Clinicians from Royal North Shore Hospital (RNSH) are investigating strategies to improve triage agreement between shoulder surgeons and physiotherapists.
Advanced scope physiotherapists are increasingly involved in both the decision-making and triage of referrals to orthopaedic clinics across NSW, helping patients to access timely orthopaedic care. Advanced scope physiotherapists are highly experienced clinicians, often performing tasks historically performed by medical professionals.
Our project examines the independent triage agreement between physiotherapists and surgeons working together in the Orthopaedic Shoulder and Elbow Clinic at RNSH.
A collaborative mode of care
Between 2019 and 2024, RNSH trialled a collaborative model of care called SHoulder/ELbow Triage and Assessment (SHELTA). It involved surgeons and physiotherapists working together to triage and assess patients referred to the hospital’s Orthopaedic Shoulder and Elbow Clinic.
The model:
- successfully reduced waitlists
- improved access to care
- had good clinical outcomes and high patient satisfaction.
Part of the model involved the collaborative triage of referrals to the clinic – where surgeons and physiotherapists triaged incoming referrals together as either urgent or non-urgent, and made decisions regarding appropriateness for physiotherapy care while awaiting surgeon review.
We have undertaken this project to understand whether surgeons and physiotherapists would agree when triaging referrals independently. This is to ensure a high standard of clinical governance and improve the established model of care where possible. Having high levels of agreement could reduce the need for collaborative referral, lead to faster triage processes and free surgeons’ time for other tasks.
Similar services interstate have investigated the agreement between physiotherapists and surgeons on triage and treatment decisions, but this has never been performed in NSW where clinic processes and environments may be different.
Developing clear criteria for triage
We took a sample of historical, anonymised referrals to the Orthopaedic Shoulder and Elbow Clinic, and asked 2 surgeons and 2 physiotherapists who had been involved in the SHELTA model of care to triage referrals based on:
- clinical urgency (i.e. urgent Category 1 referral to be seen within 30 days, or nonurgent Category 2 or 3 referrals to be seen within 90 and 365 days respectively)
- appropriateness for the physiotherapy arm of the SHELTA model of care.
We compared the agreement in triage decisions, and found that when we analysed the results, there was lower agreement than we originally expected.
We have developed several strategies to improve agreement, including:
- developing and adopting clear criteria and triage recommendations – our team participated in the development of the Statewide Referral Criteria for Shoulder Pain and Shoulder Instability led by the Agency for Clinical Innovation
- refining our criteria for eligibility for the physiotherapy arm of the SHELTA program
- placing said criteria within the triage folder so that it was readily accessible at the point of triage
- the project lead running a face-to-face education session informing triaging physiotherapists and surgeons of the above resources.
We then took the original sample of referrals and asked the same 2 physiotherapists and 2 surgeons to triage again after exposure to the implementation strategies.
Triage improved through the use of clear criteria
We found that agreement between all raters improved following the intervention.
- Urgent vs non-urgent decisions – agreement improved from ‘moderate’ pre-intervention to ‘substantial’ post-intervention.
- Category 1/2/3 decisions – agreement improved from ‘fair’ pre-intervention to ‘moderate’ post-intervention.
- Suitability for physiotherapy decisions – agreement improved slightly, remaining ‘substantial’.
We also performed sub-analysis looking at agreement between physiotherapists and agreement between surgeons and found higher agreement between physiotherapists than between surgeons. This work highlights that agreement and consistency in decision-making in orthopaedic triage is improved by the provision of clear triage criteria.
Further work to expand the State-wide Referral Criteria for Orthopaedics, with efforts to implement them into current triage processes across the state, may result in more consistent triage decisions. These criteria may also support allied health and nursing staff in performing advanced scope roles in musculoskeletal models of care, easing burden on orthopaedic surgeons within high volume orthopaedic clinics.
