RAPID ACCESS TO INTERVENTIONAL PAIN MANAGEMENT FOR LUMBAR NERVE ROOT PAIN THROUGH COLLABORATIVE INTERPROFESSIONAL PROVIDER NETWORKS

M. Correale¹, D.G. Faclier², D.T. DiRenna², K. Sundararajan³, D.R. Bosma², D.R. Rampersaud³

Background: Low back pain (LBP) is a highly prevalent, poorly managed condition that is the number one cause of years lived with disability worldwide. The Inter-professional Spine Assessment and Education Clinics (ISAEC: www.isaec.org) is a novel multidisciplinary model of care for LBP funded by the Ontario Ministry of Health, in Canada. The model utilizes advanced practice physiotherapists to appropriately manage and triage patients for surgical intervention.  The success of advanced practice physiotherapist triage models are known in orthopedics including the emergency department as well as rheumatology.   However, to our knowledge there is no literature to support such a model for direct referral to injection therapy for pain management.

Purpose: A pilot collaborative agreement between two separately funded programs, ISAEC and the Toronto Academic Pain Medicine Institute (TAPMI), was created to reduce wait-times for targeted nerve injections (NIs).  The purpose of this quality improvement (QI) project was to assess the impact of referral from the Physiotherapy Practice Lead (PL) to NI and determine the impact on
1) wait-times and
2) agreement between the PL and Anesthesiologist for lumbar nerve injections for appropriately selected patients.

Methods: A retrospective review of prospectively collected data from a single ISAEC site. Prior to the ISAEC-TAMPI collaborative approach, ISAEC patients were referred for nerve injections (NI) through existing regional institutional options (interventional radiology or anaesthesia pain clinics). The ISAEC-TAPMI pilot collaborative facilitated dedicated NI slots for ISAEC patients meeting appropriate agreed upon criteria. The following wait-times were collected prior to and after implementation of ISAEC-TAPMI collaboration: 1) Primary Care Provider to ISAEC – community-based Advance Practice Provider assessment (PCP-APP); APP to ISAEC-centralized Speciality Practice Lead assessment (APP-PL); and PL to NI procedure (PL-NI). Descriptive statistics were utilized.

Results: There were 67 and 76 patients in the pre and post-collaboration groups respectively. The average age was 50 years with 40 females in the pre-group; and 57 years with 41 females in the post-group. Mean PCP-APP wait was 19 vs. 21 days and the mean APP-PL wait was 23 vs. 25 days in the pre vs. post group respectively. The mean PL-NI wait was 125 (43-426) vs. 42 (1-120) days in the pre vs. post group respectively. The median PL-NI was 106 vs. 40 days in the in the pre vs. post group respectively. From the perspective of the TAMPI interventional pain specialist, referral appropriateness from ISAEC PL was 98%.

Conclusion(s): Our QI project demonstrates that synergist networked collaborations can improve appropriateness and significantly reduce wait-times for specific limited access interventions. In conclusion, we found the ISAEC-TAPMI partnership improved wait-times for nerve root injections with a high degree of appropriate referrals.  Future considerations include a more formal assessment of the efficiencies and cost-effectiveness associated with advanced practice physiotherapist triage for nerve root injections.  

Implications: Developing collaborative relationships was key to maximizing efficiencies for patients with low back related symptoms, and advanced practice physiotherapists with additional training and competencies can demonstrate high agreement when selecting appropriate patients for nerve root injection.

Funding, acknowledgements: Ontario Ministry of Health - Low Back Rapid Access Clinics (ISAEC)

Keywords: Advanced Practice Physiotherapy, Spine Triage, Injection Therapy

Topic: Musculoskeletal: spine

Did this work require ethics approval? No

Institution: N/A

Committee: N/A

Reason: This was a novel quality improvement initiative to explore a new standard of care to improve service delivery