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11-2018

posted 1 Nov 2018, 09:23 by Cherelle Augustine

Hand and Wrist Virtual Fracture Clinic Pathway


Most common fracture presentation to A&E departments, UK

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 should be 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, 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.


Introduction of a new pathway

The Hand and Wrist Virtual Fracture Clinic planned to ensure prompt access for patients with fractures to receive expert review within 72 hours, to achieve better patient outcomes, improve quality of care and improve efficiency of the system. In the pre-intervention clinical review model, 100% of patients were referred from A&E to the Hand Clinic for a face-to-face consultation with an orthopaedic consultant (average 10 days from referral to expert review, audit 2016).

 

A new pathway (See Table 1), incorporating implementation of e-referral and virtual review software was implemented to reduce the time between presentation and expert review. This led to accelerated triage of patients to one of three destinations: fracture clinic, hand therapy and direct discharge after initial presentation via Urgent care centres or ICHT A&Es.


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 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

 

Following the introduction of the Hand and Wrist Virtual Fracture Clinic, 2,449 patients were referred to the service: 60% of patients (1,451) were referred to the Hand Clinic; 22% of patients (549) were discharged with information on how to self-manage their injury; and 18% (449) were directly triaged to hand therapy. The time to expert review reduced from an average of 10 days to an average of 1 day.

The tariff for face-to-face initial hand (fracture) clinic consultation is costed at £151 per patient. For this project, 2449 patients were referred to Virtual Fracture Clinic. In the traditional pathway, all these patients would have been referred to the hand (fracture) clinic incurring a cost of £369,799. With the introduction of the Virtual Fracture Clinic Pathway, only 1451 patients were referred for a hand (fracture) clinic consultation costing £219,101 and resulting in a potential cost saving of £150,698 (setup and running costs not included).

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