunnel

APB muscle wastingAPB muscle wasting

ManagementManagement

Clinical CTS

Mild symptoms, no clinical signs

Moderate symptoms &

sensory signs

Severe symptoms/atypical

presentation/uncertain diagnosis

•Simple analgesics•NSAIDs

•Wrist splints•OT

•Weight reduction

Cortisone injection

EMG/NCS

Day case decompression

surgery

Care pathway adapted from Laitner & Young (2004)

Why audit?Why audit? Management varies between different hospitals Delays between symptom onset and treatment

1995 audit with St Albans GPs

(51% did not receive any treatment while waiting for 1st hospital referral)

WHHT 2009/10:

◦ 18 week pathway from GP referral to treatment

Are we achieving this target?Does the one-stop clinic solve the problem?

Referral timesReferral times

GP

Rheuma OPD + NCS/EMG

GP Neuro OPD

NCS/EMGNeuro OPD

Rheuma OPD

NCS/EMG

Ortho OPD

Surgery

GP

Rheuma OPD

Surgery

One stop One stop

Surgery

Ortho OPD

10wks 12wks 14 wks 26wks T=62wks

10wks 20wks T=30wks

12wks 32wks 4wks 10wks 12wks 24wks T=94wks

Jayakumar K. BJR 2006;45(S1):262

1985-1995

1995

One-Stop CTS clinicOne-Stop CTS clinic Introduced at SACH & HHGH in 1995

Clinical assessment (15-30 minutes)

EMG/NCS (15-30 minutes)

◦ Diagnosis ? CTS or not

? Radicular origin e.g. C5/6/7

? Both (“double crush”)

? neuropathy, MND

Further investigations e.g. x-rays C-spine, wrist

ultrasound

Assessment of need for surgery or other treatments

AuditAudit

Source and type of referrals

Times from referral to EMG/NCS to

surgery

Patient satisfaction

Questionnaires sent to 235

patients, seen between 2006-

2010

Graph 1Graph 1: Yearly Total CTS : Yearly Total CTS proceduresprocedures

260286

308

136

0

50

100

150

200

250

300

350

2007 2008 2009 2010

Yearly Total CTS Procedures

Total CTS Proceduresundertaken

Days

Year

Graph 2: MSK referrals 2010

16

45

10

8 8

6

10

1 12

0

2

4

6

8

10

12

14

16

MSK Treat Rheum Referral Ortho Referral Ongoing

MSK CATS Patients with Carpal Tunnel Syndrome

March-April

May-10

Jun-10

Graph 3Graph 3: Times to EMG/NCS clinic: Times to EMG/NCS clinic

0

20

40

60

80

100

120

140

2007 2008 2009 2010

Year

Day

s

360 GP referrals per year

Graph 4Graph 4: Times from EMG/NCS to : Times from EMG/NCS to surgerysurgery

Time from EMG Appointment to CTS Surgery

0

50

100

150

200

250

300

350

2007 2008 2009 2010

Year

Da

ys

Patient satisfaction questionnaire Patient satisfaction questionnaire (PSQ)(PSQ)

Symptom duration prior to EMG/NCS

Symptom severity pre-treatment

Symptom severity post-surgery

Investigations & Treatment

Overall satisfaction

Me

an

2.4

2.2

2.0

1.8

1.6

1.4

PSQ – Rating of overall service PSQ – Rating of overall service 22

ConclusionsConclusions

A unique service

Cost effective – reduced number of

outpatient clinics (6 to 2!)

Waiting times improved

Improved patient convenience

Improved overall patient satisfaction

Thank Thank you!you!