Video Enabled Care Webinars Trauma Hand Therapy Service 11/11/20 Edel Siney, Clinical Specialist OT Brian O’Ceallaigh , Senior Physiotherapist Aisling Coen, Staff Grade OT Andy Byrne, Staff Grade Physiotherapist
Agenda • Overview of Service: Plastics Service UHG, Activity Levels • Covid-19 Pandemic • Outcomes; Pros, Cons, Patient Feedback • Enablers & Barriers • Case Studies; • minor injuries • post op complication • tendon repair • outlier referral • Resources
Plastics Service UHG • Regional service • Population 730,513 – 15.3% Irish population • 6 Consultants • Staffing resources • 1 wte Clinical Specialist OT • 1 wte Senior Physio • 1 wte Staff Grade Physio • 4 consultant led post op clinics per week • Inpatient and outpatient service • Trauma and elective surgery • Direct access hand therapy for ED Minor Injuries
Activity Levels – Hand Therapy Referrals Referrals 2018 Referrals 2019 Referrals Jan – Oct 2020 (1,571) (1,620) (1,424) Plastics Plastics Plastics trauma trauma trauma (1,257) (1,264) (1,190) Minor injuries Minor injuries Minor injuries ED (225) ED (244) ED (200) Other (89) Other (112) Other (34) Plastics Hand Therapy Service growth 2003-2019 2,000 1,500 New 1,000 Referrals 500 0 2003 2013 2019
Covid-19 Pandemic Covid-19 National Guidance - Closure of outpatient services UHG Telehealth Steering Committee - Attend Anywhere Pilot Project Current Hand Therapy Service - 70/30; Telehealth vs face/face
Outcomes Pros Cons • Patient and staff safety • IT issues • Identify need for face/face review • Wifi connection • Variety of patients and services • Computer vs phone • Access to patients • Pixel quality • MDT sessions • Attend Anywhere log in trouble • Monitor progress/complications • Takes time to become confident • Visual feedback/compliance/understanding • Extra admin time • Screen Share • Not suitable for all patients • Patient reassurance • Doesn’t replace face/face • Client centred • Objective outcome measures • Economical benefit patient/health service • Patient Attendance • Clinical reasoning development • Therapist fatigue
Barriers and Enablers Practical Elements • Identifying suitable patients • Explaining telehealth • Attend Anywhere, WhatsApp, Email, Telephone • Access to online medical records • Scheduling appointments • Clinical space for telehealth • Documentation • Telehealth protocols
Case: Minor Injuries • Female, 28, referred to ED following injury to right middle finger following impact from ball while playing softball • X-ray: non-displaced avulsion fracture on volar aspect at base of middle phalanx ED Ax • Referred directly to OT from ED • History and relevant background gathered • Assessment of ROM, tendon recruitment and ligament stability. OT initial • Findings: volar plate avulsion injury PIPJ Ax • Treatment: education, dorsal block splint, coban wrap and exercises provided • Information given on Attend Anywhere, email address taken and follow up appointment arranged for 3 weeks’ time Follow • Email sent reiterating splint regime and exercise program for the next 3 weeks and up confirmation of follow-up appointment with link for Attend Anywhere attached
• DNA-> phone call to patient • Subjectively: ongoing report of pain, tenderness, swelling, ROM improving Review • Compliance with splinting and exercise programs 3/52 • Plan: remain in splint and continue exercises until follow up in 1 week. • Subjective: mild discomfort, other symptoms settling • Objective: full active extension of PIPJ, decreased active flexion Review • Plan: removal of splint in ADLs as tolerated, wear for work when needed, tendon 4/52 gliding exercises • Subjective: pain free, happy with progress, weaned out of splint for all ADLs • Objective: mild PIPJ oedema, full extension, almost full fist - passively correctable, • Plan: discontinue splint, tendon gliding exercises, theraputty strengthening, contact Final OT department if any issues Review 6/52
Reflection Pros • Convenience for patients- working from home etc. • Cohort of patients usually receptive to telehealth • Less face to face contact/less footfall through the hospital • Subjective outcomes-patient concerns at the forefront Cons • Need to send reminders for patient appointments • Technical issues for some patients- internet connection, equipment, unfamiliarity etc. • More organisation required from OT • No standardised objective measure for outcomes
Case – Post op complications Background Follow up Telehealth • 63 year old male • Patient was • Barriers: managed virtually. • 3/12 hx recurrent IF • Poor pixel quality. infections following • Weekly video calls • Decrease accuracy a laceration. to Ax ROM and with AROM Ax. wound healing. • Underwent washout • Enablers: under LA. • Week 2 concerns • Local steering raised regarding • Referred to Physio committee supports signs of infection. while an IP. the use of • Arranged • Followed up in clinic WhatsApp. immediate Attend a few days later. • Installed on our HSE Anywhere • R/ v’d by Plastics and work phone. appointment. arranged clinic f/up • Clearer quality. in 1/12 • Easily accessible and patient friendly.
Outcome: Liaised with Plastics team Dr’s. Pt was brought into hospital the following morning for washout Safety Netting If in doubt, arrange Face to Face appointment
Case – Tendon repair Referral Patient Follow up • 63yr Male • OPD Day 5 post op Factors considered; • MOI: Angle grinder • R/v by Plastics Team • Lives on island • Op notes: strong • Zone V EDC /EIP LIF • Transport issues repair, no other • RHD, retired, • No family structures involved independent nearby/isolating baseline, active, • Wound review – no • Level 5 restrictions on enjoys fishing and signs of infection, outpatients gardening dressings changed • Straightforward post and PHN f/u • Lives alone, isolated op protocol island • Hand Therapy – RM • Patient high risk protocol, splint • Non smoker, category fabricated, allowed Pancreatic CA, • Patient recently use hand functionally T1DM started using zoom within splint with family
Outcome Telehealth sessions Outcomes Supports • 2/52, 4/52, 6/52, 10/52 • 1 face/face session, 4 • PHN wound review post op - Zoom telehealth sessions and • Patient had basic d/c • Followed RM protocol computer literacy • No complications • Assess tendon • Very compliant patient recruitment • Full ROM return and • Zoom – good pixel return to baseline • Monitor wound healing quality, good function and scar management connection • Picture documentation: • Monitor for • Good communication ROM, tendon complications with surgical team recruitment, scar • Rehab programme • Plastics team • No objective measures: supportive of hand grip strength, TAM therapy & telehealth
Case – Outlier referral Patient Initial contact 6/52 Referral post op • 48yr Female • L CT decompression • Contact made by t/c • Hx. bilateral CTS • Referred at 5/52 post approx 3yrs. L>R op • Covid-19 Restrictions • RHD, Biomedical • Hypersensitivity, • Explained telehealth Engineer impaired hand function, • Patient consented unable to return to • 3 children, caring • Email URL and work for elderly mother appointment to • Evolve for medical patient notes, NCS report, post op notes, Consultant review
Pros: Initial Ax 6/52 post op Follow up 12/52 post op Effective for • Attend Anywhere • Attend Anywhere educational and • scar hypersensitivity, • ‘I’m 100% happier’ functional rehab • reduced AROM/PROM • ‘absolutely nothing like it Client centred was before’ • Reinnervation hypersensitivity in MN Assess if need for • ‘much, much, better’ distribution, face/face review • Returned to work, caring • reduced hand for family, ↓anxiety, Patient/staff safety function, improved sleep • sleep affected, • Rehab prog. progressed Cons: increased anxiety • Assess for Pixel quality, wifi • Outcome complications connection • 2 Telehealth sessions • Therapy intervention Extra admin time • No face/face contact • Education • Patient to update OT Objective measures email at 6/12 post op limited • R CT decompression 4/12
Resources • https://www.ehealthireland.ie/National-Virtual-Health- Team/National-Virtual-Health-Team/ • https://healthservice.hse.ie/staff/coronavirus/working-from- home/virtual-health/virtual-health.html • https://www2.hse.ie/services/attend-anywhere/ • https://www.aota.org/Practice/Manage/telehealth.aspx • https://www.aoti.ie/covid/OTA-Telepractice-guidelines-and- checklist# • https://otpotential.com/blog/telehealth-occupational-therapy
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