Hand and wrist fractures are the most common fracture presentation to accident and emergency departments within the UK. Complications following both simple and complex hand and wrist fractures can have devastating consequences. The British Orthopaedic Association recommends initial assessment in a fracture clinic should take place within 72 hours and any surgery performed within one week. It was the experience of Raymond Anakwe (Consultant Trauma & Orthopaedic Surgeon) of Imperial College Healthcare NHS Trust (ICHNT) that adult patients presenting with hand and wrist fractures, experienced delays in: attending fracture clinics; operative treatment; and in referral to rehabilitation. This resulted in extended recovery times, sub-optimal outcomes, an increased number of hospital visits, and overall poorer patient and staff experience.
An initial retrospective clinical audit, funded by the NIHR CLAHRC NWL showed that 31% (13/42) patients waited over 15 days and another 28% (12/42) patients waited between 8-14 days for surgery following fracture. Further analysis of these delayed patients showed that the most frequent reasons for delay is delay in initial clinical review at fracture clinic.

Key measures of improvement were:
1. (Quantitative) – Time to expert clinical review (initial assessment in virtual fracture clinic) from A&E and/or Urgent Care Centre (UCC) referral
2. (Quantitative) – Time to treatment (fracture clinic / hand therapy) from A&E / UCC referral
3. Patient and staff experience

Pre-existing data source for the quantitative measures (referral software data and Trust data warehouse) was utilised. Qualitative measures of patient and staff experience were captured through a mixed methods, and included online and verbal surveys as well as patient focus groups.

Utilising Quality Improvement methodologies, a new pathway (See Table 1), incorporating a bespoke referral and virtual review software system was implemented to reduce the time between presentation and expert review leading to accelerated triage of patients to one of three destinations: fracture clinic, hand therapy and direct discharge after referral to ICHNT.

Figure3
Table 1: Hand & Wrist virtual Fracture Clinic Pathway

Adult patients with a history of closed hand / wrist trauma, attending one of five services (two A&E departments and three UCCs) were referred to the ICHNT virtual fracture clinic (VFC) from 1st of January 2017.

Interventions

A series of interventions were implemented:

  • On-line referral system replacing paper referral
  • Text message / email system providing supportive information about injury, pathway and Virtual Fracture Clinic (VFC) contact details
  • Telephone support clinic
  • Follow-up phone call to discharged patients responding to questions / providing specific advice
  • Patient information leaflets developed and uploaded onto a public website
    • Education sessions delivered to healthcare professionals working in four of the five affiliated referral sources

There was on-going engagement of stakeholders through meetings and presentations to develop and support the new pathway, this facilitated objective setting and process mapping sessions to identify the problem and design the solutions. Evaluation of the intervention occurred on an ongoing basis using Statistical Process Control.

Improvement Findings

From the start of the project (January 2017 – December 2017) 2,449 patients have been referred to the Virtual Fracture Clinic. In the traditional referral model 100% of patients were referred to the Hand Clinic for a one to one consultation. However, following improvements by the project (see figure 1), 40% of patients were either discharged or referred to hand therapy directly from the Virtual Fracture Clinic.

SankeyDiagram
Figure 1: Hand & Wrist Virtual Fracture Clinic Flow Results 

In addition, the average time from referral to expert review (virtual fracture clinic) has been reduced to less than one day (see Figure 2).

TimeToClinicalReview
Figure 2: Average Time from Referral to VFC Clinical Review

As a balancing measure the number of patients re-entering the pathway following direct discharge were also monitored. Seventeen percent of patients discharged directly re-entered the pathway and were seen in the fracture clinic or hand therapy. Further analysis is on-going to better understand this.

Staff and Patient Feedback

Results of an anonymised survey indicated that hand therapy staff were happy with the direct to hand therapy referral pathway. However clarity was needed on patient referral to a consultant if a problem was detected.

A focus group and phone survey of patients regarding experience and satisfaction, as well as review of email and telephone conversation content, were implemented.  Results indicated satisfaction with the system and the level of information given.  Patients were pleased to have avoided unnecessary hospital attendances.


References:

  1. https://www.boa.ac.uk/wp-content/uploads/2014/12/BOAST-7.pdf Access date: 2 February 2018
  1. Jenkins PJ, Morton A, Andersen G et al. Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care. Bone Joint Res 2016.5(2):33-36.
  2. Vardy J, Jenkins PJ, Clark K et al. Effect of a redesigned fracture management pathway and ‘virtual’ fracture clinic on ED performance. BMJ Open. 2014.13;4(6)
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