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Quality improvement changes reduce waiting times for lymphoedema patients

Te Tāhū Hauora Health Quality & Safety Commission
01 October 2019

Changes to the way lymphoedema patients are reassessed for new compression garments at North Shore Hospital’s outpatient physiotherapy lymphoedema service have reduced waiting times by a third.

Lymphoedema is localised fluid retention and tissue swelling caused by a compromised lymphatic system, most commonly seen in an arm or leg. It is a common complication following treatment for cancer, especially when lymph nodes have been removed and/or following nodal radiotherapy. Lymphoedema can also develop as a congenital condition, as a consequence of longstanding venous disease, recurrent cellulitis and, increasingly, obesity.

Because of the elastic nature of compression garments, the greatest benefit is provided in the first six months of daily use. After that, the amount of compression provided lessens, allowing the limb to swell, so patients are reassessed for replacements every six months to ensure adequate control of their lymphoedema symptoms.

Dr Gloria Paterson, Senior Physiotherapist Outpatient, Lymphoedema and Pelvic Health, says the number of referrals to the service for compression garment replacement nearly tripled between 2015 and 2018, from 65 to 191.

‘Each reassessment of these priority 3 patients was being treated as a new episode of care, with a 60-minute time slot allocated to assess them and complete the associated paperwork, which required a full review of their medical history. As demand on the service grew, so did the waiting times for reassessment, from six months to more than nine.

‘Lymphoedema is a life-long condition that has a significant negative impact on quality-of-life for patients following cancer treatment. For many, having their reassessment date delayed meant undue stress and, in some cases, their symptoms worsened.’

The quality improvement project aimed to reduce the number of backlogged lymphoedema garment replacement patients at the end of each month from an average of 17 to less than 5, in order to keep to the six-month reassessment schedule.

Improvements included updating the reassessment paperwork. ‘We established that we didn’t need to take a full medical history at each reassessment appointment, so we now focus on any changes since the patient last presented to the service, which has halved the length of the appointment from 60 to 30 minutes,’ says Gloria.

Administrators, who book patient appointments, were trained in a new telephone screening procedure to determine whether a 30- or 60-minute appointment was needed. One clinician was involved in Waitematā District Health Board’s (DHB’s) ‘Zoom’ telehealth pilot project, so patients suitable for 30-minute assessment appointments are now offered that option.

‘We achieved our outcomes without increasing in clinical resources and there were no unforeseen negative consequences on staff, patient outcomes and experience or the rest of the lymphoedema service,’ says Gloria.

‘In fact, there has been a really positive impact on waiting times for all patients, regardless of priority, since the integration of the new reassessment process. Feedback from patients is that the service flows better and they no longer feel as though they are having to chase reassessment appointments because they are being offered on schedule.

‘The lymphoedema physiotherapists are also able to streamline their time and provide an equitable service to more patients with no impact on clinical practice.

‘Because telehealth appointments can be run out of an office, we can offer our patients more options in a timely manner, while decreasing demands on clinical space.’

She says the vision is to implement the changes across Waitematā District Health Board’s outpatient physiotherapy lymphoedema service, allowing all patients in the catchment to access clinicians, regardless of their location.

‘Waitakere Hospital outpatient physiotherapy lymphoedema service patients are now being recruited to the telehealth option and we’re assessing whether there has been a similar positive impact on the patient experience there.

‘We’re also exploring ways the therapy assistants can perform some baseline measurements and compression garment fitting, to further improve the service.’

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