The evolution of fracture clinic design

Transcription

1 TRAUMA The evolution of fracture clinic design THE ACTIVITY AND SAFETY OF THE EDINBURGH TRAUMA TRIAGE CLINIC, WITH ONE-YEAR FOLLOW-UP T. O. White, S. P. Mackenzie, T. H. Carter, J. G. Jefferies, O. R. Prescott, A. D. Duckworth, J. F. Keating From Royal Infirmary of Edinburgh, Edinburgh, United Kingdom T. O. White, FRCSEd(Tr&Orth), MD, FFTEd, Consultant Orthopaedic Trauma Surgeon S. P. Mackenzie, MBChB, BSc MedSci (Hons), MRCS, Specialty Registrar T. H. Carter, BSc(Hons), MBChB, MRCS(Ed), Specialty Registrar O. R. Prescott, BSC BMBS PGCert, Foundation Doctor A. D. Duckworth, BSc(Hons), MBChB, MSc, FRCSEd(Tr&Orth), PhD, Specialty Registrar J. F. Keating, MPhil, FRCSEd(Tr&Orth), Consultant Orthopaedic Trauma Surgeon, Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SU, UK. J. G. Jefferies, MBChB, Specialty Registrar, Department of Trauma and Orthopaedic Surgery Queen Elizabeth University Hospital, 1345 Govan Road, Glasgow, G51 4TF, UK. Correspondence should be sent to T. O. White; The British Editorial Society of Bone & Joint Surgery doi: / x.99b4. BJJ R1 $2.00 Bone Joint J 2017;99-B: Received 29 August 2016; Accepted after revision 7 November 2016 Aims Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a Trauma Triage Clinic (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results. Patients and Methods We review the management of all patients referred to our service in the calendar year 2014, with a minimum of one year follow-up during the calendar year Results Following the successful introduction of the TTC, only 2836 patients (23.5%) who would previously have been reviewed in the general fracture clinic were brought back to such a clinic to be seen by a surgeon. An additional 2366 patients (19.6%) were brought back to a sub-specialist injury-specific clinic. Another 2776 patients (23%) with relatively predictable injuries were reviewed by a nurse practitioner according to an established protocol or specific consultant instructions. A further 3222 patients (26.7%) were discharged from the service without attending the clinic. No significant errors or omissions occurred with the introduction of the TTC. Conclusion We have found that our TTC allows large numbers of referrals to be reviewed and triaged safely and effectively, to the benefit and satisfaction of patients, consultants, trainees, staff and the organisation. This paper provides the first large-scale review of the instigation of a TTC, and its effect, acceptability and safety. Cite this article: Bone Joint J 2017;99-B: As the number of patients referred to fracture clinics over the last decade has increased, it has been our perception, and that of our patients also, that the quality of these services has been reduced. The causes of the increased rate of referral are complex, but senescence, frailty, patient expectation and time and target pressures on emergency departments play a part. Locally, the first author s (TOW) weekly fracture clinic saw an average of 119 patients over a three-hour session on Wednesday afternoons. Such a workload inevitably has consequences for patient experience, staff morale and training, and quality of care. A more detailed exploration of the implications is outlined in Table I. In 2013, we started to develop a Trauma Triage Clinic (TTC) that would allow referrals from the Emergency Department and GPs to be triaged by a consultant to an appropriate, patient-centred pathway. The development of this service required a year of interdepartmental negotiations and planning within the hospital, the creation of a bespoke information technology system, based on the patient administration system (PAS) in the hospital and linking the Emergency Department with the Orthopaedic Department, and the reorganisation of the duties for a range of staff. Substantial changes were also required within the Emergency Department including the development of new Electronic Patient Record software and screens, the adoption of clinical management and referral protocols and a move to the routine use of removable splints and orthoses in place of plaster of Paris backslabs. The orthopaedic trauma surgeons in our VOL. 99-B, No. 4, APRIL

2 504 T. O. WHITE, S. P. MACKENZIE, T. H. CARTER, J. G. JEFFERIES, O. R. PRESCOTT, A. D. DUCKWORTH, J. F. KEATING Table I. Weaknesses of the previous service Affected party Patients Consultant Trainees Service Weakness Long waits, crowded conditions. Time off work for attendance, cost of travel and parking. Spent < 5 mins with the clinician. Often seen by unsupervised junior doctors. Attendances were often unnecessary minor self-limiting injuries already treated in emergency department. Unnecessary attendances to be referred to further, specialist clinic. Attendances often at an inappropriate time in natural history of injury. Personally saw only small proportion of patients. Had little time available to spend with complex cases. Large numbers of trainees required for service provision. Exposed to risk due to scarcity of consultant time for advice. Little educational value to clinics. Burden increased as training numbers reduced. Large numbers difficult to accommodate comfortably and safely. Regular complaints about waiting times and patient experience. Table II. Range of options for disposition from the Triage Trauma Clinic Options Fracture clinic Hand trauma clinic Shoulder/elbow trauma clinic Knee trauma clinic Foot and ankle trauma clinic Nurse practitioner clinic Nurse practitioner to telephone Surgeon to contact Research Other clinic Physiotherapy General fracture clinic at 1, 2, 3, 4, 5 or 6 wks. Sub-specialist trauma clinics at 1,2,3,4,5 or 6 wks. Common injuries (e.g. Colles fracture) to be reviewed according to a protocol at 1,2,3,4,5 or 6 wks. Detailed instructions given on what information to check, and whether the patient is to be discharged or invited back to a clinic. Patients requiring investigation or intervention do not necessarily need to attend clinic first, and are contacted directly by the surgeon. Patients invited directly to a clinic running a research study connected to the injury. Patients who would be best seen in another part of the service, for example those with degenerative arthritis or possible tumours, are routed directly to the most appropriate specialty. Direct discharge to physiotherapy where appropriate. department absorbed the additional work of running the TTCs pro bono for the first year while the system was refined and its impact on consultant job plans assessed. After the first year, work in this clinic was included in consultants job plans. The British Orthopaedic Association Standards for Trauma guidelines 1 recommend that all patients should be physically seen by a consultant within 72 hours of referral, and that any guidelines that deviate from these recommendations should be prospectively evaluated to support this change in practice. In 2015 the National Clinical Director for Trauma, Professor Chris Moran, raised the question of the ability of the TTC process to identify safely certain injuries of low-prevalence, but high potential morbidity, where plain radiographs in particular may be misinterpreted. These would include injuries with significant soft-tissue instability of the shoulder, carpus, knee and tarsometatarsal joint, as well as subtle fractures such as those of the talus. The aim of this observational, one-year cohort study was to review the working, safety and efficacy of a TTC. Patients and Methods Patients in the Emergency Department with musculoskeletal injuries that may require review are referred via the PAS. Key information such as age, place of residence, comorbidities and level of functional independence, and the date, mechanism and place of injury are recorded, followed by a free-text clinical note. The software then automatically generates an Emergency Department clinical record, a letter to the patient s GP and referral to the TTC. The patient is then added to the orthopaedic consultant s PAS workbench. The consultant has immediate electronic access to the Emergency Department record and any radiographs on the picture archiving and communication system, permitting a decision on the most appropriate disposition of the patient (Table II). This is recorded by two or three keystrokes and a succinct management plan is then dictated onto the system. The patient s record then moves to the PAS workbench of the next appropriate individual, such as a bookings clerk or trauma nurse practitioner. The task can be undertaken at any time convenient to the consultant and performed offsite if necessary. No additional staff are required. THE BONE & JOINT JOURNAL

3 THE EVOLUTION OF FRACTURE CLINIC DESIGN 505 Table III. Self-limiting injuries Potentially dischargeable injuries Patients with these injuries are provided with a leaflet describing the natural history of the injury and treatment plan and are informed that their notes and radiographs will be reviewed by a consultant orthopaedic trauma surgeon within 48 hrs. Patients are informed that they will not be contacted unless there is a concern, but are provided with helpline numbers. Mallet finger injuries without bony component. Boxers fractures of the fifth metacarpal neck. Radial head or neck fractures that are minimally displaced or comminuted (Mason type I or II). Fractures of the fifth metatarsal base. Lesser toe fractures. Table IV. The 20 most common referral diagnoses with typical current Triage Trauma Clinic (TTC) management decisions Diagnosis n TTC Wrist: Undisplaced/minimally displaced distal radial fracture 951 NC1 Hand: Phalangeal fracture 797 #1 Ankle: Ankle fracture: lateral malleolus only, stable 595 NC1 Wrist: Dorsally displaced (Colles' type) extra-articular fracture 578 NC1 Foot: Metatarsal: fifth - isolated fracture 560 D Elbow: Radial head fracture 526 D Hand: Metacarpal, fifth, shaft or neck (boxer's) fracture 473 D Shoulder: Fracture clavicle 461 #2 Hand: Carpus: clinically suspected scaphoid fracture 823 R Hand: Metacarpal, other fracture 381 #1 Shoulder: Proximal humerus fracture (not isolated tuberosity) 380 #1 Shoulder: Shoulder dislocation: no fracture 344 #2 Wrist: Other wrist fracture 277 #1 Knee: Possible meniscal lesion 247 K2 Wrist: Non-specific wrist pain 220 #2 Foot: Metatarsal: isolated other fracture 189 #2/D Foot: Phalanges: Hallux fracture 173 #2/D Knee: Knee pain, not otherwise specified 173 K2 Hand: Interphalangeal joint dislocation 158 #2 Hand: Mallet finger 136 D D, discharge from Emergency Department with information leaflet and helpline number; NC1, nurse practitioner clinic within one week; #1, fracture clinic at 5 to 8 days; #2, fracture clinic in two weeks; R, research clinic On discharge from the Emergency Department, patients were given a leaflet with contact numbers for administrative and clinical staff. A key component of the concept was the use of removable orthoses to permit patient-led mobilisation without a requirement to attend hospital for the removal of plaster. A simple feedback and governance mechanism for the reporting, recording and analysis of errors was established. During the 12-month period between 01 January and 31 December 2014, patients with injuries meeting inclusion listed in Table III were referred from the Emergency Department to the TTC. Patient characteristics, injuries, outcomes and complications were obtained from the electronic records generated in the routine operation of the system. Results The most common diagnoses accompanying decisions made at the TTC are shown in Table IV. The distribution of patients is shown in Figure 1. Only 2836 patients (23.5%) who would previously have been reviewed in the general fracture clinic were recalled for surgical review. An additional 2366 patients (19.6%) were triaged directly to a sub-specialist, injury-specific clinic, thereby avoiding an additional appointment in the general fracture clinic which they would previously have attended. A consultant-supervised nurse practitioner undertook the protocol-led management of 2776 patients (23%) with relatively straightforward injuries and 3222 patients (26.7%) were discharged from the service, either directly from the Emergency Department or after a telephone consultation with a nurse practitioner. Consultant-delivered telephone consultations were offered to 145 patients (1.2%) who required further investigation or intervention. Our institution is the only provider of orthopaedic care to a relatively static population of about and so it was assumed that any missed cases would re-present to one of our emergency departments or our Orthopaedic Trauma Service. From its inception until 01 January 2016 (a minimum of 12 months follow-up), no missed or under-diagnosed injuries were reported. Specifically, for instance, all complex carpal instability injuries and talar fractures were correctly diagnosed in the Emergency Department and referred to the on-call service. Of the 12 Lisfranc injuries, which were seen, ten were referred to the on-call service and two were diagnosed after referral from minor injuries VOL. 99-B, No. 4, APRIL 2017

4 506 T. O. WHITE, S. P. MACKENZIE, T. H. CARTER, J. G. JEFFERIES, O. R. PRESCOTT, A. D. DUCKWORTH, J. F. KEATING Arthroplasty (0.4%) Physiotherapy (0.3%) Elbow trauma (0.7%) Foot and ankle trauma (1.5%) Shoulder trauma (4.4%) Research (0.3%) Contact directly (1.2%) Hand trauma (6.3%) Fracture clinic (23.5%) Knee trauma (6.7%) Discharge (11.1%) Nurse clinic (23%) Nurse call (15.6%) Fig. 1 Triage Trauma Clinic decisions for the referrals. Table V. Benefits of the Trauma Triage Clinic system Affected party Patients Consultant Trainee Service Emergency department Benefits Rapid, consultant-delivered case review. Fewer attendances and no wasted appointments. Access to an experienced nurse-led helpline for advice, and re-appointment to clinic if necessary. Appropriate numbers of patients in each clinic with realistic appointment times. More time for the consultation. More likelihood of being seen by a consultant. Sees more patients personally, with or without trainee. Can devote appropriate time to complex cases. Can refer to the consultant s written management plan for each patient. More time to discuss, and see patients together, with consultant. Smaller clinics. No complaints to date. Cost savings in terms of both staffing and facilities. The controlled flow of patients allows easy management of research and audit. feedback from the triaging consultant permits inter-departmental quality improvement in realtime. units to the TTC as fractures of the base of metatarsals. Of the 20 patients with a posterior dislocation of the shoulder, seven were referred directly to the on-call team and 13 were referred correctly through the TTC process. Some of the positive feedback pertaining to the process is outlined in (Table V). Discussion It is widely perceived amongst orthopaedic surgeons that many fracture clinics fail to provide optimal care because of a relentless increase in the numbers of patients referred, which has not been matched by an increase in resources. Similarly, it is widely perceived that the severity of injuries that are referred has also declined, with many patients suffering minor self-limiting injuries who require reassurance and information, but who do not need to attend a hospital fracture clinic. The TTC provides a different model of care, comprising a consultant review of all referrals, and resulting in an individualised management plan for each patient to be seen at THE BONE & JOINT JOURNAL

5 THE EVOLUTION OF FRACTURE CLINIC DESIGN 507 Table VI. Diagnoses of low prevalence but high morbidity Injury Treated in 2014 (n) Direct on-call referrals Trauma Triage Centre referrals Cases missed Complex carpal instability Talar fractures Lisfranc injury Posterior dislocation of the shoulder the right time by the most appropriate person. We believe that this level of expertise at the point of triaging is important; a high index of suspicion is required for some injuries, particularly those of low prevalence but high morbidity (Table VI). Others, such as soft-tissue injuries of the knee, are also difficult to exclude on the basis of Emergency Department notes and radiographs, and usually require a clinical appraisal in clinic. This change has resulted in fracture clinics where the consultant is able to spend appropriate time with patients who require it, often with a trainee who is able to learn and discuss cases, to the benefit of all concerned. Our impression is that reducing unnecessary attendances has also improved the patients experience, and we are currently preparing a paper on a comparison of outcomes and satisfaction before and after the change in practice. Our service development in Edinburgh has proceeded with the support of the hospital administration and NHS Scotland, and several other Scottish centres have adopted a similar model, particularly in Glasgow where the concept was popularised. In Scotland, unlike England, there is no tariff for an attendance at a fracture clinic and hence no economic disincentive to the institution to discharge patients at the TTC. In England, in contrast, the institution would potentially lose a tariff of around 130 per patient 2 not brought to fracture clinic, and an alternative way of acknowledging the specialist and skilled service being provided in the TTC is required. We report a prospective evaluation of a change in our fracture clinic practice from a next day physical review to an electronically-managed service, in which we found that large numbers of referrals can be reviewed and triaged safely and effectively, to the benefit and satisfaction of patients, consultants, trainees, staff and the organisation. Take home message: - Traditional models of fracture clinic provision have become unsustainable in many hospitals. - The British Orthopaedic Association has required any change in this model to be evaluated prospectively. - We have shown that the Edinburgh TTC model allows large numbers of patients to be reviewed safely and effectively, and triaged appropriately. - This system is to the benefit and satisfaction of patents, consultants, trainees, staff and the organisation. Author contributions: T. O. White: Study design, Data analysis, Writing the paper, Paper submission and S. P. Mackenzie: Study design, Data collection, Writing the paper, Paper submission and T. H. Carter: Data collection, Writing the paper, Paper submission and J. G. Jefferies: Data collection, Writing the paper, Paper submission and O. R. Prescott: Data collection, Writing the paper, Paper submission and A. D. Duckworth: Study design, Writing the paper, Paper submission and J. F. Keating: Study design, Writing the paper, Paper submission and The authors would like to acknowledge and thank their trauma consultant colleagues for their hard work in delivering the TTC, especially C. M. Robinson and C. W. Oliver for their substantial contributions. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by J. Scott. References 1. No authors listed. British Orthopaedic Assocation. Standards for Trauma (BOAST) (date last accessed 23 November 2016). 2. No authors listed. NHS National Tariff Payment System 2016/ (date last accessed 03 March 2017). VOL. 99-B, No. 4, APRIL 2017