Fracture clinic redesign reduces the cost of outpatient orthopaedic trauma care

A national multicentre study of outcomes and patient satisfaction with the virtual fracture clinic and the influence of the COVID-19 pandemic: The MAVCOV study

BACKGROUND

Virtual fracture clinics (VFCs) are advocated by the British Orthopaedic Association Standards for Trauma (BOAST). We aimed to assess the impact of the transition from face-to-face fracture clinic review and identify any change in clinical outcome and patient satisfaction.

METHODS

A national, cross-sectional cohort study of VFCs across the UK over two separate two-week periods pre- and during the first UK COVID-19 lockdown was undertaken. Data comprising patient and injury characteristics, unplanned reattendance and complications within three months following discharge from VFC were collected by local collaborators. Telephone questionnaires were conducted to determine patient satisfaction and patient-reported outcome for patients discharged without face-to-face consultation. The primary outcome measure was the percentage of unplanned reattendances after direct discharge from VFC.

RESULTS

Data was analysed for 51 UK VFCs comprising 6134 patients from the pre-pandemic group (06/05/2019-19/05/2019) and 4366 patients from the first UK lockdown (04/05/2020-17/05/2020). During lockdown, the rate of direct discharge from VFC increased significantly (odds ratio (OR) 2.01, p<0.001) from 30 % (n = 1856/6134) to 46 % (n = 2021/4366). The rate of compliance with BOAST guidance recommending fracture clinic review within three days increased (OR 1.93, p<0.001) from 82 % (n = 5003/6134) to 89 % (n = 3883/4366). There were no differences in the rates of unplanned reattendance (6 % pre- and 7 % during lockdown, p = 0.281) or complications (0.2 % for both, p = 0.815). There were 1527/3877 patients discharged without face-to-face review from VFC who completed telephone questionnaires (mean follow-up 18-months in pre-pandemic group and 6-months in lockdown group). Satisfaction was high in both cohorts (80 % pre- and 76 % lockdown, p = 0.093). Dissatisfaction was associated with an unplanned reattendance (p<0.001) or a missed injury (p<0.05).

CONCLUSION

Despite a significant rise in direct discharge from VFC, there was no significant change in unplanned attendances, complications, or patient satisfaction. However, there are factors associated with dissatisfaction and these should be considered in the evolution of VFC.

Letter-only discharge process for virtual fracture clinic, a safe alternative to telephone discharge, outcomes and 12 month follow up for 1140 patients

Telephone consult has become the accepted discharge method for virtual fracture clinic (VFC) within the United Kingdom. Telephone consultations are time consuming; many orthopaedic units lack the resources and staff to deliver large numbers of daily telephone consultations which may block the development of an effective VFC. Our study aim was to validate a letter only VFC discharge process for safety and efficacy. A letter only discharge VFC was instigated in response to the COVID-19 pandemic (April 2020). No ethical approval was required, the protocol was designed as a phased service evaluation and improvement project after change in practice. After smaller pilot audits, a comprehensive review of discharges outcomes from the VFC August-September 2021 (Phase 1) and January-March 2022 (Phase 2) was completed. Electronic letters, AE (accident and emergency) attendances and PACS database images (radiography and scans) taken over a 12 month follow up were analysed for failed discharges and adverse outcomes. Of 4810 patients reviewed in VFC, 1140 were discharged (24%). Mean patient age; 35 years (range 2-98), two thirds of patients were adults (>16 years). 116 (10%) returned with symptoms related to their initial presentation usually within the first few weeks via contact with the VFC helpline. Of the returning patients 65 were discharged again with the same advice, 48 underwent further imaging (CT/ MRI/ US scanning). 6 patients (0.5%) underwent surgery for problems relating to the initial injury; 2 knee meniscal repair/debridement, 1 ACL reconstruction, 1 fixation fifth metatarsal non-union, 2 shoulder arthroscopy. All surgeries were performed on elective timescales between 4 and 12 months after injury. Discharging letters detailed rehabilitation and symptom resolution timeframes. Our approach did not result in high return rates or adverse events (unexpected operations) in comparison to published traditional telephone discharge VFC. Units with limited staffing resources wishing to implement a VFC could safely adopt this approach as an alternative to telephone discharge.

The virtual knee clinic - A tool to streamline new outpatient referrals

INTRODUCTION

Traditionally it has been the case for orthopaedic consultants to review GP referrals for the orthopaedic outpatient clinic where possible in amongst other clinical commitments. This could sometimes lead to unsuitable patients being reviewed and both patients and clinicians becoming frustrated. Building on the virtual fracture clinic, a new screening tool was implemented to streamline new referrals. The aim of this study is to investigate the change in patients given outpatient appointments following the introduction of a new streamlining protocol.

METHODS

Referrals had to meet the criteria of BMI under 40 or evidence of weight loss effort, recent radiographs and appropriate clinical details in keeping with Getting It Right First Time (GIRFT). Consultant were given dedicated clinical time to review and either triage the patient to the most appropriate clinic type, or return the referral with advice to the GP. 10 months of data was collected prior to the protocol and 10 months after implementation.

RESULTS

1781 patients were referred pre-protocol with an average of 14.2% of these being returned. Post protocol there were 2110 patients referred with 31.2% returned. There was an increase in 195% of referrals returned to the GP (p < 0.0001). The highest proportion of these was for mild to moderate osteoarthritis on the radiograph which has been proven to be unsuitable for intervention. At 12 month analysis there was no significant increase in patients re-referred to the service (p = 0.53) DISCUSSION: The new screening tool allows more appropriate referrals to be seen in clinic allowing less frustration to clinicians and patients by reducing therapeutic inertia. Furthermore it allows new referrals to be seen by the most appropriate sub-specialist. It allows advice to be given to GPs on further management for the patient. 619 appointments were saved. At a cost of £120 per appointment, this leads to a real terms cost saving of £74,280, with further savings in time and travel.

Hand Trauma Virtual Clinics Prove Effective During the COVID-19 Pandemic

BACKGROUND

Due to the devastating and far-reaching impact of the novel COVID-19 pandemic, hospital resources have been redirected to protect patients and health care staff, thereby vastly reducing the capacity for outpatient follow-up within a busy Plastic Surgery and Hand Trauma center. Through the use of telephone and video technology, virtual clinics were rapidly introduced to reduce hospital footfall.

METHODS

This retrospective cohort study analyzed patient experiences in virtual and traditional face-to-face clinics through the month of April 2020, from the second week of the government-imposed lockdown. A 5-point Visit-Specific Satisfaction Questionnaire was used to subsequently collect patients' feedback regarding their appointments.

RESULTS

A total of 107 hand injury-related follow-up appointments were recorded during the 4-week period. Sixty (56.0%) appointments were performed as a virtual consultation, and 47 (43.9%) face-to-face consultations were carried out on site. It was possible to discharge 43.3% from the virtual clinic group and 57.4% from the face-to-face group. We identified no significant difference in patient satisfaction (P = .368, Mann-Whitney U test) between the 2 cohorts.

CONCLUSION

Virtual clinics appear to be safe and effective for the follow-up of patients with traumatic hand injuries during the COVID-19 pandemic. This approach may prove beneficial in terms of workforce organization, reducing waiting times, and providing an alternative for patients unable to attend physical appointments.

A Virtual Fracture Clinic Pathway for Managing Suspected Paediatric Scaphoid Fractures

Introduction: The mismanagement of an occult scaphoid fracture is a significant concern in patients presenting with anatomical snuffbox tenderness and no radiographic signs of injury.

Aim: This study investigated whether a virtual fracture clinic (VFC) could improve care efficiency and expedite management decisions surrounding suspected pediatric scaphoid fractures.

Method: Data was reviewed for patients referred via the VFC for suspected scaphoid fractures at a local trauma unit over 19 months. Patients received an "appointment" in VFC. Based on their notes and imaging, patients were referred to an outpatient clinic for repeat radiographs within two weeks (if initial radiographs demonstrated no fracture). Patients with unremarkable second x-rays were contacted and informed to mobilize and return if the pain persisted at four weeks.

Results: The pathway received 175 referrals; 114 male, 61 female, mean age 14 years, range 9-17) with 42 scaphoid fractures diagnosed, 35 (83.3%) on first x-ray, and 7 (16.7%) occult fractures. The pathway managed all patients as intended; 71 patients were seen face-to-face in the clinic due to age or pathology picked up on the first x-ray, and 104 required repeat radiographs. Following the second radiograph, 78 patients were discharged directly. Twenty-six patients required further review in a face-to-face clinic after their second radiograph.

Conclusion: VFC appears to be a safe and efficient method of managing patients with suspected scaphoid fractures on short-term follow-up analysis. This cohort presents no 'missed' injuries and therefore appears safe compared to conventional treatment pathways.

Innovation in Orthopedics: Part 1-Design Thinking

Purpose of Review

This narrative will focus on the adoption of design thinking to improve patient-centered care innovation in Orthopedics.

Recent Findings

The literature reveals a complete set of applications of the design thinking approach in the different stages of the patient experience throughout the health context; however, the papers identified focus on specific parts of the process, and there is no systemic analysis about the different aspects involved in each stage of the complete experience. This review presents a holistic analysis concerning the application of design thinking to the distinct phases of innovation development in orthopedics, from the identification of the specific initial challenges up to the introduction of technology-based artifacts, such as innovations in the musculoskeletal health market.

Summary

Systematic description of design thinking application to orthopedics, including concepts, methods, tools, and implementation examples in the most relevant phases of the patient experience—clinical treatment, perioperative care, and rehabilitation.

Remote Follow-up of Shoulder Arthroplasty Patients During COVID-19 Pandemic - Is This the way Forward?

Background

The COVID-19 Pandemic has affected the way health care systems function across the globe. Apart from eliminating the risk of being in a vulnerable environment during the pandemic such as a hospital setting, virtual arthroplasty follow-up reduces the demand on funding and resources on the National Health Services (NHS).

Methods

We retrospectively reviewed our shoulder arthroplasty patients (55) operated between October 2018 to November 2020 at both our hospital sites. For remote follow-up, patients were contacted on a scheduled appointment date via telephone by an orthopaedic surgeon to enquire about their wound, pain and function. Patients were questioned as per questionnaire from the Oxford Shoulder Score (OSS) and American Shoulder and Elbow Surgeons (ASES) Standardised Assessment form.

Results

50 patients were included in the final data set after excluding those who had died (5 patients). All patients had had final x-rays with full Covid-19 precautions at the time of final follow-up. No patient had wound problems except one who had concerns of wound appearance. There were no cases of notching, impingement, deep infection, dislocation or nerve injury. Of the 50 patients, 40 (80%) patients were satisfied to have a remote follow-up. 36 (72%) patients said they wouldn't mind a remote follow-up appointment.

Conclusion

Remote follow-up via audio consultation may be an effective alternative to in person visits after shoulder arthroplasty. Patients in this series demonstrated a high level of satisfaction with virtual visits and post-operative complications were effectively identified.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center

Objectives:

Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic.

Design:

Retrospective chart review.

Setting:

Outpatient visits (in-person, telephone, virtual—Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic.

Intervention:

Virtual visits utilizing the Doxy.me platform.

Main Outcome Measures:

Accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Methods:

All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Results:

Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028).

Conclusion:

A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

The Use of Telehealth for Orthopedic Consultations and Assessments: A Systematic Review

As a result of the coronavirus disease 2019 (COVID-19) pandemic, tele-health for orthopedic care is expanding rapidly. The authors sought to identify the evidence describing the effectiveness, barriers, and clinical applications of telehealth for orthopedic assessments and consultations. MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched from inception to March 2020. Forty-seven studies were included, with the most common conditions evaluated being trauma related and the primary modality being videoconferencing. Available literature supports the use of telehealth for orthopedic consultations and assessments because it yields moderate-to-high patient and provider satisfaction, accurate examinations, cost-effectiveness, and reduced wait times. Most commonly reported concerns were professional liability, network security, and technical issues. Given the COVID-19 pandemic, rapid implementation and uptake of virtual assessment for patient care has occurred. The current evidence suggests that telehealth is capable of providing prompt access to quality, cost-efficient orthopedic consultations and assessments. [Orthopedics. 2021;44(4):198--206.].

Currents concepts of the perioperative management of closed ankle fractures

Ankle fractures are common injuries that can result in substantial morbidity in the population. This review discusses the management of closed ankle fractures and outlines the recent evidence and guidelines on perioperative management. In general, a detailed history should be undertaken, followed by examination and imaging of the affected limb. Fixation is based on the AO principles of fracture management that aims towards restoring stability of the joint and reducing the risk of long-term complications. A multidisciplinary approach towards perioperative management is recommended in view of the increasing proportion of aging patients with significant comorbidities.

Embracing virtual outpatient clinics in the era of COVID-19

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future. Cite this article: Bone Jt Open 2021;2(5):301-304.

The impact of digitisation of a virtual fracture clinic on referral quality, outcomes and assessment times

BACKGROUND

Virtual fracture clinics (VFCs) have become widely adopted, aiming to improve efficiency, standardise patient care and reduce clinic appointments for injuries that can be managed conservatively. A variety of means exist to manage VFC referrals and assessment, including paper-based and digital methods. This study assesses VFC referral quality and outcomes before and after implementation of a digital VFC referral and management system.

METHODS

A retrospective analysis was conducted of all VFC referrals and assessments from July 2017-March 2020 in a large UK district general hospital. All referrals and assessments were analysed for quality and completeness of referral information, grade of assessor, outcome of assessment, referral-to-assessment time, and assessment-to-surgery time (for those requiring operative management).

RESULTS

3038 paper and 9,228 digital referrals were analysed by 2 separate reviewers. Quality and completeness of referral information showed significant improvement in 11 predetermined key data points with the digital referral system (p < 0.001). Date and mechanism of injury were the most commonly missing data criteria (67.5% and 68.2%, respectively) with paper referrals. Significant improvements were noted in the proportion of Consultant delivered VFC assessments (84.2% vs 71.0%; p < 0.001), VFC discharge rate (20.8% vs 13.1%; p < 0.001) and patients recalled for urgent review (6.2% vs 0.8%; p < 0.001) with digital referrals. Mean referral-to-assessment (31.2 vs 49.9 h; p < 0.001) and assessment-to-surgery (9.2 vs 13.0 days; p = 0.01) times also reduced significantly with referral digitisation.

CONCLUSION

Improvements in virtual referral quality and completeness directly lead to facilitation of more thorough, detailed and appropriate virtual assessments; improving timely decision-making, reducing unnecessary appointments, and permitting better prioritisation of workload and earlier surgery for patients requiring operative treatment. Purpose-built digital solutions are an excellent means of achieving these aims.

Establishing a Virtual Clinic for Developmental Dysplasia of the Hip: A Prospective Study

BACKGROUND

The aim was to describe the introduction and operation of a virtual developmental dysplasia of the hip (DDH) clinic. Our secondary objectives were to provide an overview of DDH referral reasons, treatment outcomes, and adverse events associated with it.

METHODS

A prospective observational study involving all patients referred to the virtual DDH clinic was conducted. The clinic consultant delivered with 2 DDH clinical nurse specialists (CNS). The outcomes following virtual review include further virtual review, CNS review, consultant review or discharge. Treatment options include surveillance, brace therapy, or surgery. Efficiency and cost analysis were assessed.

RESULTS

Over the 3.5-year study period, 1002 patients were reviewed, of which 743 (74.2%) were female. The median age at time of referral was 7 months, (interquartile range of 5 to 11) with a median time to treatment decision of 9 days. Median waiting times from referral to treatment decision was reduced by over 70%. There were 639 virtual reviews, 186 CNS reviews, and 144 consultant reviews. The direct discharge rate was 24%. One hundred one patients (10%) had dislocated or subluxed hips at initial visit while 26.3% had radiographically normal hips. Over the study period 704 face to face (F2F) visits were avoided. Cost reductions of €170 were achieved per patient, with €588,804 achieved in total. Eighteen parents (1.8%) opted for F2F instead of virtual review. There were no unscheduled rereferrals or recorded adverse events.

CONCLUSION

We report the outcomes of the first prospective virtual DDH clinic. This clinic has demonstrated efficiency and cost-effectiveness, without reported adverse outcomes to date. It is an option to provide consultant delivered DDH care, while reducing F2F consults.

LEVEL OF EVIDENCE

Level III.

A multicentre national study of the effectiveness of virtual fracture clinic management of orthopaedic trauma during the COVID-19 pandemic (MAVCOV): a cross-sectional study protocol

Aims

Virtual fracture clinics (VFCs) are advocated by recent British Orthopaedic Association Standards for Trauma and Orthopaedics (BOASTs) to efficiently manage injuries during the COVID-19 pandemic. The primary aim of this national study is to assess the impact of these standards on patient satisfaction and clinical outcome amid the pandemic. The secondary aims are to determine the impact of the pandemic on the demographic details of injuries presenting to the VFC, and to compare outcomes and satisfaction when the BOAST guidelines were first introduced with a subsequent period when local practice would be familiar with these guidelines.

Methods

This is a national cross-sectional cohort study comprising centres with VFC services across the UK. All consecutive adult patients assessed in VFC in a two-week period pre-lockdown (6 May 2019 to 19 May 2019) and in the same two-week period at the peak of the first lockdown (4 May 2020 to 17 May 2020), and a randomly selected sample during the ‘second wave’ (October 2020) will be eligible for the study. Data comprising local VFC practice, patient and injury characteristics, unplanned re-attendances, and complications will be collected by local investigators for all time periods. A telephone questionnaire will be used to determine patient satisfaction and patient-reported outcomes for patients who were discharged following VFC assessment without face-to-face consultation.

Ethics and dissemination

The study results will identify changes in case-mix and numbers of patients managed through VFCs and whether this is safe and associated with patient satisfaction. These data will provide key information for future expert-led consensus on management of trauma injuries through the VFC. The protocol will be disseminated through conferences and peer-reviewed publication. This protocol has been reviewed by the South East Scotland Research Ethics Service and is classified as a multicentre audit.

Cite this article: Bone Jt Open 2021;2(3):211–215.

Assessment of the Efficacy of Telephone Medicine Consultations in Trauma and Orthopaedics During COVID-19 Using the Ashford Clinic Letter Score

During the coronavirus disease 2019 (COVID-19) pandemic, our aim was to protect staff and patients, therefore, face-to-face clinics were converted to telephone clinics. We retrospectively compared two groups of patients: those seen in traditional clinics pre-COVID-19 and those who had telephone clinics during the pandemic. The mean Ashford Clinic Letter Score (ACLS) for the face-to-face clinic letters was 6.7, and the letters from both groups of telemedicine appointments scored better; the first group scoring 7.1 and the second 7.45. The pandemic allowed us to show that telephone clinics are effective and can be superior to traditional clinics in a specific set of patients.

Effectiveness, Patient Satisfaction, and Cost Reduction of Virtual Joint Replacement Clinic Follow-Up of Hip and Knee Arthroplasty

BACKGROUND

Total hip and knee arthroplasties are increasingly performed operations, and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients' satisfaction, and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of total hip arthroplasty and total knee arthroplasty patients in a university hospital. VJRC is especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic.

METHODS

A total of 1749 patients who were invited for VJRC follow-up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week postoperative review. Routine VJRC postoperative review was undertaken at 1 and 7 years and then 3-yearly thereafter. We evaluated the VJRC patient response rate, acceptability, and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow-up.

RESULTS

The VJRC had a 92.05% overall response rate. Only 7.22% required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £42,644 per year at our institution. The patients' satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up.

CONCLUSION

VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.

Retrospective cohort study evaluating the efficacy and safety of an orthopaedic consultant-led virtual fracture clinic in an Australian level 1 trauma centre

BACKGROUND

In Australian health care, the consistent rise in demand for orthopaedic outpatient clinic services is creating marked challenges in the provision of quality care. This study investigates the efficacy and safety of a virtual fracture clinic (VFC) as an alternative model of care for the management of acute injuries and musculoskeletal conditions in the Australian public hospital setting.

METHODS

A retrospective cohort study of consecutive emergency department (ED) referrals to the Department of Orthopaedic Surgery was conducted comparing outcomes prior to (November 2015-February 2017) and after (March 2017-June 2018) implementation of a VFC. The primary outcome measures assessed were the proportion of referrals virtually discharged and unplanned 30-day ED re-attendance rates.

RESULTS

A total of 737 (36.4%) referrals managed by the VFC were discharged without requiring orthopaedic outpatient clinic attendance. The rate of unplanned ED re-attendances was 5.2% post-VFC implementation compared to 6.5% at baseline (P = 0.01). VFC implementation was also associated with reductions in the average number of orthopaedic outpatient clinic attendances per referral (1.1 versus 1.7, P < 0.01) and the number of referrals lost to follow-up (7.2% versus 14.7%, P < 0.01). In addition, patient wait times for first contact by the orthopaedic team were significantly reduced from a median of 7 (IQR 5, 9) days to 2 (IQR 1, 3) days post-intervention (P < 0.01). No complications or adverse events were reported.

CONCLUSION

This study demonstrates that a VFC is applicable to the Australian healthcare system, and can lead to effective and safe provision of orthopaedic outpatient care.

Primary care pathway- a novel way to reduce the burden on orthopaedic fracture clinics within the pediatric subgroup: A Queensland multi-centered review

ABSTRACT

Emergency departments receive an increasing amount of musculoskeletal injuries, with the majority referred to a fracture clinic (FCs). A literature review revealed certain orthopaedic injuries can be safely managed away from the FC pathway by general practitioners (GPs) or allied health professionals (AHPs). The present study aims to review all paediatric presentations to FCs at 2 Queensland hospitals, identifying low risk injuries that could potentially be managed by GPs or AHPs. This study is a continuation from Cleary et al in which a primary care pathway (PCP) was proposed for the management of low risk adult orthopaedic injuries. A PCP has the potential to have significant savings to the health system.A retrospective study was conducted looking at paediatric patients (<16 years) referrals to 2 FCs over 8 weeks. Injuries were categorised into those requiring FC care supervised by an orthopaedic surgeon, and those that can be safely managed by GPs or AHPs via a PCP.Four hundred ninety (57.7%) of the 849 patients referred to FC were assessed as suitable for PCP care. The most common upper limb injury deemed suitable was radius and ulna buckle fractures (18.4%), while the most common lower limb injury is ankle sprains (8%). Total failure to attend rate in the PCP group was 6.7%.Adopting the PCP has the potential to significantly reduce FC referrals. With proven success of similar pathways abroad, the PCP may generate significant time and financial savings for both the health care system and patient.

The success of virtual clinics during COVID-19: A closed loop audit of the British orthopaedic association (BOAST) guidelines of outpatient orthopaedic fracture management

COVID-19 has had profound management implications for orthopaedic management due to balancing patient outcomes with clinical safety and limited resources. The BOAST guidelines on outpatient orthopaedic fracture management took a pragmatic approach. At Great Western Hospital, Swindon, a closed loop audit was performed looking at a selection of these guidelines, to assess if our initial changes were sufficient and what could be improved.

METHOD

An audit was designed around fracture immobilisation, type of initial fracture clinic assessment, default virtual follow up clinic and late imaging. Interventions were implemented and re-audited.

RESULTS

Initially 223 patients were identified over 4 weeks. Of these, 100% had removable casts and 99% did not have late imaging. 96% of patients were initially assessed virtually or had initial orthopaedic approval to be seen in face to face clinic. 97% had virtual follow up or had documented reasons why not. The 26 patients who were initially seen face to face were put through a simulated virtual fracture clinic. 22 appointments and 13 Xray attendances could have been avoided. We implemented a change of requiring all patients to be assessed at consultant level before having a face to face appointment. The re-audit showed over 99% achievement in all areas.

CONCLUSION

Virtual fracture clinics, both triaging new patients and follow-up clinics have dramatically changed our outpatient management, helping the most appropriate patients to be seen face to face. Despite their limitations, they have been well tolerated by patients and improved patient safety and treatment.

Virtual Fracture Clinics in Orthopaedic Surgery - A Systematic Review of Current Evidence

AIMS

Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs.

MATERIALS AND METHODS

Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis.

RESULTS

Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was £71, with a mean saving of £53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively.

DISCUSSION AND CONCLUSION

This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns.

LEVEL OF EVIDENCE

IV; Systematic Review of all Levels of Evidence.

Virtual consultations: delivering outpatient clinics in paediatric surgery during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has resulted in many changes to clinical practice, including the introduction of remote clinics. Those familiar with remote clinics have reported benefits to their use, such as patient satisfaction and cost benefits; however, ongoing challenges exist, including delivering optimal patient-centred care. As a tertiary paediatric surgery unit in the UK, completing remote clinics was a new experience for most of our surgical team. We completed a service evaluation early into the COVID-19 pandemic aiming to define and address issues when delivering remote clinics in paediatric surgery. Remote clinics were observed (telephone and video), with follow-up calls to families following the consultations.

RESULTS

Eight paediatric surgeons were observed during their remote clinics (telephone n = 6, video n = 2). Surgeons new to remote clinics felt their consultations took longer and were reluctant to discharge patients. The calls did not always occur at the appointed time, causing some upset by parents. Prescription provision and outpatient investigations led to some uncertainty within the surgical team. Families (n = 11) were called following their child's appointment to determine how our remote clinics could be optimised. The parents all liked remote clinics, either as an intermediate until a face-to-face consultation or for continued care if appropriate.Our findings, combined by discussions with relevant managers and departments, led to the introduction of recommendations for the surgical team. An information sheet was introduced for the families attending remote clinics, which encouraged them to take notes before and during their consultations.

CONCLUSIONS

There must be strong support from management and appropriate departments for successful integration of remote clinics. Surgical trainees and their training should be considered when implementing remote clinics. Our learning from the pandemic may support those considering integrating remote clinics in the future.

Are Virtual Fracture Clinics During the COVID-19 Pandemic a Potential Alternative for Delivering Fracture Care? A Systematic Review

BACKGROUND

Virtual fracture clinics are an alternative to the traditional model of fracture care. Since their introduction in 2011, they have become increasingly used in the United Kingdom and Ireland. The coronavirus disease 2019 (COVID-19) health crisis has driven institutions to examine such innovative solutions to manage patient care. The current controversies include quantifying safety outcomes, such as potential delayed or missed injuries, inadequate treatment, and medicolegal claims. Questions also exist regarding the potential for cost reductions and efficiencies that may be achieved. Physical distancing has limited the number of face-to-face consultations, so this review was conducted to determine if virtual fracture clinics can provide an acceptable alternative in these challenging times.

QUESTIONS/PURPOSES

The aim of this systematic review was to describe (1) adverse outcomes, (2) cost reductions, and (3) efficiencies associated with the virtual fracture clinic model.

METHODS

A systematic review of the PubMed, MEDLINE, and Embase databases was conducted from database inception to March 2020. The keywords "virtual" or "telemedicine" or "telehealth" or "remote" or "electronic" AND "fracture" or "trauma" or "triage" AND "clinic" or "consultation" were entered, using the preferred reporting items for systematic reviews and meta-analyses. Inclusion criteria included adults and children treated for injuries by a virtual clinic model at the initial review. Eligible injuries included injuries deemed to not need surgical intervention, and those able to be treated remotely using defined protocols. Exclusion criteria consisted of patients reviewed by telemedicine using video links or in person at the initial review. Initially, 1065 articles were identified, with 665 excluded as they did not relate to virtual fracture clinics. In all, 400 articles were screened for eligibility, and 27 full-text reviews were conducted on 18 studies (30,512 virtual fracture clinic encounters). Three subdomains focusing on adverse outcomes, cost reductions, and efficiencies were recorded. The term adverse outcomes was used to describe any complications, further surgeries, re-referrals back to the clinic, or deviations from the protocols. Efficiency described the number of patients reviewed and discharged using the model, savings in clinic slots, reduced waiting times, or a reduction in consumption of resources such as radiographs. All studies were observational and the quality was assessed using Newcastle-Ottawa tool, which demonstrated a median score of 6 ± 1.8, indicating moderate quality.

RESULTS

Six studies reported adverse outcomes in detail, with events ranging from inappropriate splinting, deviations from protocols, and one patient underwent an osteotomy for a malunion. Efficiency varied from direct discharge proportions of 18% in early studies to 100% once the virtual fracture clinic model was more established. Cost reductions compared with estimates derived from conventional fracture clinics varied from USD 53 to USD 297 and USD 39,125 to USD 305876 compared with traditional fracture clinic visits.

CONCLUSIONS

Virtual fracture clinics may provide a means to treat patients remotely, using agreed-upon protocols. They have an important role in the current COVID-19 pandemic, due to the possibility to provide ongoing care in an otherwise challenging setting. More robust studies looking at this model of care will be needed to assess its long-term effects on patients, institutions, and health care systems.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

How useful are virtual fracture clinics?: a systematic review

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

Methods

We performed a systematic literature search of all papers pertaining to VFCs, using the search engines PubMed, MEDLINE, and the Cochrane Database, according to the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist. Searches were carried out and screened by two authors, with final study eligibility confirmed by the senior author.

Results

In total, 21 records were relevant to our research question. Six orthopaedic injuries were identified as suitable for VFC review, with a further four discussed in detail. A reduction of face to face appointments of up to 50% was reported with greater compliance to BOAST guidelines (46.4%) and cost saving (up to £212,000).

Conclusions

This systematic review demonstrates that the VFC model can help deliver a safe, more cost-effective, and more efficient arm of the trauma service to patients.

Cite this article: Bone Joint Open 2020;1-11:683–690.

A Service Evaluation after 4 year's use of the Virtual Fracture Clinic model by a District General Hospital in the South West of England

INTRODUCTION

A Virtual fracture clinic (VFC) was set up in 2015. An initial patient satisfaction survey demonstrated satisfaction with the service. The purpose of this service evaluation was to re-evaluate the VFC by reporting on patient satisfaction. A small audit was undertaken alongside to examine the time taken from ED presentation to VFC review against the British Orthopaedic Association Society for Trauma (BOAST) guidelines of 72 h.

PATIENTS AND METHODS

All patients discharged from VFC in August 2019 were eligible to take part in the patient satisfaction survey. The Electronic Patients Records System (EPRS) was used to generate data regarding time of review and patient return for follow up appointments.

RESULTS

The results demonstrated that 88% of patients would recommend the service to friends. More than 80% of patients were satisfied with various elements of the service and 80% of patients are seen within the target time of 72 h.

CONCLUSIONS

Patients continue to be satisfied with the VFC. There seems to be a greater acceptance of not being reviewed by a doctor. In general, patients were seen within 72 h of ED presentation but more work is needed to streamline the process of tertiary referrals.

The virtual fracture clinic improves quality of care for patients with hand and wrist injuries: an assessment of 3709 patients

Fracture clinic services are under significant pressures to meet patients' expectations of a high-quality service. The virtual fracture clinic has shown early promise in helping to reduce such pressures. We used the virtual fracture clinic for hand and wrist injuries treated in the orthopaedic fracture clinic and used key quality indicators to measure improvement. Over the first 21 months, key patient outcome measures and satisfaction scores for patients discharged from the virtual fracture clinic with education to self-care were excellent. Our results show that a virtual fracture clinic model can be applied to provide high-quality care for hand and wrist injuries. The main advantage of the virtual fracture clinic is its ability to direct patients to the right person for timely treatment. We conclude from our 21-month experience that this model of care allows safe, effective, patient-centred, efficient and equitable care to the patients with hand and wrist fractures.Level of evidence: IV.

Patient care modifications and hospital regulations during the COVID-19 crisis created inequality and functional hazard for patients with orthopaedic trauma

PURPOSE

The COVID pandemic has decreased orthopaedic fracture operative intervention and follow-up and increased the use of virtual telemedicine clinics. We assessed the implications of this management on future orthopaedic practice. We also surveyed patient satisfaction of our virtual fracture follow-up clinics.

METHOD

We prospectively analysed 154 patients during two weeks of 'lockdown' assessing their management. We surveyed 100 virtual fracture clinic follow-up patients for satisfaction, time off work and travel.

RESULTS

Forty-nine percent of patients had decisions affected by COVID. Twelve percent of patients were discharged at diagnosis having potentially unstable fractures. These were all upper limb fractures which may go onto mal-union. Twenty-nine percent of patients were discharged who would have normally had clinal or radiological follow-up. No patients had any long-term union follow-up. Virtual telemedicine clinics have been incredibly successful. The average satisfaction was 4.8/5. In only 6% of cases, the clinician felt a further face-to-face evaluation was required. Eighty-nine percent of patients would have chosen virtual follow-up under normal conditions.

CONCLUSION

Lessons for the future include potentially large numbers of upper limb mal-unions which may be symptomatic. The non-union rate is likely to be the same, but these patients are unknown due to lack of late imaging. Telemedicine certainly has a role in future orthopaedic management as it is well tolerated and efficient and provides economic and environmental benefits to both clinicians and patients.

An analysis of virtual fracture clinics in orthopaedic trauma in the UK during the coronavirus crisis

Virtual fracture clinics (VFC) are advocated by new orthopaedic (British Orthopaedic Association) and National Health Service (NHS) guidelines in the United Kingdom. We discuss benefits and limitations, reviewing the literature, as well as recommendations on introducing a VFC service during the coronavirus pandemic and into the future.A narrative review identifying current literature on virtual fracture clinic outcomes when compared to traditional model fracture clinics in the UK. We identify nine relevant publications related to VFC.The Glasgow model, initiated in 2011, has become the benchmark. Clinical efficiency can be improved, reducing the number of emergency department (ED) referrals seen in VFC by 15-28% and face-to-face consultations by 65%. After review in the VFC, 33-60% of patients may be discharged. Some studies have shown no negative impact on the ED; the time to discharge was not increased. Patient satisfaction ranges from 91-97% using a VFC service, and there may be cost-saving benefits annually of £67,385 to £212,705. Non-attendance may be reduced by 75% and there are educational opportunities for trainees. However, evidence is limited; 28% of patients prefer face-to-face consultations and not all have access to internet or email (72%).We propose a pathway integrating the VFC model, whilst having senior orthopaedic decision makers available in the ED, during normal working hours, to cope with the pandemic. Beyond the pandemic, evidence suggests the Glasgow model is viable for day-to-day practice. Cite this article: EFORT Open Rev 2020;5:442-448. DOI: 10.1302/2058-5241.5.200041.

Working through the COVID-19 outbreak: Rapid review and recommendations for MSK and allied heath personnel

The coronavirus (COVID-19) pandemic has caused the world to undergo unprecedented change in a short space of time. This disease has devastated the economy, infringed personal freedom, and has taken a toll on healthcare systems worldwide. This review aims to highlight aspects of this pandemic with a specific emphasis on musculoskeletal work within the secondary care setting.

Reducing attendance at trauma clinics by providing first-point-of-contact treatment

In 2016, the urgent and ambulatory care service in Oxfordshire formed part of a cross-organisational partnership working group. The group consisted of Oxford Health NHS Foundation Trust community minor injury units (MIUs) at Abingdon and Witney, and Oxford University Hospitals NHS Foundation Trust (OUH) trauma and orthopaedic specialties and emergency department (ED). The aim was to redesign fracture management pathways and delivery of definitive care at patients' first point of contact with the NHS. This article discusses the implementation of the trauma pathways in two of Oxfordshire's community MIUs. In total, a range of seven common fracture pathways seen in the ED and community MIUs were redesigned so that patients were treated definitively at the first point of contact and discharged with a safety net supported by leaflets; a direct contact facility to OUH trauma specialties was part of the safety net allowing patients to self-refer to the trauma clinic if they had any concerns. In total, 513 patients were treated and discharged on see, treat and discharge fracture pathways in the first year of pathway operation, which represented a 21% decrease in patient referral rates to the trauma clinic at OUH compared with the previous year.

Validation of the Primary Care Pathway Model for Management of Orthopedic Injuries: Results of a Prospective, Queensland Study

Objective:

A “virtual fracture clinic” (VFC) is viewed as a safe, cost effective method of managing suitable low risk orthopedic injuries without direct orthopedic review. This method is used throughout the Glasgow Royal Infirmary (GRI) and National Health System (NHS) as a cornerstone for efficient patient care. This study assessed the outcomes of a newly implemented Queensland based Primary Care Pathway (PCP) for management of simple orthopedic injuries.

Methods:

A prospective cohort was formed of patients presenting over a 4-week period with an acute orthopedic injury to either the Emergency Department (ED) or Primary Care Providers within the Logan Hospital catchment in Queensland, Australia. Patients were triaged to either a PCP management protocol with General Practitioners (GP), Allied-Health Professionals (AHP) or to a traditional in-person Fracture Clinic (FC) orthopedic review. Patients were followed for 6-months. Data were collected about epidemiology, complications, appropriate allocation, and injury type.

Results:

A total of 1283 patients were referred over the study period, of which 267 were triaged to PCP management. ED referrals accounted for 62.5% of appropriate referrals to either clinic. Upper limb injuries were the most common conditions managed through the PCP. Patients managed by the PCP model of care experienced a 4.29% complication rate over the 6-month follow-up period.

Conclusion:

The PCP model of care is effective in managing criteria specific, low risk orthopedic injuries with a low rate of complications (4.29%) without direct orthopedic FC review. Use of a PCP reduces demand on hospital resources, and provides a safe, cost-effective alternative to a resource-restricted outpatient service.

Extended Routine Follow-up of Primary Uncomplicated Hip and Knee Arthroplasty is not Necessary

Aims:

To create a more effective system to identify patients in need of revision surgery.

Background:

There are over 160,000 total hip and knee replacements performed per year in England and Wales. Currently, most trusts review patients for up to 10 years or more. When we consider the cost of prolonged reviews, we cannot justify the expenditure within a limited budget.

Study Design & Methods:

We reviewed all patients' notes that underwent primary hip and knee revision surgery at our institution, noting age, gender, symptoms at presentation, referral source, details of the surgery, reason for revision and follow up history from primary surgery.

Results:

There were 145 revision arthroplasties (60 THR and 85 TKR) that met our inclusion criteria. Within the hip arthroplasty group, indications for revision included aseptic loosening (37), dislocation (10), and infection (3), periprosthetic fracture, acetabular liner wear and implant failure. All thirty-seven patients with aseptic loosening presented with pain. Twenty-five were referred from general practice with new symptoms. The remaining were clinic follow-ups. The most common reason for knee revision was aseptic loosening (37), followed by infection (21) and then progressive osteoarthritis (8). Most were referred from GP as a new referral or were clinic follow-ups. All patients were symptomatic.

Conclusion:

All the patients that underwent revision arthroplasty were symptomatic. Rather than yearly follow up, we recommend a cost-effective system. We are implementing a 'non face-to-face' system. Patients would be directly sent a questionnaire and x-ray form. The radiographs and forms will be reviewed by an experienced arthroplasty surgeon. The concerning cases will be seen urgently in a face-to-face clinic.

Standardised virtual fracture clinic management of Achilles tendon ruptures is safe and reproducible

BACKGROUND

Traditional fracture clinics are some of the busiest clinics in a hospital, often with significant patient waiting times and delays. The use of virtual fracture clinic (VFC) for the management of certain injuries to reduce the workload on the traditional fracture clinic, in addition to reducing costs is growing in popularity. The tendoachilles is the most frequently ruptured tendon in the body but despite this, management remains a keenly debated topic.

METHODS

All adult patients referred to the VFC with an actual or suspected Achilles tendon rupture were identified between January 2015 to October 2017.

RESULTS

This study found that patient with and acute achilles tendon ruptures managed according to a standardised VFC protocol had a re-rupture rate of 3.82%.

CONCLUSIONS

One of the advantages of a VFC model that is standardised, initiated in the ED, is that it has no variation in outcome seen in our patient group.

Patient Characteristics, Treatment, and Presenting PROMIS Scores Associated with Number of Office Visits for Traumatic Hand and Wrist Conditions

BACKGROUND

Overuse of healthcare resources is burdensome on society. Prior research has demonstrated that many patients with traumatic musculoskeletal injuries continue to seek care long after appropriate healing is well established, suggesting an overuse of services. However, few studies have examined the factors-including patient-reported outcomes-associated with an increased number of clinic visits for traumatic hand and wrist conditions.

QUESTIONS/PURPOSES

(1) After accounting for surgical treatment, surgeon, and demographic factors, is a patient's PROMIS Pain Interference score associated with the total number of office visits? (2) Is PROMIS Depression, combination of PROMIS Depression and Pain Interference, or Physical Function scores associated with the number of office visits?

METHODS

Between June 2015 and May 2018, 1098 patients presenting for a new patient visit at a single, urban academic medical center for distal radius fracture, wrist or hand sprain, tendon rupture, traumatic finger amputation, or scaphoid fracture were identified. Of those, 823 (75%) patients completed all PROMIS domains and presented before the trailing period and thus were included in this retrospective study. We recorded a number of variables including: Total number of office visits, age, sex, race, marital status, diagnosis, provider, and operative or nonoperative treatment. Multivariable Poisson regression analysis was conducted to determine whether Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS PI), Physical Function (PROMIS PF), and Depression scores measured at the first visit were associated with the total number of office visits, after accounting for the other factors we measured.

RESULTS

Higher PROMIS PI scores were associated with greater number of clinic visits (0.0077; 95% CI, 0.0018-0.014; p = 0.010). Although PROMIS Depression scores were not associated with the number of office visits (0.0042; 95% CI, -0.0099 to 0.0094; p = 0.112), higher PROMIS PF scores were associated with fewer office visits when accounting for confounding variables (-0.0077; 95% CI, -0.0012 to -0.0029; p = 0.001). Additionally, across all individual PROMIS models, there was an association between the variables "operative treatment" (PI: 0.85; 95% CI, 0.72-0.98; p < 0.001; Depression: 0.87; 95% CI, 0.74-1.0; p < 0.001; PF: 0.85; 95% CI, 0.72-0.99; p < 0.001) and "traumatic finger amputation" (PI: 0.22; 95% CI, 0.016-0.42; p = 0.034; Depression: 0.2; 95% CI, 0.086-0.47; p = 0.005; PF: 0.21; 95% CI, 0.014-0.41; p = 0.036) with an increased total number of office visits. Provider team 5 (PI: -0.62; 95% CI, -0.98 to -0.27; p = 0.001; Depression: -0.61; 95% CI, -0.96 to -0.26; p = 0.001; PF: -0.60; 95% CI, -0.96 to -0.25; p = 0.001) was associated with fewer office visits. In both the PROMIS Depression and PROMIS PF regression models, increasing age (Depression: -0.0048; 95% CI, -0.0088 to -0.00081; p = 0.018; PF: -0.0045; 95% CI, -0.0085 to -0.0006; p = 0.024) was also associated with fewer total number of office visits.

CONCLUSIONS

This study helps surgeons understand that patients who present at their initial office visit for traumatic hand and wrist conditions displaying worse pain coping strategies and decreased physical function will have more office visits. We recommend that surgeons engage in a comprehensive care approach that is empathetic, fosters effective pain coping strategies (and so might decrease PROMIS PI scores), and educates patients about expectations by providing educational materials and/or including other health professionals (such as, social work, physical therapy, mental health professional) as needed. This may decrease healthcare use in patients with traumatic hand and wrist conditions.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland

INTRODUCTION

The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot.

METHODS AND PATIENTS

Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment.

RESULTS

To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment.

CONCLUSION

Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.

Requesting spinal MRIs effectively from primary care referrals

OBJECTIVE

To define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey. The demand for outpatient spinal appointments significantly exceeds our services' ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation.

METHODS

During routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters.

RESULTS

149 patients were included [101 females, 48 males, mean age 49 (16-87)]. There were 125 routine, 21 urgent, and 3 'urgent-suspected cancer' referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits.

CONCLUSIONS

MRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings. These slides can be retrieved under Electronic Supplementary Material.

Discharged but not dissatisfied: outcomes and satisfaction of patients discharged from the Edinburgh Trauma Triage Clinic

Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Patients and Methods

A total of 628 patients who had sustained these injuries over a one-year period were identified. There were 337 patients in the pre-TTC group and 289 in the post-TTC group. The Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) or Foot and Ankle Disability Index (FADI), EuroQol-5D (EQ-5D), visual analogue scale (VAS) pain score, satisfaction rates, and return to work/sport were assessed six months post-injury. The development of late complications was excluded by an electronic record evaluation at three years post-injury. A cost analysis was performed.

Results

Outcomes were as good or better post-TTC, compared with pre-TTC scores. At three years, the pre-TTC group required a total of 496 fracture clinic appointments compared with 61 in the post-TTC group. Mean cost per patient was nearly fourfold less after the commencement of the TTC.

Conclusion

Management of minor fractures through the Edinburgh TTC results in clinical outcomes that are comparable with the previous system of routine face-to-face consultation. Outpatient workload for these injures was reduced by 88%. Cite this article: Bone Joint J 2018;100-B:959–65.

Changing practice for hip arthroplasty and its implications

This overview provides insight into changes in clinical practice and the implications for nursing staff and clinicians who are involved in the management of patients undergoing primary total hip arthroplasty. The review highlights commonly used surgical approaches, their advantages, their associated risks and how to manage complications if they occur.

Virtual stone clinic – the future of stone management?

Objectives:

Increasing demands on the urology outpatient department at Brighton and Sussex University Hospitals (BSUH) have posed a significant challenge on the provision of a timely service for patients with stone disease. This study aimed to evaluate the patient outcomes and waiting times achieved with a newly implemented virtual stone clinic (VSC).

Materials and methods:

All new stone referrals received between August 2016 to January 2017 at BSUH were discussed in the VSC. Patients were reviewed within seven days of referral by a multidisciplinary team led by a consultant stone surgeon. A prospectively collected database was generated with primary outcomes including discharge to primary care, need for further diagnostics, re-review at VSC, direct booking for treatment and referral to a traditional outpatient stone clinic. Waiting times between the VSC and previously used outpatient stone clinic were also compared.

Results:

A total of 526 cases were reviewed in the VSC. One-quarter of patients were discharged following initial VSC review with a further two-thirds discharged after re-review. Treatment was offered to 101 patients, primarily in the form of lithotripsy (65%). Eighty-six patients required formal outpatient clinic appointments. Waiting lists for stone appointments were cleared within two months of implementation of the VSC. Outcomes were very favourable, with only three patients requiring emergency admission for management of their stone disease.

Conclusion:

The VSC model provides a clinically and cost-effective method of managing patients with urinary tract stones with significantly reduced waiting times and overall improved patient satisfaction. Level of evidence: Not applicable for this multicentre audit.

Preschool growth and nutrition service - addressing common nutritional problems: a community based, primary care led intervention

Childhood obesity has been prioritised by the World Health Organization in a recent report, which calls for a holistic multiagency approach to tackling and reducing future risks of obesity and its associated co-morbidities. This article examines a health service approach to improving recognition and management of pre-school nutritional problems as part of training health care professionals. It explores the practicalities of setting up a local pathway for managing cases in the community with appropriate specialist support. This model, developed for the management of weight faltering, has now been adapted to tackle childhood obesity.

Paediatric fracture clinic re-design: Incorporating a virtual fracture clinic

INTRODUCTION

The use of virtual fracture clinics (VFCs) and home management protocols is increasing. The main aim of this research is to determine whether a paediatric home management programme and VFC can be used safely to manage a range of suitable fractures in children.

MATERIALS AND METHODS

Protocols for the home management of stable paediatric fractures were designed by two consultant paediatric orthopaedic surgeons. These were for children between the ages of 18 months and 15 years 364 days. A new tariff was negotiated with the clinical commissioning groups (CCGs) for a VFC new patient review. A prospective analysis was performed for the first 2 months of the programme. Further review periods were undertaken 6 months later and 12 months after that.

RESULTS

Sixty-five patients were reviewed in the first 10 VFCs (mean 6.5 cases per week). After 6 months, 164 patients were reviewed in a 3-month period in the VFC, a mean of 11 cases per week. A year later the number of patients reviewed in the VFC had continued to increase with a total of 253 patients in 3 months, mean 21 cases per week. This gave a saving to the CCG of £45,000 per year and to the hospital of £106,000 per year. There were no serious adverse consequences to any patients from the use of the pathway.

DISCUSSION AND CONCLUSION

We have reported on the introduction of a paediatric VFC and a home management programme for stable paediatric fractures. We are not aware of any reports in the orthopaedic literature that have described such a comprehensive and innovative re-organisation of paediatric fracture services. We estimate that the NHS could save approximately £10.1 million if all hospitals in England introduced this.

Standardised virtual fracture clinic management of radiographically stable Weber B ankle fractures is safe, cost effective and reproducible

BACKGROUND

Virtual clinics have been shown to be safe and cost-effective in many specialties, yet barriers exist to their implementation in orthopaedics. Ankle fractures are common and therefore represent a significant clinical workload. The aim of this study was to evaluate the management of radiographically stable Weber B ankle fractures using a standardised treatment protocol in a virtual fracture clinic setting, to assess clinical outcomes, any complications and its cost effectiveness.

METHODS

All patients referred to the VFC with an actual or suspected stable Weber B ankle fracture between September 2013 and September 2015 were identified. The primary outcome measure was successful fracture union. Any complications were noted and a cost analysis comparing the VFC and traditional fracture clinic models was undertaken.

RESULTS

314 patients referred with a radiographically stable Weber B ankle fracture were identified. Follow up was complete for 98.4% (309/314) of patients. The union rate was 99.4% (307/309) in patients where follow up was completed. 3.5% (11/309) of patients were underwent acute surgical intervention. Of these patients, 6 were identified as having an unstable injury on weight bearing radiographs at 2 weeks and underwent ORIF, 4 were identified as having an unstable injury on EUA and underwent ORIF and 1 had an EUA with no fixation. 2 patients required ORIF for radiographically confirmed non-union. A cost saving analysis comparing the traditional fracture clinic model and VFC model revealed a saving of £237 per patient (32% reduction) with a VFC model. This represents an estimated saving of almost £40,000 per year for the management of this injury alone in our institution.

CONCLUSION

Our study supports the use of a virtual fracture clinic model that is standardised, initiated in ED, and is both safe and cost-effective in the management of radiographically stable Weber B ankle fractures.

LEVEL OF EVIDENCE

Level III-Retrospective Cohort Study.

Do all adult orthopaedic injuries seen in emergency departments need to attend fracture clinic? A Queensland multicentred review

OBJECTIVE

Musculoskeletal injuries account for a significant proportion of ED presentations annually, with a large percentage being referred to the fracture clinic (FC). A literature review found that many referrals could be safely managed outside the traditional model of care. The present study aims to review all adult presentations to FCs at two Queensland metropolitan hospitals, finding low-risk injuries that can safely and appropriately be managed by their general practitioner (GP) or allied health professionals (AHPs), potentially affording significant savings to the health system.

METHODS

A retrospective study at Logan and Redland Hospitals was undertaken, reviewing all adult patients (≥16 years) referred to FCs over an eight week period. Injuries were categorised into those requiring FC care supervised by an orthopaedic surgeon (fracture clinic pathway) and those that could be safely managed by GPs or AHPs, with the aid of evidence-based, protocol-driven guidelines known as the primary care pathway (PCP).

RESULTS

A total of 1367 patients were referred to FC over the study period, of whom 546 (40%) were assessed as suitable candidates for PCP. Redland Hospital accounted for 65% of all PCP-suitable patients, whereas Logan Hospital accounted for 35%. Failure-to-attend rates were significantly higher (P < 0.001) in the PCP patients compared to other patients attending FCs.

CONCLUSION

Adopting the PCP could potentially reduce fracture clinic referrals by 40%. Having a structured pathway has the potential to empower primary health professionals, which could result in a more streamlined process that aids in significant time and financial savings and maintains good patient satisfaction and outcomes.

The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison

Objectives

To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA).

Methods

This was a retrospective study including all patients (17 116) referred to fracture clinics in a London District General Hospital from May 2013 to April 2016, using hospital-level data. We used interrupted time series analysis with segmented regression, and direct before-and-after comparison, to study the impact of VFCs introduced in December 2014 on six clinical parameters and on local Clinical Commissioning Group (CCG) spend. Student’s t-tests were used for direct comparison, whilst segmented regression was employed for projection analysis.

Results

There were statistically significant reductions in numbers of new patients seen face-to-face (140.4, sd 39.6 versus 461.6, sd 61.63, p < 0.0001), days to first orthopaedic review (5.2, sd 0.66 versus 10.9, sd 1.5, p < 0.0001), discharges (33.5, sd 3.66 versus 129.2, sd 7.36, p < 0.0001) and non-attendees (14.82, sd 1.48 versus 60.47, sd 2.68, p < 0.0001), in addition to a statistically significant increase in number of patients seen within 72-hours (46.4% 3873 of 8345 versus 5.1% 447 of 8771, p < 0.0001). There was a non-significant increase in consultation time of 1 minute 9 seconds (14 minutes 53 seconds sd 106 seconds versus 13 minutes 44 seconds sd 128 seconds, p = 0.0878). VFC saved the local CCG £67 385.67 in the first year and is set to save £129 885.67 annually thereafter.

Conclusions

We have shown VFCs are clinically and cost-effective, with improvement across several clinical performance parameters and substantial financial savings for CCGs. To our knowledge this is the largest study addressing clinical practice implications of VFCs in England, using robust methodology to adjust for pre-existing trends. Further studies are required to appreciate whether our results are reproducible with local variations in the VFC model and payment tariffs.

Cite this article: A. McKirdy, A. M. Imbuldeniya. The clinical and cost effectiveness of a virtual fracture clinic service: An interrupted time series analysis and before-and-after comparison. Bone Joint Res 2017;6:–269. DOI: 10.1302/2046-3758.65.BJR-2017-0330.R1.