NOTIFICATION OF PROPOSED ADJUSTMENT TO THE SCOPE OF PRACTICE

PROPOSAL FOR THE SET UP OF A PHYSIOTHERAPY LED POST OPERATIVE SHOULDER CLINIC

BY TENDAYI MUTSOPOTSI BSc. (HPT) MSc. ORTHO-MED MCSP MSOM

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

01/07/2008

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NOTIFICATION OF PROPOSED ADJUSTMENT TO THE SCOPE OF PRACTICE Introduction This document outlines proposal for the set up of a physiotherapy led post-operative shoulder rehabilitation clinic. Shoulder Orthopaedic Rehabilitation Clinic is a combined Orthopaedic assessment and rehabilitation advice clinic for post operative elective shoulder surgery patients. It is run by an Orthopaedic Physiotherapy Practitioner (OPP) and operates alongside one of the shoulder unit clinics. The clinic is a follow-up clinic where patients are reviewed and their postoperative rehabilitation is introduced and/ or progressed. Occasionally patients need to be referred to physiotherapy, but this is infrequent rather than routine. Any concerns about a patients post-operative recovery can immediately be discussed with the Orthopaedic Consultant or his SPR, but most patients attend the Rehabilation clinic until discharge without the need for more specialist Orthopaedic review. Principles of the proposal are based on lessons learnt from shoulder units at St Marys (Praed Street), Reading, Basildon and Royal National Orthopaedic hospitals which have in the long term optimised patient outcomes, freed Consultants time, reduced waiting times, and costs combined with high levels of patient satisfaction. The proposed model of care will be underpinned by relevant education, audit and research to facilitate continuous improvement and success. Benefits 1. Optimises use of Consultant time Increase Consultant ability to see new patients and reduce pressure on Consultant Reduce financial pressure 2. Post op complications can be picked quickly e.g. avascular necrosis, frozen shoulder, infection 3. Facilitates skills escalation in line with NHS Plan 4. Improves performance in relation to care access targets i.e. Supporting the 18week pathway Reducing referrals to physiotherapy department Reducing amount of follow up appointments so that they can see additional referrals Reducing patient over treatment 5. Underpinning audit and research
Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

01/07/2008

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6. MDT approach improves team working and morale 7. Increase opportunities for physiotherapy roles e.g. Senior 1 development into specialist role 8. Facilitates and improves a fluent patient pathway Patients seen appropriately, timely and cost-effectively 9. Improves communication and saves time regarding communication within the multiprofessional team Current Service Model GPOrthopaedics (Shoulder clinic) InvestigationShoulder ClinicSurgeryShoulder Clinic review (2 weeks) PhysiotherapyShoulder Clinic review (5-6wks) Physiotherapy (continue total sessions6 sessions? Shoulder Clinic final review Proposed Service Model GP Orthopaedics (Shoulder clinic) InvestigationShoulder ClinicSurgeryPhysioled post-op clinic (Consultant/Registrar consulted? complications/difficult cases 3-4 sessions. Clinic set-up eight 20minute slots and build up to ten 20 minutes slots. Proposed adjustment to practice: To provide an Orthopaedic Physiotherapy Practitioner led shoulder rehabilitation clinic in the Outpatient Orthopaedic service at Chelsea & Westminster Foundation Hospital. Clinical area applicable to: Orthopaedic outpatients at Chelsea & Westminster Foundation Hospital. Applicable to: Physiotherapists who fulfil the following criteria: A minimum of five years post graduate physiotherapy experience A minimum of three years experience in the management of musculoskeletal conditions. Can demonstrate competence to work in the OPP role following a comprehensive training programme. Has a special interest and knowledge in the management of complex and post operative shoulder conditions

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

01/07/2008

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Discussed with: Mr. Andrew Sankey: Clinical lead in Orthopaedics Douline Shoermann - Manager of Therapy Services Dr. Jerry Healy: Clinical Lead, Radiology Dr Jeremy Lewis Consultant Physiotherapist

Proposed Development Programme: Completion of the study days and shadowing at RNOH and St Marys Hospital shoulder and elbow units Completion of relevant courses in rehabilitation of rotator cuff, impingement, stiff, instability and post operative shoulder conditions

Signature of Line Manager: Full Name: Date:

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

01/07/2008

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RATIFICATION OF ADJUSTMENT TO THE SCOPE OF PRACTICE The proposed adjustment to the scope of professional practice, as defined overleaf, is within the remit of the policy and, as such, ratified.

Signature: Director of Nursing on behalf of the Clinical Guidelines, Group Directions and Adjustment to Scope of Professional Practice Group. Date: .. The proposed adjustment to practice is: a) New to the Trust b) Already an adjusted area of practice An appropriate training package has been developed Yes / No Yes / No Yes / No

Review Date: _____________________________________________

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

01/07/2008

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OPP SHOULDER CLINIC COMPETENCY In order to undertake this clinic the OPP requires: Knowledge of the implications of different surgical procedures Familiarity with the different postoperative rehabilitation protocols Knowledge of the key milestones in recovery for each procedure Knowledge of potential post operative complications and their management The performance criteria to achieve competency are evaluated by observation and questioning from Orthopedic Consultant/ Physiotherapy Consultant.
Competency 1. Observational 2. Fully supervised 3. Independent with feedback all cases 4. Independent with random and difficult cases discussed 5. Independent On-going assessment 1. 1st year : 3, 6, 9 and 12 monthly reviews 2. On-going years 6-9 monthly reviews
3. Audit of outcomes to clinics

Theoretical knowledge requirements: 1. Comprehensive knowledge of operative procedures (and their indications) for shoulder pathology including: Arthroscopic Subacromial Decompression, Rotator Cuff repair, Hemi and Total Shoulder Arthroplasty, Acromio-Clavicular Joint procedures, Eden Langer, Weaver Dunn, Investigative arthroscopy, Shoulder Stabilization procedures; open and arthroscopic. Performance Criteria Demonstrate knowledge in this area on questioning Explain procedures to patients appropriately Apply knowledge of procedures to post op protocols Actions Attend shoulder surgery at Chelsea & Westminster Foundation Hospital Read journal articles, text books, attend core curriculum meetings Case studies

2. Knowledge of the post op protocols for the above procedures and usual recovery times. Performance Criteria Identifies normal recovery of patients Post-Op Implements appropriate Post-Op management
Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

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Identifies complications with patients not responding as expected

Actions Read protocols Watched with patients in clinic Case studies 3. Independently able to manage shoulder patients in the rehab clinic after the above procedures with access to Mr. Andrew Sankey or Registrar. Performance Criteria Assesses patients appropriately Implements Post-Op Protocol appropriately Seeks help from Orthopaedic Team when necessary Refers to physiotherapy appropriately Orders investigations appropriately Satisfactory agreement with Mr. Andrew Sankey Actions Attend clinic with Mr. Andrew Sankey progressing through levels of supervision Prepare case studies on each of the pathologies Keep logbook of all activities related to competency 4. Knowledge of wound management for post-op patients Performance Criteria Able to assess post-op incision wound for healing process To demonstrate knowledge of wound management i.e.: infected wound Able to discuss management options with Orthopaedic Team Satisfactory agreement with Mr. Andrew Sankey Actions

Attend Mr. Andrew Sankeys clinic for observation Wound inspection assessed by nursing staff Documentation of wound assessment in the medical notes Referral for drug management Referral to medical management if required i.e.: washout procedure

5. Knowledge of the management and investigation process of NPs referred to Mr. Andrew Sankeys clinic Performance Criteria Able to identify patients suitable for surgical intervention v conservative management
Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

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 Actions 6.

Able to demonstrate knowledge of orthopaedic management and investigation of shoulder presentation Able to discus management options with Orthopaedic Team Satisfactory agreement with Mr. Andrew Sankey Attend Mr. Andrew Sankeys clinic Observe Mr. Andrew Sankey in surgery

Able to request appropriate investigations when necessary, including X-ray, US and MRI, CT, Arthroscopy

Performance Criteria Requests appropriate pathology specific investigations Agreement with Mr. Andrew Sankey All shoulder surgery that has metal fixation will have to have post-op check x-ray Actions Watched clinics with Mr. Andrew Sankey Check x-ray requested in follow-up session if required Read chapter on x-ray and shoulder pathology Attend US, MRI sessions with Consultant Radiologist when appropriate Attend Chelsea & Westminster radiation protection course 7. Able to use the constant score as an outcome measure for all patients Performance Criteria Evaluates Oxford Shoulder Score for all patients Actions Read information in shoulder clinic Calculate scores for patients in clinic

8. Have up to date knowledge of the current practices, research and development in the area of should pathologies

Performance Criteria On discussion, demonstrates knowledge of the above Actions

Attend regional Orthopaedic Conference where relevant Read relevant journal articles 01/07/2008 Page 8

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

Author: Tendayi Mutsopotsi Msc Ortho-Med MCSP

Attend BESS conferences as appropriate Discuss with orthopaedic team Attend courses as appropriate

9. Able to carry out all necessary administrative and related documentation procedures Performance Criteria Knows booking procedure Completes all records and letters, including use of dictaphone Can order investigations and get results Complete required statistics Actions Induction into admin procedure by one of the Nursing Managers Induction the documentation by secretary DECLARATION OF COMPETENCE

I . (Print full name) Have assessed myself against the competencies and standard for the practice of ..

(Describe new skill/competence), and am, therefore, adjusting my scope of practice in this area. I acknowledge my own personal accountability to adhere to the Policy on the Scope of Professional Practice, and the Chartered Society of Physiotherapists, professional bodys statements. I also acknowledge the need to continually review my skills and knowledge, and formally at the annual appraisal update them when: Practice changes and developments occur The personal opportunity to maintain competence has been limited

Signature: Date: Copy: Personal Portfolio Personal File Trusts master index file

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

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EVALUATING COMPETENCE

The induction process is designed to equip a clinical specialist physiotherapist with the necessary extra skills and knowledge to extend their scope of practice. Certificates of competence for the various aspects of extended scope work are being developed. Where these are available, they are completed, and kept with each Orthopaedic Scope Practitioners portfolio. They attest that a specialist in the field agrees that the Orthopaedic Scope Practitioner has achieved the required standard or level of competence. They are signed by trainer, trainee and dated. A certificate should be completed on each occasion. Throughout the induction, specific training needs are to be identified and addressed, and a personal development plan is written. This includes, a time frame, and is reviewed regularly by the Orthopaedic Physiotherapy Practitioner Line Manager. On completion of the induction programme, an appropriate specialist, who may be the Doctor or an established Orthopaedic Physiotherapy Practitioner, evaluates competence. A system of peer view has been developed, to allow on-going reflective learning. Clinical reasoning is evaluated, and discussed between peers with the aim of further developing reasoning skills, and improving standards of practice.

MAINTAINING COMPETENCE

It is vital, that knowledge and skills of Orthopaedic Physiotherapy Practitioners are continually updated. To facilitate this, each Orthopaedic Physiotherapy Practitioner keeps a written record of all relevant training and learning experiences. This record is dated and regularly updated. It is kept in the physiotherapy department, and forms part of the individuals professional development record. There is no set format of documentation, as different activities require different recording methods. Reflective learning and goal setting within the chosen framework is essential.

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

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List of all staff consulted as part of guideline development

Name

Title Assistant Director of Nursing and Clinical Governance Consultant Clinical Supervisor Therapy Services Manager Assistant Director Consultant Consultant

Department Nursing and Clinical Governance Orthopaedic Department Clinical Governance Physiotherapy Department Public Health Radiology Department Pain Team Rheumatology Department Physiotherapy Department

Adjustment To Scope Of Practice: Post Operative Shoulder Clinic

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PROTOCOL FOR USE BY ORTHOPAEDIC PHYSIOTHERAPY PRACTITIONER (OPP) Post-Operative Shoulder Clinic

These guidelines have been approved by the Clinical Policies and Procedures Sub-Group Signed: Signed by Chair _____________________________ Date: _______________

These guidelines have been approved by the Professional Executive Committee Signed: Signed by PEC Chair _____________________________ Date: _______________

These guidelines have been approved by the Board Signed: Signed by Board Chair _____________________________ Date: _______________

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DECLARATION OF COMPETENCE I .. (Print Full Name) Have assessed myself against the competencies and standard for the practice of ORTHOPAEDICPHYSIOTHERAPYPRACTITIONER (Describe New Skill / Competence) and am, therefore, adjusting my scope of practice in this area. I acknowledge my own personal accountability and responsibility to adhere to the Policy on the Scope of Professional Practice and the Chartered Society of Physiotherapists professional bodys statements. I also acknowledge the need to continually review my skills and knowledge and formally at the annual appraisal update them when: - Practice changes and developments occur - The personal opportunity to maintain competence has been limited.

Signature Date Copy: personal portfolio, personal file and trusts master index file

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