Referral-to-Treatment for Surgical Carpal Tunnel ... - 18 Weeks

Referral-to-Treatment for Surgical Carpal Tunnel Syndrome 

patients 

A Report from the Musculoskeletal Audit 

Interpretive text in blue from David Lawrie (Consultant Orthopaedic and Hand Surgeon, Aberdeen 

Royal Infirmary) and Tim Hems (Consultant Hand and Orthopaedic Surgeon, Greater Glasgow and 

Clyde) 

This report is the second in a series of sprint audit reports looking at different orthopaedic 

conditions from the Musculoskeletal Audit (MSk) and looks at referral to surgery data for patients 

undergoing surgery for Carpal Tunnel Syndrome (CTS). 

The carpal tunnel syndrome audit period ran for 14 weeks from 5th January to 9th April in all reported 

hospitals, and for up to twelve weeks before this in selected hospitals to increase sample sizes. We included 

all patients listed for an elective carpal tunnel release. MSk Local Audit Co-ordinators collected data from 

patient case notes, patient information systems, results reporting and referral management systems. 

We are aware that many CTS patients are not treated surgically, and that pathways may differ 

between units. Here we only include CTS patients treated surgically, because such patients were 

readily identifiable at the point of treatment. However, we also identified all new CTS referrals during 

the audit period (January 5th to April 9th) for a subsequent audit later in the year which will also 

include non-surgical patients. 

This report is not intended to assess hospitals and waiting times, and does not take into account ‘stops’ 

that are beyond a hospital’s control (e.g. delays caused by patient preference). It is intended as a tool for 

management, to help managers and clinicians identify areas where Referral to Treatment delays are 

occurring and/or may be minimised. 

Executive Summary 

• Carpal tunnel is a common condition with up to 10% of the population having symptoms 

• There are large variations in the waiting times and pathways for the management of carpal 

tunnel syndrome 

• The waiting times from referral to OPA and the surgical waiting times are similar between 

units 

• There are significant variations in the frequency and waiting times for preoperative Nerve 

Conduction Studies between centres 

• Some centres have major delays (of up to a year) accessing neurophysiology services 

Please send comments and queries to either 

Jane Campbell 01463 705850 

MSk Clinical Co-ordinator jane.campbell7@nhs.net or 

Rik Smith 0131 275 7040 

MSk Senior Analyst 

rsmith11@nhs.net

Musculoskeletal Audit (MSk) - Carpal Tunnel Surgery 

How to use this report 

The Referral to Treatment period of surgical CTS patients is summarised on an individual hospital basis, 

firstly (A) for the whole period from Referral to Treatment, then in more detail for the constituent parts of 

this process: 

B Referral to Outpatient Appointment (OPA) 

C OPA to Diagnostics/Review 

D Diagnostics 

E Surgery 

Note that not all patients followed a conventional path from referral to outpatient appointment, subsequent 

diagnostics and review to surgery (e.g. patients could be referred into the system to an NHS hospital from a 

private clinic). Also, some dates for various parts of the patient journey (particularly vetting and allocation 

dates) were not always available. This explains variation in sample sizes across the report. 

The 18-week Referral to Treatment target does, of course, allow for clock-stopping for circumstances 

beyond a hospital’s control. Allowing for all such patient-centred delays was beyond the remit of this audit, 

although some summary data are included. Inspection of the constituent parts of the patient referral-tosurgery 

period should reveal the main limiting steps in each unit, but, if it would be useful, please ask us to 

select or break down your information further. 

During the audit period the Local Audit Co-ordinators achieved a near 100% inclusion rate of carpal tunnel 

release patients in most participating hospitals (Table 1). Almost all Carpal Tunnel surgery was carried out 

by the Orthopaedic specialty, except in StJohns/RIE (98% by Plastics) and ARI/Woodend (24% by 

Neurology/Neurosurgery). 

Table 1: Number of patients reported on 

Hospital Audit period * 

Number of surgical CTS 

patients identified in 

report period in each 

hospital 

Number of surgical 

CTS patients included 

in this report* 

Wishaw Oct 2009-Apr 2010 32 32 

GRI / Stobhill Oct 2009-Apr 2010 80 80 

DGRI / Garrick Oct 2009-Apr 2010 67 67 

QMH / Victoria Jan 2010-Apr 2010 101 101 

Elgin Nov 2009-Apr 2010 32 32 

Borders Oct 2009-Apr 2010 69 69 

Ninewells / Stracathro ** Jan 2010-Apr 2010 94 94 

RAH/VOL Nov 2009-Apr 2010 91 91 

ARI / Woodend Jan 2010-Apr 2010 91 90 

Perth Jan 2010-Apr 2010 25 25 

Monklands *** Oct 2009-Apr 2010 54 54 

Hairmyres Oct 2009-Apr 2010 107 107 

St Johns / RIE Jan 2010-Apr 2010 187 178 

Raigmore Oct 2009-Apr 2010 73 71 

Inverclyde / Dunoon Oct 2009-Apr 2010 59 59 

Forth Valley Oct 2009-Apr 2010 68 68 

Total 1230 1218 

* End of Audit period was 9th April 2010 for all hospitals 

** Includes 9 patients originating at Ninewells who were operated on at PRI 

*** Includes 5 patients originating at Monklands who were operated on at Hairmyres 

Patients sent to Golden Jubilee National Hospital for surgery between October and 9th April (57 altogether, including 43 

from Lothian HB and 9 from Dumfries and Galloway) are not included in Table 1 or in other sections of this report. 

Data from Ayrshire and Arran was less complete than for other hospitals and is not included in this report 

- - 2

A) Summary of overall period from Referral to Treatment 


Although many patients are referred or diagnosed with bilateral carpal tunnel syndrome, the patient 

pathway (and consequently the length of time from referral to treatment) varies significantly between 

treatment for first and second procedures. Due to these differences, all data contained in parts A-E 

of this report pertain to the hand treated first, unless there was a considerable time gap before the 

second hand necessitating a completely independent diagnosis and treatment cycle. Second/subsequent 

procedures that followed on immediately after treatment of the first hand (15% of all carpal tunnel 

operations) are detailed separately in part F. 

Fig. 1: Length of time from referral to surgery - all patients 

Percentage of patients 

100 

80 

60 

40 

20 

0 

Wishaw 

GRI/Stobhill 

DGRI/Garrick 

QMH/Victoria 

Elgin 

Borders 

Ninewells/Stra 

RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

1 year Missing data 

Missing data occurred if referral date was not known, often from an unconventional source (e.g. referral from a review of 

another treatment, or straight to Nerve Conduction Studies or a private patient listed for surgery) 

Fig. 1 includes 273 (26%) patients who had indicated that they were unavailable at some stage between 

referral and surgery. If unavailable at some stage, documented unavailability averaged 45 days (median=32 

days), and 100 (10%) patients were known to be unavailable for more than six weeks. 

Only 11% of patients who had indicated that they were unavailable at some stage between referral and 

surgery were treated within 18 weeks, compared to 28% of patients who were available throughout. Fig. 2 

reports the percentage of patients who met the 18-week Referral to Treatment target after excluding these 

unavailable patients. 

Fig. 2: Length of time from referral to surgery - excluding patients who were unavailable at some 

stage during this period 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 


- - 3


Altogether 38% of all patients had some patient-centred delay (unavailability; cancelled OPA, review or 

surgery; did not attend OPA, review or surgery; declined appointment; medically unfit for theatre; Fig. 3). 

These patients took a median of 35 weeks from referral to surgery, compared to 22 weeks in patients with no 

documented patient-centred delay. 

Fig. 3: Percentage of patients with some documented patient-centred delay (see text for definition) 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

As with the arthroscopy report, Fig. 3 shows that a substantial number of patients fail to attend or elect to be 

“unavailable” at some point in the patient pathway and that unavailability rates continue to vary widely across 

the country. 

- - 4


Fig. 4: Average time spent in each stage of the Referral to Treatment process - all patients 

Mean number of weeks 

50 

40 

30 

20 

10 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

From referral to OPA 

Diag/review to theatre list 

OPA to diagnostics/review 

Theatre list to surgery 

NOTES 

• Times are means for each stage for patients whose data was available 

• Time from OPA to diagnostics/review is to the first review clinic, or the date the diagnostic (NCS) was performed if the patient 

was reviewed by phone or letter 

• Time from diagnostics/review to the date the patient was added to the theatre list is time from first review, and may have 

included subsequent reviews/diagnostics 

• If patients were added to the theatre list at the initial OPA, and were not referred for diagnostics or a subsequent review 

(approximately half of all patients), OPA to diagnostics/review was included as 0 weeks (SO AVERAGE REFLECTS NUMBER 

WHO HAD NCS AS WELL AS AVERAGE WAIT OF THOSE WHO HAD NCS - SEE LAST BULLET), and diagnostics/review 

to theatre list as the time between the initial OPA and the date the patient was added to the theatre list. 

• A small number of patients had diagnostics/reviews after they were apparently added to the theatre list. These were excluded 

from calculation of time from diagnostics/review to theatre list 

• The ‘mean’ time for OPA to diagnostics/review includes many patients who were added to the waiting list for surgery at the 

initial OPA (i.e. time from OPA to diagnostics/review=0 weeks). Therefore the actual distribution of times from OPA to 

diagnostics/review is not reflected by the mean, and may be skewed by a small number of long waiting times, OR BY A 

LARGE NUMBER OF PATIENTS WHO WERE NOT SENT FOR NCS. 

Note that the above figure will not show patient preference delays. For example, some clinics/waiting lists 

may phone patients to offer a choice of dates for OPA or surgery, and the only data available to the MSk 

Audit was the date accepted. 

Note that the time spent waiting from referral to outpatient clinic and on the theatre waiting list is 

relatively similar between centres. However, there is significantly more variation between centres in 

time spent waiting for diagnostic investigations (Nerve Conduction Studies), and also the time taken 

from Diagnostics/Review to being placed on the surgical waiting list. The availability and waiting 

time for neurophysiology investigations will play a major factor in these differences. The use in some 

centres of one-stop carpal tunnel clinics with on-site Nerve Conduction Studies will eliminate the 

wait from OPA to Diagnostics/Review. 

- - 5


B) Referral to Outpatient Appointment 

92% of 1021 patients with documented length of time from Referral to Outpatient Appointment were seen 

within 15 weeks (Fig. 5). However, a large proportion of patients waited for 10 to 15 weeks before their 

Outpatient Appointment, leaving little time in the proposed 18 week pathway for investigations 

and/or treatment to occur. 

Fig. 5: Length of time from Referral to Outpatient Appointment 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

15 weeks Missing data 

Fig. 5 includes all patients irrespective of any reason for delay, and reflects the 15-week target for referral to Outpatient 

Appointment in operation at the start of the audit period. Comparison against the 12-week target times which came into 

place in March 2010 are available on request 

Although it was usually possible to find out who vetted patients and the vetting outcome, in many hospitals 

first vetting date was often unavailable (Table 2). This may improve with the introduction of e-vetting in some 

sites, and recording of vetting dates by whichever method has increased from 42% during the arthroscopy 

audit to 61% during the CTS audit period. Amongst patients whose vetting times were known, 91% of 

patients were vetted within a week (Table 2). 

Table 2: Average time from Referral to First Vetting 

% of patients whose vetting 

dates was documented 

Number of patients 

documented 

Referral to vetting 

Mean 

(weeks) 

% > 1 

week 

Wishaw 0% 0 - - 

GRI/Stobhill 92% 60 0.0 0% 

DGRI/Garrick 100% 64 0.0 0% 

QMH/Victoria 65% 51 1.4 53% 

Elgin 21% 5 0.0 0% 

Borders 96% 55 0.0 0% 

Ninewells/Stracathro 28% 22 0.4 5% 

RAH/VOL 28% 20 1.2 50% 

ARI/Woodend 7% 4 * * 

Perth 89% 17 0.2 0% 

Monklands 78% 31 0.9 19% 

Hairmyres 21% 19 0.8 16% 

St Johns/RIE 96% 146 0.1 1% 

Raigmore 89% 55 0.1 0% 

Inverclyde/Dunoon 66% 31 0.6 0% 

Forth Valley 37% 20 0.7 15% 

All patients 61% 600 0.3 9% 

* Data omitted if based on fewer than 5 patients 

- - 6


Hospital vetting policies vary considerably (Fig. 6). Fig. 6 also highlights the ongoing problem of poor 

documentation of the vetting process in some sites. If known, almost all patients originally vetted by 

clerical staff were subsequently vetted by medical staff. The overall time from referral to surgery was 

shorter if patients were first vetted by medical staff compared to ESPs or clerical staff (median 21 weeks 

compared to 29 or 33 weeks). When known, 83% of patients who were vetted twice were second-vetted 

within a week. 

Fig. 6: Who first vetted patients post Referral 

100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 


Medical staff ESP Clerical staff Not vetted Missing data 

53% of patients who were not vetted were unscheduled referrals (e.g. from ED). Others included patients going on to 

have Carpal Tunnel surgery following referrals or reviews for other procedures. 

As expected, much of the time elapsed between Referral and Outpatient Appointment occurred whilst the 

patient awaited their offered OPA date. The average wait from the date the OPA was ready for allocation to 

the date offered for OPA was 7.8 weeks, but many hospitals had a considerable proportion of patients who 

waited more than eight weeks (Table 3). 

Table 3: Average times from Vetting to Outpatient Appointment 

Vetting to Ready for 

Allocation 

N 

Mean 

(weeks 

) 

% > 8 

week 

s 

N 

Allocation to Date 

Offered 

Mean 

(weeks) 

% > 8 

weeks 

Date Offered to OPA 

attendance 

N 

Mean 

(weeks 

) 

% > 8 

week 

s 

Wishaw 0 - - 26 10.9 92% 27 0.0 0% 

GRI/Stobhill 59 0.3 0% 65 10.8 75% 66 1.7 5% 

DGRI/Garrick 64 0.6 0% 65 7.3 51% 65 0.1 0% 

QMH/Victoria 50 5.1 10% 78 3.9 5% 79 0.3 0% 

Elgin 6 0.0 0% 25 7.6 36% 26 0.5 4% 

Borders 55 0.0 0% 59 8.9 61% 62 0.9 3% 

Ninewells/Stracathro 22 2.3 5% 76 4.0 3% 84 0.4 1% 

RAH/VOL 20 0.4 0% 75 7.2 48% 80 0.5 0% 

ARI/Woodend 2 * * 43 6.0 9% 66 0.4 2% 

Perth 17 0.3 0% 17 10.9 76% 18 0.6 0% 

Monklands 31 0.0 0% 42 10.5 86% 42 0.7 2% 

Hairmyres 19 0.0 0% 99 10.1 82% 100 0.5 4% 

St Johns/RIE 144 2.3 5% 145 8.8 77% 148 0.6 3% 

Raigmore 56 0.1 0% 60 9.1 65% 61 0.4 0% 

Inverclyde/Dunoon 31 3.6 3% 42 4.2 2% 46 0.8 2% 

Forth Valley 20 0.0 0% 44 7.4 39% 54 0.1 0% 

All patients 596 1.4 2% 961 7.8 51% 1024 0.6 2% 

* Data omitted if based on fewer than 5 patients; sample sizes vary between columns due to availability of data 

- - 7


Nine per cent of OPAs were delayed because patients either Did Not Attend, cancelled or were otherwise 

unavailable (Fig. 7). A further 2% were delayed because the hospital cancelled the appointments. 

Fig. 7: First reason 

for delay to OPA 


30 

20 

10 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

No delay 

Unknown reason 

Patient unavailable (includes 'declined appt') 

Clinic cancelled original appointment 

Patient cancelled original appointment 

Did Not Attend 

Excludes 17 patients whose offer date for OPA was unknown, or who were referred directly for diagnostics or surgery 

without a conventional OPA (e.g. after review for a different condition, or from private clinics for NHS treatment, etc) 

Borders General Hospital had higher than usual cancelled clinics in the audit period due to temporary staffing difficulties 

- - 8

C) Time from Outpatient Appointment to Diagnostics/Review 


Carpal tunnel patients were managed in a number of different ways following their initial Outpatient 

Appointment (Fig. 8). 50% were added to the waiting list for surgery without further diagnostic tests or further 

review. 39% were sent for Nerve Conduction Studies (only rarely for other diagnostic tests), and were then 

either reviewed by further OPA or by phone/letter. Most of the remaining 11% were referred for continuing 

management, treatment or to other clinicians, and were reviewed by further OPA prior to surgery (Fig. 8). 

Fig. 8: Path from Outpatient Appointment to Surgery 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

Added to surgical waiting list at OPA 

NCS - reviewed by phone/letter 

Other 

NCS - reviewed by further OPA 

No NCS, but further review OPA 

‘Other’ encompasses a number of patients with unusual paths to surgery, including some private patients, those who left 

their OPA to consider options before getting back in touch, reviewed by letter without an OPA, or sent for diagnostics but 

cancelled and added straight to list 

Fig. 8 highlights the considerable variation in use of Nerve Conduction Studies between centres. In 

some centres, the vast majority of carpal tunnel decompressions are performed without Nerve 

Conduction Studies. It remains controversial as to which patients should have pre-operative Nerve 

Conduction Studies. In the UK it is generally accepted that not all patients with carpal tunnel 

syndrome necessarily need pre-operative Nerve Conduction Studies. However, the consensus in the 

hand surgery community is that Nerve Conduction Studies are an important diagnostic tool and 

should be available for the assessment of patients with carpal tunnel syndrome. 

- - 9


Of those that were sent for further review or Nerve Conduction Studies only 55% were reviewed 

within 15 weeks (Fig. 9). 

Fig. 9: Length of time from Outpatient Appointment to Diagnostics/Review 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 


Time is from OPA to first review OPA, or to date of NCS if patient was reviewed by phone/letter. Excludes patients who 

had neither NCS nor a further review 

- - 10


Fig. 10 clearly shows that there is a considerable delay associated with Nerve Conduction Studies. 

Fig. 10: Median time from OPA to Review in relation to whether NCS were carried out and review 

method 

Median time (weeks) to review 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 


NCS, reviewed by phone/letter 

NCS, reviewed by further OPA 

Time is to first review or to date of NCS if reviewed by phone/letter. For some hospitals there were fewer than three 

patients in one or more categories in Fig. 10, so data is not shown 

If a further review appointment was made, 85% of patients with known planned review dates were reviewed 

on that date. 55 (15%) patients who attended later attended a mean of 6 weeks later. Most delays were due 

to patients who cancelled or Did Not Attend, but 14 patients were cancelled by the clinics. 

Thirteen per cent of all patients had more than one review clinic (27% of all patients who had diagnostics 

and/or subsequent review). Of the 88 patients known to have two reviews, mean time between reviews was 

16 weeks (median 13 weeks). 50 patients had more than two reviews and a mean time of 38 weeks between 

first and last reviews (median 32 weeks). 

Although Fig. 10 shows that the time from OPA to review is shorter when Nerve Conduction results 

are given by telephone or sent out by letter, many clinicians prefer to review their patients in the 

clinic to fully discuss the findings of the NCS report. 

- - 11


D) Diagnostics 

The mean length of time from when Nerve Conduction Studies were ordered to when they were carried out 

was 16 weeks, but this varied greatly across hospitals (0-63 weeks). The distribution of waiting times for 

NCS is shown in Fig. 11. 

Fig. 11: Time from date of NCS request to NCS performed 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

0-8 weeks 8-16 weeks 16-25 weeks 25-50 weeks 

>50 weeks Missing data 

Within any particular hospital, Nerve Conduction Studies tended to be done either inhouse or offsite. GRI, 

QMH, Ninewells, ARI and Raigmore carried out NCS inhouse. All other hospitals carried out NCS mainly 

offsite. Neurophysiologists carried out the majority of NCS for many units (Fig. 12). 

Fig. 12: Grade of staff who carried out NCS 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

Neurophysiologist Technician Other medical staff Missing data 

In most units, patients who had their NCS carried out by technicians had them done more quickly than those 

carried out by neurophysiologists. However a neurophysiologist will still need to issue the final report, which 

may result in further delay. 

- - 12


Once Nerve Conduction Studies were ordered, there were significant differences in subsequent waiting time 

between the units conducting NCS (Fig. 13). 

Fig. 13: Time to NCS by hospital and NCS unit 

Time to NCS (weeks) 

80 

60 

40 

20 

0 

Each triangle colour represents a 

different unit that carries out 

Wishaw 

RAH/VOL 

Monklands 

Hairmyres 

IRH/Dunoon 

Elgin 

ARI/Woodend 

Raigmore 


Perth 

DGRI/Garrick 

Borders 

St Johns/RIE 

Forth Valley 



Triangles are the mean time from when NCS were ordered to when they were carried out. Upper and lower lines show 

range of time during which 25-75% of NCS were carried out (so 25% were done before the minimum point of the line and 

25% were done after the upper point of the line). Each different coloured triangle represents a different NCS unit (i.e. all 

hospitals with the same colour of triangle had NCS done at the same unit). 

It appears that in units where Nerve Conduction Studies are carried out by a neurophysiology 

service covering several hospitals that there are longer waiting times. This would suggest that in 

these areas the neurophysiology service is not currently sufficient to cover the work load. Is one way 

of easing this problem by increasing the amount of technicians available to assist the 

neurophysiologists and a more robust referral and triaging system in place to determine which grade 

of staff is required to carry out the NCS 

Although local Nerve Conduction practises appear to hide any relationship between the average 

length of wait for Nerve Conduction Studies and the proportion of each centre’s patients that have 

NCS, long delays may deter consultants from ordering NCS. In some centres Nerve Conduction 

Studies may be used more often if they were more readily available. 

- - 13


If patients had Nerve Conduction Studies and were then reviewed by a further Outpatient Appointment, the 

average time from NCS to the review OPA was 8 weeks (median 6 weeks), and this varied between 4 and 

14 weeks between hospitals. 92% of patients had their review OPA within 15 weeks of NCS, but this varied 

from 64% to 100% between hospitals (Fig. 14). 

Fig. 14: Time to post-NCS review 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

0-5 weeks 5-10 weeks 10-15 weeks >15 weeks 

There are also large variations in the time taken from NCS to subsequent outpatient review (Fig. 14). 

This is again a significant delaying point in the patient pathway. Some delay will occur whilst reports 

are prepared by neurophysiologists, and there may be further delay whilst patients are booked back 

into a clinic to be given their NCS results. Delay in this stage of the pathway is probably multifactorial, 

a combination of administration delays and trying to slot patients into already heavily 

booked clinics. 

- - 14


E) Surgery 

82% of patients were operated on within 15 weeks of being added to the theatre waiting list (Fig. 15). 

However, 26% were in the period from 10-15 weeks, a substantial chunk of the future 18-week RTT target 

period. 

At the beginning of the audit period the target time for the whole period from diagnostic to surgery was 15 

weeks, but this reduced to 12 weeks in March 2010. 

Fig. 15: Length of time to surgery after being added to the theatre waiting list 


100 

80 

60 

40 

20 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 


Fig. 15 includes all patients irrespective of any reason for delay. 

Table 4: Average component times from Decision for Surgery to Date of Surgery 

Time from last 

OPA/diagnostic to 

date added to theatre 

waiting list** 

Time from being 

added to theatre 

waiting list to first 

theatre date booked 

% not 

operate 

d on at 

first 

theatre 

date 

booked 

Time from first date 

offered to actual 

theatre date 

N 

Mean % > 8 Mean % > 8 

Mean % > 8 

N 

N 

(weeks) weeks (weeks) weeks 

(weeks) weeks 

Wishaw 27 0.0 0% 27 8.1 37% 7% 27 0.1 0% 

GRI/Stobhill 65 0.7 3% 66 9.5 61% 6% 66 0.6 2% 

DGRI/Garrick 64 0.0 0% 65 8.8 29% 11% 65 0.7 3% 

QMH/Victoria 79 0.0 0% 79 8.2 58% 13% 79 0.9 5% 

Elgin 25 0.8 3% 30 7.4 40% 7% 30 0.1 0% 

Borders 62 0.0 0% 62 9.4 55% 16% 62 0.6 0% 

Ninewells/Stracathro 83 0.2 1% 84 9.2 55% 18% 85 1.2 6% 

RAH/VOL 79 0.5 4% 80 8.0 56% 20% 80 2.6 9% 

ARI/Woodend 65 0.6 3% 66 12.1 76% 0% 66 0.0 0% 

Perth 21 0.7 5% 21 12.6 90% 10% 21 1.7 10% 

Monklands 42 0.3 2% 43 6.9 35% 2% 43 0.3 2% 

Hairmyres 100 1.0 6% 101 8.8 48% 1% 101 0.1 0% 

St Johns/RIE 152 0.1 0% 150 14.2 85% 14% 150 1.8 5% 

Raigmore 61 0.3 0% 63 9.4 73% 6% 63 1.0 3% 

Inverclyde/Dunoon 47 0.0 0% 47 6.9 36% 17% 47 1.3 4% 

Forth Valley 52 0.5 2% 54 10.1 72% 28% 54 2.2 7% 

All patients 1046 0.4 2% 1040 9.7 59% 12% 1042 1.0 3% 

* Data omitted if based on fewer than 5 patients; sample sizes vary between columns due to availability of data 

** Includes patients who went straight to theatre waiting list following their initial Outpatient Appointment. Some patients 

were added to the theatre waiting list before their final diagnostics result was available and are included above as being 

added immediately 

- - 15


On average 11% of all patients did not go to surgery on their original booked date (Fig. 16). 

Fig. 16: Reason for delay 

from first booked theatre 

date to actual date of 

operation 


30 

20 

10 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

No delay 

Missing data 

Surgery cancelled following admission 

Failed pre-assessment 

Hospital cancelled 

Patient cancelled 

Did Not Attend 

Ninety-seven percent of carpal tunnel patients were operated on as daypatients. 

- - 16


F) Second hands 

Carpal tunnel commonly affects both hands. Patients often present with bilateral symptoms and 

having undergone investigations and surgery for the first side they are often placed directly back on 

the waiting list for the second hand. 

As explained earlier, this report has concentrated on time to Carpal Tunnel surgery on ‘new’ Carpal Tunnel 

patients or those who were not immediately referred for surgery on the second hand. However, an average 

of 15% of operations were on the second hand, following directly on from the first (Fig. 17). 

Fig. 17: Percentage of operations that were on the opposite hand following earlier surgery on the 

first 


40 

30 

20 

10 

0 

Wishaw 


DGRI/Garrick 


Elgin 

Borders 


RAH/VOL 

Patients were only included as ‘second’ hands if the decision for treatment on the second hand was made upon review of 

surgery on the first hand. 

ARI/Woodend 

Perth 

Monklands 

Hairmyres 

St Johns/RIE 

Raigmore 

IRH/Dunoon 

Forth Valley 

All patients 

The length of time to surgery on the second hand was much reduced compared to the first (Fig. 18). 

Fig. 18: Length of overall time from referral to surgery - first hands versus second hands 

100 


80 

60 

40 

20 

0 

First hand 

Second hand 


Missing data if referral date was not known (see Fig. 1) 

- - 17


As expected, the delay before being added to a theatre list was much reduced for second hands compared 

to first (Fig. 19) because there is little need for or use of further review appointments or Nerve Conduction 

Studies (Fig. 20). However, patients still then wait an average of eleven weeks prior to second surgery. 

Fig. 19: Average time spent in each stage of the Referral to Treatment process - first versus second 

hands 

50 

Mean number of weeks 

40 

30 

20 

10 

0 

First hand 

Second hand 

From referral to OPA 

Diag/review to theatre list 

OPA to diagnostics/review 

Theatre list to surgery 

See Figure 4 for method of calculation of average times 

Fig. 20: Path from Outpatient Appointment to Surgery - first versus second hands 

100 


80 

60 

40 

20 

0 

First hand 

Second hand 

Added to surgical waiting list at OPA 

NCS - reviewed by phone/letter 

Other 

NCS - reviewed by further OPA 


‘Other’ encompasses a number of patients with unusual paths to surgery, including some private patients, those who left 

their OPA to consider options before getting back in touch, those reviewed by letter without an OPA, those sent for 

diagnostics but cancelled and added straight to the waiting list for surgery, or, in the case of second hands, those added 

directly onto the surgical list on the day of surgery for their first hands 

- - 18

Referral-to-Treatment for Surgical Carpal Tunnel ... - 18 Weeks

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