1. Using Simulation To Understand Orthopaedic Flow Through Triage
Ekwutosi Chigbo Ezeh
Supervised by Dr Navid Izady
16/10/13
University of Southampton
University Hospital Southampton - Solent NHS – ISTC (CARE UK)
Southampton City Clinical Commissioning Group

2. Background
When patients require orthopaedic assessment they are referred by their GP to an Integrated Medical Assessment and Treatment (IMAT) service for triage to determine the appropriate referral pathway
For orthopaedics, these routes include physiotherapy, podiatry, rehabilitation programmes, pain management services, and community re-ablement services, as well as orthopaedic surgery (three tier system)
Evidence that some patients are routed incorrectly, leading to wastage and poor patient experience
Aims: to identify how patients are referred, then triaged then routed; quantify where patients are initially routed incorrectly and subsequently rerouted; use simulation to test alternative pathway designs
Pathway – clinical (progression of a patients health status)
operational (movements of patients through a set of locations in a healthcare segment
Common feature of a pathway- entrance, exit, path from entrance to exit & a random variety of healthcare elements in between.

3. Providers modelled
In the Southampton Musculoskeletal service (including IMATs, physiotherapy, rheumatology and pain management) served 16,000 patients and provided 38,000 outpatient appointments
Southampton City CCG (Tier 1)
NHS Solent (Moorgreen Hospital) – community-based outpatient clinics, physio and reablement (Tier 2)
Independent Sector Treatment Centre at the Royal South Hants hospital (Tiers 2 & 3)
University Hospital Southampton (Tiers 2 & 3)
Many others – highly complex patient flow through different sectors with a multiplicity of providers and over 400 pathways, which were modelled as a series of clinics
Pathway – clinical (progression of a patients health status)
operational (movements of patients through a set of locations in a healthcare segment
Common feature of a pathway- entrance, exit, path from entrance to exit & a random variety of healthcare elements in between.

4. Patient flow between providers
Patients can leave this system to private care or return from private care.

5. Challenges
Limited data available for modelling the whole system (lack of referral numbers; medical conditions recorded; referral destination; no entrance data for cohort)
Significant differences in data across providers
No universal identifiers linking data
Appointment scheduling procedures required to model waiting times, but were not available
Lack of referral numbers
Lack of medical conditions recorded
Lack of referral destination
No entrance data for cohort

6. Moorgreen Hospital Simul8 Model
I60 pathways at moorgreen hospital
160 pathways in total!

7. Outpatient Clinics

8. Solent : Accepted & Cancelled Referrals

9. Top 95% of pathways in Solent NHS
CLINIC
No. of Appts
% of Total
Cumulative %
MGH MSK Physio
6913
29.78%
ADC MSK Physio
6567
28.29%
58.07%
MGH MSK SPINAL
1933
8.33%
66.40%
MGH CAS
1813
7.81%
74.21%
MGH MSK HAND
924
3.98%
78.19%
MGH MSK LOWER LIMB
914
3.94%
82.13%
ADC MSK SHOULDER
650
2.80%
84.93%
ADC MSK SPINAL
649
87.72%
ADC MSK FEET
648
2.79%
90.51%
ADC MSK LOWER LIMB
504
2.17%
92.69%
MGH MSK FEET
359
1.55%
94.23%
MGH MSK SHOULDER
186
0.80%
95.03%

10. Number of consecutive appointments per pathway

11. Conclusions Many limitations of model due to data challenges
Enhancement of current data available needed to effectively model this
We found less inefficiency in the system than was perhaps initially perceived by our “client”: the majority of patients are correctly triaged at Tier 1, while 94% of patients referred to Tier 2 attend only the first clinic they are referred to
Despite the data limitations, the modelling process highlighted many key issues for the providers to think about

12. OR - clinical perspective
Dr Cathy Price
UHS FT

13. NHS perspective Are pathways of care
Timely? - treatment delivered within an acceptable waiting period (need to understand rate of deterioration whilst waiting)
Effective? - no bounce around, minimal follow ups
Efficient? - minimal number of follow ups

14. Commissioning Landscape
Multiple Providers within small geography
Confusing entry criteria
One large teaching hospital
Multiple Signposting “Tier 2” services for GP’s
Collaboration difficult across providers
Commissioned time points for providers to meet to review cases (“virtual clinics”)
Patient experience “confusing”
Clinical effectiveness unclear

15. Modelling /OR – comments
Brought some clarity on efficiency (minimal follow ups) in Signposting service – pretty efficient
Clinical Effectiveness hard to ascertain within timescale (no follow ups per provider – needed to be accurately agreed )
Model built that allowed for varying scenarios
Concerning number of differing outcomes for patients (400+ pathways )
No easy way to ID patient through whole system i.e. more confident modelling would require this