Implementation of an ED Direct Discharge for the Management of Specific Fractures

Purpose

The purpose of the ED Direct Discharge was to redesign the pathway of care for the management of 6 specific fractures and injuries. All patients with acute fractures have traditionally been referred to a fracture clinic soon after injury. However, many simple stable fractures and injuries can be discharged from the Emergency Department (ED) with standardised advice leaflets, access to telephone advice and no further follow up in fracture clinic.

In collaboration between the ED physiotherapist and Orthopaedic Consultants, a redesigned fracture management system with guidelines on treatment, criteria and discharge advice leaflets was agreed.

81 (51%) out of a possible 160 patients
were put onto the SCP.
Only 1% of those put onto the SCP correctly
required an orthopaedic review due to ongoing pain.
Of the 20 patients contacted on the telephone review,
95% reported normal function and near/full recovery from their injury.
71 fracture clinic appointments
were not needed. 

Approach

Implementation of the ED Direct Discharge commenced on the 1st Oct 2018 and data was collected prospectively until the 28th Feb 2019. The 6 specific injuries that met the criteria were:

1. Torus /Buckle fracture wrist

2. Radial Head/Neck 

3. Base 5th MT

4. Paediatric Clavicle fracture

5. Neck 5th MC

6. Mallet Injury

 

An ED clinician who diagnosed one of the 6 specific injuries were put onto the 'Self Care Pathway' (SCP). Patients received the appropriate treatment and an advice leaflet, prior to being discharged from the ED. During the implementation phase, the ED physiotherapist collated patients put onto the SCP and reviewed the notes/X-Rays with an Orthopaedic Consultant to ensure patients' appropriately discharged from the ED. Patients remained either on the SCP, were recalled to attend fracture clinic or referred to OT for onward management (Mallet injuries only). At 6-8 weeks post injury, the ED physiotherapist carried out a telephone review for patients who remained on the pathway.

Outcomes

During 1st Oct 2018 and 28th Feb 2019, 81 patients' were put onto the SCP. A further 79 patients were seen in the fracture clinic with one of the 6 injuries, (referred by ED or a local MIU) who should have been put onto the SCP.

Of the 81 patients, 71 remained on the SCP following the orthopaedic review, 9 were recalled to fracture clinic (of which 8 did not have injuries meeting the criteria) and 1 was booked to see an upper limb orthopaedic consultant with ongoing pain/disability.

A telephone review was carried out for 20 patients, of which 19 reported near of full recovery and satisfaction with their outcome. 14 patients were unable to be contacted after repeated attempts. The remaining patients were either under the care of OT, fracture clinic or not 6-8 weeks post injury.

81 (51%) out of a possible 160 patients were put onto the SCP. Only 1% of those put onto the SCP correctly required an orthopaedic review due to ongoing pain. Of the 20 patients contacted on the telephone review, 95% reported normal function and near/full recovery from their injury. 71 fracture clinic appointments were not needed. 

Implications

  • Improved pathway of care without compromising the overall outcome.
  • Less travel time and time off work for the patient to attend an appointment.
  • Fewer fracture clinic appointments, thus reducing the workload of the fracture clinic staff and allowing the orthopaedic consultants to dedicate more time on complex presentations.

Funding acknowledgements

No additional funding was received during the service redesign and implementation

Additional notes

This work was presented at Physiotherapy UK 2019