This article was published in the APCP Newsletter 30/9/19
Hip X-ray Screening for Children with Cerebral Palsy
In 2016, we completed an audit at Dorset County Hospital NHS Foundation Trust (DCHFT), which showed that we did not meet the Cerebral Palsy Integrated Pathway (CPIP) standards. We have been striving since to establish this pathway locally, and have been successful in starting one part, an integrated CPIP radiology clinic. This is the x-ray surveillance part of CPIP. This clinic has been running as a unique joint initiative at DCHFT with radiology and children’s physiotherapy from April 2017. Since April 2017, 68% (n=63) of our CP children under 16 years old have been imaged, and of those we have identified 9% (n=10) children whose hips were in danger of further migration leading to dislocation. These children have subsequently been followed up sooner, and their therapy intervention altered in response to these findings. We have had fantastic patient and parent feedback from these interdisciplinary x-ray clinics. As professionals, we have been able to draw on and combine our individual expertise to improve the quality of the service offered.
As a physiotherapist, I am able to use my skills such as influencing tone through positioning and handling. I have the added benefit of knowing many of the families attending for an x-ray. Familiarity with staff helps to put the child at ease and relax, which has led to an enhanced experience not only for the patient but also the carer and staff involved. This combined with the radiology expertise in acquiring diagnostic images has shown a significant improvement in image quality compared with imaging prior to the introduction of CPIP. This enabled the evaluation of the image in determining the migration indices, acetabular angles and femoral shaft angle. Prior to CPIP, the radiological measurements were not routinely measured or recorded. Image quality was inconsistent and the patient experience was less favourable due to a number of factors.
We were asked to present our experience of running this clinic at the Dorset Allied Health Professionals into Action Conference in February 2018, which was well received.
The audit was repeated in 2018 and highlighted that 100% of the children imaged met the criteria for quality and timing of imaging and recording of radiological measurements. To date, over half of the local CP population have been imaged, and we are on target to image all children by 2020. This audit/service improvement initiative was presented as a poster at The Association of Paediatric Chartered Physiotherapists Annual Conference in November 2018. The clinic was also runner up at Dorset County Hospital 2018 Going the Extra Mile (GEM) awards and has been recognised as outstanding following the most recent Care Quality Commission inspection.
Our work will be presented at the Wessex Safety, Quality and Improvement Conference this coming October 2019. The abstract has also been accepted for poster presentation at Physiotherapy UK Conference this November. Please come and say hello to us at these events if you are there and interested. Following on from the Physiotherapy UK, our work will also be going up onto the CSP Innovations Platform, so please look out for it.
We have since trained radiologists and paediatric physiotherapists in surrounding hospitals at Poole and Yeovil in how to x-ray image as per CPIP. Poole has now been successful in securing a fellowship with Wessex School of Quality Improvement to look at implementing CPIP in our region.
Our vision is to run a ‘one stop shop’ clinic, where the child can have their hip x-ray and see their paediatrician, physiotherapist, and occupational therapist at one clinic appointment. This would save the family repeated trips to see multiple clinicians and in the long run, save clinician time. We are currently unable to deliver the clinical measurement standards in full, which is the next part of the pathway. A risk and business case has been completed by my manager, who is fully supportive of CPIP. This has consequently been highlighted as a priority within our service.
Having now attended Ionising Radiation Medical Exposure Regulations (IRMER) legislation awareness training, I am now an authorised non-medical referrer. I am able to refer patients direct to radiology. The CPIP radiographer is now reporting the CPIP images with the appropriate measurements. This is making the referral to reporting process quicker for families, and negating the need for paediatrician and radiologist involvement at this stage. Our therapy assistant co-ordinates the clinics and has set up a calendar system which flags up when repeat x-rays are needed thus reducing over or under imaging and ensuring timely recall.
I would encourage all physiotherapists to use audit as a tool. This audit highlighted difficulties and gaps within the service. It allowed us to determine a baseline from which we could make improvements from. It also started an open discussion within the team regarding our service provision. Although at the time, I felt like this audit was an additional burden on top of an already busy clinical workload, it has been vital to improve and guide service development and ultimately improve the quality and safety of our service.
I would also encourage all physiotherapists to approach their radiology department and make those links. It is excellent interdisciplinary working, and new relationships have been formed across professions, breaking down boundaries. We have learnt so much from this process and the families and children we work with have gained even more. We would be interested in hearing from other departments as to how they are implementing CPIP and are happy to support anyone with this.
Anna Jones (Highly Specialist Paediatric Physiotherapist) anna.jones@dchft.nhs.uk
Janice Pryke (Lead Reporting Radiographer) janice.pryke@dchft.nhs.uk
September 2019