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Bridges CS, Taylor TN, Han A, Gladstein AZ, Smith BG, Kan JH. The Gartland classification for expediting supracondylar humerus fracture triage: a collaborative approach to structured reporting between pediatric radiologists and orthopedists. Clin Imaging 2024; 109:110118. [PMID: 38520814 DOI: 10.1016/j.clinimag.2024.110118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 02/12/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND The modified Gartland classification is an important tool for evaluation of pediatric supracondylar humerus fractures (SCHF) because it can direct treatment decisions. Gartland type I can be managed outpatient, while emergent surgical consult occurs with type II and III. This study assesses the interobserver reliability of the Gartland classification between pediatric radiologists and orthopedic providers. METHODS A retrospective review of 320 children diagnosed with a SCHF at a single tertiary children's hospital during 2022 was conducted. The Gartland classification documented in the radiographic report by a pediatric radiologist and the classification documented in the first encounter with an orthopedic provider was collected. Kappa value was used to assess interobserver reliability of classifications between radiologists and orthopedic providers. A second group of 76 Gartland type I SCHF from 2015, prior to our institution's implementation of structured reporting, was reviewed for comparison of unnecessary orthopedic consults at initial presentation. RESULTS The Gartland classification has excellent interobserver reliability between radiologists and orthopedic providers with 90 % (289/320) agreement and kappa of 0.854 (confidence interval: 0.805-0.903). The most frequent disagreement that occurred was fractures classified as type II by radiology and type III by orthopedics. There were similar rates of consults for the 2015 and 2022 cohorts (p = 0.26). CONCLUSION The Gartland classification system is a reliable and effective tool for communication between radiologists and orthopedic providers. Implementing a structured reporting system has the potential to improve triage efficiency for SCHF.
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Affiliation(s)
- Callie S Bridges
- Department of Orthopedics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Tristen N Taylor
- Department of Orthopedics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Albert Han
- Department of Orthopedics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Aharon Z Gladstein
- Department of Orthopedics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Brian G Smith
- Department of Orthopedics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - J Herman Kan
- Department of Radiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Thomas-Jones I, Kocialkowski C, Dominguez E, Williams J. Lessons From the Virtual Fracture Clinic: An Efficient Model With Satisfied Patients. Cureus 2022; 14:e30413. [PMID: 36407215 PMCID: PMC9669813 DOI: 10.7759/cureus.30413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2022] [Indexed: 06/16/2023] Open
Abstract
Introduction The virtual fracture clinic (VFC) can be an effective means of managing specific musculoskeletal injuries, including through protocol-driven direct discharge from the emergency department (ED) or minor injury unit (MIU). This study aimed to measure the efficiency of the VFC triage process while quantifying patient satisfaction after direct discharge from the VFC without routine face-to-face review. Methods We conducted a retrospective analysis of a prospectively collected database to ascertain VFC outcomes for 9064 patients from February 2017 to July 2018. We analysed consultant variation in VFC review and the mean time taken per patient. Patient satisfaction was investigated in 100 chronological patients initially managed via the VFC. Results The mean time to triage each patient was 74 seconds, and a mean of 503 patients was triaged each month. The telephone helpline received a mean of 0.9 calls per week. Seventy-seven percent of patients stated they were happy to be managed without a fracture clinic appointment, and 82% of patients received virtual leaflets in the ED or MIU as per protocol. The number of fracture clinic appointments was reduced by 24% as patients were discharged directly or seen instead by allied health professionals. The median patient satisfaction with VFC management was 90%, and the mean satisfaction with VFC communication was 80%. Conclusion Virtual review of fracture clinic referral enables stratification of patients according to clinical urgency and saves patients from attending unnecessary appointments. This is achieved in a patient population generally satisfied with their overall management. Our study results support the growing trend of VFCs as pivotal systems in streamlining the care of musculoskeletal injuries while adhering to British Orthopaedic Association Standards for Trauma guidelines for Fracture Clinic Services.
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Affiliation(s)
- Iolo Thomas-Jones
- Bristol Medical School, University of Bristol, Bristol, GBR
- Department of Trauma and Orthopaedics, Musgrove Park Hospital, Taunton, GBR
| | | | - Elizabeth Dominguez
- Bristol Medical School, University of Bristol, Bristol, GBR
- Department of Trauma and Orthopaedics, Musgrove Park Hospital, Taunton, GBR
| | - James Williams
- Department of Trauma and Orthopaedics, Musgrove Park Hospital, Taunton, GBR
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Davey MS, Coveney E, Rowan F, Cassidy JT, Cleary MS. Virtual Fracture Clinics in Orthopaedic Surgery - A Systematic Review of Current Evidence. Injury 2020; 51:2757-2762. [PMID: 33162011 DOI: 10.1016/j.injury.2020.11.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Martin S Davey
- University Hospital Waterford, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Eamonn Coveney
- University Hospital Waterford, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiachra Rowan
- University Hospital Waterford, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - J Tristan Cassidy
- University Hospital Waterford, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - May S Cleary
- University Hospital Waterford, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; University College Cork, Ireland
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Salem A, Elamir H, Alfoudri H, Shamsah M, Abdelraheem S, Abdo I, Galal M, Ali L. Improving management of hospitalised patients with COVID-19: algorithms and tools for implementation and measurement. BMJ Open Qual 2020; 9:e001130. [PMID: 33199287 PMCID: PMC7670554 DOI: 10.1136/bmjoq-2020-001130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/12/2020] [Accepted: 11/08/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic represents an unprecedented challenge to healthcare systems and nations across the world. Particularly challenging are the lack of agreed-upon management guidelines and variations in practice. Our hospital is a large, secondary-care government hospital in Kuwait, which has increased its capacity by approximately 28% to manage the care of patients with COVID-19. The surge in capacity has necessitated the redeployment of staff who are not well-trained to manage such conditions. There was a great need to develop a tool to help redeployed staff in decision-making for patients with COVID-19, a tool which could also be used for training. METHODS Based on the best available clinical knowledge and best practices, an eight member multidisciplinary group of clinical and quality experts undertook the development of a clinical algorithm-based toolkit to guide training and practice for the management of patients with COVID-19. The team followed Horabin and Lewis' seven-step approach in developing the algorithms and a five-step method in writing them. Moreover, we applied Rosenfeld et al's five points to each algorithm. RESULTS A set of seven clinical algorithms and one illustrative layout diagram were developed. The algorithms were augmented with documentation forms, data-collection online forms and spreadsheets and an indicators' reference sheet to guide implementation and performance measurement. The final version underwent several revisions and amendments prior to approval. CONCLUSIONS A large volume of published literature on the topic of COVID-19 pandemic was translated into a user-friendly, algorithm-based toolkit for the management of patients with COVID-19. This toolkit can be used for training and decision-making to improve the quality of care provided to patients with COVID-19.
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Affiliation(s)
- Ahmed Salem
- Anaesthesia and Intensive Care Department, Sabah Al Ahmad Urology Centre, Ministry of Health, Sabah, Kuwait
- Anaesthesia and Intensive Care Department, Faculty of Medicine, Banha University, Benha, Egypt
| | - Hossam Elamir
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
| | - Huda Alfoudri
- Anaesthesia, Critical Care and Pain Management Department, Adan Hospital, Ministry of Health, Hadiya, Kuwait
| | - Mohammed Shamsah
- Anaesthesia, Critical Care and Pain Management Department, Adan Hospital, Ministry of Health, Hadiya, Kuwait
| | - Shams Abdelraheem
- Critical Care Department, Manchester University NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Ibtissam Abdo
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
| | - Mohammad Galal
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
| | - Lamiaa Ali
- Quality and Accreditation Directorate, Ministry of Health, Safat, Kuwait
- Public Health Department, Fayoum University Faculty of Medicine, Fayoum, Egypt
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Rhind JH, Ramhamadany E, Collins R, Govilkar S, Dass D, Hay S. An analysis of virtual fracture clinics in orthopaedic trauma in the UK during the coronavirus crisis. EFORT Open Rev 2020; 5:442-448. [PMID: 32818071 PMCID: PMC7407867 DOI: 10.1302/2058-5241.5.200041] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Ruaraidh Collins
- Basingstoke and North Hampshire Hospital, Basingstoke, Hampshire, UK
| | | | - Debashis Dass
- Robert Jones Agnes Hunt Hospital, Oswestry, Shropshire, UK
| | - Stuart Hay
- Robert Jones Agnes Hunt Hospital, Oswestry, Shropshire, UK
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Robertson A, Godavitarne C, Bellringer S, Guryel E, Auld F, Cassidy L, Gibbs J. Standardised virtual fracture clinic management of Achilles tendon ruptures is safe and reproducible. Foot Ankle Surg 2019; 25:782-784. [PMID: 30686540 DOI: 10.1016/j.fas.2018.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/27/2018] [Accepted: 10/16/2018] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Alastair Robertson
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom.
| | - Charles Godavitarne
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Simon Bellringer
- Western Sussex Hospitals NHS Foundation Trust, Spitalfield Lane, Chichester, West Sussex, PO19 6SE, United Kingdom
| | - Enis Guryel
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Felicity Auld
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | | | - James Gibbs
- Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
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Inappropriately Timed Pediatric Orthopaedic Referrals From the Emergency Department Result in Unnecessary Appointments and Financial Burden for Patients. J Pediatr Orthop 2018; 38:e128-e132. [PMID: 29324529 DOI: 10.1097/bpo.0000000000001132] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Musculoskeletal injuries are among the most common reasons for emergency department (ED) visits in the pediatric population. Many such injuries can be managed with a single follow-up outpatient visit. However, untimely (ie, premature) referrals by emergency physicians to orthopaedic surgeons are common and may inadvertently create need for a second visit, generating unnecessary expenditures. We sought to elucidate the cost of premature musculoskeletal follow-up visits to the patients, families, and the health care system. METHODS We performed a retrospective review of pediatric patients with acute musculoskeletal injuries referred from our ED (without a formal orthopaedic consult) to our outpatient clinic. Patients were retrospectively reviewed in a consecutive fashion. The appropriateness of the recommended follow-up time interval was determined for each patient, and the direct and indirect cost of the inappropriate services were calculated utilizing a combination of traditional cost accounting techniques and time-driven activity-based costing. The characteristics of patients with appropriate and untimely follow-up referrals were compared. RESULTS Two hundred consecutive referrals from the ED were reviewed. Overall, 96.5% of the follow-up visits recommended by the ED were premature, which led 106 (53%) patients to require a second visit to complete their clinical care. Patients who required a second visit were significantly younger (P=0.005), more likely to be male (P=0.042), more likely to have a fracture (P<0.001), and less likely to have a sprain (P<0.001) or dislocation/subluxation (P<0.001). Over 40% of second visits were accounted for by 3 diagnoses (distal radius buckle fractures, nondisplaced Salter-Harris 1 fractures of the ankle, and buckle fractures of the finger). Across the whole cohort, the total financial impact of untimely visits was $36,265.78, representing an average cost of $342.93 per patient. CONCLUSIONS Untimely referrals for follow-up of acute pediatric musculoskeletal conditions are very common and represent a significant financial burden to patients, families, and the health care system. Over 40% of unnecessary visits resulted from just 3 diagnoses. Improved orthopaedic follow-up guidelines, particularly for these readily recognizable conditions, and feedback to referring providers may reduce poorly timed clinic visits and decrease costs in the treatment of common orthopaedic injuries in pediatric patients. LEVEL OF EVIDENCE Level III.
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