This project commenced in April 2017 and is a joint initiative between the paediatric physiotherapy department and the radiology department at Dorset County Hospital (DCH) to implement a UK wide standardised programme to prevent hip dislocations in children with Cerebral Palsy (CP) - Cerebral Palsy Integrated Pathway (CPIP) for hip management in Children and Young People.
Children with CP are at greater risk of developing musculoskeletal contractures and deformities. A child with most severe form of CP has a 90% chance of developing hip problems - commonly hip dislocations (Hagglund 2005).
CPIP is an evidence based multi-professional standardised approach to prevent and reduce hip dislocation and musculoskeletal deformities. NICE guideline for spasticity in under 19's (CG145) recommendation 1.1.17 is for all children with bilateral cerebral palsy to have hip surveillance x-ray at 2 years of age. Subsequent imaging is in accordance with the child's Gross Motor Function Classification Score (GMFCS) determined by the activities they can perform and demonstrates implementation of recommendation 1.1.18 in the NICE guideline.
Hip surveillance facilitates appropriate management and interventions, with the aim of preventing hip dislocations and ensure a seamless transition into adult services. There are 3 parts to the process: x-ray surveillance, clinical measurement and data recording.
CPIP at Dorset County Hospital (DCH) is a collaborative project to improve access to care and management using a standardised surveillance programme for children diagnosed with CP. Collaborative working with the radiology department ensures optimisation of image quality and standardisation of radiological reports.
Aims and objectives
- To standardise the clinical examination, the assessment method and interval surveillance screening.
- To train a small number of radiographers in specific technique with the assistance of a physiotherapist who will perform physiotherapy to modify muscle tone and enable accurate positioning whilst in the X-ray room. This optimises image quality and patient experience. Fundamentally allows for accurate measurements to be taken and establishing the level of risk of hip migration/dislocation.
- To improve communication between members of the network team - paediatricians, orthopaedic surgeons, physiotherapist and radiographers.
- To provide a 'one stop shop' - X-ray surveillance, clinical measurements by physiotherapist and recording on a local and national database. Surveillance enables early referral for orthopaedic opinion and possible interventions either surgical or therapeutic.
- To have a database for the recording of measurements and to audit quality - this will facilitate a seamless transition should the child move into a different area (continuation of care) or into adult services. The database provides a record to ensure the child has timely follow up surveillance screening as per the CPIP programme safeguarding against unnecessary radiation exposures.
- All children and young people in UK with a diagnosis of CP in West Dorset to be on the CPIP by year end 2019.
Reasons for implementing your project
Dorset County Hospital (DCH) is an acute general hospital serving the population of West Dorset (>215,000). Dorset is predominantly a rural county with no cities or motorways. Over the past 10 years Dorset’s population grew by 12,000, (4% growth compared with 8% nationally) with a high proportion of elderly residents.
The radiology department within the hospital performs more than 166,000 examinations per annum. This project involves the population of children aged 2 years-
16 years with a diagnosis of cerebral palsy (CP) resident in West Dorset. Nationally prevalence estimates of CP ranges from 1.5 to 4 per 1,000 live births. With no prior agreed pathways in place and ineffective communication amongst the health professionals children may have had insufficient screening or conversely unnecessary frequent screening (radiation dose implications).
X-ray attendances were not planned and this caused stress for patient, carer and staff. This compromised patient positioning and subsequent image quality and accuracy of radiology report. Patient experience and outcomes were not optimized and no feedback from the clinicians.
Pre-implementation of CPIP:
The CP population was unknown and poorly documented. Management was not standardised nor monitored accurately. This cohort was at risk with haphazard access to a network of care with no agreed standardised care pathways and ineffective communication amongst the care providers.
X-ray images from both technical and timing perspective were not standardised. Imaging is challenging in this patient cohort due to muscle tone, pain, fear, behavioural issues and difficulties in comprehension. In 2016 5% patients were X-rayed at the correct age but none used standardised technique. 3% patients had the migration percentiles recorded.
These patients were receiving inconsistent care and treatment they need for the developmental and clinical comorbidities associated with CP so that they can be as active and independent as possible. Improvement in the patient experience and having a 'joined up' service was vital.
How did you implement the project
Since April 2017 myself and the CPIP lead paediatric physiotherapist have been instrumental in the education and training of the clinicians and promoting this service.
We have implemented monthly clinics whereby the appointment slot is determined by the GMFCS.
X-ray room prepared with all relevant positioning aids, personal protective equipment and hoist.
The radiology report writing has been delegated to the reporting radiographer following training to specify the migration indices and other measurements required by the physiotherapists, paediatricians and orthopaedic surgeons.
The physiotherapy assistant has developed a local database to record all data.
We have designed a booklet which is sent out with the appointment letter to give a pictorial guide to what to expect when the child attends the X-ray department.
Feedback sheets are given to the carer after the procedure - all feedback since implementation has been excellent (this continues to be audited).
CPIP is evidence based:
'Number of children with dislocated hips fell from 7.7% to 0.8% of CP population in Southern Sweden. Proportion of children treated with orthopaedic surgery for contractures or skeletal torsion deformity decreased from 40% to 15%' (Hagglund G, et al., ‘Prevention of dislocation of the hip in children with cerebral palsy', 2005).
Extrapolation of data from local database may corroborate this over time.
By year end we will have screened all current local CP population aged 2-16 years. Since April 2017 100% (n=96) of children who have been screened at the correct age, achieving CPIP technical standards and migration percentiles recorded on the local database.
Fundamentally CPIP will transform the health and wellbeing of the CP population. We are committed to change and to demonstrate that Allied Health Professionals (AHPs) can lead this change, develop self and others and evaluate outcomes through audit and feedback.
CPIP delivers three of the four impacts described in 'AHPs into Action':
- Improved health and wellbeing of CP population
- Supporting integration of interprofessional working to reduce duplication and fragmentation
- Delivering evidence based practice to address unnecessary variances in service quality and inefficiencies.
CPIP is an effective and efficient use of Allied Health Professional (AHPs) in the delivery of evidence based practice in promoting improved outcomes by using a 'traffic light system' to highlight the degree of risk of hip dislocations and determine early interventions. Fundamentally, CPIP will enhance quality of life in adulthood and will deliver long term cost savings.
Key learning points
We were uncertain of the number of children with CP in West Dorset due to lack of data and joined up documentation. This project was an unknown entity and neither of us had any prior knowledge of implementing a new service.
We were naïve and were driven by our enthusiasm that this could only be a good idea. We did not look at the bigger picture of funding for sustainability. It may have been useful to visit other sites to see how they implement the CPIP standards and audited.
We took advice from the Wessex Academic Health Science Network in order to present to senior management why this project should continue, resulting in funding for the physiotherapists to perform clinical measurements. However, the funding does not currently meet demands and it is not sustainable in the longer term.
We are seeking further support at Trust level to meet the NICE standards and fully implement the recommendations. We shall continue to promote the pathway both regionally and nationally.