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Computer-based musculoskeletal triage can reduce pressure on ERs

By Dr. Charles Young

We all know that health systems around the world are increasingly overloaded by the numbers of patients and carers who access them – or try to. In Ontario, for example, more than 90 percent of people have a primary care provider who they can see regularly. However, less than 50 percent of those Ontarians are able to see their primary care provider when they need to most – the same day, or even the next day, when they are sick.

Another example of the growing pressure on primary care comes from the United Kingdom. Towards the end of last year representatives of 7,000 general practitioners made a submission to the Government which stated that “…saturation point has been hit even by the most competently working practices in London…”

Also in England this winter the public were told to buy their own supplies of pain killers and cough medicines, and to avoid going to Accident & Emergency (A&E) departments, if possible. The fear was that emergency departments simply would not be able to cope with the numbers of patients seeking help.

The president of the UK’s Royal College of Emergency Medicine advised patients to use the NHS’s 111 telephone triage service as an alternative.

At present, a spectrum of clinical decision support (CDS), tools are available to clinicians and also, although much less commonly, to patients and carers. This CDS spectrum ranges from surprisingly unsophisticated, and often unhelpful, ‘digital text books’ through to much more useful purpose built tools such as BMJ Best Practice or Dynamed.

Within this spectrum, tools which assist with clinical triage (the process of deciding which patients should be treated first based on their injuries or illnesses), are key to helping reduce the growing demand on overloaded primary care and emergency services.

Triage tools achieve this outcome by appropriately redirecting patients who would otherwise have accessed an emergency care service, or urgently consulted their general practitioner, to a less acute service or even to self-care. This type of triage is often achieved by the patient or their carer calling a telephone triage service, like the NHS’s 111 service or Australia’s Healthdirect service, where a clinical telephonist supported by a digital triage tool will help direct the patient to an appropriate level of care.

Newer, more sophisticated triage solutions go one step further by providing patients or carers with direct triage advice using online tools, reducing the demand and costs of telephone triage services.

Recent research has shown that the most common reason for patients attending A&E departments unnecessarily was due to musculoskeletal problems. Last year, Professor Karen Middleton, CEO of the UK’s Chartered Society of Physiotherapists also identified that, “Up to 30 percent of patients seeking a GP consultation each year do so with a musculoskeletal complaint, such as back or neck pain. This equates to more than 100 million appointments that could be freed up in England alone if patients were given the choice of a physiotherapist as their first point of contact.”

In this context, we know that physiotherapists are good at musculoskeletal triage. A systematic review published last year found that out of 146 studies identified by the review 14 were eligible for inclusion and that, “all studies reported favourable outcomes for ESPs (Extended Scope Physiotherapists) in MSK triage clinics, with ESPs demonstrating a good level of diagnostic ability in comparison with a gold standard such as surgery.”

In another UK example, this time from north Wales, two physiotherapists working in four general practices saw 1,525 patients who would normally have seen the GP. The physiotherapists found that only 23 (1.5 percent) of these patients actually needed to see a GP.

There are research data to support musculoskeletal telephone triage. In 2012, a large, pragmatic randomized controlled research trial investigating a Physiodirect service (direct telephone assessment by a physiotherapist), in over 2,000 primary care patients found that “Compared with usual care based on waiting lists for face-to-face appointments, a care pathway based on PhysioDirect is equally clinically effective, provides faster access to advice and treatment, and seems to be safe.”

Primary and emergency care services around the world are overloaded and musculoskeletal problems account for much of this burden. Identifying patients with musculoskeletal illness and safely directing them to the right level of care, often not the emergency department or even their GP, is an important global health priority.

Not only does this musculoskeletal triage provide fast and effective care for the patients themselves, it also frees up precious primary and emergency care services to help other patients who desperately need them. In a logical, and research-based sequence this musculoskeletal triage has evolved from face to face consultations to telephone based services.

The next stage of this evolution will be for patients to self-triage and self-refer using sophisticated purpose built online triage tools. These tools will empower patients to make informed decisions about what their next level of care should be, for example direct access to a physiotherapist, or maybe a non-urgent appointment with their GP.

The few patients who do need urgent treatment will be identified early. The majority with less acute problems will also be provided with health related advice, and those in whom self-care is appropriate will be directed to online resources to facilitate that management. Digital, patient-focused musculoskeletal self-triage and self-referral is a key part of the clinical decision support spectrum and one that will have a big impact on the delivery of high quality healthcare in the immediate future.

As professor Middleton says, “…the critical point with self-referral is the vast improvement it offers for patient care. Self-referral helps prevent acute problems from becoming chronic and reduces long term pain and disability.”

Dr Charles Young is CMO at Capita Healthcare Decisions. He trained in medicine in London and continues to practice as an emergency physician for one day each week at St Thomas’ hospital, London. For the last 16 years, he has spent the majority of his time in a range of editorial, evidence-based medicine, clinical decision support and healthcare IT strategic leadership roles. Capita’s decision support software and clinical content is used by some of the world’s leading healthcare providers.

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