Development and implementation of a hand therapy extended ...handconsult.com/images/downloads/Development_of_an_Extended_Scope... · Original article Development and implementation

Original article

Development and implementationof a hand therapy extended scopepractitioner clinic to supportthe 18-week waiting list initiative

Robyn-Lee Rose and Sara Probert

Guy’s & St Thomas NHS Foundation Trust, London, UK

Correspondence: Robyn-Lee Rose, Occupational Therapy Department, Ground Floor, Tower Wing, Guy’s Hospital, London SE1 9RT, UK.Email: [email protected]

AbstractBackground. A changing and competitive health market demands the need to reviewexisting services and develop new ways of working in order to improve and maintain servicedelivery. Developing the role of the extended scope practitioner (ESP) and altering patientpathways through specialist hand units is one way that service delivery can be improved toadhere to the 18-week waiting time from a General Practitioner (GP) referral to the start oftreatment.Methods. One-hundred GP referrals for carpal tunnel syndrome (CTS) and first carpome-tacarpal osteoarthritis (CMC OA) were selected to attend an ESP clinic audit led by twospecialist occupational therapists for diagnosis and implementation of a conservativetreatment programme, which was confirmed by a consultant. The ESP clinic was auditedagainst key performance indicators to evaluate ESP effectiveness and improvements in thepatient pathway.Results. The ESP can effectively diagnose and manage CTS and CMC OA patients withoutincreasing the demand for surgical opinion or procedures. The ESP is also effective indiagnosing other conditions such as early-onset Dupuytren’s disease, de Quervain’s disease,ganglions and trigger finger.Conclusions. ESP clinics have the potential to improve the patient pathway by providingearlier access to a specialist opinion for a diagnosis and management of hand conditionsthereby improving service delivery.

Keywords: Extended scope practitioner, waiting time initiative, carpal tunnel syndrome

Introduction

The National Health Service (NHS) is entering anew era of competing with independent health-care service providers while meeting governmenttargets of adhering to the 18-week waiting timefrom a general practitioner (GP) referral to thestart of treatment.

As of April 2008, the patient choice policywas implemented by the Department of Health.1

This will challenge the NHS to compete withindependent health-care organizations to providediagnostic services to Primary Care Trusts in orderto attract patients and maintain financial targetsas well as meet government initiatives of

Hand Therapy 2009; 14: 95–104. DOI: 10.1258/ht.2009.009016

Hand Therapy Vol. 14 No. 4 December 2009 95

adhering to the 18-week waiting time from a GPreferral to the start of treatment. Managers aretherefore challenged to develop new ways ofworking in order to deliver a more efficient andcost-effective health-care service. Altering patientpathways through specialist hand units withinhospital trusts is one way in which service deliv-ery can be improved and maintained.2

In 2006, two specialist occupational therapistsbegan the process of establishing an extendedscope practitioner (ESP) clinic and altering thepatient pathway for selected hand conditionswithin the hospital trust. This process involved anumber of stages that led to the submission oftwo business case proposals to the surgical andtherapy directorates. These proposals wouldfirstly permit a trial ESP clinic and secondly agreethe implementation of a new patient pathway forcarpal tunnel syndrome (CTS) and carpometa-carpal osteoarthritis (CMC OA) with a view toincluding other hand conditions once the trialESP clinic had been evaluated.

The process of establishing an ESP clinic isoutlined, explained and represented on a Ganttchart in Appendix A, which can be used as aguideline for establishing an ESP clinic in otherhospitals. Appendix A is available online only athttp://ht.rsmjournals.com/cgi/content/full/14/4/95/DC1

History of ESPs

In the late 1980s clinical nurse specialists weredeveloped to perform extended roles to assistwith reducing junior doctors’ hours.3 Thisprompted allied health professionals to enhancetheir scope of professional practice through theacquisition of extra skills and knowledge.4

Over the past decade hand therapists havefacilitated the development of ESP clinics withinthe United Kingdom (UK).5–8 However, literatureon ESPs in hand therapy is limited to a series ofclinical audits rather than randomized controlledstudies.

Our review of the literature aimed to evaluatethe role and efficacy of ESPs in hand therapy andhighlight pertinent issues that would need to beaddressed when developing an ESP clinic.

In 2001, Ellis and Kersten9 conducted a surveyto identify the number of hand therapistsworking as ESPs in the UK, their scope of practiceand the training that was available for handtherapists practising as ESPs. It was establishedthat there were 35 ESPs who worked in their ownclinic environment, rheumatology departments

and in pre- or postoperative clinics. ESP trainingwas predominantly experiential and included aperiod of observation, clinical supervision by theconsultant and participation in combined surgi-cal team training programmes, such as woundcare and X-rays. Some ESPs completed singlemodules or entire masters programmes in handtherapy. ESP activities included making diag-noses, providing injections, performing jointaspirations, taking care of wounds, making refer-rals for surgery and doing investigative pro-cedures, and implementing therapeutic regimens.The authors emphasized the need for ESPs toregister nationally.9

In 2001, Peck et al. introduced an ESP clinicwithin the field of hand therapy in SouthManchester. They conducted an audit that eval-uated their practitioner-led clinic in terms ofwaiting times, did not attend (DNA) rates, patientsatisfaction, secretarial and clerical staff satisfac-tion, the number of patients who requiredmedical intervention and the number of patientswho attended consultant hand clinics. A total of649 patient visits to the practitioner-led clinicwere recorded. The results of the audit suggestedthat the practitioner-led clinic provided anincrease in patient turnover and increased patientsatisfaction with a closer adherence to rehabili-tation regimens, resulting in lower postoperativetendon rupture rates.5

Subsequent to this audit, Peck et al. conductedan additional audit over a 17-month period thatevaluated the influence of ESP clinics on rupturerates following three types of primary tendonrepairs in the hand. These included primaryrepairs of flexor tendons in zone II, Flexor PollicusLongus (FPL) and Extensor Pollicus Longus (EPL)tendons. The results of the audit indicated areduction in the incidence of tendon dehiscencefrom 30% to 17% for zone II flexor tendonrepairs, 16% to 4% for FPL and 5% to 0% for EPLrepairs with improved continuity of care.6

In 2004, Warwick and Belward reported theirexperience of running a diagnostic hand therapistcarpal tunnel clinic over a three-year period.The report included the reasons why it was set up,the process by which it was run and the effect ithad on practice. The resulting positive impact onpatient care indicates that the efficient processingof an ESP clinic must match efficient provision ofoperating facilities. Although the report includedonly the results of a single-diagnosis clinic, it wasemphasized that the process by which the clinicwas established could be applied to another clinicenvironment, provided that distinct patient

R-L Rose and S Probert Developing an extended scope practitioner clinic

96 Hand Therapy Vol. 14 No. 4 December 2009

management pathways are established for con-ditions that are referred by the consultant to theESP clinic.7

In 2008, Storey et al. presented an audit of anESP clinic for CTS in primary care. The results oftheir audit indicated that their clinic removed46% of CTS referrals from the hand centreclinics and waiting times to first assessment werereduced from an average of 91 days for the con-sultant clinic to 20 days for the ESP clinic.Their audit established that mild and moderateCTS could be effectively managed by acommunity-based ESP clinic in a manner thatis superior to that experienced by most CTSpatients at a tertiary care clinic in terms of access,splint choice, patient information andempowerment.8

In summary, the development of ESPs in handtherapy has improved access to a specialistopinion and improved continuity and quality ofcare.5–8 However, there is still a need for furtherresearch in the form of randomized controlledtrials to evaluate the effectiveness of ESPs in handtherapy.

Development of an ESP clinic

Review of trust strategic data and waitingtimes

Four pertinent themes emerged from a review ofthe strategic data and waiting times. Theseincluded clinical quality, access, clinical effec-tiveness and new ways of delivering services.10

A review of the 2004/2005 waiting times forinpatient procedures indicated that 81% ofpatients were waiting up to six months for aprocedure. As a result, the development of atrust-wide approach to extended scope practicebecame a key priority.11

Review of the original patient pathway

The original patient pathway of CTS and CMC OAwas reviewed to evaluate access to a specialistopinion and its clinical effectiveness (seeFigure 1). The pathway was complex and requirednumerous outpatient appointments and was atrisk of breaching government targets.

Figure 1 Original carpal tunnel syndrome (CTS) and first carpometacarpal osteoarthritis (CMC I OA) patient pathway



It was established that the development of anESP pathway should improve the originalpathway by providing earlier access to a diagnos-tic service, be less complex and commence treat-ment at the first appointment.

The results of the review of the trust’s strategicdata and waiting times as well as the key issuesthat emerged from the literature review wereintegrated into a Strengths, Weaknesses,Opportunities and Threats (SWOT) analysis tosupport the development of the ESP role whensubmitting a business case proposal.

ESP training

Once it was agreed that the ESP role should bedeveloped, training competencies were identifiedby the ESP and an in-house training programmewas developed (Appendix B). Appendix B isavailable online only at http://ht.rsmjournals.com/cgi/content/full/14/4/95/DC2. This train-ing approach was chosen as a result of a studythat was published in 2005, which examined therole parameters and requirements of extendedscope practice in hand therapy using the Delphimethod.12 The training aimed to ensure compe-tencies in understanding disease pathology andindependently request procedures for orderingX-rays and blood tests in order to make a diag-nosis and/or clinical decisions with regards to apatient’s treatment. The programme includeddiagnostic skills training in a trauma clinic withthe consultant, attendance at formal trainingcourses and self-directed learning. In addition,

the trust’s radiology department providedIonising Radiation Medical Exposure Regulation(IRMER) 2000 training.13

ESP assessment forms

The assessment forms were developed by theESP and agreed by the consultant for the trialESP clinic. The forms were designed as an audittool to compare the ESP and consultant diagnosisand management plans. It was expected that theESP would use advanced clinical judgement skillsand be alerted to possible associated conditionssuch as diabetes, pregnancy, compression syn-dromes or possible fractures when examining thepatient.

The assessment forms included a review of apatient’s medical, social and work history as wellas a clinical examination component. Tables 1and 2 present the clinical examination com-ponent of the assessment forms. A scoring systemwas used for each diagnosis where a score of 1was allocated to each positive test or response.A minimum score of 3 was required to diagnoseeach condition. This scoring system provides anadditional means of evaluating symptom pro-gression over time.

When appropriate, X-rays and/or electromyo-graphy were used to support the clinical diagnosis.

Use of an effective outcome measure

Outcome measures are used routinely in clinicalpractice to evaluate if a patient’s health status

Table 1 Carpal tunnel assessment

Common clinical tests Assessment method Left Right

1 Positive Phalen test Paresthesias in the distribution of the median nerve when the patient fully

flexes the wrist for 60 seconds2 Positive Tinel percussion over

median nerve – at wristParesthesias and pain in the distribution of the median nerve when the

therapist taps the volar distal wrist crease with wrist slightly extended

3 Weak thumb abduction Weakness of resisted thumb abduction – compared with the other side4 Diminished two-point

discrimination

Diminished ability to correctly identify two points that are set 4–6 mm apart

5 Closed fist sign Paresthesias in the distribution of the median nerve when the patientactively flexes their fingers into a closed fist for 60 seconds

6 Thenar wasting Sometimes known as the Monkey handPatient reported symptoms

7 Night time paresthesias Patient will describe waking up with numbness in the distribution of the median nerve8 Flick manoeuvre When the therapist asks the patient to describe what they do to relieve the symptoms

of numbness the patient may describe a flicking motion of their hand/wrist

Total

If the answer to the question is YES, please allocate a score of: 1If the answer to the question is NO, please allocate a score of: 0Minimum score allocation for a diagnosis is 3Maximum score allocation for a diagnosis is 8. Test both left and right hands



has improved as a result of an intervention. Theaudit required a standardized self-reportingoutcome measure that was specific to the upperlimb and/or CTS and that was easily understoodby the patients and quick to complete. Anumber of standardized measures are available.These include the Disabilities of the Arm,Shoulder, and Hand (DASH),14 the BostonCarpal Tunnel Questionnaire (BCTQ)15 and TheUpper Limb Functional Index (ULFI).16 Theauthors have used the BCTQ with a carpaltunnel information group but many of the termsand phrases were unfamiliar in the UKpopulation.

The ULFI is a single-page, three-part Self-Reported Outcome Measure (SROM) that has 25statements that are related to function only.The ULFI was developed to improve on otherself-report outcome measures that were criticizedfor poor clinical utility, missing responses andpoor psychometric properties.17 The ULFI has acombined patient completion and therapistscoring time of less than three minutes and tendsto limit item redundancy. A prospective studyconfirmed the reliability, validity and respon-siveness of the ULFI and correlation with theDASH (r ¼ 0.85).17

The ULFI was therefore chosen as an outcomemeasure for the audit as it has both methodo-logical and practical characteristic advantages formeasuring upper extremity disorders that issuperior to other SROMs. In addition, the ULFIprovides a means of clarifying clinical statusand subsequent changes that may result from theintervention over time.17 Therefore, it was estab-lished that the ULFI self-assessment would beimplemented at both initial and follow-upappointments in order to evaluate functionalperformance outcomes following conservativemanagement.

Trial ESP patient pathway

The trial ESP patient pathway is represented inFigure 1. This pathway was more complex than theoriginal pathway as patients were seen by both theESP and the consultant at the initial and follow-upappointments in order to confirm the ESP diag-nosis and management plans. Prior to imple-menting the trial patient pathway, a clinical auditproposal was submitted and accepted by the trust.

Development of specialist investigationrequesting policies

To ensure complete autonomy of the ESP, it wasagreed that specialist investigations could beordered by the ESP to confirm a diagnosis.Initially it was agreed that ESPs could order X-raysand blood tests, therefore a policy for requestingradiological investigations and blood tests wasdeveloped by the hand therapy department. Thepolicy was agreed by the radiology and pathologydepartment service heads following the resolu-tion of a number of contentious issues and rati-fied by the trust’s Clinical Governancecommittee. At a later date policies to requestelectromyography (EMG), dynamic ultrasound(DU) and magnetic resonance imaging (MRI)were approved by clinical governance.

Outline of contentious issues:(1) Laboratory medicine assay and ordering

criteriaIt was agreed that rheumatoid factor, full blood

count, thyroid profile, Erythrocyte SedimentationRate (ESR), C-reactive protein (CRP) tests could beordered when inflammatory or metabolic dis-orders are suspected. ESR and CRP tests would notbe ordered together. CRP will be ordered in theacute phase of an inflammatory response and ESRin the chronic phase. Recent test results would be

Table 2 CMC OA assessment

Common clinical tests Assessment method Left Right

1 Pain felt in the CMC on administering theGrind Test

The examiner grasps the patients thumb and performs grindingmotions while compressing the MC into the CMC longitudinally

2 Creptius felt in the CMC on administering the

Crank Test

Axial loading of the CMC joint of the thumb with simultaneous

passive flexion and extension of the MC baseFirst CMC Osteoarthritis Signs and symptoms Comments

3 Pain localized to CMC during activities of daily living4 Swelling noted around the CMC joint

Total

CMC OA, carpometacarpal osteoarthritis; CMC, carpometacarpal; MC, metacarpalIf the answer to the question is YES, please allocate a score of: 1If the answer to the question is NO, please allocate a score of: 0Maximum score allocation for a diagnosis is 5Minimum score allocation for a diagnosis is 3



checked on the electronic patient record (EPR)prior to ordering more tests to prevent repeatorders.

(2) TerminologyAll tests must be ordered on ‘behalf of’ a doctor

and the names of the tests that are included inthe specialist investigations requesting policymust match EPR. For example, when orderingX-rays the term radius and ulna must be usedinstead of forearm.

(3) Adverse incident reportingAny suspected adverse incidents relating to the

ordering of specialist investigations or subsequentpatient management must be reported to amedical practitioner and documented in thepatient’s health-care record.

(4) AuditRegular audits must be carried out to monitor

adherence to trust and departmental policies.

Business case proposal

A business case proposal was submitted to thesurgical and therapy directorates that proposed

the development of the ESP role and implemen-tation of an ESP clinic in two phases. In phase I,100 patients with CTS and CMC OA would beselected to attend a trial ESP clinic following apredictable pathway (see Figure 2). In phase II, anew patient pathway would be implemented fol-lowing an audit of key performance indicators.

Key performance indicators included:

† Reduction in orthopaedic outpatient clinicwaiting list for CTS and CMC OA (supports18-week initiative);

† Improved patient pathway to first appoint-ment and confirmation of diagnosis;

† Improved patient satisfaction;† Improved functional performance outcomes;† More effective use of clinical staff supporting

cost efficiencies.

The business proposal included the SWOT analy-sis, plans for the ESP in-house training programmeand requesting policies. The proposal stipulatedthat the ESP would be able to independentlyperform clinical tests for the selected diagnoses

Figure 2 Trial extended scope practitioner (ESP) clinic and first carpometacarpal osteoarthritis (CMC OA) pathway



and order blood tests and X-rays in order to make adiagnosis and/or clinical decisions with regards toa patient’s management plan.

The business case proposal was approved andformal recognition and liability cover wereobtained in accordance with the College ofOccupational Therapy/British Association ofOccupational Therapy briefing 14 on extendedscope practice.18

Phase I: trial ESP CTS and CMC OA clinic

Once the resources for the outpatient clinic weresecured, 100 patients were selected for the ESP trialclinic by the consultant based on the GP referralletter and agreed by the ESP. A large sample wasused for audit purposes to analyse the efficacy ofthe ESP clinic. Potential risk to the patient wasminimized through the implementation of ade-quate risk management strategies by providingthe ESP with ongoing training, supervision andmentoring by the consultant.19 Patients wereprovided with an appointment within 2–4 weeksof the referral. ESP referrals were managed bythe clinic clerk who advised the patient thatthey would be assessed in both the consultantand ESP clinics on separate days for an initial andfollow-up appointment. Patients were assessedby the ESP and referred for blood tests or X-raysto support the differential diagnosis if necessary.All patients were referred for EMG by theconsultant to confirm the diagnosis of CTS.ESPs did not have rights to order EMG duringthe trial period. This delayed the confirmation ofthe diagnosis and prevented the ESP from beingcompletely autonomous in the management ofthese diagnoses. ESP management plans wereconfirmed by the consultant at the follow-upassessment with the consultant. Patients whorequired injection therapy were managed by theconsultant and referred on to hand therapy at alater date.

At the initial consultation with the ESP,patients were provided with education abouttheir condition, Futura splints for CTS or neo-prene thumb splints if they presented with CMCOA. Appropriate patients were referred to handtherapy for custom-made splints, ergonomiceducation, activity modification or neuralmobilizations. Patients were referred back to theESP clinic following treatment before being dis-charged to the GP. The trial phase was completedonce 100 patients had been assessed by the ESPs

and diagnosis and management plans were con-firmed by the consultant.

Phase II: review of key performanceindicators and implementationof a new patient pathway

The results indicate that an ESP clinic has thepotential to reduce orthopaedic and/or plasticsurgery outpatient clinic waiting lists for CTS andCMC OA without increasing the demand for sur-gical procedures. The reduction in waiting times(2–4 weeks) to the first appointment for aspecialist opinion supports the 18-week initiative.A formal analysis of cost efficiencies was notpossible to calculate as patients were seen by theconsultant and ESP. However, the implemen-tation of the new patient pathway is intended tosupport cost efficiencies. An additional businessplan was then submitted to the surgical andtherapy directorates where it was agreed that anew CTS and CMC OA patient pathway should beimplemented.

The new CTS and CMC OA patient pathway

A new patient pathway for CTS and CMC OAwas developed and is presented in Figure 3. Thenew pathway is less complex, demands feweroutpatient appointments and provides thepatient with early access to carpal tunnel groupclass, which has been developed in response toincreasing numbers of patients referred to handtherapy from the ESP clinic.

Further developments

The ESP role has developed to ensure completeautonomy to maximize clinic efficiency. Delaysin confirming a diagnosis have been reduced byextending the requesting policy to include EMG,DU and MRIs. The comparison of the surgeonand ESP management plans confirmed that theESP is effective in diagnosing CTS as well as otherconditions such as early-onset Dupuytren’sdisease, wrist injuries, de Quervain’s disease,ganglions and trigger finger. This is of benefit tothe patient as treatment can be initiated while thepatient waits for an appointment with a consul-tant. Subsequently, the ESP role has developed toinclude obtaining first-line consent for specifiedelective hand surgery procedures in accordancewith the trust’s consent policy following a



competency-based training programme as agreedby clinical governance. Specific elective handsurgical procedures that have been included inthe training are as follows:

† Carpal tunnel decompression;† Trigger finger or thumb release;† Dupuytren’s disease;† Ganglion excision;† Wrist arthroscopy.

Once the ESP has assessed the patient and deter-mined the need for surgery, a treatment plan isdeveloped in liaison with the surgeon. Thereafter,the ESP will list the patient for surgery and takefirst-line consent rather than the consultant orthe registrar.

Discussion

The development of the ESP role and new patientpathway within our trust was a complex processthat involved careful planning and considerationin order to meet the standards set by clinical

governance and minimize the risk to both thepatient and the ESP. We found the trial clinic tobe an important part of the training process as itprovided the ESP with the confidence to take fullresponsibility for making a diagnosis, referring forspecialist investigations and determining themanagement plan. Furthermore, the trial pro-vided evidence to support the ESP clinic whenaudited against key performance indicators.However, based on our experience, a trial clinicneed not include 100 patients to determine theaccuracy of ESP diagnosis and management plans,particularly if an ESP has more than five yearsexperience in hand therapy. An audit of 50patients would be sufficient.

Patients’ health and recovery can be at risk ifinvestigations are not performed and patients aremisdiagnosed by the ESP.14 This could result in adelay in the patient receiving the appropriateinvestigations and treatment. In such cases,the 18-week target from referral to treatment willbe breached. Conversely, if a large number ofpatients are listed for surgery from the ESP clinic,a bottleneck to the consultant clinic may occur,

Figure 3 New carpal tunnel syndrome (CTS) and first carpometacarpal osteoarthritis (CMC OA) pathway



placing increased pressure on the consultantclinics. However, according to Burke et al.20,25% of the patients listed for carpal tunneldecompression do not proceed to surgery.

Conclusion and recommendations

ESPs are clinical experts who have demonstratedflexibility to develop their roles to meet the needsof health services during changing times and arelikely to continue to do so in an evolving andcompetitive health-care market.21 Therefore, ESPshave the potential to provide a service that is inline with global health trends that can improveservice delivery in a way that is supported byclinical governance.

This paper described the practical aspectsinvolved in the development and implemen-tation of an ESP clinic to support the 18-weekinitiative and was audited against key perfor-mance indicators. It was established that an ESPclinic has the potential to reduce waiting times tothe first appointment where diagnosis can beconfirmed and treatment can be provided.

The following is recommended when develop-ing an ESP clinic:

† Commitment within the trust to implementnew patient pathways and provide theongoing training and development of the ESProle;

† Enthusiastic leadership to mentor the devel-opment of an ESP and provide in-housetraining;

† ESP literature, trust strategic data and currentpatient pathway reviews are synthesized into aSWOT analysis to support a business caseproposal;

† Key performance indicators and trainingcompetencies are identified;

† An agreed training programme isimplemented and financed;

† Radiology, haematology and neurophysiologydepartments are consulted when developingrequesting policies;

† The ESP has rights to order the necessaryspecialist investigations;

† Clinical Governance ratification for all therequired requesting and consent policies isobtained prior to implementing the trial/ESPclinic;

† Liability cover is provided by the trust;† Risk management strategies are in place to

protect the ESP and the patient;

† A trial ESP and consultant clinic is run simul-taneously to prevent the delay in confirmingthe diagnosis and management plans;

† Referral selection procedures for the ESP clinicare established and implemented;

† Adequate geographical and administrativeresources are provided to support an ESPclinic;

† Bottleneck to surgery is prevented by ensuringthat efficiency of the ESP clinic matches sur-gical capacity;

† ESP skills develop further to include certainprocedures such as providing injectiontherapy to manage selected diagnoses.

In conclusion, it is recommended that the role ofthe ESP continues to develop nationally andsupport the need for a national ESP register.Further research in the form of randomized con-trolled trials is needed to evaluate the efficacy ofESPs in hand therapy.

Acknowledgements: The authors would like tooffer sincere thanks to Associate Professor Povlsen,Consultant Orthopaedic Surgeon for mentoring thedevelopment and training of the OccupationalTherapists to that of Extended Scope Practitioner.Sincere thanks are also extended to ElizabethMaclennan, Trust Head Occupational Therapist forproviding support and expert clinical guidance tosupport the development of the Extended ScopePractitioner role within the Trust.

Competing interests: None declared.

Accepted: 3 April 2009

References

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2 18 Weeks – Delivering the 18 week patient pathway.www.18weeks.nhs.uk (last accessed 24 November2008)

3 Dowling S, Barrett S, West R. With nurse prac-titioners, who needs house officers? Br Med J1995;311:309–13

4 English T. Personal paper: medicine in the 1990sneeds a team approach. Br Med J 1997;314:661–3

5 Peck F, Kennedy S, Mckirdy L. The introductionof practitioner-led clinics in South Manchester.Br J Hand Ther 2001;6:41–4



6 Peck F, Kennedy SM, Watson JS, Lees VS. Anevaluation of the influence of practitioner-led handclinics on rupture rates following primary repair inthe hand. Br J Plast Surg 2004;57:45–9

7 Warwick D, Belward P. Hand therapist carpal tunnelclinic. Br J Hand Ther 2004;9:23–6

8 Storey PA, Dear H, Bradley M, Couchman L, BurkeF. Audit of a therapist-led clinic for carpal tunnelsyndrome in primary care. Br J Hand Ther 2008;13:72–8

9 Ellis B, Kersten P. An exploration of the developingroles of hand therapists as extended scope prac-titioners. Br J Hand Ther 2001;6:126–30

10 GSTT Hot Topics. Future Services Strategy: Trauma& Elective Orthopaedics, 2004. (www) http://tww:8080 (last accessed 7 September 2004)

11 Parrott J, Ridley M. Trust Management Executive,Strategic Update, 2004. (www) http://tww:8080(last accessed 8 September 2004)

12 Ellis B, Kersten P, Sibley A. A Delphi study of therole parameters and requirements of extendedscope practitioners in hand therapy. Br J Hand Ther2005;10:80–6

13 Department of Health. The Ionising Radiation(Medical Exposure) Regulations 2000, 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007957 (last accessed 25 November 2008)

14 Beaton DE, Katz JN, Fossel AH, et al. Measuring thewhole or the parts? Validity, reliability, and

responsiveness of the disabilities of the arm,shoulder and hand outcome measure in differentregions of the upper extremity. J Hand Ther2001;14:128–46

15 Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment ofseverity of symptoms and functional status incarpal tunnel syndrome. J Bone Joint Surg 1993;75:1585–92

16 Gabel P, Michener L, Burkett B, Neller A. The upperlimb functional index: development and determi-nation of reliablity, validity and responsiveness.J Hand Ther 2006;19:328–48

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Appendix B Outline of training competencies and mentored training programme

Skills/knowledgestandards required to leadan ESP clinic

Essential Desirable Consultantteaching

Internal orexternaltraining

Self-directedstudy

Oneday

1–3months

3–6months

>6months

Anatomy reviewp p p p p

Surface and internal anatomy ofthe hand

Surface and internal anatomy ofthe wrist

Surface and internal anatomy of

the forearm and elbowSurface and internal anatomy of

the upper arm

Anatomy of the brachial plexus

Disease pathology of CTSp p p p

Factors concerning the internalanatomy of the wrist that can

lead to CTSCommon reported symptomsCommon assessments that can be

carried out in clinicOther investigations that will assist

with a diagnosisOther conditions that present like

CTS

Therapy treatment optionsOther conservative treatment

options

Surgical and other options

Disease pathogenesis of CMCOA

p p p p

Clear understanding of anatomy

and disease pathologyCommon assessments/tests that

will assist with a diagnosis

Knowledge of the use of specificblood screening tests in order to

exclude other serious pathologywhen making a diagnosis

Therapy treatment options

Disease pathogenesis ofrheumatology

p p p p

Clear understanding of anatomyand disease pathology

Understanding of investigations

that will assist with a diagnosisKnowledge of the use of specific

blood screening tests in order toexclude other serious pathologywhen making a diagnosis

Other conservative treatmentoptions

Surgical and other options

Skills/knowledge standardsrequired to request X-rays

p p p p p

Appropriate views for conditionsseen

Knowledge of indications andcontraindications for requestingX-rays



Appendix B (Continued)




Self-directedstudy

Oneday

1–3months

3–6months

>6months

Knowledge of the use of X-rays to

diagnose fractures or jointabnormalities and demonstratepractical technique/skill in

making clinical decisions withregards to making a diagnosis

Knowledge of the hospitalelectronic requesting systemincluding use of the electronic

patient record and PACS systemfor viewing X-rays

IRMER Regulation 2000 as they

pertain to the referrerKnowledge of the Royal College of

Radiologists’ guideline fordoctors

Pharmacologyp p p

Pain assessment and managementBasic knowledge of

pharmacological actions ofanalgesia and the types of

analgesiaPain assessment and management

Consent trainingGenericKnowledge of the trust consent

policy and conform to it

p p p

Pass the ‘Generic ConsentKnowledge Assessment’

Procedure-specificp p p p

In-depth knowledge of related

anatomical and physiologicalaspects of the surgicalprocedure

Able to clearly describe theprocedure with relevant

diagramsIn-depth knowledge of, and able

to communicate, risks and

benefits to the patient of theprocedure, with degree of riskinvolved

Able to offer alternative therapiesto the patient

Aware of information leaflets thatmay benefit the patient indecision-making

Aware of own knowledgelimitations and how to access

the health professional carryingout the procedure if necessary

Observe consultant plastic

surgeon seeking consent threetimes for each relevant specified

procedureSeek consent under supervision of

consultant plastic surgeon three

times for each specifiedprocedure

(Continued)



Appendix B (Continued)




Self-directedstudy

Oneday

1–3months

3–6months

>6months

Observe each specified procedure

being performed – a minimumof three times

The ‘Competency to Consent’

form (a record of observationand supervision) to be

completed and signed

Trust IT skillsp p p

PIMS: ordering and prescribing

EPR: ordering and prescribing

Generic IT skillsp p p

Basic ExcelIntermediate Excel

Advanced Microsoft Word

Organizational and timemanagement skills

p p p

Leading an empoweredorganization

Training

Research/audit method skillsp p p p

OtherEthical and legal issues related to

practice

p p p p p p

Risk managementBAHT accreditation

ESP, extended scope practitioner; CTS, carpal tunnel syndrome; PACS, Picture Archiving and Communication Systems; IRMER, Ionising Radiation MedicalExposure Regulation; BAHT, British Association of Hand Therapists



Documents

Development and implementation of a hand therapy extended ...handconsult.com/images/downloads/Development_of_an_Extended_Scope... · Original article Development and implementation