Authors (including presenting author) :
Chan E (1), Leung K (1), Lee C(2), Leung F(3), Fang C(3)
Affiliation :
(1) Occupational Therapy Department, David Trench Rehabilitation Centre, (2) Occupational Therapy Department, Queen Mary Hospital, (3) Department of Orthopaedics & Traumatology, The University of Hong Kong
Introduction :
For preventing cross transmission of COVID, Allied Health departments were recommended to reduce out-patient visits effective from 29/1/2020. Patients with Distal Radius Fractures (DRF) conventionally demand frequent out-patient treatment sessions and face to face clinical follow up. The Division of Orthopaedic Trauma of Queen Mary Hospital and the Occupational Therapy Department of David Trench Rehabilitation Centre designed a novel patient stratification method and modified rehabilitation programme to facilitate off-site clinical consultation in lieu of conventional practice.
Objectives :
A novel pre-clinic triage method and "off-site" pathway aims at reducing the number of clinic attendances and rehabilitative therapy sessions while increasing patient adherence to intensive home training (IHT). At each pre-clinic triage assessment, therapists measured wrist movement range and grip power and patient filled electronic qDASH questionnaire. qDASH score was graded as above average or below average by the ‘growth’ chart like normative curve designated for DRF. Patient were offered “off-site” consultation if they fulfilled three criteria: Firstly, above average qDASH score; secondly, no active clinical complain; thirdly, willingness to comply with off-site medical consultation. “Off-site” pathway patients were prescribed multimedia instructions for IHT along with reduced therapy sessions. This study aims to determine the efficacy in reducing treatment sessions, face to face consultation and gauge any impact on the clinical outcome.
Methodology :
In a cohort study of surgically repaired adult DRF patients from 2016 to 2020. COVID pandemic (after 1 Feb 2020) affected patients are recruited to follow the new pathway and compared against historical patients. Three epochs were defined for grouping patients. The first epoch (Pre-COVID) had DRF operation dates before 31 Jan 2019. The second epoch (Peri-COVID) had surgery between 1 Feb 2019 and 31 Jan 2020, and the third epoch (COVID) had surgery after 1 Feb 2020. For each epoch we reported and compared three metrics: Firstly, the total number of occupational therapy attendances, secondly their clinical stratification to “off-site” consultation pathway and thirdly their clinical outcomes. The main outcomes are the number of occupational therapy episodes within the first 12 months following surgery and clinical outcomes scores. Including wrist flexion-extension arc, normal grip power fraction and Quick DASH (qDASH) scores were reported at 6 and 12 months.
Result & Outcome :
There were 274 and 169 and 145 patients grouped withing the pre-COVID, peri-COVID and COVID epochs with mean age 63.4, 57.2, 62.0. Peri-COVID epoch significantly younger (ANOVA F2, 574 = 10.106, p < 0.001). Male to female ratio 37%, 30%, 35%, Chi square test indicated no association was found between gender and three epochs (Χ2(4)> 9.042, p = 0.06). The average occupational therapy attendance within the first 12 months post surgery was respectively 48.4, 33.5, 28.3. COVID epoch had significantly difference in low treatment episode among them (ANOVA F2, 574 = 23.348, p < 0.001). Within three epochs there were 9(3.3%), 52(31.4%), 54(37.2%) patients stratified to the “off-site” medical consultation. The 6 and 12-months clinical outcomes for the three epochs were not different except qDASH 6 months. Wrist flexion-extension arc of 3 months (ANOVA, F2,263 =0.253, p=.777) & 6 months (ANOVA, F2,240 = 2.907, p= .057) were no significant different. Normal grip power fraction of 6 months (ANOVA, F2,260 =0.055, p=.946) & 12 months (ANOVA, F2,226=0.508, p=.603) were no significant different. qDASH mean scores at 6 months of three epochs were 19.93, 13.57, 13.58 (ANOVA, F 2,448=7.836, p < .0001) with significant difference in pre-COVID epoch. 12 months qDASH scores (ANOVA, F2,404=1.441, p=..238) with no significant difference. No patient died within the 1 year post-operative period in all epochs.
For patients within each epoch there were strong correlations between the patients 3 months, 6 months and 12 months clinical outcome. Wrist flexion-extension arc(r=.653, p< .0001), grip power fraction(r=.585, p< .0001), qDASH (r=.647, p< .001) There is no significant difference in the correlational coefficients between each epoch.
Conclusion
Our novel pre-clinic triage method and "off-site" pathway with the intensive home traiining programme was effective at reducing approximately 6500 occupational therapy attendance and 115 face to face medical consultation. Implementation of the new pathway did not negatively impact the patients’ outcomes.
