Carpal Tunnel Syndrome Carpal Tunnel Syndrome A clinical audit of the local service Dr Elena Nikiphorou Dr Adam Young Suzanne Jenkins (Research Assistant)
Dec 26, 2015
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
A clinical audit of the local service
Dr Elena NikiphorouDr Adam YoungSuzanne Jenkins (Research Assistant)
BackgroundBackground
Incidence: 1 per 1000 people/year
Prevalence: 3% population
Gender/age: commoner in F 4:1, peak 45-54 in F, increases with age in M
Pathogenesis: compression of median nerve within the carpal tunnel
ManagementManagement
Clinical CTS
Mild symptoms, no clinical signs
Moderate symptoms &
sensory signs
Severe symptoms/atypical
presentation/uncertain diagnosis
•Simple analgesics•NSAIDs
•Wrist splints•OT
•Weight reduction
Cortisone injection
EMG/NCS
Day case decompression
surgery
Care pathway adapted from Laitner & Young (2004)
Why audit?Why audit? Management varies between different hospitals Delays between symptom onset and treatment
1995 audit with St Albans GPs
(51% did not receive any treatment while waiting for 1st hospital referral)
WHHT 2009/10:
◦ 18 week pathway from GP referral to treatment
Are we achieving this target?Does the one-stop clinic solve the problem?
Referral timesReferral times
GP
Rheuma OPD + NCS/EMG
GP Neuro OPD
NCS/EMGNeuro OPD
Rheuma OPD
NCS/EMG
Ortho OPD
Surgery
GP
Rheuma OPD
Surgery
One stop One stop
Surgery
Ortho OPD
10wks 12wks 14 wks 26wks T=62wks
10wks 20wks T=30wks
12wks 32wks 4wks 10wks 12wks 24wks T=94wks
Jayakumar K. BJR 2006;45(S1):262
1985-1995
1995
One-Stop CTS clinicOne-Stop CTS clinic Introduced at SACH & HHGH in 1995
Clinical assessment (15-30 minutes)
EMG/NCS (15-30 minutes)
◦ Diagnosis ? CTS or not
? Radicular origin e.g. C5/6/7
? Both (“double crush”)
? neuropathy, MND
Further investigations e.g. x-rays C-spine, wrist
ultrasound
Assessment of need for surgery or other treatments
AuditAudit
Source and type of referrals
Times from referral to EMG/NCS to
surgery
Patient satisfaction
Questionnaires sent to 235
patients, seen between 2006-
2010
Graph 1Graph 1: Yearly Total CTS : Yearly Total CTS proceduresprocedures
260286
308
136
0
50
100
150
200
250
300
350
2007 2008 2009 2010
Yearly Total CTS Procedures
Total CTS Proceduresundertaken
Days
Year
Graph 2: MSK referrals 2010
16
45
10
8 8
6
10
1 12
0
2
4
6
8
10
12
14
16
MSK Treat Rheum Referral Ortho Referral Ongoing
MSK CATS Patients with Carpal Tunnel Syndrome
March-April
May-10
Jun-10
Graph 3Graph 3: Times to EMG/NCS clinic: Times to EMG/NCS clinic
0
20
40
60
80
100
120
140
2007 2008 2009 2010
Year
Day
s
360 GP referrals per year
Graph 4Graph 4: Times from EMG/NCS to : Times from EMG/NCS to surgerysurgery
Time from EMG Appointment to CTS Surgery
0
50
100
150
200
250
300
350
2007 2008 2009 2010
Year
Da
ys
Patient satisfaction questionnaire Patient satisfaction questionnaire (PSQ)(PSQ)
Symptom duration prior to EMG/NCS
Symptom severity pre-treatment
Symptom severity post-surgery
Investigations & Treatment
Overall satisfaction
ConclusionsConclusions
A unique service
Cost effective – reduced number of
outpatient clinics (6 to 2!)
Waiting times improved
Improved patient convenience
Improved overall patient satisfaction