GetUBetter – how we can implement a digital self-management tool into a busy emergency department for patients with back pain

getUBetter© is being piloted in St Georges Hospital Emergency Department

About four years ago, I found myself working in the Emergency Department (ED) at St George’s Hospital (SGH), south west London. This was where the problems facing patients with back pain or sciatica were first highlighted to me.  I found that these patients weren’t in the right place to be managed appropriately and were often given inconsistent discharge messages and advice and eventually sent back to their GPs.

Understandably, the ED is not a place where clinicians have the time to do anything but rule out serious pathologies, but equally, it felt to me like something was missing.  Could we potentially prevent a huge number of patients returning to healthcare settings by empowering them with the knowledge and tools to recover well, then and there?  This is what the literature advises, after all.

To be able to act on this four years later, with the help from the Innovations Grants Programme 2021 – has been extremely exciting for me.  We have been working on a real-world evaluation study in SGH ED, implementing the NHSx endorsed digital self-management tool getUBetter© for patients with back pain or sciatica.

The app supports patients by providing personalised and targeted day-by-day support, as well as advice and direction to local healthcare providers and services (including NHS physiotherapy) when needed.

Implementing this has been challenging, but hopefully, it will be the first step in showcasing the value of this kind of tool to reduce the burden on our overwhelmed EDs and improve the experience for patients and clinicians alike.

There is a consensus of negative feelings towards being faced with a patient with back pain in an ED.  This is understandable as there are often queues out the doors and down the corridors and no time or resources to complete a holistic assessment.  Hopefully, this feeling can now begin to change, as there’s now a streamlined pathway with an evidence-based tool to match.

I have highlighted some of the positives, challenges, and next steps for this project below.

Positives

We have changed the back pain pathway to signpost clinicians to the getUBetter tool, for all patients discharged from the ED with MSK related back pain or sciatica.  This has required a lot of teaching and promotion to improve awareness and has included e-mails, teaching sessions, drop-in sessions, and posters.  There have been lots of positive messages so far about this such as

Many clinicians have felt this tool has filled a gap in the management of these patients. One said; “The app was easy to use, and the patient was able to download it there and then in the clinic.”

Challenges

Trying to change someone’s practice is always challenging, and I think this has been made more so by clinicians working in an often very stressful and busy department.  There are also frequent, large turnovers of staff as well as slow Wi-Fi and computer systems which can make referrals more clunky.

Inappropriate and unscheduled care for back pain in the urgent care system is a significant challenge to influence.  This project is an opportunity to raise awareness of this to clinicians and patients, to increase the number of patients being referred to the appropriate health care service in future.  A drop in the ocean – but an important one!

We have listened to feedback so far to simplify the referral process and now have QR codes on business card-sized handouts.  One of the most important things I have learned so far is to keep things as simple as possible when introducing a new process.

Still to come…

• We are collecting feedback from patients and clinicians on the acceptability of this app
• We will continue to promote the use of this tool, if agreed with all stakeholders, and support other EDs to use it in their practice
• We will explore expanding to all other MSK conditions (which are already set up on the app)

The opportunity to make these positive changes to patient and clinician’s experiences of managing back pain and sciatica has been made possible through the HINs innovation grants programme.  It is truly exciting for me that patients are now being given a standardised and evidence-based tool to enable them to self-manage their condition from the outset at St George’s Hospital.

Do you know?

Low Back Pain is the leading cause of disability globally¹.  It is the most common MSK complaint in EDs in the UK; but the good news is that most people should be able to self-manage with minimal support if they are given the correct advice²,³.

Attendances to the ED show a higher incidence of back pain in ethnic minorities.  The care given to ethnic minorities  can be different and driven by an entrenched unconscious bias within healthcare professionals⁴.  More work needs to be done but hopefully, this project is one small step in the right direction.

The NHS’ Long-Term plan highlights the need to deliver ‘digitally enabled care.’  The getUBetter app is the only app of its kind that offers the key features of self-management, behaviour change techniques and referral to local services and signposting⁵,⁶.  It has also been rated the number one MSK app in the U.K (Orcha Health).  Providing digital solutions has never been so important as now with the current COVID-19 pandemic and an over-burdened healthcare system.

References

1. Vos, T., Abajobir, A. A., Abbafati, C., Abbas, K., Abate, K. H., Abd‐Allah, F., Abdulle, A. M., Abebo, T. A., Abera, S. F., Aboyans, V., Abu‐Raddad, L. J., Ackerman, I. N., Adamu, A. A., Adetokunboh, O., Afarideh, M., Afshin, A., Agarwal, S. K., Aggarwal, R., Agrawal, A., ... Murray, C. J. L., et al. (2016). Global, regional, and national incidence, prevalence,and years lived with disability for 328 diseases and injuries for 195 countries, 1990‐2016: A systematic analysis for the Global Burden of disease study 2016. The Lancet, 390(10100), 1211–1259.
2. Artus M, van der Windt DA, et al. Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology. 2010.
3. Foster N, Anema J, et al. Pain One Week After Associated Emergency Department Visit for Acute Low Back Pain is associated with Poor Three-month Outcomes. Academic Emergency Medicine. 2018.
4. Hoffman KM, Trawalter S, et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016.
5. https://www.csp.org.uk/system/files/documents/2020-06/digital_physiotherapy_solutions1.pdf 
6. Berry et al.  Evidencing the behaviour change model underpinning a personalised and tailored app for low back pain.  Virtual Physiotherapy UK conference. 2020.