Bateman Marcus, Davies-Jones Gareth, Tambe Amol, Clark David I
Derby Teaching Hospitals NHS Foundation Trust, UK.
BMJ Qual Improv Rep. 2016 Jun 6;5(1). doi: 10.1136/bmjquality.u211254.w4531. eCollection 2016.
Shoulder problems account for 2.4% of GP consultations in the United Kingdom and of those 70% are related to the rotator cuff. Many rotator cuff tears are of a degenerate nature but they can occur as a result of trauma in 8% of cases. Evidence suggests that patients with traumatic rotator cuff tears gain a better outcome in terms of pain and function if the tear is repaired early after injury. A specialist shoulder soft tissue injury clinic was set up in a large UK NHS teaching hospital with the primary purpose in the first year to halve the length of time patients with traumatic rotator cuff tears had to wait to consult a specialist and double the number of patients undergoing surgical repair within three months. The secondary purpose was to ensure that the new clinic was utilised to capacity by the end of the first year. The clinic was later expanded to manage patients with acute glenohumeral joint (GHJ) or acromioclavicular joint (ACJ) dislocations and identify those patients requiring surgical stabilisation. The new service involved referral of all patients presenting to the Accident & Emergency department with recent shoulder trauma and either an inability to raise the arm over shoulder height with a normal set of radiographs, or a confirmed GHJ or ACJ dislocation; to a specialist clinic run by an experienced upper limb physiotherapist. Patients were reassessed and referred for further imaging if required. Those patients found to have traumatic rotator cuff tears or structural instability lesions were listed for expedited surgery. The clinic ran alongside a consultant-led fracture clinic giving fast access to surgical decision-making. The service was reviewed after 3, 6, and 12 months and findings compared to a sample of 30 consecutive patients having undergone rotator cuff repair surgery via the previous pathway. 144 patients were referred to the clinic in the first year: 62 with rotator cuff symptoms, 38 with GHJ instability, 13 with ACJ instability, and 33 others. 7 missed fractures were identified. 12 patients subsequently underwent rotator cuff repair surgery, 10 GHJ stabilisation, and 1 ACJ stabilisation. Mean referral time to first clinical assessment improved from 37 days to 8 days. For rotator cuff repair: mean referral to surgery time was 86 days compared with 115 days on the old pathway. 58% of patients underwent surgery within 90 days of injury compared with 20% previously. Our new service resulted in surgical repair of traumatic rotator cuff tears 29 days faster than the traditional system with an extra 38% of patients having surgery within 90 days of injury - a benchmark thought to improve outcome. Future work will aim to improve this percentage further and include long term patient follow up of outcome measures after surgery.
在英国，肩部问题占全科医生诊疗量的2.4%，其中70%与肩袖有关。许多肩袖撕裂是退行性的，但8%的病例是由创伤引起的。有证据表明，创伤性肩袖撕裂患者若在受伤后早期进行修复，在疼痛和功能方面会取得更好的效果。英国一家大型国民保健服务（NHS）教学医院设立了一家专门的肩部软组织损伤诊所，第一年的主要目的是将创伤性肩袖撕裂患者等待专科会诊的时间减半，并在三个月内将接受手术修复的患者数量增加一倍。次要目的是确保新诊所在第一年年末满负荷运转。该诊所后来扩大到管理急性盂肱关节（GHJ）或肩锁关节（ACJ）脱位的患者，并确定那些需要手术稳定治疗的患者。这项新服务包括将所有因近期肩部创伤就诊于急诊科、无法将手臂举过肩高且有一套正常X光片，或确诊为GHJ或ACJ脱位的患者，转诊至由经验丰富的上肢物理治疗师管理的专科诊所。对患者进行重新评估，必要时转诊做进一步影像学检查。那些被发现有创伤性肩袖撕裂或结构不稳定损伤的患者被安排进行快速手术。该诊所与由顾问主导的骨折诊所并行，能快速做出手术决策。在3个月、6个月和12个月后对这项服务进行了评估，并将结果与30例通过以前途径接受肩袖修复手术的连续患者样本进行了比较。第一年有144名患者被转诊至该诊所：62例有肩袖症状，38例有GHJ不稳定，13例有ACJ不稳定，其他33例。发现了7例漏诊骨折。随后12例患者接受了肩袖修复手术，10例进行了GHJ稳定手术，1例进行了ACJ稳定手术。首次临床评估的平均转诊时间从37天缩短至8天。对于肩袖修复：平均转诊至手术的时间为86天，而旧途径为115天。58%的患者在受伤后90天内接受了手术，而之前为20%。我们的新服务使创伤性肩袖撕裂的手术修复比传统系统快29天，且受伤后90天内接受手术的患者多了38%——这一基准被认为能改善治疗效果。未来的工作将致力于进一步提高这一比例，并包括对患者术后结果指标的长期随访。
