Therapy department
The SWLEOC Therapy team is an integrated team of Physiotherapists, Occupational Therapists, and Therapy Technical Instructors. The service is a modernised approach to elective orthopaedic recovery and evidence-based care, with service provision being individualised based on patient need.
The SWLEOC therapy team provides therapy input in the pre-operative, perioperative and post-operative phase of the patient journey.
The patient completes a lifestyle questionnaire on the electronic pre-operative assessment tool (LifeBox), which provides information about their home environment, their support structures, how they are coping at home and if they have any concerns about their discharge. This is triaged by the pre-operative assessment nurses and any concerns escalated to the most appropriate clinicians to action, including discharge nurses, ward team and therapy team. This pre-admission discharge planning enables early action, optimisation, equipment provision and highlights the potential need for post-discharge social care input and multidisciplinary problem solving to minimise any potential barrier or delay in discharge.
Preparing for surgery classes are now provided in the form of AI supported videos that SWLEOC developed in collaboration with our digital partners ‘Lifebox’. The videos provide information in relation to preparing themselves as well as the home environment prior to their surgery. It also provides them an overview of what to expect through their journey in SWLEOC.
Patients are sent the specific video link (links below) by the Lifebox support team, as they set up an account for the patient and remind them to watch the video. The Pre-operative assessment team confirms with the patient that the video information was received, that they watched the video and clarify any questions that they may have. Any patients who have not received the video link will be sent the link as an Envoy text message or email link by one of the discharge nursing team/admin staff.
Non-digital patients are identified at the pre-operative assessment point and are offered face to face sessions as required.
Please see links below:
Unicompartmental Knee Replacement
Patients are provided with very comprehensive patient information booklets, containing all the information about preparing for their surgery, their hospital stay and their recovery. Patients are also signposted to view this information in the form of videos. They are encouraged to complete the pre-surgery exercise program to maximise their strength and function following surgery.
Enhanced recovery and fast track pathways are followed, where the patient’s post-operative rehabilitation starts on the same day of their surgery, aiming for mobilisation between 2- and 4-hours post-surgery. The team aims to complete 2 sessions per day, individualised and based on patient need and depending on their length of stay.
We aim for all patients to recover in their home environment as soon as possible following surgery once all discharge criteria have been met. Patients having primary joint replacement surgery can go home from the same day of their surgery.
Discharge criteria includes:
- Medically fit for discharge;
- safely mobilising with the appropriate aid;
- able to transfer safely and independently;
- able to safely negotiate stairs if required;
- X-ray viewed by the consultant or one of their team and deemed satisfactory; and
- a family member/friend to stay overnight in the first 24 hours following surgery, if having general anaesthetic.
The SWLEOC Therapy team aim to ensure that the patient has the best possible recovery journey, tailored specifically to their needs. This is based on their pre-surgery level of function, the type of surgery that they have had and how they manage while they are with us in hospital. Through a shared decision-making conversation, the 4 possible post-operative patient rehabilitation journeys include:
Patient Initiated Follow Up (PIFU): If patients have progressed well as an inpatient, are coping well with the home exercise program, and team is confident that they will be able to complete their home exercise program without supervision, they are discharged to self-manage, on a PIFU pathway, and contact the SWLEOC therapy team should they have any concerns or questions following discharge. They are provided with the mid stage and late-stage exercises and can progress to these as directed. (This pathway applies mainly to Primary Total Hip Replacements).
SWLEOC Post-Operative Physiotherapy: The patient is booked into a ring-fenced face to face clinic with one of the SWLEOC Physiotherapists after their surgery, at an individualised time point. (This pathway applies to all Primary and Revision Total Knee and Unicompartmental Knee Replacement patients).
Community MSK: The Therapy team refer patients to their local community for ongoing physiotherapy and rehabilitation, at the point of discharge, to help them achieve their goals beyond the acute phase of recovery. (This pathway applies to patients having had Knee Arthroscopy based only on need, all Hip Arthroscopy, Revision Hip Replacement, all Shoulder and Elbow surgery).
Combination of SWLEOC Physiotherapy and Community Physiotherapy: The Therapy team refer patients to their local area for ongoing physiotherapy and rehabilitation at the point of discharge. In addition, the SWLEOC Physiotherapy team review the patient virtually Anterior Cruciate Ligament Reconstruction (ACLR), Posterior Cruciate Ligament Reconstruction (PCLR), Medial Patello-femoral Ligament Reconstruction (MPFLR) or face to face (Total Shoulder Replacement, Rotator Cuff Repair and Capsular Release, Revision Knee Replacement) to check on their recovery and assess that they have met the milestones that we have set for them.
The team starts planning for discharge as soon as the patient is admitted, any concerns or potential cause for delay are escalated early to enable multidisciplinary discharge planning.
Patients having had Primary Total Hip Replacement surgery do not follow hip precautions and Knee Replacement patients discharged on Day 0 or Day 1 are not required to achieve 90 degrees knee bend for discharge and are only required to have functional range of movement.
The SWLEOC Team ensure that they complete a robust and comprehensive discharge with the patient, that includes relevant patient information, post-operative exercise progression, information about their recovery journey so that the patient knows what to expect, and important contact numbers for the patient to contact the SWLEOC team with any concerns or complications following discharge.
SWLEOC Post-Operative face to face clinic:
This clinic is for all primary and revision total and Unicompartmental knee replacement patients.
Patients discharged on Day 0 or Day 1 will be reviewed five days post-surgery (in a group of four) and for patients discharged Day 2+, two weeks following surgery (individual appointment). They will have up to two face to face appointments with the SWLEOC team.
The aim of this appointment is to assess milestones of gait, range of movement, strength and pain levels, manual treatment if required and their exercise programme and mobility is progressed.
Based on this assessment, the patient is either, discharged to self-manage, reviewed in a SWLEOC Physiotherapy follow up clinic or referred onto community MSK.
Patients having had Shoulder Replacement, Rotator Cuff Repair or Capsular Release surgery are reviewed to ensure they have met the milestones that we have set for them based on individual surgeon’s protocol, as a safety net, while waiting for their community rehabilitation to start and their post-operative exercise is progressed to the next stage.
SWLEOC Post-Operative Virtual Clinic:
This clinic is for patients following ACLR, PCLR and MPFLR to ensure they have met the milestones that we have set for them according to individual surgeon protocols, as a safety net, while waiting for their community rehabilitation to start.
PIFU:
Patients contact the SWLEOC Physiotherapy team with any concerns or complications following discharge home. Based on the clinician’s assessment, patients are offered advice, referred to community MSK or a face-to-face appointment will be booked for them to be reviewed by the most appropriate clinician.
6-week Follow Up Clinic:
All patients are reviewed approximately 6 weeks following their surgery by the Consultant or one of the Consultant’s team. The Band 7 Physiotherapists form part of this team.
Metal on Metal Surveillance Clinic:
The band 7 Physiotherapists work as part of the Consultant team to review patients, according to the MHRA guidelines, who have had metal on metal hip replacements. They can compare and interpret patients’ blood results (cobalt and chromium levels), X-ray, and Oxford hip score, and determine whether the patient presentation requires escalation for consultant review.
Our post-operative physiotherapy and review clinics, offers a robust safety net and oversight of the acute part of the patient’s recovery, and follow-up is delivered by the familiar SWLEOC team. This provides consistency, ring-fenced review and prompt escalation to the most appropriate clinician, improving patient confidence and reducing anxiety. In addition, it reduces GP and A&E visits and improves community MSK capacity.
The above applies to surgical post-operative concerns and complications and excludes medical emergency.
The Therapy service was set up when the Centre opened in 2004 and was purely an in-patient service. Initially, the therapy service was provided by an independent provider but was transferred to SWLEOC in 2017. The working hours changed from a traditional 8am to 4pm service to extended hours of therapy cover aligned with the nursing team 7.30am to 8pm, 7 days per week. This enables a joint multidisciplinary handover in the morning and maximises the ability to discharge patients who are ready to go home, in the evening. Another benefit is that it promotes integrated, multi-professional team working.
The post-operative physiotherapy service was established in June 2020 following the first wave of COVID 19 as part of the recovery of services and ensuring patients are supported by the surgical team following their discharge, together with an individualised post-operative recovery journey. This started as virtual and telephone clinics but has evolved to include face to face clinics for all patients having had knee replacement surgery. This service also enabled day case joint arthroplasty.
The skill-mix of staff has changed to a higher skill mix based on the evolution of the service. With the service being fast paced and clinicians required to work more autonomously, there are no longer Band 3 Rehabilitation Support Workers. Band 4 Therapy Technicians can discharge independently, with support of registered staff where required.
The Therapy team interacts with the whole multidisciplinary team in the inpatient and outpatient environment. In the in-patient unit, the integrated team meets in “safety huddles” 3 times per day and there are many informal opportunities to meet with the relevant clinician throughout the day. In the outpatient setting, the Physiotherapist can quickly escalate post discharge concerns to the right clinician depending on the patient presentation. This includes the Consultant, Intensivist or Nurse Practitioners, Pharmacist, Radiologists as well as having access to the Trust Radiology and Doppler scans.
The team also interacts with administrative staff aligned to different parts of the patient journey, including triage, outpatients and physiotherapy administration, appointment bookings, transport bookings and sending of community physiotherapy referrals.
The team undertakes its work on the wards and in the Post Anaesthetic Care Unit in the in-patient setting. The outpatient clinic is run in a purpose-built clinic room in the reception area of SWLEOC. The Therapy office is located within the ward and enables strong communication and planning as a close working team.
- Bluespier;
- Clinical Manager;
- PACS;and
- LifeBox.
It is important from the outset to build strong relationships across the multi-professional team to ensure integrated and collaborative working with one team ethos.
Have structured, standardised pathways for all patients to ensure care delivery is streamlined and organised.
Have strong communication links and robust pathways with not only community MSK services but with social care by Borough to ensure the post discharge pathway is streamlined, the post discharge services are in place, and that there is not any unnecessary delay to discharge. If offering mutual aid, to patients from other regions, it is imperative that this is in place prior to admitting the first patient.
- when a patient’s motor power and sensation has not sufficiently returned to enable safe mobility and same day discharge;
- when patients are waiting for social services input and discharge is delayed due to capacity (package of care, rehabilitation bed, equipment).
Outpatient setting:
- patient demand exceeding clinic capacity;
- availability of workforce to run the clinic.
In-patient unit:
Ongoing audit and monitoring to feedback to anaesthetists about the average time for motor power or sensation to return following primary joint arthroplasty. Data collected to evaluate trends: Anaesthetist, start time of spinal anaesthetic, type, concentration and volume of anaesthetic drug used, any additional nerve block given, duration of surgery.
Close working with discharge nurses. Strong relationships with social services in the different Boroughs. Robust documentation and pathway information, based on each Borough, that is regularly updated to ensure that it is current.
Outpatient setting:
Adding additional clinic capacity on Sunday afternoon when the inpatient unit is quieter.
Business case approval to recruit 2 additional staff members.
We did not have an outpatient physiotherapy service and thus patients were discharged to community services with a blanket referral to community MSK services. There was no oversight or input into the patients’ post-operative recovery journey and their care could not be individualised. Feedback from patients included that Community MSK services work in silo and are variable in terms of wait times, frequency and type of treatment.
- Inconsistent staffing levels and recruitment of experienced staff;
- Because of the extended hours of service, fixed staffing patterns reduce flexibility in the rota;
- as a hub based elective orthopaedic service requires constant innovation, change is inevitable and regular. Change fatigue and staff resilience during change can be challenging;
- although integrated working is fundamental, and generally classified as a strength in SWLEOC, it can occasionally be a challenge based on different professional’s opinion and approach.
- Integrated working: To successfully implement enhanced recovery pathways, it is imperative to harness the wealth of expertise in the individual professions within the Centre and ensure one builds a multi-skilled and sustainable workforce who are able to overlap in areas of care provision. This collaboration is successful in improving patient outcomes, satisfaction and confidence, improves staff morale, and reduces length of stay and variation in care delivery.
- Consistent Communication: It is essential that all team members are consistent with their message. This manages patient expectations, reduces anxiety and improves the confidence the patient has in the team looking after them.
- Patient Information: Comprehensive and clear patient information should be provided in written (paper and online) and video format so that patients adequately prepare for their surgery and know what to expect.
- Ring-fenced post-operative appointments: This offers a robust safety net and oversight of the patients’ acute recovery journey. This individualised journey allows for encouragement of self-management, prompt escalation to the most appropriate clinician and minimised unnecessary follow up.
- Multidisciplinary handover and safety huddles (3 x daily): This eliminates the necessity for multiple handovers, enables streamlined and MDT discharge planning, accurate sharing of information, and MDT problem solving. A dynamic and visible therapy allocation board improves communication and daily caseload management.
- Consultant Communication links: Being a surgical hub with consultants from multiple Trusts, it is essential to have access to consultants to be able to promptly escalate concerns and to implement the most appropriate management plan, quickly.
- SWLEOC ring-fenced outpatient X-ray: This enables fast track and ring-fenced X-ray for any post-operative concerns of increased pain, difficulty weight bearing or change to mobility. This eliminates the necessity of attending A&E.
- Extended hours Therapy service: A shift pattern aligned with nursing staff 7.30am to 8pm, 7 days per week, enables MDT handover, integrated working, enhanced recovery and day case discharge pathways. The level and quality of service provision is the same 7 days per week.
- Higher skill mix: Due to the high volume and fast paced nature of the orthopaedic unit, together with allowing for treatment of more complex patients, the staffing model encompasses a higher skill mix of more experienced and specialist staff.
- Implementation of a Day Case Joint Arthroplasty Pathway;
- removal of 90 degrees knee flexion as a discharge criteria for most Primary Knee Replacements discharged on Day 0 or Day 1 following surgery;
- implementation of a SWLEOC Post-Operative Rehabilitation Service so that we have oversight of patients’ recovery following their discharge.
The clinic slots were booked without administrative or catch-up gaps. Clinics were overrunning and staff were becoming stressed. A gap was implemented halfway through the clinic and the clinician swaps with a colleague.
Staff
Staff Member: Clinical Therapy Lead (Band 8a x 1 WTE)
Role:
- Leadership and Management 15 hours;
- clinical 15 hours;
- Education, Training & Staff Management 7.5 hours.
What this staff member does in relation to this activity
- To be responsible for the Physiotherapy and Occupational therapy teams within SWLEOC by leading and managing the therapies staff through the effective use of resources ensuring patient outcomes are optimised.
- To be responsible for the provision of a high quality, responsive therapy service to SWLEOC patients in partnership with other disciplines.
- To identify areas for improvement and development across the therapies services within SWLEOC.
- To undertake a clinical caseload of patients using highly developed clinical reasoning skills, theoretical knowledge and high levels of practice experience to formulate a specialised programme of care.
- To manage specific projects facilitating a modern approach to the therapies services within SWLEOC.
- To co-ordinate and produce reports/statistical information, on a regular basis, required by the management team.
Staff member’s other roles in the centre:
- attend monthly senior manager meetings;
- demonstrate a high level of interpersonal communication skills with both clinical and non- clinical staff and senior managers;
- to ensure staff support and supervisory mechanisms are in place to maintain a safe and effective practice within individual’s professional capacity;
- to represent the therapies team at internal and external meetings;
- manage frequent stressful and upsetting or emotional situations in an empathetic manner i.e., dealing with staff issues and complaints;
- advise other disciplines to ensure a multidisciplinary approach to care;
- communicate highly complex and occasionally sensitive information to patients and staff;
- to undertake tasks appropriate to clinical and management skills;
- undertake a range of specific delegated projects on behalf of the senior management team;
- ensure that the Service/Directorate’s services are focused on the needs of patients and clients.
Staff Member: Senior Physiotherapy Team Leader (Band 7 x 4.52 WTE)
Hours per week that this staff member spends on this specific activity:
- managerial 15 hours;
- clinical 22.5 hours.
What this staff member does in relation to this activity:
- Team leadership and daily service delivery coordination (7.5 hours per week);
- Referral triage (4 hours per week);
- Complex in-patient caseload (7.5 hours per week);
- Outpatient clinics – Physiotherapy, shoulder clinic, metal on metal surveillance, 6 week follow up, post discharge review (4 hours per week);
- IRMER trained and able to request imaging and bloods (2 hours per week);
- Preparing for surgery class (1 hour per week);
- HR management (2 hours per week);
- Rota management (7.5 hours per week);
- Deputising for Clinical Therapy Lead (2 hours per week).
Staff member’s other roles in the centre:
- Supervision;
- equipment provision and stock control;
- quality improvement projects, service evaluation.
Staff Member: Senior Physiotherapist (Band 6 x 8 WTE)
Hours per week that this staff member spends on this specific activity:
- inpatient caseload of mixed complexity (27.5 hours per week);
- outpatient caseload of mixed complexity (8 hours);
- deputising for Band 7 (2 hours).
What this staff member does in relation to this activity
- Inpatient and outpatient clinical caseload.
Staff member’s other roles in the centre:
- supervision;
- equipment provision and stock control;
- quality improvement projects, service evaluation.
Staff Member: Physiotherapist (Band 5 x 2 WTE)
1 post is rotational with the base trust and the staff member rotates into a different physiotherapy sub-speciality every 4 months, the other post is static.
Role:
Inpatient caseload of lower complexity (37.5 hours per week)
Staff Member: Technical Instructor (Band 4 x 4 WTE)
Role:
- integrated OT/PT therapy technician with equipment control and ordering (2 hours per week);
- autonomous caseload and independent discharge of lower complexity patients with support of registered clinician (27.5 hours per week);
- upskilled to treat and discharge non-complex day cases (foot and ankle and knee arthroscopy) (8 hours per week).
Staff Member: Senior Occupational Therapist (Band 7 x 0.6 WTE)
Hours per week that this staff member spends on this activity:
- Complex discharge planning (7.5 hours per week);
- Complex equipment provision (7.5 hours per week);
- Collaboration with social services in all Boroughs (7.5 hours per week);
- Home visits if required (4 hours per month).
What does this staff member do in relation to this activity?
- Complex discharge planning;
- complex equipment provision;
- collaboration with social services in all Boroughs;
- home visits if required;
- management of peripheral equipment store.
Staff members other roles in the Centre:
Daily Staffing Model: Daily staffing is planned according to activity in the in-patient unit, outpatient clinic and additional activities. This is dynamic and flexible based on service need but provides the team with structure and an understanding of their responsibilities on any given day. It is also an opportunity to identify gaps in staffing to be amended in advance. The minimum staffing on any day will include 4 registered and 2 unregistered staff members on the in-patient unit and 1 registered staff member on, Monday to Friday, allocated to clinic.
Please note that the hours staff members spend on tasks varies based on service need and non-clinical time which will be built within their role. In addition, all staff members spend time on shared tasks including supervision, equipment provision and stock control, quality improvement projects and service evaluation.