ED Reference Guideline for Common Adult Orthopaedic Limb Injuries

Aim

The aim is to improve the efficiency and quality of care for common orthopaedic limb injuries presenting to the ED and to minimize variation in practice through the implementation of a reference guideline.

Benefits

Clinical

• Improved quality of care for common orthopaedic limb presentations, with reduced variation in practice.

Operational and workflow

• Enhanced efficiency in decision-making to support timely early management and care planning.
• Improved early access to appropriate care, supporting patient flow through ED front of house/fast track.
• Reduced reliance on and workload for the orthopaedic team concerning common presentations.

Alignment with national standards

• Clinical Governance
• Comprehensive Care
• Communicating for Safety

Background

Orthopaedic limb injuries constitute a significant portion of Emergency Department presentations. The complexity of orthopaedic care ranges from weight-bearing and mobility considerations to full immobilization. Many tertiary centers have reference guidelines for managing common orthopaedic limb injuries in the ED, especially those manageable as outpatients. Such guidelines standardize early management of common injuries, enhancing efficiency and quality of care, and facilitating timely discussions with the orthopaedic team for relevant cases.

Prior to this initiative, such guidelines had not been developed in emergency care within SCHHS, leading to practice variation and increased consultation requests with orthopaedic teams regarding common presentations. This contributed to longer wait and management times in the ED, negatively impacting access and flow. Implementing a facility guideline ensures efficient and high-quality ED assessment and management of acute orthopaedic limb injuries, focusing on outpatient-manageable cases, thereby minimizing practice variation and facilitating ED access and flow.

Evaluation and results

Outcomes will be assessed through

• Long-term follow-up of clinical data in the ED front of house (FOH) approximately one year post-implementation, with comparisons to historical data from the year prior to implementation.
• Pre- and post-implementation ED staff surveys (RMO, Registrar, SMO, Nurse Practitioner).
• Annual review and audit of common presentations in the ED FOH, including NEAT targets and recalls/representations, 12 months post-implementation.
• Review of RiskMan data from orthopaedic follow-up clinics, 12 months post-implementation (around November 2024).

Future plans include tracking the frequency of electronic access to the guideline.

Lessons learnt

Several challenges during development and implementation provided valuable lessons for future approaches

• Stakeholder feedback requires time and relies on shared goals and directives. Identifying and emphasizing reciprocal benefits for work unit management and patient care in the ED and follow-up care is crucial for stakeholder engagement and buy-in.
• Easy access to guidelines and procedures is paramount. If a guideline is not readily accessible with minimal effort, it is unlikely to be utilized. Resources spread across multiple platforms may be ineffective due to inconsistent access by clinicians during care.
• Centralising resources to a single document made our guideline centralised, and by placing upon the two most commonly access platforms in our setting (QHEPS and DEM tools) coupled to regular staff education and circulation in comms, ensured staff were aware of and using this resource. The nature of constantly rotating junior staff in ED is challenging to ensure all aware of guideline, how and when to access. Our strategy was to include our guideline within routine education and training programs, and once embedded senior medical staff would direct staff to its use.
• Guidelines are useful but need not be rigid due to variation in patient presentation and concurrent or comorbid factors. Hence our guideline served as a decision-making tool rather than a rigid procedural document
• Guidelines need constant monitoring and updating as clinical care evolves or unique situations are identified that reveal limitations. Therefore, a centralised document that can be easily updates in lien with clinical needs is important. Many platforms for guideline publications can make this difficult or cumbersome, with delays to re-publication that may impact immediate change in care/practice.
• Unfortunately, we could not record how often our guideline was accessed in its electronic locations. Moving forward we will plan to have this recorded as part of future data collection.
• Future plans will include QR code-based resources for patient specifics to different presentations, and additional clinician resources for assessment procedures.

References

Orthobullets.com

Wolturs Kluwer UpToDate

Further reading

Pondicherry, N., Schwartz, H., Stark, N., Dhanoa, J., Emanuels, D., Singh, M., & Peabody, C. R. (2023). Designing clinical guidelines that improve access and satisfaction in the emergency department. Journal of the American College of Emergency Physicians Open, 4(2), e12919.​