Title Protocol for the Management of Shoulder Injuries in MIUs and WICs

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Rudolph Hudson
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1 Document Control Title in MIUs and WICs Author Author s job title Professional Lead, Minor Injuries Unit Directorate, Logistics and Resilience Department Emergency Department Version Date Issued Status Comment / Changes / Approval 0.1 Apr Draft Initial version for consultation Apr 2016 Final Approved by (Clinician) and (Clinical Director) June 2015 and published on Bob. 1.1 Feb 2017 Revision Amendment to protocol, age reference under section Purpose Main Contact Tel: Direct Dial Emergency Department North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Lead Director Medical Director Document Class Protocol Target Audience Nursing, MIU Staff Distribution List Senior Management Distribution Method Trust s internal website Superseded Documents N/A Issue Date Review Date April 2016 April 2019 Consulted with the following stakeholders: (list all) ED Consultant MIU Leads Review Cycle Three years Approval and Review Process Lead Clinician for Emergency Department Local Archive Reference G:\Policies and Protocols Local Path MIU Filename v1.1 Apr16 v1.1 Feb17 Page 1 of 11

2 Policy categories for Trust s internal website (Bob) MIU Protocol Tags for Trust s internal website (Bob) None v1.1 Feb17 Page 2 of 11

3 1. Table of Contents Document Control Purpose Presenting Symptoms History Taking Document Clinical Examination Look Feel Move Tests Investigations Treatment Pathway Clavicle Fractures Humerus Fracture Humerus Fracture Involving Surgical Neck Acromioclavicular Joint Disruption Humeral Shaft Fractures Sternoclavicular Dislocation Scapula Fractures Anterior and Posterior Shoulder Dislocations Ruptured Biceps tendon Frozen Shoulder Rotator Cuff Tears Acute Calcific Tendonitis Discharge Pathway DOCUMENTATION TO BE COMPLETED BEFORE DISCHARGE ENSURE References... 8 APPENDIX A Essential Documentation for All Patients Attending Unit or Centre... 9 APPENDIX B Essential Documentation for All Patients Attending Unit or Centre APPENDIX C Training Competency Form v1.1 Feb17 Page 3 of 11

4 2. Purpose This Protocol is for the use by staff employed by Northern Devon Healthcare Trust who have achieved the agreed clinical competencies to work under this protocol. The protocol is for all patients in the Walk-In Centres and for patients over two years old in the MIUs. Any child under this age must be referred to a GP. 3. Presenting Symptoms Swelling Decreased range of movement Wounds Pain Bruising Deformity / dislocation Reduced strength and power Muscle wasting Loss of function Warmth 4. History Taking 4.1 Document Direct trauma Sudden traction to the shoulder Fall onto outstretched hand Chronic or degenerative conditions of the shoulder Cervical spondylosis Non-traumatic pain Referred shoulder tip pain Hand dominance All patients on oral anticoagulants seek medical advice Social problems with elderly patients 5. Clinical Examination 5.1 Look Symmetry Swelling Deformity of clavicle or acromioclavicular joint Subluxation Dislocation Localised erythema / redness Step in deltoid contour v1.1 Feb17 Page 4 of 11

5 Deltoid wasting Winging of scapula Wounds 5.2 Feel Cervical spine tenderness Bony tenderness Crepitus Soft tissue tenderness Muscle tenderness Step / deformity Distal neurovascular sensation Brachial Plexus 5.3 Move Test range of active and passive Movements Abduction / adduction Forward flexion Backward extension Internal rotation touch opposite scapula External rotation touch the back of head Painful arc 5.4 Tests Test the badge area of the proximal lateral arm to test for axillary nerve sensation Drop arm test Scarf test 5.5 Investigations X-rays of shoulder 6. Treatment Pathway 6.1 Clavicle Fractures Critical skin refer to orthopaedics via Emergency Department Treatment Analgesia as PGD or OTC Broad arm sling Fracture clinic follow up v1.1 Feb17 Page 5 of 11

6 6.2 Humerus Fracture Treatment Analgesia as PGD or OTC Collar and cuff Fracture clinic follow up If displacement or angulation present discuss with Emergency Department If neurovascular sensation affected, discuss with ED 6.3 Humerus Fracture Involving Surgical Neck Analgesia as PGD Collar and cuff Fracture clinic follow up Refer severely displaced fractures to the Emergency Department For displaced fractures of the anatomical neck, greater tuberosity or lesser tuberosity or angulated, displaced fractures in children, discuss with Emergency Department 6.4 Acromioclavicular Joint Disruption Analgesia as PGD or OTC analgesia Broad arm sling Fracture clinic follow up 6.5 Humeral Shaft Fractures Analgesia as PGD or OTC Collar and cuff Refer to orthopaedics for advice Check for radial nerve damage / wrist dorsiflexion and radial artery damage 6.6 Sternoclavicular Dislocation Analgesia as PGD Refer to orthopaedics for opinion 6.7 Scapula Fractures Analgesia as PGD Refer to orthopaedics for opinion 6.8 Anterior and Posterior Shoulder Dislocations Analgesia as PGD Consider Entonox as PGD Refer to Emergency Department for reduction v1.1 Feb17 Page 6 of 11

7 6.9 Ruptured Biceps tendon (palpable bulge above elbow) Treatment Analgesia as PGD or OTC Broad arm sling Contact Emergency Department for advice 6.10 Frozen Shoulder Gradual onset of pain and limited movement especially on external rotation Treatment Analgesia as PGD or OTC advise to move shoulder if not too painful Refer to GP for physiotherapy 6.11 Rotator Cuff Tears Usually supraspinatus rupture, may follow chronic tendonitis in older patients May be spontaneous following a fall Tenderness over cuff insertions and subacromial area Unable to abduct normally Painful arc Treatment X-ray if follows trauma refer fractures to fracture clinic Broad arm sling Analgesia as PGD or OTC Refer to GP to arrange physiotherapy 6.12 Acute Calcific Tendonitis Analgesia as PGD or OTC analgesia Refer to medical practitioner for further treatment 7. Discharge Pathway Assess and document pain score prior to discharge Ensure patient is issued with appropriate advice sheet (if available) and that patient understands the need to return if symptoms change or worsens. Discuss home analgesia with patient, parent or carer and advise OTC medication or administer TTO medication as per PGD. v1.1 Feb17 Page 7 of 11

8 7.1 DOCUMENTATION TO BE COMPLETED Clinical treatment record as per Documentation & record keeping policies. Copy of clinical treatment record to General Practitioner; to be sent to surgery as per Record keeping policy. For patients being transferred to secondary care, ensure a copy of the clinical treatment record is sent with patient. A copy will also be sent to surgery in normal manner. For patients seeing their General Practitioner in next 24 hours ensure patient is given a copy of the clinical treatment record to take with them. A copy will also be sent to surgery in the normal manner. 7.2 BEFORE DISCHARGE 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 administered and correct information and documentation is given to the patient. The patient understands that if condition deteriorates or they have further concerns they should seek further advice. The patient demonstrates understanding of advice given during consultation. The patient has been provided with written advice leaflet to re-enforce advice given during consultation. The patient demonstrates an understanding of how to manage subsequent problems. 8. References Bates Clinical Guide to Examination Clinical Knowledge Summaries shoulder Pain April 2015 McRae R. (2010) Orthopaedics and Fractures 6 th Edition Edinburgh Churchill Livingstone CKS Shoulders April 2015 v1.1 Feb17 Page 8 of 11

9 APPENDIX A Essential Documentation for All Patients Attending Unit or Centre Adults Consent Gain consent to be seen by a nurse practitioner Gain consent for treatment and sharing information and document. Clinical Presentation If unwell assess for: Airway Breathing Circulation Disability Exposure Document a full set of observations including neurological observations including Glasgow coma score if applicable. Record EWS: if 7 or above arrange immediate transfer to secondary care. Document pain score using numeric rating scale. For cognitively impaired patients document any signs of pain (e.g. grimaces or distress). Safeguarding Assess for mental capacity and if person is a vulnerable adult. Assess for learning disability and whether patient has a hospital passport in place. Assess for risk of domestic abuse. Assess falls risk. Complete falls referral if applicable. Document names of persons accompanying patient. v1.1 Feb17 Page 9 of 11

10 APPENDIX B Essential Documentation for All Patients Attending Unit or Centre Child and Young Persons under 18 Years Old Consent Gain consent to be seen by a nurse practitioner Gain consent for treatment and sharing information Assess and document Gillick competency according to Fraser guideline if applicable. Document name of person's accompanying patient Clinical Presentation If unwell assess for: Airway Breathing Circulation Disability Exposure Record PEWS: if any one parameter is triggered transfer to secondary care or seek advice from medical practitioner. Use guideline Traffic Light System (NICE) 2013 if applicable. Use guideline Feverish Illness (NICE) 2013 if applicable. Document pain score using FLACC, Wong Baker Faces or numeric rating scale. Safeguarding Assess safeguarding Assess for domestic abuse in the home Assess for learning disability DOCUMENT ALL FINDINGS IN THE CLINICAL TREATMENT RECORD AND ACT ON THEM FOLLOWING NDHCT GUIDELINES. v1.1 Feb17 Page 10 of 11

11 APPENDIX C Training Competency Form Protocol operational from April 2016 and expires end of April 2019 The registered health professional named below, being employees of Northern Devon Healthcare Trust based at. have received training and are competent to operate under this protocol NAME (please print) PROFESSIONAL TITLE SIGNATURE AUTHORISING MANAGER (please print) MANAGER S SIGNATURE DATE Keep original with the authorising manager and send a copy to: Emergency Department, Northern Devon Healthcare Trust NHS, Raleigh Park, Barnstaple, Devon, EX31 4JB v1.1 Feb17 Page 11 of 11

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Document Control Title Protocol for Insect Bites Stings for Patients in MIUs and WICs Author Author s job title Professional Lead, Minor Injuries Unit Directorate, Logistics and Resilience Department Emergency