FRACTURE CLINICA TIME FOR CHANGE?

Ro Kulkarni

Current State

Over booked clinics – little time with patients

Inappropriate referrals – A & E – one visit - discharge / or not

Inappropriate speciality – one visit - referral to appropriate speciality

No teaching time Increasing complaints – junior decision

making – never seen a consultant Poor patient experience – parking, waiting,

and time with doctor

Models/Ideas

Scottish new designLech RymaszewskiGRI

Leicester format Exeter ideas – Nigel Giles Swedish model My DH outpatient tariff work My ideas

Will Change Help

Better patient experience – appropriate visits, less visits, quicker decisions and appropriate Rx

The right patient seen in the right clinic at the right time

Better trainee experience, teaching and support

Better staff experience More time with patients Financial saving

Key rules

Focus on quality and patient experience

Not to decrease number of fracture clinics

Not to replace fracture clinic time with elective

patients

Not to increase numbers

To protect teaching and patient contact times

Statistics

A & E referrals to # clinic March - Sept 2012 = 3281 ( 5624)

7% reattenders, rest new

A & E referrals to # clinic – per day – 18 (6-30)

Speciality break down

Hand and wrist – 31% Feet/ankle – 17% Shoulder & Elbows – 12% Knees – 6% Unknown Dx – 8% The rest – Mixed bag

Three Point Plan

Decrease Inappropriate A & E Referrals

Methodology - Decrease Inappropriate A & E Referrals

Torus #s, Radial head(Mason 1), Mallet finger, Neck of 5th metacarpal, 5th metatarsal #s & paediatric clavicle #s

Perhaps others NO need for # clinic follow up Exclusions - A & E education Appropriate advice given Appropriate method of access for

problems

Methodology - Decrease Inappropriate A & E Referrals

Seen in A & E Treated with support that can be

discarded by patient -Disposable splints for 5th MT #s and

torus fractures Appropriate advice given Protocol leaflets given No follow up

RK 04/13

Our Follow Up Statistics

Torus #s = 2 Radial head(undisplaced) = 2

Mallet fingers= 3Neck of 5th metacarpal= 25th metatarsal #s= 3.5Paediatric clavicle #s= 2.5

Virtual Clinic

Virtual Clinic

No routine appointments to # clinic All A & E referred patients screened in a

virtual clinic All referrals except discharges form ortho Out of area attenders Only attend – for something to be done

AssessmentPOP offInvestigationetc

Virtual Clinic

Consultant review A & E notes and images pre loaded App 2 mins per patient Diagnosis and plan recorded Average 18 patients per day - app 40 mins 10pm to 10 pm Dictated by 12 next day for action by 3 pm On call consultant Job plan

Virtual clinic

Options # clinic – speciality(shoulder/knee/hand/team etc) # clinic - generic ( any team) Wound/dressing clinic Time of review – next clinic/ one week etc Discharged (no need for follow up)with advice

Nurse prac Discharged and same week patients phoned

same day Letter to GP OP appointment booked through booking centre

RK 04/13

Improve Patient experience and quality

of care

Pre Fracture Triage Clinic

Consultant led Team approach( Medical, nursing, plaster, x-ray

etc) All new patients notes and x-rays reviewed Information recorded Diagnosis Plan – pre being seen – ROP, x-ray, wound check Plan after being seen – will need FU next week,

scan, rule out cuff injury etc To be seen by – SHO, Reg, Consultant etc To be discussed with consultant after review

Advantages

All new patients ‘reviewed’ by Consultant Teaching Robust treatment plans Decrease in follow up ( to see how they

are doing!) Time saving Team approach

Advantages

Appropriate patients seen In the right Clinic At the right time Better patient experience Money saved

Is It Safe?

Yes - Multiple senior review

A&E review

Virtual Clinic Consultant review

Fracture clinic Consultant Review

Actual clinic review

GRI ‐ FRACTURE CLINIC Oct 2011 –Mar 2012

GRI ‐ FRACTURE CLINIC Oct 2011 –Mar 2012

Has It Worked For Us?

Consultant buy in

Management support

A & E support

No need for extra finance or infrastructure

6 months data

New slots – 3270 New filled – 2452 25% decrease

F/U slots – 6960 F/U filled – 4550 35% decrease

Total DNA – 967 – 14% New DNA – 5% NO complaints or adverse incidents