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Advanced Clinical Practitioners in arthroplasty care
Catherine Armstrong and Rachael Daw
Rachael Daw trained as a Physiotherapist at the University of Liverpool and worked for the NHS for nearly 20 years, specialising in care and surveillance for upper limb arthroplasty. Rachael completed a Master’s degree in Advanced Practice in Healthcare in 2016 and went on to be a lecturer in Advanced Clinical Practice at the University of Liverpool, before joining the RCP in 2022 where she is now a Senior Educationalist.
Over the last decade, demand for joint arthroplasty surgery in the UK has increased significantly. In many centres, Advanced Clinical Practitioner (ACP) roles, typically fulfilled by specialist nurses or physiotherapists, have been developed to alleviate service pressures and enhance outcomes for the growing number of patients undergoing arthroplasty surgery. ACPs in arthroplasty care are involved across the entire patient journey, requiring expertise across the four pillars of advanced clinical practice.
The National Joint Registry for England, Wales and Northern Ireland (NJR) has recorded significant increases of hip, knee and shoulder replacements over the last decade [1], trends which are also reflected in the Scottish Arthroplasty Project [2]. Increasing numbers, coupled with pressures on services, have meant that new models for providing care for these patients are essential to improve equitable access to services and reduce waiting times.
Arthroplasty clinics where ACPs substitute for surgeons for routine post-operative care, were originally pioneered in the UK in the 1980s and have since been replicated worldwide with the aim of reducing pressure on surgeon-led services. Evidence suggests that these ACP clinics are safe and effective, and patient satisfaction is equal to that for surgeon-led clinics [3-6]. Most ACP led clinics have primarily targeted patient cohorts undergoing lower-limb arthroplasties, however more recently specialist ACP-led services for shoulder and elbow arthroplasty have developed to meet emerging demands.
ACP-led arthroplasty care is largely fulfilled by advanced practice physiotherapists and advanced nurse practitioners [3,4], as illustrated by the membership of the Arthroplasty Care Practitioners Association (ACPA) [7], see Figure 1.
To our knowledge, there are no studies that have investigated the relative advantages of either of the parent professions, and the decision of who to employ in these roles would appear to be dependent on the local service requirements. Regardless of parent profession, the role domains of the ACP in arthroplasty care including clinical practice, leadership, research, and education and professional development [4] define a skill-set clearly commensurate with the four pillars of Advanced Clinical Practice set out in the Multi professional Framework (MPF) for Advanced Clinical Practice [8].
Clinical practice
Pre-operative care
Post-operative inpatient length of stay has decreased significantly in recent years due to the evolution of rapid recovery protocols. These protocols place a greater burden on service requirement for pre-operative care to ensure that timely and safe discharge will be possible. In many UK centres, ACPs are often responsible for pre-operative assessment of patients to evaluate their fitness for surgery, provide necessary education regarding procedures and post-op protocols, make referrals for post-operative care packages and rehabilitation, and support discharge arrangements. In some centres (with appropriate training) ACPs may also consent patients for surgery.
Peri-operative care
In 2012, the Peri-operative Care Collaboration defined roles for non-medically qualified professionals including Surgical Care Practitioners (SCP) [9]. SCPs are registered healthcare professionals who have extended their scope of practice to work as members of the surgical team. Under the supervision and direction of a consultant surgeon (but not independently) they can perform surgical intervention in addition to pre-operative and post-operative care [10]. Currently the extended role of the SCP continues to develop and may be fulfilled by ACPs.
As with all ACP roles, SCPs must ensure that they remain within the limits of their competence, skill, and experience [11,12] and within their scope of practice where this has been defined. ACPs must therefore have the requisite experience and education to demonstrate satisfactorily their competency in the appropriate areas of surgical practice.
Post-operative care
ACPs contribute to all stages of postoperative care from early review to long-term surveillance. The role of the ACP includes patient assessment, physical examination and ordering routine imaging as well as any additional investigations such as blood tests or ultrasound scans. ACPs can also facilitate effective communication between the surgical team and other healthcare providers and, where they have evaluated the need, referral to other services
To independently fulfil the service and care requirements of patients undergoing arthroplasty surgery ACPs require advanced clinical skills and expertise in relevant musculoskeletal assessment, along with evaluation of investigations. Specialist training in image interpretation is often a requirement for individuals undertaking such roles. Currently in the UK there is no specified or standardised educational route to competency in the specialised skills required for ACP in arthroplasty care, however, ACPA have developed a competency framework, that may provide guidance on training for the role, and also run bespoke image interpretation courses to facilitate practitioner learning [7].
One of the key purposes of long-term review clinics in arthroplasty care is to identify complications, particularly in asymptomatic patients and instigate risk management as necessary [13]. It is therefore vital that the ACP working autonomously in this scenario understands the scope of normal presentations and the presentation of possible complications, which may or may not be symptomatic, includin infection and aseptic prosthetic loosening. ACPs can effectively identify when patients need orthopaedic consultant review, and therefore have the potential to initiate early investigation and treatment of complications [3,5]. Effective management of patients with identified complications relies on clear and efficient pathways between the ACP and consultant services.
Research
As well as the opportunity to review clinical progress, clinical encounters offer an opportunity to evaluate outcomes and collect data [14]. ACPs in arthroplasty care are often responsible for essential data collection, contributing to clinical trials and working with industry and joint registries to inform evaluation and development of prostheses and procedures. Data collection might include a variety of objective clinical measurements and patient reported outcome measures (PROMS) which the arthroplasty ACP must be competent in implementing and evaluating. The ACP may also inform patients about potential research projects, consent patients for participation and collect data for research outcomes. To support this the ACP must have knowledge and competency with research procedures, ethics and governance, requiring training such as the NIHR’s Good Clinical Practice [15].
Education
The Multi–Professional Framework for ACP [8] promotes an advanced skill set encompassing four pillars of advanced practice which should be at Masters Level or equivalent. Self-awareness and reflection are essential for the individual to recognise their own learning needs to satisfy the specific requirements of their role. Supervision from experienced colleagues and support for continued professional development are also critical for developing the novice to meet the ACP requirements and for sustained development throughout their career. Voluntary membership of special interest groups can also provide networking and development opportunities, educational and support (see Table 1).
Experienced arthroplasty ACPs are experts in the field with breadth and depth of clinical and professional knowledge related to their area of practice. Due to their unique position, working almost exclusively with a specific patient cohort, these ACPs rapidly gain extensive ‘patient mileage’ and are at the forefront of clinical and policy developments, making them well placed to offer education and advice to patients, junior colleagues, and the extended MDT.
Leadership and management
The ACP with responsibility for arthroplasty clinics must ensure that the services offered are in keeping with local and national guidelines and that patients can make contact with appropriately skilled professionals in the right place, at the right time.
It is acknowledged that leadership is not just about service management, but should also encompass clinical and professional leadership, as well as leadership in health policy and health systems [16]. In the arthroplasty community there are several examples of ACP-led regional and national developments and contributions to national policy demonstrating the potential impact of this influential group of professionals.
Future developments and challenges
There is ongoing debate in orthopaedic communities regarding the long-term follow-up of patients following arthroplasty surgery, in terms of the frequency, duration, location and personnel involved in reviewing patients, and recent guidelines from the National Institute for Clinical Excellence (NICE) [17] were inconclusive in providing firm recommendations. Despite these challenges, it is understood that follow-up is essential and ACPs can have an important role in providing efficient best quality services for patients. For many years there has been a move towards providing a virtual clinic model for routine arthroplasty follow-up care [14]. This enables patients who have uncomplicated arthroplasty to have a remote appointment, and X-ray, without attending for a face-toface consultation. ACPs are ideally placed to provide this virtual link and to provide a triaging portal for patients to get in touch if they have concerns.
Conclusion
Advanced practice roles in arthroplasty care have been long established and are frequently fulfilled by nurses or physiotherapists. The ACP in arthroplasty care will require a skill set that encompasses expertise across all four pillars of the HEE framework [8] and in many cases will develop beyond the level of expert to influence patient care. The ACP is integral to patient experience throughout all stages of their journey and will continue to be vital to the delivery of efficient and cost-effective services as they evolve in the future.
References
References can be found online at www.boa.ac.uk/publications/JTO.
