CHICAGO — A new triage system that puts critical information about patients with spinal symptoms before the eyes of a neurosurgeon early in the triage process dramatically improved patient access to neurosurgeons and spine specialists, William D. Tobler, M.D., reported in a poster presentation at the annual meeting of the North American Spine Society.
“It's helped us sift out the patients who really don't need to be seen by a surgeon,” Dr. Tobler, a neurosurgeon at the Mayfield Clinic in Cincinnati, told CLINICAL NEUROLOGY NEWS. “There are patients who have a whiplash injury that are told by their chiropractor to see a neurosurgeon. But when we review the x-rays, it's obvious [these patients] need to be seen by a rehabilitation therapist. It takes 45 minutes to see a patient and if you see six or eight [patients] a week who are clearly nonsurgical, you've occupied a significant part of that surgeon's time.”
The overall surgery rate for all new patients seen by a neurosurgeon has doubled from 22% to 44% since the Mayfield Clinic implemented the new triage system.
Under the “Priority Consult” triage system, intake specialists take scripted medical histories from new patients with spinal symptoms over the telephone and enter the information in a secure database. The patients are told to take any relevant imaging studies to the clinic in advance of any appointment.
Among clinic patients, 90% already have MRI or CT scans available and frequently use couriers, although electronic transmission is gaining ground.
A neurosurgeon then reviews the patient's history and imaging studies, if available, and determines whether the patient should undergo additional tests, receive treatment from a nonsurgical spine physician, or have an in-office consultation with a surgeon. Once the neurosurgeon has noted electronically which step should be taken next, the staff makes the appropriate arrangements for the patient, whether it be tests, treatment, or surgical consultation.
From January 2002 to July 2003, 8,783 new patient histories were entered into the database at the Mayfield Clinic. After the triage system was implemented, 3,213 patients (37%) were seen initially by a spine surgeon, of whom 1,354 (42%) required surgery.
Of 5,570 patients (63%) referred for treatment or nonsurgical evaluation, 4,233 (76%) were discharged without needing a surgical consultation.
Surgeons reviewed medical histories and imaging studies within 72 hours of an appointment request or of receiving the studies, compared with 30 days previously.
The average wait time for an initial appointment with a neurosurgeon decreased from about 6-8 weeks to 20 days, Dr. Tobler said. Because of the streamlined process, the average time it took to review a new spine patient's information also dropped from the previous average of 30-45 minutes to just about 5 minutes.
Of the 5,570 patients initially referred for nonsurgical consultation, 1,337 (24%) were eventually referred back to the surgeon for a surgical consult. Of these, 638 (47%) had surgery.
Not only does the system free up neurosurgeons, but it also takes pressure off primary care physicians, said Dr. Tobler, who is a shareholder in the Mayfield Clinic.
“The process begins to bottleneck for everyone. The primary care physicians start having to deal with patients who are unhappy because they can't be seen for weeks by the doctor they were referred to. This [triage system] gives the referring physicians some satisfaction because the problems are being taken care of,” he said.
Dr. Tobler said the triage system is applicable to smaller practices and is now in use even in three-person practices.