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Hip and knee pathway for patients with osteoarthritis requiring large joint

arthroplasty only.

Hip and knee arthroplasty referral form included

Delivering the 18 week patient pathway

Date for review - 1st November 2010

Approved by Derbyshire County PCT Clinical Effectiveness Group 19th December 2007. Approved by Chesterfield Royal Hospital Orthopaedic Directorate Clinical Governance Group 11th February 2008. Pathway devised by: Chesterfield Royal Hospital: Derbyshire County PCT: Mr Fazal Ali [Consultant Surgeon] Dr Richard Bull [GP] Sara Golding [Directorate Manager] Sally Baughen [18 week lead] Sylvia Causer [Head of Service Improvement] Trish Bailey [MSK service lead] Philip Hope [Physiotherapy ESP] Dominic Gage [Physiotherapy ESP]

Vickie Walker [Commissioning

Improvement Team]

Contact Lead: Sally Baughen, Derbyshire County PCT, St Mary’s Court, Chesterfield.

NHS Derbyshire County and Chesterfield Royal Hospital NHS Foundation Trust

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Patient presents with Hip or Knee Pain

1a) Advice: Weight reduction. Low impact exercise. Patient leaflet. [2]

Trust receives referral. Decisions regarding further investigations are made / organised, when Consultant / Staff Grade vets referral.

GP or MSK Services examination / assessment: [5] Complete online Oxford Hip or Knee Score. For patients scoring 0-29 consideration should be given for Orthopaedic Surgical Opinion. Review following investigations prior to referral on: Request weight bearing X-ray / Record Blood Pressure / Calculate BMI / Request Full Blood Count, Ferritin Assay, eGFR if appropriate & HbA1C if known diabetes. [6]

GP / MSK Services to complete referral form and include all information as requested.

1b) Medication / drug therapy: Analgesia. Trial

1c) Consider other treatments: Refer to Physiotherapy & / or Occupational Therapy. High-impact insoles. Walking stick. Lifestyle changes.

1e) If diagnosis uncertain: Refer to Musculoskeletal Services for Triage / Specialist Opinion [4]

Primary care treatment [1]

Decision to refer to consultant. Offer Choice of Provider [7]. Prior to referral ensure: [8] Patient prepared to consider surgery and is available for surgery within 18-week timeframe.

Primary Assessment Phase

Secondary Assessment Phase

If incomplete referral received: Letter sent to referrer from trust requesting additional information.

Patient attends 1st appointment: Decision for surgery made.

Listed for surgery and given choice of date.

3 – 4 weeks before surgery: Pre-operative assessment

completed. Consent obtained.

Day before surgery: Patient attends Trust

for Tinzaparin.

Patient

admitted on day of

surgery

Post-operative day 1: Patient trained to self-administer Tinzaparin.

6 – 12 months post-operative

follow up appointment: Oxford Hip or Knee Score

completed. Ideally at 1 year [or at discharge if discharged at 6 months].

Please refer to pages 3 to 5 for supporting notes which relate to the pink numbers below

1d) Injection options: To defer / avoid knee surgery for those who don’t want surgery. [3]

Post-operative day 10: Patient requires blood test to check platelet

count. [9]

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SUPPORTING NOTES [1] Primary care treatment: 1a to 1e should be considered before referral to Orthopaedic Consultant is a realistic option. [2] Advice: Patient information leaflets are available on the following websites: www.patient.co.uk/DisplayConcepts.asp

www.patient.co.uk/showdoc/359

Derbyshire County PCT website: http://www.derbyshirecountypct.nhs.uk/

View the “Prescribing and Clinical Guidelines” page, then click on the “Patient Information Leaflets link” then click on the link for one of the leaflets named below:

� Practical help on the management of Osteoarthritis of the knee. � Practical help on the management of Osteoarthritis of the hip.

[3] Injection options to defer/avoid knee surgery: To defer / avoid knee surgery for those who don’t want surgery consider option of Steroid injections. For those GPs who don’t want to perform steroid injections there is the option of injection clinics. These services are accessed via:

� The Walton Hospital Injection Clinic:

The clinic runs every Tuesday morning from 09.00am to 12.30pm. The clinic is on Choose and Book as an indirectly bookable service. Therefore referrals can be made either via: Choose and Book electronically, or, by paper referral addressed to: Physiotherapy Injection Clinic, Walton Hospital, Whitecotes Lane, Chesterfield, S40 3HW.

� Chesterfield Royal Hospital Injection Clinic:

The clinic runs on the first Thursday of the month. Referrals should be addressed to: Injection Clinic, C/O Phil Hope, Physiotherapy Department, Chesterfield Royal Hospital, Calow, S44 5BL.

[4] The following Musculoskeletal [MSK] Services, which offer ESP /

Physiotherapy triage, are available in the PCT: MSK referrals should contain the following information: Blood Pressure, BMI, eGFR {if appropriate} and HbA1C {if known diabetes}. MSK services can refer straight on to a Consultant, if required.

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PCT Locality Area Referrals Accepted From Triage Coverage

Amber Valley

PCT Physiotherapy All Practices Spinal, Upper and Lower Limb

Sarah Walker Riversdale, Green Lane & Appletree Practices

Hip, knee and some Shoulders

Chesterfield

PCT Physiotherapy All Practices Spinal and Peripheral Joint

Derbyshire Dales & South Derbyshire

PCT Physiotherapy All Practices Spinal

Greystone Physiotherapy – Belinda Holloway

South Dales Practices [Swadlincote, Overseal etc]

Hip and Knee

Ashbourne Physiotherapy – Lorna

Short

Ashbourne, Wirksworth, Brailsford and Hilton

Practices.

Hip and Knee

Erewash

PCT Physiotherapy All Practices Spinal, Upper and Lower Limb

High Peak and Dales

PCT Physiotherapy All Practices Spinal, Upper and Lower Limb

North East Derbyshire

CNDRH Physiotherapy

All Practices Mainly Spinal, but also Peripheral Joint

[5] GP examination / assessment:

� GP to calculate Oxford score using on-line Oxford Hip or Oxford Knee Score: http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html

http://www.orthopaedicscore.com/scorepages/oxford_knee_score.html Only if patient scores 0-29 consider Orthopaedic Surgical opinion.

� Request weight bearing X-ray to confirm moderate or severe Osteoarthritis [OA]. Oxford score to be completed prior to referral to X-ray as existing Merle d’Aubigne score is being replaced on x-ray referral request by Oxford Score.

� Record Blood Pressure. If GP has documented that BP under control, there is an agreement that the referral is accepted.

[6] Referral information for surgery: The following referral information for surgery has been agreed with the anaesthetists at Chesterfield Royal Hospital. However it is acknowledged that being didactic about required levels is difficult, as the patient as a whole needs to be considered, rather than individual figures. � Blood Pressure [BP]: For elective procedures patients should have BP's within

the normotensive range. If a patient is a known hypertensive then the referral letter should give reassurance that recent BP measurements have been within the normal range, if they are not then treatment should be amended accordingly within primary care before referral. If a patient not known to be hypertensive is found to have a high reading then this should be addressed within primary care, either before referral, or, at the same time, so that a follow up letter can be sent to the

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hospital confirming BP is within normal limits on several checks. If it is not, then treatment should be commenced.

� BMI: Limits here will be very much whole patient driven. A patient with a very high

BMI with a non-life threatening condition may be considered suitable for surgery if they are in constant severe pain, whilst one that has only intermittent symptoms may be considered not suitable. All patients with BMI greater than 30 should be given dietary advice at referral and consideration regarding delaying referral should occur with BMI's > 35. However, patients may be considered suitable with higher BMI's depending on symptomatology.

� Full Blood Count and Ferritin Assay: Patients at risk of significant blood loss whilst undergoing elective major surgical procedures, must have a pre-operative blood count and ferritin assay to assess their suitability for surgery. Patients who are anaemic, with iron deficent red cell indices, or low ferritin values should be investigated and treated before being referred for surgery

� EGFR {if appropriate}: No definite limits. This is likely to be something that is difficult to improve and therefore a low eGFR may alter the type of treatment offered and only in extreme cases is it likely to make the patient totally unsuitable for surgery and anaesthesia.

� HbA1c: The hospital policy on the management of the diabetic surgical patient states this should ideally be < 9%.

[7] Choose and Book information: Regardless of how many choices of hospital your patient leaves the practice with, the pathway document recommends that the online Oxford Hip or Knee score is carried out in the consultation as, in recognition of consistency for GPs, all hospitals commissioned by the PCT are being encouraged to accept it as part of the referral. Results of a weight bearing x-ray and a completed referral form are also required, as part of the referral process. You can click on the ‘Service Name’ (on the ‘Service Results’ page) to view the useful information hospitals load ‘behind C&B’. The Referral Form has been included as a web link within this information. The Referral Form and background information has also been uploaded to the PCT’s Choose and Book Intranet – the link is http://nww.derbyshirecountypct.nhs.uk/referral-templates-non-2ww.asp

[8] Patients are only eligible for referral if:

� Oxford Hip or Knee score is 0-29, include score in referral information � Radiographic changes confirm moderate or severe OA changes � Patient prepared to consider surgery � Patient aware surgery should be undertaken within an 18-week timeframe

[9] Post operative day 10 blood test: In line with NICE Venous thromboembolism clinical guideline 46, patients will be taught to self- administer Tinzaparin for 28 days post operatively [PO]. If patients are unable to self-administer, this will be noted in their discharge plan to ensure these patients are picked up by community nursing. A full blood count is required on day 3 PO [in hospital] and day 10 PO [in primary care] to monitor for heparin induced thrombocytopenia. The Trust’s Consultant Haematologist will screen the day 10 PO

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blood result and the GP will be alerted and advised if changes to the patient’s management are required.

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Name of Referrer: Name of GP Practice:

Hip and knee arthroplasty referral form

PLEASE NOTE: This form is to be accompanied by a referral letter and a data print out giving patient’s: Past Medical History, Drug History, Allergies and Social Background

Patient details

Name Address NHS No Date of birth Date of referral

Site

Hip Knee Right Left Bilateral

Diagnosis

Rheumatoid Osteoarthrosis Other

Duration < 3 months 3 – 6 months 6 – 12 months 1 – 3 years > 3 years

Past and current treatment Comments:

Injection Medical Physiotherapy Osteotomy Arthrodesis Arthroplasty

Current Analgesia

1) 2)

3) 4)

BP

BMI

FBC

Ferritin

eGFR

HbA1C

Radiographic changes

Include weight bearing X-ray date, X-ray report reference number, report précis, or append a print-off or photocopy:

Oxford Score Please complete on-line Oxford Hip or Knee Score http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html http://www.orthopaedicscore.com/scorepages/oxford_knee_score.html

Score

Please tick box to indicate patient meets criteria for referral:

Oxford Hip or Knee Score is 0-29

Radiographic changes confirm moderate or severe OA changes

Patient prepared to consider surgery

Patient aware surgery should be undertaken within an 18-week timeframe