The MSK Referral System

Dr Louise PollardConsultant Rheumatologist

Lewisham and Greenwich NHS Trust

•MSK Clinical Assessment Triage and Treatment Service (MCATTS) commissioned to include MCATS and triage element

•Central access point for ALL MSK referrals (orthopaedic and rheumatology) using standardised referral template

•Does not include pain clinic•Referrer indicates referral route which is subject to triage by consultant rheumatologist

•Where secondary care management is appropriate, choice of provider will be offered by the service (GSTT/Kings/QEH/PRUH)

•Service committed to delivering ‘one stop shop’ approach with lower follow up rates across the pathway (although investigations can be undertaken if needed)

Summary of pathway:

REFERRAL FORM

Lewisham - Musculoskeletal Referral Template PLEASE USE THIS REFERRAL FORM TO REFER ALL MSK PATIENTS (16+) FOR SPECIALIST OPINION

THIS INCLUDES ALL ORTHOPAEDIC AND RHEUMATOLOGY REFERRALS Referrals for the Lewisham GP direct access physiotherapy service should be sent using the separate dedicated form

Please indicate your diagnosed referral route by ticking ONE BOX ONLY – THIS WILL BE SUBJECT TO TRIAGE

EMERGENCY CASES

REFER PATIENT TO A&E

Acutely ill patients History of significant, relevant acute trauma or fracture Septic arthritis Symptoms and signs of cauda equina syndrome or cord compression

RED FLAGS

(These patients will be seen urgently in secondary

care)

Systemically unwell e.g. o Suspected malignancy o Suspected acute systemic inflammatory disease o Immune suppressed

New onset back pain aged > 60 years old Inflammatory arthritis: Please describe joints affected Night pain – constant & unremitting

Significantly elevated ESR – i.e. if greater than

2

10Age

Lewisham MSK community assessment and treatment

service (MCATS)

For non complex upper/lower limb and foot MSK problems including hip and knee OA considering joint replacement, localised tendonitis/enthesitis e.g. elbow/shoulder, carpal tunnel, orthotics

Complex and longstanding back pain +/- sciatica (ESR required) For simple back pain and new onset back pain +/- sciatica please

refer directly to physiotherapy

Routine secondary care (Rheumatology)

Connective tissue diseases Osteoporosis Multiple site problems Consideration for referral to Lewisham Centre for Active Lifestyle

Management (CALM)

Routine secondary care (Orthopaedics)

Complications / revisions of previous surgery

NOTE Recent ESR result must be included for ALL back/neck referrals

Referral Details (please specify referral date and associated information for current problem)

Referral Date Referral Date Body part affected (please indicate if current, single problem is affecting multiple sites by ticking all relevant boxes)

Lower limb Hip Knee Ankle Foot Leg (non joint)

Upper limb Shoulder Elbow Wrist Hand Arm (non joint)

Back / Neck Back Neck Other

Reason for referral (This area must be completed as fully as possible to enable an effective triage) Reason for referral and examination findings:

Treatments patient has had before for this condition

Physio MCATS Surgery

Podiatry Analgesia CALM

Injection Therapy Exercise Therapy Other

Referrer Details

Referrer Name: Referring User Referrer Position: Click to Pick

Practice Code: Organisation National Practice Code Practice Address: Organisation Name Organisation Full Address (single line)

Telephone: Organisation Telephone Number Fax: Organisation Fax Number

Aim of Referral Form

• All Musculoskeletal Referrals– Upper limb– Lower limb– Foot– Back– Orthotics– Rheumatology– Orthopaedics

• Separate Physiotherapy Referral Form

MCATTS Upper, Lower Limb and Foot Clinics

• Upper limb clinics– Rheumatologists– Upper limb orthopaedic surgeons– (Extended scope physiotherapist)

• Lower limb clinics– Orthopaedic surgeons

• Foot clinics– Extended scope podiatrists

What is The MCATTS Upper and Lower Limb Clinic Best For?

• Simple, non complex joint and soft tissue conditions– Rotator cuff pathology/Frozen shoulder– Epicondylitis– CTS– Tendinopathies– Consideration of joint replacement

What is Upper and Lower Limb MCATTS Clinic not Good For?

• Complex conditions• Chronic pain syndromes (only chronic spinal pain suitable for

MCATTS)• Patients who have had multiple treatments and been seen in

other departments already or under follow up• Not a suitable clinic ‘for another opinion’• Patients with previous joint replacement or complex surgery

of affected joint• Abdominal and chest pain

MCATTS Foot Service• Aim is a short episode of care which may include:

– Diagnostics– Injection therapy– Provision of orthotics– Referral to other services – physiotherapy, secondary

care – Referral to foot health services for intensive course of

treatment or for on going treatment

MCATTS Foot Service• Extended Scope Podiatrist led service:

• Managed separately from Foot Health Services

• Appropriate patients are those with MSK foot problems and those who may benefit from foot orthotics or footwear

• Designed for patients not already known to Foot Health Services

• For other types of foot problem or urgent access it is more appropriate to refer directly to Foot Health Services

• Referral process to Foot Health Services remains unchanged

Foot Health Referral Guidelinesfor Primary CarePathway Type of Conditions Referral Route

General Podiatry

Skin lesions (corns/callous), Nail pathologies, foot deformities, vascular assessment. People with diabetes identified as ‘at or high’ risk of foot ulceration.Non painful - Musculoskeletal related foot pathologies e.g flat feet., Pes cavus etc

Community Foot Health Service

MSK Foot Painful - Musculoskeletal related foot pathologies MSK Service

Foot Surgery All cases requiring a surgical opinion MSK Service

Ingrowing Toenails Acute ingrowing toenailsWalk in ‘emergency nail clinic’ at the Ladywell Building (South UHL) - every Mon & Thurs 1.30-3.00pm

Minor Foot ulcer / wound

Localised cellulitis Superficial ulceration/wound Minimal purulence Not probing to bone No systemic signs/symptoms of infection

Urgent referral (within 1 working day) to Community Foot Health Service

Significant Foot Ulcer wound/infection

Spreading cellulitis (>5cm) Deep/penetrating ulcers Probing to bone

Immediate referral to the ‘acute foot/diabetic unit’ in the hospital they attend for their diabetes or vascular care.

Limb/life threatening wound/infection

Limb/life threatening infection New/spreading gangrene/extensive necrosis Extensive cellulitis/ lymphangitis requiring IV antibiotics Patient systemically unwell, requiring IV antibiotics

Immediate referral to nearest A&E

MCATTS Back (Spinal) Service

• When to refer directly to physiotherapy

• When to refer to MCATTS

What to Refer to MCATTS?• Complex Spinal Problems ie: with history of previous surgery, with

associated psychosocial issues / high levels of anxiety

• Patients who have had several courses of conservative treatment ie: physiotherapy / other interventions with no improvement

• Patients with persistent / worsening neurological signs where further investigations are indicated

• For advice on further management

• Patients with high levels of distress and anxiety

What to refer directly to GP Direct Access Physiotherapy

• Simple mechanical low back pain

• Back pain with sciatica with minimal / no neurology

• Simple mechanical neck pain• Neck pain with referred symptoms with minimal / no

neurology

MCATTS Back

• Care to avoid giving patient expectation of scan• Include all relevant psychosocial / past medical history

on referral• Helpful to include any clinical / management questions

you have• Avoid duplicate referral

• Not quicker to refer to MSK Backs for physiotherapy if direct access physiotherapy is what is required

What to Put on the Referral Form

• The more information we have the easier and better triage will be.

• MCATTS back (Lower Back and Neck)– Must have ESR available at time of triage– Patients with high ESR cannot be seen in MCATTS– If ESR high consider cause, investigate appropriately– If high ESR felt rheumatological, refer rheumatology– ESR one of most useful discriminators in distinguishing

simple back pain from cancer etc.

What to Put on the Referral Form

• If you are unsure of where the problem is (neck/shoulder)– Give as much information as possible– Patients will get the most out of their appointment if we can triage to

the correct clinic

• If the patient has had surgery on the joint before please give details– Previous replacements and complex reconstructions will be seen in

orthopaedics not MCATTS

• Ensure history of trauma is described

What to Put on the Referral Form

• If the patient has chronic pain please give that information

– Chronic pain syndromes (other than chronic back pain) are not suitable for MCATTS

– These patients take a lot of time to be seen– Cause delay the MCATTS clinic– Better seen in secondary care

Key Messages• All MSK referrals should be made on the MCATTS referral form and sent

through the central MCATTS pathway• Please provide as much information as possible• Please don’t refer chronic pain (except chronic back pain) to MCATTS• Clearly describe history of trauma• ESR required for spinal referrals• Patients should be told to cancel appointments if no longer needed• Please refer one condition at a time (i.e. unconnected problems should be

referred separately as will need to be managed separately)• Please don’t send duplicate referrals to different services

Any Questions