3.2. History; refer to protocol for History taking and Clinical Documentation and the Protocol for the Management of soft tissue limb injuries;

Transcription

1 Title: MIU Elbow injuries- management of Ref No: 1953 Version 2 Document Author: Ratified by: Senior Manager MIU Services Nurse Consultant Emergency care Care & Clinical Policies Group Meeting Clinical Director of Pharmacy Date 18 October 2017 Date: 18 October December 2017 Review date: 19 January 2021 Links to policies: 1. Purpose of this document - This clinical protocol provides a clear framework for nurse/paramedic practitioners employed by Torbay & South Devon NHS Foundation Trust when providing care to patients over 2 years of age presenting at Minor injury Units with elbow injuries. 2. Scope of the Policy: This protocol is for the use by Minor Injury and Emergency Department practitioners employed by Torbay & South Devon NHS Foundation Trust who has achieved the agreed Trust clinical competencies to work under this protocol. 2.1 Red Flag: Ensure all patients on anticoagulants i.e. Warfarin Dabigatran etexilate (Pradaxa ), Apixaban (eliquis ) and Rivaroxaban (Xarelto ) have appropriate medical follow up/review, blood tests/inr review 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Pain, swelling, bruising, redness, wounds, inflammation/heat, reduced or loss of function, deformity/dislocation History; refer to protocol for History taking and Clinical Documentation and the Protocol for the Management of soft tissue limb injuries; Specific: Traumatic (direct/indirect), non -traumatic Establish when, where and how the injury occurred. Establish Exact mechanism of injury e.g. fall onto outstretched hand, direct fall/blow onto elbow, height of fall History of a pulled elbow; Subluxation of the radial head through the annular ligament, occurring in the 2 6 age group and usually caused by pulling of the child s arm through swinging the child by the arms, the child falling while being held by the hand or a clumsy pull by an older person/sibling. Version 2 (January 2018) Page 1 of 5

2 4. Clinical Examination; to include the whole of the upper limb 4.1. Look Symmetry (compare right elbow with left) Swelling (general, bursitis) Bruising/discolouration Wounds/grazing Deformity/dislocation 4.2. Feel (palpate) Note any bony tenderness, crepitus, step/deformity over; Humerus including epicondyles Ulna including olecranon Radius including radial head 4.3. Move 5. Treatment Flexion/Extension Supination and pronation of forearm 4.4. Special Tests Sensation/circulation distal to and over injured site Investigations X-ray where there is clinical indication of fracture or dislocation If the history of a pulled elbow is clear there is no need to X-ray (X-rays would be normal in appearance with a pulled elbow) 5.1 Pulled Elbow (determined on history) Provide analgesia as per patient Group Direction according to patients Pain score. Reduction: support the back of the elbow in one hand with your thumb over the radial head to feel the click if a successful reduction. With your other hand flex the elbow to 90 degrees then pronate with gentle axial pressure towards the elbow. A click heard or felt with the thumb is diagnostic. After Reduction leave the child to recover and play for a period of time, usually full arm movement returns within a few minutes and no further treatment is required. If no improvement and the child is comfortable rest the arm in a collar and cuff, provided or advised simple analgesia as per patient group direction and review in hours. If no improvement attempt reduction if supported by patient and parents but if unsuccessful following good attempts refer to ED Senior clinician. 5.2 Tennis Elbow Clinical Findings: Pain on lateral side of elbow Difficulty in holding a Heavy object at arm s length. Treatment: Sports person: rest or modification of flawed game playing technique. Manual worker: Avoidance if suspected casual/repetitive activity. Version 2 (January 2018) Page 2 of 5

3 5.3 Golfers Elbow Clinical Findings: Pain on medial aspect of elbow Treatment: As for Tennis elbow. 5.4 Olecranon Bursitis Clinical Findings: Swelling of Olecranon Bursa Treatment: Avoidance if repetitive Strain where possible but generally no treatment required except rest, occasionally excision is advised for cosmetic reasons. 5.5 Infective Olecranon Bursitis Clinical findings: Swelling of Olecranon Bursa with localised tenderness, redness/heat, and pyrexia. Treatment: Give Flucloxacillin and Non- steroidal anti -inflammatory Ibuprofen as per Patient Group Direction (PGD) and arrange GP review. If clinically unwell discuss with Senior ED clinician or orthopaedics for potential IV antibiotics and/or drainage. 5.6 Radial Head Fractures Undisplaced: broad arm sling, provide/ advise analgesia as per Patient Group Direction. Discharge as per orthopaedic ED/MIU fracture and Trauma triage guidelines with radial head discharge information leaflet. Displaced radial head fractures: treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines with above elbow plaster and Displaced/comminuted: refer to duty Orthopaedics. Apply plaster of Paris (POP) above elbow back slab prior to transfer. Provide analgesia as per Patient Group direction according to patients pain score. 5.7 Supracondylar fractures: NB check pulse. Undisplaced Fracture: Treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines in an above Elbow POP backslab, broad arm sling, Trauma Triage appointment. Advise Analgesia or provide analgesia to take home according to PGD Displaced fracture: treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines refer to Orthopaedics. Provide POP above elbow back slab/splint for comfort and broad arm sling. Give analgesia as per PGD according to pain score. 5.8 Olecranon Fractures Undisplaced fractures treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines with Broad arm sling and Trauma Triage Displaced Fractures: Treat as per orthopaedic ED/MIU fracture and Trauma triage guidelines Refer to Orthopaedics. Provide POP above elbow back slab/splint for comfort and broad arm sling. Give analgesia as per PGD according to pain score. 5.9 Elbow dislocations/ fracture dislocations: Check neurovascular statues Refer to ED for reduction via ambulance. Provide support splint and give analgesia according to PGD. Version 2 (January 2018) Page 3 of 5

4 5.10 Other Fractures: Refer to orthopaedic ED/MIU fracture and Trauma Triage guidelines or discuss with Orthopaedics. 6. Documentation 6.1. Clinical records must be written in accordance with Torbay and South Devon NHS Foundation Trust History Taking and Clinical Documentation protocol, Nursing & Midwifery Council standards including record keeping records and record management (2009) or relevant registering body e.g. Health & care professional Council (HCPC) standards including record keeping guidance A summary letter of the MIU/ED attendance and the care delivered must also be sent to the General practitioner and also the health visitor if less than 5yrs or school nurse if aged between 5yrs and 16yrs to ensure the central medical record of the patient is accurate For patients being transferred to the Emergency department, ensure records are completed in a timely manner on the Shared Symphony IT system. A summary letter will be sent to the General practitioner in the normal manner For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance summary to take with them. A summary letter will be sent to the General practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation 7.5 The patient/carer demonstrates and understanding of how to manage subsequent problems. 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool _ Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References Accident & Emergency, theory into practice. Dolan B, Holt L Version 2 (January 2018) Page 4 of 5

5 British National Formulary 2017 Clinical orthopaedic Examination. McRae R. 5 th edition 2004 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Guide to physical examination and History Taking. Bickley 2003 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 NICE Fractures (non complex) Assessment and Management NG NICE fractures (complex) Assessment and Management NG South & West Devon formulary Amendment History Issue Status Date Reason for Change Authorised 1 Created February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for elbow injuries 1.1 Reviewed August 2015 Reviewed no clinical changes. Amendment to 5.6 included virtual fracture clinic. Documentation reflects new symphony IT system 2 Revised 19 January 2018 Trust name Orthopaedic ED/MIU guidelines on management of injuries Reference NICE guidance CG37 & 38 Senior Manager MIU Services Nurse Consultant Emergency care Senior Manager MIU Services Nurse Consultant Emergency care Care and Clinical Policies Group Clinical Director of Pharmacy Version 2 (January 2018) Page 5 of 5

6 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. Version 2 (January 2018) The Mental Capacity Act Page 1 of 1

7 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Version and Date Policy Author An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favourably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net Version 2 (January 2018) Rapid (E)quality Impact Assessment Page 1 of 2

8 For Torbay and South Devon NHS Trusts, please call or This form should be published with the policy and a signed copy sent to your relevant organisation. 1 Consider any additional needs of carers/ parents/ advocates etc, in addition to the service user 2 Travelers may not be registered with a GP - consider how they may access/ be aware of services available to them 3 Consider any provisions for those with no fixed abode, particularly relating to impact on discharge 4 Consider how someone will be aware of (or access) a service if socially or geographically isolated 5 Language must be relevant and appropriate, for example referring to partners, not husbands or wives 6 Consider both physical access to services and how information/ communication in available in an accessible format 7 Example: a telephone-based service may discriminate against people who are d/deaf. Whilst someone may be able to act on their behalf, this does not promote independence or autonomy Version 2 (January 2018) Rapid (E)quality Impact Assessment Page 2 of 2

9 Clinical and Non-Clinical Policies New Data Protection Regulation (NDPR) Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU New Data Protection Regulation (NDPR) in mind and therefore provides the reader with assurance of effective information governance practice. NDPR intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, NDPR requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. The most effective way of being open is through data mapping. Data mapping for NDPR was initially undertaken in November 2017 and must be completed on a triannual (every 3 years) basis to maintain compliance. This policy supports the data mapping requirement of the NDPR. For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our GDPR page on ICON. Version 2 (January 2018) New Data Protection Regulation (NDPR) Page 1 of 1