Loree K. Kalliainen, MD, MA, FACS
Department of Plastic and Hand Surgery
St. Paul, MN
Zeke McKinney, MD
Department of Occupational Medicine
St. Paul, MN
A review of our group’s use of collagen nerve conduits was published in 2011 in Hand. Several findings were concerning to me: the loss of 33% (32 of 96 patients) of our patients to long-term followup (>30 days), and a relatively poor degree of postoperative improvement (43% of 96 patients). With respect to follow-up, nerve growth is likely just starting to advance by the end of the first postoperative month. Longer follow-up is important to determine efficacy of surgery and to optimize therapeutic interventions such as cortical remodeling, desensitization, nerve glide exercises, and, scar management. Inadequate follow-up could have contributed to our relatively low rate of subjective or objective improvement. To address this issue, I worked with our Epic (electronic health record) specialist to create a Best Practice Alert (BPA) that would fire when a nerve injury code (955.x) was entered into the patient’s electronic medical record. The goal of the BPA was to remind physicians to refer the patient to hand therapy. The BPAs started on 2/1/11 and data was gathered on patients from that time until 7/21/13.
The charts of 120 nerve-injured patients were reviewed for firing of the BPA, duration of follow-up by a surgeon, hand therapy visits, the use of the hand therapy nerve recovery protocol, and notation of recovery of nerve function.
The BPA only fired for 32/120 patients. Our Epic specialist is looking into this, but it could be due to a member of the care team not entering an appropriate diagnostic ICD-9 code in Epic. Our surgeons are not asked to enter operative codes into Epic at the time of surgery; this is done by the billing and coding department. In postoperative clinic visits, though, a diagnosis code must be entered by the surgeon or mid-level practitioner to close the chart. Entering a nerve injury code could be avoided if a postoperative event code (V67.00 or Z09) were entered or if a different injury diagnosis code (eg, open wound, tendon injury, fracture). In these situations, the reminder to refer to hand therapy would not appear.
Despite the poor rate of BPA firing, loss of patients to long-term followup (>30 days) was slightly improved: 89 patients (74%) had follow-up greater than 30 days with short-term follow-up only in 31 patients (26%). The average followup with the surgeon was 122 days (range, 0-991) and with the hand therapists was 86 days (range, 0-352). 92% of all patients (109/120) were seen by hand therapy postoperatively, and in 63% (76/120), the cortical remodeling protocol was used. The nerve recovery protocol has been used for the past five years by our hand therapists and incorporates early sensory and auditory stimulation along with mirror therapy as has been discussed by Lundborg and Rosen. Nerve recovery was noted in 83% of our patients treated with the nerve recovery protocol and only in 54% of patients in whom the nerve recovery protocol was not used. As opposed to our earlier study of collagen conduits, there was evidence of nerve recovery in 74% of our patient with collagen conduits, similar to 78% of patients in patients who had primary repair.
One of the concerns raised about alerts in the EHR is “alert fatigue”, so it is reasonable to ask whether the BPA was effective or useful. The 7% improvement in long-term followup may be partially due to the BPA, and occasionally seeing the BPA may have served as a reminder to our practitioners to order hand therapy for all patients with nerve injuries. In addition to the BPA, awareness has increased in general in our department about postoperative options for nerve-injured patients. We have had internal presentations about the cortical remodeling protocol, one of our hand therapists presented our data at last year’s AAHS meeting, and an article has been submitted for publication to the Journal of Hand Therapy. There have been no voiced departmental complaints about seeing the BPA, and so keeping it is unlikely to be unpopular. It may serve to remind rotating trainees to refer patients to hand therapy. We are pleased, though, that the use of the cortical remodeling protocol may have improved nerve repair outcomes. We will be looking into this in more depth.
- Wangensteen KJ, Kalliainen LK. Collagen tube conduits in peripheral nerve repair: a retrospective analysis. Hand. 5(3):273,2010.
- Lundborg G, Rosen B, Lindberg S. Hearing as substitution for sensation: a new principle for artificial sensibility. J Hand Surg 1999;24A:219–224.
- Lundborg G. Brain plasticity and hand surgery: an overview. J Hand Surg (Br), 2000;25(3):242-252.
- Kesselheim AS, Cresswell K, Phansalkar S, Bates DW, Sheikh A. Clinical decision support systems could be modified to reduce ‘Alert Fatigue’ while still minimizing the risk of litigation. Health Affairs, 2011;30(12):2310-2317.