Referral to Treatment Pathways for Surgical Carpal Tunnel Syndrome Patients

Referral to Treatment Pathways for Surgical Carpal Tunnel Syndrome Patients A Report from the Musculoskeletal Audit on behalf of the Scottish Government The information in this report is intended to be used for improvement purposes. Please treat the material and any indication of the results as restricted. The information has been collected through the MSK Audit by local MSK Audit co-ordinators based in each hospital. These statistics have not been through the official statistics quality assurance process but have been subject to the MSK Audit s own quality assurance process. This data represents a subset of the orthopaedic workload and has been collected independently of ISD s New Ways statistics. It should not be directly compared to the official statistics on 18 Week Referral to Treatment or Stage of Treatment Measures. These measures can be found at: http://www.isdscotland.org/health-topics/waiting-times/ This report from the Musculoskeletal (MSk) Audit looks at referral to surgery data for patients who underwent surgery for Carpal Tunnel Syndrome (CTS) between 31 st October 211 and 23 rd January 212. We included all patients listed for an elective carpal tunnel release. MSk Local Audit Co-ordinators collected data from patient case notes, patient information systems, results reporting and referral management systems. The audit collected information on clinical elements and Referral to Treatment (RTT) timing information along the pathway. The clinical elements have been reported on separately in a report titled Referral and pathways for surgically managed Carpal Tunnel Syndrome patients: guidelines and current practice. The audit only included patients treated surgically. A separate audit of patients treated conservatively was undertaken in 21 and can be found at http://www.18weeks.scot.nhs.uk/task-and-finishgroups/orthopaedic-services/ This report is intended to be used, in conjunction with local data, to help managers and clinicians identify opportunities where referral and pathway processes could potentially be improved. It is not intended to be used to make judgements about current performance but rather to stimulate further investigation to understand where the opportunities for improvement exist. Contacts: Please send comments and queries to one of the following: Kate James Orthopaedic Services Improvement Project Manager, Scottish Government (Kate.James@scotland.gsi.gov.uk ) Rik Smith MSK Audit Analyst (rsmith11@nhs.net) Jane Campbell MSK Audit Clinical Co-ordinator (Jane.Campbell7@nhs.net)

Executive Summary For patients in this audit (CTS surgery between Nov 211 to January 212), 43% of surgical carpal tunnel syndrome RTT patient pathways were completed within 18 weeks net of unavailability and clock resets for DNAs and cancellations (Fig. 2). 45% of patients were unavailable at some stage during their RTT journey, but this varied considerably between units (Fig. 3). 18% of patients cancelled or did not attend an appointment or surgery. Unavailability, CNA and DNA analyses (Figs. 3-5) provide information for hospitals to benchmark themselves against other hospitals, identify areas for improvement and potentially identify hospitals where examples of good practice can be implemented elsewhere. Fig. 6 provides an overview of the whole patient pathway and the opportunity for improvement focus on different stages of the pathway where waits are longest and delays are easiest to eliminate. The use of One-stop Carpal Tunnel clinics with on-site Nerve Conduction Studies in sites such as and Woodend has eliminated the wait from Outpatient Appointment (OPA) to Diagnostics/Review and should be considered by other hospitals. 79% of patients were seen at an Outpatient Appointment within 12 weeks of referral (net of unavailability and clock resets for DNAs and cancellations), but there was considerable variation between units (Fig. 7). The tables and graphs in this section breakdown the stage from referral to first OPA into constituent parts and provide Boards with the opportunity to benchmark their hospitals against other hospitals, identify areas for specific improvement focus, and potentially identify hospitals where examples of good practice can be implemented elsewhere. Table 2 provides the opportunity for Boards to assess the efficiency of their vetting and booking processes and sub-specialty outpatient capacity issues. Some units take more than a week to vet a sizeable proportion of referrals, adding a considerable challenge to the overall achievement of 18 weeks RTT. It is noted however that the units with the two highest percentages on this table do see 99% of their patients at first OPA within 12 weeks so the delay in vetting is made up for with efficient booking and sufficient clinic capacity. Fig. 1 highlights the considerable variation in use of Nerve Conduction Studies (NCS) between centres. In some centres, the majority of carpal tunnel decompressions are performed without NCS. It remains controversial as to which patients should have preoperative NCS. In the UK it is generally accepted that not all patients with carpal tunnel syndrome necessarily need pre-operative NCS. However, the consensus in the hand surgery community is that NCS are an important diagnostic tool and should be available for the assessment of patients with carpal tunnel syndrome. Boards are encouraged to develop NCS guidelines detailing the criteria for which patients would benefit from NCS. The time taken to perform NCS and review the subsequent results (Figs. 11-16) is the part of the pathway that Boards are probably finding the most challenging but where improvements could have the greatest impact. Only 8% of patients underwent NCS and subsequent review within 4 weeks of the OPA when they were ordered, and 51% of patients waited more than 12 weeks (Fig. 11). This is a significant challenge to the overall achievement of the 18 Weeks standard for such patients. There are a number of options that may be a way forward in some units, including review by phone or letter (rather than an appointment), and One-stop CTS clinics with the capability of carrying out and reviewing same-day NCS. There may be an opportunity, particularly for those Boards sending patients for NCS to another Board, to set out clear criteria for which patients it is appropriate to refer to either a technician or neurophysiologist depending on patient symptoms as this has a considerable affect on waiting times. For example, Boards sending patients to Lothian are having NCS undertaken by a neurophysiologist for a considerably higher percentage of referrals than Lothian themselves (Fig. 13). - - 2

Although the waiting times for NCS (Fig. 14) have reduced considerably since the previous audit in 21 (especially in Greater Glasgow and Clyde) the waits at most locations are still too long to enable patients to achieve the 18 Week RTT standard. Variation in the length of wait within units should also be addressed. Long delays to NCS may discourage consultants from ordering them when clinically appropriate. Centres that had a long average length of wait for NCS sent fewer patients for NCS (see text above fig 12). Delay between carrying out NCS and then reviewing them with the patient (Figs. 15, 16) is likely to be multi-factorial, including a combination of administration delays and trying to slot patients into already heavily booked clinics. It would appear however that review dates are often booked at the first OPA and often for a significant number of weeks in the future as NCS waits are known to be long and sometimes unpredictable. Much shorter times to post- NCS review could potentially be achieved if the review date was booked as soon as the NCS date was known and for a date soon after the NCS date. This, however, is a significant challenge for the majority of Boards where NCS are booked on separate systems to orthopaedic appointments, particularly where NCS are undertaken at a different Board. Boards are encouraged to use a LEAN approach to this process and share best practice between Boards. 84% of patients were operated on within nine weeks of being added to the theatre waiting list (Fig. 17). Further breakdown of timings and delays to surgery (Table 4, Fig. 18) provides information for hospitals to benchmark themselves against other hospitals, identify areas for improvement focus and potentially identify hospitals where examples of good practice can be implemented elsewhere. A number of Boards need to continue to work on the accuracy of their outcome codes for 18 Weeks measurement (Fig. 19). Across all boards 8% of episodes of care were deemed to be accurately outcomed. There were, however, 1% of cases with missing outcomes. In 5% of cases the recorded outcome appeared to be inaccurate but did not affect the clock. The remaining 5% appeared to be inaccurate and would have affected the clock stop. Units should ensure that outcome codes are applied at all appointments, and that staff understand which codes to apply in which circumstances. Contents: How to use this report Page 4 Summary of overall period from Referral to Treatment Pages 6-9 Overall RTT time, unavailability, CNAs/DNAs, stage times Referral to First Outpatient Appointment Pages 1-13 Timings, vetting, delays Outpatient Appointment to Diagnostics/Review Pages 14-15 Pathway to surgery, timing Diagnostics Pages 16-19 NCS timings, grade of staff, and subsequent review Surgery Pages 2-21 Timings, delays Outcome code recording Page 22 Second procedures Pages 23-24 - - 3

How to use this report The Referral to Treatment period for surgical CTS patients is summarised on an individual hospital basis, firstly in section A for the whole period from Referral to Treatment, then in more detail for the constituent parts of this journey in the following sections: B Referral to First Outpatient Appointment (OPA) C OPA to Diagnostics/Review D Diagnostics E Surgery Note that not all patients followed a conventional path from referral to Outpatient Appointment, subsequent diagnostics and review to surgery (e.g. patients could be referred into the system to an NHS hospital from a private clinic). Also, some dates for various parts of the patient journey (particularly vetting and allocation dates) were not always available. This explains variation in sample sizes across the report. The 18-week Referral to Treatment standard allows for clock pauses. We subtracted documented periods of patient unavailability from overall RTT times and the relevant stage of the RTT journey. Clocks were also reset to zero for a stage of treatment when patients cancelled an appointment or did not attend. This methodology follows the guidelines supplied to Boards for 18 Week RTT measurement, but does not necessarily produce exactly the same measurement as those produced locally at Boards. It is not intended that the results of this report are used for waiting times measurements but rather for improvement purposes to identify delays in the pathway that can be removed. Analysis of the constituent parts of the patient journey reported here should identify the main limiting steps in each unit, but, if it would be useful, please ask us to select or break down your information further. During the audit period the MSk Audit Local Audit Co-ordinators achieved a near 1% inclusion rate of carpal tunnel release patients in most participating hospitals (Table 1). Almost all Carpal Tunnel surgery was carried out by the Orthopaedic specialty, except in Lothian (91% by Plastics including 54% undertaken by the Lothian plastic surgeons at GJNH), Aberdeen (25% by Neurosurgery) and (23% by Plastics or Neurosurgery, but none of these patients were included in the audit). Table 1: Number of patients reported on Hospital patient referred to Number of surgical CTS patients audited (31/1/11 to 23/1/12) Number (%) identified but not audited Operating hospitals 45 (45) 18 (14), (3), (1) 35 (34), (1) 45 RAH (21), VOL (24) /Gartnavel 34 /Gartnavel (34) /Stobhill 35 /Stobhill (35) 9 13 (13%) ARI (22), Woodend (68) 79 7 (8%) (79) 28 PRI (28) 75 22 (23%) * (6), PRI (34), Stracathro (35) 142 St Johns (53), RIE (13), GJNH (76) 48 FVRH (48) 35 2 (5%) (35 ) /Garrick 62 (5), Garrick (12) 78 17 (18%) QMH (6), VI (18) 31 (31) 21 (2), (1) 91 6 (6%) * The 22 patients who were identified but not audited were those operated on by Plastics (1) and Neurosurgery (12). In other units the patients who were identified but not audited were those whose notes could not be found, or were unavailable during the time allocated for this audit. Although we collected data on all patients who had carpal tunnel surgery during the audit period (Table 1), this report concentrates on the 75% of patients who were new referrals that went on to have carpal tunnel - - 4

release as their definitive treatment as the endpoint of their 18-week RTT pathway (Fig. 1). We do not report on the 8% of patients who were originally new referrals but had a clockstop outcome (codes 1-7) prior to surgery, such as a steroid injection or wrist splints as definitive treatment (1), or a period where it was decided that the patient would be actively monitored (4), but no further treatment was currently thought to be necessary. We also mainly exclude the 17% of operations on second procedures on the other hand. These were usually planned treatments immediately after surgery on the first hand, and are summarised briefly at the end of the report. Note that all units referred to on the tables and figures are where the patient was initially referred rather than the operating hospital. Fig. 1: The proportion of carpal tunnel releases that concluded an 18-week pathway, compared to pathways that stopped prior to surgery and those that were second hand procedures 1 8 6 4 2 Treated after first operation - 'second hand' New Referral RTT Pathway, treatment commenced before surgery New Referral RTT Pathway ended with surgery Procedures were only considered to be second hands if the decision for treatment on the second hand was made prior to or upon review of surgery on the first hand Notes on calculation of length of RTT journeys and other waits In the previous (21) MSk Audit report on carpal tunnel surgery we did not attempt to adjust reported times for the referral to treatment period (or any parts of it) for patient unavailability, patient cancellations or nonattendance. In this report we have made these adjustments, subtracting periods of patient unavailability and re-setting the clock to zero for any stage of treatment where a patient cancelled or did not attend an appointment or surgery. Each Board also uses appointment outcome codes to calculate RTT journey times. In section F we report on how often RTT journeys appeared to have either missing outcome codes or potential discrepancies that could have affected the Board s calculation of the RTT journey time. Throughout this report we calculated journey times using the outcome that should have been applied. This was established by the MSk Audit Local Audit Co-ordinators by further checking of what happened to the patients according to the hospitals electronic systems and casenotes. - - 5

A) Summary of overall period from Referral to Treatment Musculoskeletal (MSk) Audit - RTT Pathways for Surgical CTS Patients As described above (see Fig. 1), all data in section A refers to 18-week RTT journeys for patients that were new referrals for carpal tunnel syndrome that had carpal tunnel release as the endpoint of their journey between 31 st October 211 and 23 rd January 212. Patients that had an RTT clock stop before surgery were excluded. Second/subsequent procedures that followed on immediately after treatment of the first hand (17% of all carpal tunnel operations) were also excluded, but see summary information detailed separately in part G. After excluding periods of patient unavailability, and re-setting RTT clocks to zero if the patient cancelled or did not attend, 43% of carpal tunnel release journeys were completed within 18 weeks (Fig. 2). A further 25% were completed within the next six weeks, but 32% took longer than 24 weeks. Fig. 2: Length of time from referral to surgery net of unavailability and clock resets 1 8 6 4 2 <=12 weeks 12-18 weeks 18-24 weeks 24+ weeks Missing data Data are for RTT journeys that ended in carpal tunnel surgery during the audit period (31 st October 211 to 23 rd January 212). 8% of these journeys began with referrals in 21 without a known intervening clock stop. Clocks were reset to zero for a stage of treatment when patients cancelled or did not attend an appointment, diagnostic or surgery. This included any intermediate period between the patient s first OPA following referral and when they were listed for theatre. - - 6

Unavailability and CNA/DNA rates Figs. 3-5 show that a substantial number of patients fail to attend or elect to be unavailable at some point in the patient pathway and that unavailability rates vary widely across the country. Fig. 3: Length of Patient unavailability 1 8 6 4 2 Percentage of journeys 3+ months 1-3 months Up to four weeks No unavailability recorded Fig 4: Type of documented patient unavailability Percentage of journeys 1 8 6 4 2 * Patient choice - specific hospital or consultant Unfit/clinical/medical Deferred at start No unavailability Patient choice - holiday/work/social Other Not known Data are provided on a per patient basis. If the patient had more than one period of unavailability, data are given for the longest recorded period of unavailability - - 7

Fig. 5: CNA/DNA rates Percentage of journeys 4 3 2 1 CNA reset DNA reset Both No CNA/DNA The Unavailability, CNA and DNA analyses provide information for hospitals to benchmark themselves against other hospitals, identify areas for improvement and potentially identify hospitals where examples of good practice can be implemented elsewhere. - - 8

Average times by stage of treatment Fig. 6: Average time spent in each stage of the Referral to Treatment pathway 3 25 2 15 1 5 Total Mean number of weeks From referral to OPA Diagnostics/review to theatre list OPA to diagnostics/review Theatre list to surgery NOTES Times are means for each stage for patients whose data was available Time from OPA to diagnostics/review is to the first review clinic, or the date the diagnostic (NCS) was performed if the patient was reviewed by phone or letter Time from diagnostics/review to the date the patient was added to the theatre list is time from first review, and may have included subsequent reviews/diagnostics If patients were added to the theatre list at the initial OPA, and were not referred for diagnostics or a subsequent review (68% of all patients): o OPA to diagnostics/review was included as weeks (SO THE AVERAGE REFLECTS THE NUMBER WHO HAD NCS o AS WELL AS THEIR AVERAGE WAIT) Diagnostics/review to theatre list was included as the time elapsed between the first OPA and the date the patient was added to the theatre list A small number of patients had diagnostics/reviews after they were apparently added to the theatre list. These were excluded from calculation of time from diagnostics/review to theatre list This analysis provides the opportunity for improvement focus on different stages of the pathway where waits are longest and delays are easiest to eliminate. The use of One-stop Carpal Tunnel clinics with on-site Nerve Conduction Studies in sites such as and Woodend has eliminated the wait from OPA to Diagnostics/Review and should be considered by other hospitals. - - 9

B) Referral to First Outpatient Appointment Musculoskeletal (MSk) Audit - RTT Pathways for Surgical CTS Patients In order to allow us to report on a reasonably current view of patient waiting times in different parts of the total RTT journey, the following stage of treatment sections exclude the 8% of carpal tunnel patients whose surgical RTT journeys began prior to 1 st January 211. 82% of the included patients were referred after April 211. 79% of 618 patients with documented length of time from Referral to first Outpatient Appointment were seen within 12 weeks (Fig. 7). Fig. 7: Length of time from Referral to Outpatient Appointment 1 8 6 4 2 <=9 weeks 9-12 weeks 12-15 weeks >15 weeks Missing data Data are for RTT journeys that ended in carpal tunnel surgery during the audit period (31 st October 211 to 23 rd January 212). Analysis restricted to 211 referrals to reduce time-related variation. Note, however, that there was little evidence for any reduction in the mean time from referral to OPA throughout 211. This analysis shows significant variation between hospitals. Together with the other tables and figures in this section, it provides the opportunity for Boards to assess the efficiency of their vetting and booking processes and sub-specialty outpatient capacity issues. - - 1

Although it was usually possible to identify who vetted patients and the vetting outcome, in some hospitals first vetting date was often unavailable (Table 2). This has improved with the introduction of e-vetting, and recording of vetting dates has increased from 61% to 83% since the previous CTS audit period in early 21. Amongst patients whose vetting times were known, 93% of patients were vetted within a week (Table 2), compared to 91% in 21. Table 2: Average time from Referral to First Vetting % of patients whose vetting dates were documented Number of patients documented Referral to vetting Mean (weeks) % > 1 week 76% 26.2 % 1% 14.1 % 96% 25.2 8% 73% 24 1.2 54% 1% 22.2 % 1% 2.1 % - - - - 85% 44.4 14% 1% 13. % 81% 42.1 % 1% 96. 1% 81% 22 1. 36% 95% 2.1 % 98% 46.1 % 91% 41. % 81% 17.5 12% 93% 13.5 8% 83% 491.2 7% Woodend / ARI data has been removed from this table as vetting dates are frequently missing as a result of the paper based vetting process. This will hopefully be resolved with the introduction of e-vetting. Taking more than a week to vet a sizeable proportion of referrals adds a significant challenge to the overall achievement of 18 weeks RTT. It is noted however that the hospitals with the two highest percentages on Table 2 do see 99% of their patients at first OPA within 12 weeks so the delay in vetting is made up for with efficient booking and sufficient clinic capacity. Hospital vetting policies vary considerably. Where known, almost all patients originally vetted by clerical staff were subsequently vetted by medical staff or ESPs (Fig. 8). Fig. 8: Who first vetted patients? 1 8 6 4 2 Medical staff ESP Clerical staff Not vetted Missing data Patients who were not vetted included unscheduled referrals (e.g. from the Emergency Department, patients going on to have Carpal Tunnel surgery following referrals or reviews for other procedures, or patients given open appointments following a diagnosis of CTS). - - 11

Much of the time elapsed between Referral and first Outpatient Appointment occurred whilst the patient awaited their offered OPA date. The average wait from the date the OPA was ready for allocation to the date offered for OPA was 8 weeks, but many hospitals had a considerable proportion of patients who waited more than eight weeks (Table 3). Table 3: Average times from Vetting to Outpatient Appointment Time from vetting to ready for allocation N Mean (weeks ) % > 1 week Time from ready for allocation to date offered N Mean (weeks) % > 8 weeks Time from first date offered to OPA attendance N Mean (weeks ) % > 1 week 26. % 36 8.8 58% 36.2 3% 14 1. 36% 14 8.1 64% 15. % 25. % 26 9.2 62% 27.3 7% 23 1.4 61% 3 7. 27% 38.7 13% 22. % 22 1.1 86% 22.2 5% 2. % 2 7.3 25% 2.5 1% - - - - - - 56.3 4% 44.6 2% 54 11.4 76% 58.1 3% 13.8 8% 13 9.6 62% 13. % 42 5.9 81% 54 3.9 6% 58.6 14% 96. % 96 1.7 79% 98.6 8% 22.1 % 26 5.8 23% 27.2 7% 2. % 2 8.7 6% 22. % 46.2 % 46 5.9 24% 49.1 2% 36.7 11% 38 7.9 45% 45.6 2% 16.4 6% 19 1.7 68% 21.1 5% 12. % 13 11.3 85% 14.1 7% 481.8 15% 527 7.9 52% 619.3 7% Sample sizes vary between columns due to availability of data Woodend / ARI data has been removed from this table as vetting dates are frequently missing as a result of the paperbased vetting process. This will hopefully be resolved with the introduction of e-vetting. It is noted that the process appears to be different from that at other hospitals. The longer time taken from when the referral is vetted until it is ready for allocation is made up for by the shorter time from allocation to date offered. - - 12

Eight per cent of OPAs were delayed because patients either Did Not Attend, cancelled or were otherwise unavailable (Fig. 9). A further 3% were delayed because the hospital cancelled the appointments. Fig. 9: First reason for delay to OPA 3 2 1 DNA Clinic cancelled original appointment No delay Patient cancelled original appointment Patient unavailable (includes 'declined appt') The table and graph provide Boards with the opportunity to benchmark their hospitals against other hospitals, identify areas for specific improvement focus, and potentially identify hospitals where examples of good practice can be implemented elsewhere. - - 13

C) Time from Outpatient Appointment to Diagnostics/Review Musculoskeletal (MSk) Audit - RTT Pathways for Surgical CTS Patients Carpal tunnel patients were managed in a number of different ways following their first Outpatient Appointment (Fig. 1). 67% were added to the waiting list for surgery at the first OPA compared to 5% in 21. 28% were sent for Nerve Conduction Studies (only rarely for other diagnostic tests), and were then either reviewed by a further OPA or by phone/letter. The remaining 5% were either reviewed once (but did not have NCS), or were reviewed twice or more (with or without NCS at some stage) (Fig. 1). Fig. 1: Path from Outpatient Appointment to Surgery 1 8 6 4 2 Listed at first OPA - NCS same-day or earlier Listed at first OPA - no NCS * Listed when NCS reviewed - return OPA Listed when NCS reviewed - phone/letter or on day Listed after single review, no NCS Listed after multiple reviews * Four patients were listed at first OPA but also had post-opa confirmatory NCS Fig. 1 highlights the considerable variation in use of Nerve Conduction Studies between centres. In some centres, the majority of carpal tunnel decompressions are performed without Nerve Conduction Studies. It remains controversial as to which patients should have pre-operative Nerve Conduction Studies. In the UK it is generally accepted that not all patients with carpal tunnel syndrome necessarily need pre-operative Nerve Conduction Studies. However, the consensus in the hand surgery community is that Nerve Conduction Studies are an important diagnostic tool and should be available for the assessment of patients with carpal tunnel syndrome. Boards are encouraged to develop NCS guidelines detailing the criteria for which patients would benefit from NCS. - - 14

Of those that were sent for further review or Nerve Conduction Studies only 8% underwent NCS and subsequent review within 4 weeks of the first OPA, and 51% of patients waited more than 12 weeks (Fig. 11). Fig. 11: Length of time from first Outpatient Appointment to first review, including post-ncs reviews by phone/letter 1 8 6 4 2 * * * <=4 weeks 4-8 weeks 8-12 weeks >12 weeks Time is from OPA to first review OPA, or to the date NCS were conducted if the patient was reviewed by phone/letter. Excludes patients who had neither NCS nor a further review * Denotes data based on 3 patients or fewer If a further review appointment was made, 85% of patients with known planned review dates were reviewed on that date. 25 (15%) patients who attended later than the planned date attended a mean of four weeks later. Most delays were due to patients who cancelled or Did Not Attend, but six patients were cancelled by the clinics. Only 14 (2%) of all patients had more than one review clinic without an intervening clockstop (6% of all patients who had diagnostics and/or subsequent review). All 14 patients had two reviews separated by a mean time of eight weeks. This is the part of the pathway that Boards are probably finding the most challenging but where improvements could have the greatest impact. See the next section for further details that will help focus improvement efforts. - - 15

D) Diagnostics Not all hospitals have the facility to undertake Nerve Conduction Studies on site.,,, and carry out all or most of their NCS on site. Some hospitals provide NCS within the Board but at another site (e.g. Lothian, St Johns patients are sent to WGH). All other hospitals have an arrangement with another Board for the undertaking of NCS (indicated on Fig. 14). The mean length of time from when Nerve Conduction Studies were ordered to when they were carried out has decreased from 16 weeks in 21 to 6 weeks in 212. However, the average wait for patients is still in excess of 1 weeks in three hospitals. The longer the average length of time that hospitals had to wait for Nerve Conduction Studies, the less likely they were to request NCS for their patients (n=17 hospitals, r=-.52, p=.3). The distribution of waiting times for NCS is shown in Fig. 12. Fig. 12: Time from date of NCS request to NCS performed 1 8 6 4 2 * * * -4 weeks 4-8 weeks 8-12 weeks 12-26 weeks Missing data * Denotes data based on 3 NCS patients or fewer Fig. 13: Grade of staff who carried out NCS 1 8 6 4 2 * * * Neurophysiologist Technician Other medical staff Not known * Denotes data based on 3 NCS patients or fewer In almost all units, patients who had their NCS carried out by technicians had them carried out more quickly than those carried out by neurophysiologists. In most cases, however a neurophysiologist issues the final report, which may result in further delay unless a technician is working in an extended scope of practice, often within a one-stop clinic. - - 16

Any wait of more than 4 weeks from request of NCS to results becoming available gives a significant challenge to the overall achievement of the 18 Weeks standard for that patient. Overall, less than 25% of journeys are achieving NCS in less than 4 weeks. Most of these are achieved where there are one-stop CTS clinics. Other potential options that may be appropriate in some cases include review by phone or letter rather than an appointment. There may be an opportunity, particularly for those Boards sending patients for NCS to another Board, to set out clear criteria for which patients it is appropriate to refer to either a technician or neurophysiologist depending on patient symptoms as this has a considerable affect on waiting times. For example, Boards sending patients to Lothian are having NCS undertaken by a neurophysiologist for a considerably higher percentage of referrals than Lothian themselves. Once Nerve Conduction Studies were ordered, there were differences in waiting time between the units conducting NCS (Fig. 14). Fig. 14: Time to NCS by hospital and NCS unit where tests undertaken 2 Each triangle colour represents a different unit that carries out NCS: Time to NCS (weeks) 15 1 5 * * * SGH - Glasgow - inhouse WGH - Edinburgh - inhouse - inhouse The position of the triangle indicates the mean time from when NCS were ordered to when they were carried out. Upper and lower lines show the range of time during which 25-75% of NCS were carried out (so 25% were undertaken before the minimum point of the line and 25% were undertaken after the upper point of the line). Each different coloured triangle represents a different NCS unit (i.e. all hospitals with the same colour of triangle carried out most of their NCS at the same unit). * Denotes data based on 3 NCS patients or fewer Although this analysis shows significant improvements since the previous audit (especially at Greater Glasgow and Clyde) both in terms of mean waits and the range of waits, the waits at most locations are still too long to enable patients to achieve the 18 Week RTT standard. Considerable variation in the length of wait within units (e.g. for Borders patients) should also be addressed. Long delays to Nerve Conduction Studies may discourage consultants from ordering them when clinically appropriate. Centres that had a long average length of wait for Nerve Conduction Studies order fewer NCS for their patients (see text above Fig 12). - - 17

The overall time from the first OPA to listing is reduced considerably if the NCS are reviewed without taking the patient back for a return OPA (Fig. 15). However, 84% of patients (Fig. 1) were given the results at a further review OPA rather than by phone or letter. This is probably because most clinicians prefer to review their patients in the clinic to fully discuss the findings of the NCS report. Fig. 15: Median time from first OPA to listing for surgery in relation to post-ncs review method Median time (weeks) OPA to listing 3 25 2 15 1 5 Return OPA Phone/letter Hospitals or categories with fewer than three patients are not shown Also excludes a small number of patients that had multiple post-ncs reviews - - 18

Amongst patients who were listed for surgery when they returned to the clinic for their post-ncs Outpatient Appointment, the average time from NCS to the review OPA was 7 weeks (median=6 weeks). This is again a significant delaying point in the patient pathway. This varied between 4 and 12 weeks between units, and has changed little since 21. 83% of patients had their review OPA within 12 weeks of NCS, but this also varied markedly between units (Fig. 16). Some delay will occur whilst reports are prepared by neurophysiologists, and there may be further delay whilst patients are booked back into a clinic to be given their NCS results. Fig. 16: Time from NCS performed to post-ncs review 1 8 6 4 2 * * * * * * -4 w eeks 4-8 w eeks 8-12 w eeks >12 w eeks Not know n * Denotes data based on 3 NCS patients or fewer Delay in this stage of the pathway is likely to be multi-factorial, involving a combination of administration delays and trying to slot patients into already heavily booked clinics. It would appear that review dates are often booked at the first OPA and often for a significant number of weeks in the future as NCS waits are known to be long and sometimes unpredictable. Much shorter times to post-ncs review could potentially be achieved if the review date was booked as soon as the NCS date was known and for a date soon after the NCS date. This, however, is a significant challenge for the majority of Boards where NCS are booked on separate systems to orthopaedic appointments, particularly where NCS are undertaken at a different Board. Boards are encouraged to use a LEAN approach to this process and share best practice between Boards. - - 19

E) Surgery 84% of patients were operated on within 9 weeks of being added to the theatre waiting list (Fig. 17). Fig. 17: Length of time to surgery after being added to the theatre waiting list 1 8 6 4 2 <=6 weeks 6-9 weeks 9-12 weeks >12 weeks. Table 4: Average component times from Decision for Surgery to Date of Surgery Time from last OPA/diagnostic to date added to theatre waiting list * N Mean (weeks) % > 1 week Time from being added to theatre waiting list to first theatre date booked N Mean (weeks) % > 9 weeks % not operate d on at first theatre date booked Time from first date offered to actual theatre date N Mean (weeks) % > 1 week 36.2 6% 36 7.8 22% 8% 36.1 3% 15. % 15 6.8 % 13% 15.4 13% 27. % 27 4.1 4% 11% 27.4 4% 38.4 11% 38 5.6 18% 5% 38.1 3% 22. % 22 8.1 41% % 22. % 2.3 15% 2 6.6 2% 1% 2.9 1% 56.2 7% 56 5. 18% 16% 56.3 5% 58.2 7% 58 6.6 17% % 58. % 13. % 13 5.2 8% 8% 13.1 % 58.8 19% 58 6.5 7% 14% 58.6 14% 98.1 5% 98 6.1 5% 9% 98.3 8% 27. % 27 7.3 22% 7% 27. % 22. % 22 5.8 5% 5% 22.1 5% 49.1 4% 49 9.8 29% % 49. % 45. 2% 45 6.6 18% 7% 45.1 7% 21.5 14% 21 5.7 14% 1% 21.4 1% 14 1. 21% 14 2.8 % 14% 14.1 7% 619.2 7% 619 6.4 15% 8% 619.2 5% * Includes patients who went straight to theatre waiting list following their first Outpatient Appointment. Some patients were added to the theatre waiting list before their final diagnostics result was available and are included above as being added immediately. - - 2

On average 8% of all patients did not go to surgery on their original booked date (Fig. 18). Fig. 18: Reason for delay from first booked theatre date to actual date of operation 3 2 1 DNA Hospital cancelled No delay Patient cancelled Failed pre-assessment/medically unfit Ninety-eight percent of carpal tunnel patients were operated on as daypatients. Ten patients were treated as inpatients, and nine of these were taken to theatre on the day of admission. This analysis of time to surgery provides information for hospitals to benchmark themselves against other hospitals, identify areas for improvement focus and potentially identify hospitals where examples of good practice can be implemented elsewhere. - - 21

F) Outcome Code recording Each Board uses appointment outcome codes to calculate RTT journey times. In this section we report on how often RTT journeys appeared to have either missing outcome codes or potential discrepancies that could have affected the Board s calculation of the RTT journey time. Throughout this report we calculated journey times using the outcome that should have been applied. This was established by the MSk Audit Local Audit Co-ordinators by further checking of what happened to the patients according to the hospitals electronic systems and casenotes. Fig. 19 indicates that 8% of outcome coding across Scotland appeared accurate for RTT journeys that ended in a surgical clock-stop. 1% had intermediate outcome codes missing but this would not have affected the RTT journey time for this group of surgical patients. Another 5% appeared to have the wrong outcome code applied, but these would not have affected the RTT journey time because they did not stop the clock. However, the remaining five per cent of journeys appeared to have had a code applied that affected the clock-stop date. For this last group the RTT time calculated by the Board would have been shorter than the actual time because a clock-stop had been applied before surgery. Previous data collection by the MSk Audit has shown that inaccurate outcome coding can also result in the Board not stopping the clock when it could have been stopped. However, this is not reflected by Fig. 19 because by definition all journeys reported here were stopped at surgery. Fig. 19: Percentage of journeys with missing Outcome Codes or potential discrepancies with Outcome Codes recorded during the patient pathway 6 4 2 Codes correct Code missing - didn't affect stop Potential discrepancy with code applied - didn't affect stop Potential discrepancy with code applied - affected stop A number of Boards need to continue to work on ensuring that outcome codes are applied at all appointments and which code to apply in which circumstances is well understood to ensure the accuracy of 18 Weeks measurement. - - 22

G) Second procedures Carpal tunnel syndrome commonly affects both hands. Patients often present with bilateral symptoms and having undergone investigations and surgery for the first side they are often placed directly back on the waiting list for a second procedure on the other hand. The length of time to surgery on the second hand was much reduced compared to the first (Figs. 2 & 21) because there is little need for or use of further review appointments or Nerve Conduction Studies (Fig. 22). 75% of patients continuing for carpal tunnel surgery on their other hand were operated on within 9 weeks of being listed (Fig. 2). Fig. 2: Length of time from referral to surgery net of unavailability and clock resets 1 8 6 4 2 Single or first procedure Second procedure (other hand) <=9 weeks 9-12 weeks 12-18 weeks 18-24 weeks 24+ weeks Missing data Fig. 21: Average time spent in each stage of the Referral to Treatment process - first versus second procedures 3 Mean number of weeks 25 2 15 1 5 Single or first procedure Second procedure (other hand) From referral to OPA Diag/review to theatre list OPA to diagnostics/review Theatre list to surgery See Fig. 6 for method of calculation of average times - - 23

Fig. 22: Path from Outpatient Appointment to Surgery - first versus second hands 1 8 6 4 2 Single or first procedure Second procedure (other hand) Added to surgical list immediately - one OPA * Listed after two reviews, no NCS Listed on review of NCS Listed after multiple reviews * For first hands, this would usually be at first OPA; for second hands it would be at the post-op review following the first operation, or on the date of the first operation if there was no review - - 24