From Referrals to Results: The Many Faces of Orthopaedic Triage

Dr Angela Cadogan, PhD, NZRPS
​Specialist Physiotherapist (MSK)

"Orthopaedic triage" is becoming a common term in the world of physiotherapy and musculoskeletal care. As healthcare systems evolve to meet the rising demand for elective musculoskeletal and orthopaedic services, orthopaedic triage has found itself in the spotlight.

An increasing number of physiotherapists are working in “orthopaedic triage” roles in elective (non-acute) settings in both the private and public sector. Elective services include anything that is not urgent or emergent. In New Zealand, examples of elective orthopaedic services include community-based ACC funded ICP/ECP pathways, referrals to private orthopaedic services and referrals by GPs to elective orthopaedic services in the public hospital.

​But here’s the issue – the term “orthopaedic triage” doesn’t mean the same thing to everyone. Depending on where you work or who you talk to, "orthopaedic triage" can take on different meanings, leading to confusion and inconsistent practices. A shared understanding of what “orthopaedic triage” is in the elective setting is needed to help us prepare for these roles as they emerge.

In this post, we’ll take a look at what orthopaedic triage is (and isn’t), we’ll explore definitions and why these matter, and review the purpose of triage and some of the factors that shape it. 

​What is Orthopaedic Triage?

Definitions
“Orthopaedic triage” has become one of those buzzwords that everyone is using right now. So, what is “orthopaedic triage”? Here are some definitions from the Merriam-Webster dictionary:

Orthopaedic (ˌɔːθəˈpiːdɪk): “a branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the skeleton and associated structures (such as tendons and ligaments)”

Triage (trē-ˈäzh)-ˌ 1. the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximise the number of survivors. 2. the sorting of patients (as in an emergency room) according to the urgency of their need for care.

Interestingly, there is no universal definition of the combined term “orthopaedic triage” in the elective setting. “Orthopaedic triage” means something different depending on who you ask. And that’s where the confusion sets in. Let’s get some clarity on this.

Orthopaedic Triage
“Triage” is currently being inconsistently described as both the triage of patients, and the triage of referrals. So, which is it?

Triage of patients:
In acute health services, e.g emergency departments, the “sorting and allocation of treatment according to urgency” (see previous definition) is based on an initial brief assessment of the patient by gathering information on symptoms and measuring vital signs on entry to the department.

Triage of referrals:
This differs in elective (non-acute) musculoskeletal and orthopaedic services where ‘optimising survivorship’ is not the issue as the conditions being referred are not life-threatening. In elective orthopaedic settings the “sorting and allocation of treatment according to urgency” is based on information provided in a written referral without any contact with the patient. In this context, the triaging clinician uses the information provided on the referral along with any other available information (e.g patient health records and imaging investigations) to decide on the appropriate clinical pathway and level of urgency.

Referral triage in the elective setting is thus a non-contact procedure that is often used as a pre-cursor a more detailed clinic-based assessment through appropriate clinical pathways that usually occurs days, weeks or months later.

Triage vs Clinical Assessment
Triage of elective orthopaedic referrals does not involve patient contact. This is a distinct and separate role from the clinic-based assessment and treatment planning role that occurs within specific clinical pathways which involves direct contact with the patient.

For example, physiotherapists working in a community clinic might use the term ‘orthopaedic triage’ to describe the process by which decisions are made about whether a patient with a confirmed diagnosis of knee osteoarthritis should be on a non-surgical pathway or needs surgical review based on clinical assessment of the patient. While this is an important clinical decision, this isn’t the same as “triage” (referral management).

In contrast, physiotherapists working in referral management roles within orthopaedic sub-specialty services in secondary care (e.g., Spine, Shoulder, Elbow, and Hand services) are often working with limited or variable information in the referrals, leading to diagnostic uncertainty. These referrals frequently involve complex cases and a high prevalence of serious pathologies, many of which fall outside the physiotherapy scope of practice. These two roles require different levels of clinician competency and involve the knowledge and utilisation of distinct clinical pathways.

The triage clinician in the elective setting is required to make a ‘best-guess’ at possible diagnoses from the (variable) information provided in the referral and allocate the patient to the appropriate clinical assessment service for further differential diagnosis and/or treatment.

Why Clear Definitions Matter
Without clear definitions, it’s easy for confusion to arise – not just among clinicians, but also among patients, employers, funders, and regulators about the role, its’ purpose, practitioner capability and resource requirements.

Clear definitions are important to employers to ensure appropriately skilled clinicians are recruited for specific roles. They are important to physiotherapists to understand the scope, skill and CPD requirements for the role. They are important for regulators to understand scope of practice and to benchmark standards and monitor adverse events. They are important to funders to prioritise funding for greatest value. They are important for politicians to ensure government healthcare priorities are achieved.

Clear definitions thus help ensure that everyone – from clinicians to regulators – understands what orthopaedic triage entails in elective orthopaedic settings. As these roles emerge at the very least, we need context-specific operational definitions for “orthopaedic triage” in elective orthopaedic settings to guide this process.

Now let’s review the purpose of orthopaedic triage and some of the factors that shape it.

The Purpose of Triage
In broad terms the goal of triage is to get the right patient to the right place at the right time by allocating patients to appropriate services for further assessment, diagnosis, and treatment. In doing so, orthopaedic triage services help by:

Managing Wait Lists:
By prioritising patients based on the severity of their condition, clinics can ensure that those in most urgent need receive care as quickly as possible.

Screening and Streamlining Care:
By allocating patients to an appropriate surgical, non-surgical or alternative clinical pathway for further assessment, diagnostic workup, and specific treatment planning. Where a trial of non-surgical management has failed, patients can then be ‘re-triaged’ for surgical assessment. This helps make best use of surgeon clinic time by prioritising patients with the greatest surgical need.

Accessing Treatment:
​In some cases, patients are referred through orthopaedic pathways simply to access treatment services not available to them in the community. Such is the situation in New Zealand at present with a general lack of primary care funding for the non-surgical management of non-accident-related musculoskeletal conditions including physiotherapy treatment and injections.

Effective triage can help reduce unnecessary healthcare costs by avoiding inappropriate investigations and treatment. Effective triage also optimises patient outcomes by minimising downstream negative impacts on health and quality of life that result from delayed access to appropriate treatment.

Key Variables in Orthopaedic Triage
While there are many variables involved in elective orthopaedic triage, here are some of the key variables that influence and shape who, how and where ‘triage’ occurs.

Where Referrals Come From
The source of referrals to elective services influences the information available at the point of orthopaedic triage. Common referral sources include:
- General Practitioners (GPs)
- Other Orthopaedic Specialists
- Physiotherapists
- Nurse Practitioners and other Allied Health Professionals
- Community Cultural Health Centres

The amount and quality of information in the referral can vary depending on the professional background of the referrer, the location and setting in which they work and the diagnostic investigations available to them. This influences the extent to which the triaging clinician can determine a differential diagnosis and therefore allocate an appropriate clinical assessment and treatment pathway. Sometimes the triaging clinician needs to request or obtain more information such as additional imaging to make this decision.

Reason for Referral
The reason for referral plays a big part in determining the knowledge and skill requirements of the triaging clinician. Common reasons for referral include:

Diagnosis and Treatment Planning:
In most cases, patients are referred to orthopaedic services for a musculoskeletal condition either because the diagnosis is unclear, or because the patient is not making adequate progress with non-surgical treatment. The goals are to ensure diagnostic clarity and to access and provide appropriate treatment or onward referral.

Additional Investigations:
Sometimes radiologists make recommendations for further high-tech imaging to characterise lesions seen on routine imaging to exclude serious pathologies such as metastases or other concerning bone lesions. Primary care clinicians often cannot access these investigations and send a referral to orthopaedic services for that purpose. After triaging the referral, the recommended investigation is requested, and results followed up to allocate the patient to the appropriate pathway.

Inter-Orthopaedic Surgical Requests:
Other orthopaedic surgeons in the private or public sector who have already seen and assessed a patient and determined a need for surgery may refer patients to elective services if the planned surgery can’t be performed in the private setting e.g ACC declined funding, or if the surgery can’t be performed within a specific clinical subspecialty or geographic area.

Who Does the Triage?
This can range from single-discipline professionals to multidisciplinary teams (1):

Surgeons:
In more serious cases or when surgery is a likely outcome, surgeons might conduct the triage themselves. This is less common but can be necessary for high-stakes situations.

Physiotherapists:
Increasingly, physiotherapists undertake triage (referral management) in collaboration with a surgeon either on-site or remotely (1).

Multidisciplinary Teams:
Sometimes, triage is a team effort involving surgeons, physiotherapists, nurses, or other allied health practitioners. There may be two or more people involved in the process. This approach is particularly effective in complex cases, ensuring that patients are directed to the most appropriate care pathway. An example of this in New Zealand is the Comprehensive Primary and Community Care Teams recently implemented by Health New Zealand.

The referral source, reason for referral, triage location, setting & personnel all shape the triage requirements in elective orthopaedic settings and represent important factors in triage clinician scope & capability.

Conclusion
Orthopaedic triage in the elective orthopaedic context refers to the triage of paper or electronic referrals and allocation and prioritisation of patients to specific clinical pathways for the purpose of accessing further appropriate diagnostic assessment and treatment planning. As these roles evolve, clear definitions and role descriptions are essential for ensuring appropriate resourcing and funding, identifying key clinical competencies and matching skilled clinicians to the roles. This will help turn referrals into results and lay the groundwork for data-driven evaluation of the impact of triage services on the increasing demand for elective orthopaedic care.

References

1. Morris JH, James RE, Davey R, Waddington G. What is orthopaedic triage? A systematic review. J Eval Clin Pract. 2015;21(1):128-36.

 
Acknowledgements:
Thanks to Mr Khalid Mohammed and Mr Alex Malone for their contributions.