Surgical hand hub – safe, efficient and sustainable

By Shamim Umarji
Consultant Orthopaedic Hand Surgeon, St George’s University Hospitals NHS Foundation Trust

Corresponding author e-mail: [email protected]

Published 03 November 2023

The Hand Hub aims to provide safe, efficient and sustainable care for patients with the following High Volume Low Complexity (HVLC) Hand conditions:

• Carpal Tunnel Syndrome (CTS)
• De Quervain’s
• Trigger finger
• Basal thumb arthritis requiring image guided injections
• Ganglia

CTS is a common condition affecting 5% of the population. It can cause numbness, paraesthesia, pain, weakness and loss of function. It is categorised as a ‘priority 2’ condition (must treat within four weeks) by the Royal College of Surgeons of England. Surgical release or carpal tunnel decompression (CTD) provides excellent relief of symptoms for the c.90% of patients. The procedure is safe, clinically effective and further, it is highly cost effective in terms of QALYS (Quality adjusted Life years). A carpal tunnel release provides 0.78 QALYs for approximately £1,000 which is well below the threshold used by NICE to guide NHS commissioning of £30,000 per QALY.

Patients with suspected CTS are reviewed in the hand hub with available Nerve Conduction Study (NCS) results which will have been ordered at virtual triage.  Virtual triage is performed by a Specialist Hand Nurse who ensures that the right patients are seen in the right place.

In the hand hub, patients with positive carpal tunnel results and concordant symptoms are seen, assessed, consented and added to the waiting list for future surgery. Symptomatic patients with negative NCS results are offered either a same day diagnostic steroid injection or USS scanning to look for median nerve compression.

De Quervain’s, trigger digit, and basal thumb arthritis are also common hand conditions which cause pain, stiffness and loss of dexterity and have an effective first line treatment in the form of steroid injections. These are performed on the same day in the hand hub, with (image guidance where appropriate). Steroid injections have an 75% chance of completely resolving symptoms from trigger digit and De Quervain’s, and many patients with basal thumb arthritis will have excellent pain relief following an image guided injection for several months.

Given the effectiveness and good safety profile of steroid injections for trigger finger, De Quervain’s and basal thumb arthritis, further follow-up of these patients is not anticipated. Instead they are discharged with written safety-net advice and patient initiated follow-up is possible if required via a digital patient portal (My Care app).

Minimum staffing for the hand hub comprises a hand consultant, a nurse consultant and a radiologist. The hand hub is geographically sighted away from the main acute hospital which effectively ring-fences elective activity and protects training opportunities for junior doctors.

Hospital visits reduced

Reduction in the number of hospital visits is important and pre-pandemic care pathways were inefficient with all consultations previously being face-to-face. Prior to hub, the model of care for CTS would comprise a total of five face-to-face visits from first consultation to post-operative follow-up.

The hub model comprises an initial telephone consultation conducted by a nurse consultant, followed by first face-to-face consultation in the hand hub, a same day test, same day injection (for appropriate cases) or placement on waiting list. There are three total face-to-face visits (reduced from five).  High volumes of patients with suspected CTS are seen and when upscaled there is a significant reduction in the number of hospital visits. This releases outpatient and theatre capacity for other more complex conditions.

For trigger finger, ganglia, De Quervain’s and basal thumb OA, there is an initial telephone consultation, then a face-to-face consultation in the hand hub and same day USS / injection, and discharge plus digital feedback via a patient portal. Therefore, this is single visit for the vast majority of patients. Pre-pandemic, these patients would have been seen face-to-face and some would have been suitable for same day injection (70%) whilst a proportion would have been be referred for a diagnostic test (second visit), return for result and treatment (third visit) and then a further follow-up to evaluate effectiveness of treatment (fourth visit). Here there is a huge reduction from four potential visits to a single one with digital follow-up.

Avoiding unnecessary surgery

The hand hub is based on established care pathways from BSSH/GIRFT which promote first line non-operative treatments in appropriate cases. This reduces variation in practise and importantly will discourage unnecessary surgery as only patients meeting the threshold criteria are listed for surgery.

Sustainable and efficient model of care

This model has the added advantage of being environmentally sustainable with a significant reduction in carbon footprint compared to pre-pandemic and current care pathways. This is achieved by efficiency in volume, reduction of patient travel (fewer face-to-face consultations), more virtual consultations, reduction of unnecessary surgery through evidence-based care pathways and therefore standardisation of care, same day diagnostics and treatments and ultimately surgery under local or regional anaesthesia (avoiding gaseous anaesthesia), removing unnecessary follow-up and use of digital patient portals to ensure high standards of patient education and communication.

The ambition is to reproduce several hand hubs in the sector as part of ICS working. At present 1,109 nerve conduction studies are performed across the sector per annum with an average waiting time of seven weeks. Each hand hub would perform an extra 672 nerve conduction studies and see an extra 1,680 patients. If 95% of patients required no further follow-up then this in itself would save £239,400 in follow-up alone.

The hand hub allows hand specialists to deliver safe, effective and evidence-based treatment for patients. Patients can be assessed and many are treated on a same day basis, minimising the disruption to their daily working lives with obvious socio-economic benefits.

References

NHS - Carpal tunnel syndrome: www.nhs.uk/conditions/carpal-tunnel-syndrome.

Burke, F. The British Society for Surgery of the Hand (BSSH). The role of hand surgeons is more important than ever. November 2018. Available at: www.bssh.ac.uk/about/news/133/the_role_of_hand_surgeons_is_more_important_than_ever